Laparoscopy -- The Kinder Cut
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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Laparoscopy 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?
Most infertile women require diagnostic laparoscopy in order to complete
their evaluation. Generally, the procedure is performed after the basic
infertility tests, although the presence of pain or other problems (such as a
history of previous surgery) may signal that a laparoscopy until the rest of
your evaluation is completed, since it is a surgical procedure.
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
Some doctors try to perform the diagnostic laparoscopy during the
periovulatory period (i.e., when the eggs are ripe, as judged by ultrasound)
because such timing allows them to visualize follicular development. Some others
prefer this timing so that they can treat the infertility at the same by doing
an intratubal insemination (also called SIFT or sperm intrafallopian transfer)
in that cycle, if appropriate. This would be possible only if a previously done
HSG showed be possible only if a previously done HSG showed that the tubes were
Precautions before 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.
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.
Another advanced technique available now is called videolaparoscopy. It is
possible to connect a video camera to the laparoscopy, 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 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
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
aforementioned procedure 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.
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.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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