What is laparoscopy ?

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.

When is laparoscopy done?

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.

What precautions need to be taken before laparoscopic surgery ?

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.

How is the laparoscopy performed ?

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.

What is an operative laparoscopy ?

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.

What is a second-look laparoscopy ?

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.

What can you expect to feel after the laparoscopy ?

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.

What are the complications of laparoscopy ?

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.

How can I be sure my doctor will perform the laparoscopy properly ?

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.

1. How many laparoscopies have you done?
2. Do you use multiple punctures?
3. Do you use a video for recording the operation?
4. 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.

Which is better - a laparoscopy or a HSG ?

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.

Why we don't do laparoscopies any more

Many doctors still routinely perform a laparoscopy for infertile women, and we used to do so ourselves until a few years ago. However, we have now stopped doing so, for the simple reason that we do not think it is cost effective to subject all infertile women to this invasive surgical procedure. We use a HSG ( hysterosalpingogram, X-ray of the uterus and tubes) to determine if the fallopian tubes are normal or not, because this is much less expensive and does not involve surgery. What about the argument that we may miss the diagnosis of mild endometriosis or peritubal adhesions on the HSG ? This is true, but since there is no evidence that treating mild endometriosis or removing peritubal adhesions at the time of laparoscopy helps to increase fertility, we feel we are justified in our decision not to subject our patients to this surgical procedure on a routine basis. Moreover, since the next step in our treatment of women with a normal HSG is IUI ( intrauterine insemination) , the results of the laparoscopy do not affect our treatment plan at all. The fact is that the yield of routine laparoscopies in infertile women is very low, since the vast majority are normal, and this should also cause doctors to re-think their old-fashioned approach to performing laparoscopies mindlessly for all infertile women.

What happens after the laparoscopy ?

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:

1. Normal findings: Such findings are the commonest result and can be very assuring ! These help to confirm the diagnosis of unexplained infertility.
2. 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.
3. 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).