Laparoscopic Surgery In Gynaecology
Yuen Pong Mo*, MBChB, MRCOG Advantages of Laparoscopic Surgery
Senior Medical Officer
Department of Obstetrics and Gynaecology Post-operative pain, complications and
Prince of Wales Hospital recovery times are related almost exclusively to
Shatin the size and position of the initial surgical incision.
Traditional laparotomy requires a large surgical
Laparoscopy is the visualisation of the incision which increases the morbidity of the
abdomino-pelvic cavity by the use of a telescope. operation. The wound is painful and requires
It is commonly used for the diagnosis of pelvic powerful analgesic medication. These reduce the
pain, both acute and chronic, and as part of the patient's mobility and increase dependency time.
basic workup of the infertile couple. Laparoscopic Irrespective of what procedure has been
surgery is the performance of a surgical procedure performed underneath the scar, most patients
with the aid of laparoscopic visualisation. require around 7 to 10 days in the hospital to
recover from the abdominal wound. Similarly, the
post-operative convalescence time is also
History prolonged to around 2 to 3 months after a major
operation, delaying patients from returning to
The history of laparoscopy is relatively short. work. The recovery period is further increased if
In 1910, Jacobaeus of Sweden first recorded the the patient has had pervious laparotomy, is obese,
use of a cystoscope to visualise the human or suffers from diabetes mellitus. Furthermore,
abdominal cavity in patients with ascites, and the operation leaves a long scar on the abdomen
applied the name laparoscopy1. The use of which may not be cosmetically acceptable by
laparoscopy was initially limited to diagnostic patients, especially younger female patients.
procedures only. Ruddock, in 1934, was the first
to realise that laparoscopy should be considered a The advance in technology and the
surgical procedure2. In the early 1970s, development of endoscopic instruments allow
laparoscopy was first applied as a safe and operations to be performed laparoscopically
effective method of tubal sterilisation. In 1974, without making a large incision on the abdomen.
Semm of Germany reported the use of The patient is usually fit to return home within
laparoscopy to perform adhesiolysis, 24-28 hours after the procedure, irrespective of
salpingectomy, salpingostomy, ovarian cystectomy, the duration of the operation or the nature of the
oophorectomy and myomectomy and the term pathology. The convalescence time is also
pelviscopy emerged3. With the development of significantly reduced. Small incision wounds heal
chip video camera, the breadth of surgical with minimal scarring and have a very good
procedures spread rapidly, both in gynaecology cosmetic result. In economic terms, laparoscopic
and other surgical specialties such as general, surgery is associated with a 69% reduction in
thoracic and urologic surgery. hospital stay and 51% reduction in hospital cost4.
*Address for correspondence: Dr. Yuen Pong Mo, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Shatin, N.T.
Hong Kong Practitioner 16 (1) January 1994
Laparoscopic surgery is less likely to cause Laparoscopic ovarian surgery carries with it
adhesion formation than laparotomy5-6. This is the possibility of misdiagnosing a malignancy.
especially important in young female patients as In fact, a total of 42 cases of laparoscopic
adhesions may cause tubal occlusion and/or excision of ovarian neoplasms subsequently
interfere with tubal motility, therefore found to be malignant was reported in a survey
jeopardizing fertility potential. Finally, the conducted by the members of the Society of
likelihood of incisional hernia after laparoscopic Gynaecologic Oncologists15. This resulted in a
surgery is also minimal. delay in definitive surgical management and the
possibility of a worsening prognosis. Therefore
laparoscopic ovarian surgery should only be
Scope of Laparoscopic Surgery performed in patients with no risk factors for
Laparoscopic salpingostomy and salping- Uterine Surgery
ectomy have proved to be an effective way of
treating tubal pregnancy7-12. Patients with Many techniques of laparoscopic
ectopic pregnancies treated laparoscopically myomectomy have been described in the
stayed in hospital for a mean of 1.7 days literature3'16'17. However, the outcome and
compared with 5.2 days following laparotomy. results of the procedure have not been fully
They also returned to work much earlier evaluated. Even more controversial is the
following laparoscopic treatment (2.5 weeks Vs operation of laparoscopic hysterectomy. The
5.7 weeks). aim of laparoscopic hysterectomy is to convert
an ' otherwise abdominal hysterectomy into a
Laparoscopic salpingostomy has been shown vaginal hysterectomy. Laparoscopically assisted
to result in patency rate of 83%13. However, vaginal hysterectomy combines operative
persistent trophoblastic activity occurs in 5-15%7 laparoscopic techniques with vaginal
and therefore serial 8-HCG levels must be hysterectomy and a variety of techniques using
monitored. different instruments has been reported18-12.
The operating and anaesthetic times are usually
increased and there is no randomised clinical
Ovarian Surgery study on the their benefits over conventional
The use of laparoscopic surgery for the
management of ovarian cysts has increased
dramatically in the past few years. Other Surgeries
Laparoscopic ovarian cystectomy has been
described for endometriomas, dermoids, and Operative laparoscopy can also be applied
cystadenomas14. Ovarian cystectomy is in adhesiolysis22, drainage of pelvic abscess23'24,
preferable to oophorectomy in women who suspension of the uterus25, presacral
desire a future pregnancy, especially when a neurectomy and colposuspension. More
single ovary is present. However, cystectomy is advanced procedures include lymphadenectomy27"
not appropriate when malignancy is suspected , radical hysterectomy with lymphadenectomy30
as in the presence of septae, internal echoes, or and other surgical treatment for gynaecological
solid areas as detected on ultrasonography. malignancies27,31.
(Continued on page 27)
Hong Kong Practitioner 16 (1) January 1994
Contraindications pneumoperitoneum can result in cardiac
There are no absolute contraindications to
laparoscopy provided that the operator Complications from laparoscopy are multiple
understands the limitations of the procedure. and well known. They can be early or delayed.
The benefits of laparoscopy should be weighed Early complications are usually recognized and
against its risks. When there is a very high corrected. These include bowel or bladder
chance of organ(s) injury as in the presence of perforation and vascular injury. Delayed
extensive abdomino-pelvic adhesions or a very complications require a high index of suspicion for
large abdominal/pelvic mass, laparoscopy should diagnosis. These include unrecognized bowel or
not be performed. Patients with severe cardio- bladder injuries with subsequent infection and
pulmonary disease, significant abdominal or sepsis, or fistula formation. Delayed haemorrhage
diaphragmatic hernia cannot tolerate the can also occur, especially when haemostasis was
Trendelenburg position and the creation of not assured at the end of the operation.
pneumoperitoneum, making laparoscopy not
desirable. Although some complications are
unavoidable, the surgeon's experience and the use
Massive obesity is a relative contraindication of proper instruments are the major factors in
because of the difficulty in visualisation of the determining complication rates. Irrespective of
pelvis and manipulation of the instruments seniority and proficiency at open surgical
through ancillary puncture sites. techniques these procedures should not be
attempted before the operator has received proper
The major contraindication to laparoscopic and extensive training and the necessary
surgery is probably inexperience of the surgeon. equipments are available.
This kind of operation should not be performed if
the surgeon has not received proper training and
the appropriate instruments are not available. Conclusion
Laparoscopic surgery is a safe procedure
Risks and Complications when its limitations are known. Its benefits
include reduced morbidity, short hospitalisation
Every operation carries risks and and convalescence, and early return to work.
complications. There is no exception to this rule However, its value has not been exposed to
in laparoscopic surgeries. Most complications are prospective randomised clinical trials and whether
associated with trocar insertion or the induction of it is really superior to traditional open surgery is
pneumoperitoneum. still not clear. •
Laparoscopic surgery has two unique
problems that make anaesthesia more challenging. References
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