By Dr.Ashadullah Khan
Laparoscopy is a form of minimally invasive surgery. Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, keyhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions. The surgeon inserts a tiny telescope (laparascope) through a small incision at the umbilicus (belly-button). The laparoscope allows the surgeon to visualize the pelvic organs on a video monitor. Several additional smaller incisions are made in the abdomen for the surgeon to place specially designed surgical instruments, which help the surgeon carry out the same procedure as in open surgery.
Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.
How is Lparoscopy Performed?
The key element in laparoscopic surgery is the use of a laparoscope. There are two types: a telescopic rod lens system, that is usually connected to a video camera or a digital laparoscope where the charge-coupled device is placed at the end of the laparoscope, eliminating the rod lens system. After the general anesthesia is given, a small incision is usually made below or inside the umbilicus (belly-button). Carbon dioxide gas is then put into the abdomen by inserting a special needle through the umbilicus. The gas allows the pelvic organs to be seen more clearly. Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking). Rather than a minimum 20cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0cm will be sufficient to perform a laparoscopic removal of a gallbladder. After an adequate volume of gas is insufflated into the abdominal cavity, the surgeon removes the needle and inserts a trocar. A trocar is a specially designed tube, 5 or 10 mm in diameter, with a valve through which a surgeon can insert special instruments. The patient’s body will be tilted slightly with the feet raised higher than the head. This shifts some of the abdominal organs into the upper abdomen and out of the way. The laparoscope is placed through the trocar sleeve in the umbilicus. Additional incisions are made just at the pubic hairline and in the left and right lower abdomen. Using special surgical instruments the procedure is completed through these small incisions. A device called a uterine manipulator may be placed in the uterus through the vagina to move the uterus during the procedure. Following the procedure the instruments are removed and the gas is released. The incisions are then closed with steri-strips or with stitches that dissolve.
ADVANTAGES OF LAPROSCOPY
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:
1. Reduced bleeding , which reduces the chance of needing a blood transfusion.
2. Smaller incision, which reduces pain and shortens recovery time.
3. Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
4. Less pain, leading to less pain medication needed.
5. Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
RISK OF LAPROSCOPIC SURGERY
The risks are similar for both laparoscopic and open surgery. First and foremost, there is always the possibility that surgeon may not be able to complete the procedure laparoscopically. This may be secondary to unexpected complications or because the surgery cannot be safely performed with a laparoscopic approach. Complications specific to laparoscopy include injury to the bowel, bladder and blood vessels at the time of insertion of the surgical instruments and hernia formation at an incision site. Other complications not specific to laparoscopy include infection, bleeding and deep vein thrombosis (blood clot in the legs). Death is also a potential but Rare complication of any type of surgery.
The most significant risks are from trocar injuries to either blood vessels or small or large bowel. The risk of such injuries is increased in patients who are obese or have a history of prior abdominal surgery. The initial trocar is typically inserted blindly. While these injuries are rare, significant complications can occur. Vascular injuries can result in hemorrhage that may be life threatening. Injuries to the bowel can cause a delayed peritonitis.
What can anyone expect immediately following laparoscopic surgery?
Generally, the experience are any of the following symptoms within the first twenty-four to forty-eight hours
1. Nausea and lightheadedness
2. Scratchy throat if a breathing tube was used during the general anesthesia
3. Pain around the incisions
4. Abdominal pain or uterine cramping
5. Shoulder tip pain-secondary to the carbon dioxide gas
6. Tender umbilicus (belly-button)
7. Gassy or bloated feeling
8. Vaginal bleeding or discharge (like a menstrual flow)
What is the normal recovery time following laparoscopic surgery?
Recovery depends on the type of procedure performed. Most patients feel well within days of surgery. But if major surgery has been performed rest is still required. Most patients will require some form of pain medicine in the immediate postoperative period. A prescription for a narcotic as well as an anti-inflammatory, will be provided prior to discharge. Avoidance of heavy lifting (greater then 10 pounds), jumping and jogging is recommended until 4 weeks postoperatively. Sexual intercourse should also be postponed for 4 weeks. It is preferable not to put anything into the vagina for at least 4 weeks including tampons. The timing for returning to work depends on the procedure performed. Most patients who undergo an ovarian cystectomy or ectopic pregnancy are ready to return to work within 2 weeks. If a hysterectomy is performed, 4 to 6 weeks off work is recommended. The doctor will discuss this with you after surgery and help you make an informed choice.
COMPLICATIONS
1. Wound infection
2. Bruising
3. Hematoma formation
4. Anesthesia-related complications
5. Injury to blood vessels of the abdominal wall or those of the lower abdomen and pelvic sidewall. Injury to the urinary trac or the bowel
Is it possible to perform other surgery at the time of laparoscopy?
Yes. Occasionally two procedures are scheduled at the same time. Hysteroscopy is frequently performed at the same time as laparoscopy. Women may also elect to have another elective surgery performed in combination with their gynecologic procedure. Surgeries that have been performed concurrently have included liposuction, gallbladder removal and breast implants.
Can endometriosis be treated laparoscopically?
Yes. A laparoscopic biopsy is required to diagnose endometriosis. Endometriotic implants can also be treated laparoscopically with excision or burning. This treatment usually produces more immediate results in terms of pain relief and fertility compared to medical therapy.
How is endometriosis treated?
Endometriosis can be treated with medications, surgical excision, or combination of the two methods. You should discuss the treatment options with your gynecologist.
What is the treatment for ovarian cyst?
A cyst is a fluid filled cavity. Cysts can often be found in the ovaries. Ovarian cysts are usually diagnosed by pelvic exam or ultrasound. If the cyst is entirely filled with fluid it is called a “simple cyst”. Ovarian follicles as they undergo maturation may appear on ultrasound as simple cysts or occasionally as complex cysts. These cysts usually resolve within one to two months. Simple cysts are almost always benign. Removal is indicated if they are bigger than 5-6 cm in diameter or if they cause symptoms. If the cyst contains echogenic structures (shadows by ultrasound) it is categorized as a “complex cyst”. Complex cysts can represent endometriosis, infection, benign tumors, and rarely malignancies. It is generally recommended that complex cysts be evaluated laparoscopically and possibly removed. The majority of ovarian cysts can be removed laparoscopically.
What are fibroids?
Fibroids are benign growths of the uterus. They occur in 20 to 25 percent of women. Fibroids are most common in women aged 30 to 40 but may occur at any age. Women may have one fibroid or many fibroids. The size of the fibroid also varies from the size of a small pee to more then 6 inches wide.. Some women may be entirely asymptomatic and others may complain of changes in menstruation, pain, pressure, miscarriages and infertility.
Can I have fibroids removed laparoscopically rather then having a hysterectomy?
Yes. Some women may have their fibroids (benign growths on the uterus) excised laparoscopically. This procedure is limited to fibroids that are on the outside of the uterus (Pedunculated) or just under the uterine wall (subserosal). Fibroids that are buried deep in the uterus cannot be removed with this approach. The fibroids are then morcellated (ground) and removed through the small incisions. Occasionally, with resection of a fibroid, the uterine cavity may be entered and suturing is required. This usually can be performed using special laparoscopic instruments but infrequently a small (”mini”) pfannensteil (”bikini”) incision is made to repair the uterus. Rarely a hysterectomy must be performed because of heavy bleeding or inability to reconstruct the uterus. Sometimes a drug (GnRH agonist) may be used to shrink the fibroid and control bleeding prior to surgery.
Can fibroids removed if they are located inside the uterus (submucosal)?
It can be removed by hysteroscopy if it is inside of the uterus. By laparoscopy they cannot be approached laparoscopically. Rather, your physician may recommend a hysteroscopic approach.
Can uterus be removed laparoscopically?
In most cases the uterus can be safely removed laparoscopically. This is not an option when the uterus is very large (greater then 18 week pregnancy in size). Recovery after laparoscopic hysterectomy is usually quicker than after abdominal hysterectomy. To help you choose the most suitable and safe surgery the doctor will consider all these factors prior to proceeding with a laparoscopic hysterectomy.
Does cervix have to be removed at the time of hysterectomy?
It is not necessary, some women elect to have a subtotal hysterectomy. This simply means that the fundus of the uterus is removed and the cervix is maintained. The uterus is removed with the help of a morcelator . This instrument allows the surgeon to remove large uteri through small incisions. Not all women are candidates for a subtotal hysterectomy. A previous history of abnormal pap smears would be a contraindication to this approach. To help you choose the most suitable and safe procedure the doctor will consider all these factors prior to proceeding with a subtotal hysterectomy. All women who undergo a subtotal hysterectomy must still have pap smears performed yearly.
Why subtotal hysterectomy is rather then a total hysterectomy?
This procedure is often faster, associated with fewer surgical complications and more rapid return to normal activities. There is also some evidence to suggest that there is less disruption of the pelvic floor and, therefore, less pelvic prolapse requiring additional surgery in the future. The cervix may also play a role in female orgasm. Many women request a subtotal hysterectomy in order to retain their cervix for sexual function. It is important to realize, however, that just as many women who have had a total hysterectomy have very normal sexual function.
What are the other alternatives to hysterectomy?
Depending upon symptoms, there are several different alternatives to hysterectomy. Majority of hysterectomies are performed either due to abnormal bleeding or fibroids. If you have irregular bleeding and your uterus is not too big, endometrial ablation can be viable option to hysterectomy. If there are fibroids, a myomectomy may be viable treatment for you. If you have large uterine fibroid, uterine artery embolization may be an alternative to hysterectomy.
What self-care is necessary after returning home?
Leave the adhesive bandage or dressing on the incision for five days. During that period, keep the incision area dry. Avoid lifting heavy weights.
How long will it take for full recovery?
The following is a normal timetable for recovery from minimally invasive surgery on the abdomen
•The groggy feeling from the anesthetic disappears the day after surgery and the individual is fully alert once again.
•Any pain in the shoulders or neck area usually goes away after a few days.
•Soreness in the incisions disappears within a few days and the incisions heal after about five days.
•The bloated feeling after abdominal or pelvic laparoscopy goes away within a few days.
How much time it takes to return to work?
Depending on the procedure most people feel well enough to return to work or normal daily activities two to three days after laparoscopy, although some people may need a week of rest.