LAPAROSCOPY

LAPAROSCOPY OVERVIEW

Laparoscopy is a procedure to look inside your tummy (abdomen) by using a laparoscope. It is also referred to a ‘key-hole’ or ‘minimally invasive’ surgery. A laparoscope is a thin telescope with a light source. It is used to light up and magnify the structures inside the abdomen. A laparoscope is passed into the abdomen through a small cut (incision) in the skin, usually in the umbilical (‘belly-button’) area. A laparoscopy enables a doctor to see clearly inside your abdomen as high definition video images are relayed directly to a monitor.

A laparoscopy may be performed to find the cause of symptoms such as pelvic pain or subfertility – this is known as a diagnostic laparoscopy. It helps your gynaecologist make a diagnosis.

Many gynaecological conditions can be treated using a laparoscopic approach – this is called therapeutic or operative laparoscopy.

• Additional small incisions (usually 1-3 depending on the case) are made in the abdomen through which fine instruments are passed. These instruments are used to perform the relevant surgery.

Laparoscopy

INDICATIONS FOR LAPAROSCOPY

Some common conditions which may be diagnosed by laparoscopy include:

• Pelvic pain – There are many possible causes of pelvic pain that can be diagnosed with laparoscopy. These include endometriosis, adhesions (scar tissue), ovarian cysts, uterine fibroids, ectopic pregnancy and pelvic inflammatory disease (PID). However, there are limitations – in 50% of women with a normal ultrasound but suffering pelvic pain, the laparoscopy may not be able to identify an obvious cause.
• Fertility problems – A laparoscopy can determine if there is any abnormal anatomy, endometriosis, blocked fallopian tubes, or some other reason for infertility. A dye may be injected through the neck of the womb via the vagina to see if the fallopian tubes are open. If the tubes are open, the dye will be seen spilling out of the ends.

THERAPEUTIC (OPERATIVE) LAPAROSCOPY

Laparoscopic surgery can be used for various procedures including:

• Sterilisation. In this operation both fallopian tubes are sealed with a clip.
• Ectopic pregnancy. If a fertilised egg becomes embedded outside the uterus, usually in the fallopian tube, an operation can be performed to remove the developing embryo. Usually the affected tube is removed, though sometimes an attempt can be made to remove the pregnancy whilst leaving the tube in place.
• Endometriosis. This is a condition in which tissue resembling the lining of the uterus (endometrium) is found outside the uterus in other parts of the pelvic cavity. This can sometimes cause cysts to form in one or both ovaries. Endometriosis is usually diagnosed with laparoscopy, although a pelvic ultrasound scan can often pick up ovarian cysts caused by endometriosis. The gold-standard for the surgical management of endometriosis is the use of laparoscopic techniques.
• Ovarian cysts. Cysts in the ovaries can be removed using laparoscopy, or the whole ovary can be removed.
• Adhesiolysis. Adhesions (scarring) between organs within the abdomen or pelvis may in some cases be associated with pain and/or subfertility. The adhesions may result from previous surgery, infections, or endometriosis. Cutting these adhesions, known as adhesiolysis, may improve symptoms.
• Biopsy. This involves taking a sample/specimen of various structures inside the abdomen, which can be looked at under the microscope and/or tested in other ways.
• Fibroids. Fibroids in the uterus may be removed using laparoscopy. However, there are many issues to consider and the various risks, benefits and alternatives should be discussed with your gynaecologist.
• Hysterectomy. This procedure to remove the uterus can, in many cases, be performed using minimally invasive or laparoscopic techniques. The hysterectomy is carried out using laparoscopic instruments and then the uterus is removed through the vagina. Only gynaecological surgeons with specialist and advanced training in these techniques should perform laparoscopic hysterectomy.

HOW IS A LAPAROSCOPY PERFORMED?

It is usually done while you are asleep under general anaesthesia. The skin over the tummy (abdomen) is cleaned and covered with sterile drapes. A bladder catheter is usually inserted.

The gynaecologist then makes a small cut (incision) about 1-1.5 cm long in the area of the belly button (umbilicus). Carbon dioxide gas is injected through the cut to slightly expand/distend the abdominal cavity. This makes it easier to see the internal organs and gives more room to work. A laparoscope with a camera attached is then gently pushed through the cut into the abdominal cavity. The gynaecologist looks at high definition video images on a TV monitor.

One or more additional small incisions may be made in the abdominal skin. These allow thin and specially designed instruments to be inserted into the abdominal cavity. The gynaecologist can see the ends of these instruments with the laparoscope and so can perform the required procedure.

When the gynaecologist has finished, the laparoscope and other instruments are removed and the gas is let out of your abdomen. The incisions are stitched with absorbable sutures and local anaesthesia is injected into the skin to reduce postoperative discomfort. Dressings are then applied to cover the incision sites.

HOW LONG DOES IT TAKE?

When laparoscopy is used solely for diagnostic purposes, the procedure usually takes 30-60 minutes, including anaesthetic time.

It will take longer if the surgeon is treating a condition, depending on the type of surgery being carried out.

BENEFITS OF LAPAROSCOPIC SURGERY

In general, compared with traditional ‘open’ surgery (laparotomy), with laparoscopic surgery there is usually:

• less pain following the procedure;
• a shorter hospital stay and a quicker recovery;
• faster return to work and social activities;
• a much smaller (cosmetic) scar.

RISKS OF LAPAROSCOPIC SURGERY

Laparoscopy is a commonly performed procedure and fortunately serious complications are rare.

Minor complications are estimated to occur in one or two out of every 100 cases following laparoscopy. They include:

• wound (incision site) or pelvic infection;
• minor bleeding and bruising around the incision;
• shoulder-tip pain (caused by the gas used to inflate the abdomen);
• feeling sick and vomiting.

Serious complications – the overall risk of a serious complication is about two women in every 1,000 (uncommon):

• damage to bowel, bladder, ureters (tubes connecting the kidneys to the bladder) or major blood vessels which would require immediate repair by laparoscopy or laparotomy (larger incision in the abdomen). However, up to 15% of bowel injuries might not be diagnosed at the time of laparoscopy. Rarely, a blood transfusion may be necessary;
• failure to gain entry to the abdominal cavity and to complete the intended procedure;
• hernia at site of skin entry – called ‘port site herniation’;
• serious allergic reaction to a general anaesthetic;
• complications arising from the use of carbon dioxide during the procedure, such as the gas bubbles entering your veins or arteries;
• a blood clot developing in a vein, usually in one of the legs (deep vein thrombosis or DVT), which can break off and block the blood flow in one of the blood vessels in the lungs (pulmonary embolism);

WHAT CAN I EXPECT AFTER A LAPAROSCOPY?

Please refer to the following patient information leaflets for detailed information in this regard: