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The operating room set up for conventional laparoscopy has the patient lying on the operating table set at an incline. Under general anaesthetic, the surgeon makes a small incision in the navel and a slender spring loaded instrument called the veress needle is inserted. Carbon dioxide gas is passed continuously into the abdominal cavity to distend the abdomen. The distended abdomen makes it safer when inserting other sharp operating ports into the abdomen. The surgeon and the assistant stand on either side of the patient when operating. Laparoscopic instruments are then inserted into the abdominal cavity via small operating ports. The incision size for the operating ports measures 5 mm to 10 mm in diameter. A laparoscope containing a camera and a light source is inserted into the abdomen via the navel port. A high definition flat screen monitor is placed midline in between the surgeon and the assistant and situated 1.5 m downstream from the patient’s navel. The laparoscope camera captures a magnified 2-D view of the pelvis and the image is projected onto the monitor allowing the surgeon and the assistant to visualise the operating field. At the end of the procedure, the carbon dioxide gas is released from the abdominal cavity and the instruments and ports are then removed. Each incision is closed with either a stitch, surgical tape or special tissue glue. For incisions 10 mm or longer, the deeper tissue layer called the sheath is closed separately to minimize the risk of hernia formation. Most laparoscopic cases are performed as day-only procedures. You may experience the following symptoms and signs after laparoscopy – tiredness, muscle pain, mild nausea, pain or discomfort at the incisional sites, cramps similar to period cramps, vaginal discharge or bleeding, a sensation of swelling of the abdomen, sluggish bowels or slow return to normal function and shoulder tip or neck pain. Shoulder tip pain is thought to be due to trapping of carbon dioxide gas under the diaphragm irritating its nerve supply and this causes referred pain. Most discomfort will settle in a week or two and simple analgesics containing paracetamol, codeine and non-steroidal anti-inflammatory medications such as voltaren are normally adequate to control the pain.

All surgery carries some degree of risks. Dr. Leong will make every attempt to minimize risks but complications may occur that may carry permanent effects. Complications from laparoscopic surgeries arise in 1-5% of cases with the risk of death at 5 per 10,000 cases. You must make sure you understand about all the risks associated with laparoscopy and be fully satisfied with the explanation of the procedure, risks and complications involved. There are two types of risks. Firstly, risks general to all undergoing surgery such as bleeding during, soon after or some days after surgery. You may require a blood transfusion if heavy bleeding occurs though this is quite uncommon these days especially after laparoscopic surgery. There are infection risks, potential anaesthetic and cardiovascular complications such as heart attack, stroke or deep venous thrombosis (DVT). Keloid or hypertrophic scarring of the laparoscopic incision sites may occur on some individuals. These scars are raised, itchy, inflamed and can be annoying though they are not life-threatening. If the incision length is greater than 10 mm, the risk of incisional hernia increases. An incisional hernia may contain intestine or omental fat protruding through a weakened scar in the abdominal sheath into the abdominal wall. It is seen as a lump along the scar.

Risks that are specific to laparoscopy include unavoidable damage (cut, puncture or diathermy burns) to major blood vessels (1 in 2000 cases), bladder, ureters, stomach, small or large intestine (1 in 3000 cases for bowels). Overly thin or obese patients are at an increased risk for these complications.  When complications or heavy bleeding are encountered, a large incision may need to be performed (laparotomy) to allow rapid entry into the abdominal or pelvic cavity for major surgical repair. Very rarely, if a segment of bowel is resected, a temporary colostomy (an external bag connected to the intestine) may be needed. Gas embolism may also occur where a bubble of carbon dioxide gas enters the bloodstream, traveling to the heart and lungs and becomes life-threatening. This type of complication is rare, occurring about 1 in 100,000 to 1 in a million cases. Some patients may be susceptible to heart arrhythmia where carbon dioxide gas absorbed through the lining of the abdominal cavity may interfere with the heart rhythm. This condition resolves with treatment. Similarly patients with pre-existing heart problems may have their conditions worsen during surgery or immediately afterwards. It is important that you inform Dr Leong and the anaesthetist of any heart condition so that appropriate precautions are taken. Breathing difficulty during or after surgery may occur because of the inflation of the abdominal cavity with carbon dioxide gas putting pressure on the diaphragm. When this arises, the anaesthetist can treat this problem. Rarely a nerve injury may occur due to positioning of the patient during the procedure. Prolonged pressure on a nerve causes numbness and sometimes loss of muscle control. Sensation and muscle control should return after a short while. Aside from temporary inconvenience, there is usually no permanent damage to the nerve from compression during surgery.

Total laparoscopic hysterectomy

This is an advanced operative laparoscopic procedure involving the complete removal of uterus, cervix, fallopian tubes and occasionally both ovaries. The abovementioned organs are devitalized and their support structures divided with electrocautery and scissors before retrieval via the vagina. If the tissues are too bulky they will need to be dissected into smaller pieces for removal vaginally. Sometimes vaginal debulking is not possible because the uterus is just too big e.g. above 16 week pregnancy size and morcellation has to be performed with a special morcellator (an instrument much like a potato peeler) before the uterus can be removed in strips via an enlarged laparoscopic port. The opening at the top of the vagina is then closed with a suture with knots tied inside the pelvis. There is another variation to this method where the surgeon divides the supporting ligaments to the fallopian tubes and blood supply to the uterus before completing the hysterectomy via the vaginal route. This is known as laparoscopic assisted vaginal hysterectomy. This procedure is performed less now as surgeons have become more adept at suturing the vaginal vault laparoscopically. The hospital stay after a TLH is often around two days. You may need about two weeks off before you feel well enough in returning to work. This would also depend on the nature of your work. If your work requires that you do heavy lifting of loads greater than 10 kg, you may have to stay away from work or perform light duties for up to six weeks post surgery. You will need to abstain from sexual intercourse for six weeks after a hysterectomy so that the insides are allowed to heal sufficiently. The risks and complications are those of laparoscopy. Please read the sections on conventional laparoscopy. There are a few important points to note after a hysterectomy. You may feel down or depressed from a feeling of loss afterwards. Sexual activity may also feel a bit awkward or tight initially but this tends to improve with time. Please use a lubricant. For most women, sensation and sexual enjoyment do not alter much after a hysterectomy. If you have a normal Pap smear history, you don’t need to have further pap smears after a complete hysterectomy where the cervix was also removed. If the cervix was left behind or you have a history of abnormal pap smears or cancer of the womb, then you will need to continue with regular pap smears. If the ovaries and fallopian tubes are removed then your ovarian cancer risk afterwards is significantly lower. However the removal of ovaries before your natural menopausal age will make you menopausal soon after the surgery. Menopausal symptoms such as hot flushes may be quite severe, debilitating and interfere with quality of life. Hence hormone replacement therapy may be appropriate depending on the woman’s age, unique circumstances and risk factors. Dr Leong will be able to discuss this with you during the consultation.

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Ureter
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Total Laparoscopic Hysterectomy
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Laparoscopic tubal re-anastamosis

Approximately one fifth of women express regret after tubal ligation 8 to 14 years later according to a 5 year US study - U.S. Collaborative Review of Sterilisation. For women under the age of 25, up to 40% of women may regret afterwards. For women older than 30 years old at the time of tubal ligation, about one tenth may regret years later. Hence the decision for tubal ligation must never be taken lightly. There are many long-term but non-permanent contraceptive choices available these days before considering tubal ligation. However, one understands that even for women who are absolutely sure, life circumstances do change e.g. death of a young child, re-partnering etc. Fortunately tubal ligation can be reversed quite successfully either using the conventional open microsurgical technique or laparoscopy. Dr. Leong performs tubal reversal surgery using both methods however has particular expertise in the laparoscopic approach. As alluded, microsurgery is performed with open surgical technique where an incision of about 10 cm is made in the lower abdomen just above the pubic hairline. A microscope is then used to magnify the operating field. Both fallopian tubes will be rejoined if possible. The edges of the severed fallopian tubes are trimmed and fresh edges created. A very fine suture is used to close both cut ends together, starting on the inner layer first. The outer serosal layers are then closed separately. The tubes are then checked for patency. The sheath layer of the abdominal wall is then closed with a strong and tough suture and the skin closed separately with an absorbable subcuticular (under the skin) suture. It generally takes about six weeks to recover from this open surgery and you will need the corresponding amount of time off work.

For laparoscopic tubal reversal, mini laparoscopic instruments are used, measuring 2-3 mm in diameter. Small incisions are made on the abdomen (one in the navel, one midline above the pubic hairline and possibly two more small incisions on either side of the abdomen. The set up is the same for general laparoscopy. The severed and occluded ends of the fallopian tubes are trimmed and fresh edges created. Then using laparoscopic needle holders, very fine sutures are then used to join the two ends together. Laparoscopic tubal reversal is performed as day-only procedure and you will be discharged home on the same day. Usually, you will be well enough to return to work after two weeks of convalescence. It will take six weeks for the ends to join together properly and you may try to conceive after that time. Successful reversal can be measured in two ways – tubal patency and pregnancy chances. About 75% of tubes can be successfully reversed and patency achieved. However pregnancy rates depend not only on achieving tubal patency but on the overall fertility prospect of the couple. So for a young couple with no other underlying infertility problems, pregnancy rates approach that of the general population. For older women, the chances of pregnancy may not be as good and IVF may be a better solution.

Laparoscopic tubal reversal - note the two blind ends of the right fallopian tube.
Laparoscopic tubal reversal - note the two blind ends of the right fallopian tube
Laparoscopic tubal reversal - Both blind end tips resected and edges freshened before the two ends are joined again
Laparoscopic tubal reversal - Both blind end tips resected and edges freshened before the two ends are joined again
Laparoscopic tubal reversal - The two ends of the previously cut right fallopian tube are stitched together
Laparoscopic tubal reversal - The two ends of the previously cut right fallopian tube are stitched together

Laparoscopic tubal reversal
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Laparoscopic excision of endometriosis

Laparoscopy has become the mainstay of surgical management of endometriosis. This is not to say that all women with suspected endometriosis will require surgery. The need for surgery depends on the signs and symptoms, desirability for fertility and findings of significant endometriosis on any imaging scan such as ultrasound scan or MRI. The laparoscopic approach is far superior then open surgery these days. The set up is the same as for other gynaecology laparoscopy. It is important that bowels are adequately prepared with a bowel preparation the day before surgery. Small incisions 5-10 mm are made in the abdomen usually in the same configuration as for other laparoscopic surgery. Laparoscopic instruments are passed into the abdomen via laparoscopic ports to allow for surgery. A blunt uterine manipulator is inserted into the uterus via the vagina to move pelvic organs around allowing all areas within the pelvis to be inspected closely for endometriosis. As a rule endometriosis lesions are best treated by excision or surgical removal. This allows for laboratory confirmation for endometriosis. Furthermore removing specimens containing diseased tissues affords confidence that disease clearance is achieved. Occasionally, disease can be found in areas where excision may not be possible and diathermy of the lesions is therefore warranted. Severe endometriosis can be found on ovaries and is known as endometrioma. It is also called "chocolate cyst" because it contains old and dark altered blood. The content of endometrioma should be drained and the capsular wall of the cyst removed to minimize the risk of it returning. Laparoscopy lends itself very well to this type of surgery. After excision, the raw surface is applied with a spray-on anti-adhesion barrier to minimize scar formation. It is not uncommon for women to still feel pain one to two months after surgery especially when significant resection was performed for severe disease. Some patients may also develop difficulty passing urine or opening their bowels 24 – 48 hours afterwards. Occasionally this may prolong their length of stay in hospital.

A few studies have demonstrated that excision offers the best way to manage pain associated with endometriosis. Diathermy may be adequate for superficial lesions. However, it must be said that superficial lesions may in fact not be superficial because some endometriosis may present like an iceberg with only the tip visible but there is a large amount of disease much deeper down. Hence merely burning the tip of the lesion by diathermy would not be enough.

For mild to moderate disease, surgical treatment is effective in improving one’s fertility prospect. However for severe disease, surgery may not necessary improve one’s prospect of natural conception and ART (assisted reproductive treatment) may well be required. It remains contentious whether surgery before IVF actually improves one’s prospect of conceiving via IVF. Studies have been lacking but in the presence of pain or abnormal findings such as endometriomas, laparoscopy beforehand will provide symptomatic relief as well as reduce the risk of pelvic infection associated with the endometriomas. During IVF, egg retrieval requires passing a needle into the pelvis by piercing the vagina to access the ovaries. Bacteria can be spread into the endometrioma causing deep pelvic infection. The removal of endometrioma prior to IVF will reduce the risk of pelvic infection significantly. This should almost always be performed.

Endometrioma or chocolate cyst on right ovary drained and cyst wall stripped
Endometrioma or chocolate cyst on right ovary drained and cyst wall stripped
Endometrioma or chocolate cyst on right ovary. Stripping of the chocolate cyst wall
Endometrioma or chocolate cyst on right ovary. Stripping of the chocolate cyst wall
Excision of a small lesion of endometriosis on left pelvic sidewall
Excision of a small lesion of endometriosis on left pelvic sidewall
Laparoscopic excision endometriosis - Endometriosis on right uterosacral ligament and right ovarian fossa
Laparoscopic excision endometriosis - Endometriosis on right uterosacral ligament and right ovarian fossa
Laparoscopic excision of endometriosis - left ovary adherent to endometriosis nodule on left pelvic sidewall
Laparoscopic excision of endometriosis - left ovary adherent to endometriosis nodule on left pelvic sidewall
Laparoscopic excision of endometriosis - two small superficial spots of endometriosis on bladder
Laparoscopic excision of endometriosis - two small superficial spots of endometriosis on bladder
Laparoscopic excision of endometriosis - small spot of endometriosis in pouch of douglas
Laparoscopic excision of endometriosis - small spot of endometriosis in pouch of douglas
Laparoscopic excision endometriosis - two superficial bladder nodules excised
Laparoscopic excision endometriosis - two superficial bladder nodules excised
Laparoscopic excision of endometriosis - Left ovary mobilised and pelvic sidewall nodule removed.Ureter exposed
Laparoscopic excision of endometriosis - Left ovary mobilised and pelvic sidewall nodule removed. Ureter exposed
Laparoscopic excision of endometriosis over right uterosacral ligament. See exposed pelvic vessels
Laparoscopic excision of endometriosis over right uterosacral ligament. See exposed pelvic vessels
Superficial endometriosis on right ovary. See blisters and fine vessels. Diathermy to endometriosis
Superficial endometriosis on right ovary. See blisters and fine vessels. Diathermy to endometriosis
Laparoscopic excision of endometriosis - pelvic sidewall and pouch of douglas resected
Laparoscopic excision of endometriosis - pelvic sidewall and pouch of douglas resected
Laparoscopic excision of endometriosis - fairly extensive stripping of pelvic lining containing endometriosis
Laparoscopic excision of endometriosis - fairly extensive stripping of pelvic lining containing endometriosis
Lap excision of endo - sprayshield post resection to prevent adhesion
Lap excision of endo - sprayshield post resection to prevent adhesion

Laparoscopic female fertility evaluation

Occasionally, a diagnostic laparoscopy is required to investigate the reasons for infertility. This is recommended when there are no obvious reasons to explain the problem after standard investigations with blood tests and an ultrasound scan. A laparoscopy is performed to exclude the possibility of occult endometriosis, scarred or blocked fallopian tubes or congenitally or acquired abnormal uterus. The laparoscopy is normally performed with hysteroscopy at the same time.

The set up is the same as for other gynaecology laparoscopy. CO2 is pumped into the abdominal cavity and operating ports are inserted through small incisions made on the abdomen. The internal pelvic organ is inspected closely for any disease. Any adhesions or scarring can be divided with cautery or laparoscopic scissors. A special cone shape device is inserted into the cervix and a blue dye injected to check if the fallopian tubes are patent. When patent, dye is seen filling the fallopian tube and spilling out into the pelvic cavity quite easily. If disease is present along the fallopian tube, one may see a “hold up” of dye at a particular point along the tube. Blocked fallopian tubes may sometimes be unblocked by exerting pressure on the plunger of the syringe and gently pushing the dye out through the tubes. However, more severe scarring or blockage may require dissection with scissors especially if it involves the fimbrial end of the tube. In many instances, tubal obstruction cannot be unblocked and IVF is the only option.

Laparoscopy - blue dye is injected into uterus via vagina. Note left tube patent. See dye running freely from tube
Laparoscopy - blue dye is injected into uterus via vagina. Note left tube patent. See dye running freely from tube
Laparoscopy - blue dye is injected into uterus via vagina. Note right tube patent. See dye running freely from tube
Laparoscopy - blue dye is injected into uterus via vagina. Note right tube patent. See dye running freely from tube

Laparoscopic PCO treatment

Women with trouble ovulating and has polycystic ovaries may sometimes benefit from a laparoscopy and ovarian drilling procedure. On occasions, ovulation induction medication such as clomiphene or metformin may not be successful in making the woman ovulate. In ‘refractory’ cases, ovarian drilling may actually help the woman ovulate afterwards. Some women may not want to take ovulation induction medication because of side effects and the unwanted risks of multiple pregnancies.

Usually, a diathermy needle is applied four to six times to each ovary. The needle causes a cautery burn deep in the inner stroma of the ovary. For reasons that are not fully understood, this changes the hormonal environment in the ovary resulting in a decrease in the production of male androgens. This seems to reset the ovary and make it ovulate again. During drilling, saline irrigation is applied to each ovary to ‘cool’ it down and this may help to prevent adhesions.

Up to 50% of women will ovulate within three months after ovarian drilling. Unfortunately ovulation does not tend to persist beyond six months.

Laparoscopic myomectomy

Uterine leiomyomata or fibroids are a fairly common occurrence and may present a unique surgical challenge. Fibroids can grow to quite a large size and they often present in multiples. As previously mentioned they can cause significant symptoms and compromise one’s fertility prospect if left untreated.

The surgical approach to the removal of fibroids, myomectomy, can now be undertaken successfully almost always using the laparoscopic approach. This can be done either with conventional laparoscopy or robotic laparoscopy. This section will cover the conventional laparoscopic approach. This type of surgery is known as advanced laparoscopic surgery. Depending on the size and location of the fibroids, you may be prescribed a medication to shrink the fibroids prior to surgery. This may need to be taken for up to three months beforehand. Bowel preparation is also important to reduce the risks of bowel injuries during laparoscopy. The incisions are similarly small (5-10 mm) and made the usual way on the abdomen. A larger incision of around 15 mm may need to be made on the lower aspect of the abdomen for the morcellation procedure. Morcellation involves the insertion of a rotary bladed instrument to ‘peel’ the fibroids and the specimen can then be retrieved in strips. The camera port may need to be located higher then the navel depending on the size of the fibroid uterus. Specialized laparoscopic instruments are used for myomectomy. A haemostatic solution is injected into the uterus along the area where an incision is to be made. This helps to reduce blood loss significantly. An incision is made on the uterus down to the depth of the fibroid capsule. The fibroid is then ‘shelled’ out leaving a defect of varying size and depth in the muscle wall. Bleeding vessels are sealed using diathermy before the muscular defect is closed using a barb suture in multiple layers. This process is repeated until all fibroids are removed. The detached fibroids are then morcellated and the skin incisions closed in the usual manner. For large fibroids, the defect created in the muscle wall is deep and sometimes may extend down to the uterine cavity. This tends to leave a large scar in the muscle wall and scars are considerably weaker than normal tissue. A scar put under pressure during labour can tear and result in uterine rupture. Hence, normal labour after myomectomy is generally discouraged and elective caesarean section is preferred. Blood loss and pain after laparoscopic myomectomy are considerably less than the open approach. Consequently, requirement for pain relievers is less and discharge occurs after a short stay of 1-2 days in hospital. Convalescence generally takes about two weeks and return to full function would follow suit.

lap myomectomy - enucleation
lap myomectomy - enucleation
lap myomectomy - fibroid detached
lap myomectomy - fibroid detached
Lap myomectomy - fibroid removed by morcellation with a PK morcellator
Lap myomectomy - fibroid removed by morcellation with a PK morcellator
lap myomectomy - multilayered closure of defect
lap myomectomy - multilayered closure of defect

Conventional Laparoscopic Myomectomy
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Laparoscopic ovarian cystectomy and salpingectomy

Conventional laparoscopy is the best approach for removing ovarian cysts and diseased fallopian tubes. Most ovarian cysts encountered in the reproductive age group are benign and are due to simple cysts (which usually resolve by themselves), dermoid or cystadenomas. These cysts can and should be removed via laparoscopy. It is important that the cyst wall or capsule be removed in the process to prevent it from ever returning. Dermoid cyst or benign cystic teratoma often contains a large amount of sebum or fat, hair and sometimes teeth. It may be solitary or occur on both ovaries. If left untreated, they can grow to quite a large size and removal may rarely have to be performed as an open procedure. Dermoid cyst can also undergo torsion where the cyst and ovary twist on the pedicle and ‘cut off’ the blood supply. This results in acute pain, vomiting and perspiration. If torsion is not treated promptly, the ovary will die. Cystadenoma should also be treated. If untreated it tends to suffer the same fate as dermoid cyst.

Cancerous ovarian cyst on the other hand if suspected should generally not be removed by laparoscopy because there is a very high chance of spread. Ovarian cancer very often presents late. So ovarian cancer is best dealt with via open laparotomy where the uterus, ovaries, fallopian tubes, cervix and omentum are all removed en bloc.

Fallopian tubes can be affected by disease such as pelvic infections, endometriosis or ectopic pregnancy. Laparoscopy is the ideal approach for fallopian tube pathology because the minimally invasive method ensures that the patient recovers quickly from the operation. The laparoscopic approach for these types of surgery usually involve four incisions, one in the navel, one in the midpoint of the pubic hairline, and one on each side of the abdomen about two centimeters up from the hip bone. Most women will be able to go home on the same day of surgery. Convalescence will take one to two weeks and that means restful recovery at home.

Another right ovarian cyst. A bipolar diathermy instrument used to coagulate tissue before cutting
Another right ovarian cyst. A bipolar diathermy instrument used to coagulate tissue before cutting
Laparoscopic salpingectomy. Uterus with both fallopian tubes removed
Laparoscopic salpingectomy. Uterus with both fallopian tubes removed
Large left ovarian cyst
Large left ovarian cyst
Left Ovarian cyst. Incision made on ovary and cyst underneath peeled off
Left Ovarian cyst. Incision made on ovary and cyst underneath peeled off
Twisted left ovarian cyst
Twisted left ovarian cyst

 

Single Incision Laparoscopic Surgery (SILS)

In certain circumstances laparoscopic surgery can even be further minimalised with single port surgery. Instead of using the traditional four port configuration common in most conventional laparoscopic surgery, a single port can be used for the entire operation. The single port is normally placed at the umbilicus through an incision of about 2.5 cm in length. A special funnel shaped single port is used. Normal straight stick operating instruments are used along with a long and flexible laparoscope. Generally speaking the more straightforward and less complex cases are suitable for single port surgery. E.g. single port laparoscopic hysterectomy, single port laparoscopic myomectomy and single port laparoscopic ovarian cystectomy.

Perhaps the pinnacle of advanced laparoscopic surgery is the yet to come single incision robotic laparoscopic surgery. At this point in time, it is only approved to be used for gall bladder surgery in the USA. Watch this space for exciting development!

Dr. Leong performs conventional SILS and also plan to do robotic SILS when it becomes available in gynaecology.

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