LAPAROSCOPY

An overview of Laparoscoic Surgery. This page contains an English version below the Bahasa Malaysia one.

Pembedahan yang selalu digelar “teropong” ini dilakukan dengan membuat belahan kecil (0.5 cm) di abdomen. Tiga belahan atau “incision” dibuat dan pembedahan utama (major) boleh dilaksanakan melalui lubang-lubang ini. Belahan pertama dilakukan di pusat. Teropong atau laparoskop dimasukkan ke dalam abdomen dan kamera video diletakkan pada penghujung luar teropong ini. 

Gambar A. Gambaran melalui teropong memperlihatkan rahim, ovari dan
tiub serta suasana dalaman pelvis

Gambaran dalam abdomen dilihat pada television dalam dewan pembedahan dan segala organ dapat dilihat dengan jelas kerana diperbesarkan (magnified).

Selepas teropong dimasukkan melalui pusat, dua belahan kecil lagi dibuat dibahagian bawah abdomen. Segala peralatan pembedahan dan jahitan akan dibuat melalui lubang yang dibentuk di abdomen ini. 

Gambar B. Pembedahan dilaksanakan
dari luar

Pembedahan teropong ini membenarkan pembedahan yang sungguh jitu yang tidak dapat ditandingi oleh pembedahan biasa. Kejituan pembedahan jenis ini lebih ketara semasa pembedahan untuk penyakit endometriosis, ketumbuhan, sista dan kanser. 

Gambar C. Pembedahan laparoskopi di PPW

Sebagai perbandingan, laparotomi atau pembedahan biasa mengakibatkan belahan sepanjang lima hingga sebelas inci panjang. Belahan yang beasr ini mungkin menegak atau melintang dan diperlukan untuk menampung peralatan bedah yang biasa (lihat perbandingan antara Gambar-gambar D dan E). Pembedahan sejenis ini mengakibatkan penyembuhan dan penjagaan di hospital yang lebih lama, perasaan sakit serta kemungkinan komplikasi jangkamasa panjang.  

Gambar D. Luka pembedahan laparoskopi

Gambar E. Belahan laparotomi yang besar

Kelebihan pembedahan laparoskopi berbanding dengan laparotomi jelas dilihat. Kebanyakan pesakit dibenarkan balik rumah pada hari yang sama selepas pembedahan. Pesakit selalunya sembuh dalam masa beberapa hari dan dapat berfungsi saperti biasa dalam masa seminggu. Kesakitan yang dialami pun sedikit dan pesakit lebih selesa selepas pembedahan.

Gambar F. Sista dermoid

Gambar G. Pembuangan rahim kerana
penyakit adenomyosis

Gambar H. Sebuah sista sedang dibedah melalui pembedahan laparoskopi

Walaupun pembedahan laparoskopi mempunyai banyak kelebihan berbanding dengan pembedahan tradisional, ia kurang diamalkan kerana susah dilakukan dan memerlukan kepakaran dan pengalaman untuk mencapai tahap yang sewajarnya. Tambahan pada itu, 

peralatan yang digunakan adalah mahal dan tidak didapati di kebanyakan hospital.

PUSAT PAKAR WANITA & Rawatan Endometriosis 26 Persiaran Venice Sutera 1 Desa Manjung Raya 32200 LUMUT Perak Darul Ridzuan www.ppwendometriosis.com ppw_2007@yahoo.com.my http://hanifatlumut.blogspot.com   Patient Information   Laparoscopic Surgery Prepared By Associate Professor Dr Hanifullah Khan

What is Laparoscopic Surgery? Previously, the thought of an operation conjured up visions of pain and suffering, mainly because patients envisioned a big cut with pain, bleeding and protracted recovery. Over the last few years though, many new methods and advances have occurred that have alleviated these problems. One of these is the development of Laparoscopic Surgery or commonly called “keyhole surgery”. Think of it as this; if a certain small diseased organ such as the appendix or cyst (the size of a small packet of sugar) had to be removed from the abdomen, a laparotomy had to be performed and the cut in the abdomen that had to be made was fairly large. The classic incision could be anywhere between 5-25 cm long and can cause a fair amount of bleeding and pain after surgery.

You may ask why such a big cut is needed for conventional surgery. Well, surgeons need to see what they are doing, so a large hole allows light to enter and enough space for them to use their instruments. This is unnecessary with laparoscopy as all the surgery is performed using very small instruments and viewed through a camera showing images on video panels. This avoids all the problems with laparotomy previously mentioned, as it is now possible to do abdominal surgery, big or small, through small punctures. An added advantage is that the telescope or laparoscope provides a magnified image of the organs allowing for more detail and precise surgery. This is not available in conventional surgery.

How is laparoscopic surgery done? Under general anaesthesia, a 5 mm incision is made in the abdomen (most often in the umbilicus) and carbon dioxide gas inserted to distend it. This expands the abdomen and allows for more space and room to manoeuvre, sort of like being in a cave. Then, a thin rod-like telescope is inserted and this will provide the magnified (2.5 times) image displayed on the video panel, and to aid this, illumination is supplied from a light source connected to the telescope. Subsequently, a couple more incisions are then made lower in the abdomen and long, thin operating instruments are then inserted via these incisions to begin the surgery. So you see, after such small incisions the blood loss is minimal and the pain negligible, and the patient is able to go home even on the same day.

What is the difference between laparoscopic surgery and diagnostic laparoscopy? The procedure involved is the same as above, except, diagnostic laparoscopy is used only to view inside the abdomen and pelvis so as to make a diagnosis. On the other hand, a surgeon trained in laparoscopic surgery may be able to carry out surgical procedures by just using the laparoscope. Essentially, laparoscopic surgeons are highly trained individuals able to perform risky major surgery using a technique that causes little discomfort to the patient.

What procedures can be performed with laparoscopic surgery? Any and all procedures traditionally performed via laparotomy can be done laparoscopically. Among others, these include infertility assessment, removal of ectopic pregnancy, removal of growths such as fibroids and cysts, hysterectomy and even cancer surgery. Other surgical procedures routinely carried out include removal of the appendix and gall bladder.

What preparations are necessary for laparoscopic surgery? The preparations can be essentially divided between anaesthetic and surgical. To decrease anaesthetic risk, a patient should not eat or drink for at least 6 hours prior to surgery. This ensures the stomach is empty and prevents vomiting which can lead to food particles entering into the lungs. For patients at higher risk (such as the elderly), blood, heart and lung assessment may be necessary to confirm the patient is fit for surgery. As for the surgical part, you may be asked to insert a couple of tablets into the vagina 3 hours prior to surgery to help dilate the cervix and allow a thin instrument into the uterus for assessment as well as manipulation purposes. Sometimes medication to empty the bowels may be given a day before as an aid to better viewing and decrease the risk of bowel injury. All this is at the jurisdiction of the surgeon and also depends a lot on the type of surgery involved.

What happens after the procedure? Although the patient awakes immediately after the surgery, there is usually nausea, grogginess and drowsiness as a result of the anaesthetic medication. Pain relief medication may further add to these sensations. However, all this is temporary and more of a nuisance rather than a complication. Once recovered (usually after 6 hours), the patient can walk about and go to the toilet or shower. Food intake depends on the extent of the surgery and return of bowel function, which is signified by the passage of flatus. For short duration surgeries, you can usually have normal food almost immediately as long as you do not experience nausea or vomiting. Longer and more extensive surgery may require food intake to be delayed. As previously mentioned, there is minimal pain but this is very subjective and each person reacts differently. If required, pain medication can be given through a drip, but most patients get by with oral paracetamol or NSAIDs. Patients are usually discharged from between 6 to 24 hours after surgery.

What are the risks associated with laparoscopic surgery? All surgical procedures entail a certain amount of risk and this is the same for laparoscopic surgery. These include bowel or bladder injury and bleeding. The risks are not much higher than for conventional laparotomy. However, the type of patient presenting for laparoscopy is sometimes at a higher risk, for example, patients with severe endometriosis. Nevertheless, laparoscopic surgeons have an increased awareness of possible complications and are trained to avoid them or deal with them adequately.

Conclusion. In summary, laparoscopic surgery is designed with patient welfare in mind with decreased pain and complications as well as faster recovery periods. All types of surgery are possible and patient stay in the ward is of very short duration. The magnification obtained via the telescope allows for more detailed and precise procedures thus leading to better patient treatment outcomes. The risks of complications are similar to any surgery and are low, but if they do occur then they can be adequately dealt with during the operation. All in all, laparoscopic surgery in trained hands is the better treatment option for abdominal.