Laparoscopy ( also called endoscopy or
pelviscopy) is a surgical procedure in which a telescope
is inserted inside the abdomen through a small cut below
the navel, so that the doctor can have a look at the
pelvic organs in the infertile woman. A laparoscopy can
lead to the diagnosis of many problems which cause
infertility including damaged tubes, endometriosis,
adhesions and tuberculosis.
In the past, a diagnostic laparoscopy
was a routine part of the workup in infertile women, in
order to complete their evaluation. Generally, the
procedure was performed after the basic infertility
tests were done, since it is a surgical ( invasive)
procedure. Today, however, the utility of laparoscopy in
treating infertile women is very limited, and we rarely
perform laparoscopies in our clinic.
Timing the
surgery
Some doctors will time the laparoscopy during the
premenstrual phase (the week before the next period is
due). They combine the laparoscopy with a dilatation and
curettage (D & C) (scraping the inside of the uterine
cavity) so that they can also get information on the
woman's ovulatory status in the same procedure.
Some doctors try to perform the
diagnostic laparoscopy during the post-menstrual phase ,
when the uterine lining is thin, so that they can
combine it with a hysteroscopy at the same time.
The patient is advised not to eat or drink anything
for a specific time before the operation. Some tests may
also be done before the procedure, to ensure safety for
anesthesia, though for most young healthy women tests
are usually not needed. Some doctors may want a HSG
(hysterosalpingogram) done before performing a
laparoscopy.
The surgery is usually done on a
day-care basis. Laparoscopy is done under general
anesthesia so that the patient remains asleep during
surgery and does not feel any discomfort.
The
laparoscopic procedure
First of all, the abdomen is cleansed and draped for
the procedure. Then an instrument may be placed in the
uterus through the vagina. A gas, such as carbon dioxide
or nitrous oxide or air is then allowed to flow into the
abdomen just below the belly button. This gas creates a
space inside by pushing the abdominal wall and the bowel
away from the organs in the pelvic area and makes it
easier to see the reproductive organs clearly.
The laparoscope, which is a slender
tube, like a miniature telescope, is then inserted
through a small incision just below the navel. During
the laparoscopy a small probe is placed through another
incision in order to move the pelvic organs into clear
view. A diagnostic laparoscopy is incomplete without a
"second puncture" because, without this second probe, it
is not possible to visualize all the structures
completely.
During the laparoscopy the entire
pelvis is carefully scanned and the organs inspected
systematically - the uterus; the ovaries; and the lining
of the abdomen, called the peritoneum. In addition to
looking for diseases affecting these structures, the
doctor also looks for adhesions (bands of scar tissue),
endometriosis and tubercles. In case abnormalities are
found, the doctor can either try to correct them
(operative laparoscopy), or take out bits of tissue for
histologic examination (biopsy) with a biopsy forceps. A
blue dye (methylene blue) is then injected through the
uterus and fallopian tubes to check whether the tubes
are open. When the surgery is complete, the gas is
removed and one or two stitches inserted to close the
incisions. Since the incisions are so small, often
stitches are not needed and they can be closed with
Band-Aids.
Fig 1. A laparoscopy being performed. Note that the
view through the laparoscope can be seen on the TV
monitor.
Fig 2. Normal pelvis as seen during a laparoscopy. The
uterus is the reddish structure in the center; on either
side of which are the pink fallopian tubes. These run
towards the ovaries, which are white in colour.
As stated earlier, along with
laparoscopy, some doctors carry out a dilatation and
curettage (D & C) and send the endometrial curettings
for histologic examination to rule out the possibility
of hidden tuberculosis, and also to find out if
ovulation is taking place. Others will do a diagnostic
hysteroscopy at the same time, to ensure that the
uterine cavity is normal.
Most doctors today use
videolaparoscopy, in which a video camera is connected
to the laparoscope, so that what the surgeon sees can be
displayed on a TV monitor. This kind of laparoscopy can
be very useful for documentation and record-keeping. It
is also very helpful for patient education, since the
doctors can use the video or CD later on to
explain to the patient the exact nature of her problem.
Recent advances in miniaturization
have allowed companies to manufacture very tiny
laparoscopes. These are as thin as a needle, and are
called microlaparoscopes or needlescopes. These allow
doctors to perform laparoscopy in the clinic itself,
without using anesthesia. However, the quality of the
images is still not very good with these tiny scopes.
Dr Brosens from Belgium has also
introduced the technique of transvaginal
hydrolaparoscopy. This allows the doctor to examine the
pelvis by inserting a tiny scope through the vagina, so
that no abdominal incision needs to be made. The value
of this technique as compared to conventional
laparoscopy is still being studied.
During operative laparoscopy, many problems which
cause infertility can be safely treated through the
laparoscope at the same time that the diagnosis is made.
When performing operative laparoscopy, additional
instruments such as probes, scissors, biopsy forceps,
coagulators and suture materials are placed into the
abdomen, either through the laparoscope or through two
or three additional incisions called "suprapubic
punctures", which are made above the pubis.
Some of the disorders that can be
corrected with the help of the procedures above
include: releasing scar tissue and/or adhesions from
around the fallopian tubes and ovaries; opening blocked
tubes; and removing ovarian cysts. Endometriosis can
also be destroyed by burning it from the back of the
uterus, ovaries, or peritoneum during operative
laparoscopy. Under certain circumstances, small fibroid
tumors can be removed and ectopic pregnancies can be
treated.
When performing operative laparoscopy,
surgeons may use electrocautery instruments, lasers, and
sutures. The choice of the technique used depends on
many factors including the surgeon's training, location
of the problem, and availability of equipment.
In this video, you can watch Dr Anjali Malpani
perform an operative laparoscopy , in which she performs
drills the ovaries to treat a patient with PCOD (
polycystic ovarian disease).
This is what the surgeon sees on the
video screen when operating.
Sometimes, a "second-look" laparoscopy
may be recommended. This procedure is performed
following either operative laparoscopy or major tubal
surgery. Second-look laparoscopy can take place within a
few days following the initial surgery or many months
afterwards. During the procedure, the doctor determines
whether adhesions are re-forming or if endometriosis is
returning and these conditions can be treated in needed.
After surgery, the patient needs to
rest for about 2 to 4 hours in order to recover from the
effects of anesthesia. She can usually go home the same
day and resume normal work in 2 to 3 days. Sexual
activity can be resumed in a week or so, depending upon
the doctor's advice.
After the operation, there may be some
discomfort. This may include:
Mild nausea as a result of the
medication or the surgical procedure
Pain in the neck and shoulder due
to the gas inside the abdomen, which irritates the
phrenic nerve and causes "referred pain" perceived
in the shoulder
Pain in the areas where the
instruments passed through the abdominal wall
A scratchy throat and hoarse voice
if a breathing tube was used during general
anesthesia
Cramps, like menstrual cramps
Discharge like a menstrual flow for
a day or two
Muscle aches
Most of these minor symptoms will
disappear within a day or two after surgery. The abdomen
may feel swollen for a few days. Any unusual or peculiar
symptoms should be reported at once to the doctor.
To really appreciate the benefits of
laparoscopy, one should remember that the alternative is
major surgery (laparotomy) which involves a large
abdominal incision, a four to six day hospital stay, and
four to six weeks of postoperative recovery time.
While the doctors may term laparoscopy
as being "minor" surgery, remember that for the patient
all surgery is major! The risk of laparoscopy are
minimal. But certain conditions increase the possibility
of complications. If there has been previous surgery in
the abdomen, especially involving the bowel, there is an
increased risk. Other conditions that lead to a higher
risk of complications are evidence of an infection in
the abdomen, a large growth or tumor within the abdomen,
and obesity.
Complications among young, healthy
women under going laparoscopy are rare and occur only in
about three out of 1000 cases. These complications can
include injuries to structures in the abdomen such as
the bowel, a blood vessel or the bladder. Most often,
these injuries occur when the laparoscope is placed
through the navel. If such an injury occurs during the
procedure, the physician can perform major surgery and
correct the damage through a longer abdominal incision.
Sometimes, complications may arise after surgery. If
bleeding or pain appears excessive or if high fever
develops, the doctor should be informed.
Unfortunately, many gynecologists are
not skilled at performing a laparoscopy properly. In
order to choose the best doctor for performing your
laparoscopy, you need to ask him the following
questions.
How many laparoscopies have you
done?
Do you use multiple punctures?
Do you use a video for recording
the operation?
If you find a problem, will you
correct it at the same time? Ideally, if the doctor
finds a problem during the laparoscopy, he should
correct it at the same time, rather than call you
again for a second surgical procedure, which only
adds to your expense and risk.
A good doctor has a lot of experience in performing
laparoscopies; uses multiple punctures, so he can
assess the pelvis properly; and always provides
documentation ( in the form of a video, CD or DVD)
so the findings can be reviewed by another doctor.
Comparing
laparoscopy and HSG
In our practise, we prefer using an HSG to document
tubal patency, because it is much less expensive; is
non-surgical; and provides a hard copy record , which
all doctors can refer to later on. Some doctors still
believe that both the HSG and laparoscopy are
complementary procedures, and you may even need both,
especially if your tubes are blocked. HSG provides
information only about the inside of the tubes and
uterine cavity, whereas in laparoscopy, not only can the
tubal patency be determined, but two other disorders (
endometriosis and tubal adhesions) inside the abdomen
which affect tubal function and which do not show up on
HSG can also be diagnosed. However, while it is true
that a laparoscopy offers the doctor a chance to
diagnose and treat these problems at the same time , it
is still unsure whether correcting these problems
actually helps to improve the patient's fertility !
A common problem which patients face
in practice is that many doctors will insist on
repeating the laparoscopy. One reason for this is that
doctors feel that they need to do the laparoscopy for
themselves, because they cannot "trust" another doctor's
judgment. This is, of course a major problem for
patients, who suffer repeated (and unnecessary)
laparoscopies. Having a video record should help to
minimize this problem.
What happens if your laparoscopy was
normal and the second doctor wants to repeat it anyway?
Sometimes doctors have little to offer in the way of
effective treatment and since there is nothing else to
do, they suggest a repeat laparoscopy to which the
hapless patient is forced to agree. If your first
laparoscopy did, in fact indicate you had a problem, a
second look laparoscopy may be indicated (and this
should have been discussed with you after the first
laparoscopy) to determine if the problem has been
successfully resolved. Ask the doctor what information
he hopes to get by doing the repeat laparoscopy and how
this will change your treatment. If you feel the doctor
wants to do a laparoscopy for no very good reason,
refuse. It's a surgical procedure after all - and it's
your body.
Thinking it
over
One benefit of laparoscopy is that in addition to
allowing the accurate diagnosis of a problem, if it
exists, operative laparoscopy can also be done in the
same surgery to correct the problem. However, we feel
that the routine use of laparoscopy is not called for in
treating infertile patients, since a HSG can provide
similar information at much less risk and expense. We
use the procedure very sparingly in our practise.
At the follow-up visit, discuss with the doctor what
he found at the time of the laparoscopy and also how to
proceed on the basis of the findings. There are three
possible courses of action:
Normal findings: Such findings are
the commonest result and can be very assuring !
These help to confirm the diagnosis of "unexplained
infertility".
Abnormal findings, such as
peritubal adhesions or endometriosis, which
could be corrected at the time of laparoscopy
itself: Perhaps the doctor may suggest a second look
laparoscopy or HSG after some time to document that
the problem has, in fact been corrected or else in
addition medical treatment may be advised to try to
correct a residual problem (e.g. antibiotics for
pelvic infection).
A quandary may arise when the laparoscopy reveals a
finding which may be of no relevance to the problem
of infertility. For example during laparoscopy the
doctor may detect small fibroids, early
endometriosis, or an ovarian cyst.
These are common disorders and are often found in
fertile women as well. Just making a diagnosis of
these disorders does not automatically mean that
they need to be corrected: they may be red herrings,
which do not affect fertility. In fact, unnecessary
surgery to remove these disorders can aggravate your
infertility.
Abnormal findings: which could not
be corrected during the laparoscopy: For treatment
of these problems, the doctor may advise IVF (for
example, for patients with irreparably damaged
fallopian tubes).
