Introduction

Small incision surgery has revolutionized the field of gynaecological surgery and changed the way lower abdominal surgery has been practised over the past decade. This has come about with the realization that the minimal access approach, in trained hands, allowed for a much more elegant form of surgery with reduced injury to the abdominal wall and the surrounding tissue.

The concept behind small incision/laparoscopic surgery revolves around the fact that if the access to the operating site is reached with minimal interference to the surrounding body structures, then the events following surgery would also return back to normal in a shorter span of time. In other words, this implies improved patient recovery with reduced post-operative pain, shorter hospitalization, and an earlier return to normal function. Although the above-mentioned benefits are almost never realized by the patient until the completion of the surgical procedure, the main motivating factor for patients to choose this method of surgery is the fact that the patients do not have any incision. Going a bit deeper than ‘the skin and the scar’ issue, I shall explain in this article how laparoscopic surgery can really be the surgery of choice under given circumstances, and how awareness of this surgical modality by the patient would help them to choose this method over the more invasive conventional gynaecological surgeries.

Hysterectomy

Hysterectomy refers to the removal of the womb in the event of a disease, dysfunction or cancer of the womb.

Conventional surgery for the removal of the womb is called ‘total abdominal hysterectomy’ or TAH in common medical language. This involves giving a vertical or horizontal 8 to 10 centimetres incision on the abdomen and removing the womb.

By the minimal access approach, the same procedure can be performed by gaining access to the womb through the vagina with or without the assistance of a laparoscope. The advantages of this procedure over the conventional hysterectomy are:

* No incision

* Less post-operative pain and discomfort

* Faster recuperation

* No pain of removal of skin stitches as there is no incision on the skin!

Ectopic pregnancies

and ovarian cysts

An ectopic pregnancy is a pregnancy that grows in the tube instead of the lining of the womb. These pregnancies do not go a long way, and could end up with catastrophic consequences. In earlier times these pregnancies used to be terminated by removing the tube carrying it. The earlier approach to the tube removal would mean opening the abdomen with a vertical or horizontal cut. Apart from the abdominal scar, such a procedure could reduce the chances of future child-bearing, because the handling of the pelvic organs might cause an alteration in the normal anatomy due to adhesions.

The newer approach to this condition by using the laparoscope can reduce the above-mentioned complications along with the usual benefits of minimal access as mentioned earlier with TAH.

The same concept of tissue removal also applies to the removal of cysts of the ovary, carrying with it the same benefits as that of tube removal by the laparoscope, especially in young women desirous of future child bearing.

Infertility

In cases of infertility, the procedure of diagnostic hystero-laparoscopy has no substitute. It remains the gold standard for investigating the cause of difficulty in conceiving. Unnecessary tests like hormone assays and the ‘clean out’ procedures are not only of no benefit, but could actually be detrimental to the woman.

After investigating the male partner, the first step in investigating the female partner is the diagnostic laparoscopy. During this procedure, using minimal access surgery (laparoscope), the tubes are checked under direct vision, as opposed to an x-ray, and in women with hormone imbalances the ovarian cysts are drilled, thereby equalizing the hormonal imbalances and helping in regular egg release. At the same time, the rest of the anatomy is checked and if abnormal, is corrected.

All of this, one should remember, is done with special instruments by a gynaecologist with adequate laparoscopic skills, and without a large ugly scar defacing the patient’s abdomen.

In conclusion, women today should be aware that when they are advised to have surgery, not only should they ask, why? but they should also ask how? and why not laparoscopically? All of this because laparoscopic surgery is now available in Guyana and contrary to popular belief, it does not cost more than conventional surgery. With all the benefits of minimal access, it is high time that both the medical care provider and the beneficiary go the small way, not because small is beautiful, but because of the big benefits to the patient.

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