LAPAROSCOPY
it is the surgical method which provides access to the internal gynecological organs through small incisions in the skin
it provides several advantages over traditional open surgery
it is carried out using a laparoscope, a special instrument with a built-in camera and light source, which enters the abdominal cavity or pelvis through small incisions in the skin and clearly visualizes the internal organs in real time
- diagnostic laparoscopy
- ovarian cyst or mass
- intramural and submucosal fibroids
- endometriosis
- ectopic pregnancy
- infertility investigation – Tubal patency investigation
- pelvic adhesions – frozen pelvis
- cancer of the uterus, ovaries, fallopian tubes, cervix
- small incisions with a better aesthetic result
- fast healing
- minimal blood loss
- shorter and less postoperative pain
- shorter hospitalisation time
- easier recovery and return to daily habits
under general anaesthesia, the patient is placed in a special position on the surgical bed and appropriate preparations are made for antisepsis of the surgical field
a small incision is made near the navel, through which the laparoscope is inserted
gas is injected into the abdominal cavity for better imaging of all intra-abdominal organs
the laparoscope relays the image on high-definition screens
then two extra incisions are made in the abdomen through which the surgical instruments pass
at the end of the operation, all instruments are removed
the gas is evacuated from the abdominal cavity
and the procedure finishes with suturing of small incisions of the skin
it is used to investigate:
- all condtions related to the uterus, ovaries and fallopian tubes
- ambiguous ultrasound findings
- chronic or acute abdominal pain
- infertility
- recurrent miscarriages
- the patency of the tubes
- the stage of endometriosis
- the identification of pregnancies of unknown location – exclusion of ectopic pregnancy
what is an ovarian cyst?
masses on or inside the ovary
types:
functional cysts: formed when the dominant follicle of the cycle does not rupture – usually automatically absorbed – rarely needs removal
teratomas or dermoid cysts: contain tissues from different parts of the body and are of embryological origin
cystadenomas: usually benign and rarely can progress to tumors of marginal malignancy
endometriomas: development of endometriosis cysts in the ovaries with typical ultrasound imaging
salpinx-ovarian abscesses: cystic pelvic masses with inflammatory elements due to a microbial infection of the pelvis
cystic masses of intermediate malignancy: can develop into cancer if not treated
cancer: rare occurrence and requires immediate treatment
symptoms of ovarian cysts
- menstruation disorders
- dysmenorrhea
- bleeding
- abdominal pain
- discomfort during sexual intercourse
- infertility
- swelling in the abdomen
- frequent urination
- constipation
diagnosis of ovarian cysts
gynecological ultrasound
blood tests for Ca 125
diagnostic laparoscopy
diagnostic laparoscopy can accurately capture the shape of cysts and their complications, such as ruptured or inflamed cysts and ovarian torsion
monitoring and not removal is recommended:
in some cases of cysts with a clear benign appearance, conservative treatment is recommended, as they may gradually subside with or without medication
laparoscopy rather than monitoring is recommended when:
the type, size and location of ovarian cysts is suspicious
the patient wishes to have children
the clinical picture requires the surgery (e.g. constipation, pain, painful symptoms)
laparoscopy and a not an open surgical treatment as
healthy ovarian tissue environment is maintained and ovarian reserve is not significantly affected
fibroids are benign tumors of the muscle layer of the uterus and can be found in:
in the uterine cavity (submucosal)
on the wall of the uterus (intramural)
outside the uterus (subserosal)
surgical treatment rather than monitoring is recommended due to:
the imaging findings – suspicious evidence
the size – if it is over 4 cm
their location – if they are inside the uterine cavity
clinical findings – bleeding, infertility, pain
the woman’s age, history and physical condition
laparoscopy or standard surgical treatment:
laparoscopy is the ideal method for removing fibroids up to 10-12 cm in diameter
endometriosis – what it is
it is the disease where endometrial tissue is located outside the uterus such as in the ovaries, fallopian tubes and any other organ of the body
chronic disease
it concerns women of all ages
main symptoms of endometriosis:
- problems during period:
- severe pain – dysmenorrhea
- bleeding
- pain and blood when urinating or defecating
- nausea and constipation
- severe abdominal pain
- pain during intercourse
- infertility
- discomfort from all body parts showing endometriosis e.g. gastrointestinal symptoms
diagnosis
clinical picture and history
gynecological examination
vaginal ultrasound
biochemical indicators Ca 125/ TnF- a
pelvic MRI
diagnostic laparoscopy is the only method that can accurately diagnose the presence and stage of endometriosis
laparoscopy rather than conservative treatment of endometriosis is recommended due to:
severe clinical symptoms
ultrasound findings e.g. endometriomas over 4 cm
infertility
laparoscopy and endometriosis:
the type of laparoscopy depends on the stage of endometriosis
in early-stage superficial endometriosis, electrocautery of all foci
in cystic endometriosis masses (endometriomas), removal of all foci
in advanced-stage endometriosis, a more invasive laparoscopy is performed, removing all the pathological tissue, effectively restoring pelvic organ function and completely eliminating pain
what is an ectopic pregnancy:
pregnancy where the embryo is implanted outside the intrauterine cavity, most commonly in the fallopian tubes
usually caused when the fallopian tubes are narrow or closed and especially when inflammation is present
symptoms
a positive pregnancy test with common pregnancy symptoms such as:
- period delay
- nausea and vomiting
- severe fatigue
- tenderness and swelling in the chest
- frequent urination or constipation
- vaginal secretions
- differences in appetite and taste
symptoms associated with abnormal pregnancy:
- vaginal bleeding
- intense pain in the abdomen, localized low in the abdomen
- weakness, dizziness or fainting
diagnosis
HCG monitoring – abnormal levels
vaginal ultrasound – no finding of intrauterine sac after one week of delay or with HCG levels of over 1000iu
laparoscopy rather than conservative treatment of ectopic pregnancy
It is the most appropriate method of treatment
rarely accomplished through medication
the types of laparoscopy for the treatment of ectopic pregnancy depend on the extent to which the fallopian tube has been affected by the ectopic pregnancy:
- preserving the fallopian tube through tubal ligation (opening of the fallopian tubes) and salpingoplasty
- with removal of the fallopian tube
causes of infertility that can be detected and treated through laparoscopy are the following:
- fibroids
- endometriosis
- cystic ovarian masses
- polycystic ovary syndrome
- malformations of the uterus
- pelvic adhesions – pelvic inflammatory disease
- assessment of the condition and patency of the tubes
its usefulness is determined based on the patient’s history
pelvic adhesions are the formation of abnormal connections of fibrous tissue between the organs of the pelvis by gluing the organs together
the organs where pelvic adhesions are formed, are the uterus, ovaries, fallopian tubes, bowel and bladder, but most problems are caused by pelvic adhesions of the fallopian tubes
causes:
infections and pelvic inflammation
previous surgical procedures due to problematic tissue healing
conditions such as endometriosis
clinical picture:
- usually asymptomatic
- abdominal pain
- nausea or vomiting
- discomfort during sexual intercourse
- gastrointestinal problems
- infertility
diagnosis: the only way to diagnose and treat is laparoscopy with adhesiolysis
treatment – laparoscopy:
removal by laparoscopic adhesiolysis
the function of the pelvic organs is restored
the likelihood of new adhesions forming in the future is significantly reduced
comparative advantages of the laparoscopic method over open surgery
it involves the removal of the uterus, cervix and can be combined with removal of the fallopian tubes, ovaries and part of the vagina if necessary
indications for hysterectomy
- uterine fibroid
- adenomyosis – severe endometriosis
- endometrial cancer
- cervical cancer
- ovarian cancer
- cancer of the fallopian tubes
methods of hysterectomy
laparoscopic removal of the uterus
the most painless and effective method
it is carried out under general anesthesia
three small incisions of 1 cm in the abdomen
return home on the same day and to daily activities in five days
open surgery in cases where laparoscopy is not feasible
uterine prolapse is the condition where the uterus begins to retract from its position and descend into or out of the vagina
symptoms:
- a feeling of weight or a mass coming out of the vaginal area
- frequent urination
- urinary incontinence
- constipation
- vaginal bleeding
- feeling of pressure during sexual intercourse
diagnosis:
Medical history
gynecological examination
vaginal ultrasound
causes:
- increased number of normal deliveries
- normal delivery of babies with increased weight
- history of vbac
- individual history of interventions in the pelvic region
- menopause
- obesity
- constipation
- chronic cough
- intense exercise
treatment of uterine prolapse
in mild form, monitoring and conservative treatment is recommended:
change of diet to facilitate the gastrointestinal system
weight loss
pelvic muscle strengthening exercises program
avoidance of weight lifting and carrying
in cases of moderate or severe uterine prolapse, laparoscopy is recommended
two types of laparoscopy – the choice depends on:
the degree of prolapse
the severity of the symptoms
the general state of health
the desire to have children
the types of laparoscopy for the treatment of uterine prolapse are:
correction with preservation of the uterus
the uterus is returned to its original position and stabilized by placing a special synthetic mesh between the uterus and the sacrum
hysterectomy
laparoscopic removal of the uterus in more severe cases of uterine prolapse in women who have completed childbearing
correction of vaginal prolapse after hysterectomy
it is a prolapse of the vaginal coloboma in women who have undergone a total hysterectomy
laparoscopic restoration is made through a special mesh and the technique of sacropexy