Laparoscopic Surgery in Gynaecology
Generally, there are two ways of performing gynaecological surgery: laparotomy and laparoscopy. Laparotomy is also the conventional open surgery, where an incision of several inches long is required. Two of the most common incisions for laparotomy in gynaecology are the lower midline incision, a vertical incision below the umbilicus, and the Pfannenstiel incision, a transverse incision just above the pubis.
The laparoscopy, on the other hand, is performed through several small "keyhole" incisions in the abdomen, where instruments like a laparoscope (a thin telescope-like instrument), scissors and graspers are inserted.
Figure 1: Four keyhole
incisions in laparoscopy
where trocars of diameter
10mm and 5mm are inserted.
When is laparoscopy needed?
Laparoscopy is performed either for diagnostic or operative purposes. Diagnostic laparoscopy is a procedure that allows the doctor to directly view the pelvic organs to investigate pelvic pain, infertility, suspected ectopic pregnancy, endometriosis, etc. Usually it is recommended when the cause or symptom of a disease cannot be confirmed via other diagnostic tests, such as ordinary questioning, physical examination, ultrasound and radiological (X-ray) examinations . Operative laparoscopy allows doctor to perform gynaecological surgeries at a minimally-invasive manner.
Preparing for a Laparoscopy Surgery
Patient needs to be fasted for at least 6 hours before the surgery. In some surgeries, patient may be given medication to empty the bowel.
How is Laparoscopic Surgery Performed?
Laparoscopic surgery is performed under general anaesthesia. Prior to the laparoscopy, a Foley catheter may be inserted into the bladder to drain the urine during the surgery (see Figure 2). A 10 mm incision is made at the umbilicus and a Veress needle is inserted into the abdomen. The Veress
Figure 2: A Foley catheter is inserted to empty the bladder prior to the surgery.
needle is then connected to a CO2 insufflation tubing. Gas is passed into the abdominal cavity to distend the abdomen, so as to allow the doctor to see the pelvic organs and to perform the surgery more easily. A 10 mm trocar is placed at the umbilicus, followed by several 5 mm trocars, which are placed at the lower abdomen.
A laparoscope attached to a video camera is passed through the 10 mm port. Video images captured by the video camera are displayed on a video monitor. A powerful light source is channeled into the abdominal cavity for illumination purpose. Instruments like laparoscopic scissors, graspers are also inserted through other 5mm ports to perform the surgery (see Figure 3). At the end of the surgery, all the instruments are removed and the CO2 gas is released. The incisions are either sutured or taped. In some patients, a drainage tube is left in the pelvis to drain out any fluid that may accumulate after the surgery.
Figure 3: The laparoscopic surgery.
Advantages of Laparoscopic Surgery
- Less postoperative pain. In laparotomy, a large incision is usually made and the layers of the abdomen are separated in order to access the abdominal and pelvic organs. These layers are then sutured one by one on closure of the abdomen. On the contrary, only small punctures (keyholes) are made in laparoscopy. Thus, postoperative pain as a result of the wound healing is more severe in laparotomy than in laparoscopy.
- Quicker return of bowel function. Due to the fact that bowel is manipulated less in laparoscopy, the return of bowel function is faster in laparoscopy than in laparotomy.
- Quicker return to solid food.
- Quicker return to daily activities.
- Reduced chance of scar formation in the abdomen. In laparoscopy only fine instruments are used to perform the surgery whereas in laparotomy, the surgeon places his hands into the abdomen and pelvis to perform the surgery. Therefore, laparotomy has a higher likelihood of developing adhesions (scar tissue in the abdomen) than laparoscopy. This is especially important for patients who want to conceive because adhesions in the area of fallopian tubes and ovaries may lead to difficulty in conceiving.
- Reduced infection rate because of the small incisions and hence the internal organs are not exposed to the air in the operating room.
- Reduced bleeding during surgery.
- Shorter hospital stay.
- Smaller scars on the skin.
- Video magnification offers surgeon a better view of diseased organs and its surrounding vessels and nerves.
Patient is allowed to drink some clear fluids after surgery. Once she has passed flatus, she is allowed to consume other drinks and later solid food. The drainage tube in patient's bladder may be removed immediately after the surgery or several days later, depending on the type of surgery. For minor laparoscopic surgery, patient may resume normal activities and sexual intercourse within a few days. In major laparoscopic procedures, light physical activities can be performed in about one week. Sexual intercourse may only be possible after about six to eight weeks.
Possible Postoperative Effects of Laparoscopic Surgery
- Aching of muscles.
- Discomfort and tiredness for up to five days.
- Increased urge to urinate because the CO2 insufflated during the surgery can apply pressure on the bladder.
- Pain at the incision sites. Medication is usually prescribed to alleviate it.
- Period-like pain and a few days of vaginal bleeding or discharge.
- Shoulder pain for a few days because the CO2 insufflated can irritate the diaphragm, which shares the same nerves (predominantly the phrenic nerve) as the shoulder.
Risks of Laparoscopic Surgery
- Anaesthetic problems such as pneumonia.
- Bleeding caused by accidental injury to blood vessels or organs.
- Blood clot in the veins of the leg (deep vein thrombosis) or in the lung (pulmonary embolus).
- Incisional hernia.
- Infections of the incision sites or in the pelvis or abdomen.
- Leakage of body fluids due to accidental injury to bowel, bladder, ureter.
If the injuries are detected during the surgery, emergency surgery is necessary to repair the damaged sites. This is usually done laparoscopically but sometimes a laparotomy may be needed. Otherwise, if the injuries are not detected immediately and are only discovered during the recovery period, a second surgery may be required. Certain patients may require blood transfusion during or after the surgery.
Suitable Candidate for Laparoscopic Surgery
Patients with the following conditions may not be suitable to undergo laparoscopic surgery:
- History of bleeding. Laparoscopic surgery may not be suitable for patients who suffer from bleeding disorders, as it may increase their risk of profuse bleeding during the surgery.
- History of laparotomy. Patients who previously had a laparotomy may not be suitable for laparoscopic surgery because laparotomy can lead to scarring which may cause the pelvic and abdominal organs to adhere to the abdominal wall. Separation of these scar tissues may lead to complications. However, an experienced surgeon can still perform laparoscopic surgery on patients with such condition.
- Pregnancy. Due to the enlarged uterus, inadvertent uterine injuries from trocar placement may occur. The other possible problem is that, due to CO2 insufflation, acid-base imbalance from CO2 absorption may lead to hypercarbia (excessive carbon dioxide in the bloodstream), which may compromise the fetus. However, with adequate precautions, laparoscopic surgery can still be performed on pregnant women especially during the early stages of pregnancy.
All in all, a doctor's own skills and experience are crucial in determining whether he can perform the surgery laparoscopically. Doctors who have only received basic laparoscopy training, could not perform more advanced and complicated laparoscopic surgeries.
Lastly, the above information merely serves as guidelines. It is always best to consult your doctor to find out if you are a candidate for laparoscopic surgery.