Consultant Minimal Access Gynaecologist

(with special interest in Endometriosis and Keyhole Surgery)

 

 
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LAPAROSCOPIC (KEYHOLE) SURGERY

-GUIDE AND POSTOPERATIVE ADVICE

General information to Laparoscopic Assisted (Keyhole) Surgery

Laparoscopic surgery means that a surgical procedure is carried out through a very small incision in the abdomen.  Two small punctures (5 – 12 mm size) lower down in the abdominal wall is necessary to insert long narrow instruments which are used to perform the surgery.  The Surgeon watches the operation on the video screen while he is undertaking the operation.

The advantage of this operation is that no large cut has to be made in the abdomen nor does abdominal wall need to pulled with metal retractors for a long period during the operation as in a conventional operation, which means that there is less post-operative pain.  The time spent in hospital, therefore, is much less usually 24 – 48 hours, the recovery period is much shorter (2 – 4 weeks) thus less disruption to the family life.  Laparoscopic approach enables thorough pelvic inspection and thus helps in detecting conditions like endometriosis, adhesions, cysts, post-operative bleeding and clots etc., which could have been missed during a conventional vaginal hysterectomy resulting in continuation of symptoms and re-operation.  Other advantages of keyhole surgery are summarized below:

BENEFIT TO PATIENTS

•Less post operative pain
•Less wound complications:
      -Infection
      -Haematoma (blood collection in the wound)
      -Dehiscence (wound gaping)
      -Hernia (weak wound resulting in protrusion of abdominal content)
• Less disruption to bowel and bladder function
• Less infection of operation site (operation site is not exposed to external environment)
• Less risk of chest infection
• Less risk of Deep Vein Thrombosis (clot formation in the leg veins)
• Less adhesion (sticking of the organ) and scar formation (since the operation is performed under magnification; thus the surgery is more precise )
• Better cosmetic results
• Shorter convalescent time and so less disruption to family life and early return to work
• Less restriction to type of work one can do post-operatively

BENEFIT TO THE HOSPITAL

• Saving of Hospital Beds due to early discharge from hospital results in
      - Resource saving as each day in hospital costs approximately £200 - £350/Day
      - Less Cancellation of elective operations due to more availability of beds
      - Reduction of waiting time in A&E department due to more availability of beds
• Reduction of Hospital acquired infection due to early discharge from hospital
(Long stay in the hospital is one of the causes of hospital-acquired infection)
      - Resource saving as hospital infection costs NHS £1 billion per year
      - Hospital infection affects 1 in 11 NHS patients & kills 5000 patients a year

BENEFIT TO THE COMMUNITY (TREASURY)

• Early recovery and return to work saves treasury billions of pounds
By decreasing
      - the loss of production
      - hiring extra staff
      - cost of treatment

It is important to appreciate that for technical reasons it may occasionally be necessary to revert to a traditional open operation during the course of any keyhole surgery.

Can all the operations be performed this way?

All major/complex gynaecological conditions are treated by Mr Trehan via keyhole surgery except for the following for which a traditional operation with a large incision on the abdomen is required:

  • Hysterectomies for a uterus larger than a uterus which is 24 weeks into preganancy.

  • Myomectomy (removal of fibroids from the uterus)  for multiple large fibroids.

  • Operations for cancer.

Risks, complications & prognosis

No major operation (keyhole/traditional) is complication/risk free.  There are risks of general anaesthetic and surgery.  Although rare, risks of surgery include: Injury to internal organ, such as bowel, bladder (urine bag), ureter (tube carrying urine), blood vessels; infection; haemorrhage (blood loss); blood clots leading to Pulmonary Embolism etc.  The only assurance Mr. Trehan can give you is that he has an excellent past record, and his complication rates are among the lowest reported in the literature.  Click here to view his outcome results.  You should also be aware there is no 100% guarantee that your symptoms will be fully cured following the surgery or you will definitely achieve pregnancy if you had your operation for fertility.  You are free to discuss these risks and prognosis before you sign the consent.

Which operations can be performed?

In gynaecology many of the procedures traditionally performed through “open” surgery may now be performed using laparoscopic technique. Mr Trehan feels that most of the operations for benign gynaecological conditions which are usually done by laparotomy (open cut on the tummy) can be undertaken by keyhole operation. Some of the commonly performed operations in Mr Trehan’s unit are as follows:

  • Laparoscopic assisted vaginal hysterectomy (removing the womb & neck of the womb)

  • Laparoscopic excision of endometriosis (Peeling of Endometriosis)

  • Laparoscopic ovarian cystectomy (removing the cyst from the ovary)

  • Laparoscopic salpingo-oophorectomy (removing the fallopian  tubes and ovaries)

  • Laparoscopic ovarian drilling (treatment for polycystic ovaries)

  • Laparoscopic cuff salpingostomy/Tubal Surgery (opening the tubes if blocked in an infertile patient and surgery for infertility)

  •  Laparoscopic salpingectomy (removing the diseased fallopian tubes)

  • Laparoscopic removal of an ectopic pregnancy (removing a pregnancy, which becomes “stuck” in the fallopian tube and begins to develop there instead of the womb)

  • Laparoscopic adhesiolysis (separating 2 organs fixed together)

  • Laparoscopic venstrosuspension (correcting the position of a tilted womb)

  • Excision of post hysterectomy vaginal vault scar (removing the scar tissue at the top of the vagina to  help with continuing pain and painful intercourse following hysterectomy)

  • Laparsocopic temporary ovarian suspension (treatment for ovarian adhesions)

  • LUNA – Laparoscopic utero sacral nerve ablation (cutting ligament which carries painful nerves to uterus)

INCISION FOR KEYHOLE SURGERY

 

Post Operative Advice

Laparoscopic Assisted (keyhole) Surgery

 

OPERATION

We will undertake your operation under a general anaesthetic and your operation may last anything from one hour to eight hours depending upon your pathology (inside condition). 

POST OPERATIVE PERIOD IN THE HOSPITAL

  • You will have a drip running which will be discontinued as soon as you can drink freely and start eating.  In most cases this could be on the same day of the operation or occasionally the following morning.

  • You may have a catheter draining your bladder, this will be removed in the night of the operation day or the following morning.

  • You can be up and about as soon as you feel okay, it could be on the same day of the operation or the following morning.  You should aim to spend 70-80% of the time out of your bed and walking around on the following day after your operation.

  • The Nurse will wash you on the following morning but I would recommend that you have a shower including washing your hair.

  • Half to one litre of special fluid is left in your tummy to prevent adhesions (organs sticking together).  The fluid may occasionally leak out of your wound or form a collection around your wound.  This is not a cause for any concern, moreover as this fluid stays in your tummy for four to five days it may give you a bloated feeling or a feeling of something shifting around your tummy.

DISCHARGE

You are usually discharged home within 24 – 48 hours, depending upon your recovery.  Most women (over 90%) are fit to leave hospital after an overnight stay following the above surgery.

PAIN

Keyhole operation is not a pain free operation.  You will have some pain but it will be much less than conventional operation.  You may have some pain when you leave hospital but it should be controlled by the painkillers you take home.  The pain usually subsides within a few days except discomfort following ventrosuspension, which may continue for a few weeks.  Occasionally one of the wound  sites, usually the left, may have more pain or the pain may continue for a longer period than the other wounds.  You must not get concerned as that wound is slightly bigger and has one stitch inside too.   You can expect to have pain under your ribs and around your shoulder tips.  This is caused by wind. We will supply the appropriate medication for you to take at home.  Take the pain tablets (analgesic) regularly for the first 3-5 days after your operation and then gradually reduce the dose.

BOWELS

You may not have opened your bowels before going home. It is very important to avoid constipation. Eat a diet high in fibre, fresh fruit and vegetables. Ensure you drink plenty of fluid i.e. water. You will be given some medicine (laxative) to take home to help your bowels and avoid constipation.

BLADDER

You may have a sensitive bladder resulting in disconfort or sting on passing urine following a hysterectomy or excision of endometriosis.  This may very occassionally last a few months.  It is due to the healing process, and over time, this pain should disappear.

WOUNDS

You will usually have 3 incision sites. Before you go home the Nurse looking after you should remove your dressings and spray the 3 sites with a clear spray. This protects the areas. Do not use the bath for the first week, have a shower. This reduces the risk of wound infection. When you come to the hospital for your one-week check-up we will usually remove your stitches. If you are bigger than average we may leave them in for a few more days. See district nurse/GP for removal of stitches if not removed at your first visit.

Ovarian Suspension Wound - your ovaries may have been suspended to prevent ovarian adhesions.  The suspension wound will be covered with a transparent dressing.  Do not disturb the dressing until the day of the removal of the stiches which is on the 6th or 7th postoperative day.  It is not uncommon for a pink coloured fluid to leak around the stitch.  This fluid has been intentionally left within in order to flot your organs and prevent adhesion formation.

PHYSICAL ACTIVITIES

Your recovery would be quicker if you remained active after the operation. You may start routine household work e.g. cooking, ironing and hoovering etc as soon as you feel able. There is no restriction to any type of physical activity. There is no need to stay at home but remember you will tire easily at first.

VAGINAL BLEEDING

Some of you can expect to get some vaginal bleeding, spotting and discharge. Vaginal bleeding may come on a few days after the operation. Bleeding is usually dark but may be dark red like a normal period. If the bleeding is excessive for instance soaks a few pads in a short period of time or contains clots especially after having keyhole hysterectomy or excision of vaginal vault please contact the hospital (NHS - Ward 1 or Private Patient - Elland Hospital). You may lose pieces of thread if you had keyhole hysterectomy or excision of vaginal vault. Discharge or spotting may continue for 4-6 weeks following operation. Use a sanitary towel not tampons for protection.

INTERCOURSE

If you have a vaginal wound as in cases of keyhole hysterectomy and excision of vaginal vault you will need to avoid intercourse for approximately 5 weeks but for all other operations you may resume intercourse whenever you feel ready.

DRIVING

You may drive your car a few days after your operation depending upon how you feel; if you are able to forcefully push against the ground with your feet without much discomfort/pain, you should be able to drive. Make sure you use the controls especially the brakes without excessive pain.

WORK

You may return to work as soon as you feel able, it depends on the type of work you do and how you feel. You should need no longer than 2 weeks (2-4 weeks following keyhole hysterectomy) off work, In cases where ventrosuspension has been undertaken you may need a little longer because of continuing discomfort. You will not damage anything or spoil the operation by work.

EMOTIONS

Following operations, especially after losing organs like uterus (hysterectomy) ovaries (oophorectomy) it is not unusual for a few women to become very emotional within first few days of operation. If is happens to you be assured you will get over it very quickly.

MEDICATION

We will give you a supply of the following medications to take home:

• Painkiller: Please take them regularly for at least 3-5 days. Gradually reduce the dose. Do not stop suddenly.

• Antibiotics: Please start taking them one week after your operation and continue until the course is completed.  Occasionally we may request you to start taking them on the day of discharge.

• Laxative: We will also give you Lactulose or alternative to help you open your bowels.

FOLLOW UP

• Telephone:

The gynae staff may phone you during the first postoperative week to see how you are getting on. (Please make sure you leave a contact number).

• Hospital:

First appointment - approximately 7-10 days after your operation. At this visit we will check your recovery and remove your stitches but if they are not removed you will need to see your District Nurse.

Second appointment - 6 months to check your final recovery and take your pain scores but if you had had keyhole hysterectomy and excision of vault you would be seen in clinic at 8-10 weeks to check your inside healing (vaginal wound healing) It is important that you are seen at both of these appointments. If you have not got an appointment when you go home we will phone you to arrange a time.

• Patients travelling from a distance:

You may not have to follow what is stated above regarding attending hospital; Mr Trehan makes special arrangements based on individual circumstances.

NB: There might be some alterations to the general rule depending upon the extent of the operation.

HOW TO CONTACT US IN THE CASE OF AN EMERGENCY:

In the case of an emergency, you should contact the hospital where you were operated upon.  The contact details are below:

Gynae Ward 1, Dewsbury Hospital, 0844 811 8110, ext. 3259 or their direct line number 01924 816001.

Elland Hospital – Private 01422 324000 / 01422 324094 during evenings and weekends.

For general contact details and for all other enquires, please click here.

If you have any concerns regarding your recovery within the first 6 weeks of your operation, please call on the above numbers. Mr Trehan is usually available round the clock to advise his patients and takes full responsibility of your care. You do not have to visit your GP or the Accident and Emergency department regarding operation related concerns. You must remember that you have had a major operation. Do not force yourself. Increase activity gradually as your body allows.

 

  
      ©Mr A K Trehan