Laparoscopic Surgery is commonly known as "Keyhole Surgery", "Minimally Invasive Surgery", "Minimal Access Surgery", "Operative Endoscopy" and even “Laser Surgery”.  It was wrongly called "Laser Surgery" because the early users emphasized the use of laser rather than the small size of incisions in the laparoscopic technique.

Laparoscopic surgery is now firmly established as the operation of choice or “Gold standard” for treatment of most gynaecological problems needing surgery. Laparoscopy is now fully accepted as the treatment of choice for conditions like ectopic pregnancies, pain due to adhesions, non-cancerous ovarian cysts, endometriosis, and infertility.

Laparoscopy also has a major role in the treatment of uterine fibroids, uterine diseases needing hysterectomy e.g. adenomyosis, early uterine cancers, urinary stress incontinence, and uterine prolapse. For these procedures, there is still debate on the role of laparoscopy. About 30% of these types of surgery are being carried out by laparoscopic surgery. The skill level needed to achieve good results in this is higher and not all gynecologists are expected to attain competence in all the procedures. However, progress is being made in increasing skill levels and enabling more patients to enjoy the benefits of laparoscopic surgery.

To help you understand the various procedures, a series of annotated pictures are shown:
Adhesiolysis | Ovarian Cysts | Myomectomy | Hysterectomy

Adhesiolysis
Adhesions are scar tissue within the abdomen which can cause pain and infertility. They can be filmy and are easily cauterized to prevent bleeding. They are then cut and removed. Here the adhesions are between the intestines and the uterus.

The uterus here is stuck to the bladder by dense adhesions. The main complaint in this patient is that she has to go to the washroom very often (medically termed frequency of micturition). Freeing up of the adhesions enabled her to reduce visits to the toilet drastically.

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Ovarian Cysts
Ovarian cysts are detected during ultrasound. Sometimes they are large or are twisted and cause pain. They are usually non-cancerous (in about 99% in women under 45 years of age). However, they are best removed completely to prevent spillage of contents in the abdomen.

This cyst is in the right ovary. The right ovary measures about 5 cm across. The left ovary is not visible here. There is a small fibroid on the left side of the uterus.

During the operation, the cyst is dissected free and separated from the ovary. The normal part of the ovary is preserved and only the abnormal areas are removed.

The removed cyst is placed in a bag and deflated before removal to prevent spillage. Any spillage will be collected in the bag which is removed through a 10 mm (1 cm) cut in the belly button.

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Myomectomy
Myomectomy, or removal of fibroids, can be easy as in the first sequence or difficult as in the second which show a large fibroid buried within the muscles of the uterus.

This picture shows a 4 cm fibroid attached to the uterus by a stalk.

First, medicine (pitressin) is injected to reduce bleeding when the fibroid is cut.

The stalk of the fibroid can be cut using ultrasound energy as illustrated here or with electrical energy. Both methods avoid excessive blood loss.

This shows the stalk almost completely cut through.

The small raw area left after removal is stitched close.

The fibroid is then removed from the body with a morcellator, a piece of equipment best described as a circular saw.

This second picture is of a much larger fibroid buried within the uterus – an intramural fibroid. The surgery is best done as open surgery for those planning to have babies but in skilled hands, laparoscopic removal is feasible. The measuring instrument shows that the fibroid is about 8 cm. across.

An incision is made across the uterus to expose the fibroid.

The fibroid is seen dissected free. There is a large gaping wound in the uterus.

This wound is closed with 2 to 3 layers of sutures. As a finishing touch, the final layers of sutures are being put in place with a curved needle.

The large fibroid is morcellated and removed from the body as 1 cm thick strips.

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Hysterectomy
Hysterectomy when necessary can be done laparoscopically, avoiding the need for a large cut in the abdomen. The picture below shows the abdomen being closed up after hysterectomy

This show the view of a uterus enlarged by fibroids. It is about 12 weeks in size, equivalent to a 3 month pregnancy in size or about 12 cm across.

After the main blood vessels are tied and cut, the uterus looks congested and dark just prior to removal through the vagina.

After the uterus is removed the pelvis looks clear. The cut in the vaginal vault is closed with sutures in a manner similar to that done in myomectomy.

If you would like to know more about our MIS services or to book an appointment, please contact our MIS Centre at Tel: 6347 6788.

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