DIAGNOSTIC LAPAROSCOPY

Problems that occur with a woman's reproductive organs sometimes cannot be found by a physical examination alone. Other tests, X-ray, or ultrasound may still leave some uncertainty. In these cases, a type of diagnostic surgery, called laparoscopy, may be performed. It allows the doctor to look inside the abdomen at these organs.
Laparoscopy is done with a slender telescope-like instrument, called a laparoscope, that is inserted through a small cut just below the navel. Although this method does represent surgery that requires anesthesia and involves some discomfort afterward, it is usually safe, and the recovery period is short.
Laparoscopy is done to help your doctor determine what is wrong. Laparoscopy is also used as a method of sterilization or as a method of treatment, but only diagnostic uses are discussed here. If you have any questions about laparoscopy or why you are having it, discuss them with your doctor.

A WOMAN'S REPRODUCTIVE SYSTEM

A woman's reproductive organs are in her lower abdomen. The uterus is the organ in which the fertilized egg develops into a fetus and grows until birth. The uterus is a pear-shaped muscle that is broad at the top and narrow at the bottom. At each side of the upper part of the uterus is a fallopian tube leading outward toward an ovary. The tubes transport eggs from the ovaries to the uterus. If a sperm joins with an egg in the tube, fertilization occurs. The ovaries contain many ova, or eggs, and release one during each menstrual cycle. The lower end of the uterus, called the cervix, is a narrow channel with a very small opening. It opens into the vagina.

USES OF DIAGNOSTIC LAPAROSCOPY

Laparoscopy is often used to find the cause of abdominal pain, infertility, or other problems in the reproductive organs. In these cases, a doctor cannot tell from a physical exam or from a patient's symptoms exactly what is wrong. A look inside the body is needed.

Abdominal Pain

Pain in the lower abdomen can have many causes. If the pain occurs early in pregnancy, a diagnostic laparoscopy may be performed because of the risk of ectopic pregnancy. In a normal pregnancy the fertilized egg develops in the uterus, but in an ectopic pregnancy, the egg may lodge elsewhere, such as in a tube. As the egg grows, the thin wall of the tube balloons outward and eventually may burst. With laparoscopy, some pregnancies that develop outside the uterus can be diagnosed in time to protect the mother's health and prevent severe damage to the tubes so that future pregnancies are possible.
Sharp, deep pain in the pelvis during intercourse or at other times may be caused by endometriosis. This is a condition in which tissue like the inner lining of the uterus is found growing in other areas in the pelvis. Sometimes this tissue is seen on the surface of the tubes, ovaries, uterus, bowel, or on other parts of the body in the lower abdomen. This tissue bleeds at the end of each menstrual cycle, just as if it were in the uterus. Since the fluid cannot be flushed freely out of the body, it can build up inside, causing nearby tissues to become red, swollen, and painful.
Adhesions can also cause pain. This occurs when, during the healing process, tissues grow together, which can occur with infection, endometriosis, and surgery. Movements of the body will stretch the adhesions, causing a discomfort or a sense of binding. If adhesions are found, they can be separated surgically during laparoscopy.

Infertility

Laparoscopy may be used to determine the cause of infertility. In some women the fallopian tubes are blocked. This can prevent sperm and egg from coming together, causing infertility. With laparoscopy, a simple test confirms this possibility. A colored fluid is injected through the uterus. If the tubes are open the fluid will flow out the ends of the tubes into the abdomen. The surgeon can see this through the laparoscope.

Cysts and Tumors

The ovaries sometimes develop cysts, or fluid-filled sacs. These cysts my be harmless, causing only mild pain. Some cause infertility or menstrual disorders. Ovarian cysts may disappear after a short time. If they don't, your doctor may wan t to perform laparoscopy to find out what type they are, since some of these cysts on the ovaries may need to be removed surgically. Tumors of the uterus can also be examined by laparoscopy.
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SPECIAL PRECAUTIONS

Some conditions increase the risk of complications with laparoscopy:
  • Obesity
  • Previous lower abdominal surgery
  • Heart or lung disease
Sometimes a condition is serious enough to require laparoscopy, even though a patient has one of these medical problems. If so, it may be more difficult to insert the instruments into the pelvic cavity or to see through the laparoscope. In these cases, the doctor may have to make a larger incision to insert the instrument - this is called open laparoscopy.

BEFORE SURGERY

Usually you will be advised not to eat or drink anything for a specific time before the operation. You will be asked to undergo some laboratory tests before the procedure.
Laparoscopy is performed with an anesthetic. You and your doctor can discuss which type is best for you. With general anesthesia, you will be asleep, so you will not feel any discomfort. With local anesthesia, you will be awake during the operation. There may be minor discomfort. If a local anesthetic is used, you may be given medication to help you relax before the anesthetic is injected.
The abdomen is cleansed and draped for the procedure. Then an instrument may be placed in the uterus through the vagina.


The Laparoscopic Procedure

During surgery, the woman's body is tilted slightly with the feet raised higher than the head. This allows some of the abdominal organs to shift upward toward the chest and out of the way. A gas, such as carbon dioxide or nitrous oxide, is allowed to flow into the abdomen through a special needle. As the gas enters the abdomen, it creates a space inside by pushing the abdominal wall and the bowel away from the organs in the pelvic area. This makes it easier for the surgeon to see the reproductive organs.
The laparoscope is a slender tube, like a miniature telescope, that is inserted through a small incision just below the navel. It is equipped with a lens for a clear view. A special attachment transmits light down through the tube, into the abdomen, so the doctor can see the ovaries, uterus, fallopian tubes, and nearby organs.
If needed, surgical instruments can be inserted through the laparoscope or another small incision lower in the abdomen. With the aid of the laparoscope and these instruments...

  • Pelvic organs can be seen
  • Adhesions can be separated
  • Tissue can be sampled
  • An intrauterine device (IUD), if found outside of the uterus in the abdomen, can be removed

Once the procedure is completed, the instruments are removed, the gas is released, and the incisions are closed. A small adhesive bandage may be placed over the incisions.


COMPLICATIONS

Laparoscopy is an operation with minimal risk. Complications occur in about 3 of every 1000 women who have diagnostic laparoscopy. These complications can include minor problems as well as injuries to nearby organs, bleeding, or complications from anesthesia. Talking over the possibilities ahead of time will help you prepare for them. Most often the problems can be treated and corrected. On occasion, the surgeon may need to make a separate incision and perform a separate operation.
A small cut in the bowel or any of the other abdominal organs could require more surgery. Usually these problems are avoided by the steps taken to push these organs out of the path of the laparoscope. Despite these efforts, unforeseen problems, such as abnormal changes in the abdomen caused by disease or organs that are not in their normal positions, make it impossible to entirely avoid complications. In most cases, these injuries can be recognized when they occur and can be repaired.
Sometimes the injury may not be evident at the time of the laparoscopic operation, but appears several days later. This must be repaired with another operation.


RECOVERY

After surgery, you will be allowed to rest about 2-4 hours to recover from the anesthesia. If there were no complications, you can go home the same day.
After the operation, you may feel some discomfort that usually disappears in a day:

  • Mild nausea from the medication or the procedure
  • Pains in your neck and shoulders from the gas put inside the abdomen
  • Pain where the instruments passed through the abdominal wall
  • A scratchy throat if a breathing tube was used during general anesthesia
  • Cramps like menstrual cramps
  • Discharge like a menstrual flow for a day or two
Most of these minor symptoms will be gone by the day after surgery, though you may be tired and have muscle ache for a day or two more. In addition, your abdomen may feel swollen for a few days.
Bruising may occur at the site of the incision. If you feel up to it, you can shower or bathe within 24 hours. If the incision appears infected or is tender, or if you develop a fever, contact your doctor. It is safe to resume normal activities as soon as you feel able. Ask your doctor about resuming sexual activity.
Any unusual symptom, either minor or severe, should be reported to your doctor at once.

Thinking It Over...

Laparoscopy often leads to an accurate diagnosis which leads to more appropriate and specific treatment. Once your laparoscopy is over, your doctor will usually have a good idea what is wrong. You may be relieved to know what was causing the symptoms you were having. Whatever the problem is, you can be assured that the chances of being treated effectively are improved now that the diagnosis is accurate.


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