Laparoscopy: Indications, Preparations, Procedure methods and Recovery

Medically reviewed: 10, February 2024

Laparoscopy: preparation, testimony and consequences, advice

Laparoscopy is a minimally invasive, without a cut-through incision of the anterior abdominal wall, an operation that is performed by means of special optical (endoscopic) equipment for examination of the abdominal cavity organs. Its introduction into practice significantly expanded the capabilities of general surgical, gynecological and urological physicians.

The vast experience accumulated to date has shown that rehabilitation after laparoscopy, in comparison with traditional laparotomy access, proceeds much easier and shorter in duration.

Laparoscopy in gynecology

Laparoscopy in gynecology has become particularly important. It is used both for the diagnosis of many pathological conditions, and for the purposes of surgical treatment. According to different data in many departments of the gynecological profile, about 90% of all operations are performed by laparoscopic access.

Indications and contraindications for laparoscopy

Diagnostic laparoscopy can be planned or emergency.

Indications

Scheduled diagnostics include:

• The formation of a tumor-like nature of an unknown origin in the ovary region (for more details on ovarian laparoscopy, see our previous article).
• Necessity of differential diagnostics of tumor-shaped formation of internal genital organs with such intestine.
• The need for biopsies in the syndrome of polycystic ovaries or other tumors.
• Suspicion of intact ectopic pregnancy.
• Diagnosis of patency of the fallopian tubes, performed in order to establish the cause of infertility (in cases of impossibility of carrying it through more sparing methods).
• Clarification of the presence and nature of anomalies in the development of internal genital organs.
• The need to determine the stage of the malignant process to address the issue of the scope and scope of surgical treatment.
• Differential diagnosis of chronic pelvic pain in endometriosis with other pains of unclear etiology.
• Dynamic control of the effectiveness of treatment of inflammatory processes in the organs of the small pelvis.
• The need to control the preservation of the integrity of the uterine wall when carrying out hysteresisectoscopic operations.

Emergency laparoscopic diagnosis is performed in the following cases:

• Assumptions about the possible perforation of the uterine wall by the curette when performing diagnostic curettage or instrumental abortion.

Suspicions for:

• torsion of the cyst leg, tumor of the ovary or of the subserous mitomatous node;
• apoplexy of the ovary or rupture of its cyst;
• progressive tubal pregnancy or impaired ectopic pregnancy as a tubal abortion;
• inflammatory tubo-ovarian formation, pyosalpinx, especially with the destruction of the uterine tube and the development of pelvioperitonitis;

• Necrosis of the myomatous node.

Increase in symptoms during 12 hours or absence during 2 days of positive dynamics in the treatment of acute inflammatory process in the appendages of the uterus.

Acute pain syndrome in the lower abdomen of unclear etiology and the need for differential diagnosis with acute appendicitis, perforation of the ileum diverticulum, with terminal ileitis, acute necrosis of the fat suspension.

After clarifying the diagnosis, diagnostic laparoscopy often turns into a therapeutic laparoscopy, that is, laparoscopic removal of the uterine tube, ovary, suturing of the uterus with its perforation, emergency myomectomy with necrosis of the myomatous node, dissection of the adhesions of the abdominal cavity, restoration of the passableness of the fallopian tubes, etc.

• Planned operations

except for some of the already mentioned ones, are plastic or ligation of the fallopian tubes, planned myomectomy, treatment of endometriosis and polycystic ovaries, hysterectomy and some others.

Contraindications

Contraindications can be absolute and relative.

The main absolute contraindications:

• The presence of hemorrhagic shock, which is often met with a rupture of the fallopian tube or, much less often, with apoplexy of the ovary, rupture of the cyst and other pathologies.
• Noncorrectable bleeding disorders.
• Chronic diseases of the cardiovascular or respiratory systems in the stage of decompensation.
• The inadmissibility of giving the patient Trendelenburg position, which consists in tilting (during the procedure) of the operating table in such a way that its head end is below the foot. This can not be done in the presence of a woman’s pathology associated with cerebral vessels, the residual consequences of a trauma of the latter, a sliding hernia of the diaphragm or esophagus and some other diseases.
• An established malignant tumor of the ovary and fallopian tube, except for the cases when it is necessary to control the effectiveness of the radiotherapy or chemotherapy.
• Acute renal and hepatic insufficiency.

Relative contraindications:

• Hypersensitivity simultaneously to several types of allergens (polyvalent allergy).
• Assumption of a malignant tumor of the uterine appendages.
• Spilled peritonitis.
• Significant adhesion process of the small pelvis, which developed as a result of inflammatory processes or previous surgical interventions.
• An ovarian tumor whose diameter is more than 14 cm.
• Pregnancy, which is longer than 16-18 weeks.
• Uterine fibroids larger than 16 weeks.

Preparation for laparoscopy and the principle of its implementation

Preparation for the laparoscopy

The operation is performed under general anesthesia, therefore, in the preparatory period the patient is examined by the operating gynecologist and anesthesiologist, and if necessary by other specialists, depending on the presence of concomitant diseases or questionable questions in terms of diagnosis of the underlying pathology (surgeon, urologist, therapist, etc.).

Analyses and tests before surgery

In addition, laboratory and instrumental studies are additionally assigned. Obligatory analyzes before laparoscopy are the same as for any surgical interventions-general blood and urine tests, a biochemical blood test involving blood glucose, electrolytes, prothrombin and some other parameters, coagulogram, determination of the group and Rh factor, syphilis, hepatitis and HIV.

Chest fluorography, electrocardiography and ultrasound of the pelvic organs are repeated (if necessary). In the evening on the eve of the operation, food is not allowed, and in the morning on the day of the operation – food and liquids. In addition, in the evening and in the morning a cleansing enema is prescribed.

If laparoscopy is performed according to emergency indications, the number of examinations is limited to general blood and urine tests, coagulogram, determination of the blood group and Rh factor, electrocardiogram. The remaining analyzes (glucose and electrolytes content) are carried out only if necessary.

No food before surgery

It is forbidden to take food and liquids 2 hours before an emergency operation, a cleansing enema is prescribed and, if possible, gastric lavage is carried out through the probe in order to prevent emesis and regurgitation of gastric contents in the respiratory tract during anesthesia.

On what day of the cycle are laparoscopy done?

During menstruation, the bleeding of tissues is increased. In this regard, the planned operation, as a rule, is appointed on any day after the 5th – 7th day from the start of the last menstruation. If laparoscopy is carried out urgently, then the presence of menstruation is not a contraindication for it, but is taken into account by the surgeon and anesthesiologist.

Direct preparation

General anesthesia with laparoscopy may be intravenous, but, as a rule, it is endotracheal anesthesia, which can be combined with intravenous.

Further preparation for the operation is carried out in stages.

An hour before the patient’s transfer to the operating room, still in the ward, an appointment is made by the anesthesiologist – the introduction of the necessary drugs that help prevent some complications at the time of injection into anesthesia and improve its course.

In the operating room, a woman is provided with a dropper for intravenous administration of the necessary drugs, and monitor electrodes, in order to continuously monitor the function of the heart activity and hemoglobin saturation during anesthesia and surgical intervention.

Conduction of intravenous anesthesia followed by intravenous introduction of relaxants for total relaxation of the entire musculature, which makes it possible to insert the endotracheal tube into the trachea and increases the possibility of a survey of the abdominal cavity during laparoscopy.

The introduction of the endotracheal tube and its connection to the anesthesia apparatus, through which artificial ventilation of the lungs is carried out and the supply of inhalation anesthetics to maintain anesthesia. The latter can be carried out in combination with intravenous drugs for anesthesia or without them.

This completes the preparation for the operation.

How is laparoscopy performed?

The very principle of the methodology is as follows:

The application of pneumoperitoneum – the injection of gas into the abdominal cavity. This allows you to increase the volume of the latter by creating a free space in the abdomen, which provides a review and makes it possible to freely manipulate tools without significant risk of damage to neighboring organs.

Introduction to the abdominal cavity of tubes – hollow tubes, intended for carrying through them endoscopic instruments.

Superimposition of pneumoperitoneum

In the navel area, a skin incision is made from 0.5 to 1.0 cm in length (depending on the diameter of the tube), the anterior abdominal wall is lifted behind the skin fold and a special needle is inserted into the abdominal cavity under a slight inclination towards the small pelvis.

About 3 – 4 liters of carbon dioxide are injected through it under pressure control, which should not exceed 12-14 mm Hg.

Higher pressure in the abdominal cavity compresses the venous vessels and disrupts the return of venous blood, raises the level of the diaphragm standing, which “presses” the lungs.

Reducing the volume of the lungs creates significant difficulties for the anesthesiologist in terms of adequate implementation of their artificial ventilation and maintenance of cardiac function.

Inserting the tubes

The needle is removed after reaching the necessary pressure, and the main tube is inserted through the same cutaneous incision into the abdominal cavity at an angle of up to 60 ° with the help of a trocar placed in it (an instrument for piercing the abdominal wall while maintaining its tightness).

Trocar is removed, and a laparoscope with a light guide (for lighting) connected to it and a video camera through which an enlarged image is transmitted to the monitor screen via a fiber-optic connection is carried through the tube to the abdominal cavity.

Then at the two other corresponding points, the dermal dimensions of the same length are made, and in the same way additional tubes for manipulation tools are inserted.

Various tools used in laparoscopy

After this, a revision (a general panoramic examination) of the entire abdominal cavity is performed, which allows to detect the presence of purulent, serous or hemorrhagic contents in the abdomen, tumors, adhesions, fibrin deposits, the state of the intestine and liver.

Then the patient is tilted the operating table to the position of Fauler (on its side) or Trendelenburg. This facilitates the displacement of the intestine and facilitates manipulation during the detailed targeted diagnostic examination of the pelvic organs.

After a diagnostic examination, the question of choosing a further tactic is decided, which may consist of:

implementation of laparoscopic or laparotomic surgical treatment;

• biopsy;
• drainage of the abdominal cavity;
• completion of laparoscopic diagnostics by removing gas and tubes from the abdominal cavity.

Three short incisions are applied cosmetic sutures, which subsequently dissolve themselves. If non-absorbable seams are applied, they are removed after 7-10 days. Formed on the site of the cuts, the scars become almost invisible with time.

If necessary, diagnostic laparoscopy is translated into a therapeutic one, that is, surgical treatment with a laparoscopic method is performed.

Possible complications after laparoscopy

Complications of diagnostic laparoscopy are extremely rare. The most dangerous of them arise when introducing trocar and introducing carbon dioxide. These include:

• massive bleeding as a result of the injury of a large vessel of the anterior abdominal wall, mesenteric vessels, aorta or
• inferior vena cava, internal iliac artery or vein;
• gas embolism as a result of gas entering a damaged vessel;
• dererosirovanie (damage to the outer shell) of the intestine or its perforation (perforation of the wall);
• pneumothorax;
• a common subcutaneous emphysema with a shift in the mediastinum or compression of its organs.

After laparoscopy: Postoperative period

Long-term negative consequences

The most frequent negative consequences of laparoscopy in the near and distant postoperative periods are spikes that can cause infertility, bowel dysfunction and adhesive intestinal obstruction. Their formation can occur as a result of traumatically conducted manipulations with insufficient experience of the surgeon or already existing pathology in the abdominal cavity.

But more often it depends on the individual characteristics of the woman’s body.

Another serious complication in the postoperative period is a slow bleeding into the abdominal cavity from the damaged small vessels or as a result of even a slight rupture of the liver capsule that may occur during a panoramic revision of the abdominal cavity. Such complication arises only in cases when the damage was not noticed and not eliminated by the doctor during the operation, which occurs in exceptional cases.

Other consequences that do not pose a risk include hematomas and a small amount of gas in the subcutaneous tissues in the area of ​​introduction of trocars that dissolve independently, the development of purulent inflammation (very rarely) in the wound region, the formation of a postoperative hernia.

Recovery period after laparoscopy

Recovery after laparoscopy occurs, as a rule, quickly and proceeds smoothly. Active movements in bed are recommended already in the first hours, and walking – after a few (5-7) hours, depending on the state of health. This helps to prevent the development of intestinal paresis (absence of peristalsis). As a rule, after 7 hours or the next day the patient is discharged from the department.

Relatively intense soreness in the abdomen and lumbar region remains only the first few hours after the operation and usually does not require the use of pain medications. By the evening of the same day and the next day, subfebrile (up to 37.5 ° C) temperature and saccharine, and subsequently mucous excreted without blood from the genital tract. The latter can persist on an average of one, a maximum of 2 weeks.

When and what can you eat after the operation?

As a result of the effects of anesthesia, irritation of the peritoneum and abdominal organs, especially the intestines, gas and laparoscopic instruments, some women may experience nausea, single, rarely repeated vomiting in the first hours after the procedure and sometimes throughout the day.

It is also possible paresis of the intestine, which sometimes persists the next day.

In this connection, 2 hours after the operation, in the absence of nausea and vomiting, only 2-3 gulps of still water are allowed, gradually adding its reception to the required volume by the evening. The next day, in the absence of nausea and bloating and with the presence of active intestinal peristalsis, which is determined by the attending physician, one can consume ordinary non-carbonated mineral water in unlimited quantities and easily digestible food.

If the symptoms described above persist the next day, the patient continues treatment in a hospital. It consists of a hunger diet, stimulation of bowel function and intravenous drip administration of solutions with electrolytes.

When will my menstrual cycle be restored?

The next month after laparoscopy, if it was done in the first days after menstruation, usually appear in normal time, but the bloody discharge can be much more plentiful than usual. In some cases, menstruation may be delayed up to 7-14 days. If the operation is carried out later, then this day is considered the first day of the last menstruation.

Can I sunbathe?

Staying in direct sunlight is not recommended for 2-3 weeks.

When can I get pregnant?

The timing of a possible pregnancy and attempts at its implementation are not limited to anything, but only if the operation was exceptionally diagnostic.

Attempts to carry out pregnancy after laparoscopy, which was conducted in occasion of infertility and accompanied by removal of adhesions, are recommended after 1 month (after the next menstruation) throughout the year. If the removal of fibroids has been performed – not earlier than in six months.

Laparoscopy is low-traumatic, relatively safe and low-risk complications, a cosmetically acceptable and cost-effective method of surgical intervention.