Laparoscopic Surgery

Laparoscopic surgery has gained popularity over the last decades as an alternative method for performing a multitude of procedures. In many cases it has practically replaced conventional open surgery via laparotomy, i.e. a large incision made into the abdomen (horizontally or vertically). Gallbladder removalsurgery (medical term: gallbladder - cholecystectomy) is a typical example, as well as a wide range of procedures for gynecological conditions (e.g. ovarian cysts, uterine fibroids, endometriosis, urinary incontinence, tumors etc.).

What is laparoscopic surgery (or simply laparoscopy)?
The defining characteristic of laparoscopic surgery is the elimination of the need for a large abdominal incision, replaced by much smaller entry incisions of up to 1cm in diameter. A long, thin tube with a tiny camera attached is passed through one of those small incisions, allowing the direct visualization of the interior of the abdomen, which is displayed on a special high-definition (HD) zoom monitor. Very thin, long special instruments are inserted into the other incisions (usually two to four) (Figures 1, 2). This is how the procedure is performed, with the surgeon’s hands outside the patient’s body.

Advantages of laparoscopic surgery
The benefits of laparoscopic surgery are due to minimizing the surgical trauma to the abdominal wall, thus resulting in:

Shortened hospital stay, usually 24h;
Significantly reduced postoperative pain;
Faster recovery. Most patients are able to resume eating light meals and moving the same day following surgery, having fully recovered a couple of weeks later. Many patients are also able to return to work within a week depending on the nature of the surgery;
The best possible aesthetic result. The larger abdominal incision is replaced by smaller incisions up to 1cm. These incisions are usually placed in “hidden” areas of the body, such as the navel and the hairy part under the abdomen;
Fewer scars on the inside of the abdomen, a cause of ileum or postoperative pain.

Which patients are considered suitable for laparoscopy?
Any patient may be suitable for laparoscopic surgery. Absolute contraindications include severe heart and respiratory conditions, as well as acute internal bleeding. A relative contraindication is the presence of severe generalized intra-abdominal infection (peritonitis).

It should be noted that any laparoscopic procedure is founded on many of the same principles and surgical steps used in open surgery. Successful outcome and possible complications depend not only on the particularities of each case, but also on the experience and background of the surgeon.

Laparoscopic surgery is now the standard of care for surgical treatment in:

Ovarian cysts
Ovarian cysts are the most common finding in pelvic ultrasounds for women of reproductive age. In most cases (about 99%) they are benign. There are three main types of ovarian cysts: a) functional cysts (follicular, corpus luteum and multilocular cysts); b) endometrial cysts; and c) neoplastic cysts (less common). If a cyst turns out to be neoplastic, the probability of being malignant (cancerous) in women aged 15-45 years old is low, at around 12%. In post-menopausal women this probability is about 45%. Regardless of type, as a rule of thumb, any cysts over 8cm in diameter (the size of a small orange) should be removed. Nowadays, ovarian cyst removal via laparoscopy is the most common laparoscopic procedure for women. Today, 7-8 in 10 patients with ovarian cysts undergo laparoscopy.

Endometriosis and chronic pelvic pain
Endometriosis is a common condition that affects the gynecological organs; its main symptoms include pain in the lower abdominal area (i.e. pelvic pain) and infertility or a combination of both. The pain is usually dull and intense. There are three types of pain: pain during the period (dysmenorrhea); deep (not external) pain during intercourse (dyspareunia); and permanent pain in the lower abdominal area (chronic pelvic pain). In specific, the pain: a) usually onsets at a later age than the age of the first period; b) steadily deteriorates over the years; c) gets worse during the period. There may also be local symptoms caused by specific localization in various other non-gynecological organs (i.e. colon, bladder, etc.), e.g. acute pain during defecation or urination.

Laparoscopy is still the best method to treat endometriosis, thanks to the zoom options of the special camera that helps detect foci not visible to the naked eye. It also makes it possible to remove many deeper foci around vital organs, such as arteries, veins, etc. using special instruments and delicate manipulation.

The ideal procedure for endometriosis is minimally traumatic to gynecological organs, it restores the affected organs to their original position and, finally, it removes completely (rather than just cauterizing) all foci. Laparoscopic surgical procedures for advanced endometriosis are considered to be the most complex ones from a technical point of view and require experience and special surgical training.

Uterine fibroids
Uterine fibroids are benign growths that develop in the muscular wall of the uterus. One in two women will develop uterine fibroids by the age of fifty. Unless symptomatic, it is not necessary to have them removed. Common symptoms include heavy menstrual bleeding; irregular period; pressure symptoms such as a heavy sensation in the pelvis, pollakiuria or constipation due to bladder or colon pressure, respectively. A decision to remove uterine fibroids should be taken only after having excluded all other possible causes (hormonal, gastroenterological or urological) for the symptoms, and after consultation regarding possible pharmacological methods.

The laparoscopic removal of uterine fibroids is an ideal alternative especially for patients with no children. The removal of uterine fibroids in patients over 40 with children may be unnecessary. In such a case, uterus removal is recommended. If the patient is against this, then pharmacological suppression of fibroids and reassessment after a certain period of time is recommended.

Fibroids inside the uterine cavity (submucosal) are removed via hysteroscopy (a procedure similar to laparoscopy).

Removal of the entire uterus (total hysterectomy)
Removal of the entire uterus is usually recommended for benign (and sometimes malignant) conditions. The most common reasons are heavy bleeding that does not respond to pharmacological or other methods and multiple uterine fibroids for the same reasons as described above.

The laparoscopic removal of the uterus is much preferred by women, since it allows for faster recovery; patients may return home the day following the procedure, and fully recover a couple of weeks later, rather than being hospitalized for 4-5 days. The surgery scars are minimal and postoperative pain is significantly reduced.

Just as in advanced endometriosis, laparoscopic removal of the uterus should be performed by well-trained surgeons.

In total hysterectomy, theovaries are not necessarily removed, especially when it comes to patients under 45.

Treatment/staging of first- and second-stage gynecologic cancers

"Radical" hysterectomy is a type of procedure strongly recommended for gynecologic cancers, especially for cervical cancer. It differs from total hysterectomy (removal of the entire uterus) as follows:

1. It is a more serious and wider surgical procedure with a high degree of technical difficulty;
2. Along with the uterus, other parts or even entire ligaments holding the uterus in place within the pelvis, are being removed, thus reaching the lateral pelvic walls;
3. It is usually accompanied by lymph node removal around the pelvic arteries and veins, and sometimes around the aorta.

The uterine ligaments and lymph nodes are dissected in order to ensure the removal of microscopic tumor foci possibly hiding inside them.

In 1989, a world first cervical cancer removal (radical hysterectomy) was performed exclusively via laparoscopy by a living legend, Dr. Camran Nezhat, Gynecology surgeon at STANFORD University Hospital, US. Since then, some of the most acclaimed medical centers in the US and Europe have been performing major surgeries, such as oncologic procedures, via laparoscopy.

The first procedure via laparoscopic radical hysterectomy along with lymph node dissection (aorta and pelvis) was performed for the first time in Greece in 2004 by Dr. Hilaris and his team. Our team leads the way having performed a great number of such procedures throughout Greece since then.

Moreover, over a decade, international scientific studies have confirmed the benefits, safety and efficacy of laparoscopy in removing gynecologic tumors (especially when detected early).

We have also performed the first robot-assisted gynecologic oncology procedure in Greece, as well as at IASO and other hospitals in Greece.