ADVANCED LAPAROSCOPIC SURGERY
Laparoscopic (keyhole) surgery combines the benefits of simplicity and short hospital stay (mostly day case) with minimal abdominal scarring and faster recovery.
What is laparoscopy?
Laparoscopy is the technique of inspecting or operating on the inside of the abdomen and/or pelvis through small ‘keyhole’ cuts, thereby avoiding open abdominal surgery (laparotomy) for which bigger abdominal cuts are necessary. Laparoscopy is safely achieved by inflating the abdomen with gas (carbon dioxide), making 2-4 small cuts in the abdomen (usually only 0.5-1cm long) as depicted in the diagram below, and introducing ports through which the camera/equipment are introduced into the body. The small cuts made for laparoscopy normally only require skin glue to close them. Laparoscopy has major advantages over laparotomy, including shorter hospital admission, faster recovery and return to normal functioning, reduced post-operative pain, reduced risk of post-operative adhesion formation (fibrous scarring that can form between different body tissues), and a more aesthetically pleasing abdominal scar.
Belly button area
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x x = abdominal cuts
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Our scope of advanced laparoscopic surgery procedures includes:
Laparoscopic reversal of sterilisation
This involves reopening the fallopian tubes in women who were previously sterilised but now wish to try for natural pregnancy. This is achieved by keyhole surgery with a high success rate (about 85%) that makes it very worthwhile. The advantage of this over IVF treatment is that the woman can potentially have more children without the need for further medical intervention. This is normally a day case procedure with about 2 weeks’ recuperation.
Laparoscopic uterine cerclage
This involves placing a permanent stitch around the neck of the womb by keyhole surgery in women who have repeated mid-pregnancy miscarriages and for whom vaginal/cervical stitches have been unsuccessful. This is normally a day case procedure requiring about 2 weeks’ recuperation.
Laparoscopic tubal surgery
This involves repairing/reopening the fallopian tubes in women with some types of tubal infertility (damage/blockage) to assist them to conceive naturally. The advantage of this over IVF treatment is that the woman can potentially have several more children without the need for more medical interventions. This is normally a day case procedure requiring about 2 weeks’ recuperation.
Laparoscopic excision of endometriosis
At Aurora, we pride ourselves with being one of the leading UK centres offering excisional surgery for endometriosis and our laparoscopic excisions typically involve ‘Total Peritoneal Excision’ as a matter of course. The scope of this type of keyhole surgery ranges from simple excision of mild endometriosis all the way to more complex procedures to remove endometriosis from the rectovaginal septum. We also work closely with Colorectal Surgery and Urology colleagues to excise endometriosis in the bowel and urinary tract. We utilise various forms of energy to achieve these including ultrasound and diathermy. Excision of simple/moderate endometriosis is normally a day case procedure requiring 2 weeks’ recuperation while radical resection of rectovaginal endometriosis requires up to 2 days of hospital stay with about 4 weeks’ recuperation. Aurora has established a BSGE accredited specialist endometriosis centre called ‘Cheshire Endometriosis Centre’ which means we comply with the rigorous regulatory demands of expertly managing endometriosis.
Laparoscopic excision of ovarian cysts
This involves removal of troublesome cysts from the ovaries whilst retaining healthy ovarian tissue so that they continue to function normally. We deal with all types and sizes of ovarian cysts including endometriotic, dermoid, haemorrhagic and simple cysts. This is normally a day case procedure requiring about 2 weeks’ recuperation.
Laparoscopic hysterectomy
This involves removing the entire womb (total laparoscopic hysterectomy) or the womb without the cervix (subtotal hysterectomy) for any reason. This normally involves a 1/2-day hospital stay and about 4 weeks’ recuperation.
Laparoscopic myomectomy
This involves removal of uterine fibroids from the womb while conserving the womb and it is particularly beneficial for women with fibroids who wish to retain the option of future fertility. This normally involves a 1/2-day hospital stay and about 4 weeks’ recuperation.
Laparoscopic adhesiolysis
Adhesions are sometimes associated with pelvic pain, delay in conceiving and interference with internal organ (mostly bowel) function. We remove problematic adhesions by keyhole surgery and this is normally a day case procedure with about 2 weeks’ recuperation.
What to expect following laparoscopic surgery
Anti-adhesion agents: we take active measures to reduce the risk of adhesions forming after laparoscopic surgery. We do this in two ways: i) by leaving about one liter of a special fluid (called Adept) in the abdomen – this gets absorbed by the body within a week; ii) occasionally by spraying a special gel (called Coseal) on the surface of the tissues we have operated on before closing the abdomen. Adept might give rise to a feeling of heaviness and fluid moving around the pelvic area for a few days.
Abdominal wounds: these are normally closed with skin glue which does not need any special treatment afterwards. The glue will eventually wash off after the wound heals. We recommend that you keep the wound surfaces dry and prevent water from getting onto them for about 48 hours. You might notice painless swelling of the tissues around the wound or in the vulval area; this is usually nothing to worry about as it usually reflects seepage of fluid from the abdominal cavity into the abdominal wall and/or vulval tissues and should resolve in a few days. Very occasionally, there may be seepage of fluid through one or more abdominal wounds; this is again nothing to worry about and we recommend you simply cover the affected wound with dry plaster. You do not need to do anything special to the wounds and should avoid rubbing any substance into them.
Passing urine: depending on the procedure you had, you may be able to pass urine on your own or you may need to have a bladder catheter in place for a few days. Most women will have no problems passing urine after the catheter is removed, and in the very few who do, any difficulty is usually overcome by keeping the catheter in place for a little longer.
Pain: the first 24 hours after laparoscopic surgery can be associated with significant abdominal and pelvic pains for which we provide strong painkillers. We recommend you use the painkillers to keep on top of the pain so it remains manageable. The pain usually becomes much less troubling by the second day and thereafter resolves gradually.
Hospital stay: this depends on the procedure performed. The vast majority of laparoscopic surgery is performed as day case. Operations needing inpatient hospital stay usually involve 1/2-day hospital stays. We advise women to continue with adequate bed rest and restricted activity for 1-2 weeks on discharge home.
Return to normal routines: this also depends on the procedure performed but is significantly shorter than the time it takes following open abdominal surgery. We recommend staying off work for 1 week after a mild procedure, 2 weeks after an intermediate procedure, and 4-6 weeks after a major procedure.
Hospital follow-up: this might not be necessary for some women but where indicated is usually arranged about 4-6 weeks after surgery.
Benefits of laparoscopic surgery
- Reduced operative blood loss and need for blood transfusion.
- Shorter hospital stay.
- Faster recovery and return to normal routines.
- Reduced post-operative pain.
- Smaller and more aesthetically pleasing abdominal scars.
- Reduced risk of adhesions and their long-term complications of infertility, pelvic pain and intestinal obstruction.
- Greater post-operative satisfaction with the treatment.
Risks of laparoscopic surgery
Our current state of knowledge indicates that laparoscopic surgery is not riskier than traditional abdominal surgery; on the contrary it is often safer. Having said that, no operation is completely risk free and so we’ve listed below common and serious risks of laparoscopic surgery.
Bleeding: the risk of significant bleeding during laparoscopic surgery depends on the type and complexity of the operation. Bleeding can occur during the operation or afterwards and this could lead to a collection of blood in the pelvis; this is known as a haematoma. Excessive bleeding is unusual during/following laparoscopic surgery and when it occurs may necessitate a blood transfusion.
Injury to abdominal organs: the organs at greatest risk of injury are the bladder, ureters and intestines. The risks of injury are small, less than 1 in 100, and most such injuries are usually obvious and so treatable at the time of the operation.
Adhesion formation: adhesion formation complicates all types of surgery but evidence indicates that this is less with laparoscopic surgery. We take active measures during the surgery to reduce this risk.
Infection: these can affect the pelvis, urinary tract or abdominal wounds. Infections are uncommon, complicating less than 1 in 100 operations. It is not uncommon for women to develop a transient high temperature within 24 hours of surgery; this is usually not due to infection and does not require any special treatment. We normally use prophylactic antibiotics during surgery to reduce the risk of infection, and those that develop later usually respond well to further courses of antibiotics.
Deep vein thrombosis (blood clots): the risk of blood clots in the veins is much lower with laparoscopic compared to abdominal surgery. Nonetheless, we put in place blood strategies to further reduce this risk for high risk cases.
Conversion to abdominal surgery: occasionally, we might decide it is safer to abandon the laparoscopic route and complete the surgery abdominally. The risk of this depends on the complexity of the surgery but averages less than 1 in every 100 operative laparoscopic procedures.
