Diagnostic laparoscopy
A look inside without treatment. We do very few of these, because a careful history usually makes the diagnosis.
The idea that endometriosis can only be diagnosed surgically is outdated, and it has cost a great many patients years and operations. A thorough history and examination usually reaches a clinical diagnosis. When we do operate, the intention is to treat what we find in the same sitting.
Where the idea comes from
A lot of people have heard that the only way to diagnose endometriosis is to look inside surgically, take samples, and find something that looks like it under a microscope. That is what the textbooks said, and it is why the phrase is so familiar.
The difficulty is that this is an operation. Tissue is disturbed, there is inflammation afterwards, and you have to recover from it. That is a considerable amount to ask of someone in order to be told something.
Why you probably don't need one
For most doctors who specialize in endometriosis, it is now a matter of talking to you for a while and working out what is actually going on. Reaching a diagnosis of endometriosis or adenomyosis is often straightforward.
The part that takes time is everything around it: where the disease is, what will make it better, which medications or physical therapy are needed, whether further imaging would help, and whether a complicated case needs another surgeon involved.
For many patients we can reach the diagnosis in a few minutes. It is all the rest of it that takes the hour.
When it is the right thing to do
There is still a role for it, and it matters that this is said clearly rather than argued away.
The situation is usually this: imaging is not going to show anything, or has not shown anything in the past, and the symptoms are either unusual or so subtle that a very good history still does not settle it.
The commonest version by far is unexplained infertility. Someone has had imaging, labs and tests such as an HSG to check the fallopian tubes, and everything looks fine. Something may well be wrong, but nothing is saying what, and there are few symptoms to go on. It may be endometriosis presenting quietly, and establishing that changes the whole path forward.
It is closer to an imaging test than it sounds
Thought about honestly, a diagnostic laparoscopy in that situation is a form of imaging. It costs about what an MRI costs. The surgical and anesthetic risks are very small, and broadly comparable to the risk of reacting to the contrast dye used for an MRI.
It has one advantage no scan has. If we see something, we may be able to fix it there and then.
And it has one other. Ultrasound and MRI have improved a great deal, but we are still interpreting an unclear image and making our best judgment about what we are looking at. Sometimes that judgment is good. Sometimes several things would look the same. A laparoscopy is not an interpretation. It shows what is actually there.
If you have been told you need one
It is usually worth speaking to an endometriosis surgeon first, to see whether the diagnosis can be reached without an operation. Mostly that is a matter of speed: it is quicker, and it comes with the context and the plan attached.
If you have already had one and were told it was normal
This happens, and it is worth understanding why rather than being angry about it.
Endometriosis has around twenty different appearances and a lot of them are subtle. Recognizing the quiet ones is a matter of how often you look at them, which is a question of exposure rather than of care. A surgeon following the textbook, doing the operation it recommended, can look at genuinely abnormal tissue and reasonably conclude that it looks unremarkable.
So patients arrive having been told everything was fine, still feeling exactly as unwell as before, and by then doubting themselves. If you have the photographs from that operation, bring them. We can often see the disease in them, and tell you what we are seeing.
That makes a previous laparoscopy something other than a waste. It is information, and it moves you forward.
What we would ask you to agree to beforehand
There is a real ambiguity in this operation, and it is worth being straightforward about it. The advantage of looking is that if we find something we may be able to treat it. The complication is that treating it properly is sometimes quick and sometimes takes hours.
So the conversation we have beforehand is this. If we find something we can fix, may we fix it, within reason. If it will be quick, if the recovery will be reasonable, and if the risk is much the same as the operation you already agreed to, then it is fair to get on and help you.
If what we find is several hours of work around major structures, carrying more risk and a much longer recovery, that is not a decision to take while you are asleep. It changes your life for a period and you are entitled to weigh that yourself. In that case we stop, and we sit down with you afterwards and go through all of it, and you decide.
Where imaging actually fits
Most of the time the diagnosis comes from the history, so scans are not doing the diagnosing. They are doing something else, and it is worth knowing what.
The first is looking for endometriomas, because they usually make an operation longer. Not only because of the cyst itself, but because their presence generally means more disease and more scarring elsewhere.
The second is when the symptoms suggest disease involving the bladder or the bowel. That may mean a colorectal surgeon or a urologist needs to be in the room, and an MRI beforehand tells us whether the operation has to be arranged differently. That is largely our problem rather than yours, but it does change what we need to explain to you about what the surgery would involve.
So no, not everyone needs a complicated MRI as a substitute for a laparoscopy. We reach the diagnosis in clinic, and use imaging where it adds something the history cannot.