Laparoscopy has become the most common way to diagnose and surgically treat endometriosis. The procedure has come a long way since the 1970s when surgeons used it exclusively for tubal ligations and simple diagnoses. In its early days, the telescope optics and the brightness of the light sources were barely adequate to see fuzzy shapes, and surgeons had only a few crude instruments. These limitations minimized the usefulness of laparoscopy.
However, with the explosion of technology in surgical instruments (refer to "Naming the Surgical Tools" later in this chapter for more specifics) and training in this procedure over the past three decades, laparoscopy has become very popular. For example, many training programs include extensive labs with computer-aided simulations and animal labs that offer doctors invaluable experience and training. Numerous post-graduate courses are available for doctors who didn't get this training in their residency program — probably because it hadn't been invented yet!
However, even with all this progress, not every gynecologic surgeon can do advanced laparoscopic surgery. Be sure you ask your surgeon about his qualifications because he needs to feel comfortable about his skills — and so do you! Note: Just because a doctor doesn't want to work through the laparoscope doesn't mean he's a poor surgeon. Actually, the opposite is true; doing a procedure through the scope may not be in your best interest. Discuss the pros and cons of each approach with your doctor.
Laparoscopy is practical for almost any type of surgery imaginable, including hysterectomy, removal of ectopic pregnancies, appendectomy, gall bladder removal, bowel resection, stomach stapling for obesity, removal of lungs, and even radical surgery for cancer. The list gets longer every day.
In gynecologic surgery, a laparoscopy has the nickname of belly button surgery because it almost always uses a small incision in, or just below, the umbilicus. (Obviously you need to shelve any navel embellishments or jewelry for this surgery!) Rarely, the entrance incision is somewhere else on the abdominal wall.
A laparoscopy (check out Figure 11-1) usually follows these steps:
Laparoscopic surgery utilizes very small incisions, and a lighted laparoscope.
Laparoscope provides surgeon with a clear view of the organs.
Laparoscope provides surgeon with a clear view of the organs.
1. An anesthesiologist or an anesthetist puts you to sleep.
(Check out the next section for more anesthesia information.)
2. The surgeon performs a vaginal exam before the surgery while you're asleep or relaxed.
This exam can be more accurate than one in the office because you're more relaxed (you can't get much more relaxed than asleep!), and your bladder is empty and doesn't get in the way (see Chapter 3 to see the close proximity of the uterus and bladder). You have a catheter during the surgery, and it may remain until you're fully awake.
3. The surgeon makes a small incision into your abdominal cavity.
4. Using a small, blunt needle or a similar device, the surgeon inserts gas (usually carbon dioxide) into the abdominal cavity.
5. The surgeon slides a trocar (a tube with a valve to prevent loss of the gas) into the cavity, allowing him to place the scope and see inside.
Because the surgeon can't see or avoid possible abnormal anatomy, he must place the needle and trocar (most have fairly sharp ends!) blindly into the area. This step is the most risky part of the procedure.
6. The surgeon makes at least one additional incision (and usually two or three) as an accessory port below the umbilical incision.
These incisions are usually about a half-inch long and provide access to the site for other instruments, such as scissors, lasers, or graspers during the procedure. Sometimes a larger accessory port is necessary for removal of big pieces of tissue or organs.
7. A camera at the end of the scope (some have the camera at the tip that goes inside you but most are on the end that is outside you) feeds the image to a monitor (large TV) so the surgeon and assistants can see their work.
Because the image is limited to two dimensions, the surgeon must rely on his experience and use great care to prevent complications. Picture printers, VCRs, or CD recorders can record your surgery for future reference (and may be available for your records).
8. Because the surgeon can now see inside the cavity with the laparo-scope and avoid vulnerable structures, he can insert the accessory ports safely.
9. Using a gentle probe or a grasper to move organs, the surgeon looks around the entire abdominal cavity, checking out your liver, gall bladder, intestines, bladder, and pelvic organs.
He can deal with any problems at this point or document them for future
10. Your surgeon may do a dilation and curettage (D&C) or hysteroscopy (a technique to examine the inside of the uterus with a smaller telescope).
These techniques allow him to be sure the inside of the uterus has no abnormalities, and he may run dye through the fallopian tubes to check for blockage.
11. At the end of the procedure, the surgeon closes all incisions under the skin with dissolving sutures or with tissue glue closure that requires no sutures.
You may have a small bandage over the incisions to keep them clean (thus another nickname — band-aid surgery). Sometimes a harmless string emerges at the incision site and either dissolves or can be removed.
If you've had a previous laparotomy or have a known infection in the abdominal cavity, the chance of running into adhesions and intestinal or bladder injury on insertion of the needle or trocar can be high. In this case, your surgeon may make a slightly larger opening into the abdominal cavity first and then place a blunt trocar to avoid the risky blind insertion with a sharp instrument. However, because studies don't show that this approach greatly reduces injury and is larger and more time consuming, it's fairly uncommon.
Almost all laparoscopies require general anesthesia, especially if your doctor expects to remove or rearrange tissues. General anesthesia allows for better and more predictable relaxation of the abdominal muscles, which makes the surgery safer and easier.
The newer anesthetic medications
1 Are very safe and gentle on your system
1 Put you to sleep quickly, easily, and safely and allow you to awaken just as quickly
1 Have an amnesiac effect so you don't remember any discomfort
1 Often include an analgesic so you have pain relief before you perceive any pain (a definite plus!)
Usually a person from the anesthesia department interviews you about your medical and surgical history before the surgery and tells you about the drugs and what to expect. A representative from your doctor's office, the hospital, or the anesthesia department will also contact you with specific instructions for you to follow before your arrival.
On the day of surgery, the following steps occur:
1. A nurse places an intravenous line (the IV) in your arm to provide your future medications quickly and easily — and without more needles.
2. You may receive a sedative to help you relax while you wait.
In the operating room, the following take place:
1. You're moved onto the operating table, and the anesthetist or anesthesiologist gives you several medications.
2. A mask is placed over your mouth with oxygen to ensure that you have enough oxygen during the surgery.
3. As soon as you're deeply asleep and your muscles are relaxed, a tube or similar device is placed through your mouth or nose into the trachea (wind pipe) to
• Be sure you receive enough oxygen.
• Prevent stomach contents or excess saliva from getting into your lungs.
Anesthesia has greatly improved over the years. Still, don't plan on driving or making important decisions for 24 hours!
Using MAC during surgery: Advantages and disadvantages
Some surgeons and anesthesiologists perform uncomplicated and quick procedures (usually tubal ligations or purely diagnostic procedures) with local anesthesia and intravenous sedation known as Monitored Anesthesia Care (MAC). The plus side: You aren't as deeply asleep with MAC, and you don't have a breathing tube.
MAC has some disadvantages for abdominal surgery, however, so be sure you know the facts before you opt for this approach. Some disadvantages are
I Your abdominal organs may not be as relaxed as they are with general anesthesia.
I Although the surgeon can numb the incision areas with a local anesthetic (such as Novocain), he can't adequately anesthetize the internal covering of the cavity or the organs that he moves and pokes. As a result, you may have some very uncomfortable moments, and you can't just stop in the middle of the procedure!
I The pressure of the gas that separates the organs can make you feel like you can't breathe — not a pleasant feeling and highly anxiety-provoking.
While your surgeon is looking inside you, what can he do if he finds endometriosis (or any other problem for that matter)? The answer depends on what you discussed when you signed the informed consent.
For example, if this is purely a diagnostic procedure, the surgeon looks around, possibly puts dye through the tubes, and may break up minor adhesions. If you hope to get pregnant and signed a consent for the surgeon to take any necessary steps, he can also try to make the anatomy as normal as possible. If you've had multiple surgeries and this surgery is an attempt to end the problem forever, he can do a hysterectomy and remove the tubes and ovaries (check out "Having a hysterectomy" later in this chapter for more information).
In short, your doctor's actions during the laparoscopy depend on your previous discussions about possible complications and risks, the severity of your symptoms, your previous history, your expectations, your desire for pregnancy now or in the future, your age, and the comfort level of the surgeon (that is, his skill level, his assessment of the risks and benefits for you, and his understanding of your expectations).
People have different pain tolerances, so predicting when you'll be back to normal after laparoscopy isn't easy. Some patients return to work the next day, and other people take weeks. Your recovery also depends on the actual procedures during surgery. Cutting a few adhesions and removing implants and cysts can be fairly pain-free because these structures have no pain nerves. But if your doctor has removed a lot of peritoneum or vaporized or cauterized endometriosis, you may have more pain because the peritoneum has pain fibers that respond to any disturbance.
Your doctor can let you know about returning to normal activities, but again, a lot depends on the surgery and how your body responds to it. Be sure to ask about sexual activity. Each surgeon has suggestions on timing, but some of the decision depends on the extent and type of surgery (such as vaginal work, D&C, or a hysteroscopy).
The wounds on the skin of the abdomen can hurt just like any other cut. Many surgeons use a local anesthetic, such as marcaine, in these sites to help relieve pain. The size of the incision can also, of course, add to the discomfort. And types of closure also affect your recovery. Sutures through the skin are more painful than sutures underneath, and a tissue glue closure normally causes the least pain.
No matter what kind of closure or incisions you have, you can decrease the recovery discomfort in several ways:
il Keep the wounds clean and covered until your doctor tells you to remove the bandage.
I Don't let clothing (especially elastic bands or belts) or jewelry rub against the wounds.
i Use a mild soap to gently lather the area, then rinse it well and replace the bandage.
I Apply an ice pack for 30 minutes and then remove it for 30 minutes as often as feasible the day of surgery. (For the first 24 hours, an ice pack can help decrease the swelling and inflammation.)
i After this first 24 hours, heat can help healing in the area. Three or four times a day, use heat just above body temperature for 20 to 30 minutes.
Your doctor prescribes pain medication based on the extent of the surgery, including ibuprofen to opioids. If you're not getting adequate pain relief from your medication, let your doctor know.
Ouch! Why your throat may hurt
Perhaps the worst part of the immediate recovery is the sore throat from the breathing tube. Though the anesthesiologist may give you medication to prevent it, most people still feel the effects. The discomfort usually doesn't last long, and you shouldn't see any blood. The treatment is the same as for any sore throat: lozenges, warm saltwater gargles, or analgesics.
Before you leave the recovery area, ask the anesthesiologist about any special difficulties you may have had during surgery so she can help you deal with them. If your sore throat persists or gets severe or if you see blood in your sputum or have trouble breathing, let your doctor know immediately.
The breathing tube is necessary because your abdominal muscles need to relax for surgery. The anesthesiologist administers a paralyzing medication to relax these muscles, but the drug also reduces your ability to breathe on your own. So, the anesthesiologist inserts an endotracheal tube into your bronchus to provide additional oxygen and to prevent you from aspirating (getting something into your lungs — not good). Although the endotracheal tube is the safest and most common instrument, other devices are also available, such as the laryngeal mask airway (LMA) or the nasotracheal tube, but they all accomplish the same goal.
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