Conservative laparotomy and hysterectomy for endometriosis are described in detail later in this chapter.

Things to think about before a laparotomy

Before your operation it is important that you make sure that you and your gynaecologist agree on the purpose and nature of your surgery and that you have resolved any questions or concerns that you may have. If necessary you should make a special visit to discuss these issues. Ideally, the preparation for your surgery should involve preparing yourself physically and emotionally for the operation itself as well as planning for your recuperation period afterwards.

The healthier you are before surgery the more quickly you are likely to recover afterwards. It might be worthwhile taking a few steps to improve your general health if necessary.

Measures that might be worth considering include eating a nutritious diet, taking vitamin and mineral supplements, particularly vitamins B, E and C, and exercising regularly.

If you are a smoker it would be advisable for you to quit smoking at least one to two days before your operation to reduce the likelihood of anaesthetic complications. If you are taking the oral contraceptive pill it may be best to stop taking it for a month or so before your surgery to reduce the risk of complications, particularly thrombosis. If you are overweight, losing some weight will help reduce the risk of complications.

You should also make sure that you are completely happy with your decision to have the surgery. Do not hesitate to seek the advice and support of others if necessary.

Before you go into hospital you should arrange to have some help with household tasks such as cooking, laundry and cleaning when you return home.

What happens with a laparotomy

Precisely what will happen when you have your laparotomy will depend to some degree on what sort of surgery you are having, the practices of your gynaecologist and the practices of the hospital. What follows should only be used as a guide.

You will probably be in hospital for about five to seven days if you are having a conservative laparotomy, or seven to ten days if you are having a hysterectomy.

You will usually be admitted to the hospital the day before the operation. After you have gone through the formalities of being admitted to the ward someone will probably take your medical history. A nurse will take and record your temperature, pulse, breathing rate and blood pressure. An electrocardiogram and blood and urine tests may be taken, particularly if you are having a hysterectomy. Your pubic hair and the lower part of your abdomen will usually be shaved and you may be given a suppository if you have not opened your bowels that day.

A physiotherapist may visit you and teach you some breathing and foot and leg exercises to do after the operation, especially if you are a smoker, an asthmatic or prone to chest infections.

The anaesthetist will visit you to discuss the operation and ask you about any allergies and previous problems that you may have had with a general anaesthetic, such as nausea.

Some time before your operation you will be given a consent form to sign so that you can give your permission to undergoing the operation. You may have previously signed the consent form when you discussed the operation with your gynaecologist during an earlier visit.

At bedtime you may be offered a sleeping tablet to help you sleep in the unfamiliar hospital ward. It is important to have a good night’s sleep before your operation so it is advisable to take the sleeping tablet if it is offered.

You will not be allowed to have any food or drink for at least six hours before the operation. Shortly before the operation you will be asked to shower and put on a gown and you will be asked to empty your bladder. About an hour before you are due to go to the operating theatre you will probably be given an injection, known as a pre-med or a premedication, which will probably make you feel relaxed and sleepy and make your mouth dry.

If you are apprehensive about your surgery you may like to ask if you can have your partner or a friend or a close relative come to stay with you for the hour or two before you go into theatre.

Immediately before the operation you will be taken to the operating theatre. In the operating theatre an intravenous drip will be inserted into your arm and you will be given the general anaesthetic. After you have lost consciousness a tube will be placed in your throat and connected to a machine that breathes for you.

A tube known as a catheter may be inserted into your bladder to drain the urine.

A horizontal cut about ten centimetres in length will usually be made across the abdomen along the pubic hairline. Sometimes the cut will be made vertically between the middle of the pubic hairline and the navel, particularly if you have previously had a vertical cut or if bowel surgery is likely.

The gynaecologist will then thoroughly inspect the pelvic cavity for any signs of endometriosis, adhesions and other damage so that she or he can plan the operation and decide which procedures need to be carried out.

When the surgery has been completed the gynaecologist will stitch up the wound and the tube in your throat will be removed. You will then be taken to the recovery room for about half an hour before being taken back to your bed in the ward.

After a laparotomy

After your operation you will have an intravenous drip in your arm to provide you with fluids so that you do not become dehydrated as you will not be allowed to drink. You will usually have a catheter draining your bladder for the first day or two if you have had a hysterectomy. You may also have a tube coming out of the surgical wound to drain any excess fluid and debris from the area of the operation.

For the first twenty four hours after your operation the nurses will observe you closely. They will chart your pulse, breathing rate, blood pressure and temperature frequently and check your wound and record any vaginal bleeding. During this time your gynaecologist will come and discuss the operation with you.

The physiotherapist may visit you again to help you with your breathing and foot and leg exercises.

You may experience some nausea and/or vomiting immediately after the operation. To help relieve this you may require an injection.

You will usually feel drowsy and experience pain for the first few days following your surgery, particularly from your wound. The tube that was placed in your throat may give you a sore throat for the first day or so. Two to four days after your operation you will probably experience wind pain which can be very unpleasant and uncomfortable.

For the first day or two you will either be given painkilling drugs continuously through your intravenous drip or you will be given painkilling injections every four to six hours. You will then progress to painkilling tablets.

When you first start to drink again you will be allowed only to suck ice and sip small quantities of fluid. Once you are able to cope with fluids and any nausea and vomiting has ceased your intravenous drip will be removed. When you have passed wind you will be able to progress onto a light diet of semi-solids and then onto a normal diet if you have no problems. You will probably not open your bowels for the first two to four days after your operation but if constipation becomes a problem you may be offered suppositories.

You will sit out of bed for a short time on the day after your operation and you will be encouraged to move around a little more each day as your condition improves.

When you return home you will then require another three to five weeks of recuperation if you have had a conservative laparotomy, or another three to seven weeks if you have had a hysterectomy. It is important that you do not just rest in bed but that you move and walk around each day and gradually increase your activity level as you recover and feel better.

You may tire quickly for the first week or two, so you will need some help with household tasks for the first one to three weeks, especially if you have children. When you start to do the household jobs again you should do a little at a time and still have plenty of rest. Do not try to be a superwoman as it will only slow down your recovery in the long-term.

For the first week or two after you return home you may still have some discomfort or pain so a mild painkiller such as Panadeine or Panadol may be necessary. The vaginal discharge, if you have had it, usually persists for about two weeks after surgery but it may last for up to six or eight weeks following a hysterectomy.

Most of the healing of the wound occurs in the first two weeks after surgery. After that you can lift light loads but it is probably best to avoid lifting heavy loads if possible for the first month or so. You can drive the car again when you are fit enough to do light gardening and walk up stairs quickly, generally about three to six weeks after surgery. You can have sexual intercourse again when your doctor has examined you about six weeks after your operation.

You should notify your gynaecologist immediately if you develop any of the following symptoms:

A fever

Your wound becomes tender, swollen and red

A discharge appears from your wound

Severe abdominal pain or cramps

Urinary frequency and scalding when passing urine

Pain or bleeding when using your bowels

Your vaginal discharge develops an unpleasant odour

Your vaginal discharge persists beyond six to eight weeks

Tenderness and/or swelling in your calf muscles

Increasing soreness of the calf muscles when walking

Shortness of breath, chest pain or pain when breathing.

Risks and complications of a laparotomy

The risks associated with a laparotomy are greater than those associated with a laparoscopy but they are still fairly low. Most of the complications are relatively minor and they usually resolve themselves fairly quickly.

The complications which may occur at the time of surgery include an allergic reaction to the anaesthetic, uncontrolled bleeding and accidental damage to internal organs such as the bowel or bladder.

Complications which may develop after the operation while you are still in hospital include constipation, bleeding at the wound site, urinary infection, wound infection, chest infection, heavy vaginal bleeding, difficulty emptying the bladder, and thrombosis (when a blood clot forms in a vein, usually in the pelvis or a leg) and embolism (when a blood clot lodges in the lung).

Complications which may develop after you return home include wound infection, bleeding from the wound, urinary infection, a vaginal discharge with an unpleasant odour and a change in bladder and/or bowel function which may persist for one to two months.

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Day 1-5: menstruation (the menstrual period);

Day 3-13: the proliferative or follicular phase;

Day 14: ovulation;

Day 15-28: the luteal or secretory phase.

Although the first day of menstruation is usually referred to as the start of the menstrual cycle, the menstrual period (days 1-5) is actually the culmination of the hormonal changes which make up the menstrual cycle.

Ovulation-On about day 14 the oestrogen levels in the bloodstream reach a peak which causes the pituitary gland to release a surge of luteinising hormone (LH). This surge of LH causes the mature ovarian follicle in the ovary to rupture and release its ovum. This process is known as ovulation.

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Blocked Fallopian Tubes

The fallopian tubes are the route between the ovaries and the womb. The sperm swim along these tubes in order to reach the egg. The fallopian tube also provides a home for the fertilised egg for the first seven days of life, before it gets to the womb where it will implant itself. If the tubes are blocked then this is a major problem and medical intervention is needed.

Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the main reason why some women stop ovulating. In its most extreme form, it can be a very distressing condition. Women affected by PCOS will tend to be overweight, prone to acne, menstruate seldom or not at all, grow unsightly body hair (often on the face, breasts and inside of the legs), and be susceptible to mood swings.

Fibroids

Fibroids are non-cancerous growths which grow in or on the wall of the womb. They are very common and many women never realize they have them, as they may not cause any symptoms. If they grow in a way that doesn’t exert pressure on neighboring organs, a woman can live with large fibroids for many years without needing medical help. They can, however, cause infertility and some fibroids can cause miscarriages. Fibroids can vary in number and size. If the fibroids grow significantly they can cause the uterus to enlarge and/or distort which makes it difficult for the embryo to implant properly. So you might conceive easily but miscarry unawares, at a very early stage, because the fertilised egg could not ‘hold on’ with the fibroid there. The size of a fibroid is usually compared to a foetus of that size (e.g. a 12-week fibroid) but some can be as small as a pea.

Endometriosis

Endometriosis is a condition where the lining of the womb (the endometrium) grows in places other than the womb. Sections of womb lining may grow in the fallopian tubes, ovaries, bowel and bladder. More uncommon places include the lung, heart, eye or knee. The womb lining, no matter where it is situated, then responds to the natural hormone cycle and will bleed when the period occurs. This can be extremely painful, especially in those sites where there is no natural escape route for the blood, and inflammation may occur. For instance, I have seen women who get a nose bleed during their period because the womb lining has migrated to the nasal passages and bleeds when they menstruate.

Endometriosis can affect female fertility because it can cause scarring and blockages inside the pelvic cavity, and it is thought that 50 per cent of women with endometriosis may have problems getting pregnant. It is more common in women over 30 who have not had children. So, as more women delay having children, the possibility of infertility being caused by endometriosis rises.

In some cases the endometriosis scars and obstructs the fallopian tubes so severely that the tubes cannot pick up the egg. And if the ovaries are scarred badly then ovulation may not occur. When the endometrial tissue implants on the ovary then cysts may form called ‘chocolate cysts’ because they are filled with dark, brown, old blood.

Coeliac Disease

This is a medical condition caused by intolerance to gluten which pre-vents food being absorbed properly. Symptoms can include foul-smelling greasy stools, weight loss, anaemia, bloating, fatigue, and signs of multiple vitamin and mineral deficiencies.

Unfortunately, coeliac disease can also cause fertility problems. A study in 1996 confirmed that women with coeliac disease were sub-fertile and had an increased risk of stillbirths and perinatal deaths.

Gluten is a major component of wheat; and other cereals, such as rye, barley and oats, can also be a problem. Rice and corn are fine. The gluten damages the villi, which are minute, hair-like projections lining the intestine, and this can stop the absorption of vital nutrients. The disorder is diagnosed by having a biopsy in which a sample of the small intestine is removed for examination.

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