Why & When Laparoscopic Surgery in Infertility with Fibroid
Video:
Infertility with fibroid is very common findings in many cases. Per say presence of fibroid may not be responsible for infertility and removal. In many scientific studies, when other causes of Infertility, has been ruled out and submucous fibroid of any size and intramural fibroid of more than 4 cms size is found to be affecting fertility outcome and recommended to be removed Laparoscopically. Expert TVUSG with Color Doppler should be done to exclude Adenomyosis. Patient must be counseled for the possibility of Adenomyosis before fibroid surgery in doubtful case in sonography report, as fertility outcome is poor with Adenomyosis vs fibroid after surgery. Fibroid mapping should be done for the size, extent and locations of different fibroids before surgery as it helps surgeon to plan & access each of them during surgery. Sub mucus fibroid is approached hysteroscopically. Providing Video of laparoscopic surgery of fibroids removal helps in conveying the quality of Mymectomy we have done. Adequate Laparoscopic suturing is mandatory to offer uterine scar integrity and safety during next pregnancy following Myomectomy surgery. Adequate Haemostasis & copious irrigation with ringer lactate helps in preventing post-operative adhesions. This surgery requires lot of experience & expertise. Patient can be discharged on the same day or on the next day of operation.
Benefits of Laparoscopy Surgery:
- Shorter Hospital stay,
- Earlier return to your routine work,
- Cosmetically vary small scar,
- Less pain after operation,
- Best fertility enhancement & Fertility results following Laparoscopy,
- Video-live operative file available in CD/DVD for future reference (Transparency about surgical procedure and outcome during pregnancy).
- The possibility of post-operative adhesion formation will be less, and the possibility of pain because of post-operative adhesions will also be less.
- Associate endometriosis found during laparoscopy also helps us to treat them simultaneously.
Pre-operative Check Lists:
- Investigation for Surgery (Urine complete & Blood complete, HbsAg, HIV, R.B.S.etc.)
- Expert Pelvic Trance vaginal USG report for fibroid mapping, Blood tests for Tumor markers. Sometime MRI to exclude the possibility of Adenomyosis from fibroid before surgery.
- Specific Investigations for Infertility (Endocrine, Blood, Genetic, Husband’s Semen report c etc.) If the couple is infertile.
- Operation planned from 4th to 10th day of Menstrual Cycleif Laparoscopy is done for simultaneous tubal testing and addressing other causes of Infertility.
- Enema & preparation/shaving of local parts.
No. Of Cuts on Abdomen:
Three cuts: Two of 5 mm size & two of 10 mm size.
Average Stay in Hospital:
8 to 12 hours. (DAY CARE SURGERY)
Average Duration of Surgery:
30-40 minutes depending upon the no. & size of fibroids.
Average Blood loss during Surgery:
50-80 cc. For bigger size fibroid blood loss may be more. But in most of the cases blood transfusion is not required.
Average time after operation to resume normal activities/work:
Within 24 hours. 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 is 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 pelvic 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.
Tubal testing is done to check their Patency by pushing methyline Blue dye from below. Uterine wall & Fibroid capsule is infiltrated with 10% vasopressin around the attachment of fibroid with uterus. Adequate incision is made with edge of spatula on the bulge of Fibroid with Monopolar unmodulating current, till fibroid is reached. Fibroid is fixed with Myoma screw and from another port spatula or suction irrigation cannula is used to dissect out the fibroid from its bed gently. Any bleeders or blood vessels are sealed with bipolar desiccation. Suction irrigation done in the bed to identify any bleeder and desiccated with Bipolar. Uterine defect of the uterus is closed with No. 1 Vicryl suture and with figure of 8” stitch to obliterate the defect adequately, so most of the dead space is taken care of. Left 10 mm port is used for introduction of Morcellator. Fibroid is grasped with 10 mm claw forcep from Lt. Port. Fibroid is morcellated under vision to prevent injury to surrounding organs. Long fibroid strips are made and removed with help of Morcellator. Haemostasis checked. Fibroids send for HPE.
Post-operative Course:
- Patient remains drowsy/sedated for 2-3 hours after laparoscopy but conscious & pain free.
- Patient can take fluids 6-8 hours after laparoscopy & light food after 8-10 hours. She may feel little abdominal pain after laparoscopy for 24 hours but it can be relived with pain killer tabs.
- Most of the patients can walk normally without support and can take normal diet 24 hours after the laparoscopy.
- She can be discharged on the same day or next day of the operation.
- Few patients may feel nausea & vomiting after laparoscopy, which can be very well controlled with injection.
- Patient can do her normal activity within 24 hours after laparoscopy.
- Patient is advised to take antibiotics & analgesic tabs. For 7 days following laparoscopy.
- Patient is advised to report to doctor for severe pain or bleeding or fever in postoperative period (Day-1 to Day-7) immediately.
- Patient is advised to come for follow up 7 days after the Laparoscopy.
