Laparoscopy for endometriosis

Definition

Laparoscopy is a surgical procedure in which a laparoscope, a telescope-like instrument, is inserted into the abdomen through a small incision and used to diagnose or treat various diseases. Specifically, laparoscopy may be used to diagnose and treat endometriosis, a condition in which the tissue that lines the uterus grows elsewhere in the body, usually in the abdominal cavity.

Purpose

The endometrium is the inner lining of the uterus; it is where a fertilized egg will implant during the early days of pregnancy. The endometrium normally sheds during each menstrual cycle if the egg released during ovulation has not been fertilized. Endometriosis is a condition that occurs when cells from the endometrium begin growing outside the uterus. The outlying endometrial cells respond to the hormones that control the menstrual cycle, bleeding each month the way the lining of the uterus does. This causes irritation of the surrounding tissue, leading to pain and scarring.

Endometrial growths are most commonly found on the pelvic organs, including the ovaries (the most common site), fallopian tubes, bladder, rectum, cervix, vagina, and the outer surface of the uterus. Growths are also sometimes found in other areas of the body, including the skin, lungs, brain, or surgical scars. There are numerous theories as to the cause of endometriosis; these include retrograde menstruation (movement of menstrual blood up through the fallopian tubes), movement of endometrial tissue through the blood or lymph system, or surgical transplantation (when endometriosis is found in surgical scars).

There are a number of reasons why laparoscopy is used to treat endometriosis. It is useful as both a diagnostic tool (to visualize structures in the abdominal cavity and examine them for endometrial growths) and as an operative tool (to excise or destroy endometrial growths). A patient's recovery time following laparoscopic surgery is shorter and less painful than following a traditional laparotomy (a larger surgical incision into the abdominal cavity). A disadvantage to laparoscopy is that some growths may be too large or extensive to remove with laparoscopic instruments, necessitating a laparotomy.

Demographics

Endometriosis has been estimated to affect up to 10% of women. Approximately four out of every 1,000 women are hospitalized as a result of endometriosis each year. Women ages 25–35 are most affected, with 27 being the average age at diagnosis. The incidence of endometriosis is higher among white women and among women who have a family history of the disease.

Description

The patient is given anesthesia before the procedure commences. The method of anesthesia depends on the type and duration of surgery, the patient's preference, and the recommendation of the physician. General anesthesia is most common for operative laparoscopy, while diagnostic laparoscopy is often performed under regional or local anesthesia. A catheter is inserted into the bladder to empty it of urine; this is done to minimize the risk of injury to the bladder.

A small incision is first made into the patient's abdomen in or near the belly button. A gas such as carbon dioxide is used to inflate the abdomen to allow the surgeon a better view of the surgical field. The laparoscope is a thin, lighted tube that is inserted into the abdominal cavity through the incision. Images taken by the laparoscope may be seen on a video monitor connected to the scope.

For this procedure, three or four incisions may be made in the woman's lower abdomen (A). Carbon dioxide is pumped into the abdomen to create a condition called pneumoperitoneum, which gives the surgeon more room to work (B). A laparoscope with video monitor is used to view the internal structures, while endometrial growths are removed with other tools (C). (

Illustration by GGS Inc.

)

The surgeon will examine the pelvic organs for endometrial growths or adhesions (bands of scar tissue that may form after surgery or trauma). Other incisions may be made to insert additional instruments; this would allow the surgeon to better position the internal organs for viewing. To remove or destroy endometrial growths, a laser or electric current (electrocautery) may be used. Alternatively, implants may be cut away with a scalpel (surgical knife). After the procedure is completed, any incisions are closed with stitches.

Diagnosis/Preparation

Some of the symptoms of endometriosis include pelvic pain (constant or during menstruation), infertility, painful intercourse, and painful urination and/or bowel movements during menstruation. Such symptoms, however, are also exhibited by a number of other diseases. A definitive diagnosis of endometriosis may only be made by laparoscopy or laparotomy.

Prior to surgery, the patient may be asked to refrain from eating or drinking after midnight on the day of surgery. An intravenous (IV) line will be placed for administration of fluids and/or medications.

Aftercare

After the procedure is completed, the patient will usually spend several hours in the recovery room to ensure that she recovers from the anesthesia without complication. After leaving the hospital, she may experience soreness around the incision, shoulder pain from the gas used to inflate the abdomen, cramping, or constipation. Most symptoms resolve within one to three days.

Risks

Risks that are associated with laparoscopy include complications due to anesthesia, infection, injury to organs or other structures, and bleeding. There is a risk that endometriosis will reoccur or that not all of the endometrial implants will be removed with surgery.

Normal results

After laparoscopy for endometriosis, a woman should recover quickly from the surgery and experience a significant improvement in symptoms. Some studies suggest that surgical treatment of endometriosis may improve a sub-fertile woman's chance of getting pregnant.

Morbidity and mortality rates

The overall rate of risks associated with laparoscopy is approximately 1–2%, with serious complications occurring in only 0.2% of patients. The rate of reoccurrence of endometrial growths after laparoscopic surgery is approximately 19%. The mortality rate associated with laparoscopy is less than five per 100,000 cases.

Alternatives

While laparoscopy remains the definitive approach to diagnosing endometriosis, some larger endometrial growths may be located by ultrasound, a procedure that uses high-frequency sound waves to visualize structures in the human body. Ultrasound is a noninvasive technique that may detect endometriomas (cysts filled with old blood) larger than 0.4 in (1 cm).

A physician may recommend noninvasive measures to treat endometriosis before resorting to surgical treatment. Over-the-counter or prescription pain medications may be recommended to relieve pain-related symptoms. Oral contraceptives or other hormone drugs may be prescribed to suppress ovulation and menstruation. Some women seek alternative medical therapies such as acupuncture, management of diet, or herbal treatments to reduce pain.

Severe endometriosis may need to be treated by more extensive surgery. Conservative surgery consists of excision of all endometrial implants in the abdominal cavity, with or without removal of bowel that is involved by the disease. Semi-conservative surgery involves removing some of the pelvic organs; examples are hysterectomy (removal of the uterus) and oophorectomy (removal of the ovaries). Radical surgery involves removing the uterus, cervix, ovaries, and fallopian tubes (called a total hysterectomy with bilateral salpingo-oophorectomy ).

See also Laparoscopy .

Resources

PERIODICALS

Prentice, Andrew. "Endometriosis." British Medical Journal 323 (July 14, 2001): 93–95.

Wellbery, Caroline. "Diagnosis and Treatment of Endometriosis." American Family Physician 60 (October 1, 1999): 1753–68.

ORGANIZATIONS

American Association of Gynecologic Laparoscopists. 13021 East Florence Ave., Sante Fe Springs, CA 90670-4505. (800) 554-AAGL. http://www.aagl.com .

Endometriosis Association. 8585 North 76th Place, Milwaukee, WI 53223. (414) 355-2200. http://www.endometriosisassn.org .

OTHER

"Endometriosis." UC Davis Health System. 2002 [cited March 22, 2003]. <http://www.ucdmc.ucdavis.edu/ucdhs/health/a-z/74Endometriosis__/ #x003E; .

Hurd, William W., and Janice M. Duke. "Gynecologic Laparoscopy." eMedicine. November 27, 2002 [cited March 22, 2003]. http://www.emedicine.com/med/topic3299.htm .

Kapoor, Dharmesh. "Endometriosis." eMedicine. September 17, 2002 [cited March 22, 2003]. http://www.emedicine.com/med/topic3419.htm .

"What is Endometriosis?" Endometriosis Association. 2002 [cited March 22, 2003]. http://www.endometriosisassn.org/endo.html .

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Laparoscopy for endometriosis is performed by a surgeon or gynecologist who has been trained in laparoscopic techniques. A gynecologist is a medical doctor who has completed specialized training in the areas of women's general and reproductive health, pregnancy, labor and delivery, and prenatal testing. Laparoscopy is usually performed in a hospital on an outpatient basis.

QUESTIONS TO ASK THE DOCTOR

• Why is laparoscopic surgery recommended for my particular case?
• Will operative laparoscopy be performed if endometriosis is diagnosed?
• What options do I have in terms of anesthesia and pain relief?
• What are the risks if I decide against surgical treatment?
• What alternatives to laparoscopy are available to me?