Veronica Lerner MD Minimally Invasive Surgery and Urogynecology
Laparoscopy is an extremely valuable procedure in gynecology. It may be performed to establish a diagnosis, such as determining the cause of infertility or pelvic pain. It is often used as therapy, such as removing ovarian tumors or destroying endometriosis. It is also a preferred way to do a hysterectomy (if it is not possible to do it vaginally) or do surgery on ovaries and fallopian tubes.
If you are having vaginal or open surgery, your doctor will explain that approach.
No surgery is “minor.” Although we as surgeons may make the distinction between major and minor procedures, nothing done to you requiring anesthesia, should ever be considered “minor.” We recognize that surgery, no matter how “minimally invasive,” represents a significant stress to the body and is associated with some risk. Although the risks associated with laparoscopic and vaginal surgery in general are smaller (on a percentage basis) compared to open surgery, we are always cognizant of them and seek to prevent them as much as possible.
In preparing for surgery, you should maintain an appropriate diet and hydration, unless instructed otherwise by your physician. In general, you should not put anything in your mouth after midnight on the night before surgery. In some cases it is okay to take an important medication with a sip of water on the morning of surgery, but this should be discussed with your surgeon and anesthesiologist in advance.
For gynecologic/pelvic surgery, there is usually no need for bowel preps or enemas prior to the surgery. Likewise, shaving or clipping hair is also unnecessary and may be associated with higher risks for infection. If clipping is necessary, it will be done by your surgeon in the operating room, as this is associated with the lowest risk of infection. Aspirin and similar medications called NSAIDs—non-steroidal anti-inflammatory drugs (e.g., Motrin, Ibuprofen, Advil, Aleve) may increase bleeding in the operating room and therefore should be avoided starting at least 10 days prior to surgery. Tylenol (acetaminophen) does not cause bleeding problems and may be used.
Either residents (doctors who finished medical school and are undergoing specialization in obstetrics and gynecology) or physician’s assistants will be present and will function as surgical assistants. Medical students are at times present during a surgery as well. The role of residents as surgical assistants varies depending on the case, but they are supervised and directed at all times by an attending surgeon.
Robotically assisted laparoscopy:
You might experience pain in your shoulder, chest, and upper abdominal areas caused by the gas. It is normal to have tenderness at the incision sites. These discomforts usually diminish markedly after 2 days. Because fluids are often left in the abdomen to prevent adhesion formation, you might notice that fluid might leak from the incisions and observe swelling in these areas. This fluid leakage and swelling should disappear within 2 days. There is usually some bruising at the incision sites. This disappears in approximately 2 weeks. Most patients go home the day of the surgery and need to be accompanied home by a responsible adult.
Risks of Surgery
· As with all surgery, the degree of risk depends upon the patient (age, health status, medical condition, size of the uterus, pelvic adhesions/scarring). This risk assessment will be performed by your doctor during your pre-operative evaluation and shared with you. Risks listed below are described in detail, but they are not limited to what is listed.
· Injuries to Organs:
o The pelvic organs are surrounded by adjacent organs of the urinary and intestinal tracts. There is, therefore, a small risk of injury to these structures during gynecologic/urogynecologic procedures. The risk of injury to organs surrounding the uterus is about 6 in 1,000 operations (approximately 1% or less). Previous abdominal/pelvic surgery and pelvic infections will increase the risk for these problems. Your surgeon will evaluate for the possibility of such injury during surgery and address any problem thus identified. In some cases, problems do not become evident until some time after the initial surgery. When a problem in one of these systems arises, it may need to be treated with more extensive surgical and invasive procedures. Examples of these types of issues would include bowel obstruction (usually caused by adhesions/scar tissue) and fistula formation (abnormal connection between two organs/areas not normally connected), usually arising from infections and inflammatory/healing issues.
o Gastrointestinal injuries: Injuries to the intestinal tract (small and large intestine, rectum) occur approximately 1 per 500 operations but varies from case to case. This may happen when establishing the portals of entry from the instruments as well as during pelvic dissection. This is a serious complication and must be rectified. The repair usually requires major surgery. Although a colostomy is a possibility, it is a remote one.
o Urologic injury: Because much dissection is done around the drainage tubes from the kidney (ureters) or the urinary bladder, there is always the possibility of injury to one of these structures. These may be minor or serious, resulting in major surgery and even, rarely, loss of a kidney.
o Neurologic injuries: Pelvic nerve injuries may occur when extensive pelvic dissection is required. These are most often characterized by temporary numbness or tingling in the abdomen or lower extremities, but muscle weakness may occur rarely and be permanent. Similarly, weakness of the upper extremity has been reported, but fortunately, is very infrequent.
o Neurologic Symptoms: Rarely, patients whose legs are in the positions utilized for gynecologic/urogynecologic procedures will develop problems with sensation or movement in their lower extremities after surgery. When they occur, these symptoms typically resolve within a few days to weeks. In some cases, patients require physical therapy for improvement and extremely rarely, surgery.
o Internal scarring with creation of adhesions could occur with all abdominal surgeries. In rare cases, it can cause infertility, pelvic pain and intestinal obstruction that need to be treated with surgical measures.
o The patient may experience tenderness along the vein used for intravenous administration of fluids and medications. This responds to warm compressed and is usually temporary. Occasionally, a small lump at the intravenous site will persist.
· Allergic reactions:
o Several medications are used during surgery, and there is always possibility of a reaction to one or more of them. Appropriate steps are taken to counteract it.
· Ovarian failure:
o The ovary(ies) may go into permanent failure after surgery. This is usually associated with extensive ovarian surgery, such as removal of cysts and rarely after a hysterectomy.
· Failed procedure:
o Occasionally the surgeon will have to terminate the operation due to technical problems or because the procedure is inappropriate for the disease, as in the discovery of a pelvic malignancy. Major surgery would be done at that time only for an urgent problem, and, if appropriate, after consultation with the family.
· Conversion to open surgery:
o In a case when procedure cannot be completed laparoscopically (for instance, difficult anatomy, extensive scar tissue, bleeding that cannot be controlled or other unexpected findings), open incision needs to be made to complete surgery. Converting the procedure to open could mean a longer operative time, long time under anesthesia, and could lead to increased complications.
· Patients should consider that risks of any surgery include:
o Potential for human error
o Potential for equipment failure
· Risk specific to minimally invasive surgery may include: a longer operative time compared to open procedure but faster recovery and other benefits.
· Death and chronic disability: catastrophic complications resulting in death of the patient are rare. Re-operations to correct complications are at times needed. The risk of death from a hysterectomy is 6 in 10,000 for all women; 3 in 10,000 for women aged 35-44; and 37 in 10,000 when the operation is performed to remove cancer because of more extensive surgery.
· Risks related to removal of fibroids (tissue extraction): please see separate information sheet on this topic.