Gynecology_Novak

Gynecology_Novak. Preoperative mechanical bowel preparation was perceived as reducing the morbidity of colonic surgery should an injury occur and improving visualization and exposure of the operative field at laparoscopy. There is an abundance of high-quality evidence demonstrating that preoperative mechanical bowel preparation does not reduce the morbidity of colonic surgery (77). There is one high-quality trial that shows that mechanical bowel preparation may not improve visualization at gynecologic laparoscopy (78). It is premature to abandon preoperative bowel preparation to improve visualization, because, in a small subset of patients, it may facilitate surgery. Mechanical bowel preparation should be considered to help improve visualization in selected instances where stool in the colon might compromise visualization of the operative field.


Gynecology_Novak

Gynecology_Novak. Communication with the family or other designated individuals should be arranged prior to the procedure. The patient should arrange for a friend or family member to be present to discuss the results of the procedure with the physician and to drive her home if she is discharged the same day. To facilitate the discussion of laparoscopic equipment, supplies, and techniques, it is useful to divide procedures into “core competencies,” which are as follows: 1. 2. 3. 4. 5. Manipulation of tissue and ﬂuid 6. Cutting, hemostasis, and tissue fastening 7. 8.


Gynecology_Novak

Gynecology_Novak. 2. 3. 4. 5. Manipulation of tissue and ﬂuid 6. Cutting, hemostasis, and tissue fastening 7. 8. Patient Positioning Proper positioning of the patient is essential for patient safety, comfort of the operator, and optimal visualization of the pelvic organs. There may be advantages to positioning the patient while awake to reduce the frequency of positioning-related complications. Laparoscopy is performed on an operating table that can be tipped to create a steep, head-down (Trendelenburg) position that allows the bowel to move out of the pelvis to facilitate visualization after the cannulas is placed. The footrest can be dropped to allow access to the perineum. The patient is placed in the low lithotomy position, with the legs appropriately supported in stirrups and the buttocks protruding slightly from the lower edge of the table (Fig. 23.1). The thighs are usually kept in the neutral position to preserve the sacroiliac angle, reducing the tendency of


Gynecology_Novak

Gynecology_Novak. Figure 23.1 Patient positioning: the low lithotomy position. The patient’s buttocks are positioned so that the perineum is at the edge of the table. The legs are well supported with stirrups, with the thighs in slight ﬂexion. Too much ﬂexion may impede the manipulation of laparoscopic instruments while in the Trendelenburg (head-down) position. bowel to slide into the peritoneal cavity. The feet should rest ﬂat, and the lateral aspect of the knee should be protected with padding or a special stirrup to avoid peroneal nerve injury.


Gynecology_Novak

Gynecology_Novak. bowel to slide into the peritoneal cavity. The feet should rest ﬂat, and the lateral aspect of the knee should be protected with padding or a special stirrup to avoid peroneal nerve injury. The knees should be kept in at least slight ﬂexion to minimize stretching of the sciatic nerve and to provide more stability in the Trendelenburg position. The arms are positioned at the patient’s side by adduction and pronation to allow freedom of movement for the surgeon and to lower the risk for brachial plexus injury (Fig. 23.2). Care must be exercised to protect the patient’s fingers and hands from injury when the foot of the table is raised or lowered. After the patient is properly positioned, the bladder should be emptied with a catheter and a uterine manipulator positioned in the endometrial cavity and secured either by an intracavitary balloon or attached to the cervix as appropriate.


Gynecology_Novak

Gynecology_Novak. The arrangement of instruments and equipment is important for safety and efficiency. The orientation depends on the operation, the instruments used, and whether the surgeon is right-or left-handed. An orientation for a right-handed operator is shown in Figure 23.2. For pelvic surgery, the television monitor is typically placed at or over the foot of the table within the angle formed by the patient’s legs. If two monitors are available, one may be positioned at each foot of the patient allowing both the surgeon and the assistant the opportunity to view the surgical field without having to turn the head.


Gynecology_Novak

Gynecology_Novak. The surgeon usually stands by the patient’s left side, at an angle facing the patient’s contralateral foot. The nurse or technician and instrument table are positioned near the foot of the operating table to avoid obscuring the video monitor. The insufﬂator may be placed on the patient’s right side, in front of the surgeon, to allow continuous monitoring of the inﬂation rate and intra-abdominal pressure. The energy source (e.g., electrosurgical or ultrasonic generator) may be positioned on the patient’s right side to permit visualization of the power output. Figure 23.2 Operating room organization. The patient’s arms are at the sides. The right-handed surgeon stands on the patient’s left. Instruments and equipment are distributed around the patient within view of the surgeon. For pelvic surgery, the monitor should be located between the patient’s legs.


Gynecology_Novak

Gynecology_Novak. Peritoneal Access Before inserting the laparoscope, a primary cannula (or port) must be positioned in the abdominal wall to establish access to the peritoneal cavity. The closed technique is a blind approach in which the cannula is introduced with an obturator designed to penetrate the abdominal layers. In open laparoscopy, initial entry into the peritoneal cavity is achieved with minilaparotomy using either a transverse subumbilical or midline infraumbilical incision down to the rectus fascia, to which the cannula is fixed into position with sutures or other suitable techniques. Gynecologists generally favor a closed technique, preinﬂating the peritoneal cavity with CO2 through a hollow insufﬂation needle. In either case, additional cannulas are


Gynecology_Novak

Gynecology_Novak. Figure 23.3 Vascular anatomy of the anterior abdominal Figure 23.3 wall relative to the sites of port insertion. The location of the vessels that can be traumatized when inserting trocars into the anterior abdominal wall is indicated. The lateral trocars should be placed lateral to the inferior epigastric vessels that course medially to lie under the rectus muscle anterior to the posterior rectus sheath. The relative anatomy of the left upper quadrant port site is shown: the closest structure is the stomach (A) (approximately 4 cm away) and the left lobe of the liver (B) approximately (4 cm away). The spleen (C) is approximately 12 cm away. subsequently inserted under direct vision to allow the use of laparoscopic hand instruments such as scissors, probes, and other manipulating devices.


Gynecology_Novak

Gynecology_Novak. Insertion of the insufﬂation needle and primary cannula is aided by an understanding of the normal underlying anatomy, especially the location of the larger retroperitoneal vessels (Fig. 23.3). A “safety zone” exists inferior to the sacral promontory in the area bounded cephalad by the bifurcation of the aorta, posteriorly by the sacrum, and laterally by the iliac vessels (79). In women placed in the Trendelenburg position, the great vessels are oriented more cephalad and anterior, making them more vulnerable to injury unless appropriate adjustments are made in the angle of insertion (Fig. 23.4) (80). Therefore, positioning of the insufﬂation needle and the primary cannula is best accomplished with the patient in an unaltered supine (horizontal) position. This approach facilitates the evaluation of the upper abdomen, which is limited if the intraperitoneal contents are shifted cephalad by the head-down (Trendelenburg) position.


Gynecology_Novak

Gynecology_Novak. Virtually all insufﬂation needles are modifications of the hollow needle designed by Verres (Fig. 23.5). In cases uncomplicated by previous pelvic surgery, the preferred site for insertion is the base of the umbilicus, where the abdominal wall is the thinnest and usually avascular. 1. A midline infraumbilical incision adequate for the needle is made at the base of the umbilicus with a small scalpel, and the abdominal wall is maximally lifted, either manually or with instruments. Elevation is accomplished manually after affixing towel clips to the abdominal wall on either side lateral to the umbilicus or opposite one another within the edge of the umbilical incision itself (81). Figure 23.4 Vascular anatomy. Location of the great vessels and their changing relationship to the umbilicus with increasing patient weight (from left to right).


Gynecology_Novak

Gynecology_Novak. Figure 23.4 Vascular anatomy. Location of the great vessels and their changing relationship to the umbilicus with increasing patient weight (from left to right). Safe insertion of the insufﬂation needle mandates that the instrument be maintained in a midline, sagittal plane while the operator directs the tip between the iliac vessels, anterior to the sacrum but inferior to the bifurcation of the aorta and the proximal aspect of the vena cava. Because the sacral promontory is commonly covered in part by the left common iliac vein, vascular injury may occur in the midline below the bifurcation (82).


Gynecology_Novak

Gynecology_Novak. To reduce the risk of retroperitoneal vascular injury while minimizing the chance of inadvertent preperitoneal insufﬂation, in women of average weight, the insufﬂation needle is directed to the patient’s spine at a 45-degree angle. In heavy to obese individuals, this angle may be increased incrementally to nearly 90 degrees, accounting for the increasing thickness of the abdominal wall and the tendency of the umbilicus to gravitate caudad with increasing abdominal girth (79,83). The needle’s shaft is held by the tips of the fingers and steadily but purposefully guided into position only far enough to allow the tip’s entry into the peritoneal cavity. The tactile and visual feedback created when the needle passes through the facial and peritoneal layers of the abdominal wall may provide guidance and help prevent overaggressive insertion attempts. This proprioceptive feedback is less apparent with disposable needles than with the classic Verres needle. With the former, the surgeon must


Gynecology_Novak

Gynecology_Novak. and help prevent overaggressive insertion attempts. This proprioceptive feedback is less apparent with disposable needles than with the classic Verres needle. With the former, the surgeon must listen to the “clicks” as the needle obturator retracts when it passes through the rectus fascia and the peritoneum. The needle should never be forced. Regardless of technique, the underlying retroperitoneal vessels are protected ultimately by limiting the insertion depth of the insufﬂation needle.


Gynecology_Novak

Gynecology_Novak. Figure 23.5 Insufﬂation needle. When pressed against tissue such as fascia or peritoneum, the spring-loaded blunt obturator (inset) is pushed back into the hollow needle, revealing its sharpened end. When the needle enters the peritoneal cavity, the obturator springs back into position, protecting the intraabdominal contents from injury. The handle of the hollow needle allows the attachment of a syringe or tubing for insufﬂation of the distention gas. Figure 23.6 Insufﬂation needle and cannula insertion sites. In most instances, both the insufﬂation needle, if used, and the primary cannula are inserted through the umbilicus. When subumbilical adhesions are known or suspected, the insufﬂation needle may be placed through the pouch of Douglas or in the left upper quadrant after evacuation of the gastric contents with an orogastric tube. 2.


Gynecology_Novak

Gynecology_Novak. In instances where known or suspected intra-abdominal adhesions surround the umbilicus, alternative sites should be used for insufﬂation needle insertion. These sites include the left upper quadrant, most often at the left costal margin, the pouch of Douglas, and the fundus of the uterus (Fig. 23.6). The left upper quadrant is preferred if hepatosplenomegaly is not present and the patient has not previously had surgery in this area. In such patients, the stomach must be decompressed with a nasogastric or orogastric tube before the needle is inserted (84). While at this location the distance between the skin and the posterior peritoneum is generally more than 11 cm, in thin individuals, it may be as little as 7 cm, so the angle of insertion should take this into account. The needle should be directed medially, about 10 to 15 degrees to avoid the kidney and renal artery; in women of relatively high body mass index it can be placed at a 90-degree angle to the skin, and in thin women,


Gynecology_Novak

Gynecology_Novak. be directed medially, about 10 to 15 degrees to avoid the kidney and renal artery; in women of relatively high body mass index it can be placed at a 90-degree angle to the skin, and in thin women, this angle should be reduced to about 45 degrees (84,85).


Gynecology_Novak

Gynecology_Novak. 3. Before insufﬂation, the operator should try to detect whether the insufﬂation needle was malpositioned in the omentum, mesentery, blood vessels, or hollow organs such as the stomach or bowel. The most direct approach is to use a specially designed insufﬂation needle that has an integrated cannula through which a small diameter (2 mm) laparoscope can be passed to visualize the point of entry. Otherwise, indirect methods are necessary. Using a syringe attached to the insufﬂation needle, blood or gastrointestinal contents may be aspirated. To facilitate this examination, a small amount of saline may be injected into the syringe. If the needle is appropriately positioned, negative intra-abdominal pressure is created by lifting the abdominal wall. This negative pressure may be demonstrated by aspiration of a drop of saline placed over the open, proximal end of the needle or, preferably, by using the digital pressure gauge on the insufﬂator. 4.


Gynecology_Novak

Gynecology_Novak. 4. Additional signs of proper placement may be sought after starting insufﬂation. The intra-abdominal pressure reading should be low, reﬂecting only systemic resistance to the ﬂow of CO2. Consequently, there should be little deviation from a baseline measurement, generally less than 10 mm Hg. The pressure varies with respiration and is slightly higher in obese patients. The earliest reassuring sign is the loss of liver “dullness” over the lateral aspect of the right costal margin. This sign may be absent if there are dense adhesions in the area, usually the result of previous surgery. Symmetric distention is unlikely to occur when the needle is positioned extraperitoneally. Proper positioning can be shown by lightly compressing the xiphoid process, which increases the pressure measured by the insufﬂator. 5.


Gynecology_Novak

Gynecology_Novak. 5. The amount of gas transmitted into the peritoneal cavity should depend on the measured intraperitoneal pressure, not the volume of gas inﬂated. Intraperitoneal volume capacity varies significantly between individuals. Many surgeons prefer to insufﬂate to 25 to 30 mm Hg for positioning the cannulas, and a body of evidence exists supporting this approach (86). This level usually provides extra volume and enough counter pressure against the peritoneum, facilitating introduction of the cannula and potentially reducing the chance of bowel or posterior abdominal wall and vessel trauma. After placement of the cannulas, the pressure should be dropped to 10 to 15 mm Hg, which reduces the risk of subcutaneous insufﬂation leading to crepitus and essentially eliminates hypercarbia or decreased venous return of blood to the heart (84,86,87).


Gynecology_Novak

Gynecology_Novak. Laparoscopic cannulas (or ports) allow the insertion of laparoscopic instruments into the peritoneal cavity while maintaining the pressure created by the distending gas (Figs. 23.7 and 23.8). Cannulas are hollow tubes with a valve or sealing mechanism at or near the proximal end. The cannula may be fitted with a Luer-type port that allows attachment to tubing connected with the CO2 insufﬂator. Larger-diameter cannulas (8 to 15 mm) may be fitted with adapters or specialized valves that allow the insertion of smaller-diameter instruments without loss of intraperitoneal pressure.


Gynecology_Novak

Gynecology_Novak. The obturator is a longer instrument of slightly smaller diameter that is passed through the cannula, exposing its tip. Most obturators are called trocars because their tip is designed to penetrate the abdominal wall after the creation of an appropriately sized skin incision. Many disposable trocar-cannula systems are designed with a safety mechanism—usually a pressure-sensitive spring that either retracts the trocar or deploys a protective sheath around its tip after passage through the abdominal wall. None of these protective devices makes insertion safer, and they all increase the cost of the equipment.


Gynecology_Novak

Gynecology_Novak. In the “closed” laparoscopic access technique, cannulas can be inserted either after the successful creation of a pneumoperitoneum or without previously instilling intraperitoneal gas, also referred to as direct insertion. With open laparoscopy, there may be less risk of injury to the major blood vessels such as the aorta, inferior vena cava, and common iliacs. Open laparoscopy cannot prevent all insertion accidents because intestine can be entered inadvertently no matter how small the incision. There is little evidence that a pneumoperitoneum is necessary, at least in the absence of preexisting abdominal wall adhesions. In women with no previous surgery, the primary puncture can be performed with a trocar-cannula system, which reduces operating time. The first, or primary, cannula must be of sufficient caliber to permit passage of the laparoscope and usually is inserted in or at the lower border of the umbilicus. The incision should be extended only enough to allow insertion of the


Gynecology_Novak

Gynecology_Novak. be of sufficient caliber to permit passage of the laparoscope and usually is inserted in or at the lower border of the umbilicus. The incision should be extended only enough to allow insertion of the cannula; otherwise, leakage of gas may occur around the sheath. The patient should be in an unaltered supine position during placement of the primary cannula. For the primary puncture, either the surgeon or the assistant should elevate the abdominal wall as described previously. Both hands can be positioned on the device, using one to provide counter pressure and control to


Gynecology_Novak

Gynecology_Novak. Figure 23.7 Disposable access systems. These instruments are designed for single use. A 12-mm internal diameter blunt access system is shown in (A). The next device (B)hasa12mm internal diameter, but has a deployable blade that is used to cut through the abdominal wall. A smaller diameter blunt conical device is shown in (C) while a sharp conical access system is presented in (D). Both (C) and (D) have a 5-mm inside diameter. A narrow, 2.7-mm diameter cannula is shown in (E). The trocar for this system is a long insufﬂation needle with a spring deployable obturator.


Gynecology_Novak

Gynecology_Novak. prevent “overshoot” and resultant injury to bowel or vessels. The angle of insertion is the same as for the insufﬂation needle; adjustments are made according to the patient’s weight and body habitus (79). The laparoscope should be inserted to confirm proper intraperitoneal placement before the insufﬂation gas is allowed to ﬂow. Previous abdominal surgery increases the incidence of adhesions of the bowel to the anterior abdominal wall, frequently near the umbilicus and in the path of the primary trocar-cannula system (88,89). In such patients, Figure 23.8 Reusable access systems. A: A sharp conical device, while (B) represents a pyramidal-tipped design. C and D (and inset): Images of the so-called EndoTip device that can be positioned in the abdominal wall by simply twisting or screwing it in without the requirement of a trocar.


Gynecology_Novak

Gynecology_Novak. another primary insertion site, such as the left upper quadrant, should be selected, even if it is used solely for conveying a narrow “scout” laparoscope, some types of which can be inserted through a trocar cannula system with a design similar to that of an insufﬂation needle (Fig. 23.9). Using such a laparoscope, the presence of adhesions under the incision can be identified and the umbilical cannula can be inserted under direct vision. If adhesions are noted under the incision, appropriate placement of secondary cannulas may be used to introduce instruments for adhesiolysis. Alternate insertion sites for primary cannulas are shown in Figure 23.6. Figure 23.9 “Scout” laparoscope. The 2-mm laparoscope from Figure 23.8 and the 2.7-mm access system from Figure 23.7 are shown here assembled. The tubing is connected to inﬂow gas, usually carbon dioxide.


Gynecology_Novak

Gynecology_Novak. Ancillary cannulas are necessary to perform most diagnostic and operative laparoscopic procedures. Most currently available disposable ancillary cannulas are identical to those designed for insertion of the primary cannula; however, simple cannulas without the so-called safety mechanisms and insufﬂation ports are generally sufficient (Figs. 23.7D and 23.8D). Some investigators are evaluating the value of systems that allow the insertion of multiple cannulas through a single port, an approach that has the potential to improve surgical cosmesis by reducing the number of incisions created (90–92).


Gynecology_Novak

Gynecology_Novak. Proper positioning of these ancillary cannulas depends on a sound knowledge of the abdominal wall vascular anatomy. For the secondary puncture, the patient may be tipped head down (Trendelenburg), allowing the abdominal contents to shift from beneath the incision sites, and thus making it unnecessary to lift the abdominal wall during secondary cannula insertion. Alternatively, the intraperitoneal pressure may be maintained at 25 to 30 mm Hg to allow insertion of the secondary cannulas prior to placing the patient in the Trendelenburg position.


Gynecology_Novak

Gynecology_Novak. Ancillary cannulas should always be inserted under direct vision because injury to bowel or major vessels can occur. Before insertion, the bladder should be drained with a urethral catheter. The insertion sites depend on the procedure, the disease, the patient’s body habitus, and the surgeon’s preference. For diagnostic laparoscopy, the most useful and cosmetically acceptable site for insertion of an ancillary cannula is in the midline of the lower abdomen, about 2 to 4 cm above the symphysis. The ancillary cannula should not be inserted too close to the symphysis because it limits the mobility of the ancillary instruments and access to the cul-de-sac. Laparoscopic cannulas can become dislodged and slip out of the incision during a procedure. There are a variety of cannula designs designed to reduce slippage, which include those with threaded exteriors and anchoring systems with balloon tips.


Gynecology_Novak

Gynecology_Novak. Lateral placement of lower-quadrant cannulas is useful for operative laparoscopy, but the superficial and inferior epigastric vessels must be located to avoid injury (Fig. 23.3). Transillumination of the abdominal wall from within permits the identification of the superficial inferior epigastric vessels in most thin women. The deep inferior epigastric vessels cannot be identified by this mechanism because of their location deep to the rectus sheath. The most consistent landmarks are the medial umbilical ligaments (obliterated umbilical arteries) and the exit point of the round ligament into the inguinal canal. At the pubic crest, the deep inferior epigastric vessels can often be visualized between the medially located umbilical ligament and the laterally positioned exit point of the round ligament. The cannula should be inserted medial or lateral to the vessels if they are visualized. If the vessels cannot be seen and it is necessary to position the cannula laterally, the device


Gynecology_Novak

Gynecology_Novak. round ligament. The cannula should be inserted medial or lateral to the vessels if they are visualized. If the vessels cannot be seen and it is necessary to position the cannula laterally, the device should be placed 3 to 4 cm lateral to the medial umbilical ligament or lateral to the lateral margin of the rectus abdominis muscle. If the incision is placed too far laterally, it will endanger the deep circumﬂex epigastric artery. The risk of injury can be minimized by placing a 22-gauge spinal needle through the skin at the desired location, in order to directly observe the entry through the laparoscope. This provides reassurance that a safe location is identified and allows visualization of the peritoneal needle hole, which provides a precise target for inserting the cannula.


Gynecology_Novak

Gynecology_Novak. Even after a properly positioned incision, the abdominal wall vessels can be injured if a trocar slides medially during placement. Large-diameter devices are more likely to cause injury; therefore, the smallest cannulas necessary to perform the procedure should be used. Ancillary cannulas should not be placed too close together because this results in hindrance of the hand instruments, which compromises access and maneuverability. The incision made must be of adequate length to allow easy insertion of the device through the skin—a 1-cm long incision is inadequate to allow passage of a 1-cm diameter device. It is important to know that the outside diameter of a cannula is larger than the inside diameter, to allow for the thickness of the material used to create the port. In some instances, this can add two or more millimeters to the device diameter, and, therefore, increase the length of the required incision.


Gynecology_Novak

Gynecology_Novak. During endoscopy, the image must be transferred through an optical system. Although direct optical viewing is feasible and often used for diagnostic purposes, virtually all operative laparoscopy is performed using video guidance. Figure 23.10 Laparoscopes. Three 0-degree laparoscopes are shown. From top to bottom, 2-mm, 5-mm and 10-mm diameter.


Gynecology_Novak

Gynecology_Novak. Laparoscopes are more than simple telescopes; they serve a dual purpose—transmission of light into a dark and closed cavity and provision of an image of the operative field. The light is generally transmitted from a cold light source via a fiberoptic cable to an attachment on the endoscope that passes the light to the distal end of the telescope via a peripherally arranged array of fiberoptic bundles. The image is obtained by a distally positioned lens and transmitted to the eyepiece via a series of rod shaped lenses. The eyepiece can be used to view the peritoneal contents directly or can serve as a point of attachment for a digital video camera. Some endoscopes transmit the image through a collection of densely packed fiberoptic bundles—an approach that diminishes resolution, but allows ﬂexibility of the endoscope, and that is of great value for small-caliber telescopes or when the device is designed to be steerable with an articulated distal end. Another option is to position a


Gynecology_Novak

Gynecology_Novak. ﬂexibility of the endoscope, and that is of great value for small-caliber telescopes or when the device is designed to be steerable with an articulated distal end. Another option is to position a digital chip on the end of the system, which then functions as a camera, obviating the need to have any lenses or fibers to transmit the image, a design that is colloquially called “chip-on-a-stick.”


Gynecology_Novak

Gynecology_Novak. A laparoscope with an integrated straight channel, parallel to the optical axis, is called an operating laparoscope because the channel allows for the introduction of operating instruments. Operative endoscopes are of relatively larger caliber than standard laparoscopes, may have smaller fields of view, and may present increased risks associated with the use of monopolar electrosurgical instruments. Standard, viewing-only laparoscopes permit better visualization at a given diameter.


Gynecology_Novak

Gynecology_Novak. In general, the wider the diameter of the laparoscope, the brighter the image, resulting from either more light or wider lenses, which improve the viewing experience for the surgeon. Narrow-diameter laparoscopes generally allow reduced transfer of light both into and out of the peritoneal cavity; therefore, they require a more sensitive camera or a more powerful light source for adequate illumination. In the past, ideal illumination was provided by 10-mm diagnostic laparoscopes, but improvements in optics allowed the 5-mm diameter laparoscope to become the standard in many operating rooms (Fig. 23.10).


Gynecology_Novak

Gynecology_Novak. The viewing angle depicts the relationship of the visual field to the axis of the endoscope and typically ranges from 0 to 45 degrees to the horizontal. The 0-degree scope is the standard for gynecologic surgery. The 30-degree angle scope is invaluable in difficult situations, such as the performance of laparoscopic sacrocolpopexy, some myomectomies, and hysterectomy in the presence of large myomas.


Gynecology_Novak

Gynecology_Novak. The video camera is usually attached to the eyepiece of the endoscope where it captures the image and transmits it to the body of the camera located outside the operative field, where it is processed and sent to a monitor and, if desired, a recording device (Fig. 23.11). Laparoscopes without an optical path were introduced, with the sensor located on the distal tip of the endoscope, a design that requires a remote camera location. The resolution capability of the monitor should be at least equal to that provided by the camera. Most monitors have the potential to display about 800 horizontal lines of resolution while high definition (HD) systems generally possess 1,080 lines. The more light transmitted through the endoscope, the better the video visualization. The best


Gynecology_Novak

Gynecology_Novak. Figure 23.11 Laparoscopic tower. This tower comprises a monitor (A), a camera body or base unit (B) attached to a camera sensor; a light source (C) attached to a cable, which in turn will be connected with the endoscope; a still-image printer (D), and an insufﬂation machine (E). A video recorder is shown in (F). available output is achieved from 250 to 300 watts, usually using xenon or metal halide bulbs. Most camera systems are integrated with the light source to vary light output automatically, depending on the amount of exposure required. Light guides or cables transmit light from the source to the endoscope via a bundle of densely packed optical fibers (fiberoptic). Fiberoptic cables lose function over time, generally secondary to breakage of the fiber bundles, especially if they are mishandled. Creation of a Working Space


Gynecology_Novak

Gynecology_Novak. Creation of a Working Space The peritoneal cavity is only a potential space, so it is necessary to fill it with a gas, typically CO2, to create a working environment. Other approaches are being explored that use mechanical lifting systems that allow room air into the peritoneal cavity. Carbon dioxide is injected into the peritoneal cavity under pressure by a machine called an insufﬂator. The insufﬂator delivers the CO2 from a gas cylinder to the patient through tubing connected to a Luer adaptor on one of the laparoscopic cannulas. Most insufﬂators can be set to maintain a predetermined intra-abdominal pressure. High ﬂow rates (9 to 20 L per minute) are especially useful for maintaining exposure when suction of smoke or ﬂuid depletes the volume of intraperitoneal gas.


Gynecology_Novak

Gynecology_Novak. Intraperitoneal retractors attached to a pneumatic or mechanical lifting system can be used to create an intraperitoneal space much like a tent (93). This gasless or isobaric technique may have some advantages over pneumoperitoneum, particularly in patients with cardiopulmonary disease. Airtight cannulas are not necessary, and instruments do not need to have a uniform, narrow, cylindrical shape. Consequently, some conventional instruments may be used directly through the incisions. Manipulation of Tissue and Fluid Fluid Management


Gynecology_Novak

Gynecology_Novak. Manipulation of Tissue and Fluid Fluid Management Fluid may be disseminated into the peritoneal cavity through wide-caliber arthroscopy or cystoscopy tubing using gravity pressure and an infusion cuff or a high-pressure mechanical pump. The pumps deliver ﬂuid faster than the other techniques, and the highly pressurized stream of ﬂuid may facilitate blunt dissection (hydro-or aqua dissection). Small volumes of ﬂuid can be removed with a syringe attached to a cannula; for large volumes, it is necessary to use suction generated by a machine or a wall source. The type of cannulas used for suction and irrigation depends on the irrigation ﬂuid used and the ﬂuid being removed. For ruptured ectopic gestations or other procedures in which there is a large amount of blood and clots, large-diameter cannulas (7 to 10 mm) are preferred. Cannulas with narrow tips are more effective in generating the high pressure needed for hydrodissection.


Gynecology_Novak

Gynecology_Novak. If large volumes of ﬂuid are required, isotonic ﬂuids should be used to avoid ﬂuid overload and electrolyte imbalance. If electrosurgery is to be performed, small volumes of a nonelectrolytecontaining solution such as glycine or sorbitol can be used for hemostasis and irrigation. Heparin (1,000 to 5,000 U/L) can be added to irrigating solution to prevent blood from clotting and facilitate ﬂuid removal.


Gynecology_Novak

Gynecology_Novak. Uterine manipulation is an important component of the strategy to maximize visualization for most pelvic procedures, especially for myomectomy and hysterectomy. A properly designed uterine manipulator should have an intrauterine component, or obturator, and a method for attaching the device to the uterus. Articulation of the instrument permits acute anteversion or retroversion, both of which are extremely useful procedural maneuvers. If the uterus is large, longer and wider obturators can be used for more effective control. Two types of uterine manipulators are shown in Figure 23.12. A hollow channel attached to a port allows intraoperative instillation of liquid dye to aid in the identification of the endometrial cavity (during myomectomy) or to demonstrate tubal patency. The forceps used during laparoscopy should, to the extent possible, replicate those used in open surgery. Disposable instruments generally do not have the quality, strength, or precision


Gynecology_Novak

Gynecology_Novak. The forceps used during laparoscopy should, to the extent possible, replicate those used in open surgery. Disposable instruments generally do not have the quality, strength, or precision Figure 23.12 Uterine manipulators. Top: The disposable “V-Care” device. At the tip is a balloon inﬂated to maintain the device in the endometrial cavity. Next to the tip is a cervical collar that serves to facilitate identification of the vaginal fornices and cutting of the vagina in laparoscopic total hysterectomy. The blue truncated cone maintains a seal so that gas will not leak out when culdotomy is performed. Bottom: The reusable Valtchev manipulator. The ring handle allows the surgeon to antevert the uterus.


Gynecology_Novak

Gynecology_Novak. of nondisposable forceps (Fig. 23.13). Instruments with teeth (toothed forceps) are necessary to securely grasp the peritoneum or the edge of an ovary for the removal of an ovarian cyst. Instruments designed to be minimally traumatic, like Babcock clamps, are needed to retract the fallopian tube safely. Tenaculum-like instruments are desirable to retract leiomyomas or the uterus. A ratchet is useful for holding tissue without arduous hand pressure. Graspers should be insulated if unipolar radiofrequency instruments are being used to attain hemostasis. Figure 23.13 Laparoscopic instruments for grasping and manipulating tissue. A: (top and inset) are 5-mm diameter graspers with a curved tip, often called “Maryland” graspers. Other reusable tips (B) and (C) may be positioned in the same handle as is shown for (A). D: A 10-mm claw grasper, while (E) and (F) are 5-and 2-mm manipulating probes respectively. G: A 2-mm grasping forceps. Cutting, Hemostasis, and Tissue Fixation


Gynecology_Novak

Gynecology_Novak. Cutting, Hemostasis, and Tissue Fixation Cutting can be achieved by mechanical means or by using laser, radiofrequency electrical, or ultrasonic energy. The methods for maintaining or securing hemostasis include sutures, clips, linear staplers, energy sources, and topical or injectable substances. Secure apposition or tissue fixation may be accomplished with sutures, clips, or staples. With appropriate training, a skilled surgeon can obtain good results with any combination of these techniques for cutting, hemostasis, and tissue fixation. Studies in animals have not demonstrated any difference in injury characteristics when cutting is performed with either laser or radiofrequency energy and randomized controlled studies have shown no differences in fertility outcomes (59–61,94). Therefore, differences in results are likely to be caused by other factors, such as patient selection, extent of disease, and degree of surgical expertise.


Gynecology_Novak

Gynecology_Novak. The most useful cutting instruments are scissors (Fig. 23.14, bottom). Because it is difficult to sharpen laparoscopic scissors, most surgeons prefer disposable instruments that can be used until dull and then discarded. Another mechanical cutting tool is the linear stapler–cutter that can simultaneously cut and hemostatically staple the edges of the incision. The cost and large dimensions of the instruments limit their practical use to only a few highly selected situations, such as separation of the uterus from the ovary and fallopian tube during laparoscopic hysterectomy. Devices that coagulate tissue and mechanically transect it are designed to be narrow enough to be practical and effective enough to become the dominant devices for laparoscopic cutting, when concomitant sealing of vessels is a requirement.


Gynecology_Novak

Gynecology_Novak. Laser and electrical sources of energy manifest their effect by conversion of electromagnetic energy (Fig. 23.14) to mechanical energy, which is then transformed into thermal energy. Highly focused radiofrequency electrical current (high-power or current density), generated by a specially designed electrosurgical generator produces vaporization or cutting by raising the intracellular temperature above 100◦C, which rapidly converts water to steam with a massive increase in intracellular volume. This expansion ruptures the already damaged cell membrane, resulting in cellular and tissue vaporization into a cloud of steam, ions, and protein particles. If the instrument used to focus this energy is moved in a linear fashion, tissue transection or cutting will result. Less focused radiofrequency energy (moderate current density) elevates intracellular temperature, causing desiccation, rupture of hydrogen bonds, and tissue coagulation, but vaporization does not occur.


Gynecology_Novak

Gynecology_Novak. Figure 23.14 Radiofrequency electrosurgical generator. Displayed is the Force FX generator with unipolar laparoscopic electrodes. The device is capable of outputting high-voltage (“coagulation”) and low-voltage (“cut”) waveforms for unipolar instruments and a low-voltage bipolar circuit for bipolar instruments. Figure 23.15 Laparoscopic cutting devices. Top and inset left is a bipolar electrosurgical spatula. Middle and center inset is a harmonic scalpel. This device oscillates at 55,000 Hz to cut tissue. Bottom and inset right are laparoscopic scissors. They may be connected to an electrosurgical generator to act as a unipolar electrosurgical instrument.


Gynecology_Novak

Gynecology_Novak. Monopolar electrosurgical instruments that are narrow or pointed are capable of generating the high-power densities necessary to vaporize or cut tissue. Continuous or modulated and relatively low voltage outputs tend to be the most effective. For optimal results, the instrument should be used in a noncontact fashion, following (not leading) the energy through the tissue. Specially designed bipolar cutting probes that contain both the active and dispersive electrode are available. The active electrode is shaped as a needle, or even a blade, while the other larger-surface-area electrodes are designed to be dispersive (Fig. 23.15, top). Laparoscopic scissors are generally of unipolar design and are intended to cut mechanically; energy may be applied simultaneously for desiccation and hemostasis when cutting tissue that contains small blood vessels (Fig. 23.15, bottom).


Gynecology_Novak

Gynecology_Novak. Laser energy can be focused to vaporize and cut tissue. The most efficient laser-based cutting instrument is the CO2 laser, which has the drawback of requiring linear transmission because light cannot be conducted effectively along bendable fibers. The potassium-titanyl-phosphate (KTP) and neodymium:yttrium, aluminum, garnet (Nd:YAG) lasers are effective cutting tools. They are capable of propagating energy along bendable quartz fibers but have a slightly greater degree of collateral thermal injury than radiofrequency electrical or CO2 laser energy. These limitations and their additional expense constrict the value of these lasers.


Gynecology_Novak

Gynecology_Novak. Ultrasonic cutting is accomplished mechanically using a blade that oscillates back and forth in a linear fashion (Fig. 23.15, center). The oscillation is achieved using an element located in a handle that vibrates the blade, hook, or one arm of the clamp 55,000 times per second (55 kHz). The distance of the oscillation can be varied and determines the efficiency of the cutting process. The tip of the device cuts mechanically, but there is a degree of collateral thermal tissue coagulation injury that can be used for hemostasis. In low-density tissue, the process of mechanical cutting is augmented by the process of cavitation, in which reduction of local atmospheric pressure allows vaporization of intracellular water at lower temperatures than those required for laser or electrosurgical vaporization.


Gynecology_Novak

Gynecology_Novak. Because of the visual, tactile, and mechanical limitations of laparoscopy, prevention of bleeding is important for efficient, effective, and safe procedures. Radiofrequency electricity is the least expensive and most versatile method for achieving hemostasis during laparoscopy and can be applied with either monopolar or bipolar instruments. Regardless of the type of system, the process of electrical desiccation and coagulation is best achieved by contacting the tissue with the activated electrode using continuous low-voltage or “cutting” current. With adequate power, typically 20 to 30 watts (depending, in part, on the surface area of the electrodes), tissue will be heated, desiccated, and coagulated. Blood vessels should be compressed with the blades of the forceps before the electrode is activated so that the “heat sink” effect of ﬂowing blood is eliminated. This allows the opposing walls of the vessel to bond, forming a strong tissue seal in a process called coaptive coagulation.


Gynecology_Novak

Gynecology_Novak. is activated so that the “heat sink” effect of ﬂowing blood is eliminated. This allows the opposing walls of the vessel to bond, forming a strong tissue seal in a process called coaptive coagulation. Bipolar devices can be fitted with a serial ammeter that measures the current ﬂowing through the system. When the tissue between the blades of the forceps is completely desiccated, the device is no longer able to conduct electricity, which can trigger a visual or auditory cue for the surgeon. Alternatively, the generator can be designed to stop automatically when current is no longer being conducted by the tissue between the blades of the forceps. The surgeon can reduce lateral thermal spread of radiofrequency energy by manually pulsing delivery or by simultaneously running irrigation ﬂuid over the pedicle. Automated generators that pulse energy automatically are available, and such bipolar systems can include mechanical blades to cut tissues following coagulation of the tissue (Fig.


Gynecology_Novak

Gynecology_Novak. over the pedicle. Automated generators that pulse energy automatically are available, and such bipolar systems can include mechanical blades to cut tissues following coagulation of the tissue (Fig. 23.16).


Gynecology_Novak

Gynecology_Novak. Control of superficial bleeding can be achieved with fulguration, the near-contact spraying of tissue with a unipolar instrument using modulated, high-voltage radiofrequency waveforms from the “coagulation” side of the electrosurgical generator. Care must be taken to safely perform laparoscopic fulguration, ensuring that the entire shaft of the laparoscopic instrument is well away from the bowel. Ultrasonic instruments can be used for hemostasis as well. Those with a forceps-like end effector disperse the mechanical energy in a way that allows the tissue to be heated and coagulated. These


Gynecology_Novak

Gynecology_Novak. Ultrasonic instruments can be used for hemostasis as well. Those with a forceps-like end effector disperse the mechanical energy in a way that allows the tissue to be heated and coagulated. These Figure 23.16 Displayed are two devices that cut and coagulate or seal tissue. Top (A–C) are the ligating cutting shears (LCS) that are based on the same technology as the harmonic scalpel displayed in Figure 23.13. The bottom blade oscillates (C), while the top blade is opened to grasp the tissue and used by the surgeon to slowly transect and seal the blood vessels in the tissue being transected. The PlasmaKinetic (D–F) is a bipolar radiofrequency device that, using electrical impedance, tells the surgeon when the tissue is coagulated. Then the orange trigger (top) is pushed deploying the blade (F), thereby cutting the coagulated tissue.


Gynecology_Novak

Gynecology_Novak. Figure 23.17 Laparoscopic suturing instruments. The 3-mm and 5-mm diameter laparoscopic needle drivers are displayed in (A) and (C), while a knot manipulator is shown in (B) and inset left. The device is shown transferring a knot into the peritoneal cavity (inset right). so-called ligating-cutting shears cut when high pressure is exerted in the handle by the surgeon (Fig. 23.16A–C). Hemostatic clips may be applied with specially designed laparoscopic instruments. Nonabsorbable clips made of titanium are useful for relatively narrow vessels, and longer, delayed absorbable, self-retaining clips are generally preferred for larger vessels, 3 or 4 mm or more. Clips may be of particular value when securing relatively large vessels near an important structure such as the ureter.


Gynecology_Novak

Gynecology_Novak. Laparoscopic suturing is a method for maintaining hemostasis (95–97). Compared with clips or linear staplers, suturing has a relatively low materials cost, although operating time may be longer and more expensive. The two basic methods for securing a ligature around a blood vessel depend on where the knot is tied; ligatures are intracorporeal and extracorporeal. Intracorporeal knots replicate the standard instrument-tied knot and are formed within the peritoneal cavity. Extracorporeal knots are created outside the abdomen under direct vision and then transferred into the peritoneal cavity by knot manipulators (Fig. 23.17). Pretied knotted suture loops attached to long introducers, called Endoloops®, may be used to secure vascular pedicles. Care should be taken to make sure that they are tightly secured and that no other tissue is incorporated in the loop. A number of devices that facilitate the formation and tying of knots are either available or in development.


Gynecology_Novak

Gynecology_Novak. Small areas of low volume bleeding can be treated with topical hemostatic agents. Topical agents such as microfibrillar collagen are available in 5-mm and 10-mm diameter laparoscopic applicators (Fig. 23.13). Fibrin sealants (e.g., Tisseel®) and bovine thrombin and gelatin (Floseal®)can also be used. A solution of dilute vasopressin may be injected locally to maintain hemostasis for myomectomy or removal of ectopic pregnancy.


Gynecology_Novak

Gynecology_Novak. Tissue Extraction After excising tissue, it is usually necessary to remove it from the peritoneal cavity. Small samples can be pulled through an appropriate-sized cannula with grasping forceps; however, larger specimens may not fit. If the specimen is cystic, it may be drained by a needle or incised, shrinking it to a size suitable for removal through the cannula or one of the small laparoscopic incisions. If there is concern for malignancy, an alternative is to place the specimen in an endoscopic retrieval bag before drainage to prevent spillage (Fig. 23.18). More solid tissue may be morcellated with scissors, ultrasonic equipment, electrosurgery or electromechanical morcellators. If monopolar radiofrequency instruments are used for electrosurgical morcellation, the specimen must remain attached to the patient to preserve the integrity of the electrical circuit. Alternatively, special bipolar needles are available that do not require a dispersive electrode.


Gynecology_Novak

Gynecology_Novak. Figure 23.18 Specimen removal bag. This 10-mm diameter bag is positioned in the peritoneal cavity. Then the bag is deployed (insets), allowing the surgeon to place specimens for removal. Larger specimens may be removed by inserting a larger cannula through an incision in the cul-desac (posterior culdotomy) or by extending one of the laparoscopy incisions. With the exception of culdotomy (colpotomy), extension of the umbilical incision may be the most cosmetic approach because incisions up to 3 cm in length can be concealed successfully. When the umbilical location is selected, removal of the tissue can be directed from an endoscope positioned in one of the ancillary ports. Electronic morcellators are available to remove large tissue specimens by reducing them to smaller sections (Fig. 23.19). These are especially useful for laparoscopic myomectomy and laparoscopic supracervical hysterectomy.


Gynecology_Novak

Gynecology_Novak. Incision Management Dehiscence and hernia risk appear to significantly increase when the fascial incision is larger than 10 mm in diameter (98,99). Closure of the fascia should take place under direct laparoscopic vision to prevent the accidental incorporation of bowel into the incisions, and the peritoneum should be included to reduce the risk of Richter’s hernia. A small-caliber laparoscope passed through one of the narrow cannulas can be used to direct the fascial closure using curved needles or a ligature carrier especially designed for this purpose. Figure 23.19 Electromechanical morcellator. This device is positioned in the peritoneal cavity and attached to the power generator (inset). The blunt obturator is removed; a grasping instrument inserted through the lumen is used to withdraw the tissue, which is cut by a cylindrical blade. The motor is activated by a foot pedal.


Gynecology_Novak

Gynecology_Novak. Complications After laparoscopic surgery patients usually experience a rapid recovery. Pain diminishes, gastrointestinal function improves quickly, and fever is extremely unusual. Therefore, if a patient’s condition is not improving, possible complications of anesthesia or surgery should be considered. Laparoscopic procedures can be complicated by infections, trauma, or hemorrhage, and by problems associated with anesthetic use. The incidence of infection is lower than with procedures performed by laparotomy. Problems associated with visualization in conjunction with the change in anatomic perspective may increase the risk of damage to blood vessels or vital structures such as the bowel, ureter, or bladder.


Gynecology_Novak

Gynecology_Novak. A review of laparoscopic tubal sterilization in 9,475 women found no deaths from complications of anesthesia (100,101). The potential risks of general anesthesia include hypoventilation, esophageal intubation, gastroesophageal reﬂux, bronchospasm, hypotension, narcotic overdose, cardiac arrhythmias, and cardiac arrest. These risks can be exacerbated by some of the inherent features of gynecologic laparoscopy. For example, the Trendelenburg position, in combination with the increased intraperitoneal pressure provided by pneumoperitoneum, places greater compression on the diaphragm, increasing the risk of hypoventilation, hypercarbia, and metabolic acidosis. This position, combined with anesthetic agents that relax the esophageal sphincter, promotes regurgitation of gastric content, which in turn can lead to aspiration, bronchospasm, pneumonitis, and pneumonia. Parameters of cardiopulmonary function associated with both CO2 and N2O insufﬂation include reduced PO2,O2 saturation, tidal


Gynecology_Novak

Gynecology_Novak. in turn can lead to aspiration, bronchospasm, pneumonitis, and pneumonia. Parameters of cardiopulmonary function associated with both CO2 and N2O insufﬂation include reduced PO2,O2 saturation, tidal volume, and minute ventilation and increased respiratory rate. The use of intraperitoneal CO2 as a distention medium is associated with an increase in PCO2 and a decrease in pH. Elevation of the diaphragm may be associated with basilar atelectasis, resulting in right-to-left shunt and ventilation–perfusion mismatch (102).


Gynecology_Novak

Gynecology_Novak. Carbon dioxide is the most widely used peritoneal distention medium, largely because the rapid absorption of CO2 in blood reduces the significance of gas emboli. If large amounts of CO2 gain access to the central venous circulation, if peripheral vasoconstriction occurs, or if the splanchnic blood ﬂow is decreased by excessively high intraperitoneal pressure, severe cardiorespiratory compromise may result. The signs of CO2 embolus include sudden and otherwise unexplained hypotension, cardiac arrhythmia, cyanosis, and heart murmurs. The end-tidal CO2 level may increase, and findings consistent with pulmonary edema may manifest (103). Accelerating pulmonary hypertension may occur, resulting in right-sided heart failure.


Gynecology_Novak

Gynecology_Novak. Because gas embolism may result from direct intravascular injection through an insufﬂation needle, the proper placement of the insufﬂation needle must be ensured. Although the initial intraperitoneal pressure may be set at 20 to 30 mm Hg for port placement, it should be maintained at 8 to 12 mm for the rest of the case (104). The risk of CO2 embolus is reduced by careful hemostasis because open venous channels are the portal of entry for gas into the systemic circulation. The anesthesiologist should continuously monitor the patient’s color, blood pressure, heart sounds, heartbeat, and end-tidal CO2 to allow early recognition of the signs of CO2 embolus.


Gynecology_Novak

Gynecology_Novak. If CO2 embolus is suspected or diagnosed, the surgeon must evacuate the CO2 from the peritoneal cavity and place the patient in the left lateral decubitus position, with the head below the level of the right atrium. A large-bore central venous line should be inserted immediately to allow aspiration of gas from the heart. Because the findings are nonspecific, the patient should be evaluated for other causes of cardiovascular collapse. Cardiac arrhythmias occur relatively frequently during laparoscopic surgery and are related to a number of factors, the most significant of which are hypercarbia and acidemia. Early reports of laparoscopy-associated arrhythmia were associated with spontaneous respiration; therefore, most anesthesiologists adopted the practice of mechanical ventilation during laparoscopic surgery. The incidence of hypercarbia is reduced by operating with intraperitoneal pressures at levels less than 12 mm Hg (105).


Gynecology_Novak

Gynecology_Novak. The risk of cardiac arrhythmia may be reduced by using NO2 as a distending medium (see the preceding discussion in “Peritoneal Access”). Although NO2 is associated with a decreased incidence of arrhythmia, it is insoluble in blood and, therefore, its use may increase the risk of gas embolus. External lifting systems avoid the complication of hypercarbia and can provide protection against cardiac arrhythmia (106). Hypotension can occur because of decreased venous return secondary to very high intraperitoneal pressure, and this condition may be potentiated by volume depletion. Vagal discharge may occur in response to increased intraperitoneal pressure, which can cause hypotension secondary to cardiac arrhythmias (106). These side effects should be considered when performing surgery on patients with preexisting cardiovascular disease.


Gynecology_Novak

Gynecology_Novak. Gastric regurgitation and aspiration can occur during laparoscopic surgery, especially in patients with obesity, gastroparesis, hiatal hernia, or gastric outlet obstruction. In these patients, the airway must be maintained with a cuffed endotracheal tube, and the stomach must be decompressed (e.g., with a nasogastric tube). The lowest necessary intraperitoneal pressure should be used to minimize the risk of aspiration. Patients should be moved out of the Trendelenburg position before being extubated. Routine preoperative administration of metoclopramide, H2-blocking agents, and nonparticulate antacids reduces the risk of aspiration.


Gynecology_Novak

Gynecology_Novak. The most common causes of extraperitoneal insufﬂation are preperitoneal placement of the insufﬂating needle and leakage of CO2 around the cannula sites. Although this condition is usually mild and limited to the abdominal wall, subcutaneous emphysema can become extensive, involving the extremities, the neck, and the mediastinum. Another relatively common site for emphysema is the omentum or mesentery, a circumstance that may be mistaken for preperitoneal insufﬂation. Subcutaneous emphysema may be identified by the palpation of crepitus, usually in the abdominal wall. Emphysema can extend along contiguous fascial plains to the neck, where it can be visualized directly. This finding may reﬂect mediastinal emphysema, which may indicate impending cardiovascular collapse (107–110).


Gynecology_Novak

Gynecology_Novak. The risk of subcutaneous emphysema is reduced by the proper positioning of the insufﬂation needle and by maintaining a low intraperitoneal pressure after placement of the desired cannulas. Other approaches that reduce the chance of subcutaneous emphysema include open laparoscopy and the use of abdominal wall lifting systems that make gas unnecessary. If the insufﬂation occurred extraperitoneally, the laparoscope can be removed and the procedure can be repeated. Difficulty may ensue because of the altered anterior peritoneum. Open laparoscopy or the use of an alternate site, such as the left upper quadrant, should be considered. One approach is to leave the laparoscope in the expanded preperitoneal space while the insufﬂation needle is reinserted under direct vision through the peritoneal membrane caudad to the tip of the laparoscope (111).


Gynecology_Novak

Gynecology_Novak. In mild cases of subcutaneous emphysema, the findings quickly resolve after evacuation of the pneumoperitoneum, and no specific intraoperative or postoperative therapy is required. When the extravasation extends to the neck, it is usually preferable to terminate the procedure because pneumomediastinum, pneumothorax, hypercarbia, and cardiovascular collapse may result. Following termination of the procedure, it is prudent to obtain a chest x-ray. The patient’s condition should be managed expectantly unless a tension pneumothorax results, in which case immediate evacuation must be performed using a chest tube or a wide-bore needle (14 to 16 gauge) inserted in the second intercostal space in the midclavicular line.


Gynecology_Novak

Gynecology_Novak. Complications of electrosurgery occur secondary to thermal injury from unintended or inappropriate use of the active electrode, current diversion to an undesirable path, or injury at the site of the dispersive electrode. Such complications may occur with the use of these instruments during laparoscopic, abdominal, or vaginal surgery. Active electrode injury can occur with either unipolar or bipolar instruments, whereas trauma secondary to current diversion and dispersive electrode accidents occurs only with unipolar devices. Complications of electrosurgery are reduced by adherence to safety protocols coupled with a sound understanding of the principles of electrosurgery and the circumstances that can lead to injury (112).


Gynecology_Novak

Gynecology_Novak. If the foot pedal is accidentally depressed, tissue adjacent to the electrode will be traumatized. Potential sites of injury include the bowel, ureter, and other intraperitoneal structures, or, if the electrode lies on the abdomen, the skin. Injury from direct extension of thermal effect can occur when the zone of vaporization or coagulation extends to large blood vessels or vital structures such as the bladder, ureter, or bowel. Bipolar instruments may reduce but do not eliminate the risk of thermal injury to adjacent tissue (113). Blood vessels should be isolated before electrosurgical coagulation, especially when they are near vital structures, and appropriate amounts of energy must be applied to allow an adequate margin of noncoagulated tissue.


Gynecology_Novak

Gynecology_Novak. The diagnosis of direct thermal visceral injury may be difficult. If unintended activation of the electrode occurs, nearby intraperitoneal structures should be evaluated carefully. The appearance can be affected by several factors, including the output of the generator, the type of electrode, its proximity to tissue, and the duration of activation. The diagnosis of visceral thermal injury is often delayed until signs and symptoms of fistula or peritonitis secondary to perforation appear. Because these complications may not manifest until 2 to 10 days after surgery, patients should be advised to report any postoperative fever or increasing abdominal pain.


Gynecology_Novak

Gynecology_Novak. Thermal injury to the bowel, bladder, or ureter that is recognized at the time of laparoscopy should be managed immediately, taking into consideration the potential extent of the zone of coagulative necrosis (114). Incisions made with the focused energy from a pointed electrode are associated with a minimal amount of surrounding thermal injury. Prolonged or even transient contact with a relatively large-caliber electrode may produce a zone of thermal necrosis that may be much larger than visually apparent. In such cases, wide excision or resection of up to several centimeters of bowel may be necessary. The choice of route of access for any required surgical repairs depends in part on the nature of the injury and on the skills and training of the surgeon.


Gynecology_Novak

Gynecology_Novak. The incidence of unintended activation injuries can be reduced if the surgeon is always in direct control of electrode activation and if all electrosurgical hand instruments are removed from the peritoneal cavity when not in use. When removed from the peritoneal cavity, the instruments should be detached from the electrosurgical generator, or they should be stored in an insulated pouch near the operative field. These measures prevent damage to the patient’s skin if the electrode is accidentally activated.


Gynecology_Novak

Gynecology_Novak. Current diversion occurs when the radiofrequency circuit follows an unintended path between the active electrode and the electrosurgical generator. This may occur with insulation defects, direct coupling, or capacitative coupling. In older, grounded systems, unlikely to be in use, current can be diverted if any part of the patient’s body touches a conductive and grounded object. In any of these situations, if the power density becomes high enough, unintended and severe thermal injury can result.


Gynecology_Novak

Gynecology_Novak. If the insulation coating the shaft of a monopolar electrosurgical instrument becomes defective, it can allow current diversion to adjacent tissue, most often bowel, potentially resulting in significant injury. This happens in part because such defects create a zone of high current density (Fig. 23.20A). Therefore, the instruments should be examined before each procedure to detect worn or obviously defective insulation. When using monopolar laparoscopic instruments, the shaft of the device should be kept away from vital structures and, if possible, totally visible in the operative field.


Gynecology_Novak

Gynecology_Novak. Direct coupling occurs when an activated electrode touches and energizes another uninsulated metal conductor such as a laparoscope, cannula, or other instrument. Direct coupling is often used for hemostasis when a grasping instrument is used to occlude a blood vessel while a separate activated electrode is used to provide the energy for desiccation and coagulation. If this occurs while the noninsulated device rests against structures such as bowel or the urinary tract, injury may occur (Fig. 23.20B). The risk of direct coupling can be reduced by eliminating the simultaneous use of noninsulated and monopolar instruments. The surgeon should visually confirm that there is no contact with other conductive instruments before activating a monopolar instrument.


Gynecology_Novak

Gynecology_Novak. Capacitance is the ability of a conductor to establish an electrical current in an unconnected nearby circuit. An electrical field is established around the shaft of any activated unipolar instrument (including the cord), a circumstance that creates a potential capacitor. This field is harmless if the circuit is completed through a dispersive, low-power density pathway (Fig. 23.21). For example, if capacitative coupling occurs between a monopolar laparoscopic instrument and a metal cannula positioned in the abdominal wall, the current is harmlessly dispersed in the abdominal wall at the point where it connects with the dispersive electrode (Fig. 23.21A). However, if the metal cannula is anchored to the skin by a nonconductive plastic retaining sleeve or “gripper” (a hybrid system), the current cannot access the abdominal wall because the sleeve acts as an insulator (Fig. 23.21B). Instead, the capacitor will have to “look” elsewhere to complete the circuit. The bowel or any other


Gynecology_Novak

Gynecology_Novak. current cannot access the abdominal wall because the sleeve acts as an insulator (Fig. 23.21B). Instead, the capacitor will have to “look” elsewhere to complete the circuit. The bowel or any other nearby conductor can become the target of a relatively high-power density discharge (Fig. 23.21C). This situation can occur when a unipolar instrument is inserted through an operating laparoscope that, in turn, is passed through a nonconductive plastic laparoscopic cannula. In this configuration, the plastic port acts as the insulator. If the electrode capacitively couples with the metal laparoscope, nearby bowel will be at risk for significant thermal injury (115). The circumstance occurs with the relatively new “single port” systems where the laparoscope and hand instruments, including monopolar instruments, are passed through the same concentrated array of ports. This situation is identical to that of the “operating” laparoscope with an increased risk that the laparoscope or other


Gynecology_Novak

Gynecology_Novak. monopolar instruments, are passed through the same concentrated array of ports. This situation is identical to that of the “operating” laparoscope with an increased risk that the laparoscope or other instruments function as capacitors.


Gynecology_Novak

Gynecology_Novak. The risk of capacitive coupling-related complications can be reduced in a number of ways. First, it is important to avoid the use of hybrid laparoscope-cannula systems that contain a mixture of conductive and nonconductive elements. Instead, the use of all-plastic or all-metal cannula systems is preferred. It may be best to avoid or at least minimize the use of monopolar instruments Figure 23.20 Current diversion secondary to insulation defects and direct coupling. These events may occur with the use of monopolar instrumentation when there is a defect in the insulation (A) or, classically, to contact a conductive instrument that, in turn, touches other intraperitoneal structures. In the example depicted (B), the active electrode is touching the laparoscope, and current is transferred to bowel through a small enough contact point that thermal injury results. Another common target of such coupling is to noninsulated hand instruments.


Gynecology_Novak

Gynecology_Novak. using operating laparoscopes or multiport, single site access systems. If an operating laparoscope is to be used, all-metal cannula systems should be the rule unless there is no intent to use unipolar electrosurgical instruments through the operating channel. Finally, minimizing the use of high voltage, modulated current (“coagulation” current) will reduce the risk of capacitative coupling. Modern electrosurgical units are designed with isolated circuits and impedance monitoring systems that shut down the machine if dispersive electrode (“patient pad”) detachment occurs. The use of isolated-circuit electrosurgical generators with dispersive electrode monitors has virtually eliminated dispersive electrode–related thermal injury. Dispersive electrode monitoring is accomplished by measuring the impedance in the dispersive electrode, which should always be low because of the large surface area. Without such devices, partial detachment of the dispersive


Gynecology_Novak

Gynecology_Novak. Figure 23.21 Capacitative coupling. A: All activated monopolar electrodes emit a surrounding charge, proportional to the voltage of the current. This makes the electrode a potential capacitor. B: Generally, as long as the charge is allowed to disperse through the abdominal wall, no sequelae result. However, if the “return” to the dispersive electrode is blocked by insulation, such as a plastic anchor (C), the current can couple to a conductive cannula or directly to bowel. Figure 23.22 Dispersive electrode burns. If the dispersive electrode becomes partially detached, the current density may increase to the point that a skin burn results. electrode could result in a thermal injury because reducing the surface area of the electrode in contact with the skin raises the current density (Fig. 23.22).


Gynecology_Novak

Gynecology_Novak. electrode could result in a thermal injury because reducing the surface area of the electrode in contact with the skin raises the current density (Fig. 23.22). Because a few ground-referenced machines without such safeguards may still be in use, it is important to know the type of electrosurgical unit used in the operating room. If the electrosurgical generator is ground referenced and if the dispersive electrode becomes detached, unplugged, or otherwise ineffective, the current seeks any grounded conductor, such as electrocardiograph patch electrodes or the conductive metal components of the operating table (Fig. 23.23). If the conductor has a small surface area, the current or power density may become high enough to cause thermal injury (Fig. 23.24).


Gynecology_Novak

Gynecology_Novak. The most dangerous hemorrhagic complications are injuries to the great vessels, including the aorta and the vena cava, the common iliac vessels and their branches, and the internal and external iliac arteries and veins. The most catastrophic injuries occur secondary to insertion of an insufﬂation needle or the tip of the obturator (trocar) used to position the primary or ancillary cannulas. The vessels most frequently damaged are the aorta and the right common iliac artery as it branches from the aorta in the midline. The anatomically more posterior location of the vena cava and the iliac veins provides relative protection, but not immunity, from injury (116). After vascular injury, patients usually develop profound hypotension with or without hemoperitoneum. In some instances, blood is aspirated through the insufﬂation needle before the introduction of the distending gas. In such instances, the needle should be left in place while immediate preparations are made to obtain blood


Gynecology_Novak

Gynecology_Novak. is aspirated through the insufﬂation needle before the introduction of the distending gas. In such instances, the needle should be left in place while immediate preparations are made to obtain blood products and perform laparotomy.


Gynecology_Novak

Gynecology_Novak. The bleeding frequently will be contained in the retroperitoneal space, which usually delays the diagnosis; consequently, hypovolemic shock may develop. To avoid late recognition, the course of each great vessel must be identified before completing the procedure. Because it is difficult to assess the volume of blood filling the retroperitoneal space, immediate laparotomy is indicated if retroperitoneal bleeding is suspected. A midline incision should be made to allow access to the great vessels. Upon entry into the peritoneal cavity, the aorta and vena cava should immediately be compressed just below the level of the renal vessels to gain at least temporary control of blood loss. The most appropriate course of action depends on the site and extent of injury. Vascular or general surgery consultation may be necessary to evaluate and repair significant vascular injuries. Although most of these injuries are small and amenable to repair with suture, some are larger and require the


Gynecology_Novak

Gynecology_Novak. consultation may be necessary to evaluate and repair significant vascular injuries. Although most of these injuries are small and amenable to repair with suture, some are larger and require the insertion of a vascular graft. Deaths have occurred as a result of these injuries.


Gynecology_Novak

Gynecology_Novak. Figure 23.23 Risk of ground-referenced generators. Current diversion along alternate pathways is a risk associated with ground-referenced electrosurgical generators, particularly if the dispersive electrode is detached. In the example depicted, the relatively high current density at the electrocardiogram electrode site may result in a skin burn. The abdominal wall vessels most commonly injured during laparoscopy are the superficial inferior epigastric vessels as they branch from the femoral artery and vein and course cephalad in each lower quadrant. They are invariably damaged by the initial passage of an ancillary trocar-cannula system or by the introduction of a wider device later in the procedure. The problem may be recognized immediately by the observation of blood dripping along the cannula or out through the incision. However, the bleeding may be obstructed by the cannula until it is withdrawn at the end of the operation.


Gynecology_Novak

Gynecology_Novak. The more serious injuries are those to the deep inferior epigastric vessels, which are branches of the external iliac artery and vein that course cephalad but are deep to the rectus fascia and often deep to the muscles (Fig. 23.3). More laterally located are the deep circumﬂex iliac vessels, which are not often encountered in laparoscopic surgery. Laceration of these vessels may cause profound blood loss, particularly when the trauma is unrecognized and causes extraperitoneal bleeding. Signs of injury, in addition to blood dripping down the cannula, include the postoperative appearance of shock and abdominal wall discolorization or hematoma located near the incision. In some instances, the blood may track to a more distant site, presenting as a pararectal or vulvar mass. Delayed diagnosis may be prevented by laparoscopic evaluation of each peritoneal incision after removal of the cannula.


Gynecology_Novak

Gynecology_Novak. Superficial inferior epigastric vessel trauma usually stops bleeding spontaneously; therefore, expectant management is appropriate. A straight ligature carrier can be used to repair lacerated deep inferior epigastric vessels. Alternatively, a Foley catheter may be inserted through the cannula, inﬂated, put on traction, and held in place with a clamp for up to 24 hours. If a postoperative hematoma develops, local compression should be used initially. Open removal or aspiration of the hematoma should not be undertaken because it may inhibit the tamponade effect and increase the risk of abscess. If the mass continues to enlarge or if signs of hypovolemia develop, the wound must be explored.


Gynecology_Novak

Gynecology_Novak. Hemorrhage may result from inadvertent entry into a vessel or failure of a specific occlusive technique. In addition to delayed hemorrhage, there may be a further delay in diagnosis at laparoscopy as a result of the restricted visual field and the temporary occlusive pressure exerted by CO2 in the peritoneal cavity. Inadvertent division of an artery or vein is usually evident immediately. Transected arteries may go into spasm and bleed minutes to hours later, going unnoticed temporarily because of the limited visual field of the laparoscope. Therefore, at the end of the procedure, all areas of dissection must be carefully examined. Carbon dioxide should be vented, which decreases the intraperitoneal pressure so that blood vessels temporarily occluded by higher pressure can be recognized.


Gynecology_Novak

Gynecology_Novak. The stomach, the small bowel, and the colon can be injured during laparoscopy. Mechanical entry into the large or small bowel can occur 10 times more often when laparoscopy is performed in patients who have had prior intraperitoneal inﬂammation or abdominal surgery. Loops of intestine can adhere to the abdominal wall under the insertion site and be injured (117,118). Needle entry into the gastrointestinal tract may be more common than reported because it may go unnoticed and without further complication. Gastric entry may be identified by the increased filling pressure, asymmetric distention of the peritoneal cavity, or aspiration of gastric particulate matter through the lumen of the needle. Initially, the hollow, capacious stomach may allow the insufﬂation pressure to remain normal. Signs of bowel entry are the same as those for gastric injury, with the addition of feculent odor.


Gynecology_Novak

Gynecology_Novak. If particulate debris is identified, the needle should be left in place, and an alternate insertion site should be identified, such as the left upper quadrant. Immediately after successful entry into the peritoneal cavity, the site of injury can be identified. Defects must be repaired immediately by laparoscopy or laparotomy.


Gynecology_Novak

Gynecology_Novak. Damage caused by a sharp tipped obturator or trocar is usually more serious than needle injury. Inadvertent gastric entry usually is associated with stomach distention because of aerophagia, difficult or improper intubation, or mask induction with inhalation anesthetic. Most often the injury is created by the trocar-cannula system used for primary access. Ancillary cannulas may result in visceral injury, although placement of these cannulas under direct vision helps reduce the risk of injury. The risk of gastric perforation can be minimized with the selective use of preoperative nasogastric or oral gastric suction when left upper-quadrant entries are used or when the intubation was difficult. Open laparoscopy likely has little impact on the risk for gastrointestinal complications, particularly those related to adhesions to the anterior abdominal wall from previous surgery. For high-risk patients, left upper quadrant needle and trocar-cannula insertion with a properly decompressed


Gynecology_Novak

Gynecology_Novak. those related to adhesions to the anterior abdominal wall from previous surgery. For high-risk patients, left upper quadrant needle and trocar-cannula insertion with a properly decompressed stomach may be preferable (119–122).


Gynecology_Novak

Gynecology_Novak. If the trocar of a primary cannula penetrates the bowel, the condition is usually diagnosed when the mucosal lining of the gastrointestinal tract is visualized. If the large bowel is entered, a feculent odor may be noted. However, the injury may not be recognized immediately because the cannula may not stay within the bowel or may pass through the lumen. Such injuries usually occur when a single loop of bowel is adherent to the anterior abdominal wall. The injury may not be recognized until peritonitis, abscess, enterocutaneous fistula, or death occurs (123,124). Therefore, at the end of the procedure, the removal of the primary cannula must be viewed either through the cannula or an ancillary port, a process facilitated by routine direct visualization of closure of the incision of the primary port.


Gynecology_Novak

Gynecology_Novak. Trocar-related injuries to the stomach and bowel require repair as soon as they are recognized. If the injury is small, a trained operator can repair the defect under laparoscopic direction using a double layer of running 2-0 or 3-0 absorbable sutures. Extensive lesions may require resection and reanastomosis, which in most instances requires at least a small laparotomy. The preoperative use of mechanical bowel preparation in selected high-risk cases minimizes the need for laparotomy or colostomy, but recent evidence suggests that bowel surgery, if necessary, may be safely performed in unprepared bowel (125).


Gynecology_Novak

Gynecology_Novak. When mechanical bowel trauma is recognized during the dissection, treatment is the same as that described for trocar injury. Should the injury involve radiofrequency electrical energy, it is important to recognize that the zone of desiccation and coagulation may exceed the area of visual damage. This is especially true if the exact mechanism of the thermal injury is unknown or if injury results from contact with a relatively large surface area electrode that would be more likely to create a large coagulation injury. Conversely, bowel injury created under direct vision with a radiofrequency needle or blade electrode is associated with little collateral coagulation effect and can be managed similar to a mechanically induced lesion.


Gynecology_Novak

Gynecology_Novak. Consequently, surgical repair should be implemented considering these factors, and should include, if necessary, resection of ample margins around the injury. Thermal injury may be handled expectantly if the lesion seems superficial and confined, such as when fulguration (noncontact arcing of modulated high-voltage current) involves bowel. In such instances, the depth of injury is generally less than half a millimeter. In a study of 33 women with such injuries who were managed expectantly in the hospital, only 2 required laparotomy for repair of perforation (126). Urologic Injury Damage to the bladder or ureter may occur secondary to mechanical or thermal trauma incurred during laparoscopic procedures. Ideally, such injury should be prevented; otherwise, as is the case for most complications, it is preferable to identify the trauma intraoperatively.


Gynecology_Novak

Gynecology_Novak. Bladder injury can result from the perforation of the undrained bladder by an insufﬂation needle or trocar, or it may occur while the bladder is being dissected from adherent structures or from the anterior uterus (127,128). The frequency of injury is difficult to estimate and varies with the procedure. Estimates of the frequency of unintentional cystotomy associated with laparoscopic hysterectomy range from 0.4% to 3.2% and appear to be more frequent in the context of a previous cesarean section (129,130). The injury may be readily apparent by direct visualization. If an indwelling catheter is in place, hematuria or pneumaturia (CO2 in the catheter drainage system) may be noticed. A bladder laceration can be confirmed by injecting sterile milk or a diluted methylene blue solution through a transurethral catheter. Thermal injury to the bladder, however, may not be apparent initially and, if missed, can present as peritonitis or a fistula.


Gynecology_Novak

Gynecology_Novak. Routine preoperative bladder drainage usually prevents trocar-related cystotomies. Separation of the bladder from the uterus or other adherent structures requires good visualization, appropriate retraction, and excellent surgical technique. Sharp mechanical dissection is preferred, particularly when relatively dense adhesions are present. Very small-caliber injuries to the bladder (1 to 2 mm) may be treated with bladder catheterization for 3 to 7 days. If repair is undertaken immediately, catheterization is unnecessary. When a larger injury is identified, it can be repaired laparoscopically (127,128,131). If the laceration is near to or involves the trigone, an open procedure should be used. The mechanism of injury should be taken into consideration in making this evaluation because electrical injuries often extend beyond the visible limits of the apparent defect. If a coagulation-induced thermal injury occurred, the coagulated portion should be excised.


Gynecology_Novak

Gynecology_Novak. For small lesions, closure may be performed with layers of absorbable 2-0 to 3-0 sutures. Postoperative catheterization with either a transurethral or suprapubic catheter should be maintained for 2 to 5 days for small fundal lacerations and for 10 to 14 days for injuries to the trigone. Cystography should be considered before the urinary catheter is removed.


Gynecology_Novak

Gynecology_Novak. One of the most common causes of ureteral injury during laparoscopy is electrosurgical trauma (113,132,133). Ureteral injury can occur after mechanical dissection, including linear cutting and stapling devices (133–135). Although intraoperative recognition of ureteral injury is possible, the diagnosis is usually delayed (132,133). Ureteral lacerations may be confirmed intraoperatively, visually, or following the intravenous injection of indigo carmine. Thermal injury presents up to 14 days after surgery with fever, abdominal or ﬂank pain, and peritonitis. Leukocytosis may be present, and intravenous pyelography shows extravasation of urine or urinoma. Mechanical obstruction from staples or a suture may be recognized intraoperatively by direct visualization. Cystoscopy following the intravenous injection of indigo carmine may be used to confirm failure of the dye to pass through the ureter. Abdominal ultrasound may be helpful, but a CT urogram can more precisely identify the site and


Gynecology_Novak

Gynecology_Novak. injection of indigo carmine may be used to confirm failure of the dye to pass through the ureter. Abdominal ultrasound may be helpful, but a CT urogram can more precisely identify the site and degree of the obstruction. Unrecognized ureteral obstruction may present a few days to 1 week after surgery with ﬂank pain and often fever (136).


Gynecology_Novak

Gynecology_Novak. Discharge or continuous incontinence is a delayed sign of ureterovaginal or vesicovaginal fistula. A vesicovaginal fistula can be confirmed by filling the bladder with methylene blue and then detecting dye on a tampon previously placed in the vagina. With a ureterovaginal fistula, the methylene blue will not pass into the vagina, but it can be detected with the intravenous injection of indigo carmine.


Gynecology_Novak

Gynecology_Novak. Knowledge of the course of the ureter through the pelvis is a prerequisite to reducing the risk of injury. The ureter can usually be seen through the peritoneum of the pelvic sidewall between the pelvic brim and the attachment of the broad ligament. Because of variation from one patient to another or the presence of disease, the location of the ureter can become obscured, making it necessary to enter the retroperitoneal space. The techniques used for retroperitoneal dissection are important factors in reducing the risk of ureteric injury. Blunt and sharp dissection with scissors is preferred, although hydrodissection can be used (137). The selective placement of ureteral stents may be helpful in preventing injury.


Gynecology_Novak

Gynecology_Novak. Ureteral injury can be treated immediately if it is diagnosed intraoperatively. Although limited damage may heal over a ureteral stent left in place for 10 to 21 days, repair is indicated in most patients. Laparoscopic repair of ureteric lacerations and transections is performed, but most injuries require laparotomy (132,138). Incomplete or small obstructions and lacerations may be treated successfully with either a retrograde or anterograde ureteral stent. Urinomas may be drained percutaneously. If a stent cannot be placed successfully, a percutaneous nephrostomy should be performed before operative repair is undertaken. Repair may be accomplished by excision and reanastamosis, or, more commonly, ureteric reimplantation with or without facilitating procedures such as a psoas hitch or a Boarie ﬂap.


Gynecology_Novak

Gynecology_Novak. Neurologic Injury Peripheral nerve injury is usually related either to poor positioning of the patient or to excessive pressure exerted by the surgeons. Placing the patient in the modified lithotomy position while she is awake may decrease this risk because the patient can determine whether any undue pressure or discomfort is felt (139). Nerve injury may also occur as a result of the surgical dissection.


Gynecology_Novak

Gynecology_Novak. In the extremities, the trauma may be direct, such as when the common peroneal nerve is compressed against a stirrup. The femoral nerve or the sciatic nerve or its branches may be overstretched and damaged by excessive ﬂexion or external rotation of the hips. The peroneal nerve may be injured by compression if the lateral head of the fibula rests against the stirrup (139–141). Brachial plexus injuries may occur secondary to the surgeon or assistants leaning against an abducted arm during the procedure. If the patient is placed in a steep Trendelenburg position, the brachial plexus may be damaged because of the pressure exerted on the shoulder joint. In most cases, sensory or motor deficits are found as the patient emerges from anesthesia. The likelihood of brachial plexus injury can be reduced with adequate padding and support of the arms and shoulders or by placing the patient’s arms in an adducted position.


Gynecology_Novak

Gynecology_Novak. Most injuries to peripheral nerves resolve spontaneously. The time to recovery depends on the site and severity of the lesion. For most peripheral injuries, full sensory nerve recovery occurs in 3 to 6 months. Recovery may be hastened by the use of physical therapy, appropriate braces, and electrical stimulation of the affected muscles. Open microsurgery should be performed for transection of major intrapelvic nerves. Incisional hernia after laparoscopy was reported in more than 900 cases (98,99). The most common defect is dehiscence that develops in the immediate postoperative period. Hernias may be asymptomatic or may cause pain, fever, periumbilical mass, obvious evisceration, and the symptoms and signs of mechanical bowel obstruction. Although no incision is immune to the risk, defects that are larger than 10 mm in diameter are particularly vulnerable (99,142,143).


Gynecology_Novak

Gynecology_Novak. Richter’s hernias contain only a portion of the intestine in the defect, and the diagnosis is often delayed because the typical symptoms and findings of mechanical bowel obstruction may be absent. The initial symptom is usually pain. These hernias most often occur in incisions that are lateral to the midline where there is a greater amount of preperitoneal fat creating a potential space for incarceration. Fever can be present if incarceration occurs, and peritonitis may result from subsequent perforation. The condition is difficult to diagnose, requires a high index of suspicion, and may be confirmed with ultrasonography or CT (144).


Gynecology_Novak

Gynecology_Novak. In most cases, these occurrences can be prevented by using small-caliber cannulas, when possible, and with routine fascial and peritoneal closure of defects made by peritoneal access. The risk of inadvertent incorporation of the intestine into the wound can be reduced by viewing the closure with a smaller-caliber laparoscope passed through a narrow caliber ancillary port. All ancillary cannulas should be removed under direct vision to ensure that bowel is not drawn into the incision and that there is an absence of active incisional bleeding.


Gynecology_Novak

Gynecology_Novak. The management of laparoscopic incisional defects depends on the time of presentation and the presence and condition of entrapped bowel. Evisceration always requires surgical intervention. If the condition is diagnosed immediately, the intestine is replaced in the peritoneal cavity (if there is no evidence of necrosis or intestinal defect), and the incision is repaired, usually with laparoscopic guidance. If the diagnosis is delayed or the bowel is incarcerated or at risk of perforation, laparotomy is necessary to repair or resect the intestine. Wound infections after laparoscopy are uncommon; most are minor skin infections that can be treated successfully with expectant management, drainage, or antibiotics (145). Severe necrotizing fasciitis rarely occurs. Bladder infection, pelvic cellulitis, and pelvic abscess were reported (146).


Gynecology_Novak

Gynecology_Novak. Laparoscopy is associated with a much lower risk of infection than open abdominal or vaginal surgery. Prophylactic antibiotics should be offered to selected patients (e.g., those with enhanced risk for bacterial endocarditis and those for whom total hysterectomy is planned). Patients should be instructed to monitor their body temperature after discharge and to report immediately a temperature higher than 38◦C.


Gynecology_Novak

Gynecology_Novak. The hysteroscope is an endoluminal endoscope, adapted from the urological cystoscope that can be used to aid diagnosis or to direct the performance of a variety of intrauterine procedures. Hysteroscopic lysis of intrauterine adhesions was first described in 1973 (147). The technique of endoscopically guided electrosurgical resection was adapted from urology to gynecology for the removal of uterine leiomyomas (148). Hysteroscopic division of uterine septa was originally developed using a mechanical technique with specially designed scissors (149). Hysteroscopic destruction of the endometrium, generally termed endometrial ablation (EA), was originally reported using Nd:YAG laser vaporization, but subsequent innovators used the urological resectoscope to ablate the endometrium using electrosurgical coagulation, resection, or vaporization (150–152). Hysteroscopically guided thermal ablation with heated ﬂuid was described, as the only endoscopically guided technique for nonresectoscopic


Gynecology_Novak

Gynecology_Novak. coagulation, resection, or vaporization (150–152). Hysteroscopically guided thermal ablation with heated ﬂuid was described, as the only endoscopically guided technique for nonresectoscopic EA. Developments in the design of endoscopes resulted in smaller-diameter instruments that retain the ability to provide a high-quality image and facilitate the use of hysteroscopy in an office or procedure room setting.


Gynecology_Novak

Gynecology_Novak. Diagnostic Hysteroscopy The goal for evaluation of the uterine cavity is to obtain either a sample of the endometrium, usually for the detection of hyperplasia or neoplasia, or to identify structural abnormalities, typically a uterine septum or focal lesions, such as adhesions, polyps, or myomas. Blind endometrial sampling is the diagnostic mainstay for the detection of endometrial hyperplasia, whereas transvaginal ultrasonography, hysterography, MRI and hysteroscopy are options for the detection and characterization of structural anomalies. Hysteroscopic examination is superior to hysterography for evaluation of the endometrial cavity, but the diagnostic accuracy of transvaginal ultrasonography is comparable, when intrauterine saline or gel is used as a contrast medium, a procedure called sonohysterography or saline infusion sonography (SIS) (153–156). MRI and ultrasound-based techniques have the advantage of allowing evaluation of the myometrium, whereas office-based hysteroscopy


Gynecology_Novak

Gynecology_Novak. sonohysterography or saline infusion sonography (SIS) (153–156). MRI and ultrasound-based techniques have the advantage of allowing evaluation of the myometrium, whereas office-based hysteroscopy allows simultaneous removal of small polyps and even some myomas. Diagnostic hysteroscopy provides information not obtained by blind endometrial sampling, such as detection of endometrial polyps or submucous leiomyomas (157–163). Malignant or hyperplastic polyps or other localized lesions can be identified with hysteroscopy and removed via directed biopsy (160). Blind curettage remains an effective approach for the identification of global endometrial histopathology (157,162,164). Following are potential indications for diagnostic hysteroscopy: 1.


Gynecology_Novak

2. 3. 3. Recurrent spontaneous abortion

Gynecology_Novak. 2. 3. 3. Recurrent spontaneous abortion


Gynecology_Novak

Gynecology_Novak. For most patients, diagnostic hysteroscopy can be performed in an office or procedure room setting with minimal discomfort and at a much lower cost than in a surgical center or a traditional operating room. For some, concerns about patient comfort or a preexisting medical condition may preclude office hysteroscopy. In many patients hysteroscopy can provide more information than blind curettage, but it should be used prudently. For most patients, other diagnostic or therapeutic measures can be undertaken before, or instead of, diagnostic hysteroscopy. For example, for women in the late reproductive years who have abnormal uterine bleeding (AUB) or for those with postmenopausal bleeding, transvaginal sonography or office endometrial biopsy or curettage is typically adequate to evaluate for neoplasia and provide enough information to support an initial management strategy. In the absence of a satisfactory diagnosis or if unexplained bleeding continues without response to treatment,