Laparoscopy is a procedure that involves insertion of a narrow telescope-like instrument through a small incision in or near the belly button. This allows visualization of the abdominal and pelvic organs including the uterus, fallopian tubes and ovaries. Laparoscopy is sometimes referred to as ‘band-aid’ surgery since the incisions are very small and usually covered with a band-aid (Steri-strip). Some people refer to it as a key- hole surgery or minimally invasive surgery.
Normal Uterus with bilateral tubes and ovaries on diagnostic laparoscopy
Do all women with infertility need to undergo this surgery?
Laparoscopy is not indicated as a routine investigation in all women who have difficulty in conceiving.
There are specific indications for undergoing laparoscopy and the decision for the same is taken in consultation with your infertility specialist.
What are the indications for laparoscopy?
Laparoscopy is indicated whenever the history of the patient, clinical examination or other investigations such as Ultrasonography (USG) or Hysterosalpingography (HSG) indicate an abnormality in pelvic region. Hysteroscopy usually goes hand in hand with laparoscopy.
Common indications being:
Diagnostic laparoscopy – It is generally done to visualize check whether the uterus and its surrounding structures are normal. A blue coloured dye can be injected from the cervix (mouth of the uterus) by an assistant and the dye is seen coming out through the fallopian tubes via the telescope, thus confirming that the tubes are open (chromopertubation).
Endometrioma (Cyst in ovary containing blood)
Hydrosalpinx or pyosalpinx (Infective fluid or pus in uterine tubes)
Pelvic adhesions (sticky bands similar to what is seen when there is fevicol smeared in between our fingers ) with or without tubo ovarian mass (Usually these occur following infection in pelvic region)
Bulky polycystic ovaries (PCOS) not responding to medical line of management
Fibroids of uterus
Failure of IUI (Intrauterine insemination) – When more than 6 consecutive cycles have not been able to achieve pregnancy.
Prior to IVF (if needed) – Sometimes the history of the couple and previous investigations lead to the conclusion that IVF (test tube baby) may be needed. In these cases endoscopic surgery may be needed to visualize the uterine cavity, particularly its lining on hysteroscopy and uterus or ovaries on laparoscopy for any abnormality which can be corrected prior to the procedure.
In women with long term unexplained infertility (where all other standard or routine investigations are normal). In these cases endoscopic surgery (Laparoscopy or hysteroscopy) may be needed to search for any factor which may have been missed by routine non invasive tests like USG ( ultra sonography) or HSG (Hysterosalpingography)
What do you mean by diagnostic laparoscopy and operative laparoscopy?
Diagnostic laparoscopy is performed as a part of investigation for infertility in cases where no abnormality is detected on non invasive tests like USG (ultrasound) or HSG (hysterosalpingography). It is usually performed in women with unexplained infertility, following failure of repeated IUIs or along with operative hysteroscopy. The pelvic anatomy is visualized with a telescope like instrument. The uterus, tubes, ovaries and there surrounding structures are systematically checked. A blue coloured dye is injected from the cervix (mouth of the uterus) by an assistant and the dye is seen coming out through the fallopian tubes via the telescope, thus confirming that the tubes are open. This is known as chromopertubation.
Diagnostic Laparoscopy Video
Video Bilateral Tubo Ovarian Mass
Diagnostic or operative hysteroscopy usually accompanies this procedure.
A review of literature shows that even among women whose tubes were found to be unobstructed or patent (open) using HSG (which shows the inside image of the fallopian tubes), 18% were found to have tubal obstruction or peritubal adhesions (outer side of the fallopian tubes) using laparoscopy and a further 34% were found to have endometriosis or fibroids (again outer side of the fallopian tube is involved or compressed). These conditions remain silent and cannot be diagnosed on non invasive tests (USG or HSG).
If there is any abnormality like fibroids, endometriosis, pelvic adhesions or blocked tubes, these can be tackled at the same time.
Many a times a diagnostic laparoscopy is done along with operative hysteroscopy in cases like hysteroscopic fibroid removal and septum resection for extra seafety of the patients, to know the end point and to prevent complications like uterine perforation.
Whenever some surgery is performed in addition to chromopertubation, like removal of fibroid, endometrioma removal, fulguration (burning) of endometriosis, adhesiolysis(separation of adhesions in pelvis) or delinking of hydrosalpinx or pyosalpinx, is called operative laparoscopy.
How is laparoscopy performed?
Laparoscopy procedure is usually done as a day care surgery (you can get admitted, undergo surgery and discharged on the very same day or the next day but generally within 24 hours) under general anaesthesia. It usually takes about few minutes to less than an hour.
During this procedure a small cut is made on or near the belly button (this leaves a minute scar which is almost invisibles). A telescope (laparoscope) is then inserted through the umbilicus and gas (carbon dioxide) is pumped into the abdomen to push the intestine away. A powerful light is then shone down through the laparoscope. The endoscopic surgeon then inspects the inside of the abdomen and pelvis including the outside of the womb / uterus, the tubes and ovaries as seen on the video monitor.
A second incision (1-1.5cm) is also made on the left or right lateral side of the lower abdomen so that another probe can be inserted in order to move pelvic organs such as the ovaries or bowels to get a clear view. A blue coloured dye (methylene blue) is then injected through the cervix (mouth of uterus). If the tubes are not blocked the dye should pass along them and spill into the abdomen.
If an abnormality is found during laparoscopy, this may be dealt with at the same time thus avoiding another operation. When performing operative laparoscopy such as opening of blocked tubes, cutting of adhesions and freeing of the tubes etc. additional instrument such as micro-scissors and forceps are placed in the abdomen through additional cuts generally on the lateral side of the abdomen.
When the surgery is completed, the gas is removed and a stitch is taken to close the incisions.
Is it a big procedure? How much work would I miss?
Diagnostic laparoscopy is a day care procedure and generally takes about 30 minutes. If on doing the laparoscopy any abnormality is seen like adhesions, cyst etc and operative work is required, the procedure might take a little longer. The woman is generally discharged home from the hospital on the same evening or the next day morning.
The woman will usually need to take off an additional 1-2 days from work following the procedure. Mild discomfort in the form of mild abdominal pain or shoulder tip pain, should be expected to last for up to 7 days or so after the procedure.
What are the complications of laparoscopy?
After the laparoscopy procedure the in about 3% of patients there may be some nausea, discomfort and shoulder tip pain, due to the gas that was injected into the abdomen. The discomfort usually lasts not more than 24-48 hours.
Major complications associated with operative laparoscopy include the possibility of damage to other structures in the pelvis such as the bladder, ureter, bowel and blood vessels. Unexpected open surgery (larger incision) is always a possibility, but is very uncommon.
Any surgery can have an anesthesia-related complication or be associated with post-operative infection, such as a skin infection at an incision site.
However when such surgeries are performed by experts with utmost care the possibility of complications is very rare.