Why & When Laparoscopic Surgery in Infertility with Endometriosis

Video: https://youtu.be/WMSEFCuQvho

Why :

Painful menstruation and Infertility are common findings in many studies. Chocolate cyst found during ultrasonography for Infertility assessment is also a very common finding in various scientific studies. Endometriosis should be suspected in such cases and such patients requires special attention and counselling for trying pregnancy as early as possible. According to various classification Mild, Moderate & Severe Endometriosis is scored from different scores for different lesions during laparoscopy & evaluated for their results with different treatment protocols and Laparoscopic surgical techniques so one can compare the results uniformly.

Dysmenorrohea, Dyspareunia & pelvic pain & Infertility are the common presenting symptoms. Endometriosis is the commonest cause of Infertility found during Laparoscopy even in unexplained infertility cases. Pigmented & white fibrotic lesions are the two different varieties of lesions. Endometriosis is poorly detected during Laparoscopy may sometimes results into more than 2-3 operations-Laparoscopy for infertility patient without result in our observation. Endometriosis needs to be better documented & properly addressed during Laparoscopy in video, as a residual diseases leads to recurrence & continued Infertility. Lot of awareness needs to be generated among doctors for its identification during Laparoscopy, right treatment & documentation during surgery, proper postoperative aggressive fertility treatment within nine months as its tendency for reoccurrence after nine months & follow up. Most rewarding results are achieved following Laparoscopic surgery with pregnancy rate from 50 to 70% in different series in mild, moderate to severe Endometriosis. With increased awareness it will be found more frequently during Diagnostic Laparoscopy.

Benefits of Laparoscopy Surgery:

1. Shorter Hospital stay.
2. Earlier return to your routine work.
3. Cosmetically vary small scar.
4. Less pain after operation.
5. Best fertility enhancement & Fertility results following Laparoscopy, Video-live operative file available in CD/DVD for future reference (Transparency about surgical procedure).
6. The possibility of post-operative adhesion formation will be less, and the possibility of pain because of post-operative adhesions will also be less.
7. Recorded video of surgery helps another doctor for better understanding the extent of diseases and future treatment plan & fertility outcome. Preserving patients’ video of laparoscopic surgery for endometriosis is advisable till she conceives.

Pre-operative Check Lists:

1. Investigation for Surgery (Urine complete & Blood complete, HbsAg, HIV, R.B.S.etc.); Pelvic Trance vaginal USG report. Tumor markers for ovarian mass-chocolate cyst.
2. Specific Investigations for Infertility (Endocrine-S.AMH, Blood, Genetic, Husband’s Semen report etc.) If the couple is infertile.
3. Operation planned from 4th to 10th day of Menstrual Cycle for tubal testing for planning natural conception after laparoscopic surgery in Endometriosis & Infertiity.
4. Enema & preparation of local parts.

No. Of Cuts on Abdomen:
Three cuts: all of 5 mm size.

Average Stay in Hospital:
14 to 26 hours. (DAY CARE SURGERY)

Average Duration of Surgery:
For normal Laparoscopy procedure takes about 25 to 75 minutes only. For advanced Endometriosis it may take 1-2 hours

Average Blood loss during Surgery:
50-100 cc.

Average time after operation to resume normal activities/work:
Many patients undergo Laparoscopy as Day care procedure, returning home within 24 hours of surgery. Most begin feeling much better within one day.

Anesthesia:
General Anesthesia (Patient will not feel any pain in Operation Theatre during surgery)

Operative Procedure:

Inside the Umbilicus small needle is introduced and Co2 gas is insufflated inside abdomen. Rather than creating a large incision and opening up the body, tiny incisions are made and a laparoscope is inserted. This slim scope has a lighted end. It takes pictures – actually fiber optic images – and sends them to a monitor so the surgeon can see what is going on inside.
Performing Laparoscopy usually only requires three tiny incisions less than one half inch, (about 5-10 millimeters) in length. One incision is made   inside the navel, and another two are usually made near the bikini line. The first incision allows a needle to be injected into the abdomen so carbon dioxide gas can be pumped inside the cavity of the abdomen, which helps to keep intestines & omentum up and away from organs. This allows the surgeon a better view and more working space to maneuver the laparoscope and surgical tools as needed. Using small incisions rather than opening the abdomen lessens recovery time as well as discomfort and makes surgical scars less noticeable.
Aim of the surgery is to do mapping of different Endometriotic lesions first and tubal testing is done, as most of the time tubes are not involved in Endometriosis. Adhesiolysis done to establish Tubo-ovarian relationship. Lesions on the pelvic wall & uterosacral ligaments are fulgurated with bipolar desiccation. Endometriotic lesions are excised if pain is the main complaint and fulgurated with bipolar desiccation if Infertility is the main complaint. Suction & irrigation done with Ringer lactate and Haemostasis is checked. Edges of the ovarian capsule are grasped with grasper for 2-3 minutes so ovary is restructured & Tubo-ovarian relationship established.

Post-operative Course:

Patient remains drowsy/sedated for 2-3 hours after laparoscopy but conscious & pain free. Patient can take fluids 3-4 hours after laparoscopy & light food after 6-8 hours. She may feel little abdominal pain after laparoscopy for 24-48 hours but it can be relived with pain killer tabs. Most of the patients can walk normally without support and can take normal diet 12 hours after the laparoscopy. She can be discharged on the next day of the operation. Few patients may feel nausea & vomiting after laparoscopy, which can be very well controlled with injection in post-operative room. Patient can do her normal activity within 24 hours after laparoscopy. Patient is advised to take antibiotics & analgesic tabs for 5 days following laparoscopy. Patient is advised to report to doctor for severe pain or bleeding or fever in postoperative period (Day-1 to Day-5) immediately. Patient is advised to come for follow up 7 days after the Laparoscopy.