Laparoscopic applications can be divided into two: diagnostic and therapeutic.
Diagnostic applications: Diagnostic laparoscopy has fewer indications in modern practice. It is mainly performed for women suffering from infertility. It should be preferred for women with secondary dysmenorrhea, dyspareunia, history of pelvic surgery and past sexually transmitted diseases. In such cases, pelvic adhesions, endometriosis or tubal factor can be seen during laparoscopy. Women with normal hysterosalpingography are rarely diagnosed with tubal factor during laparoscopy. Impact of mild endometriosis on fertility is a subject of debate. Mild endometriosis can be considered as unexplained infertility.
Therapeutic applications: This type of laparoscopy is performed to treat a preoperatively diagnosed diseases.
Procedures performed to improve fertility:
Adhesiolysis, salphingostomy, fimbrioplasty: Past surgery or infection may lead to distortion in pelvic structures. Mild adhesions may be treated by adhesiolysis during laparoscopy. After adhesiolysis, pregnancy rates range from 30 to 60%. If there are dense adhesions, they tend to reoccur after adhesiolysis and pregnancy rates are lower. Obliterated fallopian tubes may be treated during laparoscopy. If there is hydrosalpinx, salphingostomy may be performed. Tubes may be reobliterated in 30 to 100% of cases and pregnancy rates range from 10 to 20%. Salpingectomy is preferred if tubes are extensively damaged to increase pregnancy rates after IVF. Obliterated fallopian tubes decrease pregnancy rates after IVF.
Laparoscopic endometriosis treatment:
Endometriosis is a very common indicat,on of laparoscopy. Endometriosis is presence of endometrial glands and stroma outside the uterus. It most commonly involves the peritoneum and ovaries. Severe endometriosis distorts pelvic anatomy, may cause pain and infertility. Peritoneal implants may be treated by cotherization during laparoscopy. Treatment of endometriomas increase pregnancy rates. But, it is important not to damage ovarian tissue. Both endometrioma and laparoscopic treatment of endometrioma may decrease ovarian reserve. Thus, cases with recurrent endometriomas are better treated by IVF. But if the complaint is pain, a second surgery is required. 50% of infertile women get pregnant in 6 months after surgery. If pregnancy does not occur in a year, IVF should be performed.
Deep endometriomas located in the rectovaginal septum may also be treated by laparoscopy. Pain relieves after surgery. Laparoscopic treatment of deep endometriomas require expertise. Endometriosis is a relapsing disease. Thus, if pregnancy does not occur within 6 months after surgery, IVF should be recommended. Intrauterine insemination is not recommended as it is associated with low pregnancy rates.
Laparoscopic cystectomy:
Besides endometriomas, simple cysts and dermoid cyts also may be treated via laparoscopy. Dermoid cyts: At the very beginning of the embryonic life, 3 germ cell lines exist. These germ lines have the potential to differentiate into various tissues. Germ cells are localized into the ovaries and testes and are responsible for the production of oocytes and sperms. These cells have the potential to differentiate into various tissue, most commonly into skin and its appendixes. Thus, such a cyst is called a dermoid cyst. As a dermoid cyst involves mostly skin and its appendixes, it is usually semi-liquid, yellow-brown in color, rich in lipid and the cyst may consist of hair, tooth, bone, cartilage and nevre tissue. Its size is very variable. A dermoid cyst has few symptoms and is usually diagnosed incidentally. 65% of cases are asymptomatic. Most common symptom is pain. Abnormal vaginal bleeding and discomfort may also be seen. Rare symptoms are backache and defecation problems. Treatment is surgical. Surgery should be performed as it is diagnosed. Surgery may be performed either laparoscopically or an open surgery may be preferred. For reproductive age women, ovarian tissue should be preserved and only cystectomy is appropriate. If the cyst is ruptured during the operation, peritoneal cavity should be washed as cyst components may cause chemical peritonitis. Thus, dermoid cyst operations require expertise.
Paraovarian cysts: They develop from embryonic remnants. They are very rarely of malignant potential. They should be surgically removed if they reach huge sizes. They can easily be treated laparoscopically.
Laparoscopic myomectomy: A considerable part of myoma uteri can be removed laparoscopically. Operation indications of myoma uteri are as follows:
- Size: Myoma uteri > 6 cm should be operated
- Pressure symptoms: Intraligamentary myoma uteri may cause pressure upon ureters and cause hydronephrosis.
- Infertility: Infertile women with no other cause and with myoma uteri > 5 cm should be operated.
Myoma uteri < 8 cm, less than 3 in number and not embedded within the myometrium are candidates for laparoscopic surgery. A patient operated for myoma uteri should not get pregnant for 3 months.
Laparoscopic hysterectomy: Uterus can be removed laparoscopically. If the uterus is to be removed, vaginal hysterectomy should be preferred. If this is not possible, laparoscopic hysterectomy is a good alternative to abdominal hysterectomy.
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