Gynecological
Laparoscopy
1
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.
2
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 airways disease
Shock
3
Contraindications
Relative
Multiple abdominal incisions
Abdominal wall sepsis
Gross obesity
Hiatus hernia
Ischaemic heart disease
Blood dyscrasias and coagulopathies
4
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.
5
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.
6
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.
7
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.
8
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.
9
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
10
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.
11
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).
12
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
13
Tubal sterilization
Laparoscopic view
of the insertion of
a Filshie clip
14
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
15
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
16
LAPAROSCOPIC
SALPINGOSTOMY
17
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.
18
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 19
Laparoscopic Ovarian
Surgery
The cyst wall is Suture of the ovary
stripped out of the after cystectomy.
ovary
20
Laparoscopic Oophorectomy
Laparoscopic
oophorectomy or
salpingo-
oophorectomy are
preferred when the
cyst fills the ovary
and in
postmenopausal
women.
21
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
22
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.
23
Endometriosis
The inside wall is
ovarian cortex,
which has a
slightly pigmented
appearance.
24
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
25
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.
26
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.
27
Removal of the Myoma
The myoma is Uterine closure
isolated. (interrupted
sutures
28
CervicaI Cancer-
lymphadenectomy
Laparoscopic view
after opening of
the paravesical
space.
29
CervicaI Cancer-
lymphadenectomy
Identification and The obturator
blunt dissection of pedicle and the
the external iliac internal obturator
vein muscle.
30
CervicaI Cancer-
lymphadenectomy
Final result
31
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). 32
