What is a laparoscopy?
Laparoscopy refers to a surgical procedure where a telescope is placed into the abdomen to allow the organs of the abdomen and pelvis to be visualised. Undergoing a laparoscopy requires you to be admitted to a hospital and have a general anaesthetic before the procedure may be performed. The procedure may be performed as a same day procedure (being discharged home on the same day as admission) or may require you to stay in hospital for one or more nights.
A laparoscopy may be performed to either diagnose and/or treat a specific gynaecological problem. This may include:
- treatment for endometriosis or other types of pelvic pain
- investigation and treatment of infertility
- major surgical procedures such as removal of ovarian cysts or tumours, hysterectomy, myomectomy (removal of fibroids) or repair of pelvic floor problems.
Laparoscopy may also be used to treat emergency conditions such as ectopic pregnancy.
The advantages of laparoscopy compared with traditional surgical techniques (called laparotomy, where a large incision is made in the abdomen) include shorter hospital stay, less pain from the procedure, faster recovery times to return to normal home and/or work life and smaller scars.
For elective surgical procedures that include laparoscopy, you should consider the reason for the treatment, the alternatives and only proceed with the laparoscopy when you are satisfied that you understand all of the implications of the procedure. Before you have your laparoscopy, you will be asked to sign a consent form that will explain the procedure and the risks involved.
Before your laparoscopy
You will be given specific instructions on any dietary or fasting requirements before proceeding with your laparoscopy. The main reason for following a diet is to allow for a safe anaesthetic to be given and ensure that the stomach is empty.
Medication
You should stop aspirin 14 days prior to surgery. You may continue to take paracetamol or non-steroidal anti-inflammatory medications (such as Nurofen) for pain symptoms. Other regular medications such as blood pressure medications, diabetes treatments and the oral contraceptive pill should be continued. Contact your Alana Doctor if you are unsure about which medications to stop or continue. Smokers are recommended to stop smoking prior to your surgery and for 6 weeks after to improve your recovery and wound healing rate.
Your hospital stay
If you are having a laparoscopy, you will be admitted to Prince of Wales Private Hospital or the Royal Hospital for Women, and go through the following procedures:
- The administration process
- Admission to the ward
- The operating room
- Recovery
- Return to the ward
- The discharge process
The administration process involves the paperwork required by the hospital for your admission. You should ensure that you know what time you are expected to arrive for admission, and give yourself some leeway to arrive on time. Once the paper wok has been completed at the administration area of the hospital that you are being admitted to, you will be told where to attend for your admission to the ward.
Your admission to the ward will involve a day-stay admission if you are expected to go home on the same day as your surgery, or to a ward where you will stay for one or more nights. You will be oriented to the ward and have procedures explained to you by the nursing staff of the ward. They will take your observations such as pulse, blood pressure and temperature, ask you questions regarding your past history, any allergies you have and any medications that you take. You may also be measured and fitted with stockings to prevent clots (anti-embolism stockings). You will be seen by your anaesthetist who will perform examinations incliuding listening to your chest and heart. It is important that you tell your doctor, the nursing staff and the anaesthetist of any medications that you are on (including over the counter medications without prescription and herbal medications). Your consent form will be checked with you and you will have the opportunity to ask any questions regarding your procedure.
Once all of these checks have been completed you will wait until the operating room is ready for your case. You will be taken to the operating room either walking accompanied by a nurse or by a trolley. You will be checked into the operating theatres by a nurse who will confirm your details with you. Your anaesthetist will see you and put a drip in your arm and start fluids running into a vein. You may also receive medication at this time to help you relax and feel more comfortable. You will be moved into the operating room where you will be asked to move from the trolley to the operating bed. On some occasions a special board is placed under you to slide you across to the operating table. Monitoring devices for your heart and oxygen levels will be placed on you and the anaesthetic will begin with oxygen being given to you before you go to sleep.
In addition to your surgeon and your anaesthetist, there will be a co-surgeon present to assist your surgeon and provide additional expertise, advice and care (much like the co-pilot of a plane). Once you are asleep, you will have your legs placed in stirrups and sterile drapes are placed over your entire body. A small incision is made inside the umbilicus (belly button) and a thin hollow needle is placed to fill your abdomen up with gas. This gas fills the abdomen and allows the organs of the pelvis and the abdomen to be easily visualised. Once the gas has reached a certain level, a larger tube (called a canula) is placed in through your umbilicus and the telescope is placed through this. The telescope is attached to a camera that allows your Alana doctor and the theatre staff to see the inside of your abdomen and pelvis. There will always be at least one other incision made in the abdomen of about 0.5 cm. This allows a second, smaller cannula to be placed and instruments used to move organs so that the entire abdomen and pelvis may be seen. Depending on the type of surgery being performed, there may be two or three other incision sites in addition to these two already mentioned. This is so that specialised long instruments may be used down each of these tubes to complete the surgery.
When your surgery is complete, the instruments and their cannulas are removed and the gas is released from your abdomen. It may be necessary to place a dissolving stitch in the umbilicus (belly button) and in any incision site of more than 0.5 cm. These stitches do not need to be removed and will dissolve in a few days to a few weeks. Only in special circumstances are stitches used that need to be removed. Your Alana doctor will inform you if this is the case and arrange for the stitches to come out when necessary.
Wheyour laparoscopy has been completed you will be woken from the anaesthetic and be taken to the recovery room. You may not remember much of this part of your admission, since the effects of the anaesthetic are likely to be present. In the recovery room, you will continue to be monitored and have your vital signs taken by nursing staff. Once you are awake, your pain is under control and all your observations are stable, you will be returned to the ward for further observation before being discharged if you are a day-stay patient, or will continue to be monitored for the length of your stay. You will usually spend between 30-60 minutes in the recovery room.
When you are back on the ward, your Alana doctor will see you and explain the results of the surgery to you. Don’t worry if you do not remember all of the details at this point, as these will be explained again at any and all of your subsequent visits. If you have specific questions regarding your surgery then you may contact Alana Healthcare and we will answer your questions when possible.
When you have fully recovered, your observations are stable, your bladder is working normally, your pain is under control with oral medications and you can eat, drink and walk as normal you will be discharged home. You will be given a prescription for pain medication and instructions on wound care by the nursing staff. At the time of discharge you will be given a Discharge Summary – all patients receive this and you should ask the nursing staff if it is not given to you. It contains important information regarding your procedure and discharge instructions as well as contact phone numbers. Generally, the dressings that are put on at the time of your surgery will stay on for one week. You may shower as normal with these dressings and pat dry with a towel. At the end of one week, if the dressings have not already come off, then you should remove them and any tape that may be present underneath them.
At discharge, you cannot drive yourself home and will need to be picked up from the hospital where your surgery was performed. You are likely to experience discomfort in the following areas in the days after your surgery:
- At the wound sites
- In your pelvic area
- Under your ribs
- In your shoulder tips
This discomfort is usually mild and should get better over time. If there is no improvement after a few days, you should contact your doctor at Alana Healthcare. Simple painkillers such as paracetemol and anti-inflammatory medications (e.g. Nurofen) should help with this type of pain. Resting by lying down may help to relieve these symptoms. You may resume normal physical and sexual activity when any vaginal bleeding that is present has stopped and you are feeling well. This may take between 2 days and up to 8 weeks. Generally it should be around 2 weeks. If you experience fever, chills or sweats, an increase in pain, vaginal discharge that is offensive or copious then you should contact Alana Healthcare or attend the emergency department of your nearest hospital if you are unable to contact your Alana doctor
Complications of Laparoscopy
Whilst every effort is made to complete your surgery by laparoscopy, it may be unsafe to continue the laparoscopy due to unexpected findings or life-threatening complications. At this time, it may be necessary to perform a laparotomy, which is where a large incision is made in the abdomen. Usually this will be done under the same anaesthetic. In the case of life-threatening emergencies this will be essential. A laparotomy will only be performed when continuation of laparoscopy is unwise or unsafe. It is important to recognise that your health and safety are the most important aspects of your treatment and the necessary steps to ensure your safety is the first priority.
Serious complications at the time of laparoscopy are rare but no surgery is risk-free. Even the simplest procedure may result in a complication. The most serious complications following laparoscopy are considered to be injuries to the bladder (the organ that holds urine), the ureter (the tube that leads from the kidney to the bladder), the bowel, and the major blood vessels. In addition, medical complications such as clots that develop in the legs or lungs, or excessive stress that is placed on the heart and lungs from the surgery can occur resulting in heart attack or stroke. The likelihood of these complications occurring will depend on the reason for your laparoscopy, your past surgical and medical history and your age.
Specific problems can include bladder injuries, which are usually recognised at the time of surgery. These injuries can usually be dealt with laparoscopically, without having to make a large incision in your abdomen. Occasionally a large incision in the abdomen would have to be made to repair the bladder. If you require a bladder repair following an injury, you would have a catheter in your bladder that may stay in for up to one week. You may be able to go home with the catheter in after instruction on caring for it at home if this is your preference.
Injuries to the ureter (the tube that leads from your kidney to your bladder) may only require a stent – a small hollow tube placed through the ureter from the kidney to the bladder for about 6 weeks. These can be inserted through the bladder without an incision in the abdomen and can be removed through the bladder in a simple procedure, again without an incision in the abdomen. Sometimes the ureter must be ‘reimplanted’ in the bladder. This means that a large incision is made in the abdomen (vertical midline incision – see picture over the page), the ureter is cut and placed into the top of the bladder to drain normally. A stent would be placed as above and would need removing, usually at about 6 weeks. This procedure would normally be performed as an outpatient. The bladder and the ureter will usually function completely normally after this procedure. You will require a special X-ray test at between 6 weeks and 3 months to make sure that the bladder and the ureter are working normally.
Injuries to the large blood vessels are the most urgent complication and require immediate attention. It is likely that a very large incision (midline vertical incision – see picture) would be made in the abdomen for immediate repair. Almost certainly there would be a blood transfusion. Your stay in hospital is likely to be longer than anticipated. Injury to a blood vessel is a very serious and life-threatening complication.
Injuries to the bowel may occur during a laparoscopy and can be very serious. The injury to the bowel may be very small and may not be detected at the time of the initial surgery. If the injury is detected, it can often be repaired by laparoscopy and your post-operative treatment may not be significantly altered. It may not be possible to repair the injury by laparoscopy and you may require a laparotomy to repair the injury. You will be given antibiotics and you may require a colostomy. A colostomy is where a loop of bowel is brought to the skin and stitched in place with a bag placed over this. The bowel contents will empty into the bag. This will usually be in place for three months after the surgery to allow the bowel time to heal. When the bowel is healed, the loop of bowel is closed and placed back in the abdomen. Very occasionally the colostomy may be permanent. If a bowel injury occurs during surgery and is missed, then there may be development of a serious infection in the abdomen. This will require surgery with a large incision in the abdomen and a colostomy (see above). You are likely to have a prolonged hospital stay whilst the infection is treated and may require admission to an intensive care ward. This is a very serious and life-threatening complication. The risk of bowel injury that is missed is rare with laparoscopy being less than 1/1000 cases. That is for every 1000 laparoscopies performed, there will be approximately one missed bowel injury.
Other post-operative complications following laparoscopy may include infection in the bladder, the abdominal wounds, or medical complications such as clots developing in the legs or lungs or chest infection. Whilst in hospital your observations will be taken and signs of temperature, increasing pain or problems with your urine will be monitored. You may require more tests and treatments if one of these complications occurs.
After you have gone home, if you have an increasing amount of pain, abdominal distension or cramping, vomiting, high fever or sweats, vaginal discharge that is offensive or shortness of breath then you should contact Alana Healthcare for Women or attend the emergency department and ask for further advice.