Laparoscopy

What Is A Laparoscopy?

Laparoscopy (pronounced “lap-a-ROSS-coe-pee”) is a surgical procedure performed through very small incisions in the abdomen, using specialized instruments. A pencil-thin instrument called a laparoscope is used, and it gives the surgeon an exceptionally clear view, on a TV monitor, of the inside of the abdominal cavity.

A laparoscope has lenses like a telescope to magnify body structures, a powerful light to illuminate them, and a miniature video camera. The camera sends images of the inside of the body to a TV monitor in the operating room. Specialized surgical instruments can be inserted through the laparoscope, and through small incisions nearby.

This type of surgery is called ‘minimally invasive’ because of the very small incisions used. Yet major procedures can now be performed using this technique. The term laparoscopy is used when this type of surgery is performed in the abdomen. It’s called arthroscopy when performed in a joint, and endoscopy when done through a natural opening in the body, such as the mouth or nose.

• “Laparo” comes from a Greek word meaning “flank,” which is the side of the body between the ribs and hips. Doctors use this term to refer to the abdomen. The term “scope” means to look at or examine.
• Many procedures once done through a large opening in the abdomen can now be done with the small incisions of laparoscopy.
• Laparoscopy has become the preferred surgical technique for some conditions, such as gallbladder disease.

Laparoscopy For Diagnosis And Treatment

Laparoscopy can be used either to diagnose or to treat various conditions. Or it may be used to identify a problem and treat it in the same operation.

Diagnostic laparoscopy allows the doctor to look at structures inside the abdomen and see whether they appear normal or abnormal. It becomes valuable when physical examinations, lab tests, x-rays, and computerized scans don’t show exactly what is wrong and a diagnosis requires a direct look inside the body.

• It can be used to diagnose the cause of abdominal pain,pelvic pain, infertility, and other problems in abdominal organs.
• During a diagnostic laparoscopy, the doctor also can use tiny scissors and other instruments to snip a sample of tissue and take a biopsy. The tissue can be examined with a microscope to see if it is normal.
• Laparoscopy can be used to determine the stage of certain kinds of cancer. Stage means how far the cancer has advanced.
• Hospital emergency departments may use laparoscopy to decide on the treatment of patients with trauma, or accidental injury. The procedure can “see” internal bleeding or other problems that might not be detected otherwise.

Operative laparoscopy allows the doctor to treat a disease or condition. It usually involves removing diseased tissue or repairing damage to a structure in the abdomen. Laparoscopy also is used in assisted reproductive procedures for women who are infertile or having difficulty becoming pregnant.

For further information about infertility, go to Infertility.

What Kinds Of Surgery Can Be Performed With Minimally Invasive Methods?

Dozens of different kinds of operations are now being done using these new minimally invasive techniques. These include operations on the abdomen, heart, reproductive organs, nerves, ear, nose, sinuses, throat, joints, chest organs, urinary tract, and blood vessels. These techniques are also used in plastic and reconstructive surgery.

Minimally invasive surgery may be an appropriate choice for conditions and diseases such as the following:

Diseases and conditions of the abdominal organs, including:

• gallstones
• removal of a damaged or diseased spleen;
• inguinal hernia repairs, when part of the intestine bulges through a weakened segment of the abdominal wall;
• gastroesophageal reflux disease (GERD).
• some problems of the colon (large intestine) or rectum; and
• removal of an infected or inflamed appendix.

Gynecological conditions or procedures including:

• pelvic pain of uncertain cause;
• ovarian cysts;
• endometriosis;
• pelvic adhesions;
• ectopic pregnancy;
• infertility;
• hysterectomy; and
• tubal ligation.

Treatment of torn cartilage, ligaments, joint pain, and mobility problems in:

• the shoulder;
• knee;
• lower back pain caused by a herniated spinal disk ; and
• spine, such as fusing segments of the backbone together to make the spine more stable.

Correction of abnormalities in the paranasal sinuses that cause chronic sinus infections.

What Are The Advantages Of Laparoscopy?

Laparoscopy is easier on the patient because it uses a few very small incisions. For example, traditional “open surgery” on the abdomen usually requires a four- to five-inch incision through layers of skin and muscle. In laparoscopic surgery, the doctor usually makes two to three incisions that are about a half-inch long.

The smaller incisions cause less damage to body tissue, organs, and muscles so that the patient

• can go home sooner.

  Depending on the kind of surgery, patients may be able to return home a few hours after the operation, or after a brief stay in the hospital.

• recovers quickly.

  Many people can return to work and their normal routine three to five days after surgery. In contrast, traditional laparotomy may require a person to limit daily activities for four to eight weeks.

• experiences fewer post-operative complications and less pain.

  The amount of discomfort varies with the kind of surgery. In most cases, however, patients feel little soreness from the incisions, which heal within a few days. Most need little or no pain medicine.

• has less scaring.

  The incisions for most kinds of laparoscopic surgery heal without noticeable scars. In laparoscopic surgery on a woman’s reproductive system, for instance, one incision usually can be hidden in the belly button area. The others can be placed low in the abdomen, where any scars would be covered by a bikini.

What Are The Possible Risks Of Laparoscopy?

Since laparoscopy involves minimal damage to body tissues, it is generally safer than open operations. In diagnostic laparoscopy, for instance, complications occur in about three out of every 1,000 operations, a significantly lower number than traditional surgery. A complication is an unforeseen problem that occurs during or after surgery, such as internal bleeding or injury to a healthy organ.

Possible Complications Of Laparoscopy

• Risks for any type of surgery may be greater for people who are obese, smoke cigarettes, or have additional health problems.
• Laparoscopy usually requires general anesthesia, which carries certain risks. Modern general anesthesia, however, is safe and reactions are rare. The individual must be sure to tell the doctor if he or she had a bad reaction to anesthesia in the past, or if a close family member has experienced such a reaction.
• Injury to blood vessels or organs, which causes bleeding.
• Damage to ducts or other structures that allow body fluids to leak out.

Sometimes the surgery cannot be successfully completed by laparoscopy. Then the doctor may have to complete the operation using traditional “open” abdominal surgery, called laparotomy. This is called “converting” to laparotomy.

How Can I Pick The Best Doctor For Minimally Invasive Surgery?

Almost every kind of doctor who performs surgery may use minimally invasive methods for some kinds of operations. Obsterictians and gynecologists often use laparoscopy to diagnose and treat women’s health problems. General surgeons may use laparoscopy for gallbladder disease. Orthopedic surgeons perform minimally invasive procedures to repair the knee and other joints. Trauma surgeons may use the technique to identify and treat internal bleeding in accident victims.

• It takes special training to do laparoscopic surgery. Patients may get traditional “open” surgery because that is the only kind their doctor offers.
• Doctors need to perform laparoscopy regularly in order to develop and maintain their skills.
• Individuals considering laparoscopic surgery should ask the doctor the same basic questions that apply for any kind of surgery.

What Kind Of Anesthesia Is Used For Laparoscopy?

For laparoscopy, the patient is usually given a general anesthesia and is unconscious during the operation. General anesthesia relaxes muscles and makes it easier for the doctor to perform the surgery.

Some procedures, however, are done with a local anesthetic to numb the immediate area of the body where the incisions will be made. The patient is awake during the operation, but usually is given medication to help stay calm and relaxed.

Preparing For A Laparoscopy

Individuals scheduled for laparoscopy usually visit the doctor’s office before the operation to discuss the procedure in detail. During the visit, the doctor should fully explain the procedure, what will be done and why, the risks, and how you will benefit from the procedure. The doctor also should answer questions about the procedure.

Tests may be ordered, which include blood and urine tests, an electrocardiogram , and possibly an ultrasound scan or x-ray.

For further information about ultrasound, go to Ultrasound.

On The Day Of The Operation

Most laparoscopy is done on an outpatient basis, but this does depend on the procedure and how well the patient is.

After the surgery, the patient can usually return home the same day. Procedures may be done in a regular hospital or in an outpatient surgery center.

• Patients usually are told to arrive at the surgery facility one or two hours before the operation.
• An anesthesiologist or nurse anesthetist may ask questions about the patient’s health, discuss the procedure and explain what to expect from the anesthesia.
• Before the surgery, an intravenous line, which consists of a small flexible plastic tube, may be inserted into a vein in the patient’s arm or hand. It is used to give medications and fluids during the operation. Sometimes intravenous medication is administered before surgery to help the patient relax.

The Operation (Laparoscopy)

The procedure depends on several factors, including the area of the body, the disease, the patient’s condition, and whether the operation is to diagnose or treat. Minimally invasive surgery on the knee, for instance, is much different than surgery on the abdomen.

A typical laparoscopic gallbladder operation usually involves the following steps:

• The doctor makes a small incision just below the naval, or belly button. A tube is inserted into the incision, and harmless carbon dioxide gas flows through the tube to inflate the abdomen.
• The gas creates a space between the wall of the abdomen and the intestines. It gives the doctor more space to work, and reduces the chances that internal organs will be injured when the laparoscope and other instruments are inserted.
• Using the same incision, the doctor inserts the laparoscope into the abdomen. He can now look directly inside the abdomen and see the organs, or see them on the video monitor.
• One or more additional incisions are usually needed in the lower abdomen. They are made a few inches above the pubic bone, and used to insert other specially designed surgical instruments.
• While watching on the video monitor, the doctor performs the surgery using the specialized instruments that have been inserted through the small incisions. An assistant points the laparoscope toward the instruments, much like a helper shines a flashlight on a work area. The assistant moves the laparoscope so that the surgical area is constantly well lighted and in focus.
• When the procedure is completed, the carbon dioxide gas is allowed to escape through the incisions, and the abdomen deflates.
• The incisions are closed with one or two stitches and covered with an adhesive bandage or small dressing. The stitches may be the kind that dissolve and disappear on their own, or the doctor will remove them in about a week.

How Long Does Laparoscopy Take?

Diagnostic laparoscopy usually takes less than an hour. If the procedure is for treatment, it will depend on the condition and the complexity of the operation. It may take an hour or more and sometimes much longer, depending on the procedure.

What Happens When The Patient Wakes Up?

The effects of general anesthesia make most people feel groggy at first, but they quickly become more alert. Some people experience nausea for a short time after awakening from a general anesthesia. In the recovery room, the individual first rests in bed, then gradually sits up, stands, and walks as balance and mobility are regained.

Some laparoscopic procedures require an overnight hospital stay, or a stay of a few days.

However, most people are ready to leave the clinic or hospital two to four hours after laparoscopic surgery.

What Problems Can Occur After Laparoscopic Surgery?

Complications after laparoscopic surgery are rare. Most people recover quickly and resume their normal activities without problems. However, the risk of infection or other problems exists as with any kind of surgery.

• There may be some soreness near the incisions, especially when twisting or stretching the body.
• If a breathing tube was used for the surgery, patients may have a mild sore throat.
• There may be discomfort in the abdomen, upper chest, shoulders, and neck area due to the carbon dioxide used to inflate the abdomen, but this disappears quickly.

What Self-Care Is Necessary After Laparoscopic Surgery?

Individuals who have laparoscopic surgery should carefully follow their doctors’ instructions after going home. The exact kind of care needed depends on the type of surgery, the individual’s age and general health, and other factors. In general, people recovering from laparoscopic surgery should care for their incision as directed by the doctor, be cautious about certain activities, and watch for any of the warning signs.

Following laparoscopy on the abdomen or pelvic areas, it is most likely that one will:

• leave the adhesive bandage or dressing on the incision for two days. During that period, keep the incision area dry. Do not take a shower.
• not need to apply new bandages to the incisions unless clothing is rubbing against them.
• remove the bandages after two days, following the doctor’s instructions. Individuals usually can resume taking showers at this point.

How Long Will It Take For Full Recovery After Laparoscopic Surgery?

Recovery time depends on the kind of procedure, the patient’s age, and health before the procedure. The following is a normal timetable for recovery from minimally invasive surgery on the abdomen:

• The groggy feeling from the anesthetic disappears the day after surgery and the individual is fully alert once again.
• Any pain in the shoulders or neck area usually goes away after a few days.
• Soreness in the incisions disappears within a few days and the incisions heal after about five days.
• The bloated feeling after abdominal or pelvic laparoscopy goes away within a few days.

What’s The Latest About Laparoscopy?

New developments in minimally invasive surgery should result in operations that are even easier on the patient and the treatment of a wider range of diseases. In the future, minimally invasive surgery will:

• Use even smaller incisions that heal faster with almost invisible scars. The standard laparoscope is about one-half inch in diameter. Newer micro-laparoscopes are about one-tenth of an inch in diameter so that some procedures can be performed through small hollow needles.
• Make greater use of local anesthesia and sedation through an intravenous catheter. Local anesthesia will make laparoscopy even safer by further reducing the already-small number of complications that occur with general anesthesia.
• Be done for more and more diseases. Researchers are developing minimally invasive methods for many types of surgery that currently require larger “open” incisions.
• Use computerized technology developed to run industrial robots. A doctor located hundreds or thousands of miles from the operating room may perform laparoscopic surgery. The doctor may use an image transmitted over the Internet, and move surgical instruments by remote control. (See http://www.lap-surgery.com)

Laparoscopy: Frequently Asked Questions

Here are some frequently asked questions related to laparoscopy:

Q: I’m confused about the medical terms forminimally invasive surgery and the traditional open operations. Which is which?

A: Laparoscopy means surgery on the abdominal area using a laparoscope. This is minimally invasive, or Band-Aid, surgery, which uses small incisions. Laparotomy is the term for the traditional open surgery on the abdomen, which involves a larger incision. There are many different terms used for specific types of minimally invasive surgery and the instruments used.

Q: Why do people recover faster from minimally invasive surgery?

A: Mainly because of the small incisions. The large incision used in many traditional operations causes more damage to layers of skin, muscle, and other body tissue. It takes a long time for the body to repair that damage – usually about six weeks. During that period, patients often have to restrict their normal activities so that the incision heals properly. The incision also causes a good deal of discomfort that makes patients want to take it easy for several weeks.

Q: Since the incisions are so small, why can’t minimally invasive surgery be done with a local anesthetic?

A: Some kinds of arthoscopic surgery, such as that done on the knee, may not need general anesthesia. It still is necessary for most operations, including those on the abdomen and pelvic areas. That’s because the general anesthesia does more than block the sensation of pain; it also relaxes muscles and makes it easier for the surgeon to work inside the body and complete the operation.

Q: The doctor wants to do a diagnostic laparoscopy to find out why I’m having pelvic pain. She says the surgery will take less than an hour, and I can go home right away and back to work the next day. If it is really that simple, why do I have to bring someone to the surgery center to drive me home?

A: Because of the effects of general anesthesia. You may feel groggy for a few hours after you awake and you may not be in complete control of the reflexes needed to drive a vehicle. It is safer to have someone else who is fully alert do the driving.

Q: Why does the doctor want to videotape my surgery? Is that standard for laparoscopic operations?

A: A videotape gives the most detailed possible record of the operation. Surgeons normally dictate an account of the operation and a paper record goes into the patient’s file, but the amount of detail varies from surgeon to surgeon. Almost every operating room with modern laparoscopic equipment can videotape each procedure, creating a visual document of the operation. A record of the operation clearly shows what the surgeon found during the first operation, what difficulties were encountered, and what procedures were done. The record is very important for other doctors who may be involved in your care at some point, especially if complications occur after the first surgery or the disease comes back later on.

Q: My sister had her gallbladder removed with Band-Aid surgery. Now I need a similar operation and my doctor wants to use the old “open” surgery that will leave a bigger scar. Should I insist that the doctor use the newer surgery?

A: There may be good reasons why your doctor wants to use the traditional laparotomy operation. People who underwent previous abdominal surgery, for instance, sometimes have internal scar tissue that makes laparoscopy difficult. Your gallbladder disease may be more serious than your sister’s. There may be other problems that favor the traditional operation. If you feel uncomfortable with the doctor’s plans, consider getting a second opinion.

Q: The doctor says there’s a chance that she will have to “convert” to a laparotomy – “open” surgery with the larger incision – after starting it with belly button surgery. Why could that be necessary?

A: Even the most experienced doctors sometimes find that they cannot complete an operation as planned with the laparoscope. There are several reasons why the doctor might have to change, or convert, to an open operation. The patient’s disease, for instance, may turn out to be different or more extensive than originally thought. Organs may not be in their normal position in the body. Patients who had previous surgery in the same area may have developed scar tissue that makes it difficult for the doctor to work with a laparoscope. Bleeding, leakage of body fluids, or other problems that require open surgery may occur during the laparoscopy.

Q: What is laparoscopically-assisted surgery? My gynecologist wants to use that method for my hysterectomy.

A: It is a modern way of performing a hysterectomy that avoids a large abdominal incision. In this procedure, instead of the normal large incision, very small incisions are made for a laparoscopic procedure, and the doctor uses the laparoscope to see and cut the tough bands of tissue that hold the uterus in place. That’s the “laparoscopically-assisted” part. Then the uterus is removed through the vagina.

Questions To Ask The Doctor

Like any other kind of surgery, laparoscopy requires a skilled doctor who does enough procedures every week to maintain and build surgical skills. Generally, a doctor’s skills increase with the number of operations that he or she performs. The nurses and other individuals who assist with the operation and care for the patient right after surgery also should be experienced with these procedures.

Doctors rarely feel offended when patients ask about these matters. In fact, experienced doctors usually are proud of their track record and eager to provide patients with information. It is very important for each individual involved to fully understand the doctor’s diagnosis and planned treatment procedures.

Some questions to ask the doctor about her or his experience with laparoscopy are:

• Do you often perform laparoscopic surgery?
• How many procedures of this kind have you done in the past year?
• What types of conditions or diseases do you most often treat with laparoscopy?
• Do you make a videotape record of the operation?

Laparoscopy: Putting It All Together

Here is a summary of the important facts and information related to laparoscopy:

• Laparoscopy is surgery on the abdomen performed through very small incisions in the body. It is used to diagnose and treat many different conditions and diseases.
• Doctors perform laparoscopy with a pencil-thin instrument called a laparoscope. It has a strong light and a miniature camera that sends images of the surgery area to a video monitor above the operating table.
• Laparoscopy is called minimally invasive surgery because the incisions are so small. Common non-technical names for the procedure are belly button surgery and Band-Aid surgery.
• For minimally invasive operations on the abdomen, incisions may be only half an inch long, compared to four to six inches for traditional “open” surgery.
• Minimally invasive surgery has many advantages. Individuals remain in the hospital for a shorter period, experience less discomfort, heal quicker, and can return to daily activities faster than is possible with traditional “open surgery.”

Laparoscopy: Glossary

Here are definitions of medical terms related to laparoscopy:

Anesthesiologist: a doctor who administers anesthetics and monitors the patient’s condition until surgery is completed

Anesthesia: absence of sensation, especially artificially induced blockage of pain during surgery

Anesthetic: a drug that blocks the sensation of pain during surgery

Appendix: a finger-shaped tube of tissue (vermiform appendix) between the large and small intestine; can become inflamed or infected

Band-Aid surgery: surgery done through very small incisions that sometimes are covered with adhesive bandage strips; a common name for minimally invasive surgery

Belly button surgery: a common name for laparoscopy, minimally invasive surgery on the abdomen

Biopsy: removal of a small amount of tissue for examination under a microscope to find out whether part of the body is diseased

Diagnostic laparoscopy: laparoscopy done to diagnose a condition or disease

Ectopic pregnancy: an abnormal pregnancy in which the fertilized egg starts growing outside the uterus

Endoscope: a thin instrument, inserted through orifices of the body or through very small incisions, that allows the doctor to see inside the body, diagnose conditions, and perform surgery

Endoscopic surgery: surgery performed with an endoscope through orifices of the body or through very small incisions

Endometriosis: a condition in which tissue from the inside of the uterus starts growing in other places in the abdominal cavity, causing pain and other symptoms

Fallopian tubes: the ducts that carry eggs from the ovaries to the uterus

Fibroids: benign or non-cancerous tumors in the uterus that sometimes cause pain, heavy menstrual periods, or other symptoms

Gastroesophageal Reflux Disease (GERD) : a condition in which acid from the stomach flows backward into the esophagus, causing heartburn and other symptoms

Hysterectomy: surgical removal of the uterus

Infertility: inability to become pregnant

Inguinal hernia: a condition in which part of the intestine bulges through a weakened segment of the abdominal wall

Laparoscope: a thin fiber optic telescope equipped with a video camera, light, and other devices that allows the surgeon to see into the abdominal cavity through very small incisions

Laparoscopy: a surgical procedure in which a laparoscope and other instruments are inserted into the abdomen through small incisions to diagnose and treat diseases and conditions

Meniscus: a disc-shaped pad of tough tissue, or cartilage, in the knee

Minimally invasive surgery: surgery done through very small incisions with miniature instruments

Nurse anesthetist: a specially trained registered nurse who administers anesthetics

Otorhinolaryngology: a medical specialty dealing with the ear, nose, and throat

Ovaries: organs located on each side of the uterus that produce eggs and sex hormones

Ovarian cyst: fluid-filled growths in the ovary

Paranasal sinuses: hollow spaces in the bones of the face and skull near the nose that sometimes become infected, causing sinusitis

Pelvic adhesions: bands of tough, scar-like tissue that form inside the body and interfere with normal functioning of an organ

Pelvic pain: pain in the lower abdominal area below the navel or belly button

Spinal disks: tough pads of cartilage that separate and cushion the vertebrae, or bones, in the spinal column

Spinal fusion: surgery to join two spinal bones and make the back more stable

Spleen: an organ that removes old red blood cells and disease-causing microbes from the blood

Splenectomy: removal of the spleen

Stage: the extent to which a disease has advanced

Therapeutic laparoscopy: laparoscopy done to treat a disease or condition

Tubal ligation: female sterilization operation that seals the fallopian tubes and prevents the egg from being fertilized so the woman cannot become pregnant through sexual intercourse

Ultrasound scan: a diagnostic test that uses sound waves to detect abnormalities inside the body

Vasectomy: male sterilization operation that seals the vas deferens and prevents sperm from being transmitted through ejaculation

Laparoscopy: Additional Sources Of Information

Here are some reliable sources that can provide more information on laparoscopy:

American Association of Gynecologic Laparascopists 
Phone: 800-554-2245
Email: generalmail@aagl.com 
http://www.aagl.com

American Academy of Orthopedic Surgeons 
http://www.aaos.org

American College of Obstetricians and Gynecologists 
http://www.acog.org

American College of Surgeons 
Phone: 312-202-5000
Fax: 312-202-5001
Email: postmaster@facs.org 
http://www.facs.org

American Gastroenterological Association 
http://www.gastro.org

American Society of Gastrointestinal Endoscopy 
Phone: 978-526-8330
Fax: 978-526-4018

National Digestive Diseases Information Clearinghouse 
http://www.niddk.nih.gov/health/digest/nddic.htm

National Institute of Diabetes & Digestive & Kidney Diseases Office of Communications and Public Liaison 
http://www.niddk.nih.gov

Office of Research on Women’s Health National Institutes of Health 
http://www4.od.nih.gov/orwh

Online Laparoscopic Technical Manual Phillipe J. Quilici, MD, FACS Sisters of Providence Health System Saint Joseph Medical Center 
http://www.laparoscopy.net

Society of Laparoendoscopic Surgeons 
http://www.sls.org/