LAPAROSCOPY

Diagnostic Laparoscopy
Laparoscopy can help physicians diagnose many gynecological problems including endometriosis, uterine fibroids and other structural abnormalities, ovarian cysts, adhesions (scar tissue), and ectopic pregnancy. Many infertile patients require laparoscopy for a complete evaluation. Generally, the procedure is performed after the basic infertility tests, although the presence of pain, the history of a past infection, or other problems may signal a need to perform diagnostic laparoscopy sooner in the evaluation. The procedure is usually performed soon after menstruation in case a hysteroscopy is also necessary. The uterine cavity is more easily evaluated immediately after menstruation and there is little risk of interrupting a pregnancy.

After the medical history, which consists of questions about the patient's previous illnesses, etc., and physical examination are completed, laparoscopy is usually performed on an outpatient basis, under general anesthesia, and with minimal discomfort. After the patient is under general anesthesia, a needle is inserted through the navel and the abdomen is filled with carbon dioxide gas. The gas pushes the internal organs away from the abdominal wall so that the laparoscopy can be placed safely into the abdominal cavity to avoid injury to surrounding organs such as the bowel, bladder, and blood vessels. The laparoscopy, a long thin, lighted telescope-like instrument, is inserted through an incision in the navel.

While looking through the laparoscopy, the physician can see the reproductive organs including the uterus, fallopian tubes, and ovaries. A small probe is usually inserts through another incision above the pubic region in order to move the pelvic organs into clear view. Additionally, a blue solution is often injected through the cervix, uterus, and fallopian tubes to determine if they are open. If no abnormalities are noted at this time, one or two stitches close the incisions. If defects or abnormalities are discovered, diagnostic laparoscopy can become operative laparoscopy.

Operative Laparoscopy
During operative laparoscopy, many abdominal disorders can be safely treated through the laparoscopy at the same time that the diagnosis is made. When performing operative laparoscopy, the physician inserts additional instruments such as probes, scissors, grasping instruments, biopsy forceps, electrosurgical or laser instruments, and suture materials through two or three incisions in the area above the pubic bone. Lasers, while a significant help in certain surgeries, are expensive and are not necessarily better or more effective than other surgical techniques used during operative laparoscopy.

Some problems that can be corrected with operative laparoscopy include removing adhesions from around the fallopian tubes and ovaries, opening blocked tubes, removing ovarian cysts, and treating an ectopic pregnancy. Endometriosis can also be removed from the outside of the uterus, ovaries, or peritoneum. Under certain circumstances, fibroids on the uterus can also be removed. Operative laparoscopy can also be used to remove diseased ovaries and can assist in the performance of hysterectomy.

Sometimes a second-look laparoscopy may be recommended and is performed following a previous laparoscopy or major abdominal surgery (laparotomy). Second-look laparoscopy may be performed within a few days, weeks, or months following the initial laparoscopy or laparotomy. During a second-look procedure, the physician determines the results of the initial procedure, for example whether adhesions are performing or if endometriosis is returning. If so, these problems can be treated at the time of the second-look laparoscopy.

Risks of Laparoscopy
Serious complications of diagnostic and operative laparoscopy are rare. The major risk is damage to the bowel, bladder, ureters, uterus, major blood vessels, or other organs, which would require emergency surgery to repair. The chance that emergency surgery will be required is two to four per 1,000 procedures. Injuries can occur during the insertion of various instruments through the abdominal wall or during operative treatment. Certain conditions may increase the risk of serious complications. These include previous abdominal surgery, especially bowel surgery, and a history or presence of bowel/pelvic adhesions, severe endometriosis, pelvic infections, obesity, or excessive thinness.

There are other risks associated with laparoscopy, but they are all uncommon. Large hematomas of the abdominal wall can occur near the incisions. Pelvic or abdominal infections may occur as a result of the solution injected to see if the fallopian tubes are open. Allergic reactions, nerve damage, and anesthesia complications rarely occur. Postoperative (after the operation) complications include bladder infection, skin incision infection, urinary retention, or venous thrombosis. When all possible complications are considered, one or two woman out of every 100 may develop a complication, usually of minor consequence. The risk of death during laparoscopy, which is about one to five per 100,000, is less than the risk of death during pregnancy.

Postoperative Care
Following laparoscopy, the navel area is usually tender and the abdomen may be bruised. Gas used to distend the abdomen may cause discomfort in the shoulders and abdomen, and anesthesia can cause nausea and dizziness. The amount of discomfort depends on the type and extent of procedures performed. Normal activities can usually be resumed within a few days.

Significant abdominal pain. worsening nausea and vomiting, a temperature of 101 degrees Fahrenheit or higher, or significant bleeding from an incision requires immediate medical attention.

Considering Operative Laparoscopy Versus Laparotomy of Pelvic Surgery
Many gynecologic, reproductive, or tubal operations have been performed using "major" surgery (laparotomy). Laparotomies are generally performed through a "bikini" or through an "up and down" skin incision. Patients generally remain in the hospital between two and five days following surgery and may return to work in four to six weeks, depending on the level of physical activity required.

More recently many of these surgeries can be performed using the laparoscope (operative laparoscopy). Although the same type of procedure are performed by laparotomy, operative laparoscopy uses much smaller skin incisions, generally three to four, approximately one quarter to one-half inch wide. Following operative laparoscopy, patients are generally able to return home the day of surgery and recover more quickly, returning to full activities in three to seven days.

Notwithstanding the advantages of operative laparoscopy, not all procedure can be performed with this technique. Some types of surgeries may be too risky to perform laparoscopically, while in others it is not clear that laparoscopy yields results as good as those by laparotomy. Finally, the surgeon's training, skill, and experience also play a significant role in deciding whether operative laparoscopy or laparotomy should be used. When considering a pelvic or reproductive operation, the patient and her doctor should discuss the pros and cons of performing a laparotomy verses an operative laparoscopy, including surgical results, the surgeon's training and skill, and the overall risks.

Conclusion
Diagnosing and correcting gynecologic disorders once required major surgery and many days of hospitalization. Laparoscopy and hysteroscopy now allow physicians to diagnose and correct many of these disorders on an outpatient basis. Patient recovery time is normally only two to three days, which is significantly less than the recovery time from major abdominal surgery. The procedures also decrease patient discomfort.