Laparoscopy

Definition

Laparoscopy is a type of surgical procedure in which a small incision is made, usually in the navel, through which a viewing tube (laparoscope) is inserted. The viewing tube has a small camera on the eyepiece. This allows the doctor to examine the abdominal and pelvic organs on a video monitor connected to the tube. Other small incisions can be made to insert instruments to perform procedures. Laparoscopy can be done to diagnose conditions or to perform certain types of operations. It is less invasive than regular open abdominal surgery (laparotomy).

Purpose

Since the late 1980s, laparoscopy has been a popular diagnostic and treatment tool. The technique dates back to 1901, when it was reportedly first used in a gynecologic procedure performed in Russia. In fact, gynecologists were the first to use laparoscopy to diagnose and treat conditions relating to the female reproductive organs: uterus, fallopian tubes, and ovaries.

Laparoscopy was first used with cancer patients in 1973. In these first cases, the procedure was used to observe and biopsy the liver. Laparoscopy plays a role in the diagnosis, staging, and treatment for a variety of cancers.

As of 2001, the use of laparoscopy to completely remove cancerous growths and surrounding tissues (in place of open surgery) is controversial. The procedure is being studied to determine if it is as effective as open surgery in complex operations. Laparoscopy is also being investigated as a screening tool for ovarian cancer.

Laparoscopy is widely used in procedures for non-cancerous conditions that in the past required open surgery, such as removal of the appendix (appendectomy) and gallbladder removal (cholecystectomy).

Diagnostic procedure

As a diagnostic procedure, laparoscopy is useful in taking biopsies of abdominal or pelvic growths, as well as lymph nodes. It allows the doctor to examine the abdominal area, including the female organs, appendix, gallbladder, stomach, and the liver.

Laparoscopy is used to determine the cause of pelvic pain or gynecological symptoms that cannot be confirmed by a physical exam or ultrasound. For example, ovarian cysts, endometriosis, ectopic pregnancy, or blocked fallopian tubes can be diagnosed using this procedure. It is an important tool when trying to determine the cause of infertility.

Operative procedure

While laparoscopic surgery to completely remove cancerous tumors, surrounding tissues, and lymph nodes is used on a limited basis, this type of operation is widely used in noncancerous conditions that once required open surgery. These conditions include:

• Tubal ligation. In this procedure, the fallopian tubes are sealed or cut to prevent subsequent pregnancies.
• Ectopic pregnancy. If a fertilized egg becomes embedded outside the uterus, usually in the fallopian tube, an operation must be performed to remove the developing embryo. This often can be done with laparoscopy.
• Endometriosis. This is a condition in which tissue from inside the uterus is found outside the uterus in other parts of (or on organs within) the pelvic cavity. This can cause cysts to form. Endometriosis is diagnosed with laparoscopy, and in some cases the cysts and other tissue can be removed during laparoscopy.
• Hysterectomy. This procedure to remove the uterus can, in some cases, be performed using laparoscopy. The uterus is cut away with the aid of the laparoscopic instruments and then the uterus is removed through the vagina.
• Ovarian masses. Tumors or cysts in the ovaries can be removed using laparoscopy.
• Appendectomy. This surgery to remove an inflamed appendix required open surgery in the past. It is now routinely performed with laparoscopy.
• Cholecystectomy. Like appendectomy, this procedure to remove the gallbladder used to require open surgery. Now it can be performed with laparoscopy, in some cases.

In contrast to open abdominal surgery, laparoscopy usually involves less pain, less risk, less scarring, and faster recovery. Because laparoscopy is so much less invasive than traditional abdominal surgery, patients can leave the hospital sooner.

Cancer staging

Laparoscopy can be used in determining the spread of certain cancers. Sometimes it is combined with ultrasound. Although laparoscopy is a useful staging tool, its use depends on a variety of factors, which are considered for each patient. Types of cancers where laparoscopy may be used to determine the spread of the disease include:

• Liver cancer. Laparoscopy is an important tool for determining if cancer is present in the liver. When a patient has non-liver cancer, the liver is often checked to see if the cancer has spread there. Laparoscopy can identify up to 90% of malignant lesions that have spread to that organ from a cancer located elsewhere in the body. While computed tomography (CT) can find cancerous lesions that are 0.4 in (10 mm) in size, laparoscopy is capable of locating lesions that are as small as 0.04 in (1 millimeter).
• Pancreatic cancer. Laparoscopy has been used to evaluate pancreatic cancer for years. In fact, the first reported use of laparoscopy in the United States was in a case involving pancreatic cancer.
• Esophageal and stomach cancers. Laparoscopy has been found to be more effective than magnetic resonance imaging (MRI) or computed tomography (CT) in diagnosing the spread of cancer from these organs.
• Hodgkin's disease. Some patients with Hodgkin's disease have surgical procedures to evaluate lymph nodes for cancer. Laparoscopy is sometimes selected over laparotomy for this procedure. In addition, the spleen may be removed in patients with Hodgkin's disease. Laparoscopy is the standard surgical technique for this procedure, which is called a splenectomy.
• Prostate cancer. Patients with prostate cancer may have the nearby lymph nodes examined. Laparoscopy is an important tool in this procedure.

Cancer treatment

Laparoscopy is sometimes used as part of a palliative cancer treatment. This type of treatment is not a cure, but can often lessen the symptoms. An example is the feeding tube, which cancer patients may have if they are unable to take in food by mouth. The feeding tube provides nutrition directly into the stomach. Inserting the tube with a laparoscopy saves the patient the ordeal of open surgery.

Precautions

As with any surgery, patients should notify their physician of any medications they are taking (prescription, over-the-counter, or herbal) and of any allergies. Precautions vary due to the several different purposes for laparoscopy. Patients should expect to rest for several days after the procedure, and should set up a comfortable environment in their home (with items such as pain medication, heating pads, feminine products, comfortable clothing, and food readily accessible) prior to surgery.

Description

Laparoscopy is a surgical procedure that is done in the hospital under anesthesia. For diagnosis and biopsy, local anesthesia is sometimes used. In operative procedures, such as abdominal surgery, general anesthesia is required. Before starting the procedure, a catheter is inserted through the urethra to empty the bladder, and the skin of the abdomen is cleaned.

After the patient is anesthetized, a hollow needle is inserted into the abdomen in or near the navel, and carbon dioxide gas is pumped through the needle to expand the abdomen. This allows the surgeon a better view of the internal organs. The laparoscope is then inserted through this incision to look at the internal organs. The image from the camera attached to the end of the laparoscope is seen on a video monitor.

Sometimes, additional small incisions are made to insert other instruments that are used to lift the tubes and ovaries for examination or to perform surgical procedures.

Preparation

Patients should not eat or drink after midnight on the night before the procedure.

Aftercare

After the operation, nurses will check the vital signs of patients who had general anesthesia. If there are no complications, the patient may leave the hospital within four to eight hours. (Traditional abdominal surgery requires a hospital stay of several days).

There may be some slight pain or throbbing at the incision sites in the first day or so after the procedure. The gas that is used to expand the abdomen may cause discomfort under the ribs or in the shoulder for a few days. Depending on the reason for the laparoscopy in gynecological procedures, some women may experience some vaginal bleeding. Many patients can return to work within a week of surgery and most are back to work within two weeks.

Risks

Laparoscopy is a relatively safe procedure, especially if the physician is experienced in the technique. The risk of complication is approximately 1%.

The procedure carries a slight risk of puncturing a blood vessel or organ, which could cause blood to seep into the abdominal cavity. Puncturing the intestines could allow intestinal contents to seep into the cavity. These are serious complications and major surgery may be required to correct the problem. For operative procedures, there is the possibility that it may become apparent that open surgery is required. Serious complications occur at a rate of only 0.2%.

Rare complications include:

• Hemorrhage
• Inflammation of the abdominal cavity lining
• Abscess
• Problems related to general anesthesia

Laparoscopy is generally not used in patients with certain heart or lung conditions, or in those who have some intestinal disorders, such as bowel obstruction.

Normal results

In diagnostic procedures, normal results would indicate no abnormalities or disease of the organs or lymph nodes that were examined.

Abnormal results

A diagnostic laparoscopy may reveal cancerous or benign masses or lesions. Abnormal findings include tumors or cysts, infections (such as pelvic inflammatory disease), cirrhosis, endometriosis, fibroid tumors, or an accumulation of fluid in the cavity. If a doctor is checking for the spread of cancer, the presence of malignant lesions in areas other than the original site of malignancy is an abnormal finding.

See Also Endoscopic retrograde cholangiopancreatography; Gynecologic cancers; Liver biopsy; Lymph node biopsy; Nutritional support; Tumor grading; Tumor staging; Ultrasonography

Resources

BOOKS

Carlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn. The Harvard Guide to Women's Health. Cambridge, MA: Harvard University Press, 1996.

Cunningham, F. Gary, Paul C. MacDonald, et al. Williams Obstet rics, 20th ed. Stamford, CT: Appleton & Lange, 1997.

Kurtz, Robert C., and Robert J. Ginsberg. "Cancer Diagnosis: Endoscopy." In Cancer: Principles & Practice of Oncolo gy., edited by Vincent T. DeVita Jr. Philadelphia: Lippin cott, Williams & Wilkins, 2001, 725-27.

Lefor, Alan T. "Specialized Techniques in Cancer Manage ment." In Cancer: Principles & Practice of Oncology, 6th ed., edited by Vincent T. DeVita Jr., et al. Philadelphia: Lippincott, Williams & Wilkins, 2001, 739-57.

Ryan, Kenneth J., Ross S. Berkowitz, and Robert L. Barbieri. Kistner's Gynecology, 6th ed. St. Louis: Mosby, 1997.

OTHER

Iannitti, David A. "The Role of Laparoscopy in the Manage ment of Pancreatic Cancer." Home Journal Library Index. 23 March 2001. 27 June 2001 <http://bioscience.org/1998/v3/e/iannitti/e181-185.htm>.

Carol A. Turkington

Rhonda Cloos, R.N.

QUESTIONS TO ASK THE DOCTOR

• What is your complication rate?
• What is the purpose of this procedure?
• How often do you do laparoscopies?
• What type of anesthesia will be used?
• Will a biopsy be taken during the laparoscopy if anything abnormal is seen?
• If more surgery is needed, can it be done with a laparoscope?
• What area will be examined with the laparoscope?
• What are the risks?
• How long is the recovery time?

Biopsy

—Microscopic evaluation of a tissue sample. The tissue is closely examined for the presence of abnormal cells.

Cancer staging

—Determining the course and spread of cancer.

Cyst

—An abnormal lump or swelling that is filled with fluid or other material.

Palliative treatment

—A type of treatment that does not provide a cure, but eases the symptoms.

Tumor

—A growth of tissue, benign or malignant, often referred to as a mass.