Advanced Endoscopic Reproductive Surgery

Dr Pinar Kodaman the Director of the Endoscopic Reproductive Surgery Program

Dr. Pinar Kodaman, the Director of the Endoscopic Reproductive Surgery Program, performs robotic surgery using the Da Vinci system at Yale New Haven Hospital.

The Advanced Endoscopic Reproductive Surgery Program at Yale Reproductive Endocrinology allows for the minimally invasive surgical management of various conditions, including endometriosis, pelvic pain, ovarian cysts, fibroids, pelvic or intrauterine adhesions, blocked Fallopian tubes, abnormal uterine bleeding, and developmental anomalies of the reproductive tract. The goal of the program is to improve or maintain reproductive potential for those who desire it and to provide non- fertility sparing options to those who are done with child-bearing. A unique feature of this program is the continuity of care of patients since the surgeons are reproductive endocrinologists, who can provide ongoing treatment of conditions, such as infertility, endometriosis, and PCOS after the surgical intervention.

Minimally Invasive Surgical Options

Development of new surgical techniques and advances in surgical equipment allow us to perform the majority of gynecologic surgical procedures in a minimally invasive fashion, that is, with small incisions and with ambulatory surgeries that allow for same day discharge and an expedited recovery. Our physicians have extensive experience in these procedures and are considered the best in their field. Upon thorough evaluation of your particular condition, your physician will present you with options for surgical treatment, if indicated.

Laparoscopy is a minimally invasive surgical technique that that uses a tube with a light and a camera lens at the end (laparoscope) to examine organs and perform minimally invasive surgeries through small incisions on the abdomen. Advanced laparoscopic procedures include the following:

  • Laser excision of endometriosis
  • Excision of pelvic and abdominal adhesions (scar tissue)
  • Laparoscopic myomectomy (removal of fibroids)
  • Laparoscopic treatment of pelvic pain, including presacral neurectomy and uterosacral nerve ablation.
  • Tuboplasty (to fix blocked Fallopian tubes)
  • Removal of ovarian cysts with preservation of the ovaries
  • Supra-cervical and total laparoscopic hysterectomies
  • Removal of the tubes and/or ovaries

The addition of the daVinci Surgical SystemR to traditional laparoscopy allows for the minimally invasive surgical management of even more complex conditions, which would be difficult to perform with laparoscopy alone. This surgical system consists of a magnified, 3D high-definition vision system and laparoscopic, wristed instruments that bend like the human wrist unlike traditional laparoscopic instruments, which are un- wristed. Robot-assisted laparoscopy can be used for myomectomies and hysterectomies as well as for endometriosis resection. With respect to the latter, a special filter on the robotic camera allows for the use of indocyanine green, a compound which is injected intravascularly, that can help to visualize more subtle endometriosis lesions.

Hysteroscopy is a surgical procedure used to help diagnose and treat many uterine disorders. The hysteroscope (an instrument inserted through the vagina for a visual examination of the canal of the cervix and the interior of the uterus) transmits the images to a television screen. In addition to diagnosis of intrauterine problems, the hysteroscope, through its operative channel, can be used to treat abnormal findings at the time of the procedure. Hysteroscopy does not require any incisions as even operative hysteroscopy is done completely through the vagina. Advanced hysteroscopic procedures include the following:

  • Resections of fibroids
  • Resections of intrauterine adhesions
  • Removal of polyps
  • Corrections of tubal obstructions
  • Resection of uterine septum
  • Endometrial ablation
Condition Definition Possible Surgical Options
Fibroids Benign smooth muscle growths of the uterus that can cause bleeding, pain, pressure, infertility, pregnancy loss and pregnancy complications. Hysteroscopic myomectomy, robot-assisted laparoscopic myomectomy, laparoscopic myolysis, abdominal myomectomy
Endometriosis Growth of endometrial glands and stroma outside of the reproductive tract, which can cause pain, ovarian cysts, pelvic adhesions, and infertility. Laparoscopic excision/ablation of endometriosis, lysis of adhesions, prophylactic appendectomy, robot-assisted laparoscopy with use of indocyanine green for diagnosis/excision of endometriosis implants, laparoscopic assisted vaginal hysterectomy or (robot-assisted) total laparoscopic hysterectomy with/without removal of ovaries
Infertility Failure to conceive after 1 year of unprotected intercourse; if female age>35 years old, no conception after 6 months of trying.  Surgical indications for infertility treatment include blocked tubes, endometriosis/pelvic adhesions (scar tissue), hydrosalpinges (blocked, swollen tubes), fibroids, polyps, intra-uterine adhesions Diagnostic laparoscopy, chromopertubation, operative laparoscopy for excision of endometriosis, lysis of adhesions, myomectomy, salpingectomy for hydrosalpinges, tuboplasty, tubal anastomosis,  hysteroscopic tubal cannulation for proximal tubal blockage, diagnostic hysteroscopy, operative hysteroscopy
Abnormal Uterine Bleeding Excessive bleeding (>80 mL) with periods or bleeding in between periods. Diagnostic hysteroscopy, dilatation and curettage, operative hysteroscopy for polyps, fibroids, or endometrial ablation, cryoablation, IUD insertion, laparoscopic assisted vaginal hysterectomy or robot-assisted vaginal hysterectomy with/without removal of ovaries
Ovarian Cysts Fluid filled sacs on or within the ovary, which are usually benign, but can cause pain and discomfort, particularly if they are large Laparoscopic ovarian cystectomy, laparoscopic oophorectomy
Asherman's Syndrome Acquired intra-uterine adhesions (scar tissue) that may cause loss of menstrual flow, pelvic pain, infertility, or pregnancy loss. Hysteroscopic lysis of adhesions
Developmental Abnormalities of the Female Reproductive Tract
  • Imperforate hymen
  • Vaginal septum (transverse of longitudinal)
  • Uterine septum
  • Rudimentary uterine horn
  • Hymenectomy
  • Resection of vaginal septum
  • Hysteroscopic resection of uterine septum
  • Laparoscopic resection of rudimentary uterine horn
PCOS Irregular menstrual cycles, androgen excess (acne, excessive hair growth and or elevated male hormones), polycystic ovaries with exclusion of other hormonal problems. Laparoscopic ovarian drilling or ovarian wedge resection.

Many disorders affecting the uterus may be successfully treated without resorting to hysterectomy. A large proportion of women with uterine fibroids can be treated with the use of appropriate medications, by procedures decreasing blood flow to fibroids (embolization of uterine arteries), by myolysis (thermal or radiofrequency destruction of fibroid tissue), or by myomectomy (removal of fibroids without removing the uterus). Many myomectomies may be performed as outpatient procedures using hysteroscopy or laparoscopy, depending on their size and location. Alternatives to hysterectomy may be also offered to many women suffering from severe endometriosis, chronic pelvic pain, painful menses (dysmenorrhea), adenomyosis, and heavy periods. For example, endometrial ablation, by hysteroscopic resection or cryoablation (freezing of the uterine lining) are effective therapies for the treatment of heavy periods if a patient has completed child-bearing. Our physicians can provide guidance in selecting the optimum therapy.

Minimally invasive techniques offer many alternatives to hysterectomy for women suffering from:

  • Uterine fibroids
  • Severe endometriosis
  • Chronic pelvic pain
  • Painful menstrual cycles (dysmenorrhea)
  • Uterine thickening due to endometriosis infiltration (adenomyosis)
  • Heavy menstrual periods

Fibroids are the most common tumors of the female reproductive system. Also known as uterine myomas or leiomyomas, fibroids are firm, compact tumors that develop in the uterus. They are made of smooth muscle cells and fibrous connective tissue. Each fibroid arises from a single microscopic cell and grows slowly, usually over years.

It is estimated that 20 to 50 percent of women of reproductive age have fibroids, although not all are diagnosed. According to some estimates, 30 to 77 percent of women will develop fibroids sometime during their childbearing years, although only about one-third of these fibroids are large enough for a physician to detect on exam. They may range in size from the size of a pea to the size of a softball or small grapefruit.

In more than 99 percent of fibroid cases, the tumors are benign (non-cancerous). The tumors are not associated with cancer and do not increase a woman's risk for uterine cancer. Fibroids can be subserosal (under the out layer of the uterus), intramural (in the wall of the uterus) or submucosal (inside the cavity) and can be solitary or multiple in nature. Fibroids can cause heavy or irregular bleeding, which can result in anemia, pelvic pressure, dyspareunia (painful intercourse) or problems with fertility and reproduction. With respect to the latter, submucosal fibroids in particular have a negative impact on conception and are associated with pregnancy loss.

For more information, see the Yale Medical Group's Uterine Fibroids online health resource.