More than 20 00 surgery for big fibroid are carried out in the India each year. The decision when and whether to operate requires mature judgement. Fibroid surgery is technically difficult, demanding a high level of surgical skill. It is learnt only by lengthy apprenticeship. The after-care is equally important. The personal supervision of the surgeon who leads a coordinated team in operation theatre will ensure the best results. It is inevitable and unfortunate that mistakes will occasionally be made and only careful attention to detail in the pre-operative assessment, meticulous surgical care and supervised post-operative management will ensure consistently good results. TheLaparoscopic surgeon needs to remain up-to-date, be disciplined with a systematic and careful approach and lead a coordinated team to maintain the highest standards.

What is a patient entitled to expect at the present time and what are the standards that are recognized by the general body of Laparoscopic surgeons today?

Laparoscopic surgery for big Fibroid offers the patient a life-threatening procedure for a non-life threatening condition. There are always potential surgical complications, and although the benefits of surgery can be considerable, all reasonable conservative approaches should have been attempted first. When to operate is a difficult decision demanding fine judgement. There is a spectrum of opinion amongst surgeons for most Fibroid conditions. Some prefer a radical approach offering removal of uterus in order to hasten recovery of normal function. Others adopt a more conservative attitude in the form of only removal of Fibroid & Preserving frtility potential in future in child bearing age group.. In the long term, most Fibroid conditions have a good pregnancy outcome in future.

Patients are sometimes distressed because they believe that there has been unnecessary delay in referral to a Gynaecl unit. They may have suffered for many years with menogghagia, Infertility, pain in abdomen until finally they find an expert who is able to offer them successful Laparoscopic  surgery for Fibroid. There is always a body of reputable clinicians who would not recommend surgery for Fibroid or they may advise removal of uterus. It is reasonable to operate but it is also reasonable to encourage patients to avoid surgery.

A more frequent claim for potential medical negligence is an unacceptable delay in a patient who has a pressure symptomps.

A more frequent claim for potential medical negligence is an unacceptable delay in a patient who has a pressure symptomps.

The diagnosis of Fibroid is made from the history and the examination. Investigations are supplementary, usually to identify the level at which surgery will be required.  USG, MRI & C.T. scan may help in doing Fibroid mapping for locating different sites of Fibroids before operation. In doubtful case one should advise MRI to exclude the possibility of Adenomyosis of Uterus. When MRI is unavailable, a CT scan is the next best imaging modality

It may seem obvious that surgery should be offered only when it is in the patient's best interest. However, it is unusual to have an absolute indication for surgery on the Fibroid. As fibroid may regress after menopause.

At the present time, there are few full-time Laparoscopic surgeons in the India. Most of the Fibroid surgery is carried out by Gynaecologists who besides having a general practice take an interest in the Fibroid. In previous years, most senior Gynaecologists would do an occasional Fibroid operation by laparotomy but it is now becoming an acceptable practice for Laparoscopic surgeon to preserve Uterus & child bearing potential . This means that the majority of Fibroid surgery for big Fibroid is carried out by a Gynaecologist doing less than 20 Fibroid operations per year. There is no agreed minimum limit but competence is maintained by continued surgical practice.

There are occasions when a surgeon can predict technical difficulties. So good set up which includes Morcellator, harmonic scalpel, Vessel sealing device, Multipara monitoring with continued monitoring of EtCO2 during operation is mandatory.

For example, obesity will add to the operative difficulties and repeat Fibroidl surgery & associated Endometriosis & adhesions are more complicated than the first procedure. With such problems a good surgeon will refer to one of his more experienced colleagues. Failure to do so, and particularly failure to inform the patient of potential hazards, is poor practice.

The surgeon and the surgical team need to be vigilant in the post-operative period. As soon as the patient is awake from the anaesthetic it is important to watch for hypothermia, O2 & EtCO2 saturation and smoth reversal.

It is a difficult decision to know whether or not to operate again in the post-operative period. The complications of the second operation are greater than the first, but provided the indications are correct there can be a considerable bonus in performing this procedure. The inexperienced Laparoscopic surgeon should seek a second opinion before embarking upon repeat surgery.

One of the most common causes of patient dissatisfaction is failure to receive sufficient information about surgery and its risks. At the present time, Laparoscopic  surgeons would agree that every patient should be given information about risks and benefits. In broad terms patients should be informed about the benefits of Minimal Assess surgery & faster recovery after operation.

The patient should also be told in general terms, the risk of converting to laparotomy for the safety of the patient during operation, ofcourse the possibilities will be less.

In spite of these many pitfalls most patients do well. Fortunately those patients who have careful pre-operative selection, competent surgery and good post-operative management are significantly helped by their operation, and provide they are aware of potential risks, patients usually accept that the surgeon and the surgical team have done their best in a very difficult area of medical care.