Diagnostic Laparoscopy and hysteroscopy under general anaesthetic

What is a laparoscopy?

A laparoscopy is performed under general anaesthetic and allows a detailed inspection of the pelvic organs (womb/uterus, ovaries and fallopian tubes). A laparoscopy is a ‘keyhole’ procedure.

Why is laparoscopy done?

A laparoscopy is often recommended to fertility patients as it is the most reliable way to check the health of the pelvic organs in preparation for pregnancy. It is offered if you are troubled with pelvic pain of unknown cause. It may also be required in order to treat certain conditions, such as ovarian cysts, endometriosis and ectopic pregnancy.

Fertility patients will also have their tubes checked with a dye test to make sure the tubes are open and healthy. If you no longer wish to get pregnant you may choose to have your tubes clipped (blocked for sterilisation purposes).

How is laparoscopy done?

The laporoscope is a telescopic camera which is inserted in or just below the belly button (umbilicus) through a cut that is about 1cm long.

A further 1, 2 or 3 incisions are made lower down in the abdomen (tummy) about 0.5 – 1cm, through which the additional instruments can be inserted in order to enable careful inspection of the pelvic organs.

The pelvic organs may need to be manipulated and if problems are seen, some problems can be treated at the same time as the diagnostic procedure.

You will be asked to sign your consent to the diagnostic procedure and also for treatment of simple problems such as mild endometriosis, ovarian cysts or adhesions/scarring around the ovaries and fallopian tubes. If more severe problems are identified then treatment is usually discussed and a further operation may be required at a later date.

A diagnostic laparoscopy takes between 20 and 60 minutes. Most people are admitted on the day of the operation and they go home later that day.The small incisions on the skin are usually closed with dissolving sutures. The sutures (stitches) may take 2 to 3 weeks to dissolve and therefore sometimes they are removed after a week, usually by a nurse at your general practitioner’s surgery. It is quite common for there to be a small amount of bruising around these incisions.

The tummy cavity is inflated with carbon dioxide gas in order to be able to have a space in the tummy cavity to move the instruments that are being used for the diagnosis and treatment, during the laparoscopic procedure.

The gas is let out of the tummy cavity at the end of the operation. It is common for a small amount of gas to remain and for the tummy to feel bloated and distended for a few days. Sometimes, in addition, a small amount of fluid is left within the tummy cavity, which is thought to help with the healing process and to prevent adhesions/scar formation within the tummy cavity.

This will also result in a feeling of bloatedness and distension of the tummy for a few days. Sometimes a small amount of fluid can also leak through the incisions that are made in the skin. It is common also to feel discomfort in the shoulder tips for a day or two after the operation. Simple pain relief such as paracetamol and or ibuprofen may be taken for this.

It is preferable not to have a laparoscopy performed during a menstrual period if dye is being injected to check tubal patency.

You are advised not to have unprotected sexual intercourse from the time of your last menstrual period to until the time of the operation, in order to minimise the chance that you could be pregnant etc. The nursing staff will always check a urine pregnancy test when you are admitted to the ward. Please be ready to tell the staff the date of your last period.

What are the risks of a diagnostic laparoscopy?

All surgical procedures have risks but these are relatively minor in this routine diagnostic procedure.

Bleeding and blood transfusion

The risk of very heavy bleeding is very low. Bleeding can usually be managed with keyhole surgery techniques but rarely (less than 1 in 100 operations) the operation needs to be extended into a larger incision called a laparotomy to be able to stop the bleeding from becoming dangerous. The transfusion of blood is not commonly needed but it will be done if necessary to top up heavy blood loss.

Infection

Infection does sometimes happen in the skin wounds as they are trying to heal afterwards. It is important to keep the wounds clean and follow your aftercare instructions.

Damage to nearby structures

The pelvic organs (bladder, womb, tubes, ovaries and intestines) are all close to each other in the surgical area. The ureter is the tube that connects the kidneys to the bladder. This tube is also in the area, close to the blood vessels going to and from the legs. All these structures are vulnerable to damage as a result of surgery close to them. These complications are not common but they can be serious if they do occur. Damage to the bowel (small pin-prick or tear) can lead to infection as the contents leak out. The chance of this complication is lower than 1 in 2000 operations. Sometimes it is obvious and can be fixed at the time but sometimes it is hidden and does not cause problems until a couple of days after the surgery.

If you do not feel much better or if you have pain and a temperature (sweats and shivers) by the third day after your operation you should contact the ward and attend for a check-up.

Blood clots (deep vein thrombosis, pulmonary embolus)

Blood clots in the deep veins of the legs can happen when you are lying or sitting still for a long time. Most diagnostic laparoscopy operations are short and the risk of clots is low. People who smoke and / or are overweight and / or are taking oestrogen hormones are more at risk.

You will wear compression stockings during your admission and will be encouraged to get up and get moving soon afterwards to keep the blood in your legs flowing. You should continue to get up and about at home as well. Hydration is important and you should keep drinking plenty of water even if you do not feel like eating much in the day or so after your operation. Some people judged to be at increased risk will be given blood-thinning injections as well.

General anaesthetic

The risk of serious problems with general anesthetics is lower the younger you are. Allergic reactions are rare and can be managed. You should discuss any particular concerns you have when the anaesthetist visits you before the operation to explain what they will be doing for you to keep you comfortable during and after the procedure.

Your consultant will discuss any specific risks for you when you sign your consent for your procedure.

Other risks

Technical failure
Very rarely the telescope can not be inserted adequately and safely. Surgery may be abandoned for a further discussion of alternatives or another try at a later date.

Wound problems
Bruising is to be expected around the cuts where the instruments go through the skin. Occasionally the wound can become infected especially if the belly button is deep. You should keep the wounds clean and report to GATU or your GP if you develop red, tender swelling or pus discharge. Antibiotics will be needed.

Hernias
Where something (usually a small piece of fat, rarely a bit of the intestine) from inside your belly works its way up through the wound before it has healed closed. This causes a lump under the skin and sometimes discomfort or pain. You should see your GP or call GATU if you think this may have happened.

Treatment of Endometriosis

Endometriosis is a condition where small amounts of the endometrium (lining of the womb) spill backwards through the fallopian tubes and can settle in the pelvic cavity, usually around the ovaries and womb. This is a condition that can cause pain during periods and can sometimes cause inflammation and scar tissue, which can affect fertility. Endometriosis may be treated using diathermy (electro cautery or heat treatment) at the time of the diagnostic laparoscopy.

In some cases it is cut away. When it settles in the ovary it can form a special type of cyst (chocolate cyst) that may be drained and then the lining is removed (to prevent it from reforming).

Adhesions

Adhesions may result from endometriosis or infection. Pelvic infection can sometimes occur without realising that it has happened. Adhesions are a bit like sticky spider webs that can cause the ovaries, fallopian tubes and womb to stick together. This may cause pain and also affect fertility. Adhesions can sometimes cause the bowel to stick to the back of the womb. Adhesions can be divided using laparoscopic surgery.

Adhesions do have a tendency to reform. There are certain fluids that can be left within the tummy cavity that may help reduce the risk of adhesions coming back again after initial surgery.

Ovarian cysts

The ovaries produce cysts every month under normal conditions so an ovarian cyst is not necessarily abnormal. Cycle cysts should go away on their own. Cysts that do not disappear sometimes need a closer look and removal. These are usually detected by ultrasound scan prior to a laparoscopy. Ovarian cysts can often be removed with keyhole surgery but sometimes a laparotomy (bigger cut) is needed. Your consultant will discuss whether this is likely for you.

The usual aim is to remove a cyst and preserve normal ovary. Sometimes however, cysts can occupy the whole of the ovary leaving no normal egg-containing ovarian tissue behind. In this situation, the whole ovary may need to be removed.

Again this will be discussed with you by your consultant. If one ovary is removed, the remaining ovary will usually function to provide a monthly menstrual cycle.

Ectopic pregnancy

An ectopic pregnancy occurs when a pregnancy fails to develop within the womb, but develops outside the womb, most commonly within the fallopian tube. This may require surgery to either remove the ectopic pregnancy from the fallopian tube, or remove the entire fallopian tube.

The decision as to which operation is the most appropriate can often not be made until the laparoscopy is actually being performed and the fallopian tube being inspected. The surgeon will do what is needed to remove the ectopic pregnancy and preserve normal organs for future fertility.

Tubal surgery

If the tubes have been damaged by past infection or endometriosis, then laparoscopic surgery can sometimes help to open up the fallopian tubes and try and improve the situation.

Open fallopian tubes are not necessarily tubes that will function normally and if any surgery has been performed to the fallopian tubes, there is an increased risk of an ectopic pregnancy with future pregnancies. This means that if you conceive after laparoscopic surgery, it is important to get an early ultrasound scan to confirm the site of the pregnancy (at 6-7 weeks from the last menstrual period date).

Laparoscopic sterilisation

A laparoscopy may be performed in order to achieve sterilisation of the fallopian tubes (block them off). This is usually done by placing a ‘Filshie’ clip across each of the fallopian tubes. Once a sterilisation has been performed it should be considered to be permanent.

Whilst there are operations to reverse sterilisation, these have about a 50% chance of working and are not funded by the National Health Service. Furthermore, if a sterilisation has been performed, damage is inevitably caused to the fallopian tube and therefore reversal of the sterilisation is not always successful.

If pregnancy does occur after a sterilisation, there is also a risk of an ectopic pregnancy (see above). Sometimes the clips come off the fallopian tube. The risk of sterilisation failure (unplanned pregnancy) is 1 in 200 operations.

You may notice a change in the nature of your menstrual periods after a sterilisation operation. This is probably because you have stopped some hormonal contraception which was keeping your periods at bay. It is not the sterilisation, but the change in hormones which makes the periods different.

Diagnostic hysteroscopy

A hysteroscopy is often performed at the same time as a diagnostic laparoscopy especially when the examination is for fertility purposes.

What is hysteroscopy?

A hysteroscopy is a telescopic camera examination of the cavity of the womb. The camera is passed from the vagina, through the cervix and into the cavity of the womb to inspect the lining and openings of the fallopian tubes from the inside.

What are the risks of hysterocopy?

Bleeding
The risk of heavy bleeding is rare.

Infection
This is not common. You should report any bad smelling discharge from the vagina and / or worsening pain after your procedure. It is common to have some discharge soon after and when you stand up, as a watery solution is used to flush the area in order to be able to see properly inside. You should wear a sanitary towel and not tampons until this has settled.

Damage to nearly structures
Perforation of the womb does happen occasionally but it is not common. Usually this may cause a little bleed which settles by itself. The womb heals and recovers normally. Occasionally a course of antibiotics will be given to make sure infection does not set in. It is rare for perforation to damage the bladder or bowels beyond the womb.

Whilst it is important to appreciate the risks of surgery, fortunately, serious problems are very rare. Your surgeon will come and speak to you before you go home to explain what was seen and done and what the next steps in your care should be.
Your general practitioner will be sent a full summary of your operation, which should be received within a week of the procedure taking place.

Informed consent

This leaflet is provided to supplement verbal information that will be given to you by your healthcare provider (Doctor/ Surgeon/Nurse) as part of the consent process prior to your procedure. Information sharing between you and the clinician is essential to ensure that your decision to consent is fully informed. Please ask questions if you don’t fully understand or have any concerns about what is proposed. You have a right to be involved in these decisions and should feel supported to do so. Please take the time to consider what is important to you to ensure the information you receive is specific and individualised.

Contact us