Who is suitable for a conservative laparotomy

The reasons for having a conservative laparotomy vary widely and they may include any of the following:

Moderate or severe disease

Endometriomas or cysts greater than two centimetres in diameter

Adhesions, especially if they are causing pain or distortion of the reproductive organs

Involvement of other organs such as the bowel or bladder

Moderate or severe symptoms that have not responded to other treatments

Inability or unwillingness to take hormonal treatment

Desire to conceive immediately

Desire to avoid hysterectomy

Woman’s preference

Gynaecologist’s preference.

A conservative laparotomy is often the most appropriate form of treatment for more severe forms of endometriosis, particularly if large cysts or adhesions are present. Some gynaecologists believe that a conservative laparotomy is of little benefit for those with minimal or mild endometriosis and that in those cases it should only be used as a last resort if hormonal treatment or laparoscopic surgery is unsuccessful.

Hormonal treatment has little or no effect on adhesions or large cysts and endometriomas greater than two centimetres in diameter as they are made up largely of scar tissue. Surgery is the only way to remove or destroy any adhesions or large cysts and endometriomas.

If your endometriosis involves nearby organs such as the bowel or bladder, surgery may be necessary to ensure the normal functioning of those organs.

Things to discuss before conservative laparotomy

Before your operation it is important that you discuss with your gynaecologist what is intended to be done during the operation. Also ask any other questions or voice any concerns that you may have. In particular, you should make sure that you both agree on the purpose of the surgery and you should discuss what procedures are proposed and you should make it clear if there are any procedures that you particularly do or do not want carried out. You also need to remember that, because each case of endometriosis is unique, until your gynaecologist actually starts the surgery it is difficult to be certain what procedures will be needed.

If your symptoms are manageable and if you are contemplating becoming pregnant soon it may also be worthwhile discussing the timing of your surgery with your gynaecologist. Most infertile women with endometriosis who conceive following a conservative laparotomy do so in the first 12 months after their surgery and you are more likely to conceive after the first bout of surgery than subsequent surgeries. Some gynaecologists believe that, if possible, a conservative laparotomy should be timed for when the woman wishes to become pregnant.

What happens with conservative laparotomy

Conservative laparotomy procedures vary and are changing all the time. The nature of your surgery will depend on a number of factors including the extent and location of your disease, your symptoms, your desire for future childbearing and your gynaecologist’s training, experience and preferences.

The procedures, which will be performed as part of a laparotomy, may include any of the following:

Removal or destruction of implants and small cysts

Removal or destruction of large cysts and endometriomas

Removal of adhesions

Removal of an ovary or an ovary and fallopian tube

Removal of the appendix

Surgery on any other affected organs such as the bowel or bladder

Suspension of the uterus

Pre-sacral neurectomy or utero-sacral neurectomy

Any surgery necessary to correct other abnormalities found.

Implants and small cysts

Where possible any superficial implants and small cysts on the ovary and peritoneum will be removed or destroyed by cutting, cauterisation or vaporisation, provided that there is no danger to any underlying organs such as the bowel or bladder.

Large cysts and endometriomas

Any endometriomas will usually be removed by cutting them out. This often involves removing a small amount of the surrounding ovary as well to ensure that all the endometrial tissue is removed. Sometimes, endometriomas will be destroyed by puncturing them and then cauterising or vaporising their lining. Large cysts on the peritoneum will be removed by cutting them out.

Adhesions

Any adhesions will be cut, cauterised or vaporised and separated so that the normal positioning of the reproductive organs can be restored.

Ovaries

Sometimes an ovary will have to be removed because an endometrioma lying within it cannot be removed safely. Similarly, if one ovary and fallopian tube are severely diseased they may be removed, provided that the other ovary and tube are normal. The removal of an ovary and tube on one side does not seem to decrease the likelihood of pregnancy following surgery but does seem to reduce the risk of the disease recurring.

Appendix

Some surgeons routinely remove the appendix during a conservative laparotomy, especially if the endometriosis is extensive, but most will remove it only if endometrial implants are present.

Bowel and bladder

Most small implants on the bowel and bladder are superficial and can be removed or destroyed without any danger of damaging the underlying organs. If the implants have penetrated the wall of the bowel or bladder they must be carefully cut out and the affected area repaired. Occasionally a section of the bowel will have to be removed if the implants have surrounded and constricted it; if there is any possibility of this being done it is highly advisable that a bowel surgeon be on hand to assist.

Suspension of the uterus

Suspension of the uterus involves tightening or shortening the utero-sacral and/or the round ligaments in an attempt to hold the uterus in its normal position. This procedure is not commonly performed by gynaecologists in Australia though it is quite common in America.

Pre-sacral and utero-sacral neurectomy

A pre-sacral neurectomy and a utero-sacral neurectomy are two similar procedures which are only occasionally performed by gynaecologists in this country, although they are performed much more commonly overseas. Both procedures involve cutting the nerves that transmit pain from the uterus to the brain. The same nerves are cut in both procedures but in the case of a utero-sacral neurectomy the nerves are cut closer to the uterus than is the case with a pre-sacral neurectomy. The two procedures are performed to relieve chronic pelvic pain but they are usually only effective for a maximum of about twelve months as by then the nerves have regrown.

If you are contemplating a pre-sacral neurectomy or a utero-sacral neurectomy it is worth remembering that pain is one of the body’s warning mechanisms. If you cannot feel pain in the pelvic area you may not be aware that your endometriosis could be worsening or recurring. If you go into labour you may not be able to feel the contractions which signal the onset of labour. In addition, both procedures can occasionally interfere with normal bowel and bladder function.

Other

If your fallopian tubes are damaged or if you have any other disease or abnormality of the reproductive organs these will usually also be repaired.

Effectiveness of a conservative laparotomy

It is difficult to give an indication of the success rates of a conservative laparotomy due to the lack of large-scale studies carried out to evaluate its effectiveness. There are few statistics on the success of surgery in terms of relieving the symptoms or on the proportion of women who experience a recurrence of their symptoms following surgery. Almost all of the available statistics are concerned with the proportion of women desiring pregnancy who conceived following surgery. Although the reported figures vary widely those statistics indicate that on average approximately 60% of women with mild disease, 50% of women with moderate disease and 40% of women with severe disease, can expect to conceive following a conservative laparotomy.

Risks and complications of a conservative laparotomy

The risks and complications of a conservative laparotomy are the same as those outlined for a laparotomy.

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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.

Luteal or secretory phase-The luteal phase extends from ovulation to menstruation. It is the phase during which a variety of substances are secreted by the endometrium in order to prepare it for implantation of the fertilised ovum. It is sometimes also known as the secretory phase.

Immediately after ovulation occurs the remains of the ruptured follicle are transformed into a structure known as the corpus luteum. The corpus luteum then begins to produce progesterone and a small amount of oestrogen.

The progesterone causes the endometrium to thicken even more. It also stimulates the cells in the endometrium to secrete substances that will nourish the fertilised ovum if pregnancy occurs.

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Here are some common conditions that make men less fertile.

Low Sperm Count

If his sperm count is low (less than 20 million per milliliter) then this could definitely be reducing your chances of conceiving. Levels of 40 million would be much better.

Poor Sperm Movement

Even if there is a good sperm count, fertility will be affected if the sperm’s capacity to move itself along (its ‘motility’) is poor. The way the sperm move is important because if they are going round and round in circles they won’t be able to travel up through the cervix and into the uterus to reach the egg. Good motility is also needed to help the sperm penetrate the egg.

Agglutination

This is when sperm clump together in a circle, going nowhere. This can be caused by an infection or by antibodies.

Abnormal Sperm

All men have a percentage of abnormal sperm and up to 70 per cent is considered acceptable. The abnormal sperm can have two heads or no tails, for example. But only if there is a very high percentage of abnormal sperm will a man’s fertility be affected.

Many specialists believe that these abnormal sperm would find it difficult to get to the fallopian tube and, once there, would not be able to penetrate an egg. But some studies have shown that abnormal sperm are actually capable of reaching the fallopian tube.

Others claim that a high concentration of abnormal sperm could be connected with a high rate of miscarriages.

Research has shown that, while the possibility of conception increases with higher sperm counts, it is also vital that the sperm are normal. One study, published in the Lancet in 1998, showed that a man with a lower sperm count can still be fertile as long as there is a high proportion of normal sperm.

Varicoceles

These are enlarged veins around the testes. They need not cause any discomfort and do not affect the man’s health in any way. However, it is thought that they can overheat the testes and damage sperm production, though there are men who have varicoceles and do not have any fertility problems. For some men with infertility, tying off these veins has helped them conceive. For other men, it has made no difference at all. Unfortunately doctors cannot predict which men with varicoceles will benefit from having them treated.

Obstructions

Blockages in certain parts of the male reproductive system can affect fertility by stopping sperm getting through to be ejaculated. These blockages can occur because of scarring caused by an infection such as mycoplasma or ureaplasma, or because of previous surgery, or due to an injury (e.g. a kick in the groin while playing sport). A severe sports injury could also stop the testes producing sperm.

Undescended Testes

If the testes did not come down properly after birth, then they may not be producing sperm. The incidence of this problem is increasing and many scientists now feel that (like the drop in sperm count) it is related to environmental factors. Surgery is often used to bring down a young boy’s testes (which, earlier in childhood, have got stuck inside the body) into the scrotum. If undescended testes were not diagnosed early enough and surgery was delayed then the man’s fertility may have been affected.

Diseases

Glandular diseases, such as thyroid or diabetes mellitus, can interfere with hormonal control of sperm production. Infections of the prostate and epididymis (tubular structure on top of each of the testes, into which secretions drain) can interfere with sperm production or block the exit of sperm from the body. Other infections such as mumps orchitis (an inflammation of the testicles following the mumps) can result in permanent infertility.

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Recurrences of herpes can break out weeks, months or years after the primary attack, or never. Recurrences are rare after HSV type 1 genital infection. Your resistance to illness (immune function) is important. Recurrence is more likely when a person is ‘run down’ or if triggered by a local injury. People who get oral herpes know that it is likely to break out if they have another illness (hence the name ‘cold sores’ and ‘fever blisters’) or if they get sunburn or any other injury on the mouth.

Recurrences turn up near the spot where the primary infection occurred. They’re usually smaller, less painful and clear up more quickly than the first attack.

Most people notice prickling or itching in the area a day or so before a recurrence breaks out. This is a good warning to stop sexual contact for the time being, because the infection can be passed on from the first suggestion of symptoms until the ulcer has completely healed. Occasionally a recurrence can be so tiny and painless that it isn’t noticed, though a sexual partner may be infected. Most recurrences don’t need any treatment, but salt-water bathing and local anaesthetic jelly can be used if needed.

Why does herpes recur?

During the primary attack, some viruses get into the nerve that supplies the infected area and travel along the nerve to its root beside the spinal cord. Here it lives, mostly in a dormant state, for the rest of your life. The virus may occasionally become activated in the nerve root for reasons that we don’t understand well but think are connected with immune function. The activated virus starts to multiply and migrates down the nerve to cause a recurrence.

People who get recurrences of genital herpes often know what is likely to lead to an outbreak. Some women find that a recurrence might follow an episode of sex when they’re too dry, or follow friction from tight clothes or sanitary pads. Being otherwise unwell, overtired, emotionally upset, jet lagged or ‘hung over’ can also trigger recurrences. Worrying about having herpes and the possibility of infecting your partner might even increase the risk. Sometimes recurrences turn up for no apparent reason when everything seems to be going well. However, most people with herpes feel that they can reduce the number of recurrences by avoiding whatever is likely to bring them on.

Should antiviral drugs be used for recurrences?

They usually aren’t recommended for mild, infrequent outbreaks. If attacks occur more than 10 times a year or are becoming more severe, a course of antivirals will almost eliminate recurrences while the drug is being taken. For most people herpes will settle back into its old pattern when the antiviral is stopped, so preventative treatment may require taking an antiviral

continuously for months or years. There is a fear that HSV strains resistant to antivirals may develop. So far people have used them for up to ten years without problems and with no evidence of resistant strains developing.

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Some of the new treatments are still the subject of debate. Medical opinion can differ on what type of treatment should be offered to women with different types and stages of breast cancer.

The stages of cancer are defined according to the size and cell type of the cancer and its spread within the breast, the presence and number of axillary (armpit) lymph nodes containing cancer cells, and whether the cancer has spread beyond the breast and axilla.

Another measurement used in making decisions about the type of treatment used is the receptor status of the cancer cells. Breast cancer cells can be tested to see how they respond to ovarian hormones, which helps predict how the cancer will respond to anti-hormonal treatment.

These days women are encouraged to] take part in decisions about treatment of their breast cancer. Your doctors should give you full information about the stags of your cancer, the treatments available and why they believe any one treatment will be better than others in your case. It can be very confusing if you’re given two
different opinions. Another opinion from an oncologist (specialist in the treatment of cancer) may be helpful. You may wan your partner, another family member я close friend to be involved in discussions and decisions about treatment.

Most small cancers, when the breast doesn’t contain or is unlikely to contain other areas of cancer, are now removed’ by local excision, called ‘lumpectomy’ or ‘partial mastectomy’. This surgery is always followed by six weeks of radiotherapy, and some of the glands from the armpit will almost always be removed for examination.

The possibility of miscarriage raises a prickle of uncertainty in the minds of many women during the early months of pregnancy. Medically called spontaneous abortion, miscarriage is the loss of the foetus and all or part of the placenta during the first 20 weeks of pregnancy, before the foetus is sufficiently mature to survive. After 20 weeks it’s called ‘pre-term birth’.

Miscarriage is very common. Around 15 per cent of all diagnosed pregnancies miscarry. Many more (possibly up to 50 per cent) miscarry before the pregnancy is diagnosed or even suspected, when a woman who is trying to conceive has a slightly late and perhaps heavier than usual period. There may be no evidence of early pregnancy failure if conception fails before the next period is due.

What causes miscarriage?

Many things cause miscarriage, the most common being foetal chromosomal abnormality. It is estimated that about seven out of ten miscarriages in the first three months are due to defects in the foetus that would make survival impossible. Other possible causes include immune system disorders, temporary or permanent conditions of the uterus that it incapable of retaining a pre hormonal disorders and, less commonly, maternal illness in the early months. Researchers have tried to find links be: miscarriage and psychological stated no definite connections have been found.

When is miscarriage most likely to happen?

The risk of miscarriage is highest immediately after implantation, and diminishes as the pregnancy advances. Once you’ve passed the 12-week mark and the foetus is alive and well, the risk is small. A miscarriage after three months is more; to be due to abnormalities in the uterus or cervix.

What are the warning signs?

Bleeding or bloodstained discharge from the vagina is usually the earliest sign. Any bleeding, even slight, after a pregnancy has been diagnosed is called threatened abortion. About one-third of all pre women will have some bleeding during the first twelve weeks: less than half these will miscarry.

The blood loss of threatened miscarriage is often painless and is unrelated to activity. If it is slight and dark it usually settles down in a day or so and the pregnancy continues without further mishap. Babies born to mothers who have ‘threatened’ have no more abnormalities than those born to mothers who’ve had no bleeding.

Generally no treatment is recommended for threatened miscarriage, except to avoid intercourse and strenuous activity until bleeding stops. It’s unlikely that bed test is of any benefit, but most women prefer to take things very easily until the threat has passed.

If the bleeding becomes heavier and is accompanied by cramps, it usually means that the placenta has begun to separate from the uterus and that the pregnancy is doomed. This is an inevitable abortion. Often the pregnancy will be completely discharged from the uterus as a lump of soft, liver-like tissue consisting of the placenta lid membranes. After 10 weeks there may be a recognizable foetus. If the bleeding settles quickly and the pregnancy has been entirely expelled, a complete spontaneous portion has occurred. The uterus contracts to normal size, the cervix closes and no treatment is usually necessary.

All or part of the doomed conception may remain in the uterus, preventing it from contracting properly. This is an incomplete
abortion. In such cases profuse and dangerous bleeding can continue.

Occasionally the foetus dies but remains in the uterus, with little or no bleeding or pain. This is missed abortion, which can be difficult to diagnose because the uterus remains enlarged, though other symptoms of pregnancy usually disappear. If suspected, missed abortion can usually be diagnosed by falling levels of pregnancy hormone in the blood, and even more certainly by ultrasound examination. When missed abortion is confirmed, emptying the uterus by curettage is usually recommended.

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If you feel you’ve been discriminated against in selection or promotion or in any way intimidated or harassed because you’re a woman, you must speak out: bottling up your anger and resentment can have a bad effect on health. Report the matter promptly to your union representative, staff counsellor or personnel supervisor. Documentation and witnesses will help your case. Don’t let anyone rush you into or talk you out of taking action until you have been well counselled and feel quite sure that any possible outcome would be to your advantage.

If you want more advice or information about anything to do with workers’ health or welfare, you’ll find the Department of Industrial Relations and Employment listed in the State government section at the front of the phone book.

The economic downturn of recent years has resulted in many women and men, both young and older, being unemployed. Vocational training and tertiary education no longer guarantee employment for anyone, and many people who have spent years building up skills and experience are suddenly faced with retrenchment or early retirement.

Unemployment can be a much greater health hazard than working. The financial hardships, shattered life and career plans, changes in lifestyle and loss of self-esteem resulting from unemployment put a terrible strain on individuals and families pie Health disorders due to stress are common consequences. Most government, employment services offer counselling to help people cope better with being out of a job. But apart from heeding this advice and using your (unwanted) free time to indulge or expand your interests, we can only try to remain optimistic, especially that the economy will pick up.

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Anything that disturbs the surface layer or removes the film leads to increased loss of water and other natural emollients from the skin, resulting in roughness, flaking, chapping and cracking.
Soap and water wash off the sebum film; soap, detergents and certain oils remove the fatty substances that are important in holding the surface layer together. Dry air, extremes of weather and exposure to wind increase loss of moisture from skin. Older people produce less sebum and sweat, and are more prone to dry skin.

To correct and prevent dry skin avoid excessive washing, hot water, excessive use of soap, and dry air. The term ‘moisturiser’ has come into use since 1952, when it was shown that water, more than anything else, maintains the skin’s suppleness. This discovery led to a new development and marketing of skin cosmetics.

There are two main types of moisturisers. The most effective reduces evaporation by forming a waterproof coating on the skin’s surface. The coating may consist of lanolin, vaseline, mineral oil or other waxy and fatty substances, which are mixed into an emulsion with water to produce a creamy texture; they are then less greasy on the skin. The other class of moisturiser contains substances such as urea and sorbitol that are similar to the natural emollients. They take up water that can then be held in the skin; however, this moisture is easily lost if drying conditions persist. Many moisturisers are a blend of the two types.

Wrinkles due to sun damage and ageing are caused by changes in the deeper layers of the skin and moisturisers cannot prevent or get rid of them, but they can improve the appearance of dry skin with wrinkles.

Cracked hands and feet

Cracked hands are a common problem if you work outside, especially in cold weather. In summer, wearing open sandals, thongs or going barefoot can lead to hard cracked skin around the margin of the heel and along the inner edge of the big toe and ball of the foot. Cracked hands and feet are aggravated by washing with soap.

Once the cracks have developed it’s hard to get rid of them. Rub in emulsifying ointment, urеа cream от soap-less cleaner (from the pharmacy) before showering or bathing. A tablespoonful of emulsifying ointment may be stirred into hot water and added to a bath. If the skin is very hard, the ointment may be rubbed in gently with a pumice stone. Apply a softening cream, such as 10 per cent glycerine in sorbolene, after drying.

The mainstay of treatment (and prevention) is to protect the feet with cotton socks and shoes, and the hand with gloves in winter and when gardening, preparing vegetables, and washing dishes or clothes. This can be quite difficult. There’s a limit to how much you can do in gloves. I find it impossible to wear gardening gloves to thin out or transplant seedlings – thin latex gloves are better. But there’s always a temptation to do ‘just a little bit’ with bare hands. These little bits add up to damaged skin and more cracks, so we must be unrelenting in wearing gloves and hand cream and using soap as little as possible, even after the cracks have healed.

A bush remedy used since the pioneering days is guaranteed to keep hands free from cracks. Mutton fat is rendered down by boiling with water until the water evaporates, and a teaspoon of glycerine is added to each cup of the hot fat to soften it. Use liberally before any outdoor work. Keep in the fridge in warm weather.

If there’s any sign of dermatitis, allergy or other inflammation on cracked hands or feet, see your doctor.

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