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What
is laparoscopy?
Laparoscopy is a minimal access surgical procedure, which
uses a fine telescopic instrument to inspect the inside
of the abdomen and pelvis. Images are viewed on television
monitors in the operating theatre via a high quality miniature
camera. Laparoscopy is particularly useful in the investigation
of many gynaecological conditions, and is the only way
to confirm the diagnosis of endometriosis. Laparoscopy
also enables the surgeon to perform many operations using
fine instruments, which are inserted into the tummy through
small tubes or trocars.
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Laser Laparoscopy for Endometriosis
The use of lasers for the treatment of endometriosis was
pioneered by Professor Chris Sutton in Guildford, who
performed the first laser laparoscopy at St. Luke’s
Hospital in 1982. The development of laser laparoscopy
has revolutionised surgery for endometriosis, allowing
more accurate and targeted treatments to be delivered,
while avoiding the side-effects of a traditional open
operations with longer recovery times. Evidence from randomized
controlled trials performed in Guildford have shown that
this technique is a very effective treatment for this
disabling condition, and large series of cases have demonstrated
that when performed by surgeons trained and experienced
in this technique it offers a very good safety record.
I was fortunate to be trained by Professor Sutton in laser
laparoscopy, and I have also worked with a number of experts
in this field from the UK and from across Europe. I have
been performing complex laparoscopic surgery independently
since 1994.
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What Are the Advantages of Laparoscopic Surgery
Compared With Traditional Surgery?
Many gynaecological operations may be performed by laparoscopy,
or with laparoscopic assistance. The principal advantages
are:
· Greatly
reduced time required to return to normal activities and
work
· Earlier
mobilisation reduces the risk of serious complications
such as deep vein thrombosis, pulmonary embolism and wound
infection
· Reduced
discomfort and need for strong pain killers post-operatively
· Reduced
blood loss and likely need for blood transfusion
· Reduced
scarring and good cosmetic results
· Reduced
likelihood of adhesions developing after treatment
· Improved
vision with magnification enables more accurate surgical
treatment
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Technical Details of Laparoscopy
Laparoscopic surgery requires a general anaesthetic. Once
you are asleep the bladder is emptied with a catheter
and the abdomen is distended using inert carbon dioxide
gas (CO2) to create a space within which to operate. The
CO2 gas is usually inserted through a small needle through
the umbilicus before introduction of the trocar which
carries the telescope. This is an essentially blind procedure
and therefore carries a very small risk of injuring the
bowel or blood vessels. Suitable safety procedures are
routinely taken to minimize this risk. If you have had
abdominal surgery before, sometimes it is safer to insert
the gas through a point high on the left side of the abdomen
where adhesions are very uncommon, or alternatively the
telescope may be inserted directly through an open incision
in the umbilicus (open laparoscopy). Once the whole abdomen
has been inspected, the operating table is tilted head
down to help prevent the intestines from obscuring the
view of the pelvis. Further secondary trocars or ports
are introduced under visual control to enable fine surgical
instruments to be introduced. These are usually inserted
either just below the pubic hair line in the midline or
either side in the flank. Energy sources such as the CO2
or KTP laser may be introduced down these ports to treat
areas of endometriosis, or alternatively electrical diathermy
or the Ultracision® harmonic scalpel. This uses ultra-high
frequency sound waves transmitted via a specially designed
pair of curved scissor-tips and may be used to dissect,
desiccate, coagulate and cut tissues. The particular choice
of instruments and energy sources used depend on the individual
operative findings and procedure undertaken.
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Possible Complications of Surgery
Laparoscopic surgery enables much faster mobilization
following major procedures, and thus reduces the risk
of very serious complications such as deep vein thrombosis
and pulmonary embolism, and common post-operative problems
such as wound infection are also less likely. However,
untoward complications may occur following any invasive
medical or surgical procedure. The risk of complications
from surgery increases as the complexity of the surgery
increases, and this is true for laparoscopic surgery as
well as traditional open surgery.
The specific serious complications, which may occur following
laparoscopy, include perforation of the bowel, the bladder
or a large blood vessel, as outlined above. Any of these
unexpected events would require conversion to a more extensive
traditional operation, which is called a laparotomy. Fortunately
such events are extremely rare, with a reported frequency
of between 0.1% for diagnostic laparoscopies and 0.9%
for very complex laparoscopic operations. These rates
are comparable to the risks of damage to other organs
when performing traditional open surgery. When a serious
complication such as these occur it is most important
to recognise it promptly and deal with it appropriately
and without delay.
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Laparoscopic Surgery for Ovarian
Cysts and Masses
Laparoscopy is an extremely sensitive way of assessing
the nature of ovarian and tubal disease, and a test using
blue dye may be performed to ensure that the tubes are
patent. Almost all benign ovarian cysts including dermoid
cysts and endometriomas are suitable for laparoscopic
surgery. Specific blood tests and ultrasound scans are
very helpful in determining which ovarian cysts are suitable
for laparoscopic surgery, but sometimes for complex ovarian
masses an initial laparoscopic assessment is required
before deciding which the most suitable form of operation
is. If a mass involves the whole ovary then it may be
necessary to remove the entire ovary, while if there is
concern that the mass is cancerous, then an open laparotomy
may be indicated. If there are any such concerns these
possibilities will be fully discussed with you prior to
your laparoscopy. As an accredited gynaecological cancer
specialist, I am very experienced in recognising cysts
which are suspicious of malignancy and am fully trained
in the appropriate surgery should this prove necessary.
If large pieces of tissue need to be removed e.g. a large
ovarian cyst capsule or a fibroid, the incision just below
the pubic hair line may need to be extended by a few centimetres.
All such tissues are routinely removed using specially
designed endoscopic retrieval bags to prevent contamination
of the skin wounds, fluid is used to irrigate and wash
the inside surface of the abdomen, and the small skin
incisions are also irrigated with antiseptic solution.
All specimens that are removed are sent for detailed pathological
examination by a specialist gynaecological pathologist.
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Fibroids and Laparoscopic Myomectomy
Fibroids may either be removed individually and preserving
the uterus, which is called a myomectomy, or by removal
of the uterus, i.e. hysterectomy. Traditional open myomectomy
was quite an unpleasant operation to undergo, with significant
blood loss, considerable post-operative discomfort, and
the risk of subsequent adhesion formation which could
affect fertility. Advances in laparoscopic surgery, including
use of the Ultracision® harmonic scalpel, and in selected
cases pre-operative uterine artery embolization, have
revolutionised this procedure. Laparoscopic myomectomy
may still be technically quite difficult, and hence only
experienced laparoscopic surgeons tend to perform this
operation. Sometimes suturing of the uterus is required
to repair the defect after excision of the fibroid. Fibroids
are often best removed using a laparoscopic tissue morcellator
which uses a small rotating device to peel the fibroid
into long strips, rather like coring an apple. This allows
large fibroids to be removed via an only a15mm incision.
Occasionally for very large fibroids an open incision
is still required. Fortunately, largely thanks to technical
advances learned from laparoscopy such as Ultracision®
and new electrical diathermy equipment, methods of open
surgery have also improved enormously in recent years,
making recovery from such operations more tolerable for
the patient.
If one is planning a pregnancy following myomectomy, it
is important to discuss this with your obstetrician or
midwife, since the muscle wall of the uterus will be a
little weakened by the scar on the uterus, and precautions
should be taken in labour.
Small fibroids which impinge on the cavity of the uterus
are best treated by resection through the cervix using
an operating hysteroscope or ‘resectoscope’.
This allows the surgeon to remove strips of the fibroid
under direct vision, and restore the cavity of the uterus
to near normal. Please refer to my patient information
on hysteroscopy for more details.
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Hysterectomy
For women for whom fertility is no longer an issue, hysterectomy
is the final solution for uterine fibroids or endometriosis.
In experienced hands, even quite a large fibroid uterus
may be removed trans-vaginally without need for an abdominal
incision. Often this is performed with laparoscopic assistance,
which may also be used to treat any accompanying endometriosis
or ovarian cysts. Sometimes drugs such as Zoladex®
or similar preparations may be used to shrink the fibroids
prior to surgery to help enable this. For uterine fibroids
it is not always necessary, or desired by the patient
to remove the cervix. It is often possible to preserve
the cervix by performing a subtotal hysterectomy. This
may be performed laparoscopically for small to medium
sized fibroids. As the cervix is preserved it is important
to continue to have cervical smears, and some women continue
to menstruate, albeit usually in the form of a pink or
brown discharge for a few days each month. For very large
fibroids a traditional abdominal incision is required,
although the use of epidurals and modern anti-inflammatory
and analgesic drugs has transformed post-operative pain
relief for the first few days after surgery. Uterine artery
embolization is a valid alternative to surgery for large
fibroids, and more information may be obtained on this
from my colleague Dr. W. Walker, Consultant Radiologist,
who has the largest experience of this procedure in the
UK.
If hysterectomy is being performed for endometriosis,
it is important to remove or treat any deposits of endometriosis
outside of the uterus at the time of the operation. Laparoscopy
makes visualisation of these deposits easy, and laparoscopic
assistance is therefore often very helpful when performing
hysterectomy for endometriosis. The surface of the ovaries
is the commonest site for deposits of endometriosis, and
hence it we usually advise that both tubes and ovaries
are removed at the time of hysterectomy to reduce the
risk of further exacerbations of the disease. Deposits
also commonly lie on the side-walls of the pelvis or in
the connective tissue between the rectum and the vagina,
which often cause deep pain during intercourse or on bowel
movement. It is therefore important to remove any such
deposits at the time of hysterectomy to ensure a good
result. These additional precautions do make the surgery
more complex, however, and potentially more hazardous.
My experience and training in radical surgery for pelvic
cancers is therefore invaluable when treating severe pelvic
endometriosis.
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Adenomyosis
Adenomyosis is a variant of endometriosis where deposits
of endometrium are present deep within the muscle layer
of the uterus. This is a potent cause of period pain and
pain with intercourse. The uterus has a characteristic
dusky red slightly blotchy appearance when viewed on laparoscopy
which may otherwise be overlooked by the untrained eye
when investigating women with pelvic pain. Similar appearances
may also be seen on hysteroscopy i.e. a telescope examination
of the uterine cavity. Adenomyosis may be helped by hormonal
manipulation, like endometriosis, or may be treated surgically
by transcervical resection of the endometrium. Often,
however, adenomyosis is best treated by hysterectomy.
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Admission to Hospital
You will be admitted usually an hour or more prior to
your scheduled operation time to enable the nursing staff
to welcome you to the ward and to prepare you for surgery.
The nurse who admits you will ask a number of questions
about your general health and personal details, and she
will be very happy to answer any last minute questions
that you may have. If in doubt, please have no hesitation
in asking Mr Butler-Manuel or the anaesthetist.
Most operations may either be performed as a day-case
procedure or otherwise as an overnight stay in hospital.
This is particularly sensible if you have travelled some
distance for your operation. For more extensive procedures
such as hysterectomy you may wish to stay in for a further
day or two before returning home. For more major procedures
you may be asked to attend a pre-assessment clinic organised
by the ward nursing staff.
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Wounds and Dressings
Up to two litres of fluid may be deliberately left inside
the abdomen to minimize the risk of subsequently developing
adhesions following surgery. Some of this fluid may leak
through the small dressings when you return from theatre
and is quite normal. The majority of the fluid is absorbed
over the next five days. Rarely swelling of the vulval
skin may occur which can be uncomfortable. Local anaesthetic
is used to minimise discomfort from the wounds on your
return from theatre. Larger incisions may require sutures,
but most wounds only require small adhesive paper dressings
to close the skin. These should be left in place for a
few days until they start to fall off on their own accord.
No further dressings should be required, unless the wound
rubs on items of clothing, in which case a dry non-adherent
gauze pad may help. Showering is permitted after 24 hours,
and once the skin has closed you may enjoy a bath. When
the wounds get wet, they should simply be padded dry,
or dried with a cool hairdryer. The wounds will be checked
before you are discharged home from hospital, and re-examined
at your follow-up appointment 2-3 weeks after surgery,
when any remaining suture material is removed. The wounds
leave very acceptable small scars, with a good cosmetic
appearance.
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How Much Pain and Discomfort
Should I Expect?
It is normal to experience some pain or discomfort after
laparoscopy, but this normally resolves quite quickly
over the first 48 hours after the operation. Shoulder-tip
pain is quite commonly felt on the day after surgery due
to irritation of the diaphragm by the CO2 gas and irrigation
fluid. The abdominal discomfort should gradually improve
with time, and appropriate pain-killers will be prescribed
for you to take home with you. It is normal to feel very
tired after surgery, even after the pain has resolved,
and rest is important during your convalescence. If you
have symptoms that persist or get worse, or if you develop
a temperature, then you should seek medical advice either
from Mr. Butler-Manuel or from your General Practitioner.
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How Long Should I Take Off
Work?
This is actually quite variable depending on the extent
of the surgery performed, the nature of the work you do,
and your personal circumstances. However, most ladies
prefer to take 2 to 3 weeks off before returning to work
in good health. Most women find that once the initial
soreness has subsided, they continue to feel quite tired
for some time and often feel the need to sleep. This is
the body’s normal response to surgery, and is not
unusual.
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When Can I Drive My Car?
Since very small incisions are used and there is very
little cutting of tummy muscles, it is possible to drive
within a few days of your laparoscopy. It is not permitted
to drive the same day as a general anaesthetic, and all
patients admitted as day cases must be accompanied home
and have someone to stay with them overnight. When driving,
it is vitally important that you are confident to take
full responsibility for your own actions and therefore
that you yourself feel confident and able to drive. Check
that you are able to stamp your foot on the ground as
in an emergency stop, and that you can look over both
shoulders as if reversing. It is often wise to check with
your car insurers to check that they have no specific
rulings regarding this.
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Urinary Problems
Urinary problems such as difficulty passing urine or burning
on passing urine may be caused by the small catheter that
is passed while you are anaesthetised. This is usually
just irritation and will settle with time, but simple
measures such as cranberry juice, barley water or remedies
available in pharmacies over-the-counter to acidify the
urine may well help. If symptoms persist a specimen should
be sent for analysis to exclude infection.
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Vaginal Bleeding
A little vaginal bleeding is quite
common after laparoscopy since a small dilator is usually
passed through the cervix to manipulate the uterus to
facilitate the operation. Bleeding may also occur if a
hysteroscopy or some surgery to the cervix has been performed.
Such bleeding usually settles to a brown discharge over
a few days and should cease within 14 days.
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Follow-up
Due to the anaesthetic many patients forget detailed information
that is given immediately following surgery. It is therefore
usually preferable to return for a follow-up appointment
2 to 3 weeks after your laparoscopy to discuss the operative
findings and procedures performed, and to decide upon
your future care. It is also an opportunity to check that
the wounds have healed up satisfactorily and that you
have not developed any untoward problems. Often the maximum
benefit of laser laparoscopy is not felt until 3 months
following surgery.
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Who Do I Contact in an Emergency
or for Further Advice?
If you have any concerns regarding your laparoscopy please
feel free to contact my secretary Lynda
Moorby on 01483 555816 during
office hours who will be able to contact me for advice,
or otherwise leave a message on her answer machine. If
you have symptoms that persist or get worse following
your laparoscopy, or if you develop a temperature, then
you should seek medical advice either from me or from
your General Practitioner. For post-operative patients,
advice will also be available from the hospital ward staff
where your operation was performed, who would also be
able to contact me directly.
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