Keyhole fixes: Laparoscopy is letting surgeons use tiny cuts to cure women

How it works

Diagnostic laparoscopy is a procedure performed under general anaesthesia that allows a doctor to look inside the abdomen or pelvis with a laparoscope -- a thin viewing tube that is passed into the abdomen through a small incision.

Rama Mahendru, then 42, had uterine fibroids the size of a 30-week foetus, but she had no clue they were even there. “Except for weight gain, I had no symptoms, no pain, no bleeding. But nothing I did would rid me of my growing tummy, so in desperation I signed up for an Ayurveda weight-loss programme in Kerala in May last year,” she says.

On her first day of therapy, the masseur refused to do a weight-reduction massage saying her stomach felt too hard.

“She said something was clearly wrong and I should get an ultrasound,” says Mahendru, 43, who is a Delhi-based finance advisor. An ultrasound revealed fibroids weighing a total of more than 2 kg.

“To take something out that size would have been almost like having a baby delivered and I really didn’t want a big scar across my abdomen,” said Mahendru.

She did some online research and learnt that fibroids can be removed using laparoscopic surgery, but given the size of hers, she was still worried. She got several opinions, a third, fourth and fifth, before settling on Dr Malvika Sabharwal, director of obstetrics and gynaecology at the Jeewan Mala and Apollo Spectra Hospital.

Rama Mahendru with Dr Malvika Sabharwal of the Jeewan Mala and Apollo Spectra Hospital. Dr Sabharwal removed Mahendru’s uterus laparoscopically, to rid her of massive fibroids. (Saumya Khandelwal / HT Photo)

“Dr Sabharwal said she could remove the uterus laparoscopically, without cutting me open, and I said yes at once,” says Mahendru, who spent just two days in hospital and returned to her normal routine when she got home. “It didn’t even feel like surgery,” she says.

Uterine fibroids are very common and 35% to 60% of women develop some by age 35, with the numbers going up to 70% to 80% by age 50. Symptoms include excessive uterine bleeding, infertility and miscarriages.

“Conventional hysterectomy (uterus removal to get rid of fibroids) requires five days in hospital. We now remove the uterus laparoscopically by morcellating (cutting solid tissue into pieces) it under a day-care procedure. Rama was observed for two days after surgery because her fibroids were massive,” said Dr Sabharwal.
From diagnosis to cure

Procedures done via laparoscopic surgery include...

Hysterectomy (removal of the uterus)

Removal of ovaries; ovarian cysts

Removal of fibroids; uterine polyps

Endometrial tissue ablation (to treat endometriosis)

Adhesion removal

Reversal of tubal ligation (type of contraceptive surgery)

Over the past decade, laparoscopic surgery has evolved from being a diagnostic aid to evaluate pelvic pain, unexplained infertility, stopping of a menstrual cycle or a history of pelvic infection, to being a major surgical tool used to treat a multitude of gynaecological problems ranging from ectopic pregnancy to masses in the lower abdomen, performing hysterectomies and staging and treating gynaecological cancers.

“In 2005, diagnostic laparoscopy accounted for 62.96% of all laparascopic procedures, but by 2012, the ratio had reversed to 26.08% diagnostic procedures and 73.91% operative use,” says Dr Sabharwal, president of the Delhi Gynaecological Endoscopists Society, which is currently holding a three-day conference in New Delhi to train doctors from across India. “The procedure has several benefits and though its use has grown manifold, laparoscopic surgeries for gynaecological disorders are underused because not enough doctors are trained to do them.”

Improved endoscopic devices and growing skill among surgeons is leading to the technique being used for a wide variety of disorders and diseases.

“Laparoscopic surgery causes less postoperative pain, enables quicker healing and leads to early recovery, while keeping costs almost at par with conventional surgery by reducing hospital stay to a day at most, instead of five days,” says Dr Sabharwal.

Despite the equipment being expensive, the cost of surgery is either at par or about 20% more than conventional surgery, which, coupled with the benefits for the patient, makes it popular among both doctors and patients.

“Except for delivering a baby, all gynaecological problems can be fixed using laparoscopic surgery and now awareness is so high that women come asking for it,” says Dr Anurita Singh, gynaecologist and medical director of the Divyajyoti Specialities Hospital & Trauma Centre in Meerut.

On Thursday, she operated on a 23-year old woman with severe pain that was diagnosed as endometriosis (abnormal tissue growth outside the uterus) and appendicitis. Both surgeries were done back-to-back, using laparoscopic methods.

“You have to upgrade your skills regularly. And if it’s a technique that helps put your patient back on her feet in six hours instead of many days, without added cost for the patient or the clinic, there’s really no reason not to learn,” says Dr Singh, who has been doing laparoscopic surgery in Meerut for 12 years.

Widening scope

How surgery is done laparoscopically

A 5-mm incision is made near the navel, through which carbon dioxide gas is pumped in order to inflate the abdomen and increase working and viewing space.

A laparoscope is then inserted through the incision to relay images from inside the abdomen to a monitor in the operating room.

Two to three more tiny incisions (depending on the surgery) are made and the surgeon operates through these laparoscopic cuts while monitoring the surgery in real time on the monitor.

After the procedure, the carbon dioxide is released, the incisions are closed using staples and dressing is applied.

“It works very well for people with diabetes and obesity as the procedure is done through 5-mm ports and the lower abdominal trauma leads to faster recovery,” said Dr Tripat Choudhary, director of obstetrics and gynaecology at Fortis La Femme, New Delhi.

“The only people who should not opt for it are people with heart disease and compromised lungs because filling up the abdominal cavity with gas (carbon dioxide to increase working and viewing space) can put pressure on the diaphragm and compromise the heart and lungs,” she adds.

While laparoscopic surgery is the procedure of choice in most private hospitals and large super-specialty public hospitals, Dr Choudhary does not foresee it being widely used in small government hospitals or private clinics with fewer patients, however.

“The equipment is expensive and its maintenance can be a problem in the government sector, where getting replacements and disposables quickly remains a huge problem because of procurement protocols. In smaller clinics, making a huge investment in equipment does not make financial sense unless you use it extensively for several types of surgeries,” says Dr Choudhary.

“Laparoscopy is a learned technique that requires a unique set of surgical skills and instruments that an experienced surgeon trained in conventional surgery can automatically acquire,” adds Dr Sabharwal. “Unless more doctors train, laparoscopic surgery will only be available in large city hospitals — and that shouldn’t be the case.”