G ynecological L aparoscopy

1. Gynecological Laparoscopy

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

3. Contraindications Absolute Mechanical and paralytic ileus   • Large abdominal mass   • Generalized peritonitis  •  Irreducible external hernia  •  Cardiac failure  •  Recent myocardial infarction  •  Cardiac conduction defects   • Respiratory failure   • Severe obstructive airwaysdisease  •  Shock

4. Contraindications Relative •  Multiple abdominal incisions   • Abdominal wall sepsis   • Gross obesity  •  Hiatus hernia   • Ischaemic heart disease   • Blood dyscrasias and coagulopathies

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

6. Patient Preparation • Patient should be fasted and the bladder emptied. • Shaving is rarely necessary, but if it is it should be done immediately before the operation. • Bowel preparation is necessary if the surgery is close to or involving large bowel. • Antibiotic prophylaxis if vagina is opened or there are fluid instillations via the cervix. • Thromboembolism prophylaxis if indicated.

7. Insufflation of the Abdominal Cavity with CO2 • A vertical incision made deep inside the inferior aspect of the umbilicus, to have a nice scar resulting, deep fascia and parietal peritoneum meet. The Veress needle is inserted, initially almost at right angles (Figure), and advanced through the layers of the abdominal wall, feeling each layer as it is penetrated, for about 1cm before angling it forwards towards the anterior pelvis.

8. Entry Technique • Intraumbilical incision. Veress needle inserted vertically until peritoneum pierced and then angled towards the anterior pelvis. • Confirm peritoneal position of needle. • Insufflate until pressure of 15 mm Hg. • Insert primary trocar, withdrawing sharp point when peritoneum is pierced. • Steep Trendelenburg position once primary trocar has been correctly positioned. • Check all around umbilical area for any sign of damage to bowel. • If bowel has been damaged by the trocar it should be repaired immediately by a laparotomy.

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

10. Initial Inspection • Following insertion of the laparoscope the surgeon should perform an anatomic tour of the pelvis • The ovarian fossa and posterior surface of the ovary must also be inspected for evidence of endometriosis and subovarian adhesions

11. Insertion of the Second and Third Operative Trocars • Placement of Lateral Trocars • Positively identify the deep epigastric arteries lateral to the umbilical ligament, which are visualized from underneath the peritoneal surface • Insert lateral trocar under direct vision, vertically at first and then guiding it towards the anterior pelvic compartment.

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

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

14. Tubal sterilization • Laparoscopic view of the insertion of a Filshie clip

15. LAPAROSCOPIC FIMBRIOPLASTY • The principle of fimbrioplasty is to restore the original anatomy of the infundibulum by treating the phimosis. • Section of the adhesions reveals the tubal phimosis. A fine atraumatic forceps inserted via the contralateral trocar to the tube is then cautiously introduced into the phimosis. By gently opening it, the adhesions and bridles in the infundibulum can be observed and exposed

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

17. LAPAROSCOPIC SALPINGOSTOMY

18. Laparoscopic Ovarian Surgery General Principles • All of the general principles described for laparoscopic surgery are applied for ovarian surgery including: • Proper selection and preoperative counselling of patients. • General endotracheal anesthesia. • Urinary drainage with a Foley catheter. • Capability to perform immediate laparotomy if necessary. • Uterine manipulator placed inside the uterus. • Experience in operative laparoscopy.

19. Laparoscopic Ovarian Surgery • Technique of Ovarian Cystectomy • The ideal site is the antimesenteric portion of the ovary, away from the blood vessels of the hilus. • Figure- The cyst wall is grasped through the ovarian incision

20. The cyst wall is stripped out of the ovary Suture of the ovary after cystectomy. Laparoscopic Ovarian Surgery

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

22. Endometriosis • The endometrioma has typical features, which include: • Size not more than 12cm in diameter. • Adhesions to the pelvic sidewall and/or the posterior broad ligament. • 'Powder burns' and minute red or blue spots with adjacent puckering on the surface of the ovary. • Tarry, thick chocolate-colored fluid content. • In contrast with other ovarian cysts the walls of the small endometrioma do not usually collapse after opening the cyst, and in the absence of fibrosis have the pearl-white appearance of ovarian cortex

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

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

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

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

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

28. The myoma is isolated. Uterine closure (interrupted sutures Removal of the Myoma

29. CervicaI Cancer- lymphadenectomy • Laparoscopic view after opening of the paravesical space.

30. Identification and blunt dissection of the external iliac vein The obturator pedicle and the internal obturator muscle. CervicaI Cancer- lymphadenectomy

31. CervicaI Cancer- lymphadenectomy Final result

32. Complications of Laparoscopy • Peri-operative – pulmonary, thrombo-embolic, urinary • Anesthetic – particularly associated with long procedures and patients classed as poor anesthetic risk • Entering the peritoneal cavity – various needle injuries, trocar injuries, blood vessels potentially at risk, particularly the bowel, urinary tract and great vessels • Insertion of lateral ports – injury to epigastric vessels should largely be avoided by direct visualization internally, and lateral ports should be inserted carefully under direct vision • Electrosurgical injuries – transmitted heat, open circuit, faulty insulation, capacitative coupling; • Laser injuries (transmitted heat, overshooting of target) – • Port site complications (hematoma, infection and hernia).