Laparoscopy is a minimally invasive outpatient surgical procedure utilized to diagnose and treat a variety of infertility and gynecological conditions
including pelvic pain, uterine fibroids, endometriosis, pelvic adhesions,
tubal pregnancy, ovarian cysts and tubal disease. During laparoscopy a thin
fiber-optic tube, attached to a video camera, is inserted into the abdomen, through a small incision in the belly button. It gives the surgeon a clear
view of the uterus, ovaries and tubes on a high definition monitor (fig.1 and 2). The surgeon can then evaluate uterus, ovaries, fallopian tubes, appendix,
liver and gallbladder, helping him to diagnose and treat the cause of pain or infertility
How is Laparoscopy done?
- A small incision is made just below the belly button.
- A thin needle is inserted into the abdomen; the abdominal cavity is inflated with carbon dioxide pumped in through the needle. This is done to create working space within the abdominal cavity, and to minimize the risk of injury to the internal organs as the laparoscope is inserted into the abdomen.
- The laparoscope is equipped with a high intensity light and a camera which display the images on a video monitor, giving the surgeon an excellent view of the pelvic structures.
- 1 or 2 additional incisions are made in the lower abdomen through which scissors or graspers are inserted to help the surgeon with the operation.
- When the procedure is completed, the carbon dioxide gas is allowed to escape from the abdomina
- A CO2 laser can be attached to the laparoscope and is very helpful when treating endometriosis or pelvic adhesions.
The laparoscopy usually begins with inspection of the abdominal wall and the bladder to see if there are any adhesions (scar tissue) or
The uterus (fig. 3) is then carefully evaluated to make sure there are no abnormalities such as fibroids or congenital malformations.
The ovaries and fallopian tubes (fig.4) are carefully evaluated for endometriosis, and scar tissue. The delicate tubal fimbriae, which
trap the egg as it is released from the ovary, are carefully inspected to make sure there are no abnormalities.
The lining of the abdomen behind the uterus, called the cul de sac, is a frequent site of endometriosis. The surgeon will also look at the appendix,
liver and diaphragm to see if there is any abnormality.
The final aspect of a diagnostic laparoscopy is the injection of blue dye into the uterus through the vagina. The blue dye then enters the tubes and should spill out from their end if there is no blockage (fig. 5).
- When the procedure is completed, the carbon dioxide gas is allowed to escape from the abdominal cavity and the instruments are removed
- The incisions are closed with absorbable stitches and covered with a band aid
- The skin incisions are injected with long acting local anesthetics for a more comfortable recovery from surgery.
Types of infertility surgery performed by Laparoscopy
- Removal of uterine fibroids (myomectomy).
- Treatment of endometriosis
- Resection of pelvic adhesions (scar tissue).
- Surgery for blocked tubes
- Removal of ovarian cysts.
- Treatment of tubal pregnancy
- Reversal of tubal ligation (tubal reanastomosis).
Uterine fibroids are common benign smooth muscle tumors of the uterus found in about 20% of women in their thirties
and in about 50% of all of women at age 50. Fibroids can cause pain, abdominal pressure, abnormal uterine bleeding,
recurrent miscarriage and infertility. Preoperative evaluation includes an x-ray procedure called Hysterosalpingogram
(HSG), saline infusion sonography (SIS) or MRI scan. Preoperative treatment with gonadotropin-releasing hormone (GNRH),
such as Lupron, can help shrink the fibroid and facilitate the laparoscopic resection of the fibroid. During the
procedure you may expect to have a belly button incision measuring about ½ inch and two additional ¼ inch incisions in the
lower abdomen. A thin fiber-optic tube, equipped with a video camera is inserted into the abdomen so the surgeon can view
the uterus on a high definition monitor. More recently, outpatient minimally invasive robotic assisted laparoscopy techniques
have made fibroid surgery easier to perform.
The fibroid appears as a bulge distorting the right side of the uterus (fig. 6). The uterus is injected with a solution which causes the blood vessels feeding
the fibroid to constrict, minimizing blood loss during the surgery. Utilizing a CO2 laser or electric cautery knife, an incision is made in the uterus to expose
and remove the fibroid (fig.7). The uterine incision is then closed with sutures (fig. 8) and the fibroid is removed from the abdomen utilizing a power tool
(morcellator). The instrument cuts the fibroid into small segments which are removed through the laparoscopic incisions. The uterine incision is then covered
with a solution or an absorbable mesh to minimize the risk of adhesion (scar tissue) formation. The small abdominal incisions are closed with a dissolvable
suture and covered with a Band-Aid. Expect to spend several hours in recovery before being discharged home later in the day.
Treatment of endometriosis
Laparoscopy is utilized to make a diagnosis of endometriosis and to stage and treat the condition. In stage I or II endometriosis, few implants involve pelvic structures
such as the lining of the abdomen (fig. 9), tubes or ovaries (fig. 10). With intermediate or stage II – III disease significant scar tissue is also present. In severe
stage IV endometriosis, the disease invades into the ovaries forming chocolate cysts (fig. 11) with extensive pelvic scarring often involving the bowel and even more
distant structures. How endometriosis is treated will depend on the extent of the disease, the age of the patient and on whether fertility preservation is of concern.
Laparoscopy for Proximal Tubal Occlusion (PTO)
Sometimes the tube is blocked at its narrowest part, at the point where it is closest to the uterus (fig. 12). This is called Proximal Tubal Occlusion or PTO. This blockage is most often caused by spasm of the tube, thin scar
tissue or a mucus “plug”. The end of the tube is entirely normal and reopening the tube can be successfully accomplished with simultaneous hysteroscopic and laparoscopic surgery.
First, a fiberoptic hysteroscope is gently inserted through the cervix and advanced into the uterus. A camera attached to the hysteroscope will project a magnified view of the uterine
cavity and the opening of the tubes on a video monitor. A thin soft catheter is guided to the tubal opening (fig. 13) and advanced into the tube, clearing away the mucus plug.
Blue dye is injected into the tube (fig. 14)
The laparoscope, allows the surgeon to see the other side of the tube (the one closer to the ovary) and make sure that the dye injected into the tube (fig. 14) exits from the end of the tube (fig. 15), confirming that the tube is now open
Laparoscopic scar tissue resection
Scar tissue or adhesions occur most frequently after pelvic infection, previous surgery or endometriosis. Adhesions may cause pain and/or infertility when they involve the ovaries or the fallopian tubes. Bowel obstruction can occur when the adhesions involve the intestines.
When mild scar tissue (fig.16) involves the end of the tube (closer to the ovary), surgery is often successful. The delicate part of the tube responsible for transporting the egg into the tube can be nicely restored (fig. 17). When severe scar tissue involves the tubes and ovaries (fig. 18), surgery is unlikely to be successful, and IVF should be considered instead.
During laparoscopic surgery, absorbable adhesion barriers are often utilized to cover the surgical area and to minimize the risk of recurrence of scar tissue. It is important that your doctor is an expert in laparoscopic fertility techniques, handling the tissues delicately to avoid further damage and scar tissue formation.
Laparoscopic CO2 Laser for Distal Tubal Disease
When the tube is normal (fig. 19), blue dye injected into the uterine cavity, flows into the tube and into the abdominal cavity (fig.20). Laparoscopic surgery for distal tubal disease is most successful when mild to moderate tubal damage is present. The scar tissue between the tube and the ovary (fig. 21) is removed, preserving the delicate tubal fimbriae (fig. 22).
During fertility evaluation, the Hysterosalpingogram (HSG) (tubal x-rays) may indicate that the fallopian tubes are blocked at their ends (fig. 23). This is called hydrosalpinx or distal tubal occlusion. Hydrosalpinx is most frequently caused by Pelvic Inflammatory Disease (PID). Blue dye flowing into the tube is unable to exit the tube, causing the tube to swell and become dilated (fig. 24).
Laparoscopic surgery has been previously advocated to remove the scar tissue and open up the fallopian tubes (neosalpingostomy). Pregnancy rates within 18-24 months after surgery to open the end of the tube (neosalpingostomy) tend to be quite low, ranging between 15 and 25%. This is because recurrent tubal scarring occurs quite frequently after surgery, resulting in closure of the tube. Ectopic pregnancy is another common complication after surgery. For these reasons, In Vitro Fertilization (IVF) has replaced reconstructive tubal surgery for most women with hydrosalpinx who want to conceive.
Before undergoing IVF, surgical removal of the diseased tube is necessary, because inflammatory cells, present in the tubal fluid, can enter the uterine cavity and prevent implantation of the embryo. The surgery to remove the tubes (salpingectomy) can be accomplished by a minimally invasive outpatient laparoscopic surgery.
Laparoscopic removal of ovarian cyst Click to view Laparoscopic Cystectomy
Ovarian cysts are often encountered during laparoscopic infertility surgery. The cysts can occur with endometriosis (“chocolate cysts”), inflammatory ovarian disease, normal ovulation (corpus luteum cysts), and with various benign and malignant ovarian conditions. Fig. 25 shows the ovary to be enlarged by a dermoid cyst (fig. 26). A dermoid cyst contains various embryonic structures such as hair teeth, cartilage or thyroid tissue. At the conclusion of the surgery the ovary and tube are “wrapped” in a specialized absorbable mesh to minimize the risk of post operative scar tissue formation (fig.27).
Treatment of tubal pregnancy
Ectopic pregnancy occurs when the fertilized egg implants outside the uterine cavity. All normal pregnancies begin within the fallopian tube when an egg is fertilized by a single sperm. Several days after fertilization, the embryo is transported through the tube and into the uterus by contractions of the tube and by sweeping movement of fine, hair-like cells (cilia) lining the tube. Any condition which damages the tube can interfere with the transport process of the embryo through the tube, resulting in implantation of the embryo outside the uterine cavity.
The fallopian tube is the most common implantation site for ectopic pregnancy (fig. 28).
Tubal pregnancy can be treated either medically or surgically. Most ectopic pregnancies can be managed medically with Methotrexate if they are discovered early before they rupture the fallopian tube.
The goal of laparoscopic management of an unruptured ectopic pregnancy is to remove only the pregnancy sac and preserve the fallopian tube when possible. An incision is made in the tube over the bulging pregnancy sac (fig. 29). The pregnancy sac is identified and extracted from the tube (fig. 30). The bulge in the fallopian tube is no longer present and the tubal incision (fig. 31) will heal in a relatively short period of time. There is a 20 % risk of recurrent ectopic in the same tube or another ectopic in the opposite tube.
In more severe cases, the pregnancy causes the tube to swell (fig. 32) and rupture, resulting in abdominal bleeding (fig. 33). Laparoscopic surgery should be immediately performed to remove the affected tube (fig. 34).
Risk factors associated with tubal pregnancy:
- Previous pelvic infection
- History of previous tubal pregnancy
- Intrauterine device (IUD)
Treatment of Polycystic Ovary Syndrome (PCOS)
The PCOS ovary is easily recognizable on vaginal ultrasound The ovary is enlarged with multiple tiny cysts (fig.35 white arrows) around its periphery arranged in a “pearl necklace” formation. The end result is increased male hormone activity and disruption of ovulation. On laparoscopy, the PCOS ovary has a smooth pearly white appearance (fig. 36).
Laparoscopic treatment of PCOS, involves drilling 10-15 tiny holes into each ovary to destroy small ovarian cysts. Male hormone production from the ovary decreases, restoring ovulation with about 50% pregnancy rate.
Laparoscopic ovarian drilling for PCOS is rarely indicated because it can cause scar tissue formation around the ovaries and hinder future pregnancies. Current recommended treatments for PCOS include lifestyle modifications, ovulation induction and IVF.
What are the risks of Laparoscopy?
- All operations carry some risk. The risks associated with laparoscopy are low, and serious complications occur in less than 0.2% of cases.
- With any general anesthesia there is a risk of reaction to medications.
- Bleeding as a result of puncture of blood vessel.
- Damage to nearby organs and tissues, such as the bowel or bladder.
Preparing for laparoscopy
- A preoperative appointment will be scheduled 1-2 weeks before your surgery. A physical exam will be performed and you will be asked to sign a consent form giving your doctor permission to perform the surgery.
- Make sure you talk to your doctor about any concerns you may have, such as why is the surgery needed, what are its risks, how it will be done, and what the results will mean.
- Tell your doctor if:
- You are or might be pregnant.
- You have allergies to any medicines.
- You had a problem with anesthesia.
- You are taking blood-thinning medicines, such as aspirin or warfarin (Coumadin).
- You have any bleeding problems.
- You may be asked to use an enema a day before your surgery to empty your colon. This will help in case your bowel is injured during surgery.
- Do not eat or drink for at least 12 hours before your procedure.
- Leave your jewelry at home. Remove your glasses, contacts, or dentures before the surgery.
- DVDs, books etc. – helpful during recovery.
- You can expect some abdominal discomfort after the procedure, so you may want to prepare several comfortable, loose fitting outfits to wear while recovering from the surgery.
- Wear low-heeled, comfortable shoes. You may be still groggy and unsteady from the anesthetics administered during surgery.
- Arrange for someone to drive you home after the laparoscopy.
At the hospital before the surgery
- A nurse will insert an intravenous line or IV.
- The anesthesiologist will meet you and explain to you what to expect in the Operating Room.
- You will be given drugs and fluids through your IV to help relax you during the procedure.
- Your doctor will be available to answer any last-minute questions that you may have.
- Your family or friends may be able to stay with you until it is time for you to go to the operating room.
What to expect in the operating room?
- You will be brought into the operating room on a stretcher. The room is somewhat cold, and you will be covered with blankets to keep you comfortable.
- Once you are positioned on the operating room table, a belt will be placed around you to provide for your safety.
- An automatic blood pressure cuff will be placed on your arm, and a pulse oximeter, which measures the oxygen levels in your blood, will be taped to your finger
- You will notice monitors, anesthesia equipment, lights above the operating table, and tables of sterile instruments.
Recovering from Laparoscopy
- Right after surgery you will be taken on a stretcher bed to the Recovery Room. The nurses will care for you for about 2-4 hours until the anesthesia wears off and you are ready to go home
- The nurses will be giving you pain medication as needed to make you comfortable.
- When you are ready to go home you will be given care instructions and who to call if you have any problem.
- You will be given a post operative appointment to check your incisions and to review the operative findings
- You will experience some itching, pain and bruising around the incision for a few days after your surgery.
- Take pain medication and antibiotics as prescribed by your doctor.
- You may experience shoulder discomfort for 24-48 hours after the laparoscopy from the CO2 gas used during surgery to inflate your abdomen.
- You may shower the day after surgery but try to keep your incisions dry.
- You will be given a post operative appointment to check your incisions and to review the operative findings
- Laparoscopy is a major surgery and it typically takes between 2-7 days to recover from the surgery.
- Drink plenty of liquids after surgery and increase your diet slowly over the next 24-48 hours as tolerated.
When to call the doctor after going home?
- If you experience fever above 100 degrees.
- Excessive pain (not controlled by pain killers).
- Swelling or discharge from the wound.
- If you experience excessive bleeding.
- If you develop severe chest pain, experience persistent nausea and vomiting or shortness of breath.