Laparoscopy for abdominal/pelvic pain
This information is intended for those with lower abdominal/pelvic pain who may be
considering or undergoing a laparoscopy. It aims to summarize the role of
laparoscopy for diagnosing and treating lower abdominal/pelvic pain. Laparoscopy
(key-hole surgery) can be performed for diagnosis (diagnostic laparoscopy) or
treatment (therapeutic laparoscopy). This information aims to explain the difference
between the two procedures, along with the risks and complications in order to assist
in decision making.
What is laparoscopy ?
Laparoscopy is a type of surgical procedure that allows a surgeon to access the
inside of the abdomen (tummy) and pelvis by making small incisions in the skin. It is
also known as keyhole or minimally invasive surgery. The laparoscope is the
instrument which is used for the procedure. It is a thin telescope with a light source
and a video camera which allows inspection of the abdomen/pelvis and sends
pictures of the inside of the abdomen or pelvis in real time to a TV screen/monitor.
How is a laparoscopy carried out ?
Laparoscopy is carried out under general anaesthetic, so you will be asleep during
the procedure.
A small 1-2 cm cut is made, usually near the belly button, through which the
laparoscope is inserted. A tube is also connected to a carbon dioxide gas pump. This
is used to inflate your abdomen so that the surgeon can easily look around. The
carbon dioxide gas dissipates after the operation.
If surgical treatment is being carried out during the laparoscopy, a further two or three
small 5 mm cuts are made on the abdomen. Small surgical tools are then inserted
which the surgeon uses to cut, move and grab the tissues.
After the procedure, the gas is let out of your abdomen, the cuts are closed using
stitches and dressings are applied.
It is important that you avoid the risk of pregnancy, either by avoiding intercourse, or
by using barrier contraception before the laparoscopy.
Laparoscopy is used for diagnosis (diagnostic laparoscopy) or for treatment
(therapeutic laparoscopy)
Diagnostic laparoscopy
Laparoscopy is widely used to try to diagnose many different conditions including
unexplained pelvic or abdominal pain. However, about 4 in 10 laparoscopies do not
reveal any clear diagnosis (Howard 1993, Yasmin 2005). If your laparoscopy does
not give a clear diagnosis, it is important that you ask your doctor for further advice.
For example, many patients can benefit from being referred to a pain specialist.
(Doyle 2005, Cox 2007)
Therapeutic laparoscopy
Therapeutic laparoscopy can be performed the traditional way or with robotic
assistance (see below).
Laparoscopic surgery can be used to treat several different conditions, including :
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Treating endometriosis.In women with endometriosis, cells from the womb
lining (the endometrium) are found in other places inside the body. These
include the lining of the wall of the pelvis, ovaries, Fallopian tubes, bladder
and bowel. Removing or burning endometriosis tissue can help to relieve
painful symptoms (Cochrane review, laparoscopic surgery for pelvic pain
associated with endometriosis 2009). In severe cases, referral to a specialist
centre may be required.
Removing an inflamed or diseased appendix (Gaitan 2011)
Removing a section of bowel which has been affected by conditions such as
Crohn’s disease, diverticulitis, or endometriosis and which has not responded
to medication.
Repairing hernias, such as those in the groin
Removing some or all of an organ that has been affected by cancer
Removing fibroids.These are growths in the muscle of the womb. They are
usually small and do not cause symptoms. Occasionally, if they do cause
symptoms they can be removed.
Dividing scar tissue inside the abdomen (adhesions) which sometimes affect
some of the internal organs.
Removing the womb (hysterectomy) see NICE IPG 239. However there is no
good evidence that it will relieve symptoms of persistent pelvic pain, and
indeed it may aggravate them
Some of these procedures require specialist education and training. In our opinion
patients should ask about the experience of the surgeon who will be doing the
procedure and the outcomes, as well as the risk of adhesions. See information about
safety below.
See and Treat
This is a form of therapeutic laparoscopy, assessing what the problem is and dealing
with it at the same time. It is suggested by the Royal College of Obstetricians and
Gynaecologists that for some conditions, such as endometriosis, “See and Treat”
laparoscopy should replace diagnostic procedures. Thorough clinical assessment,
examination and tests such as transvaginal ultrasound, MRI scan, CT scan before
surgery are used to identify those who are suitable for “See and Treat” laparoscopy
(Hebbar 2005, Ball 2008).
Laparoscopy can be used to obtain a sample of tissue (biopsy), which is sent to a
laboratory for testing. We encourage you to ask your clinician to biopsy areas of
endometriosis, and areas that are suspicious, during diagnostic or therapeutic
laparoscopy ( ESHRE Endometriosis Guideline 2013 ). A separate consent form
may be needed for this as well as for therapeutic laparoscopy. You may want to ask
the surgeon if it is possible to have a video (or photos ) of the surgery as a
permanent record of the surgery. This may be useful to refer to in future.
Robotic-assisted laparoscopy
A recent development in laparoscopy is the use of robots to assist with procedures.
This is known as robotic-assisted laparoscopy.
During robotic-assisted laparoscopy, your surgeon will use a console located in the
operating theatre to carry out the procedure by controlling robotic arms. The robotic
arms hold a special laparoscopic camera and surgical equipment.
Robotic-assisted laparoscopy allows surgeons to operate with increased precision
and smaller cuts. It is now frequently used in urology and neurosurgery. Other areas
such as gynaecology are in earlier stages of development. The advantages and
disadvantages over traditional laparoscopy are still being debated.
Recovery
After laparoscopy, you may feel groggy as you recover from the effects of the
anaesthetic. Some people feel sick or vomit. These are common side effects of the
anaesthetic and should pass quickly.
Before you leave hospital, you will be told how to keep your wounds clean and when
to return for a follow-up appointment or to have your stitches removed, although
dissolvable stitches are now often used.
For a few days after the procedure, you are likely to feel some pain and discomfort
where the incisions were made and you may also have a sore throat if a breathing
tube was placed down your throat during the procedure. You will be given painkilling
medication to help relieve the pain.
Sometimes the gas used to inflate your abdomen can cause bloating and cramps.
You may also have pain in the shoulder. This is because your diaphragm (the muscle
between your chest and your abdomen that you use to breathe) can be irritated by
the stretch from the gas, and this pain is radiated to the shoulder. These symptoms
are nothing to worry about and should pass after a day or so once your body has
absorbed any remaining gas.
You may experience some vaginal bleeding. This should not be heavy and should
only last a couple of days. You should use sanitary towels rather than tampons whilst
this bleeding lasts, to avoid the risk of infection.
Over the following days or weeks, it is likely you will feel more tired than usual, as
your body is using a lot of energy to heal itself. Taking regular naps may help. The
length of time to recover may vary from person to person depending on the treatment
carried out.
Safety and Complications
Your hospital should tell you about your surgery and the different options that are
suitable. They should tell you what you need to do in order to prepare for your
laparoscopy. They should also inform you about the potential risks and side effects.
Overall, a complication occurs in 5 out of every 1,000 laparoscopies. More complex
procedures may carry higher risks ( Chapron 2001).
Scar tissue inside the abdomen(adhesions) can occur after any surgery. Adhesions
can be associated with infertility, persistent pelvic pain and small bowel obstruction
(ten Broek 2013). You may want to discuss this risk with your surgeon and see
whether you might benefit from having an anti-adhesion product introduced into your
abdomen at the end of your laparoscopy to reduce the risk (Parker 2007, Kraemer
2011,Audebert, 2012, De Wilde 2012). Some procedures such as those for
endometriosis pose an increased risk of adhesions.
Minor complications such as post operative infection, bleeding and bruising around
the site of the cut occur in 1-2 out of every 100 laparoscopies.
Serious complications after laparoscopy are infrequent; however in such cases
further laparoscopic or open surgery may be required. These complications include:
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damage to an organ, such as your bowel or bladder, which could result in the
loss of organ function
damage to a major artery
damage to nerves
air embolism: where gas bubbles collect in your veins and cause a blockage
a serious allergic reaction to the general anaesthetic
a blood clot developing in a vein, usually in one of the legs (deep vein
thrombosis or DVT), which can break off and block the blood flow in one of
the blood vessels in the lungs (pulmonary embolism)
death : between 3 and 8 in 100,000 patients die as a result of complications.
Other less serious complications can occur after discharge from hospital. If you are
given a follow-up appointment, please make sure you attend.
When to seek medical advice
It is usually recommended that you have someone stay with you for the first 24 hours
after your surgery. This is in case you experience any symptoms that suggest there
could be a problem, such as:
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a high temperature of 38°C (100.4°F) or above
chills
increasing abdominal pain
redness, pain, swelling and discharge around your wounds
pain and swelling in one of your legs
a burning or stinging sensation when urinating
If you experience any of these symptoms during your recovery, you should
contact the hospital where the procedure was carried out, your GP or NHS 111 for
advice.
If you don’t think that your laparoscopy has been successful, either in diagnosing or
treating your condition, you should ask your surgeon or GP for further advice.
Sometimes referral to another specialist is beneficial.
References and further reading:
De Wilde RL, Brölmann H, Koninckx PR, Lundorff P, Lower AM, Wattiez A, Mara
M, Wallwiener M; The Anti-Adhesions in Gynecology Expert Panel (ANGEL).
Prevention of adhesions in gynaecological surgery: the 2012 European field
guideline.Gynecol Surg. 2012 Nov
ESHRE Endometriosis Guideline September 2013
Hernando G Gaitán1,*, Ludovic Reveiz2, Cindy Farquhar3Editorial Group:
Cochrane Menstrual Disorders and Subfertility Group Laparoscopy for the
management of acute lower abdominal pain in women of childbearing
age.2011 Jan.
Jacobson TZ, Duffy JM, Barlow D, Koninckx P, Garry R5Editorial Group:
Cochrane Menstrual Disorders and Subfertility Group Laparoscopic
surgery for pelvic pain associated with endometriosis, 2009 Oct
Kraemer B, Birch JC, Birch JV, Petri N, Ahmad U, Marikar D, Wallwiener M,
Wallwiener C, Foran A, Rajab TK. Patients' awareness of postoperative adhesions:
results from a multi-centre study and online survey Arch Gynecol Obstet. 2011
May;283(5):1069-73.
RCOG Consent Advice 2: December 2008
SOGC Consensus Guideline for the Management of Chronic Pelvic Pain Part one
2005
ten Broek RP, Issa Y, van Santbrink EJ, Kruitwagen RF, Jeekel J, Bakkum EA,
Rovers MM, van Goor H. Burden of adhesions in abdominal and pelvic surgery:
systematic review and met-analysis.BMJ. 2013 Oct
PPSN-WEB-011
Issue date: February 2014
Review date: February 2017