Gynaecological laparoscopy (Key hole surgery)

Dr N Subodha *

Instruments for a laparoscopic operation :: Pix - wikipedia/ignis

Laparoscopic Surgery also known as "Key Hole" surgery is the latest form of gynecological operations. Laparoscopic surgery means visualization & examination of the abdominal cavity by means of a telescope inserted through a small incision of 5 mm or 10 mm just above or below the umbilicus and then carrying out the surgical procedure with the help of slender instruments inserted through other small portals.

The abdominal cavity is first inflated with CO2 gas or air injected through a tubular needle known as Verres' needle to create a working space inside the abdomen. Through the umbilical incision a trocar with a canula is passed inside the abdomen. The trocar is then removed and a telescope (Laparoscope) is inserted through the canula, which carries with an inbuilt lens system to send an image of the abdominal organs to the video camera and fibreoptic cables to transmit the light from the light source to illuminate the abdominal cavity. The magnified images are projected on monitors which can be visualized clearly by both the surgeon and assistants throughout the operative procedures.

After viewing the inside of the abdomen and localizing the pathology one or two more small incisions are made on the abdominal wall at vantage locations for other laparoscopic instruments to be inserted to carry out the procedure.

The first history of Laparoscopy dates back to the 10th century when Abulkasi, an Arabian physician attempted to visualize the cervix. The first full fledged laparoscopic surgery done was an appendectomy but performed by a gynaecologist. In the beginning Laparoscopy was done mainly for diagnostic purposes. The early genealogical operations using Laparoscopy were mainly for sterilization, but ever since Semm of Germany popularized operative gynaecological Laparoscopy by performing salphingectomy, myomectomy, oopherectomy, ovarian cystectomy and salphingostomy in 1974, operative Laparoscopy has gained widespread acceptance in gynaecology.

Today it can be truly said that the widest application of Laparoscopy is in gynaecology. Almost 90% of all gynaecological operations in developed countries like Europe and USA are performed laparoscopically and it has been undoubtedly accepted that wherever possible Laparoscopy is the better alternative to the conventional open surgery.

What are the gynaecological conditions which can be operated laparoscopically?

1. Hypersterectomy – Patients who have been advised hysterectomy (removal of uterus) for various disorders of the uterus can get the laparoscopic assisted vaginal hysterectomy (LAVH) or Total Laparoscopic Hysterectomy (TLH)

2. Myomectomy – Conservative operations on the uterus for removal of myomas (fibroids) can best be done wherever feasible.

3. Ovarian cystectomy (removal of cyst of ovary) and ovariotomy (removal of a diseased ovary) are better done laparoscopically.

4. Adhesiolysis (removal of adhesions) due to previous operations or infections or related with endometriosis especially in cases of infertility.

5. Ectopic pregnancy (pregnancy existing outside the uterus)

6. Diagnosis and treatment of various causes of infertility.

7. Undiagnosed chronic pelvic pain.

8. Tuboplasty (surgical reconstruction of fallopian tube for tubal obstruction in infertility)

Why should we offer laparoscopic surgery to the patients?

1. It gives rise to minimal tissue handling and much less tissue trauma to the other adjacent normal organs resulting in very less pain after surgery whereas in conventional open surgery there is more tissue handling and gives rise to reactionary swelling of the operated area and adjacent normal tissues, resulting in more post operative pain to the patient.

2. Very small incisions (0.5 to 1 cm) of Laparoscopy results in less amount of blood loss, less chance of wound infection and early healing of wound as compared to large incision (10 cm to 15 cm or bigger) of conventional surgery resulting in more amount of blood loss, more post operative pain, increased chances of wound infection, delayed healing of wound and more chances of developing hernia later on.

3. Blood loss is very less as compared to conventional surgery because even the smaller blood vessels are tied or coagulated before cutting and most of the laparoscopic cutting instruments coagulate the blood vessels while cutting.

4. Hospital stay in laparoscopic surgery is usually 1 to 3 days while in cases of conventional surgery the same procedures will require 7 days or more of hospitalization.

5. After operative Laparoscopy the patients can resume their normal day to day activity in a period of 1 to 2 weeks while in cases of conventional surgery the recovery period can extend up to 6 to 8 weeks or more.

6. For infertility patients laparoscopic surgery has come as a boon, as with minimal tissue handling and minimal blood loss thereby incurring much less chance of adhesion formation later on, the chances of achieving pregnancy are much greater than that attained by conventional surgery.

7. Very small incision produces less scarring and is much more cosmetic.

8. As far as the total expenditure is concerned, laparoscopic surgery comes out to be more cost effective than the conventional surgery in the long run because of the shorter hospital stay, decreased amount of medication and early return to work.

Where can one get laparoscopic surgery done?

Laparoscopic surgery can be done at a centre which has the complete set of laparoscopic equipments with all its back up facilities. It should be performed by a well qualified gynaecologist who is fully trained in the field of operative Laparoscopy.