After the medical history, which consists of questions about the patient's previous  illnesses, etc.. and physical examination are completed, laparoscopy is usually  performed on an outpatient basis, under general anesthesia, and with minimal  discomfort. After the patient is under general anesthesia, a needle is inserted through  the navel and the abdomen is filled with carbon dioxide gas. The gas pushes the  internal organs away from the abdominal wall so that the laparoscope can be placed safely into the abdominal cavity to avoid injury to surrounding organs such as the bowel, bladder, and blood vessels. The laparoscope. a long. thin lifted telescope-like instrument, is inserted through an incision in the navel

While looking through the laparoscope, the physician can see the reproductive organs including the uterus, fallopian tubes, and ovaries (Figure 1). A small probe is usually inserted through another incision above the pubic region in order to move  the pelvic organs into clear view (Figure 2). Additionally, a blue solution is often injected through the cervix, uterus, and fallopian tubes to determine if they are open. If no abnormalities are noted at this time, one or two stitches close the incisions. If defects or abnormalities are discovered, diagnostic laparoscopy can become operative laparoscopy.

Figure 1: Laparoscopic view of internal female reproductive organs

During operative laparoscopy, many abdominal disorders can be safely treated through the laparoscope at the same time that the diagnosis is made. When performing operative laparoscopy, the physician inserts additional instruments such as probes, scissors, grasping instruments, biopsy forceps, electrosurgical or laser instruments, and suture materials through two or three incisions in the area above the pubic bone. Lasers, while a significant help in certain surgeries, are expensive and are not necessarily better or more effective than other surgical techniques used during operative laparoscopy. The choice of technique and instrumentation depends on many factors including the physician's training, location of the problem, and availability of equipment.

Figure 2 : Diagnostic Laparoscopy

Some problems that can be corrected with operative laparoscopy include removing adhesions from around the fallopian tubes and ovaries, opening blocked tubes, removing ovarian cysts, and treating ectopic pregnancy. Endometriosis can also be removed from the outside of the uterus, ovaries, or peritoneum. Under certain circumstances, fibroids on the uterus can also be removed. Operative laparoscopy can also be used to remove diseased ovaries and can assist in the performance of hysterectomy.

Sometimes a second-look laparoscopy may be recommended and is performed following a previous laparoscopy or major abdominal surgery (laparotomy). Second-look laparoscopy may be performed within a few days. weeks, or months following the initial laparoscopy or laparotomy. During a second-look procedure the physician determines the results of the initial procedure, for example whether adhesions are reforming or if endometriosis is returning. If so. these problems can be treated at the time of the second-look laparoscopy.

Risks of Laparoscopy

Serious complications of diagnostic and operative laparoscopy are rare. The  major risk is damage to the bowel, bladder, ureters, uterus, major blood vessels, or  other organs, which would require emergency surgery to repair. The chance that  emergency surgery will be required is two to four per 1.000 procedures. Injuries can  occur during the insertion of various instruments through the abdominal wall or during operative treatment. Certain conditions may increase the risk of serious complications. These include previous abdominal surgery, especially bowel surgery and a history or presence of bowel/pelvic adhesions, severe endometriosis. Pelvic  infections, obesity, or excessive thinness.

There are other risks associated with laparoscopy. but they are all uncommon. Large hematomas of the abdominal wall can occur near the incisions. Pelvic or  abdominal infections may occur as a result of the solution injected to see it the  fallopian tubes are open. Allergic reactions, nerve damage, and anesthesia complications rarely occur. Postoperative (after operation) complications include bladder infection, skin incision infection, urinary retention, or venous thrombosis.

Postoperative Care

Following laparoscopy. the navel area is usually tender and the abdomen may be  bruised. Gas used to distend the abdomen may cause discomfort in the shoulders and   abdomen, and anesthesia can cause nausea and dizziness. The amount of  discomfort depends on the type and exent of procedures performed. Normal activities can usually be resumed within a few days.

Significant abdominal pain, worsening nausea and vomiting, a temperature of 101  degrees Fahrenheit or higher, or significant bleeding from an incision requires  immediate medical attention.

CONSIDERING OPERATIVE LAPAROSCOPY VERSUS

LAPAROTOMY FOR PELVIC SURGERY

Many gynecologic, reproductive, or tubal operations have been performed using  "major" surgery (laparotomy). Laparotomies are generally performed through a "bikini" or through an "up and down" skin incision. Patients generally remain in the hospital between two and five days following surgery and may return to work in two to six weeks, depending on the level of physical activity required. More recently many of these surgeries can be performed using the laparoscope (operative laparoscopy). Although the same type of procedures are performed by laparotomy,  operative laparoscopy uses much smaller skin incisions, generally three to four,  approximately one quarter to one-half inch wide. Following operative laparoscopy,  patients are generally able to return home the day of surgery and recover more quickly, returning to full activities in three to seven days.

Notwithstanding the advantages of operative laparoscopy, not all procedures can  be performed with this technique. Some types of surgeries may be too risky to  perform

laparoscopically, while in others it is not clear that laparoscopy yields results as good as those by laparotomy. Finally, the surgeon's training, skill, and experience also play a significant role in deciding whether operative laparoscopy or  laparotomy should be used. When considering a pelvic or reproductive  operation, the patient and her doctor should discuss the pros and cons of performing a laparotomy versus an operative laparoscopy, including surgical results, the surgeon's training and skill, and the overall risks.

DIAGNOSTIC HYSTEROSCOPY

Hysteroscopy is an important tool in the study of infertility, recurrent miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the inside of the uterus, also known as the uterine cavity (Figure 3), and is helpful in diagnosing abnormal uerine conditions such as internal fibroids, scarring, polyps, and congenital malformations. A hysterosalpingogram (an x-ray of the uterus and fallopian tubes) or an endometrial biopsy may be performed before or after diagnostic hystcroscopy.

The first step of diagnostic hysteroscopy involves slightly stretching the canal of the cervix with a series of dilatators. Once the cervix is dilated, the hysteroscope, a narrow lighted viewing instrument similar to but smaller than the laparoscope, is inserted through the cervix and into the lower end of the uterus. Carbon dioxide gas or special clear solutions are then injected into the uterus through the hysteroscope. This gas or solution expands the uterine cavity, clears blood and mucus away and enables the physician to directly view the internal structure of the uterus.

Diagnostic hysteroscopy is usually conducted on an outpatient basis with either general or local anesthesia. Diagnostic hysteroscopy is usually performed soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interupting a pregnancy.

Figure : Diagnostic Hysteroscopy

OPERATIVE HYSTEROSCOPY

Operative hysteroscopy can treat many of the abnormalities found during diagnostic hysteroscopy. Treatment may be performed at the same time as diagnostic hysteroscopy or at a later date. Operative hysteroscopy is similar to diagnostic hysteroscopy except that a wider hysteroscope is used to allow operating instruments such as scissors, biopsy forceps, electrosurgical or laser instruments, and graspers to be placed into the uterine cavity through a channel in the operative hysteroscope. Fibroids, scar tissue, and polyps can be removed from inside the uterus. Congenital abnormalities, such as a uterine septum, may also be corrected through the hysteroscope. After surgical repair of the uterine cavity, a Foley catheter or intrauterine device (IUD) may be placed inside the uterus to prevent the uterine walls from fusing together and forming scar tissue. Antibiotic and/or hormonal medication may also be prescribed after uterine surgery to prevent infection and stimulate  healing of the endometrium (uterine lining). Endometrial ablation, an operative hysteroscopy procedure in which the endometrium is destroyed, can be used to treat excessive uterine bleeding when a hysterectomy is not considered feasible.

Risks of Hysteroscopy

Complications of diagnostic hysteroscopy are rare and seldom life-threatening.  Perforation of the uterus (a hole punctured in the uterus) is the most common  complication, but the hole usually heals on its own, without requiring additional  surgery. When operative hysteroscopy is planned, diagnostic laparoscopy is  frequently performed at the same time to allow the physician to see the outside as  well as the inside of the uterus.

Complications occur in one or two out of every 100 operative hysteroscopy  procedures, with uterine perforation being the most common. Some complications related to the liquids used to distend the uterus include pulmonary edema (fluid in the lungs), breathing difficulties, blood clotting problems, decreased body  temperature, and severe allergic reactions. Complications related to the surgical procedure include damage to intra-abdominal organs and hemorrhage. Severe or life-threatening complications, however, are very uncommon.

Postoperative Care

Following hysteroscopy, some vaginal discharge and cramping may be experienced for several days. Sexual intercourse should be avoided for a few days or for as long as bleeding occurs. Normal activities can usually be resumed within one or two days. If a Foley catheter is left in the cavity, it is usually removed after several days. Hormonal treatments are often continued for several weeks after surgery.

CONCLUSION

Diagnosing and correcting gynecologic disorders once required major surgery and many days of hospitalization. Laparoscopy and hysteroscopy now allow physicians to diagnose and correct many of these disorders on an outpatient basis. Patient recovery time is normally only two to three days, which is significantly less than the recovery time from major abdominal surgery. The procedures also decrease patient discomfort. Before undergoing laparoscopy or hysteroscopy, patients should discuss with their physicians any concerns about the procedures and their risks.