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Laparoscopy in gynecology
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- 2. Contents ◉ Introduction ◉ History ◉Instruments ◉ Overview procedure ◉ Use as a diagnostic tool ◉ Use as a therapeutic modality ◉ Contraindications ◉ Risk factors ◉ Complications ◉ Recent advances ◉ Summary and conclusion
- 3. Laparoscopy A surgical procedurein which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery with help of pneumoperitoneum
- 4. Laparoscopic surgery Laparoscopic surgery,also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.5 cm)
- 5. History of laparoscopicsurgery Dr. Hans Christian Jacobaeus, a Swedish surgeon, was the first to publish a description of laparothorakoskopie in humans in 1910. Litynski GS. Laparoscopy--the early attempts: spotlighting Georg Kelling and Hans Christian Jacobaeus.JSLS. 1997. 1:83-5. He used air pneumoperitoneum and a cystoscope to evaluate the peritoneal cavity of tuberculosis patients with ascites.
- 6. History of laparoscopicsurgery 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 is still used today to create a pneumoperitoneum
- 7. History of laparoscopicsurgery 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. In addition to advocating monitoring of intra-abdominal pressure, he pioneered intra-abdominal electrocoagulation of bleeding sites, puncture of ovarian cysts, and lysis of pelvic adhesions. Palmer R. Safety in laparoscopy. J Reprod Med. 1974 Jul. 13(1):1-5.
- 8. History of laparoscopicsurgery Dr. Kurt Semm, a German gynecologist who specialized in infertility, invented the automatic insufflator & instruments like thermocoagulator, loop ligature, and devices for extracorporeal and intracorporeal endoscopic knot tying. Mettler L, Semm K, Shive K. Endoscopic management of adnexal masses. J Soc Laparoendosc Surg. 1997 Apr-Jun. 1(2):103-12.
- 9. History of laparoscopicsurgery Major breakthrough came with the introduction of the solid state video camera for laparoscopy in 1982. Both laparoscopist and assistants could simultaneously view the operative field on a video screen. By end of decade, laparoscopy became widely accepted as a safe and effective surgical approach
- 10. History of laparoscopicsurgery 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.
- 11. Basics of laparoscopy- Instruments Verres needle Used to inflate air/CO2 to the peritoneal cavity (pneumoperitoneum) through the umbilicus where there is the thinnest abdominal wall.
- 12. Basics of laparoscopy- Instruments Electronic laparoflator: Insufflator Used to insufflate through the verres needle. Maintains constant intra-abdominal pressure without exceeding the safety limit.
- 13. Basics of laparoscopy- Instruments Trocars Permit access to the intra-peritoneal cavity in which other instruments can pass. The trocar used should be adapted to the diameter of the telescope selected
- 14. Basics of laparoscopy- Instruments Telescope There are different sizes and angles, each with a different use. They are used to visualize the peritoneal cavity.
- 15. Basics of laparoscopy- Instruments Camera equipment & Light source
- 16. Basics of laparoscopy- Instruments Forceps and scissors There are two types: ◉ Disposable ◉ Reusable They can be either atraumatic or grasping foreceps.
- 17. Basics of laparoscopy- Procedure Preparation of the patient: ◉ Inform the patient about the therapeutic benefits and potential risks (informed consent). ◉ Intestinal preparation: Simple intestinal emptying, for better viewing and preventing injuries. ◉ Place the patient in the dorsolithotomy position.
- 18. Basics of laparoscopy- Procedure Creating a pneumoperitoneum: ◉ The abdominal wall is lifted by hand or by grasping forceps ◉ Pnemoperitoneum is created by verres needle introduced to the umbilical area ◉ The needle is inserted in an oblique angle toward the uterine fundus ◉ The negative pressure will allow the underlying structures to fall away. ◉ After making sure that the needle is in correct position, air flow can be increased to 2.5 L/min till a pressure of 15mmHg
- 19. Basics of laparoscopy- Procedure Trocar introduction Once the intra-abdominal pressure reaches 15 mmHg the main trocar is introduced after removal of veress needle. The position of the trocar must be verified by inserting the laparoscope and viewing the pelvic cavity.
- 20. Basics of laparoscopy- Procedure Viewing the peritoneal cavity The omentum, bowel and bifurcation of pelvic vessels should be evaluated to avoid injuries caused during the introduction of Verres needle or trocar. The site of introduction of other trocars should be verified by finger palpation and transillumination of abdominal wall to avoid injury to epigastric vessels. Identify if there is any bleeding
- 21. Basics of laparoscopy- Procedure During the operative procedure • 1 or 2 bottles of Ringer’s lactate are used to wash the peritoneal cavity after laparoscopy. • Leave 500/1000 ml of ringer’s lactate to reduce the incidence of post operative pain. After the procedure • CO2 gas must be evacuated completely to reduce post-operative pain
- 22. Applications of Laparoscopy ◉As a diagnostic tool ◉ As a therapeutic modality
- 23. Laparoscopy - asa diagnostic tool ◉ Infertility: status of the fallopian tube (morphology and functionality) and any pathological condition (e.g. adhesions) ◉ Ovarian cysts or tumors. ◉ Ectopic pregnancy. ◉ PID: tubal abscess or adhesions. ◉ Endometriosis: define the sites of implants and endometrial cysts.
- 24. Laparoscopy - asa diagnostic tool ◉ Chronic pelvic pain ◉ Ectopic pregnancy ◉ Pelvic inflammatory disease ◉ Endometriosis ◉ Adhesions ◉ Ovary: cysts, torsion ◉ Fallopian tube: torsion, salpingitis ◉ Uterus: fibroid, leiomyomata ◉ Pelvic congestion syndrome ◉ Infertility ◉ Oncologic procedures
- 25. Laparoscopy – inChronic Pelvic Pain (CPP) > 40% of gynecological diagnostic laparoscopies are done for CPP Combined results of published series of laparoscopies for CPP shows: ◉ No visible pathology is detected in 35% ◉ Endometriosis is diagnosed in 33% ◉ Adhesive disease is found in 24% A negative laparoscopy → not synonymous with no disease A meticulously performed negative laparoscopy means that a woman does not have endometriosis-associated or adhesion-associated pain The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
- 26. Laparoscopy – inEctopic pregnancy Transvaginal ultrasound has replaced laparoscopy for diagnosis of ectopic pregnancy. Laparoscopy has diagnostic role if probable tubal pregnancy or diagnosis in doubt. Large uncontrolled studies have demonstrated that > 80% of ectopic pregnancies can be managed laparoscopically The most commonly used procedures at laparoscopy are salpingectomy and salpingotomy. The role of laparoscopy in the management of ectopic pregnancy. Martin Christopher Sowter, MD, MRCOGa, Jonathan Frappell, FRCS, FRCOG Reviews in Gynaecological Practice #2 (2002) 73-82
- 27. Laparoscopy – inPelvic Inflammatory Disease (PID) Clinical diagnosis of PID is often difficult especially when symptoms are mild, as frequently when the primary organism is C. trachomatis. Laparoscopy is the gold standard for the diagnosis of PID – should be used when diagnosis is uncertain, especially in young women for whom the preservation of fertility is important. Sellors et al. reported that only by resorting to diagnostic laparoscopy were they able to demonstrate that PID was the cause of acute pelvic pain in 46% of a group of 95 women. Laparoscopy should be considered for patients who have not responded to antibiotic therapy within 48 to 72 hours. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Maria Grazia Porpora, M.D. FERTILITY AND STERILITY Vol. 6M, No. 5, November 1997.
- 28. Laparoscopy – inTubo-ovarian Abscess Most commonly isolated pathogens from a tubo- ovarian abscess are C. trachomatis and peptostreptococci. At laparoscopy the peritoneal cavity (pelvis and abdomen) is inspected carefully. The surgical steps include adhesiolysis, aspiration of the abscess cavity, dissection and excision of necrotic tissue, tubal lavage, and irrigation of the peritoneal cavity before completion of the procedure. Laparoscopic surgery combined with adequate broad- spectrum antibiotic therapy has proven successful in the treatment of more than 95% of patients.
- 29. Laparoscopy – inEndometriosis Endometriosis is a histologically-defined disease: “the presence of ectopic tissue which possesses the histological structure and function of the uterine mucosa” - Sampson,1921 Laparoscopy has largely replaced laparotomy as the diagnostic procedure for any patient suspected of having endometriosis. Based on visual appearance endometriosis are classified as atypical (red, yellow, white or clear) or typical (black-brown, black or puckered black stellate) lesions. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
- 30. Laparoscopy – inEndometriosis Endometriosis presents with a variety of appearances that may make visual diagnosis difficult and inaccurate. Brownish lesion on the ovary White fibrotic lesion on the uterosacral ligament Peritoneal pocket of endometriosis Red stellate lesions in the cul-de-sac The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
- 31. Laparoscopy – inAdhesions Presently the only definitive way to diagnose adhesions is by surgical visualization usually via laparoscopy instead of laparotomy. Laparoscopic studies reveal adhesions on average in 24% of CPP patients and 17% of non-CPP patients. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
- 32. Laparoscopy – inAdenomyosis Endometrial cells penetrate the myometrium causing either localized (adenomyoma) or diffuse overgrowth. Adenomyomas that penetrate the uterine cavity become submucosal tumors. An enlarged uterus from adenomyosis is often misdiagnosed as being from fibroids
- 33. Laparoscopy – inOvarian Cysts Most ovarian cysts are haemorrhagic corpora lutea or follicle cysts. They are usually asymptomatic and when they cause pain it is almost always acute. Laparoscopic evaluations of patients with CPP reveal ovarian cysts on average in only 3% of all cases. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
- 34. Laparoscopy – inOvarian Cysts Even when the surgeon is ‘certain’ that the ovary is benign, it is essential that tissue be sent for histological evaluation. Open the cyst and inspect the lining for papillary structures or excrescences. If these are noted, then a laparotomy should be done
- 35. Laparoscopy – inAdnexal Torsion A rare gynecologic emergency that nearly always occurs unilaterally. Relapse or bilateral adnexal torsion can cause sterility interfering with fertility. In 30% of the patients, there is torsion of a normal adnexa, while the majority of the cases are associated with ovarian pathology. Adnexal torsion in very young girls: diagnostic pitfalls. Marieke Emontsa, Heleen Doornewaardb, J.(Co’tje) F. Admiraala, European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 207-210.
- 36. Laparoscopy – inAdnexal Torsion Conservative management by laparoscopy is the best approach when tissues are viable and should be carried out promptly to preserve the adnexa (basic principles of conservative management are to untwist the structure and treat the underlying cause ‘ie - ovarian cyst’). Once untwisted, the organ must be observed to ensure color change to normal, confirming viability and blood supply. Adnexal torsion in very young girls: diagnostic pitfalls. Marieke Emontsa, Heleen Doornewaardb, J.(Co’tje) F. Admiraala, European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 207-210.
- 37. Laparoscopy – inEndosalpingiosis Endosalpingiosis is the presence of fallopian tubal glandular epithelium in an ectopic location. Visually it appears as white to yellow, opaque or translucent, punctate, cystic lesions. Endosalpingiosis is generally not recognized at the time of laparoscopic evaluation or is misdiagnosed as endometriosis. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000
- 38. Laparoscopy – inLeiomyomata (fibroids) The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000
- 39. Laparoscopy – inOncologic procedures Ghezzi F, Cromi A, Uccella S, Siesto G, Zefiro F, Bolis P. Incorporating Laparoscopy in the Practice of a Gynecologic Oncology Service: Actual Impact Beyond Clinical Trials Data. Ann Surg Oncol. 2009 May 21. Mori KM, Neubauer NL. Minimally invasive surgery in gynecologic oncology. ISRN Obstet Gynecol. 2013 Aug 12. 2013:312982. For second-look procedures following surgical and chemo treatment of malignancy. Laparoscopy has also been used for staging, including peritoneal washes with biopsy, partial omentectomy, and pelvic and periaortic lymphadenectomy Laparoscopically assisted radical vaginal hysterectomy have also been used by some gynecologic oncologists.
- 40. Laparoscopy - asa therapeutic tool 1. Management of ovarian cyst by • Drainage • Ovarian cystectomy • Ovarian drilling of the cortex and stroma to decrease androgens in the ovaries • Correcting ovarian torsion. • As a treatment of endometriosis By removal of the endometrial cyst, cauterization of endometrial spots and adhesiolysis
- 41. Laparoscopy - asa therapeutic tool 2. Management of infertility: • Adhesiolysis • Treat the cause (endometriosis, PCOS) 3. Myomectomy for fibroids: used for subserosal and intramural fibroids only, not used for submucosal fibroids. 4. Management of PID by draining tubal abscess and adhesiolysis.
- 42. Laparoscopy – inAdhesiolysis Adhesions may form due to prior infection, such as a ruptured appendix or pelvic inflammatory disease (PID), endometriosis, or previous 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
- 43. Laparoscopy – inMyomectomy The fibroid may be removed by morcellation or colpotomy. Power morcellators are available to expedite the process. If the patient has a pedunculated fibroid, the stalk may be easily incised. However, for intramural fibroids, the risk of bleeding increases.
- 44. Laparoscopy – inManagement of Ectopic Pregnancy Salpingotomy Used to preserve the tubes for desired reproductivity. Done if the patient is hemodynamicaly stable If size < 5 cm Location must be ampullary, infundibular or isthmic. Contralateral tube either normal or absent.
- 45. Laparoscopy – inManagement of Ectopic Pregnancy Salpingectomy (it is the standard for ectopic pregnancy) if: • Ruptured tube • Multiple recurrence of ectopic pregnancy • Size of ectopic > 5 cm
- 46. Laparoscopy – Tubalsterilization Tubal sterilization can be done using: ◉ Bipolar coagulation ◉ Clips (filshie clips) and rings Before the procedure, inform patient about: • Chance of irreversibility • Failure rate 1/200 • Bleeding may occur and we may shift to laparatomy.
- 47. Laparoscopic hysterectomy Laparoscopic hysterectomy: The3 basic laparoscopic approaches for hysterectomy are • laparoscopic-assisted vaginal hysterectomy (LAVH) • laparoscopic hysterectomy (LH) • laparoscopic supracervical hysterectomy (LSH)
- 48. Laparoscopy – contraindications 1.Generalized peritonitis 2. Hypovolemic shock 3. Severe cardiac disease 4. Hemoglobin less than 7 g/dL 5. Uterine size > 12 wks. 6. Multiple previous abdominal procedures 7. Extreme body weight
- 49. Laparoscopy – riskfactors Patient related risk factors ◉ Obesity ◉ Age ◉ Previous abdominal surgery Anesthetic risk factors ◉ Time since last oral intake ◉ Heart disease ◉ Pulmonary disease
- 50. Laparoscopy – Patientrelated risk factors Obesity ◉ Laparoscopy becomes more difficult and potentially more risky. ◉ Placement of laparoscopic instruments becomes much more difficult ◉ Bleeding from abdominal wall vessels may be more common because these vessels become difficult to locate. ◉ Restricted operative field secondary to retroperitoneal fat deposits in the pelvic sidewalls and increased bowel excursion into the operative field
- 51. Laparoscopy – Patientrelated risk factors Age ◉ Older patients are at increased risk of having concomitant disease processes that affect their perioperative morbidity and mortality
- 52. Laparoscopy – Patientrelated risk factors Previous abdominal surgery ◉ Risk of adhesions of omentum and/or bowel to the anterior abdominal wall after previous abdominal surgery is greater than 20%. ◉ As 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
- 53. Laparoscopy – pre-opwork-up 1. Complete blood cell count 2. Pregnancy test 3. Urinalysis 4. ECG 5. Other: • 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 6. Imaging studies: • Chest radiography • Intravenous pyelograph or kidney ultrasound • Barium enema
- 54. Laparoscopy – possible complications Laparoscopicprocedures have unique risks, related to: • methods used for the placement of abdominal wall ports • pneumoperitoneum required for laparoscopy 1. Pneumoperitoneum related complications 2. Injury to abdominal organs 3. Blood vessel injury
- 55. Laparoscopy complications – Pneumoperitoneum Pneumoperitoneumrelated complications • Extra-peritoneal emphysema due to failure of introducing verres needle correctly into the peritoneal cavity and not checking the negative pressure on the machine. • Gas may extend to the mediastinum and compromise cardiac function • Pneumo-omentum • Increased intra-abdominal pressures may increase anesthesia- related risks such as aspiration and increased difficulty ventilating the patient
- 56. Laparoscopy complications –abdominal organs Injury to abdominal organs • GI: if the intestine is distended or adherent to the abdominal wall (prevented by good intestinal preparation) and putting the patient on the telendelenburg position. • Bladder injury: prevented by emptying the bladder.
- 57. Laparoscopy complications –blood vessel injury Blood vessel injury: ◉ Pelvic, omental and mesentric blood vessel injury ◉ Prevented by introducing the verres needle in an angle. ◉ Although the risk of blood loss is relatively low, potentially massive blood loss may occur and is complicated as control may be delayed because of the time taken to perform an emergency laparotomy.
- 58. Laparoscopy – recentadvances 3 innovations that have been introduced in the field of laparoscopy: ◉ Robotic surgery ◉ Natural orifice transluminal surgery (NOTES) ◉ Single incision laparoscopic surgery (SILS). Of these 3 developing technologies, robotic surgery is having the largest impact on clinical care. Advincula AP, Wang K. Evolving role and current state of robotics in minimally invasive gynecologic surgery. J Minim Invasive Gynecol. 2009 May-Jun. 16(3):291-301 Swanström LL. Natural orifice transluminal endoscopic surgery. Endoscopy. 2009 Jan. 41(1):82-5.
- 59. Laparoscopy – roboticsurgery Robotic system advantages: • 3-dimensional, high-definition imaging and magnification. • Fully articulated instruments emulate the full range of motion of a surgeon’s wrists and hands. • Enhances the surgeon’s ability to remotely perform fine motor skills such as intricate dissections and intracorporeal suturing that remain difficult during traditional laparoscopy.
- 60. Laparoscopy – roboticsurgery Robotic system advantages: • 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. • Direct correlation between hand movements and instrument movements. Advincula AP, Wang K. Evolving role and current state of robotics in minimally invasive gynecologic surgery. J Minim Invasive Gynecol. 2009 May-Jun. 16(3):291-301.
- 61. Natural orifice transluminalsurgery Using an endoscope to access the abdominal cavity through existing body openings (Ex: mouth, rectum, and vagina) Modern NOTES uses a flexible endoscope to access the peritoneal cavity by creating an incision in the stomach or colon. ABARBANEL AR. Transvaginal pelvioscopy (peritoneoscopy); a simplified and safe technic as an office procedure. Am J Surg. 1955 Jul. 90(1):122-8.
- 62. Single incision laparoscopicsurgery Single incision laparoscopic surgery (SILS) refers to performing laparoscopy through a single incision. Bradford LS, Boruta DM. Laparoendoscopic single-site surgery in gynecology: a review of the literature, tools, and techniques. Obstet Gynecol Surv. 2013 Apr. 68(4):295-304.
- 63. Advantages vs disadvantages ◉Minimizes the number of incisions ◉ In turn results in decreased pain, improved cosmetics ◉ Reduces the risks associated with a secondary port placement. Bradford LS, Boruta DM. Laparoendoscopic single-site surgery in gynecology: a review of the literature, tools, and techniques. Obstet Gynecol Surv. 2013 Apr. 68(4):295-304. Eom JM, Choi JS, Choi WJ, Kim YH, Lee JH. Does Single-Port Laparoscopic Surgery Reduce Postoperative Pain in Women with Benign Gynecologic Disease?. J Laparoendosc Adv Surg Tech A. 2013 Oct 1. visibility, depth perception, maneuverability, reach, and the ability to create counter-traction are all limited. Advantages Disadvantages
- 64. Laparoscopy – riskvs benefit 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. Its an intra-abdominal procedure - therefore, it shares all intraoperative and postoperative risks of laparotomy, including infection and injury to adjacent intra-abdominal structures
- 65. Laparoscopy – summary Laparoscopycontinues to evolve as more sophisticated instrumentation allows a greater variety of procedures to be performed The risks and benefits of the procedures in many cases have not been fully evaluated Procedures, such as tubal ligation, ectopic pregnancy removal, and simple adhesion lysis, appear to be safely and efficiently performed laparoscopically. But more complicated procedures still need to be evaluated to determine the safest, most cost-effective, and most efficient procedure.
- 66. Laparoscopy – conclusion Laparoscopyprovides a vital tool for diagnosing pelvic pain. Laparoscopy provides first hand visual comprehension of the problem as well as an immediate opportunity to continue with therapeutic surgical correction. In the past, many of these procedures would have been limited to laparotomy and would have required a prolonged recovery period.
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