11

GGynecological ynecological LLaparoscopyaparoscopy

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IntroductionIntroduction During the past few years laparoscopy has During the past few years laparoscopy has

become one of the most frequently performed become one of the most frequently performed operations in gynecological departments. Initially operations in gynecological departments. Initially it was used for occlusion of the fallopian tube as it was used for occlusion of the fallopian tube as a simple method of female sterilization and for a simple method of female sterilization and for the diagnosis of pelvic pain and infertility, but the diagnosis of pelvic pain and infertility, but increasingly it is being used for operative increasingly it is being used for operative procedures, which are described in detail in procedures, which are described in detail in different sections of this book. Before embarking different sections of this book. Before embarking on such procedures it is essential that each on such procedures it is essential that each surgeon develops a safe technique for surgeon develops a safe technique for insufflating the abdomen and inserting the insufflating the abdomen and inserting the laparoscope and various ancillary probes and laparoscope and various ancillary probes and instruments. instruments.

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ContraindicationsContraindications AbsoluteAbsolute    

Mechanical and paralytic ileus  Mechanical and paralytic ileus  Large abdominal mass  Large abdominal mass  Generalized peritonitis Generalized peritonitis    Irreducible external hernia Irreducible external hernia    Cardiac failure Cardiac failure    Recent myocardial infarction Recent myocardial infarction    Cardiac conduction defects  Cardiac conduction defects  Respiratory failure  Respiratory failure  Severe obstructive airwaysSevere obstructive airways disease disease    ShockShock

44

ContraindicationsContraindications

RelativeRelative     Multiple abdominal incisions  Multiple abdominal incisions   Abdominal wall sepsis  Abdominal wall sepsis   Gross obesity Gross obesity    Hiatus hernia  Hiatus hernia   Ischaemic heart disease  Ischaemic heart disease   Blood dyscrasias and coagulopathiesBlood dyscrasias and coagulopathies

55

Anesthetic ConsiderationsAnesthetic Considerations

Patients are usually admitted on the day of Patients are usually admitted on the day of operation, they are given oral operation, they are given oral benzodiazepine. Intravenous induction of benzodiazepine. Intravenous induction of anesthesia is achieved with propofol and anesthesia is achieved with propofol and muscle relaxation with atracurium. muscle relaxation with atracurium. Endotracheal intubation is used for all Endotracheal intubation is used for all patients since we believe that a laryngeal patients since we believe that a laryngeal mask is inherently unsafe, particularly for mask is inherently unsafe, particularly for prolonged procedures. Analgesia is prolonged procedures. Analgesia is achieved with fentanyl and achieved with fentanyl and metoclopramide is employed as an metoclopramide is employed as an antiemetic.antiemetic.

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Patient PreparationPatient Preparation Patient should be fasted and the bladder emptied. Patient should be fasted and the bladder emptied.

Shaving is rarely necessary, but if it is it should Shaving is rarely necessary, but if it is it should be done immediately before the operation. be done immediately before the operation.

Bowel preparation is necessary if the surgery is Bowel preparation is necessary if the surgery is close to or involving large bowel. close to or involving large bowel.

Antibiotic prophylaxis if vagina is opened or there Antibiotic prophylaxis if vagina is opened or there are fluid instillations via the cervix. are fluid instillations via the cervix.

Thromboembolism prophylaxis if indicated. Thromboembolism prophylaxis if indicated.

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Insufflation of the Abdominal Insufflation of the Abdominal Cavity with CO2Cavity with CO2

A vertical incision made A vertical incision made deep inside the inferior deep inside the inferior aspect of the umbilicus, aspect of the umbilicus, to to have a nice have a nice scar resultingscar resulting, , deep fascia and parietal deep fascia and parietal peritoneum meet. The peritoneum meet. The Veress needle is inserted, Veress needle is inserted, initially almost at right initially almost at right angles (Figure), and angles (Figure), and advanced through the advanced through the layers of the abdominal layers of the abdominal wall, feeling each layer as wall, feeling each layer as it is penetrated, for about it is penetrated, for about 1cm before angling it 1cm before angling it forwards towards the forwards towards the anterior pelvis.anterior pelvis.

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Entry TechniqueEntry Technique Intraumbilical incision. Veress needle inserted Intraumbilical incision. Veress needle inserted

vertically until peritoneum pierced and then vertically until peritoneum pierced and then angled towards the anterior pelvis. angled towards the anterior pelvis.

Confirm peritoneal position of needle. Confirm peritoneal position of needle. Insufflate until pressure of 1Insufflate until pressure of 15 5 mm Hg. mm Hg. Insert primary trocar, withdrawing sharp point Insert primary trocar, withdrawing sharp point

when peritoneum is pierced. when peritoneum is pierced. Steep Trendelenburg position once primary trocar Steep Trendelenburg position once primary trocar

has been correctly positioned. has been correctly positioned. Check all around umbilical area for any sign of Check all around umbilical area for any sign of

damage to bowel. damage to bowel. If bowel has been damaged by the trocar it If bowel has been damaged by the trocar it

should be repaired immediately by a laparotomy. should be repaired immediately by a laparotomy.

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Insertion of the Umbilical Trocar Insertion of the Umbilical Trocar and Laparoscopeand Laparoscope

Once inserted, the Once inserted, the trocar is angled trocar is angled almost horizontally almost horizontally and pushed and pushed forwards towards forwards towards the anterior pelvis, the anterior pelvis, taking care to taking care to avoid the major avoid the major vessels as they vessels as they course over the course over the sacral promontory. sacral promontory.

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Initial InspectionInitial Inspection Following insertion of Following insertion of

the laparoscope the the laparoscope the surgeon should surgeon should perform an anatomic perform an anatomic tour of the pelvistour of the pelvis

The ovarian fossa and The ovarian fossa and posterior surface of posterior surface of the ovary must also be the ovary must also be inspected for evidence inspected for evidence of endometriosis and of endometriosis and subovarian adhesions subovarian adhesions

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Insertion of the Second and Insertion of the Second and Third Operative TrocarsThird Operative Trocars

Placement of Placement of Lateral TrocarsLateral Trocars

Positively identify the Positively identify the deep epigastric deep epigastric arteries lateral to the arteries lateral to the umbilical ligament, umbilical ligament, which are visualized which are visualized from underneath the from underneath the peritoneal surface peritoneal surface

Insert lateral trocar Insert lateral trocar under direct vision, under direct vision, vertically at first and vertically at first and then guiding it then guiding it towards the anterior towards the anterior pelvic compartment. pelvic compartment.

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Diagnostic laparoscopyDiagnostic laparoscopy Frequently, the physician needs to assess the Frequently, the physician needs to assess the

pelvis for acute or chronic pain, ectopic pelvis for acute or chronic pain, ectopic pregnancy, endometriosis, adnexal torsion, or pregnancy, endometriosis, adnexal torsion, or other pelvic pathology. Determination of tubal other pelvic pathology. Determination of tubal patency may also be an issue. Usually, the patency may also be an issue. Usually, the camera lens is placed infraumbilically and a camera lens is placed infraumbilically and a second port is placed suprapubically to probe second port is placed suprapubically to probe systematically and observe pelvic organs. If systematically and observe pelvic organs. If needed, a biopsy specimen can be obtained to needed, a biopsy specimen can be obtained to aid in the diagnosis of endometriosis or aid in the diagnosis of endometriosis or malignancy. If tubal patency is a concern, use of malignancy. If tubal patency is a concern, use of a uterine manipulator with a cannula allows a a uterine manipulator with a cannula allows a dilute dye to be injected transcervically dilute dye to be injected transcervically (chromopertubation). (chromopertubation).

1313

Tubal sterilizationTubal sterilization Bipolar electrosurgery, Bipolar electrosurgery,

clips, or silastic bands clips, or silastic bands may be used to may be used to occlude the tubes at occlude the tubes at the mid-isthmic the mid-isthmic portion, approximately portion, approximately 3 cm from the cornua. 3 cm from the cornua. Bipolar surgery Bipolar surgery desiccates the tube desiccates the tube with 3 adjacent passes with 3 adjacent passes to occlude to occlude approximately 2 cm of approximately 2 cm of tube. tube. Laparoscopic view of a falopian ring

in place

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Tubal sterilizationTubal sterilization

Laparoscopic view Laparoscopic view of the insertion of a of the insertion of a Filshie clip Filshie clip

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LAPAROSCOPIC FIMBRIOPLASTYLAPAROSCOPIC FIMBRIOPLASTY

The principle of fimbrioplasty is to restore The principle of fimbrioplasty is to restore the original anatomy of the infundibulum the original anatomy of the infundibulum by treating the phimosis.by treating the phimosis.

Section of the adhesions reveals the tubal Section of the adhesions reveals the tubal phimosis. A fine atraumatic forceps phimosis. A fine atraumatic forceps inserted via the contralateral trocar to the inserted via the contralateral trocar to the tube is then cautiously introduced into the tube is then cautiously introduced into the phimosis. By gently opening it, the phimosis. By gently opening it, the adhesions and bridles in the infundibulum adhesions and bridles in the infundibulum can be observed and exposed can be observed and exposed

1616

LAPAROSCOPIC LAPAROSCOPIC SALPINGOSTOMYSALPINGOSTOMY

This technique This technique consists of creating a consists of creating a new ostium in cases new ostium in cases where the distal part where the distal part of the tube is totally of the tube is totally occluded occluded (hydrosalpinx). The (hydrosalpinx). The operation comprises operation comprises two phases: incision two phases: incision and eversion and eversion

1717

LAPAROSCOPIC LAPAROSCOPIC SALPINGOSTOMYSALPINGOSTOMY

1818

Laparoscopic Ovarian SurgeryLaparoscopic Ovarian Surgery General PrinciplesGeneral Principles All of the general principles described for All of the general principles described for

laparoscopic surgery are applied for ovarian laparoscopic surgery are applied for ovarian surgery including:surgery including:

Proper selection and preoperative counselling of Proper selection and preoperative counselling of patients. patients.

General endotracheal anesthesia. General endotracheal anesthesia. Urinary drainage with a Foley catheter. Urinary drainage with a Foley catheter. Capability to perform immediate laparotomy if Capability to perform immediate laparotomy if

necessary. necessary. Uterine manipulator placed inside the uterus. Uterine manipulator placed inside the uterus. Experience in operative laparoscopy. Experience in operative laparoscopy.

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Laparoscopic Ovarian SurgeryLaparoscopic Ovarian Surgery

Technique of Ovarian Technique of Ovarian CystectomyCystectomy

The ideal site is the The ideal site is the antimesenteric antimesenteric portion of the ovary, portion of the ovary, away from the blood away from the blood vessels of the hilus.vessels of the hilus.

FigureFigure-- The cyst wall The cyst wall is grasped through is grasped through the ovarian incisionthe ovarian incision

2020

Laparoscopic Ovarian Laparoscopic Ovarian SurgerySurgery

The cyst wall is The cyst wall is stripped out of the stripped out of the ovaryovary

Suture of the ovary Suture of the ovary after cystectomy.after cystectomy.

2121

Laparoscopic Laparoscopic OophorectomyOophorectomy

Laparoscopic Laparoscopic oophorectomy or oophorectomy or salpingo-salpingo-oophorectomy are oophorectomy are preferred when the preferred when the cyst fills the ovary cyst fills the ovary and in and in postmenopausal postmenopausal women. women.

2222

EndometriosisEndometriosis The endometrioma has typical features, The endometrioma has typical features,

which iwhich include:nclude:– Size not more than 12cm in diameter. Size not more than 12cm in diameter. – Adhesions to the pelvic sidewall and/or the Adhesions to the pelvic sidewall and/or the

posterior broad ligament. posterior broad ligament. – 'Powder burns' and minute red or blue spots 'Powder burns' and minute red or blue spots

with adjacent puckering on the surface of the with adjacent puckering on the surface of the ovary. ovary.

– Tarry, thick chocolate-colored fluid content. Tarry, thick chocolate-colored fluid content. – In contrast with other ovarian cysts the walls of In contrast with other ovarian cysts the walls of

the small endometrioma do not usually the small endometrioma do not usually collapse after opening the cyst, and in the collapse after opening the cyst, and in the absence of fibrosis have the pearl-white absence of fibrosis have the pearl-white appearance of ovarian cortex appearance of ovarian cortex

2323

EndometriosisEndometriosis A typical small A typical small

endometrioma with endometrioma with the puckered scar the puckered scar closing the closing the invagination of the invagination of the ovarian cortex. The ovarian cortex. The ovary is rotated and ovary is rotated and manipulated to rest on manipulated to rest on the anterior side of the anterior side of the uterus exposing the uterus exposing the anterior face. the anterior face.

2424

EndometriosisEndometriosis

The inside wall is The inside wall is ovarian cortex, ovarian cortex, which has a slightly which has a slightly pigmented pigmented appearance.appearance.

2525

Treatment of ectopic pregnancyTreatment of ectopic pregnancy

Laparoscopy is the surgery of choice Laparoscopy is the surgery of choice for most ectopic pregnancies. A for most ectopic pregnancies. A salpingostomy or salpingectomy may salpingostomy or salpingectomy may be used to remove the embryo and be used to remove the embryo and gestational sac. Auxiliary gestational sac. Auxiliary instruments, such as pretied loops or instruments, such as pretied loops or stapling devices, may be particularly stapling devices, may be particularly well suited for the salpingectomy, well suited for the salpingectomy, although any of the power although any of the power instruments work equally well instruments work equally well

2626

Lysis of adhesionLysis of adhesion

Adhesions may form due to prior infection, Adhesions may form due to prior infection, such as a ruptured appendix or pelvic such as a ruptured appendix or pelvic inflammatory disease (PID), endometriosis, inflammatory disease (PID), endometriosis, or previous surgery. Adhesions may or previous surgery. Adhesions may contribute to infertility or chronic pelvic contribute to infertility or chronic pelvic pain. Adhesions may be lysed by blunt or pain. Adhesions may be lysed by blunt or sharp dissection. Aquadissection may aid sharp dissection. Aquadissection may aid in the development of planes prior to in the development of planes prior to lysing. lysing.

2727

Removal of the MyomaRemoval of the Myoma The myomas must The myomas must

always be extracted to always be extracted to avoid peritoneal avoid peritoneal reimplantation, which reimplantation, which causes postoperative causes postoperative pain, and also to carry pain, and also to carry out histology. The out histology. The myoma may be myoma may be removed through the removed through the suprapubic puncture suprapubic puncture site after enlargement site after enlargement of the incision (20mm) of the incision (20mm) with a one- or two-with a one- or two-tooth tenaculum. tooth tenaculum.

2828

Removal of the MyomaRemoval of the Myoma

The myoma is The myoma is isolated.isolated.

Uterine closure Uterine closure (interrupted (interrupted sutures sutures

2929

CervicaI Cancer- CervicaI Cancer- lymphadenectomylymphadenectomy

Laparoscopic view Laparoscopic view after opening of after opening of the paravesical the paravesical space.space.

3030

CervicaI Cancer- CervicaI Cancer- lymphadenectomylymphadenectomy

Identification and Identification and blunt dissection of blunt dissection of the external iliac the external iliac vein vein

TThe obturator he obturator pedicle and the pedicle and the internal obturator internal obturator muscle.muscle.

3131

CervicaI Cancer- CervicaI Cancer- lymphadenectomylymphadenectomy

Final result

3232

Complications of LaparoscopyComplications of Laparoscopy

Peri-operative – pulmonary, thrombo-embolic, urinary Peri-operative – pulmonary, thrombo-embolic, urinary Anesthetic – particularly associated with long Anesthetic – particularly associated with long

procedures and patients classed as poor anesthetic risk procedures and patients classed as poor anesthetic risk Entering the peritoneal cavity – various needle injuries, Entering the peritoneal cavity – various needle injuries,

trocar injuriestrocar injuries,, blood vessels potentially at risk, blood vessels potentially at risk, particularly the bowel, urinary tract and great vessels particularly the bowel, urinary tract and great vessels

Insertion of lateral ports – injury to epigastric vessels Insertion of lateral ports – injury to epigastric vessels should largely be avoided by direct visualization should largely be avoided by direct visualization internally, and lateral ports should be inserted carefully internally, and lateral ports should be inserted carefully under direct vision under direct vision

Electrosurgical injuries – transmitted heat, open circuit, Electrosurgical injuries – transmitted heat, open circuit, faulty insulation, capacitative coupling; faulty insulation, capacitative coupling;

Laser injuries (transmitted heat, overshooting of target) Laser injuries (transmitted heat, overshooting of target) ––

Port site complications (hematoma, infection and Port site complications (hematoma, infection and hernia). hernia).