Gynecologic Laparoscopy

During the last 50 years, laparoscopy has evolved from a limited gynecologic surgical procedure used only for diagnosis and tubal ligations to a major surgical tool used for a multitude of gynecologic and nongynecologic indications. Today, laparoscopy is one of the most common surgical procedures performed in many parts of the world.

For many gynecologic procedures, such as removal of an ectopic pregnancy, treatment of endometriosis, ovarian cystectomy, and hysterectomy, laparoscopy has become the treatment of choice. Compared with laparotomy, multiple studies have shown laparoscopy to be safer, to be less expensive, and to have a shorter recovery time. The advantages of the laparoscopic approach for other procedures, including myomectomy, sacral colpopexy, and the staging and treatment of gynecologic cancers, continue to broaden.[1]

Laparoscopic techniques have also continued to evolve, primarily as a result of technological advances. In addition to better cameras and instruments, technology has resulted in the development of robotically assisted laparoscopy, and more recently single-port laparoscopy. The relative advantages and disadvantages of these new approaches compared with traditional laparoscopy, as well as their indications, continue to be studied.

Laparoscopy was first performed in dogs in the early 1900s by Dr. Georg Kelling, a German surgeon, who called his procedure koelioskopie.[2] While experimenting with the use of air for pneumoperitoneum to stop intra-abdominal bleeding, he introduced a cystoscope into the abdomen to view the effects of increased pressure on abdominal organs.

Dr. Hans Christian Jacobaeus, a Swedish surgeon, was the first to publish a description of laparothorakoskopie in humans in 1910.[2] He used air pneumoperitoneum and a cystoscope to evaluate the peritoneal cavity of tuberculosis patients with ascites. Shortly thereafter, Dr. Bertram M. Bernheim of the Johns Hopkins Hospital, reported a series of the first human laparoscopy performed in the United States, which he called organoscopy.

Early in the 20th century, diagnostic laparoscopy was used by a limited number of general surgeons in place of diagnostic laparotomy, but had a substantial complication rate.[3] Throughout the 1920s and 1930s, advocates of the procedure continued to develop improved laparoscopic equipment, such as pyramidal trocars for port introduction and lenses with a wider angle of view than the 90° afforded by the cystoscope. During this period, Dr. Janos Veress, a Hungarian internist, developed a spring-loaded needle with an inner stylet that automatically converted the sharp cutting edge to a rounded end. The Veress needle continues to be used today to create a pneumoperitoneum.

A major step forward in the development of laparoscopy was the development of a safer laparoscopic lighting system in the 1950s. Up until that time, intra-abdominal light was produced by a small electric light bulb at the distal tip of the laparoscope analogous to a bronchoscope. The use of a quartz light rod to transmit light from an external source to the tip of the laparoscope increased brightness and decreased the risk of intra-abdominal burns. This was soon followed by the application of fiber optic technology still used in modern laparoscopes.

Dr. Raoul Palmer, a French gynecologist who specialized in infertility, was an early pioneer in the development of laparoscopy in the mid 20th century. In addition to advocating monitoring of intra-abdominal pressure, he expanded the therapeutic use of laparoscopy for such tasks as intra-abdominal electrocoagulation of bleeding sites, puncture of ovarian cysts, and lysis of pelvic adhesions. In 1961, Dr. Palmer described the first laparoscopic retrieval of oocytes, and in 1974 he described the point 3 cm below the last rib in the left mid-clavicular line. Palmer's point is often used today for left upper quadrant laparoscopic entry.[4]

Dr. Kurt Semm, a German gynecologist who specialized in infertility, was perhaps the most influential early advocate of modern operative laparoscopy.[5] In the 1960s and 1970s, Dr. Semm invented the automatic insufflator, and hundreds of laparoscopic instruments, including a thermocoagulator, loop ligature, and devices for extracorporeal and intracorporeal endoscopic knot tying. He was one of the first proponents of video monitoring for laparoscopy, using a series of lenses and mirrors in an articulated arm to connect the laparoscope to a ceiling-mounted video camera. He developed laparoscopic techniques for ovarian cystectomy, myomectomy, treatment of ectopic pregnancy, appendectomy and hysterectomy. Despite the work of Dr. Semm and other remarkable pioneers, gynecologic laparoscopy continued to be used primarily for diagnosis and tubal ligations into the 1980s.

A major breakthrough came with the introduction of the solid state video camera for laparoscopy in 1982. With the widespread application of these compact cameras, both laparoscopist and assistants could simultaneously view the operative field on a video screen. By the end of the decade, video-laparoscopy had become standard and operative laparoscopy became widely accepted as a safe and effective surgical approach. Today, operative laparoscopy is routinely used by gynecologists to perform a multitude of procedures, including hysterectomies and incontinence procedures, and for the diagnosis and treatment of gynecologic malignancies.

In recent years, 3 innovations that have been introduced or reintroduced to the field of laparoscopy: 1) robotic surgery[1] , 2) natural orifice transluminal surgery[6] , and 3) single incision laparoscopic surgery (SILS). All 3 have their advantages and disadvantages compared to traditional laparoscopy. Of these 3 developing technologies, robotic surgery is having the largest impact on clinical care.

Laparoscopy is a hybrid surgical approach that shares characteristics of both minor and major surgery. To patients, laparoscopic procedures often seem to be minor surgery because of the small incisions, relatively small amount of postoperative pain, and short convalescent period. When a laparoscopic procedure involves minimal intra-abdominal surgery (eg, diagnostic laparoscopy, tubal fulguration), both postoperative discomfort and the risk of complications may more closely resemble a minor procedure than a major procedure.

At its essence, laparoscopy remains an intra-abdominal procedure. Therefore, it shares all intraoperative and postoperative risks of laparotomy, including infection, bleeding and injury to adjacent intra-abdominal structures. When major intra-abdominal procedures are performed laparoscopically (eg, hysterectomy), the resultant postoperative pain and morbidity are still significant. However, because a large abdominal incision is unnecessary, the postoperative pain and morbidity are always less significant than similar major surgery performed by laparotomy.

Laparoscopic procedures have unique risks, which are related to methods used for the placement of abdominal wall ports and to the pneumoperitoneum required for laparoscopy. The use of energy within the abdominal cavity likewise introduces risk. These risks include injury to bowel, bladder, or major blood vessels and intravascular insufflation. In addition, increased intra-abdominal pressures associated with laparoscopy increase anesthesia-related risks such as aspiration and increased difficulty ventilating the patient. Although the risk of blood loss is relatively low for most procedures, potentially massive blood loss may occur and is complicated by the fact that control of blood loss may be delayed by the time taken to perform an emergency laparotomy.

United States statistics

Laparoscopy is one of the most common surgical procedures performed in the United States today. Approximately half of the 700,000 bilateral tubal sterilizations performed annually in the United States are performed laparoscopically. In addition to diagnostic laparoscopy, operative endoscopy is used to perform common procedures, including removal of ectopic pregnancies, treatment of endometriosis, and lysis of pelvic adhesions. Almost two thirds of the 600,000 hysterectomies performed annually in the United States are now performed with the aid of a laparoscope, with or without robotic assistance. Although the ideal role of laparoscopy in gynecologic surgery continues to be defined, it has become a standard approach for a large number of gynecologic procedures.

Diagnostic laparoscopy

Frequently, the physician needs to assess the pelvis for acute or chronic pain, ectopic pregnancy, endometriosis, adnexal torsion, or other pelvic pathology.[7, 8] Determination of tubal patency may also be an issue.[7]  Diagnostic laparoscopy can play an important role in the evaluation of unexplained infertility.[9]

Usually, a primary port for the laparoscope (also known as the "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).

Diagnostic laparoscopy is usually performed under general anesthesia, with endotracheal intubation to minimize the risk of aspiration. However, if the pressure used for peritoneal insufflation is limited, laparoscopy can be performed under conscious sedation.

Tubal sterilization

Trocar placement is similar to diagnostic laparoscopy. Bipolar electrosurgery, clips, or silastic bands may be used to occlude the tubes at the mid-isthmic portion, approximately 2-3 cm from the cornua.[10] Bipolar surgery desiccates the tube with 3 adjacent passes to occlude approximately 2 cm of tube. The auditory tone now available to verify total resistance has improved the efficacy of bipolar cautery. Pregnancy rates vary by patient age, ranging from 1-3% after 10 years.

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. The chances of pregnancy after lysis of adhesions is relatively low for most patients, and this type of surgery has been largely supplanted by in vitro fertilization and embryo transfer. Likewise, adhesiolysis is often ineffective in curing chronic pelvic pain, in part because most adhesions rapidly reform after surgery.

Adhesions may be lysed by blunt or sharp dissection. Aquadissection may aid in the development of planes prior to lysing. Any of the power instruments may be used for cutting and coagulation (see Power instruments). Although in experienced hands unipolar electrosurgery is safe, gynecologist use of unipolar electrosurgery, such as with the fine unipolar needle, is generally recommended to be limited to adhesions 1-2 cm from the ureter and bowel due to the unpredictable nature of current arcing. Other power techniques may be safer choices for adhesiolysis near the bowel.

Adhesions may reform after lysis, although this can be reduced with good hemostasis and minimal use of electrocautery.[11] Recently, a 4% icodextrin solution has been shown to decrease adhesion reformation in a controlled trial. Unfortunately, the results of laparoscopic lysis of adhesions have been disappointing in terms of improving pain relief or future fertility.

Treatment of endometriosis

Laparoscopy is the most common procedure used to diagnose and treat endometriosis.[12] Endometriotic lesions may be resected or ablated using any of the power instruments (see Power instruments). Both of these techniques have shown to improve fertility and decrease pelvic pain in multiple well-designed studies. A systematic review by Franck et al reported improvements in the quality of sexual life following laparoscopic surgery for endometriosis.[13]

Treatment of ectopic pregnancy

Laparoscopy is the surgical approach of choice for most ectopic pregnancies.[14, 15] A salpingostomy or salpingectomy may be performed to remove the embryo and gestational sac. Although auxiliary instruments (eg, pretied loops, stapling devices) can be used for the salpingectomy, most commonly, a power instrument (eg, bipolar electrosurgery, ultrasonic scalpel) is used for these procedures (see Power instruments).

Ovarian cystectomy

If a simple ovarian cyst sized 6 cm or larger persists for 2 or more cycles in a premenopausal, nonpregnant female, a cystectomy is indicated. This can be achieved using laparoscopy or laparotomy depending on the cyst size and the likelihood of the presence of malignancy.

The cyst can be removed by a number of techniques.[16, 17] If the cyst is complex, rule out malignancy by looking for signs of ascites; excrescences on the ovary; or implantations on the peritoneal, liver, or diaphragmatic surfaces. If malignancy is not apparent, carefully dissect the cyst, making an effort to remove the cyst intact. A bag may be used to transfer the cyst out of the peritoneal cavity through a 10-mm port, draining the cyst prior to removal of the bag. If any doubt exists, the cyst wall should be sent for frozen section to confirm a benign cyst. If malignancy is found, a laparotomy should be performed. Permanent section and pathological diagnosis are performed on all cysts. Ovarian cysts with septa, internal echoes, or solid tumors are not good candidates for laparoscopy unless a benign cystic teratoma is a strong possibility.

If the cyst ruptures during removal, liberally rinse the peritoneal cavity with Ringer lactate solution. A dermoid cyst is particularly concerning because of contamination of the peritoneal cavity with sebaceous material, causing a chemical peritonitis. However, 2 case series demonstrated that pregnant and nonpregnant women who had an intraoperative spillage of a dermoid cyst followed by extensive peritoneal irrigation did not have increased length of stay or increased incidence of postoperative complications. Fear of seeding the cavity with a malignant tumor has always been present, although recent data suggest that spilling does not alter the prognosis if a staging laparotomy is performed immediately.

Postmenopausal cysts may also be removed by laparoscopy, although with the increased concern for malignancy, an oophorectomy and laparotomy may be more prudent. Physicians who perform a laparoscopy should be comfortable with staging by laparoscopy or laparotomy, and malignancy should be excluded perioperatively.

Salpingo-oophorectomy

Salpingo-oophorectomy may be more appropriate in postmenopausal women with a growing or persistent cyst. Tubes and ovaries are also removed prophylactically in women with a genetic predisposition to ovarian or tubal cancer.[18] A tubal pregnancy or large hydrosalpinx with adhesions may also require ovary removal. The power instruments, pretied loops, or stapling devices may be used to occlude the infundibular ligament and safely remove the ovary. Because of ovary size, a retrieval bag is needed to remove the tissue. Options for removing the ovary from the peritoneal cavity include (1) using a 12-mm port and removing the sleeve with the bag or (2) performing a minilaparotomy or colpotomy. If a colpotomy is performed, prophylactic antibiotics should be administered.

Myomectomy

Many women with a symptomatic fibroid uterus prefer myomectomy to hysterectomy in order to preserve fertility or the uterus. If the patient has a pedunculated fibroid, the stalk may be easily incised. However, for intramural fibroids, the risk of bleeding increases. The use of a preoperative gonadotropin-releasing hormone (GnRH) agonist may be considered in patients who are anemic. However, some studies have shown longer operative times and a higher conversion to laparotomy rate associated with the use of GnRH agonists in laparoscopic myomectomy due to difficult cleavage planes. An injection of vasopressin into the uterus may help maintain hemostasis. The defect left by the fibroid must be sutured, which can be difficult laparoscopically for inexperienced practitioners. Barrier techniques may be used to decrease adhesion formation.

The fibroid may be removed by morcellation or colpotomy. The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors.[19]  To date, laparoscopy has not proven better than laparotomy for the treatment of menorrhagia or infertility. In addition, some concern exists that the risk of subsequent uterine rupture during pregnancy may be greater after myomectomy performed by laparoscopy compared with laparotomy. However, all randomized clinical trials of myomectomy performed by laparoscopy versus laparotomy did not show an increased risk of rupture or poorer reproductive outcomes. These trials were conducted by experts in laparoscopic suturing and in carefully selected patients.

Hysterectomy

Initially, laparoscopy was performed prior to vaginal hysterectomy to restore normal anatomy. However, currently, it is often used in a variety of ways, such as assessing feasibility of a vaginal hysterectomy (when adhesions, endometriosis, or a large fibroid uterus is suggested) and performing some or all of the actual hysterectomy.[20] The 3 basic laparoscopic approaches for hysterectomy are laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy (LH), and laparoscopic supracervical hysterectomy (LSH). Although the basic techniques for each approach are fairly standardized, controversy exists over the risks, benefits, and most appropriate indications of each.[21]

LAVH is the most commonly employed and technically straightforward of the 3 techniques. Using 3-4 ports, the peritoneal cavity is surveyed and lysis of adhesions is performed if necessary. The infundibular or uteroovarian ligaments are occluded and divided, depending on whether the ovaries will be removed. The round ligament is cut in a similar fashion, and the uterovesical peritoneum is incised. Depending on physician preference, the proximal uterine blood supply is occluded and divided laparoscopically. After the uterovesical peritoneum is incised, the physician may also choose to laparoscopically incise the posterior cul-de-sac. The physician then proceeds vaginally for the remainder of the case, dissecting the vesicovaginal septum anteriorly to enter the anterior cul-de-sac, ligating the uterine vessels, removing the uterus and ovaries (if appropriate), and closing the vaginal cuff.

LH, the second approach, is performed initially like the LAVH, except that the entire hysterectomy is performed laparoscopically. The surgeon would choose indications similar to LAVH but would add lack of uterine descent, which would make the vaginal approach impossible. After the infundibular, uteroovarian, and round ligament are occluded and divided, the bladder is dissected off the uterus anteriorly. The ureter is identified and dissected along its entire course, and the uterine vessels and uterosacral ligaments are then occluded and divided. After the posterior cul-de-sac is incised, the specimen is removed vaginally, and the cuff is closed.

LSH is the third approach, being most often promoted for benign indications. The technique begins again as for the LAVH, but proceeds with separating the entire fundus from the cervix after the proximal vessels are divided and the bladder is dissected away from the uterus. A special instrument is used to core-out or cauterize the endocervix, and the uterus is then removed through a 12-mm port abdominally by morcellation or transcervically with a special morcellator. Note: The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors.[19]  This approach eliminates vaginal and abdominal incisions, with no need to dissect near the uterine artery or ureter. Proponents of LSH advocate that the operating room and recovery time are decreased and risk of both infection and ureteral injury are minimized. However, an increased risk exists for reoperation for cervical bleeding and prolapse. Furthermore, patients must follow the recommendations for regular cervical cytology. 

Oncologic procedures

Laparoscopy has long been used in oncology for second-look procedures following surgical and chemical treatment of malignancy. More recently, laparoscopy has also been used for staging, including peritoneal washes with biopsy, partial omentectomy, and pelvic and periaortic lymphadenectomy.[22, 23] Procedures such as laparoscopically assisted radical vaginal hysterectomy have also been used by some gynecologic oncologists.

Robotic laparoscopic surgery appears to be changing the approach to many gynecologic cancer cases. The robotic system allows surgeons to perform procedures that previously would have been performed via laparotomy using modified laparoscopic procedures. The robotic system has the advantages of 3-dimensional, high-definition imaging and magnification that improve the topography of the pelvis and the cervicovaginal plane. Fully articulated instruments emulate the full range of motion of a surgeon’s wrists and hands. This enhances the surgeon’s ability to remotely perform fine motor skills such as intricate dissections and intracorporeal suturing that remain difficult during traditional laparoscopy.

Anterior abdominal wall anatomy should receive special attention prior to laparoscopy because many laparoscopic complications result from trocar placement.

Abdominal scars

Previous surgery is associated with a greater than 20% risk of adhesions of bowel or omentum to the anterior abdominal wall,[24] For this reason, many laparoscopists adjust their techniques in these patients to minimize the risk of bowel injury. Of special concern are incisional scars immediately adjacent to the umbilicus because bowel adherent underneath the umbilicus may be at risk for injury regardless of the technique used. Although Pfannenstiel and abdominal incisions distant to the umbilicus may also be associated with adhesions, in many laparoscopists' experiences, these incisions appear to represent less of a risk than incisions near the umbilicus.

In addition to location, the width and depth of the scar should be evaluated because a wide or retracted scar may suggest that a postoperative wound infection had occurred. Common wisdom dictates that postoperative infections may be associated with an increased risk of intra-abdominal adhesion formation, although no data are available to support this observation. If the dome of the bladder is involved in the infectious process, it may cause progression of the bladder dome higher behind the anterior abdominal wall, thus increasing the risk of bladder injury at the time of suprapubic trocar placement.[25]

Abdominal wall thickness

Although abdominal thickness correlates with patient weight, short stature or truncal obesity may increase abdominal wall thickness out of proportion to patient weight.[26] Routine evaluation of the abdominal wall prior to laparoscopy is important because the success of trocar insertion may depend on altering the technique based on abdominal wall thickness.

Umbilicus

The umbilicus should be examined for signs of umbilical hernia. Techniques for trocar insertion should be adjusted, and closure of the defect should be considered. In the absence of incarcerated bowel, the skin over the hernia can be carefully incised and the peritoneal cavity entered using an open technique. Closure of a small defect can be performed with interrupted sutures at the completion of the laparoscopic procedure. For ideal cosmetic results, larger defects may require the assistance of a surgeon experienced in umbilical hernia repair.

Abdominal wall vessels

The anterior abdominal wall contains 2 sets of bilateral vessels: the superficial and the inferior (deep) epigastric vessels. These arteries originate from the femoral and external iliac arteries, respectively, and are accompanied by a large vein in most cases. Immediately above the symphysis pubis, they are both located an average of 5.5 cm from the midline and course slightly more laterally at points more cephalad. In order to avoid injuring these vessels during lateral trocar placement, the superficial vessels should be visualized by transillumination and the inferior vessels should be laparoscopically visualized whenever possible.[27] The use of conical trocars (as opposed to pyramidal tipped trocars) can also decrease the risk of injury to these vessels.[28]

Determination of absolute contraindications to laparoscopy remains controversial. For years, previous abdominal surgery and intestinal obstruction were regarded as contraindications to laparoscopy because of an increased risk of iatrogenic bowel perforation. However, recent reports suggest that morbidity is lower with laparoscopy compared to laparotomy.

In gynecology, the most commonly suggested contraindication is hemodynamic instability resulting from a ruptured ectopic pregnancy. However, following appropriate fluid resuscitation, laparoscopy is a safe approach.

Another traditional contraindication was pregnancy. In the last few years, several large series have documented the safety of using an open technique for laparoscopy during pregnancy.

Finally, disagreement is ongoing as to whether a known gynecologic malignancy is a contraindication to laparoscopy. Several case reports and series have suggested that laparoscopy may increase the risk of intraperitoneal spread of cancer cells.

Although few absolute contraindications exist for laparoscopy, several risk factors are well appreciated.

Patient risk factors

Patient risk factors are as follows:

• Obesity

  • Obesity is a well-recognized factor that increases the risk of any abdominal surgery. For laparoscopy, increased weight takes on a special significance. Women with a body mass index (BMI) greater than 25 kg/m2 are classified as overweight, and those with a BMI greater than 30 kg/m2 are considered obese. In an average-sized woman of approximately 160 cm (64 in), these cutoff points correspond roughly to weights of 73 kg (160 lb) and 91 kg (200 lb), respectively.

  • In women who are overweight, and even more so in those who are obese, every aspect of laparoscopy becomes more difficult and potentially more risky. Placement of laparoscopic instruments becomes much more difficult and often requires special techniques. Bleeding from abdominal wall vessels may be more common because these vessels become difficult to locate. Many intra-abdominal procedures become increasingly difficult because of a restricted operative field secondary to retroperitoneal fat deposits in the pelvic sidewalls and increased bowel excursion into the operative field. This second problem is probably related to increased volume of bowel, decreased elevation of a heavier anterior abdominal wall by the pneumoperitoneum, and the inability to place many patients who are obese in steep Trendelenburg position because of ventilation considerations.

  • Recommendations from the American College of Obstetricians and Gynecologists also emphasize that laparoscopy can be more complicated in obese patients, and the risk of conversion to laparotomy is increased in this setting.[29]

  • Weight loss prior to elective surgery in patients who are overweight or obese would be ideal. Unfortunately, significant weight loss may take years and, more often than not, is impossible. A more realistic approach is to inform the patient of the increased risk associated with obesity and to limit the extent of advanced laparoscopic procedures that are attempted in patients who are obese. Although no certain weight exists at which laparoscopy is contraindicated, performing surgery in patients weighing more than 136 kg (300 lb) requires skill. In the oncology literature, several reports suggest decreased postoperative morbidity in laparoscopic surgery performed in morbidly obese women for endometrial cancer, especially in the rates of wound infection and wound dehiscence.

• Age

  • Another well-described surgical risk factor is age. As the population ages, more women of increased age will have indications for laparoscopy. Older patients are at increased risk of having concomitant disease processes that affect their perioperative morbidity and mortality.

  • Probably the single most important consideration is age-associated increase in cardiovascular disease. Intraoperative cardiac stress related to anesthesia and the surgery itself may result in sudden cardiac decompensation based on arrhythmia, ischemia, or infarct.

  • Of special importance is the increased susceptibility of elderly persons to hypothermia because the vast majority of patients experience some degree of hypothermia during laparoscopy. In older patients, even mild degrees of hypothermia may increase the risk of cardiac arrhythmia and prolong recovery time.

• Previous abdominal surgery

  • As far as laparoscopic complications are concerned, one of the most important risk factors is a history of previous abdominal surgery. The risk of adhesions of omentum and/or bowel to the anterior abdominal wall after previous abdominal surgery is greater than 20%. Because laparoscopy requires the insertion of sharp instruments into the abdominal cavity, a reasonable assumption is that previous surgery would increase the risk of bowel injury. Thus, strategies have been developed to decrease the risk of bowel injury in patients with previous abdominal surgery.

  • The most common of these strategies is the use of an open technique for laparoscopic trocar placement, as first advocated by Hasson. Open laparoscopy techniques almost certainly decrease the risk of bowel injury distant to the umbilicus. To avoid bowel injury at the site of entry, modifications of the open technique have employed blunt entry of the peritoneal cavity with a hemostat to avoid inadvertently grasping and incising the bowel. In patients with previous laparotomy in which the scar is located at the umbilicus, use of an alternative location for trocar insertion (usually in the left upper quadrant) has been recommended to avoid injury of bowel adherent immediately beneath the umbilicus. The closest organ to the left upper quadrant is the stomach (therefore, an oral gastric tube is recommended before insertion) and the left lobe of the liver. Although clinical trials are limited, this appears to be an acceptable approach.

  • Despite the potential for increased risk of bowel injury after previous laparotomy, some laparoscopists advocate the use of a closed periumbilical trocar insertion techniques in all patients, regardless of a history of previous surgery. One justification is that bowel injury is uncommon (approximately 3 cases per 10,000 procedures) and open laparoscopy does not completely avoid the risk of bowel injury.

Anesthetic risk factors

Anesthesiologists are trained not only in the art of providing anesthesia, but also to serve as consultants. This may be one of the least-used assets available to modern surgeons. Prior to surgery, discuss preparation of any patient with significant health problems with an anesthesiologist. In complex cases, these patients should be seen by an anesthesiologist for optimal preanesthesia preparation.[30]

• Time since last oral intake

  • One of the most critical time-dependent aspects of preparation is the degree to which the patient's stomach is empty because both general anesthesia and increased intra-abdominal pressure may increase the risk of regurgitation and resultant aspiration. The appropriate time to wait from the last oral intake until induction of general anesthesia is a much-debated topic. In general, the recommendation is that approximately 6 hours be allowed to elapse between the last intake of solid food and the elective induction of anesthesia. In patients with conditions associated with decreased gastric emptying (eg, diabetes-induced autonomic dysfunction) or in the presence of predisposing factors for regurgitation (eg, sliding hiatal hernia, known reflux), a longer period of fasting may be indicated.

  • Unfortunately, in emergency cases such as ectopic pregnancy or ovarian torsion, general anesthesia may be required despite a period of fasting of less than 6 hours. In these cases, always consult an anesthesiologist. In many cases, steps can be taken to decrease the incidence of aspiration pneumonia, including administration of agents to decrease gastric acidity, such as antacids or histamine receptor antagonists, or the use of drugs that increase gastric emptying, such as metoclopramide.

• Heart disease

  • Preoperative evaluation should include a search for evidence of underlying cardiac disease. With a positive history or physical examination findings suggestive of cardiac disease, preoperative evaluation by both a cardiologist and an anesthesiologist is extremely important. Patients with ischemic heart disease who undergo anesthesia may have decreased cardiac blood return coupled with an increased heart rate that may result in infarction. Laparoscopic-associated metabolic acidosis, respiratory acidosis, and hypothermia may result in arrhythmia in predisposed patients, thus increasing the risk of ischemia even further. Also, the risk of arrhythmia increases with distention of the abdomen, especially in patients who are breathing spontaneously.

  • Finally, patients at risk for congestive heart failure should be evaluated carefully prior to laparoscopy because a decrease in cardiac output may be related to decreased venous return and increased peripheral vascular resistance.

• Pulmonary disease

  • Any patient with a significant history of pulmonary problems should be evaluated by both a pulmonologist and an anesthesiologist prior to laparoscopy. When given an option, laparoscopy is preferable to laparotomy in these patients. The relatively decreased postoperative pain following laparoscopy may result in less ventilatory compromise than laparotomy and thus, fewer problems with atelectasis or pulmonary failure in those with borderline pulmonary function.

  • Special care should be taken during laparoscopy in patients with pulmonary disease. Hypercarbia and decreased ventilation associated with laparoscopy may be especially deleterious in pulmonary patients with chronic respiratory acidosis. In rare cases, pneumothorax and pneumomediastinum have been described as complications of abdominal insufflation. In patients with compromised pulmonary function, even a small intravasation of carbon dioxide could result in significant pulmonary decompensation.

Complete blood cell count

In general, one of the few required laboratory evaluations in a healthy patient is a complete blood cell count.

Anemia increases the risk of anesthetic complications and infections, both at the operative site and the skin incision. In addition, patients who are anemic have less of a safety margin in the uncommon case of significant operative blood loss. For elective surgery, every effort should be made to provide effectual treatment for anemia prior to surgery.

Pregnancy test

Many surgeons recommend routine pregnancy tests for all patients prior to elective surgery because both surgery and anesthesia should be avoided during pregnancy. Although the most commonly used anesthetics show little evidence of causing either teratogenicity or increased risk of spontaneous abortion, the medicolegal implications of electively performing surgery and administering anesthesia during pregnancy justifies establishing pregnancy status prior to surgery. Exceptions are usually made for patients who are surgically sterile or who are known to be pregnant.

A urine pregnancy test is adequate in most cases because these modern tests accurately detect beta-human chorionic gonadotropin levels of 50 mIU/mL or more, a level usually reached by 4 weeks from the last menstrual period. Because this type of pregnancy test can be performed in the presurgical area, delays related to waiting for results should be uncommon. Because no test can accurately determine very early pregnancy (prior to the expected next menstrual period), all patients should also be carefully questioned about whether they could be pregnant and about the date of their last menstrual period immediately prior to surgery.

An alternative to performing routine pregnancy tests prior to surgery is to schedule all elective surgery during the follicular phase (ie, within 2 wk of the last menstrual period). Not only does this minimize the risk of performing surgery during an undiagnosed pregnancy, but it also avoids manipulation of the endometrium and tubes around the time of ovulation and implantation.

Urinalysis

Many laparoscopists obtain a urinalysis prior to surgery. Urinalysis may help detect an unsuspected systemic disease, such as diabetes, which should be completely evaluated prior to elective surgery.

More commonly, urinalysis results may indicate the presence of a subclinical urinary tract infection that may be exacerbated by catheterizing the patient. Treating these infections prior to surgery may help avoid postoperative discomfort and potentially serious sequelae in susceptible patients.

Other laboratory evaluations

In patients with known health problems, other laboratory tests, such as liver function tests or electrolyte evaluations, may be indicated.

A thorough preoperative medical evaluation, including appropriate laboratory studies, is appropriate in anyone with significant medical problems.

Chest radiography

A routine preoperative chest radiograph (CXR) is probably unnecessary for patients with no risk factors.[31]

In patients with coexisting bronchopulmonary conditions, cardiac conditions, or abnormal clinical cardiopulmonary findings, a preoperative CXR certainly is important. CXR is also part of the basic workup for anyone who may have a gynecologic malignancy.

Intravenous pyelograph or kidney ultrasound

Radiographic or sonographic evaluation of the urinary tract is important in women with uterine anomalies, those known to have severe endometriosis, and those with an ovarian mass fixed in the pelvis. Women with uterine anomalies are at risk for concomitant urologic anomalies; thus, an intravenous pyelogram should be performed to determine kidney location and the state of the ureters.

In select cases of severe endometriosis or when a fixed pelvic mass is present, preoperative evaluation for possible ureteral involvement is also important. Hydronephrosis, indicating partial or complete obstruction of the ureter, can be excluded with the aid of a kidney ultrasound image in these cases.

Barium enema

Severe endometriosis can sometimes involve the colon. In patients with colonic symptoms, such as cyclic hematochezia or narrowing caliber of stool, a preoperative evaluation is important. However, most patients with bowel endometriosis will have normal study results. Therefore, the studies are performed to rule out other causes of the symptoms.

Alternatively, colonoscopy may be helpful in patients with these suggestive symptoms.

Electrocardiogram

A routine preoperative electrocardiogram (ECG) prior to laparoscopy is not indicated in a young, healthy woman. A preoperative ECG should be considered in all women older than 50 years because the risk of heart disease increases at this time. Although this often depends on the local requirements.

In addition, any woman with a history of cardiac disease or any physical finding or disease history that puts her at increased risk of cardiac disease (eg, diabetes mellitus, hypertension, thromboembolic diseases, stroke, renal impairment, chronic pulmonary disease) should have a preoperative ECG regardless of age.

General techniques for laparoscopy are described as follows:

Primary trocar placement

Numerous techniques exist for creating a pneumoperitoneum and placing a laparoscopic port into the abdomen. Each is purported to offer a unique advantage. Five common approaches are 1) Veress needle insertion followed by a primary trocar insertion, 2) direct trocar insertion, 3) open laparoscopy, 4) expanding-access cannulas, and 5) left upper quadrant insertion. Physician experience significantly contributes to the safety of the individual technique. Both reusable and disposable instruments are available. The choice of instrumentation should take into account the condition of the available reusable equipment and the cost of the disposable equipment.

Veress needle and primary trocar insertion

When the Veress needle is placed through the umbilicus and into the peritoneal cavity, avoidance of both the retroperitoneal vessels and the intestinal tract is of paramount importance. The patient must be in the complete horizontal position (not Trendelenburg), and the patient's body habitus should be carefully assessed, as shown below.

The abdominal wall is elevated by manually grasping the skin and subcutaneous tissue to maximize the distance between the umbilicus and the retroperitoneal vessels. An alternative method for elevation is to place penetrating towel clips at the base of the umbilicus.

In persons of average weight, the lower anterior abdominal wall is grasped and elevated and the Veress needle is inserted toward the hollow of the sacrum at a 45° angle.[26] See the image below.

In a very thin patient, the vital structures are much closer to the abdominal wall and the margin for error is reduced, with sometimes as little as 4 cm between the skin and large retroperitoneal vessels. In patients who are obese (BMI of 30 kg/m2 or more), a more vertical approach, approximately 70-80°, is required because of the increased thickness of the abdominal wall. Without the vertical insertion, the trocar would not be long enough to penetrate the layers and enter the peritoneal cavity.

Correct placement of the Veress needle may be confirmed by a number of methods, such as the hanging drop test, injection and aspiration of fluid through the Veress needle, or measurement of intra-abdominal pressure with carbon dioxide insufflation. After a pneumoperitoneum has been achieved with a Veress needle, the primary trocar with sleeve (most commonly 5 mm or 10 mm in diameter) is placed at a similar angle to the Veress needle.

Direct trocar insertion

Direct trocar insertion refers to inserting the primary trocar without having previously inserted the Veress needle and insufflating the abdomen with carbon dioxide. The primary trocar is inserted in a manner similar to the Veress needle. The sleeve from the trocar is then used to insufflate the abdomen with carbon dioxide. The advantage of this is that it avoids extraperitoneal insufflation. Although several studies suggest that the safety of this technique is equal to the Veress needle technique, large population-based reports would be needed to identify even a small difference in complications because of the low incidence of complications; for example, the rate of complications for bowel injury is between 0.06 and 0.09%.[24]

Open laparoscopy

Open laparoscopy involves incising the anterior rectus fascia and bluntly entering the peritoneal cavity with a Kelly or Crile clamp. A blunt-tipped trocar with sleeve is then placed into the peritoneal cavity. For the Hasson technique, sutures used on the fascia hold the sleeve in place and anchor the sleeve to help maintain a pneumoperitoneum. Because this method almost completely avoids the risk of retroperitoneal vessel injury and may decrease the risk of bowel injury, some laparoscopists use this approach exclusively. Many laparoscopists use this method for patients with risk of abdominal adhesions.[32]

Expanding-access cannulas

A relatively new technique for laparoscopic trocar placement is the use of expanding-access cannulas. This technique involves the placement of a Veress needle for insufflation. After the peritoneal cavity is insufflated, the Veress needle is removed and reinserted after it is placed into an expandable sleeve. Once the needle and sleeve are placed into the peritoneal cavity, the needle is removed and the sleeve is dilated to 5-10 mm in diameter to accommodate a laparoscopic lens. Although this technique has been reported in several hundred cases, the relative risk compared to older techniques remains to be established.

Left upper quadrant insertion

Left upper quadrant insertion of the primary cannula is especially useful for patients with large pelvic masses, patients with suspected abdominal wall adhesions, or in patients in the second trimester of pregnancy. Relative contraindications include ascites, hepatomegaly, and splenomegaly. After induction of general anesthesia with the patient in a horizontal supine position, a gastric drainage tube is placed to empty the stomach.

The skin incision is made 3 cm below the costal margin (4 cm for thin patients with BMI < 20 kg/m2) in the left midclavicular line. The abdominal skin is tented anteriorly and a 5-mm cannula is advanced at a 45° angle from the horizontal directly into the peritoneal cavity in the sagittal plane. After proper placement is confirmed with the laparoscope, pneumoperitoneum is obtained.

Placement of secondary trocars

Secondary trocars are used for most gynecologic laparoscopy procedures, with the exception of some diagnostic laparoscopies. After identifying the epigastric vessels by transillumination and intraperitoneal observation, 1-3 secondary trocars are placed, depending on the procedure and the number of trocars required for the operation.

The trocars are placed either in the midline, 3 cm above the pubic symphysis, or laterally, approximately 8 cm from the midline and 8 cm above the pubic symphysis to avoid the inferior epigastric vessels.[27] Lateral trocars should not be placed 5 cm from the midline and approximately 3 cm above the symphysis as some have suggested because this correlates very closely to the average location of the inferior epigastric artery, which is 5.5 cm from the midline at this level. See the image below.

Insertion of the trocar and removal of the sleeves are performed under direct laparoscopic visualization while observing for signs of hemorrhage. If the trocar is larger than 8 mm, the fascia is closed with suture after removal of the sleeve to reduce risk of hernia.

Expanding-access cannulas for secondary trocar placement

The relatively new expanding-access cannula technique described above was initially developed for placement of secondary laparoscopic trocars. This technique involves the placement of a Veress needle in an expandable sleeve through the abdominal wall at the desired site under direct visualization. Once the needle and sleeve are placed, the needle is removed and the sleeve is dilated to 10-12 mm in diameter to accommodate laparoscopic instruments. Because the risk of abdominal wall vessel injury appears to be related to the size of the trocar used, this technique appears to be effective in reducing such injuries.

Power instruments

Monopolar electrosurgery was the first methodology used for laparoscopic coagulation. In the past 20 years, other methodologies have been developed to minimize the risk of inadvertent injury to adjacent tissue, particularly the bowel. Bipolar electrosurgery offers a greater margin of safety because damage is limited by thermal spread rather than by electrical current; however, cutting ability is reduced. The laser offers a precise, rapid, and accurate method of thermally destroying the tissue, although hemostatic effects are less and the cost is more. Scissors, hook, and ball accessories are available. Similar to laser, decreased hemostasis and increased cost must be considered.

Newer energy sources are available that decrease lateral thermal spread of energy while providing hemostasis and the ability to cut tissue. Among these newer instruments are the Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio), and impedance-controlled bipolar devices.[11] The Harmonic Scalpel uses vibration at the rate of 55,000 cycles per second as an energy source to break hydrogen bonds in tissue, resulting in cutting or coaptation of vessels. It is available as a 5-mm rounded scalpel with a blunt or hooked edge or as a 5- to 10-mm shear or Harmonic ACE, which can also be used to grasp tissue. The impedance-controlled devices include Enseal (Surgrx), Plasma Kinetic dissection forceps (Gyrus Medical), and LigaSure (Valleylab). They use pressure and pulsed current to seal vessels with minimal lateral thermal spread.

Techniques for large vessel occlusion

As laparoscopy has become more prominent in gynecology, techniques have been designed to offer efficient means of tying and cutting large vessels, such as ovarian and uterine vessels. Traditional suturing with intracorporal or extracorporal knot-tying has been used effectively; however, for most surgeons, these techniques are relatively difficult and slow. The first technique developed to assist in occluding large vessels was the pretied suture loop (Endoloop, Ethicon Endo-Surgery, Inc, Cincinnati, Ohio). Although simple and quick, these types of loops can loosen in the immediate postoperative period.

More recently, new instruments have become available to aid in the suturing process. In addition, linear stapling devices have been used for occluding vessels during removal of adnexal structures or LH (Endo GIA II stapler, United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn). As with all disposable equipment, potential saved time must be balanced against increased cost. Finally, one of the best and least expensive approaches for occluding large vessels is bipolar electrocautery, although care must be taken to avoid damage to adjacent structures secondary to lateral heat spread. The newer impedance-controlled bipolar devices are able to seal and divide vessels up to 7 mm in diameter.

Robotic surgery

The only robotic system commercially available today is the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif).[1] Robotic tools attach to traditional laparoscopic ports and the robotic system is placed between the patient’s legs for hysterectomy. The surgeon controls the instruments from a console located in the same room.

Compared to traditional laparoscopy, the robotic system has the advantage of being easier for surgeons to acquire the new skills necessary to operate safely and effectively with this system. Another advantage is direct correlation between hand movements and instrument movements. This is in contrast to traditional laparoscopy, where hand movements are translated into grasping or cutting movements in different flat planes, and gross movements of laparoscopic instrument handles result in mirror image movements of the instrument tips. As a result, surgeons can become proficient in robotic surgery in a matter of months. It appears that robotic technology is allowing the more widespread application of laparoscopy for complicated gynecologic procedures.

Natural orifice transluminal surgery

Natural orifice transluminal surgery (NOTES) refers to using an endoscope to access the abdominal cavity through existing body openings, most notably the mouth, rectum, and vagina. This technique combines endoscopic and laparoscopic techniques to diagnose and treat intra-abdominal pathology.

From a historical perspective, gynecologists have reported using NOTES in the form of transvaginal laparoscopy for diagnostic purposes and to perform tubal ligations.[33] Modern NOTES uses a flexible endoscope to access the peritoneal cavity by creating an incision in the stomach or colon.

However, the ability to perform complex operative procedures has so far been limited, and the complication rate compared to traditional laparoscopy remains uncertain. For NOTES, a single operating channel coming from the same direction as the lens limits visibility and depth perception. The use of a single access port also limits maneuverability, reach, and the ability to create countertraction. So far, the role of NOTES in gynecologic practice has been relatively limited as a result of the relative advantages and low complication of traditional laparoscopy.

Single incision laparoscopic surgery

Single incision laparoscopic surgery (SILS) refers to performing laparoscopy through a single incision. This approach is also referred to as single access surgery (SAS), single port surgery (SPS), single port access (SPA), single port laparoscopy (SPL) and one port umbilical surgery (OPUS). Gynecologists have performed SILS for decades, using single channel 10 mm operating laparoscopes to perform diagnostic laparoscopy and tubal ligations.[34]

The potential benefit of SILS is similar to NOTES in that it minimizes the number of incisions. This in turn results in decreased pain, improved cosmetics, and reduces the risks associated with a secondary port placement.[35]

The disadvantages of SILS are also similar to NOTES: visibility, depth perception, maneuverability, reach, and the ability to create counter-traction are all limited. Articulating instruments are being developed to improve maneuverability; however, these tools have yet to be in common use.

Few gynecologists use the SILS approach because these disadvantages clearly outweigh the potential advantages. Future directions of SILS research include development of multichannel scopes, improved optics, maneuverability, and articulating instruments.

Preoperative medications

Preoperative medications include the following:

• Gonadotropin-releasing hormone agonists: Some premenopausal women may benefit from temporarily decreasing levels of circulating estrogen by the use of a gonadotropin-releasing hormone (GnRH) agonist. The most common situation in which this is helpful is in the presence of a large leiomyoma when size alone makes surgery difficult. This is most common when hysteroscopic resection of a large submucosal leiomyoma is to be attempted or when LAVH is planned for a markedly enlarged uterus. In general, uterine volume can be decreased by up to 50% with 2-3 months of administration of a long-acting GnRH agonist. This may also be helpful in some cases of laparoscopic myomectomy.

• Prophylactic antibiotics

  • Prophylactic antibiotics are a well-established method of decreasing risk of postoperative infections after either vaginal or abdominal hysterectomy. Although their use has not been studied in a large number of cases of laparoscopically assisted hysterectomy, intuitive sense dictates that prophylactic antibiotics would also be beneficial in these patients.

  • Another group of patients who may benefit from prophylactic antibiotics are women undergoing tubal reconstructive surgery for pelvic adhesive disease resulting from previous pelvic infections. Because these patients appear to be at increased risk for postoperative infections after genital surgery, use of an intraoperative broad-spectrum antibiotic given intravenously seems reasonable.

• Oral contraceptives

  • The risk of postoperative thromboembolism appears to be increased by the preoperative use of high-dose oral contraceptives (50 mcg ethinyl estradiol) in women undergoing major gynecologic surgery. Whether contemporary low-dose preparations (35 mcg) share this risk has not been established. Also, no proven risk exists for women using oral contraceptives prior to minor surgery in which significant periods of immobilization are unlikely.

  • Although some authors believe that oral contraceptives should be discontinued 1 month prior to any elective surgery, no study has established that continuing low-dose oral contraceptives up until the time of most laparoscopic procedures is unsafe. However, women undergoing laparoscopically assisted hysterectomy should probably discontinue oral contraceptives 1 month prior to surgery unless the patient decides that the risk of inadvertent pregnancy is greater than the small, but uncertain, increased risk of thromboembolism associated with preoperative oral contraceptives.

Preoperative gastrointestinal preparation

Preoperative gastrointestinal preparation includes the following:

• Bowel preparation

  • If significant enterolysis is planned and either endometriosis or pelvic adhesions are known or suggested to be present, preoperative bowel preparation is commonly used in an effort to decrease the risk of serious postoperative sequelae. A recent Cochrane database has questioned the entire concept of a bowel preparation. Communication with the general surgeon or colorectal surgeon of the institution avoids intraoperative surprises if bowel injury should occur.

  • Although a multitude of bowel preparations have been described, the most common oral agents are either magnesium citrate or a polyethylene glycol solution. Unfortunately, a thorough bowel preparation is often uncomfortable for the patient. However, in high-risk patients, preoperative bowel preparation may allow primary closure of an unplanned enterotomy; in the presence of an unprepared colon, a temporary diverting colostomy may be required.

• Oral intake: NPO after midnight (ie, nothing by mouth after 12:00 am) remains a sound approach in most patients undergoing early morning surgery to avoid the risk of aspiration. In patients whose cases are scheduled later, clear liquids up until 6 hours prior to surgery may make the patient more comfortable and also decrease the degree of preoperative dehydration. For emergency procedures, general anesthesia may be required despite a period of fasting of less than 6 hours.

Other preoperative considerations

Other considerations are as follows:

• Intravenous access: Because of the rare but serious risk of sudden and potentially massive blood loss during laparoscopy, establishment of intravenous access is required prior to starting the case. Usually, this is in the form of a functioning intravenous catheter of at least 18 gauge. A balanced salt solution is administered at a moderate rate to assure that the line is functioning and to hydrate the patient prior to administering regional or general anesthesia.

• Bladder catheterization: Traditionally, complete emptying of the urinary bladder with a catheter immediately prior to Veress cannula or trocar placement is performed to minimize the risk of bladder injury. Some laparoscopists advocate having the patient void immediately prior to entering the operating room. This approach, on occasion, may be associated with the discovery of a significant amount of bladder distention because of incomplete emptying or excellent urine output. In-and-out catheterization appears to more consistently result in compete bladder emptying and, when performed aseptically, appears to be associated with minimal risk of iatrogenic urinary tract infection. For procedures of longer duration, consider the use of an indwelling catheter to avoid bladder refilling, although this probably increases the risk of infection.

• Deep vein thrombosis prophylaxis

  • As many as 14% of patients who undergo gynecologic surgery for benign conditions will develop thromboembolism. The decision to provide thromboprophylaxis should be made based upon patient risk factors and the type of surgery performed. The American Academy of Chest Physicians (ACCP) routinely updates recommendations on thromboprophylaxis. They have stratified risk into low, medium, high, and highest risk scenarios.

  • The ACCP guidelines suggest that low-risk patients forgo prophylaxis. Patients at moderate risk undergo thromboprophylaxis with sequential compression devices (SCD) (lower extremity) or unfractionated heparin 5,000 units bid or low molecular weight heparin such as enoxaparin 40 mg daily. High-risk patients should be given a more frequent heparin dose of 5,000 units tid, and highest risk patients should be given both heparin therapy and SCDs.

  • Low-risk patients include those younger than 40 years with no additional risk factors whose surgery duration is less than 30 minutes. Patients at moderate risk include those aged 40-60 years with no additional risk factors undergoing surgery of any duration. High-risk patients include those aged 60 years or aged 40 years with one additional risk factor, such as prior DVT, varicose veins, infection, malignancy, obesity, estrogen therapy, or surgery lasting longer than 5 hours. Highest-risk patients are the same as the high-risk group but with more than one risk factor.

• Patient positioning

  • Gynecologic laparoscopy procedures are usually performed with the patient in the dorsal lithotomy position to allow vaginal access for uterine manipulation. In the early days of laparoscopy, this was attained by suspending the ankles in lithotomy stirrups, also known as candy cane stirrups. Unfortunately, these stirrups offer little leg support, thus putting increased stress on both the knee and hip joints. In addition, they require that patient be in high lithotomy position, in which the thighs severely limit the range of movement of the operator.

  • Most laparoscopists now use boot stirrups specially designed for laparoscopy. These resemble obstetric stirrups in that they have a footplate and also support the popliteal fossa. However, laparoscopic stirrups are more adjustable than those previously designed for obstetrics. This avoids pressure on the lateral or posterior aspect of the calf and permits easy positional changes from low lithotomy for laparoscopy to high lithotomy for vaginal procedures, such as hysteroscopy or vaginal hysterectomy.

  • For low lithotomy, the legs should be positioned so that the thigh is slightly flexed, no more than 90° from the plane of the abdomen.[36] The thighs should not be hyperextended to avoided nerve injury. For high lithotomy, the legs should be positioned so that the angle between the flexed thigh and the abdomen is no less than 45°. The buttocks should be slightly over the edge of the table, but the sacrum should be completely supported by the table to avoid back strain. Patients at greatest risk for nerve injury are those who are long-legged, obese, or short in stature. In patients who are long-legged or obese, there is a tendency for the hip to rotate externally, and in short patients, there is a tendency to have less knee flexion. In such individuals, stirrups that support the ankle and calf may be more appropriate.

  • Once the primary trocar is placed, the patient is usually placed in no more than 25° Trendelenburg position to help keep the bowel out of the pelvis. Unfortunately, the degree of tilt possible may be limited by any resulting compromise in ventilation that may occur, especially in patients who are obese. In patients who are conscious during regional or local anesthesia, discomfort and dyspnea may be limiting factors. As a warning, the use of steep Trendelenburg position for prolonged periods has been associated with Erbs palsy, especially with the use of shoulder braces.

• Skin preparation

  • Clipping the pubic hair above the symphysis may be required if hair extends to the intended site of ancillary trocar placement, usually 3-4 cm above the symphysis pubis. Standard antiseptic preparation of the abdominal skin and the vagina are followed by placement of specially designed fenestrated laparoscopy drapes. Vaginal instruments are placed for uterine manipulation and then draped to keep the abdominal field separate from the lower vaginal field.

  • After changing gloves, avoid contamination of both the abdominal field and instruments placed into the abdominal cavity. Prior to video laparoscopy, the operator's eye was placed against the laparoscope, making it impossible to keep the operating field sterile. Nevertheless, the risk of infection involving the wound or the peritoneal cavity after laparoscopy was extremely low, most likely because of the small incisions and decreased opportunity for intra-abdominal contamination. With the advent of video laparoscopy, no reason exists that standard sterile precautions cannot be applied to all laparoscopic procedures.

Type of anesthesia

Over the years, many methods of anesthesia have been employed for laparoscopy, including general anesthesia, regional blocks, and local infiltration. Because of 2 unique aspects of gynecologic laparoscopy, (1) abdominal insufflation and (2) routine use of the Trendelenburg position, general anesthesia is the most common technique used today.

Abdominal insufflation, usually with carbon dioxide at a pressure of 15-20 mm Hg, has significant physiologic effects. Transperitoneal absorption of carbon dioxide results in a relative acidosis that plateaus after approximately 15 minutes of insufflation. Acidosis can be corrected by increasing ventilation 10-25% and usually has minimal effect on healthy patients. However, in susceptible patients, these changes in acid-base status may increase the risk of cardiac arrhythmia. Probably a more significant effect of abdominal insufflation is increased pressure on abdominal structures. While associated with significant discomfort in conscious patients, increased pressure can also result in passive regurgitation of gastric contents, even in patients without a history of gastric reflux. While pressure is increased at the gastroesophageal junction, this does not prevent regurgitation.

Increased intra-abdominal pressure is also transmitted to the thorax. Pressure on the diaphragm increases breathing effort in conscious patients. In patients under general anesthesia, decreased excursion of the diaphragm can lead to atelectasis and functional pulmonary shunt, which, in turn, can result in hypercarbia and a respiratory acidosis, augmenting the acidosis associated with carbon dioxide absorption.

Abdominal insufflation can also have direct cardiac effects. Pressure on the intra-abdominal venous system can decrease the venous return to the heart. Pressure transmitted to the right atrium decreases preload further. This may be of minimal consequence in healthy patients, but it may lead to cardiac compromise in those with borderline cardiac function.

Another aspect of laparoscopy that can increase upper abdominal pressure is the use of Trendelenburg position to keep the bowel out of the pelvis. The effects of gravity on intra-abdominal contents increase pressure on the stomach and diaphragm, accentuating the problems discussed above.

Because of the discomfort and risks associated with abdominal insufflation, general anesthesia is the most common technique used for laparoscopy. To minimize the risk of aspiration, endotracheal intubation is also recommended.

Local or regional anesthesia should be used only in carefully selected patients. The chance of significant discomfort and the risk of aspiration should be discussed thoroughly with the patient, and only those able to handle some discomfort are appropriate candidates.

During laparoscopy, both the discomfort and the risk of aspiration may be decreased by using the least intra-abdominal pressure possible for insufflation (usually < 14 mm Hg) and using the least amount of Trendelenburg position necessary to visualize the pelvis. Unfortunately, this limits the ability to perform extensive procedures in many patients. This is especially problematic in patients who are obese, who often require relatively high intra-abdominal pressures and steep Trendelenburg position to obtain adequate visualization of the pelvis. For this reason, use of local or regional anesthesia should be limited to patients who are not obese who have a reasonable amount of pain tolerance and who do not require a significant degree of intra-abdominal surgery.

After any gynecologic laparoscopic procedure, progressive resolution of symptoms is to be expected 3-7 days postoperatively. With major procedures, return to completely normal bowel function may take several days. For any procedure, pain may be perceived as slightly worse on the day following the procedure but should improve after this point. Likewise, the incision should appear healthy and become almost painless within the first week.

Patients should be counseled on the natural postoperative course of events, and patients should be instructed to contact their physician if any deviation from this course occurs. A natural tendency may be to reassure a patient who calls that their postoperative discomfort is within the normal range. However, this reassurance should be offered with caution because delaying appropriate care can often compound the effects of complications and may be fatal.

Probably the most concerning postoperative symptom is worsening abdominal pain, especially in the presence of distension. Signs of an occult injury of bowel or bladder may take hours or days to develop. If a patient who calls the physician cannot be assured with absolute certainty that she is not experiencing a surgical complication, she should be advised to come in for an evaluation by someone experienced in recognizing postoperative complications.

An unusual cause of abdominal pain is an entrapped incisional hernia that can occur after laparoscopy. Herniation is rare at the site where the laparoscope is placed through the umbilicus. However, bowel herniation has been reported to occur when larger trocars (>5 mm) are used in locations lateral to the midline. Apparently, this is not related to herniation through a fascial defect, but rather entrapment of bowel that has herniated through the peritoneum into the preperitoneal space. This appears to be a different process than an incisional hernia that occurs after laparotomy, in which a palpable bulge is the most common presenting symptom and entrapment is uncommon. After laparoscopy, herniation may manifest as severe abdominal pain accompanied by signs of bowel obstruction. Although incisional hernias should always be considered as a cause of abdominal pain after laparoscopic surgery, they are relatively infrequent. Thus, other intra-abdominal processes should also be considered.

In the absence of complications, the patient should be able to return to full activity within 72 hours after most gynecologic laparoscopic procedures other than hysterectomy. Because complete healing of fascial defects takes several weeks, the patient should avoid lifting anything heavier than 15 pounds for the first month.

Recovery from laparoscopic hysterectomy can be expected within 2-3 weeks. Again, because healing continues to take place for the first month, heavy lifting should be delayed for 4 weeks. Follow-up office visits in patients without complications are usually scheduled 2-4 weeks after surgery.

In addition to the traditional risks of surgery such as infection and generalized bleeding, laparoscopy is a technique that presents its own unique complications.

Gas embolism

Because carbon dioxide is used to create the pneumoperitoneum in laparoscopic procedures, gas embolization is an uncommon but very serious complication. Embolization is usually caused by inadvertent placement of the Veress needle into a major vessel during attempts to insufflate the abdominal cavity with carbon dioxide. Placement of the Veress needle into the aorta or one of its major branches results in bleeding, but does not result in carbon dioxide injection into the vessel because the insufflation pressure is lower than the arterial pressure. On the other hand, placement of the Veress needle into the venous system can result in embolization of carbon dioxide, which may be fatal due to complete occlusion of the pulmonary artery by a large carbon dioxide embolism.

To avoid this complication, the operator must verify intraperitoneal placement of the Veress needle prior to insufflation. If results from one of the following tests indicate malposition, the needle must be repositioned.

• Open the Veress valve and observe for the flow of blood from the abdomen through the needle.

• Aspirate with a syringe through the Veress needle.

• Administer the hanging drop test by placing a drop of saline at the open end of the Veress, then observe if the drop disappears into the shaft as the abdominal wall is elevated.

• Elevate the abdomen with the Veress valve closed, then assess for a hissing sound as the Veress valve is opened. Alternatively, the Veress needle may be attached to the insufflator with the valve in the off position and the gas off. The abdomen is then elevated with the valve open and a negative pressure reading will be observed on the insufflation instrument.

Recognition and treatment of a large venous embolization must be immediate. Clinical signs include decreased end-tidal carbon dioxide, decreased oxygen saturation, a loud mill-wheel murmur, severe hypotension, and possible cardiac arrest. Treatment includes immediately stopping insufflation, removing the needle, placing the patient in the left lateral decubitus position, administering 100% oxygen, and giving cardiac support. The gas embolism may be broken up with external cardiac massage, but definitive treatment is placement of a central line for aspiration of the gas from the right side of the heart and from the pulmonary vasculature.

Retroperitoneal major vessel injury

Laceration of major abdominal blood vessels is one of the least common but most life-threatening complications in laparoscopy. Injuries, which occur in approximately 3 cases per 10,000 laparoscopies, may occur during insertion of the Veress or the primary trocar.

In theory, because the umbilicus usually lies over the bifurcation of the aorta at L4, the aorta and inferior vena cava are avoided if one inserts the Veress or trocar through the umbilicus toward the hollow of the pelvis. However, 25% of the time the bifurcation is above or below L4. Also, the left common iliac vein frequently crosses directly below the umbilicus. Patients who are thin are at an additional risk because the distance from the umbilicus to the retroperitoneal vessels may be as short as 2-3 cm. In patients who are obese, the umbilicus may not lie over L4; therefore, palpation of the iliac crest, which is lateral to L4, is a better assessment of the position of the bifurcation.

When placing the Veress needle, the patient must be in the horizontal position (not Trendelenburg), and the angle of entry varies depending on patient weight. Open laparoscopy remains an alternative for avoiding retroperitoneal injury. Immediate recognition of the injury is paramount to patient survival. If blood flows from the open Veress needle or if the patient's vital signs rapidly decompensate after Veress or trocar insertion, prompt action must be taken. With a retroperitoneal hemorrhage, the peritoneal cavity may not show signs of bleeding. If major vessel injury is a possibility, notify the anesthesiologist in order to place a central line and order blood products, make a midline incision for good exposure, and immediately call a vascular surgeon. In contrast to bowel injuries, keeping the Veress needle in place to mark the position of a vessel injury is not needed.

Abdominal wall vessel injury

As laparoscopy has become more sophisticated, the placement of numerous and larger accessory trocars lateral to the rectus muscles has increased the risk of abdominal wall vessel injury. The primary vessels injured are the epigastric vessels (inferior and superficial) and the superficial circumflex iliac vessel (see Media file 3).

The inferior epigastric vessel originates from the external iliac vessel, and the superficial vessel originates from the femoral vessel. Damage can lead to abrupt and significant blood loss, producing a hematoma or postoperative hemorrhage.[37]

The first step to avoiding injury is to know the positions of these vessels. Often, the superficial vessels can be seen by transilluminating the abdominal wall with the laparoscope. The inferior epigastric artery cannot be transilluminated but may be seen intraperitoneally beneath the peritoneum between the insertion of the round ligament at the inguinal canal and the obliterated umbilical artery. Prior to insertion of the lateral trocars, the operator should make an effort to identify and avoid these vessels.

If unable to visualize the vessels, the operator can improve the chance of successfully avoiding the vessels by placing the trocars lateral to their usual location, which is 5.5 cm from the midline. Therefore, placing the trocars 8 cm lateral to the midline and 8 cm above the pubic symphysis should help to avoid injury to the epigastric vessels. Because of anatomic variations, vessel location can vary. Therefore, additional precautions can include using the smallest trocar possible and choosing a conical-tipped over a pyramidal-tipped trocar.[38]

When an injury occurs, the operator must be prepared to control the bleeding promptly. First, an attempt can be made to coagulate the vessel with electrocautery. If another port is not available to use electrocautery, a Foley catheter can be placed through the trocar and the balloon inflated with saline. Upward traction on the catheter, maintained with a clamp on the abdominal side, slows the bleeding until more definitive measures can be performed. Once a second port is place, electrocautery can be used. If this approach does not result in hemostasis, transabdominal sutures have been advocated. However, this inexact approach has a risk of loosening in the immediate postoperative period. A more secure technique is to enlarge the incision and selectively ligate the epigastric vessels, which lie just below the rectus abdominis muscle adjacent to the peritoneum.

Intestinal injury

Both the small and large intestine can be injured during laparoscopy, posing a life-threatening situation for the patient if unrecognized. If the patient has had previous abdominal surgeries or a history of abdominal infections, such as PID or a ruptured appendix, the risk of injury to bowel adhered to the abdominal wall increases. Frequently, surgeons choose the open laparoscopy approach for these cases.[32]

Recently, with the introduction of disposable trocars, the relative safety of these instruments has been in contention. The disposable trocars have a safety shield, which is designed to extend over the blade and decrease bowel injury with entry of the trocar into the peritoneal cavity. These trocars are extremely sharp and easily penetrate the fascia, which may cause additional injury as the momentum of penetration continues into internal structures.

On the other hand, reusable trocars may not be maintained regularly, and a dull trocar pushed through the fascia with significant force may also abruptly pass through the fascia and cause internal injury. No study has examined the relative safety of disposable and reusable trocars, although one series showed the risk of bowel injury with disposable trocars to be approximately 3 times more than that reported for reusable trocars.

Thermal injury to the bowel is also a risk when using electrocautery, particularly monopolar electrosurgery, which can cause an arc of electricity to the bowel. This injury can cause peritonitis if unrecognized, and it is a life-threatening situation if not promptly treated. When using monopolar electrosurgery, having instruments checked regularly for insulation failure is important. Stray current injury can also be significantly reduced with the use of bipolar electrosurgical instruments.

If injury is recognized at the time of surgery, immediate action must be taken to repair the damage. However, frequently, minor injuries are not seen and manifest 24-48 hours after surgery. Counseling the patient before surgery is of utmost importance. Patients should be aware of symptoms that they must report, such as fever, chills, nausea and vomiting, and abdominal pain. In addition, patient counseling should include the risk of requiring a laparotomy and colostomy to repair injuries.

Urologic injuries

Injury to the bladder or ureters can occur during trocar placement or during the use of power instruments, stapling devices, or suturing devices. The greatest challenge is recognizing that the injury has occurred so that treatment can be performed in a timely manner.[25]

Draining the bladder with a catheter prior to trocar placement is the first step to preventing bladder injuries. If urine is not seen in the pelvis but an injury is likely, intravenous indigo carmine can be given and the surgeon should watch for leakage into the peritoneal cavity. If this test result is negative but injury is still suggested, a gravity cystogram may be performed. Small retroperitoneal injuries may be treated with Foley catheter placement for 7-10 days, but larger or intraperitoneal injures must be repaired through a laparotomy. Suprapubic, retroperitoneal, and transurethral drains may be used depending on the operator and the injury. If bladder injury is unrecognized at time of surgery, the patient may present with diminished urine output, hematuria, or suprapubic pain.

Ureteral injuries can occur with any procedure involving instrumentation near the ureters. Thermal injuries from laser or cautery may not be apparent for days after surgery. When a surgeon uses one of the power instruments, the operator must be aware of the position of the ureter and avoid cautery in close proximity to the ureter. If the ureter is ligated, the patient may present with flank pain secondary to hydronephrosis. If the ureter is transected, the patient may develop a urinoma or ascites and present 1-5 days postoperatively with abdominal pain, fever, or leukocytosis.

Incisional hernia

Before trocar and sleeves larger than 5 mm were used, incisional hernias were rare. However, larger ports have increased the number of incisional hernias, allowing a small amount of bowel to become trapped in the fascia. Therefore, fascial closure is recommended for incisions larger than 5 mm. Umbilical closure is not required unless a very large incision is made, such as with open laparoscopy. The patient is counseled to not perform any heavy lifting or straining for 30 days in order to minimize the risk of umbilical hernia.

Nerve injuries

Patient positioning during laparoscopic surgery is associated with a low risk of potentially serious nerve injury to either the upper or lower extremities. To minimize the risk of positional nerve injuries, laparoscopic surgeons should have a working knowledge of both the nerves at risk of injury during laparoscopy and should verify that each patient is positioned appropriately during surgery.[36]

Laparoscopic surgery is an uncommon cause of injuries to nerves of the upper extremities. Brachial plexus nerve injuries are discovered after approximately 0.16% of advanced laparoscopic procedures. To minimize the risk of brachial plexus injuries during laparoscopy, the arms should be tucked at the side of the patient whenever possible. Arms extended on arm boards should be abducted less than 90°. In addition, steep Trendelenburg position with the arms extended and shoulder braces should be avoided.

Lithotomy position for prolonged periods of time can result in injuries to nerves of the lower extremity, including the femoral, lateral femoral cutaneous, obturator, sciatic, and common peroneal nerves. Sensory deficits from such injuries are reported after 1.5% of cases performed in lithotomy position, and persistent motor deficits are found after 0.03% of cases. Careful positioning and boot stirrups both appear to decrease the risk of nerve injury, especially for laparoscopic procedures lasting more than 2 hours. Four important elements of correct lithotomy positioning include 1) hip flexion of 60-170°, 2) knee flexion of 90-120°, 3) hip abduction no more than 90°, and 4) minimal external hip rotation. Extrinsic pressure on the legs should be avoided.

Laparoscopy continues to evolve as more sophisticated instrumentation allows a greater variety of procedures to be performed. In the past, many of these procedures would have been limited to laparotomy and would have required a prolonged recovery period. The risks and benefits of the procedures in many cases have not been fully evaluated. Some procedures, such as tubal ligation, ectopic pregnancy removal, and simple adhesion lysis, appear to be safely and efficiently performed laparoscopically. However, more complicated procedures still need to be evaluated to determine the safest, most cost-effective, and most efficient procedure.

Gynecologic oncology

The laparoscopic approach for potential gynecologic malignancies remains controversial.[22] In cases of ovarian masses with low risk of malignancy, laparoscopy has become the approach of choice. In questionable cases, preliminary steps should be taken to stage the patient, including obtaining pelvic washings, inspecting the entire peritoneal cavity and pelvic structures, and biopsying suspicious lesions. Frozen section pathological evaluation can be obtained intraoperatively to diagnose or exclude malignancy.

In the case where a malignancy is unexpectedly diagnosed during laparoscopy, concern remains that spilling the contents of an ovarian malignancy into the abdominal cavity during removal might worsen the long-term prognosis. However, the patient's prognosis does not appear to be worsened as long as definitive treatment is not delayed and is carried out either immediately or within a matter of days.

Laparoscopy is used by some gynecologic oncologists for patients with known gynecologic malignancies to biopsy retroperitoneal lymph nodes and for second-look procedures to evaluate for residual tumors after chemotherapy. The unusual finding of tumor implantations at the trocar insertion sites has caused some investigators to consider whether or not some aspect of laparoscopy might promote tumor growth. Until the risk, benefits, and effects on long-term prognosis have been shown to be equal to laparotomy, the laparoscopic approach for known gynecologic malignancies will remain under close scrutiny.

Robotic laparoscopic surgery

The usefulness of robotics in laparoscopic surgery continues to be determined.[1] The first FDA-approved robotic surgical device called AESOP (Automatic Endoscopic System for Optimal Positioning, Computer Motion, Inc, Santa Barbara, Calif) was introduced in 1994. This system allowed the surgeon to control the orientation of the laparoscope through voice commands.

The da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, Calif) and Zeus Robotic Surgical System (Computer Motion, Inc, Santa Barbara, Calif) were later introduced, allowing the surgeon to operate from a remote station with hand controls, providing increased dexterity and the ability to minimize fatigue, tremors, or incidental hand movement. In 2003, these companies merged.

The da Vinci System is widely used for cardiovascular, urologic, and gynecologic applications. Prospective studies have yet to be performed to determine the advantage of the robotic approach compared with less expensive traditional laparoscopic techniques for gynecologic surgery.