What is laparoscopic surgery?
Laparoscopic surgery is a technique which allows operations within abdomen to be performed without need for a large skin incision. It is sometimes called a key hole surgery or minimally invasive surgery or microsurgery.

What are the benefits of laparoscopic surgery?
Advantages of laparoscopic surgery compared to traditional ‘open’ surgery are :

• Much less postoperative pain
• Quicker recovery, shorter hospital stay,
• Less risk of infection, bleeding
• Much quicker return to work
• Much smaller scar

What are the indications of gynaecological laparoscopic surgery?
Gynaecological causes of laparoscopy are :

• Diagnostic laparoscopy – to find out cause of infertility or abdominal pain
• Treatment of endometriosis
• Removal of ovary, ovarian cyst, tumour
• Sterilization ( ligation ) to avoid pregnancy
• Division of intraabdominal adhesion
• To treat ectopic pregnancy
• Removal of uterine fibroid (myomectomy)
• Removal of uterus – laparoscopic hysterectomy

How is it performed?
Once the patient is put under general anaesthesia, abdomen is inflated with gas for better visibility. Surgeon can get a view of interior of abdomen in a TV monitor. Depending the type of surgery, surgeon may need to make 1- 3 tiny incisions in abdomen for specialized surgical instruments. At the end of the procedure, gas is released, checked and cuts are stitched.

What are the risks of laparoscopic surgery?
Vast majority of operations are straight forward and chance of complication is not different from open surgery. Like any other surgical procedure, there is a small risk of side effects:

• Injury to intestine, blood vessels, ureter etc.
• Risk of anaesthesia, allergic reaction etc.
• Infection at stitch site requiring antibiotic

Actual risk of serious complication is very small (approximately 2 in 1000). As every case is different, your doctor can advise you regarding probability of risk in your case.

Rarely, surgeon may need to convert a laparoscopic surgery into an open procedure to complete procedure safely in the good interest of the patient.

What happens after surgery?
Once the procedure is complete, you will be brought back to your senses, but you may feel slightly drowsy for next 1-2 hours. Abdomen may feel mildly bruised.  Water and liquid diets are allowed after 3 hours and patients are encouraged to go to toilet. Majority of patients are fit to go home on the same day, others are discharged on the next day. One can resume activities after 1-2 weeks.

What is a hysterectomy?
Hysterectomy is an operation which involves removal of uterus (womb) with orwithout cervix (neck of uterus). This operation can be combined with removal of ovary and fallopian tube (salpingo-oophorectomy).

What are the reasons for hysterectomy?
Common reasons for hysterectomy are:

• Heavy periods unresponsive to medical treatment
• Fibroids
• Adenomyosis
• Endometriosis
• Prolapse of uterus – uterus coming out of body
• Along with removal of ovarian tumour (sometimes)
• Cancer of uterus, ovary
• Precancerous conditions of uterus

How is hysterectomy performed?
It is done by three ways:

• Abdominal hysterectomy : Uterus is removed through an incision made on lower part of abdomen.
• Vaginal hysterectomy : uterus is removed through a cut made within vagina and there is no externally visible scar.
• Laparoscopic Hysterectomy : Operation is carried out by key hole surgery (microsurgery) making 3-4 small holes in abdomen with very quick recovery.

What are the different types of hysterectomy?

• Subtotal hysterectomy : Body of the uterus is removed leaving the cervix in place. It is usually done to avoid injure to bladder/ intestine if these structures are densely stuck with uterus.
  
  
• Total hysterectomy : Both body and cervix of uterus are removed.
  
  
• Total hysterectomy with salpingo-oophorectomy : Uterus, ovary (is), and fallopian tube(s) are removed depending on patient’s age and other coexisting pathology.
  
  
• Radical hysterectomy : Uterus, ovaries, fallopian tubes, adjacent ligaments (parametrium), upper part of vagina and related lymph nodes. It is done as a treatment of cancer of uterus.

What happens after surgery?
Once you are back to ward following surgery, you will be given oxygen at your nose for a couple of hours. Intravenous fluid, antibiotics, pain killer and other medicines are given by injection as per requirement   Water can be taken orally after 4- 6 hours and liquid diet is allowed after 12 – 24 hours. You will be encouraged to be on your feet early. You may have a catheter which will be removed after 1 -3 days. Minor problems like pain, constipation, acidity, coughetc. will be managed by medicines. Somebody may experience some vaginal bleeding which may continue up to 3 weeks. Depending on type surgery you will be discharged after 1 – 7 days.

Is there any risk associated with hysterectomy?
There are risks, as with any  medical procedure, but vast majority of women will not have any complication and nobody will develop all complications. Every possible care is taken to eliminate and minimize risk. Antibiotics are used routinely to prevent infection. If there is more than average blood loss, one may need blood transfusion. Extremely rarely, blood clot may develop in leg veins (deep vein thrombosis), which is treated with elastic stockings and an injection.

How much rest should be taken after Hysterectomy?
It depends on how quickly one recovers, physically and emotionally and on type of work she does. Most women require 4 – 6 weeks leave from work. Recovery is quicker following laparoscopic hysterectomy.

What is endometriosis?
This is a condition where tissues similar to inner lining of uterus are found outside uterus. It is found in 10% of women, most commonly in the age group of 25 – 40 years. It is most commonly found on ligaments supporting uterus, ovaries, bladder and also in other parts of pelvis.Endometriotic tissue bleeds during  periods  causing altered blood to accumulate  forming chocolate cyst and ovarian cyst (endometrioma).  It makes pelvic organs stick with one another.

It is widely believed that endometriosis is caused by reverse menstruation when tissues from inner lining of uterus flow through fallopian tubes to pelvis and gets deposited there. Some doctors feel that there may be a genetic cause for it.

What are the symptoms of endometriosis? 
Symptoms of endometriosis are :

• -        -  Pain before or during periods
• -         - Chronic pelvic pain
• -         - Heavy menstrual bleeding
• -          - Painful intercourse
• -        -  Infertility
• -         -  Painful bowel movement

How is endometriosis diagnosed?
Diagnosis of endometriosis may take long time as often it is confused with other conditions. history and clinical examination helps in coming to a diagnosis. An ultrasonography reveals an chocolate cyst or endometrioma but not helpful in diagnosing  endometriotic spots, scars or adhesion which can only be detected by doing laparoscopy and biopsy. Laparoscopic view is superior to necked eye view in getting nature, extent and site of the disease. Many doctors use the classification provided by American Society of Reproductive Medicine to assess severity of disease. Untreated endometriosis usually worsens in symptom and extent.

How is endometriosis treated?
By and large women with endometriosis require treatment if they have pain, heavy bleeding , infertility, ureteric obstruction or chocolate cyst. Treatment is either medical or surgical or combined.

Medical : Combined oral contraceptive pills (COCP), progesterones and mirena coil placed in uterus usually relieves symptoms like pain and/or heavy bleeding.Drugs like danazol and GnRh agonists  lower estrogen level in body and give longer term relief from symptom. Medical treatment cannot be taken when somebody is trying for pregnancy.

Surgical : Endometriosis can be removed or ablated by diathermy/ laser by laparoscopic surgery.

Anatomy can be restored by separation of adhesion, removal of chocolate cyst with improvement of symptom and fertility in 70- 90 % of cases. Hysterectomy with removal of ovaries are usually needed as a last resort when fertility is not required. Recurrence following surgery is not uncommon.

Endometriosis and infertility
Endometriosis has been found in 25% of women who had laparoscopy for infertility.  It is probablyscarring , blocked tube, impaired ovulation and distorted anatomy which impairs fertility . Chance of pregnancy improves with surgery.

IVF – In Vitro Fertilisation  or ‘Test tube Pregnancy’

+  What is IVF ?
IVF, a latin ward, literally means ‘ fertilization in a glass’. It is one of the most popular and highly sophisticated technique for assisted conception practiced worldwide.

+ What are the common reasons one may need IVF ?

• Blocked tubes
• Low sperm count and quality
• Prolonged unexplained infertility
• Older age group women
• Moderate to severe endometriosis
• Wife has  ovulatory problem ,i.e, egg releasing problem
• Failure to conceive on other fertility treatments

+ What does IVF involve?
It involves a preliminary consultation with specialist doctor where an assessment of the  couple and complete planning of treatment will be done.  Detailed history, review of previous reports, an initial ultrasonography scan, discussion about steps of treatment and cost of treatment will be undertaken. One may need  some preliminary tests and a hysteroscopy – visualisation of inner lining of uterus.

If IVF is considered suitable for the couple, it is generally performed in three steps:

• Ovulation induction, where a number of eggs will be developed in wife’s ovaries by hormone injection and tablets. It is monitored by ultrasound scanning in clinic.
• Egg retrieval: When the eggs become mature, these are sucked out from ovaries by a needle under ultrasonographic guidance with painkiller/ conscious sedation. It may take 15 – 20 minutes. Eggs are fertilized with husband’s semen in laboratory. Couple can leave clinic after a 3- 4 hours.
• Embryo transfer: Fertilised eggs called embryo are transferred into wife’s uterus by a help of a very fine plastic tube under ultrasound guidance. Usually 2 – 3 eggs are transferred by a painless procedure 2 – 5 days after egg collection.
  

A pregnancy test is done 2 weeks after embryo transfer.

+ What is a donor egg IVF?
Occasionally, a woman’s ovaries cannot produce  enough good quality eggs inspite of having a healthy uterus. In this case, eggs can be taken from a healthy young woman of proven fertility potential to create an embryo.

+ What is the cost of IVF treatment?
Cost of treatment in low cost IVF set up can be 65000 to 75000 rupees .