Laparoscopy is minimally invasive abdominal surgery performed through very small incisions in the abdomen, generally a half-inch or less. The lens of a small camera is placed through one incision so that the inside of the abdomen may be seen on a TV screen. Two or three other instruments are then placed through the other incisions. These instruments can hold, cut and suture tissue, allowing the experienced laparoscopic surgeon to perform even complex surgeries. A large fibroid or even a entire uterus can then be removed through these small incisions by cutting the fibroid or other tissue into thin strips while inside the abdomen.
A diagnostic laparoscopy may be recommended to evaluate infertility, pelvic pain or rule out disease from an abnormal imaging study. If disease is present, these may be treated at the time of the diagnostic laparoscopy.
Laparoscopic Treatment of Pelvic Pain
Laparoscopy for pelvic pain is targeted to treating the source. Unfortunately, chronic pelvic pain is a difficult disease and may be caused by a single or several entities, such asendometriosis, adhesions, ovarian cysts, pelvic vein congestion or the nervous system.
If endometriosis is found, these lesions are completely resected and sent to pathology for confirmation of the disease. Endometriosis, previous inflammatory disease and previous abdominal surgery can cause scar tissue and adhesions which can distort anatomy. These are taken down to normalize the anatomy. If any ovarian cysts are found and thought to be a source of pain, these cysts are completely resected from the ovary. On occasion, based on the disease and the individual, the entire ovary may be removed. Sometimes, the veins to the ovaries can become congested and cause pain, called pelvic congestion syndrome. These veins are then transected to help resolve the pain. A uterine uplift may be recommended if there is complaint of pain with intercourse from collision of the uterus because of its natural flexion or if there is severe scar tissue under the uterus to bowel from endometriosis or previous surgeries. The uplift procedure shortens ligaments of the uterus with a permanent suture to elevate the uterus to help avoid intercourse collision pain or the reformation of scar tissue to the underside of the uterus. If patients are having chronic midline pain, without much resolution from previous therapies, a presacral neurectomy may be recommended. This is where the nerve bundle overlying the sacrum are transected and removed to alleviate pain. This procedure does not affect fertility or sexual function.
Laparoscopic Ovarian Cystectomy or Salpingo-Oophorectomy
Ovarian masses can be benign (non-cancerous) or malignant (cancerous). If the workup for an ovarian mass is thought to be malignant, a referral to a gynecologic oncologist is strongly recommended. If the ovarian mass is thought to be benign, then preservation of the ovary is strongly recommended with only removing the cyst (cystectomy) from the ovary. On occasion the entire ovary may be removed. If this is performed, generally the fallopian tube is removed as well. This procedure is called a Salpingo-oophorectomy. Any specimen, either the cyst wall or the ovary, is sent to pathology to confirm whether it is benign or malignant.
Fibroids are benign growths of the uterine muscle and most commonly do not cause any symptoms. However, symptoms of abnormal uterine bleeding, abdominal/pelvic pressure, bladder symptoms of pressure/urgency/frequency, constipation, back pain, and infertility can be experienced. If the symptoms are bothersome, surgery may be recommended. A laparoscopic myomectomy involves incising the uterus and removing the fibroids. To control blood loss, a medication called Pitressin is injected into the uterus prior to incising the uterus. Once the fibroid is removed, the uterus is then reconstructed by suturing the defect caused by the fibroid. Less than 0.5% of patients will require a blood transfusion, however, patients may donate their own blood prior to surgery in the small chance a blood transfusion is necessary. Depending on the depth of the fibroid and amount of uterine reconstruction, a cesarean section may be strongly recommended after the surgery if pregnancy is desired. Patients should wait at least 3 months before trying to conceive a pregnancy once this procedure is performed.
Laparoscopic Evaluation of Infertility
Any of the above mentioned procedures may be performed during your infertility work up with surgery so that the anatomy is restored to as normal as possible. In addition, the fallopian tubes’ patency is evaluated by injecting blue dye through the uterus and visualizing spillage of blue dye from the ends of the fallopian tubes. If any defects are seen, these may be repaired to normalize the tube. A Hysteroscopy (thin telescope placed through the vagina into the uterine cavity) is also performed to evaluate the uterine cavity.
There are two types of hysterectomy – Supracervical (Subtotal) and Total. A Supracervical hysterectomy only removes the uterus. A Total hysterectomy removes the uterus and cervix. Please see the website link for Hysterectomy for more information.
What is my recovery from a Laparoscopic procedure?
Patients usually go home the same day of the laparoscopic surgery. There may be a few occasions, such as persistent nausea/vomiting, pain control, or urinary retention, that a patient is kept overnight and sent home the morning after surgery. Recovery is usually 1-2 weeks long. Nothing should be placed in the vagina for 2 weeks, unless a total hysterectomy or any vaginal procedure has been performed. Then nothing can be placed in the vagina for at least 6 weeks and until the surgeon has examined the patient after the surgery to ensure healing. Driving is restricted to those in pain causing a slower, emergent reaction time while driving as well as those on narcotics for recovery. If a larger procedure was performed, patients may be fatigued for 6-8 weeks, however, can usually resume normal activities after 2 weeks. No heavy lifting of greater than 25 pounds for 4 weeks is generally recommended.