Laparoscopy essentially means the visualization of the abdominal organs through a scope.
Laparoscope is a tubular instrument introduced into the abdomen through a 1cm opening near the umbilicus. A CCD camera is attached to the outer end of the laparoscope.
The uterus, ovary and the rest of the pelvic and abdominal organs can be visualized through the scope and viewed on a television monitor. Instruments passed through two tiny 5mm holes lower down in the abdomen can rectify any defects in the visualized organs.
Laparoscopy is usually done under General anaesthesia. The patient’s basic blood investigations are done and she is given a laxative the previous night. The patient has to be nil by mouth on the day of the procedure.
After the procedure she is kept in the recovery room for about 3-4 hours and then taken to her room.
Usually the patient is discharged on the next day.
The advent of laparoscopy has changed the practise of gynaecology quite a lot. Laparoscopy was started in India in the 80’s as a diagnostic tool. Gradually in the 90’s operative laparoscopy came into vogue and many surgical procedures which were done by opening the abdomen through a wound in the abdomen under direct vision could now be done through small holes in the abdomen with the help of the laparoscope. Laparoscopic surgery is also called key-hole surgery.
Role of laparoscopy in gynaecology
Laparoscopy is used to diagnose many conditions in gynaecology. Since operative laparoscopy is combined with diagnostic laparoscopy, the disease can quite often be cured at the same time as the diagnosis is made. Some of the conditions where laparoscopy as a diagnostic-cum operative tool is used are infertility, chronic pelvic pain, and endometriosis.
Infertility: When a couple fails to concieve after 6 months of unprotected intercourse, the couple could be said to be suffering from infertility or, inability to concieve. In some patients, after correction of other factors causing infertility have been corrected, the couple still fail to concieve, laparoscopy may be done to see if some other factors causing infertility are there . Some of the procedures done through the laparoscope in the infertile woman are:
Diagnosis of tubal block: If a woman fails to conceive inspite of medical treatment, it may be prudent to check and see if the fallopian tubes are patent. This can be achieved by injecting fluid into the uterus through a cannula introduced through the vagina. The fluid traverses the uterus , the fallopian tubes and then comes into the abdomen through the opening of the tubes called the fimbrial end. The fimbrial ends are visualized on the laparoscopy monitor . Any blocks near the fimbrial end or any adhesions near any part of the tube can be removed through laparoscopic instruments. If there is a block near the uterine end of the tube it can be rectified through another procedure called hysteroscopic cannulation which could be done at the same sitting.
Endometriosis: In some women, there may be severe abdominal cramps near the time of menstrual periods. This could be due to a disease called endometriosis. On examination of the vagina, the doctor may find some nodularities in the vagina. Endometriosis could cause infertility in many ways and the best way to correct it is through the laparoscope. Laparoscopic correction of endometriosis yields very high pregnancy rates.
Adhesive bands: Adhesions between the uterus and ovaries could cause infertility and these could be corrected through the laparoscope.
Correction of polycystic ovaries: In women who fail to ovulate because of a condition called polycystic ovarian syndrome, if oral medications fail to achieve ovulation, laparoscopic drilling of the ovaries may be done. In polycystic ovaries, the ovaries are fully of tiny follicles with fluid in it. A few of these fluid filled follicles are punctured using an instrument introduced through the laparoscope. This causes reduced levels of hormones called androgens and subsequently there is restoration of normal ovulation. A punctured ovary can be seen in the picture below.
Continous low grade pain is a very common condition found in middleaged women. Quite often it is due to some low grade infection which can be cured when treated meticulously. In some cases of chronic pelvic pain(Defined as persistent pain of more than 6 months duration), laparoscopy may be useful in evaluating and curing the disease.
How laparoscopy can be useful:
1. Sometimes pelvic infection leaves scars around the uterus and ovaries leading to pain. Release of painful adhesions through the laparoscope could give relief.The picture shows the ovary being stuck to the patient’s abdominal wall . This was causing severe abdominal pain. The cause could not be diagnosed either by examining the patient or by doing an ultrasonography. Diagnosis of the cause, along with release of adhesions cured the patient.
2. Severe pain during periods not cured with medicines could be treated by a procedure called uterosacral nerve vaporization.
3. In patients with a disease called endometriosis , laparoscopy helps in diagnosing the condition .Resection of endometriosis from all surfaces, specially the rectovaginal septal space could give relief. Endometriosis could cause severe pain during periods, pain during intercourse, crampy pain after passing stools, etc.
4. Sometimes pelvic pain is due to dilated veins near the uterus. .In the picture, the blue colour seen in the picture is due to dilated veins. These veins extend to the side of the ovary and sometimes may go up to the upper abdomen. This is called pelvic venous congestion. Proper diagnosis can be made only from laparoscopy. The other definintive mode of diagnosis of this condition, viz;venography is not done for this condition routinely in India.
After diagnosis proper medications could be given for cure. If not properly diagnosed, many a time the woman may be subjected to hysterectomy and this would not cure the disease and the woman would end up undergoing a major surgery without getting cure for her illness.
5. Sometimes no abnormality is found on doing a laparoscopy and in these instances the patients are ready to accept the pain or control it with simple analgesics as they have the happy knowledge that nothing serious is wrong with them.
6. In some patients who have undergone major surgery like LSCS or hysterectomy the intestines may be adherent to the abdominal structures and may cause colicky pain when food passes through the adherent segment. The pain is severe a few hours after eating food . it decreases on its own in the initial phases, but persists when the condition becomes severe. In these cases, laparoscopic adhesiolysis may give relief from pain. Intestines attached to the abdomen can be seen in the picture in one such patient. Release of this intestine is being done using laparoscopic scissors.
What it involves for the Patient:
Usually the patient is admitted the previous day, and an extensive bowel enema given . She is asked to be on oral fluids from the previous day. In case of minor adhesiolysis, she is allowed to go home the next day. But if extensive intestinal adhesions , the patient is observed for 4-5 days to make sure the intestines are working properly. Before surgery these patients are also warned about the possibility of intestinal injury which might lead to opening of the abdomen for bowel repair.
Laparoscopic surgeries in gynaecology
Many of the surgeries done in the gynaecological patient are now done through laparoscopic guidance.
1. The cut or incision made on the abdomen being very small, there is less pain in the post-operative period.
2. Since the cut made in the layers of the abdomen is small, it causes less impairment to the strength of the abdominal wall. Thus the patient can start performing routine duties like lifting heavy weights much earlier.
3.Hospital stay is just for a couple of days or more, depending on the procedure, after laparoscopic surgery compared to open surgery.
4. The view offered through the laparoscope is very good and it is possible to do more meticulous surgery with the assistance of the laparoscope. Organs are seen as magnified images and thus minute changes in organs can be visualised and remedied with more accuracy.
1.Laparoscopic surgery involves a steep learning curve for the surgeon and not all gynaecologists can do good laparoscopic surgery. Thus the patient cannot know how much to expect from her gynaecologist.
2.Laparoscopic surgery involves the use of many electrical accessories like the light source, the camera, the cautery, etc and thus surgery could be delayed or interrupted when any of these equipments become defective.
3.Laparoscopy offers a two dimensional view instead of the three dimensional view offered by the open surgery. Thus in case of dire operative emergerncies, like the bleeding of a vessel, laparoscopic surgery may have to be converted to open surgery to do a quick job.
4.Not all centres offer laparoscopic surgery.
Use of laparoscopy in surgeries in gynaecology:
Many surgeries done in the past by open surgery are now done with the help of the laparoscope leading to earlier patient recovery. Some of them are listed below:
Permenant sterilisation of the female can be done by applying silastic bands on the tubes. It takes just 10 minutes to perform. It can be done under local or general anaesthesia.
Sometimes, pregnancy, instead of lodging in the uterus gets lodged in the tubes or other places besides the uterus. If it grows there, it could endanger the life of the patient. Some of these pregnancies need surgical intervention, where the tubes are either removed along with the pregnancy (Salpingectomy) or cut to remove the pregnancy alone, leaving the tube behind(Salpingostomy). If the patient comes in severe shock, laparoscopy may not be possible. In all other patients, laparoscopic surgery is superior to laparotomy for the treatment of ectopic pregnancy.
Fibroids are non-cancerous growths in the uterus. They occur in many women without causing any symptoms. however, they cause symptoms in some patients and will need to be removed. This is called myomectomy and this can be done with the help of the laparoscope. However, the selection of cases which can be done laparoscopically depends on many factors, like the number of tumours, the size of fibroids, the experience of the laparoscopic surgeon and the equipment available in the hospital. Myomectomy causes a lot of bleeding during the surgery and the uterus needs to be stitched back after removing the fibroid. If suturing is not done properly after myomectomy, the uterus might burst at the time of childbearing and this could be disasterous. All this requies a lot of surgical skill and thus laparoscopic myomectomy is done only by experienced laparoscopic surgeons.Picture below shows laparoscopic myomectomy in progress. The white structure in the centre is the fibroid.
If there are many fibroids, specially deep seated one, it may not be possible to see all of them properly through the laparoscope and unless the surgeon is very sure of removing all of them laparoscopiclly, it is better to do open surgery for multiple fibroids.
The white structures beside the uterus, called ovaries may develop cystic or solid tumours in them. Cystic tumours contain fluid components and depending on the type of cyst it may be clear, amber cooured fluid or old blood in endometrioma. These cysts can be easily removed through the laparoscope. Any adhesions between the ovaries and the surrounding structures can be removed more meticulously through the view offered with the help of the laparoscope.
Removal of uterus/Hysterectomy:
The removal of uterus or hysterectomy is a common operation performed in the female nearing or following her menopause. This can be done with the help of the laparoscope with very little convalescence needed, compared to open surgery. Here, again, the selection of case suitable for laparoscopy depends on the skill of the surgeons. Less experienced surgeons may be unwilling to take up difficult cases, like patients with previous history of caesarian section or some other open surgery, or patients with very big tumours.
Laparoscopy is the only diagnostic modality to diagnose some cases in gynaecology. As an operative tool it almost replacing open surgery and as more and more patients demand laparoscopy as the mode of surgery, there will be more training centres teaching laparoscopy with many more laparoscopic surgeons.