Diagnostic Laparoscopy

Diagnostic Laparoscopy

It has been recommended that you have a diagnostic laparoscopy (with or without other minor procedures).

This leaflet explains some of the benefits, risks and alternatives to the operation. We want you to have all the information you need to make the right decision. Please ask your Gynaecologist or Specialist Nurse about anything you do not fully understand or want to be explained in more detail.

We recommend that you read this leaflet carefully. You and your doctor (or other appropriate health professional) will also need to record that you agree to have the procedure by signing a consent form, which they will give you.

What is a laparoscopy?
Laparoscopy is a surgical procedure, which allows your gynaecologist to inspect the organs inside the pelvis and abdomen. It is often referred to as minimal access surgery, minimally invasive surgery, keyhole surgery or “endoscopy”, which means, “to look inside”.

Why do I need a laparoscopy?
A laparoscopy may be performed for diagnostic purposes to allow your gynaecologist to make a definite diagnosis of your complaint, or as an operative procedure to treat any number of known gynaecological conditions:

For diagnostic purposes:

• To investigate pelvic pain;
• To investigate infertility;
• To examine cysts and pelvic organs;
• To obtain biopsy specimens;
• To investigate suspected ectopic pregnancy.

Minor procedures:

• To treat ectopic pregnancy;
• To treat pelvic adhesions and endometriosis.

Compared to a laparotomy (surgery through a larger incision in the abdomen), laparoscopy has significant benefits such as:

• Less pain and discomfort during recovery;
• Shorter hospital stay;
• Faster recovery times for the patient and an earlier return to normal daily activities;
• Smaller and less visible scars.

The decision to undergo a laparoscopy is always yours and should not be made in a rush. Make a decision only when you are completely satisfied with the information you have received and believe that you have been well informed.
If you do decide to undergo laparoscopy we will ask you to sign a consent form, having explained the procedure and the risks involved. Before signing, do read it carefully and ask us if you have any questions.

The laparoscopic procedure
In attendance at your surgery will be the doctor, the surgical assistant, the anaesthetist, the scrub nurse, the scout nurse, and the anaesthetic nurse. When you are asleep, your doctor will insert a thin, hollow needle into the abdomen (most often through a small cut in the navel) where carbon dioxide gas is passed into the abdominal cavity. The gas gently inflates the abdomen, raising the abdominal wall above the uterus, bowel and other organs, so that visibility is increased and all areas of the pelvis can be easily inspected.

The laparoscope is then inserted. There will usually be a second incision just above the bikini line in the lower part of your abdomen in the midline. There may be up to four incisions in the abdomen to allow instruments to be inserted into the pelvis to move other pelvic organs for a clearer view or to perform surgical. A thin probe is usually inserted through the vagina and into the uterus to allow all areas of the pelvis to be inspected carefully. Occasionally a small probe is inserted into the rectum. This is usually only required to treat causes for symptoms, such as endometriosis safely, that may be located close to the bowel.

When the instruments are removed the gas is released from the abdominal cavity, and a stitch may be used to close each of the small cuts. Usually, if stitches are used they will dissolve. We will tell you if they need to be removed.

Depending on the nature of your particular surgery, the laparoscopic procedure may take anywhere from 15 minutes up to an hour. More major laparoscopic procedures may take up to several hours. Your laparoscopy may be performed in conjunction with other procedures such as hysteroscopy or insertion of a Mirena Coil (a hormone releasing contraception device). Further small procedures may include a tubal dye test, drainage or removal of ovarian cysts, division of adhesions (internal scarring) or burning away endometriosis with helica. This equipment uses helium gas and a small electric current to “dry out” the endometrioses at the same time as the laparoscopy. Local audit of helica shows that 59% of patients with endometriosis pain have improved symptoms.

In some cases, it may be unsafe to continue the laparoscopy due to unexpected or life-threatening problems, and become necessary to convert to laparotomy (open surgery through a much larger incision in the abdomen). This is only done in the interests of the well-being and safety of the patient.

Benefits of the procedure
The aim of your surgery is to:

• Investigate symptoms;
• Carry out assessment of tubes (if required);
• Carry out treatment of mild disease (if possible).

Complications of surgery
Every attempt is made to reduce the risk of complications, but minor adverse events occur in less than 3 out of 100 of cases.

Serious complications are rare (about 1 in 500 to 1 in 1000), but no surgery is without risk.

Serious or frequent risks
Everything we do in life has risks. Laparoscopic surgery has some risks associated with it.

Those specifically related to diagnostic laparoscopy (with or without minor surgery) include problems with:

• Failure to find a definite diagnosis for your symptoms.
• Failure to gain entry to abdominal cavity, so the procedure cannot be completed.
• Shoulder pain following surgery (due to some gas left behind – this settles with time).
• Uterine perforation during surgery (which will usually repair itself without any further treatment).
• Because laparoscopy requires the insertion of sharp instruments into the abdomen injury to major blood vessels, bladder, ureter, stomach and bowel is possible. This type of injury is rare. Patients who are very thin or obese, or who have had previous surgery to the abdomen, may have an increased risk for this type of injury.
• Laparotomy to repair damage to internal organs caused by the laparoscopic instruments. In the event of serious damage the surgical repairs may be extensive (1 in 1,000).
• Peritonitis is an extremely rate complication. This is an infection of the inside of the abdomen. It may not be immediately obvious and can be life threatening. In some cases, a colostomy (where the bowel empties into a bag) is created. Once again, this is an extremely unlikely complication but women undergoing laparoscopy should be made aware of this

The general risks of surgery include problems with:

• The wound (for example, bruising, infection);
• Breathing (for example, a chest infection);
• Bladder infection;
• The heart (for example, abnormal rhythm or, occasionally, a heart attack);
• Blood clots (for example, in the legs or occasionally in the lung);
• Excessive bleeding (that may require blood transfusion);
• Keloid (a surgical scar that becomes inflamed, raised and itchy). Keloid can be irritating but is no threat to your health.

Most people will not experience any serious complications from their surgery. The risks increase for elderly people, those who are overweight and people who already have heart, chest or other medical conditions such as diabetes or kidney failure. As with all surgery, there is a very small risk that you may die although this is extremely rare.

You will be cared for by a skilled team of doctors, nurses and other health-care workers who are involved in this type of surgery every day. If problems arise, we will be able to assess them and deal with them appropriately.

Other procedures that are available
Depending on the reason for your laparoscopy, other investigations or treatment options may be available. These may include an ultrasound scan or x-ray although these options may not be as informative as the planned laparoscopic investigation.

A member of the gynaecology team will discuss these options with you.

Your pre-surgery assessment visit
You may be asked to attend a pre-surgery assessment clinic before admission. This allows you, the nurse and doctor to go through all the paperwork and discuss any queries. The nurse will explain the ward routine and what to expect before and after the operation. For example, when you will be allowed to eat and drink before and after the operation, when you can expect to be out of bed and what observations the nurses need to do.

At this appointment, we will also record your current symptoms and past medical history, including any medication you are taking. Your heart and lungs will be examined to check that you are well enough for surgery. Blood tests and x-rays will usually be taken or arranged during this clinic.

The members of the gynaecology team will check that you agree to have the planned surgery. If you have been given a consent form please bring it with you, alternatively you may be given a consent form in clinic. Make sure that you have read and understood this information before your clinic visit. If you have not understood any part of the information, you will be able to ask any questions you may have about your planned surgery.

Before you come into hospital
There are some things you can do to prepare yourself for your operation and reduce the chance of difficulties with the anaesthetic.

• If you smoke, consider giving up for several weeks before the operation. Smoking reduces the amount of oxygen in your blood and increases the risks of breathing problems during and after an operation.
• If you are overweight, many of the risks of anaesthesia are increased. Reducing your weight will help.
• If you have loose or broken teeth or crowns that are not secure, you may want to visit your dentist for treatment. The anaesthetist will usually want to put a tube in your throat to help you breathe. If your teeth are not secure, they may be damaged.
• If you have long-standing medical problems, such as diabetes, hypertension (high blood pressure), asthma or epilepsy, you should consider asking your GP to give you a check-up.

There is a risk that your procedure will be cancelled if there is a chance of very early pregnancy. In order to be sure you are not pregnant at the time of the procedure you must not have sex or you must use reliable contraception between the first day of the last NORMAL period to the date of procedure.

You may be asked to stop Aspirin and other non-steroidal anti-inflammatory medications 7 days prior to surgery.

Pre-laparoscopy preparation
It is helpful if you follow a light diet the day before your laparoscopy, which reduces the incidence of intra-operative complications (such as bowel perforation) and increases visibility inside the pelvis.

A light diet should include plenty of fluids to drink and no bulky foods (which are difficult, or slow, to digest). This means you should try to avoid heavy meals such as pizza, pies, steak, chips or roast dinner and preferably stick to easily digestible food like porridge, soup and vegetables. The gynaecology team can discuss this with you in more detail.

Being admitted to the ward
You will usually be admitted on the day of your surgery we can prepare you for the surgery. We will welcome you to the ward and check your details. We will fasten an armband containing your hospital information to your wrist.

If you are at high risk of blood clots in your legs after surgery, we may give you heparin injections and ask you to wear support stockings before and after your surgery. We will usually ask you to continue with your normal medication during your stay in hospital, so please bring it with you.

Your pre-surgery visit by the anaesthetist
After you go into hospital, the anaesthetist will come to see you and ask you questions about:

• your general health and fitness;
• any serious illnesses you have had;
• any problems with previous anaesthetics;
• medicines you are taking;
• allergies you have;
• chest pain;
• shortness of breath;
• heartburn;
• problems with moving your neck or opening your mouth; and
• any loose teeth, caps, crowns or bridges.

Your anaesthetist will discuss with you the anaesthetic they will use.

On the day of your operation

Nothing to eat and drink (nil by mouth)
It is important that you follow the instructions we give you about eating and drinking. We will ask you not to eat or drink anything (including chewing gum or sucking sweets) for six hours before your operation. This is because any food or liquid in your stomach could come up into the back of your throat and go into your lungs while you are being anaesthetised. You may take a few sips of plain water up to two hours before your operation so you can take any medication tablets.

Your normal medicines

• You may be asked to stop Aspirin and other non-steroidal anti-inflammatory medications 7 days prior to surgery.
• Hormonal medications such as the oral contraceptive pill may be continued.
• Medications for diabetes and heart conditions may also be continued.

It is important to let us know, before you are admitted, if you are taking anticoagulant drugs (for example, warfarin, aspirin or clopidogrel).

Also provide us, and the anaesthetist, with a list of all the medications you are taking or have recently taken, including medicines prescribed by your family doctor and those bought “over the counter” without prescription, and also any herbal medications.
Keeping an up-to-date list of medications with you is highly recommended.

Please contact us if you are unsure which medications you must stop. If we do not want you to take your normal medication, your surgeon or anaesthetist will explain what you should do.

We will need to know if you do not feel well and have a cough, a cold or any other illness when you are due to come into hospital for your operation. Depending on your illness and how urgent your surgery is, we may need to delay your operation as it may be better for you to recover from this illness before your surgery.

Your anaesthetic
We will carry out your surgery under a general anaesthetic. This means that you will be asleep during your operation and you will feel nothing.

When it is time for your operation, a member of staff will take you from the ward to the operating theatre. They will take you into the anaesthetic room and the anaesthetist will make you ready for your anaesthetic.

To monitor you during your operation, your anaesthetist will attach you to a machine to watch your heart, your blood pressure and the oxygen level in your blood. General anaesthesia usually starts with an injection of medicine into a vein. A fine tube (venflon) will be placed in a vein in your arm or hand and the medicines will be injected through the tube. Sometimes you will be asked to breathe a mixture of gases and oxygen through a mask to give the same effect.

Once you are anaesthetised, the anaesthetist will place a tube down your airway and use a machine to ‘breathe’ for you. You will be unconscious for the whole of the operation and we will continuously monitor you. Your anaesthetist will give you painkilling drugs and fluids during your operation. At the end of the operation, the anaesthetist will stop giving you the anaesthetic drugs. Once you are waking up normally, they will take you to the recovery room.

Pain relief after surgery
Pain relief is important as it stops suffering and helps you recover more quickly. We may give you tablets or injections to make sure you have enough pain relief. Once you are comfortable and have recovered safely from your anaesthetic, we will take you back to the ward. The ward staff will continue to monitor you and assess your pain relief.

It is important that you report any pain you have as soon as you experience it.

What are the risks of anaesthetic?
Your anaesthetist will care for all aspects of your health and safety over the period of your operation and immediately afterwards. Risks depend on your overall health, the nature of your operation and how serious it is. Anaesthesia is safer than it has ever been. If you are normally fit and well, your risk of dying from any cause while under anaesthetic is less than one in 250,000. This is 25 times less likely than dying in a car accident. Side effects of having an anaesthetic include drowsiness, nausea (feeling sick), muscle pain, sore throat and headache. We will discuss with you the risks of your anaesthetic.

After your surgery

Recovering from laparoscopy
After your laparoscopy, while you are still under the effects of the anaesthetic, you will be taken to the recovery room where you will be monitored by the recovery staff until you are transferred back to the ward. Back on the ward, the nursing staff will monitor your condition and take routine observations. Our medical team will explain how the surgery went and what the findings were.

Following laparoscopy, you may experience the following:

• Tiredness;
• Muscle pain;
• Mild nausea;
• Pain or discomfort at the site of the incisions;
• Pain in one or both shoulders that may extend to the neck and rib cage (this is thought to be caused by some of the gas used during the procedure being left inside your body and may last for a number of days but will gradually wear off – often lying down can help relieve the symptoms).
• Cramps (similar to period pain);
• Vaginal discharge or bleeding for a few days;
• A sensation of bloating in the abdomen.

Leaving hospital

Length of stay
How long you will be in hospital varies from patient to patient and depends on how quickly you recover from the operation and the anaesthetic. Most patients having this type of surgery will be in hospital for a few hours but you may have to stay in overnight.

Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that you need to take when you are at home.

Convalescence
How long it takes you to recover from your surgery varies from person to person. It can take up to one to two weeks. After you return home, you will need to take it easy and should expect to get tired to begin with.

Stitches
We usually use dissolvable stitches. If these have not disappeared after seven days, they can be removed by the nurse at your GP practice.

Personal hygiene
You may bathe or shower normally after you leave hospital.

We recommend that you do not use tampons immediately after your procedure. Sanitary pads may be used and should be changed regularly.

Diet
You do not usually need to follow a special diet. If you need to change what you eat, we will give you advice before you go home. You should avoid constipation and straining for bowel motions and ensure that you get plenty of rest while you are recovering.

Exercise
You should do light exercise, such as walking and light housework, as soon as you feel well enough.

Normal physical activity may be resumed when any discomfort has disappeared, and when you are feeling well enough. This may take anywhere from three days to a few weeks, depending on the nature of your procedure and your general health.

Sex
You can continue your usual sexual activity when any bleeding and discomfort have disappeared, and when you are feeling well enough.

Driving
You should not drive until you feel confident that you could perform an emergency stop without discomfort – probably a few days after your operation. It is your responsibility to check with your insurance company.

Work
How long you will need to be away from work varies depending on:

• how serious the surgery is;
• how quickly you recover;
• whether or not your work is physical; and
• whether you need any extra treatment after surgery.

For most diagnostic and minor laparoscopic procedures you can return to work after one to three days. Please ask us if you need a medical sick note for the time you are in hospital and for the first three to four weeks after you leave.

Outpatient appointment
Before you leave hospital we may give you a follow-up appointment to come to the outpatient department, or we will send it to you in the post.

Your appointment will normally be for between four and 12 weeks after surgery. At this stage, we will discuss the surgery and findings in detail and recommend ongoing treatment options if required.

Once you leave hospital
If you experience fever-like symptoms, or excessive pain, redness and discharge at the incision sites you should contact us.
You should report to your GP or us if you experience any of the following:

• Persistent bleeding from the vagina that is smelly or becomes heavier than a normal period and is bright red;
• Persistent redness, pain, pus or swelling around the wounds, of a fever or more than 38°C, or chills, which may indicate infection;
• Pain or burning on passing urine or the need to pass urine frequently, as this may indicate a urinary tract infection;
• Increasing nausea;
• Increasing abdominal pain with vomiting.

Contact details
If you have any specific concerns that you feel have not been answered and need explaining, please contact the following:

• Worcester Royal Hospital
  Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
  Hospital Switchboard (phone 01905 763333)
• Alexandra Hospital
  Gynaecology Nursing Staff, Ward 14 (phone 01527 512100)
  Hospital Switchboard (phone 01527 503030)
• Kidderminster Treatment Centre
  Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
  Hospital Switchboard (phone 01562 823424)

Other information
The following internet websites contain information that you may find useful.

• www.patient.co.uk
  Information fact sheets on health and disease
• www.rcoa.ac.uk
  Information leaflets by the Royal College of Anaesthetists about ‘Having an anaesthetic’
• www.nhsdirect.nhs.uk
  On-line health encyclopaedia
• www.worcestershirehealth.nhs.uk/acute_trust
  Worcestershire Acute Hospitals NHS Trust

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net
Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.
If you are unable to understand this leaflet, please communicate with a member of staff.

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