INTRODUCTION

During the last 25 years, the role of gynecologic laparoscopy has evolved from a limited surgical procedure used only for diagnosis and tubal ligation, to a major surgical tool used to treat a multitude of gynecologic indications. Laparoscopy has become one of the most common surgical procedures performed by gynecologists.

For many procedures, such as removal of ectopic pregnancies and treatment of endometriosis, the cost-to-benefit ratio is well established, particularly in terms of expense and safety. For other procedures, including laparoscopically assisted hysterectomy and staging of gynecologic cancers, the ultimate utility of this approach remains to be clearly defined.

History of the Procedure: Laparoscopy was first performed in animals in the early 1900s, and the Swedish surgeon Jacobaeus coined the term laparoscopy (laparothorakoskopie) in 1901. It was not until the early 1960s, however, that better techniques were developed and laparoscopy was accepted as a safe and valuable procedure. Initially, laparoscopy was performed almost exclusively for diagnosis and sterilization. By the late 1970s, the role of laparoscopy had expanded to include lysis of adhesions and treatment of endometriosis. Technology and equipment have now advanced to include the use of laparoscopy in hysterectomies, incontinence procedures, and operations for gynecological malignancies.

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

At its essence, laparoscopy remains an intra-abdominal procedure. It therefore shares all intraoperative and postoperative risks of laparotomy, including infection 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, but they always are less significant than similar major surgery performed by laparotomy since a large abdominal incision is unnecessary.

Laparoscopic procedures have unique risks, which are related to methods used for placement of abdominal wall ports and to the pneumoperitoneum required for laparoscopy. 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 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.

Frequency: Laparoscopy is one of the most common surgical procedures performed in the United States today. Approximately half of the 700,000 bilateral tubal sterilizations done 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. Many of the 650,000 hysterectomies performed annually in the United States are now being done with laparoscopic aid. Although the ideal role of laparoscopy in gynecologic surgery is still being defined, use of this approach is likely to become more common in years to come.

INDICATIONS

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 also may 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 can be obtained to diagnose endometriosis or a malignancy. If tubal patency is a concern, use of a uterine manipulator with a cannula allows a dilute dye to be injected transcervically (chromopertubation).

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 3 cm from the cornua. 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

RELEVANT ANATOMY AND CONTRAINDICATIONS

Relevant Anatomy: Anterior abdominal wall anatomy should receive special attention prior to laparoscopy since many laparoscopic complications result from trocar placement.

Abdominal scars

As noted above, previous surgery is associated with a greater than 20% risk of adhesions of bowel or omentum to the anterior abdominal wall. For this reason, many laparoscopists adjust their techniques in these patients to minimize risk of bowel injury. Of special concern are incisional scars immediately adjacent to the umbilicus, since 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 also may be associated with adhesions, in many laparoscopists' experience, 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, since a wide or retracted scar may suggest that a postoperative wound infection had occurred. It is common wisdom 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.

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. Routine evaluation of the abdominal wall prior to laparoscopy is important since 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. Larger defects may require the assistance of a surgeon experienced in umbilical hernia repair for ideal cosmetic results.

Contraindications: 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. Recent reports, however, suggest that morbidity is lower with the laparoscopic approach than with laparotomy. In gynecology, the most commonly suggested contraindication is hemodynamic instability resulting from an unruptured ectopic pregnancy. Following appropriate fluid resuscitation, however, laparoscopy is a safe approach. Another traditional contraindication was pregnancy. In the last few years, several large series have documented the safety of laparoscopy during pregnancy with the use of an open technique. 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

Obesity

It is well appreciated that obesity 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 become more common since 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 probably is related to increased volume of bowel, decreased elevation of a heavier anterior abdominal wall by the pneumoperitoneum, and the inability to place many obese patients in steep Trendelenburg because of ventilation considerations.

Weight loss prior to elective surgery in overweight and obese patients 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 limit the extent of advanced laparoscopic procedures that are attempted in obese patients. Although no certain weight exists at which laparoscopy is contraindicated, many surgeons hesitate to perform all but the simplest laparoscopic procedures in patients weighing over 136 kg (300 lb).

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. Risk is increased even greater in women who have not taken replacement hormones after menopause. 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 the elderly to hypothermia since 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%. Since laparoscopy requires the insertion of sharp instruments into the abdominal cavity, it stands to reason that previous surgery would increase the risk of bowel injury. Thus, strategies to decrease the risk of bowel injury in patients with previous abdominal surgery have been developed.

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 utilized 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 (usually in the left upper quadrant) has been recommended for trocar insertion to avoid injury of bowel adherent immediately beneath the umbilicus. Since not much is known about the rate of injuring structures in this area (eg, spleen, colon, common iliac vessels), when using a closed insertion technique, it may be prudent to use an open approach in this alternative location for trocar insertion.

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 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 utilized 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.

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, since both general anesthesia and increased intra-abdominal pressure may increase 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, it is recommended 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 incidence of aspiration pneumonia, including administration of agents to decrease gastric acidity, such as antacids or histamine receptor antagonists, or use of drugs that increase gastric emptying, such as metoclopramide.

Heart disease

Preoperative evaluation should search for evidence of underlying cardiac disease. With a positive history or physical 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 increase 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. There also is an increase of arrhythmia with distention of the abdomen, especially in patients who are spontaneously breathing.

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

Pulmonary disease

Any patient with 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 with patients with pulmonary disease during laparoscopy. 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.

WORKUP

Lab Studies:
　

• Complete blood count

• In general, one of the few required laboratory evaluations in a healthy patient is a complete blood count (CBC).

• Anemia increases the risk of anesthetic complications and infections, both at the operative site and the skin incision. In addition, an anemic patient has 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, since both surgery and anesthesia should be avoided during pregnancy. Although the most commonly used anesthetics show little evidence of 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 were surgically sterile or who are known to be pregnant.

• A urine pregnancy test is adequate in most cases, since these modern tests accurately detect beta-hCG levels of 50 mIU/mL or more, a level usually reached by 4 weeks from the last menstrual period. Since this type of pregnancy test can be performed in the pre-surgical 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 as to whether they could be pregnant and when their last menstrual period was immediately prior to surgery.

• An alternative to performing routine pregnancy tests prior to surgery is to schedule all elective surgery during the follicular phase (i.e., within 2 weeks of the last menstrual period). Not only dose 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 detect an unsuspected systemic disease, such as diabetes, which should be completely evaluated prior to elective surgery.More commonly, urinalysis 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 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 electrolytes, may be indicated.

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

Imaging Studies:
　

• Chest radiography

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

• In patients with coexisting bronchopulmonary conditions, cardiac conditions, or abnormal clinical cardiopulmonary findings, a preoperative CXR certainly is important. CXR also is part of the basic workup for anyone suspected of having 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 also is important. Hydronephrosis, indicating partial or complete obstruction of the ureter, can be ruled out using kidney ultrasound 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 barium enema with air contrast is important.

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

Other Tests:
　

• 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 over the age of 50 years old, since risk of heart disease increases at this time.

• 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.

TREATMENT

Surgical therapy:

General techniques for laparoscopy

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. Four common approaches are Veress needle insertion followed by a primary trocar insertion, direct trocar insertion, open laparoscopy, and optical trocar placement. Physician experience significantly contributes to the safety of the individual technique. Both reusable and disposable instruments are available. Choice of instrumentation should take into account the condition of the available reusable equipment and cost of the disposable equipment.

Veress needle and primary trocar insertion

Secondary trocars are required to perform 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.

Monopolar electrosurgery was the first methodology used for laparoscopic coagulation. In the past 20 years, other methodologies have been developed to minimize 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 in more. A recent addition to laparoscopic surgery is the Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio), which uses ultrasonic waves to produce cutting and coagulation. Scissors, hook, and ball accessories are available. Like laser, decreased hemostasis and increase cost must be considered.

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, but for most surgeons is relatively difficult and slow. The first technique developed to assist in occluding large vessels was the pre-tied 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 laparoscopic hysterectomy (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.

Preoperative details:

Preoperative medications

Estrogen replacement therapy

In postmenopausal women, estrogen replacement therapy (ERT) is an excellent preoperative adjuvant from several perspectives. If surgery for pelvic relaxation (such as vaginal vault suspension) or for urinary incontinence (such as laparoscopic Burch procedure) is planned, several months of ERT prior to therapy will significantly increase tissue thickness, resilience, and blood supply. Well estrogenized genitourinary tissue will make the necessary repair much simpler and may reduce risk of operative site infection.

On a more general level, women using ERT are known to have a lower risk of coronary heart disease; therefore, they also may be reasonably expected to have a decreased risk of cardiovascular complications during surgery.

Gonadotropin-releasing hormone agonists

On the opposite end of the spectrum are premenopausal women who 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 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 laparoscopically assisted vaginal hysterectomy 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 also may 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, it makes intuitive sense that prophylactic antibiotics would be beneficial in these patients as well.

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. Since 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

Risk of postoperative thromboembolism appears to be increased by the preoperative use of high-dose oral contraceptives (50 mg of ethinyl estradiol) in women undergoing major gynecologic surgery. Whether contemporary low-dose preparations (35 mg) 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 it is unsafe to continue low-dose oral contraceptives up until the time of most laparoscopic procedures. Women undergoing laparoscopically assisted hysterectomy, however, should probably discontinue oral contraceptives 1 month prior to surgery unless the patient decides that risk of inadvertent pregnancy is greater than the small, but uncertain, increased risk of thromboembolism associated with preoperative oral contraceptives.

Preoperative gastrointestinal preparation

Bowel preparation

If significant enterolysis is planned and either endometriosis or pelvic adhesions are known or suspected to be present, preoperative bowel preparation decreases risk of serious postoperative sequelae. Although a multitude of bowel preparations have been described, the most common oral agents used are either magnesium citrate or a polyethylene glycol solution. Unfortunately, a thorough bowel preparation often is uncomfortable for the patient. In high-risk patients, however, 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" remains a sound approach in the majority of 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 fewer than 6 hours.

Other preoperative considerations

Intravenous access

Because of the rare but serious risk of sudden and potentially massive blood loss during laparoscopy, establishment of intravenous access prior to starting the case is required. 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 of 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 may, on occasion, 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 use of an indwelling catheter to avoid bladder refilling, although this probably increases the risk of infection.

Deep vein thrombosis prophylaxis

When hysterectomy is planned, intraoperative and postoperative use of pneumatic compression stocking with or without low-dose heparin decreases risk of venous thromboembolic complications. These measures also should be considered in any patient whose ability to ambulate may be decreased by conditions other than the planned surgery. After less extensive laparoscopic procedures in healthy patients, risk of thromboembolism appears to be small since most will be fully ambulatory within hours of surgery. For these patients, methods for deep vein thrombosis prophylaxis are not commonly used.

Patient positioning

Gynecologic laparoscopy procedures usually are performed 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 foot plate and also support the popliteal fossa. Laparoscopic stirrups, however, 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, legs should be positioned so that the thigh is slightly flexed, no more than 90?from the plane of the abdomen. The thighs should not be hyperextended to avoided nerve injury. For high lithotomy, legs should be positioned so that the angle between the flexed thigh and the abdomen is no less than 45? The buttock should be slightly over the edge of the table, but the sacrum should be completely supported by the table to avoid back strain.

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 obese patients. 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 for prolonged periods has been associated with Erb palsy, especially with the use of shoulder braces.

Skin preparation

Shaving of 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 place 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, risk of infection involving the wound or the peritoneal cavity after laparoscopy is extremely low, most likely because of small incisions and decreased opportunity for intra-abdominal contamination. With the advent of video laparoscopy, there is no reason that standard sterile precautions cannot be applied to all laparoscopic procedures.

Intraoperative details:

Anesthesia considerations

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, abdominal insufflation and routine use of the Trendelenburg position, general anesthesia is probably the most common technique.

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 about 15 minutes of insufflation. Acidosis can be corrected by increasing ventilation 10-25% and usually has minimal effect on healthy patients. In susceptible patients, however, these changes in acid-base status may increase risk of cardiac arrhythmia. Probably a more significant effect of abdominal insufflation is increased pressure on abdominal structures. As well as being associated with significant discomfort in conscious patients, increased pressure can 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 also is 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 have direct cardiac effects as well. 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 increases 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 also is 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 obese patients, who often require relatively high intra-abdominal pressures and steep Trendelenburg to obtain adequate visualization of the pelvis. For this reason, use of local or regional anesthesia should be limited to non-obese patients who have a reasonable amount of pain tolerance and who do not require a significant degree of intra-abdominal surgery.

Postoperative details: After any gynecologic laparoscopic procedure, progressive resolution of symptoms during the first postoperative 3-7 days is to be expected. 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. This should be done with caution, however, since delay of appropriate care often can 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. Bowel herniation, however, 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, where a palpable bulge is the most common presenting symptom, and entrapment is uncommon. After laparoscopy, herniation may present as severe abdominal pain accompanied by signs of bowel obstruction. Although incisional hernias always should be considered as a cause of abdominal pain after laparoscopic surgery, they are relatively infrequent. Thus, other intra-abdominal processes also should be considered.

Follow-up care: 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. Since 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, since 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.

COMPLICATIONS

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 in laparoscopy to create the pneumoperitoneum, a gas embolization is an uncommon but very serious complication. Embolization usually is caused by inadvertent placement of the Veress needle in a major vessel prior to insufflation of the abdominal cavity with carbon dioxide. Placement in the aorta or one of its major branches allows carbon dioxide to escape into the vessel, which produces temporary arterial occlusion. Usually the carbon dioxide is quickly absorbed from the artery, and no serious results have been reported secondary to arterial embolization. In these cases, arterial bleeding would be the major complication. On the other hand, embolization of carbon dioxide into the venous system 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 one of the following tests indicates malposition, the needle must be repositioned:

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

   　

2. Aspirate with a syringe through the Veress needle.

   　

3. 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.

   　

4. Elevate the abdomen with the Veress valve closed, then assess for a hissing sound as the Veress valve is opened. Alternatively, the Veress 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 present in approximately 3 per 10,000 laparoscopies, may occur during insertion of the Veress or the primary trocar.

In theory, the aorta and inferior vena cava are avoided if one inserts the Veress or trocar through the umbilicus toward the hollow of the pelvis, since the umbilicus usually lies over the bifurcation of the aorta at L4. However, 25% of the time the bifurcation is above or below L4. Also, the left common iliac vein frequently crosses directly below the umbilicus. The thin patient poses an additional risk since the distance from the umbilicus to the retroperitoneal vessels may be as short as 2-3 cm. In obese patients, 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 suspected, 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. Although some surgeons have advocated keeping the Veress needle in place to mark the position of the injury, this approach has never been tested and may actually impede definitive surgery or inadvertently enlarge the vessel injury.

Abdominal wall vessel injury

FUTURE AND CONTROVERSIES

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 pregnancies, and simple lysis of adhesions, appear to be safely and efficiently performed laparoscopically. More complicated procedures, however, still need to be evaluated to determine what is the safest and most efficient procedure.

The laparoscopic approach in gynecologic oncology remains very controversial and must be done with the same care (inspecting the entire peritoneal cavity and pelvic structures) as with laparotomy. Until the risk, benefits, and effects on long-term prognosis have been shown to be equal to laparotomy, the laparoscopic approach will remain under close scrutiny.