What is minimal access surgery?

Our minimal access gynaecology service uses a range of medical and surgical options to help manage common and potentially debilitating gynaecological conditions such as fibroids, endometriosis, ovarian cysts and polyps. These conditions can have a significant impact on fertility as well as the outcome of fertility treatments such as IVF. Almost all operations are performed as ‘keyhole’ surgery (small incisions in the abdomen for laparoscopic surgery or via the vagina without incisions for hysteroscopic surgery).


Laparoscopy and Hysteroscopy: Our expertise

Mr Christopoulos has trained and worked in reputed centers for advanced laparoscopic surgery in London and Brighton. He has completed a rigorous, 2-year, one-to-one training program in Advanced Gynaecological Endoscopy, which was ran jointly between the University of Surrey and the British Society for Gynaecological Endoscopy. With his team, he has performed a large number of laparoscopic and hysteroscopic preocedures to help improve the fertility outcomes of women before or after IVF treatment.


What does a laparoscopic procedure involve?

During laparoscopy, the surgeon makes a small cut (incision) of around 1 to 1.5cm (0.4 to 0.6 inches), usually near your belly button. A tube is inserted through the incision, and carbon dioxide gas is pumped through the tube to inflate your tummy (abdomen). Inflating your abdomen allows the surgeon to see your organs more clearly and gives them more room to work. A laparoscope is then inserted through this tube. The laparoscope relays images to a television monitor in the operating theatre, giving the surgeon a clear view of the whole area.

If the laparoscopy is used to carry out a surgical treatment, such as removing an ovarian cyst, further incisions will be made in your abdomen. Small, surgical instruments can be inserted through these incisions, and the surgeon can guide them to the right place using the view from the laparoscope. Once in place, the instruments can be used to carry out the required treatment. After the procedure, the carbon dioxide is let out of your abdomen, the incisions are closed using stitches or clips and a dressing is applied. When laparoscopy is used to diagnose a condition, the procedure usually takes 30-60 minutes. It will take longer if the surgeon is treating a condition, depending on the type of surgery being carried out.


Laparoscopy and Hysteroscopy

What does the preparation for minimal access surgery involve?

Depending on the type of laparoscopic procedure being performed, you’ll usually be asked not to eat or drink anything for 6 to 12 hours beforehand. If you’re taking blood-thinning medication (anticoagulants), such as aspirin or warfarin, you may be asked to stop taking it a few days beforehand. This is to prevent excessive bleeding during the operation. If you smoke, you may be advised to stop during the lead-up to the operation. This is because smoking can delay healing after surgery and increase the risk of complications such as infection. Most people can leave hospital either on the day of the procedure or the following day. Before the procedure, you’ll need to arrange for someone to drive you home because you’ll be advised not to drive for at least 24 hours afterwards.


What about the recovery after the laparoscopic procedure?

After laparoscopy, you will be monitored by a nurse for a few hours until you’re fully awake and able to eat, drink and pass urine. Before you leave hospital, you’ll be told how to keep your wounds clean and when to return for a follow-up appointment or have your stitches removed (although dissolvable stiches are often used).

The time it takes to recover from laparoscopy is different for everybody. It depends on factors such as the reason the procedure was carried out (whether it was used to diagnose or treat a condition), your general health and if any complications develop. If you’ve had laparoscopy to diagnose a condition, you’ll probably be able to resume your normal activities within 5 days. Your surgical team can give you more information about when you’ll be able to resume normal activities.


How does a laparoscopic myomectomy help remove fibroids?

In laparoscopic or robotic myomectomy, both minimally invasive procedures, your surgeon accesses and removes fibroids through several small abdominal incisions.

Compared with women who have a laparotomy, women who undergo laparoscopy have less blood loss, shorter hospital stays and recovery, and lower rates of complications and adhesion formation after surgery. There are limited comparisons between laparoscopic and robotic myomectomy. Robotic surgery may take longer and be more costly, but otherwise few differences in outcomes are reported.

  • Laparoscopic myomectomy.Your surgeon makes a small incision in or near your belly button. Then he or she inserts a laparoscope — a narrow tube fitted with a camera — into your abdomen. Your surgeon performs the surgery with instruments inserted through other small incisions in your abdominal wall.
  • Robotic myomectomy.Your surgeon inserts instruments through small incisions similar to those in a laparoscopic myomectomy, and then controls movement of the instruments from a separate console. Some surgeons are now performing single-port (one incision) laparoscopic and robotic myomectomies.

Sometimes, the fibroid is cut into pieces (morcellation) and removed through a small incision in the abdominal wall. Other times the fibroid is removed through a bigger incision in your abdomen so that it can be removed without being cut into pieces. Rarely, the fibroid may be removed through an incision in your vagina (colpotomy).


Laparoscopy and Hysteroscopy

When is a hysteroscopy selected to help remove fibroids?

To treat smaller fibroids that bulge significantly into your uterus (submucosal fibroids), your surgeon may suggest a hysteroscopic myomectomy. Your surgeon accesses and removes the fibroids using instruments inserted through your vagina and cervix into your uterus.

A hysteroscopic myomectomy generally follows this process:

  • Your surgeon inserts a small, lighted instrument through your vagina and cervix and into your uterus. He or she will most commonly use either a wire loop resectoscope to cut (resect) tissue using electricity or a hysteroscopic morcellator to manually cut the fibroid with a blade.
  • A clear liquid, usually a sterile salt solution, is inserted into your uterus to expand your uterine cavity and allow examination of the uterine walls.
  • Your surgeon shaves pieces from the fibroid using the resectoscope or the hysteroscopic morcellator, taking out the pieces from the uterus until the fibroid is completely removed. Sometimes large fibroids can’t be fully removed in one surgery, and a second surgery is needed.


How can a laparoscopic procedure help women with endometriosis?

This procedure is typically used for checking and treating:

  • Severe endometriosis and scar tissue that is thought to be interfering with internal organs, such as the bowel or bladder.
  • Endometriosis pain that has continued or returned after hormone therapy.
  • Severe endometriosis pain (some women and their doctors choose to skip medicine treatment).
  • An endometriosis cyst on an ovary (endometrioma)

There are various ways of surgically treating an endometrioma, including draining it, cutting out part of it, or removing it completely (cystectomy). Any of these treatments brings pain relief for most women but not all. Cystectomy is most likely to relieve pain for a longer time, prevent an endometrioma from growing back, and prevent the need for another surgery.

  • Endometriosis as a possible cause of infertility. The surgeon usually removes any visible implants and scar tissue. This may improve fertility.


Endometriosis treatment and infertility

If infertility is your primary concern, your doctor will probably use laparoscopy to look for and remove signs of endometriosis. After laparoscopy, your next steps depend on how severe your endometriosis is and your age. If you are older than 35, egg quality declines and miscarriage risk increases with each passing year. In that case, your doctor may recommend infertility treatment, such as fertility drugsinsemination, or in vitro fertilization. If you are younger, consider trying to conceive without infertility treatment.