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Gynecology_Novak. because of their altered rates of clearance. Sufentanil and fentanyl are the preferred narcotics. Oxazepam, a benzodiazepine that does not undergo hepatic metabolism, is considered safe. Muscle relaxants, such as D-tubocurarine, pancuronium, and vecuronium, cause prolonged neuromuscular blockade in patients with impaired liver function and are not ideal drugs to use in this situation. Atracurium is not metabolized by the liver and is the preferred muscle relaxant for patients with abnormal hepatic function. Succinylcholine metabolism is prolonged in patients with hepatic dysfunction and must be used with great caution (269).


Gynecology_Novak

Determination of Operative Risk

Gynecology_Novak. Determination of Operative Risk


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Gynecology_Novak. Although it is well known that acute hepatobiliary damage results in increased morbidity and mortality in the surgical patient, estimating the operative risk in patients with hepatic dysfunction is difficult based on the history and physical examination. The most accurate method for risk assessment of surgery in patients with hepatic dysfunction is Child’s classification (Table 22.21). Using this system, accurate assessment of morbidity and mortality can be directly related to the degree of liver dysfunction (270). The Child’s classification is useful for patients undergoing a variety of different types of abdominal surgery. Data show operative mortalities of 10%, 30%, and 82% for each of the three Child’s classifications, respectively, while other data called this into question with operative mortality of 2%, 12%, and 12% (271,272). The major cause of perioperative death was often sepsis. This classification correlated significantly with postoperative complications such as bleeding,


Gynecology_Novak

Gynecology_Novak. mortality of 2%, 12%, and 12% (271,272). The major cause of perioperative death was often sepsis. This classification correlated significantly with postoperative complications such as bleeding, renal failure, wound dehiscence, and sepsis. Another method for determining operative risk in patients with cirrhosis is the Model for End-Stage Liver Disease (MELD), which takes into account the patient’s prothrombin time, bilirubin, and creatinine with various iterations used to better predict perioperative morbidity and mortality (273,274). Originally designed to predict outcomes in cirrhotic patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure, it was further studied to include patients undergoing other surgical procedures. In patients with a MELD score greater than 15, elective surgery should be deferred (275).


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Gynecology_Novak. Acute Viral Hepatitis Acute viral hepatitis poses an increased risk of operative complications and perioperative mortality and is a contraindication for elective surgery (276). Elective surgery should be delayed for approximately 1 month after the results of all biochemical tests have returned to normal (277). In patients with ectopic pregnancy, hemorrhage, or bowel obstruction secondary to malignancy, surgical intervention must take place before normalization of serum transaminase levels (276). In these situations, the perioperative morbidity (12%) and mortality (9.5%) rates are much higher than when they are performed under ideal situations (269).


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Gynecology_Novak. Chronic Hepatitis Chronic hepatitis is a group of disorders characterized by inﬂammation of the liver for at least 6 months. The disease is divided by morphologic and clinical criteria into chronic persistent hepatitis and chronic active hepatitis. A liver biopsy is usually required to establish the extent and type of injury. The surgical risk in these patients correlates most closely with the severity of disease. The risk of surgery in patients with asymptomatic or mild disease is minimal in contrast to a significant risk for those patients who have symptomatic chronic active hepatitis (278). Elective surgery is contraindicated in symptomatic patients, and nonelective surgery is associated with significant morbidity (277). In the nonelective situation, patients taking long-term glucocorticoid therapy should be given appropriate stress coverage with a higher dose of glucocorticoids during the perioperative period. Preoperatively, patients who are not taking steroids should receive


Gynecology_Novak

Gynecology_Novak. therapy should be given appropriate stress coverage with a higher dose of glucocorticoids during the perioperative period. Preoperatively, patients who are not taking steroids should receive prednisone and azathioprine, which are shown to reduce the perioperative risk of complications and may result in remission in as many as 80% of patients (279). Asymptomatic carriers of the hepatitis B virus (HBV; individuals who test positive for the HBV surface antigen) are not at increased risk for postoperative complications in the absence of elevated aminotransferase levels and liver inﬂammation. There is a significant risk to the health care professional operating on these individuals. In cases of needlestick in which the patient’s hepatitis status is unknown, both the health care worker and the patient should be tested for hepatitis C virus (HCV) antibody and HBV serologic markers. If markers for HBV infection are present, hepatitis B immune globulin should be administered to unvaccinated


Gynecology_Novak

Gynecology_Novak. patient should be tested for hepatitis C virus (HCV) antibody and HBV serologic markers. If markers for HBV infection are present, hepatitis B immune globulin should be administered to unvaccinated medical personnel. A vaccination series should be initiated during the early postoperative period. If the health care worker is immune (surface antibody positive), no treatment is necessary (269). All medical personnel, and especially those in the surgical subspecialties, should receive a full course of recombinant hepatitis B vaccine as recommended by the CDC (280). Treatment for chronic hepatitis B in the 1990s centered around interferon-α with data in the 2000s showing increased benefit from the use of nucleoside analogues, including lamivudine and tenofovir (281,282). Pegylated interferon and ribavirin are used in the standard treatment of HCV (283). Consideration should be given to using these medications for patients in whom surgery cannot be avoided but is not emergent.


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Gynecology_Novak. Alcoholic Liver Disease Alcoholic liver disease encompasses a spectrum of diseases including fatty liver, acute alcoholic hepatitis, and cirrhosis. Elective surgery is not contraindicated in patients with fatty liver because liver function is preserved. If nutritional deficiencies are discovered, they should be corrected before elective surgery. Acute alcoholic hepatitis is characterized on biopsy by hepatocyte edema, polymorphonuclear leukocyte infiltration, necrosis, and the presence of Mallory bodies. Elective surgery in these patients is contraindicated (284). Abstinence from alcohol for approximately 6 to 12 weeks along with clinical resolution of the biochemical abnormalities are recommended before surgery is considered. Severe alcoholic hepatitis may persist for several months despite abstinence and, if any question of continued activity exists, a liver biopsy should be repeated (285). In cases of urgent or emergent surgery on patients with alcohol dependence, administration of


Gynecology_Novak

Gynecology_Novak. abstinence and, if any question of continued activity exists, a liver biopsy should be repeated (285). In cases of urgent or emergent surgery on patients with alcohol dependence, administration of tapered doses of benzodiazepine is appropriate as prophylaxis against alcohol withdrawal.


Gynecology_Novak

Gynecology_Novak. Cirrhosis Cirrhosis is an irreversible liver lesion characterized histologically by parenchymal necrosis, nodular degeneration, fibrosis, and a disorganization of hepatic lobular architecture. The most serious complication of cirrhosis is portal venous hypertension, which ultimately leads to bleeding from esophageal varices, ascites, and hepatic encephalopathy. Conventional liver biochemical test results correlate poorly with the degree of liver impairment in patients with cirrhosis. Hepatic dysfunction, may be somewhat quantified by low albumin levels and prolonged prothrombin times.


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Gynecology_Novak. Surgical risk is increased in patients with advanced liver disease, although it is substantially greater in emergency surgery than in elective surgery. Perioperative mortality correlates with the severity of cirrhosis and can be estimated through the use of the Child’s classification (Table 22.21). In patients with Child’s class A cirrhosis, surgery can usually be performed without significant risk, whereas in patients with Child’s class B or C, surgery poses a major risk and requires careful preoperative consideration. Preoperative preparation should include the following measures: (i) optimizing nutritional status by enteral and parenteral nutrition and supplementation with vitamin B1, (ii) correcting coagulopathy with administration of FFP or cryoprecipitate or both, (iii) minimizing preexisting encephalopathy, (iv) preventing sepsis from spontaneous bacterial peritonitis by administering prophylactic antibiotic therapy, and (v) optimizing renal function and carefully correcting


Gynecology_Novak

Gynecology_Novak. preexisting encephalopathy, (iv) preventing sepsis from spontaneous bacterial peritonitis by administering prophylactic antibiotic therapy, and (v) optimizing renal function and carefully correcting electrolyte abnormalities (286). Meticulous preoperative preparation focused on correcting abnormalities associated with advanced liver disease may improve surgical outcomes (287).


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Gynecology_Novak. 1. Kaye AD, Kucera I, Sabar R. Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiol Clin North Am 2004;22:125–139. 2. Philp R. Herbal-drug interactions and adverse effects: An evidence-based quick reference guide. New York: McGraw-Hill Professional, 2003. 3. Blery C, Charpak Y, Szatan M, et al. Evaluation of a protocol for selective ordering of preoperative tests. Lancet 1986;1:139–141. 4. St. Clair CM, Shah M, Diver EJ, et al. Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. Obstet Gynecol 2010;116:694–700. 5. Lamers RJ, van Engelshoven JM, Pfaff A. [Once again, the routine preoperative thorax photo]. Ned Tijdschr Geneeskd 1989;133:2288– 2291. 6. Rohrer MJ, Michelotti MC, Nahrwold DL. A prospective evaluation of the efficacy of preoperative coagulation testing. Ann Surg 1988;208:554–557. 7.


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Gynecology_Novak. 6. Rohrer MJ, Michelotti MC, Nahrwold DL. A prospective evaluation of the efficacy of preoperative coagulation testing. Ann Surg 1988;208:554–557. 7. Piscitelli JT, Simel DL, Addison WA. Who should have intravenous pyelograms before hysterectomy for benign disease? Obstet Gynecol 1987;69:541–545. 8. ACOG Committee. Opinion No. 439: informed consent. Obstet Gynecol 2009;114(Pt 1):401–408. 9. Abed H, Rogers R, Helitzer D, et al. Informed consent in gynecologic surgery. Am J Obstet Gynecol 2007;197:674 e1–e5. 10. Rosenthal RA. Nutritional concerns in the older surgical patient. J Am Coll Surg 2004;199:785–791. 11. Windsor JA, Hill GL. Weight loss with physiologic impairment. A basic indicator of surgical risk. Ann Surg 1988;207:290–296. 12. Huckleberry Y. Nutritional support and the surgical patient. Am J Health Syst Pharm 2004;61:671–684. 13.


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Gynecology_Novak. 12. Huckleberry Y. Nutritional support and the surgical patient. Am J Health Syst Pharm 2004;61:671–684. 13. Santoso JT, Canada T, Latson B, et al. Prognostic nutritional index in relation to hospital stay in women with gynecologic cancer. Obstet Gynecol 2000;95(Pt 1):844–846. 14. Salvino RM, Dechicco RS, Seidner DL. Perioperative nutrition support: who and how. Cleve Clin J Med 2004;71:345–351. 15. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg 1999;134:36–42. 16. Soper JT, Berchuck A, Creasman WT, et al. Pelvic exenteration: factors associated with major surgical morbidity. Gynecol Oncol 1989;35:93–98. 17. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991;325:525–532. 18.


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Gynecology_Novak. 17. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991;325:525–532. 18. Klein S, Kinney J, Jeejeebhoy K, et al. Nutrition support in clinical practice: review of published data and recommendations for future research directions. National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition. JPEN J Parenter Enteral Nutr 1997;21: 133–156. 19. Geisler JP, Linnemeier GC, Thomas AJ, et al. Nutritional assessment using prealbumin as an objective criterion to determine whom should not undergo primary radical cytoreductive surgery for ovarian cancer. Gynecol Oncol 2007;106:128–131. 20. Koretz RL, Lipman TO, Klein S. AGA technical review on parenteral nutrition. Gastroenterology 2001;121:970–1001. 21.


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Gynecology_Novak. 20. Koretz RL, Lipman TO, Klein S. AGA technical review on parenteral nutrition. Gastroenterology 2001;121:970–1001. 21. Heuschekel R, Duggan C. Enteral feeding: gastric versus post-pyloric. UpToDate 2010. Available online at: http://www.uptodate. 22. Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J 2002;78:198–204. 23. Duro D, Collier S, Duggan C. Overview of parenteral and enteral nutrition. UpToDate 2010. Available online at: http://www.uptodate. 24. Worthington P. Practical aspects of nutritional support: an advanced practice guide. Philadelphia, PA: Saunders, 2004. 25. Long CL, Schaffel N, Geiger JW, et al. Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN J Parenter Enteral Nutr 1979;3:452–456. 26.


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Gynecology_Novak. 58. Gajraj NM, Joshi GP. Role of cyclooxygenase-2 inhibitors in postoperative pain management. Anesthesiol Clin North Am 2005;23:49– 72. 59. Bresalier RS, Quan H, Bolognese JA, et al. Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. N Engl J Med 2005;352:1092–1102. 60. Fitzgerald GA. Coxibs and cardiovascular disease. N Engl J Med 2004;351:1709–1711. 61. FitzGerald GA, Patrono C. The coxibs, selective inhibitors of cyclooxygenase-2. N Engl J Med 2001;345:433–442. 62. Nussmeier NA, Whelton AA, Brown MT, et al. Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. N Engl J Med 2005;352:1081–1091. 63. Solomon SD, McMurray JJ, Pfeffer MA, et al. Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention. N Engl J Med 2005;352:1071–1080. 64. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med 2010;83:11–25. 65.


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Gynecology_Novak. 242. Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med 2004;350:2689–2697. 243. Barnes PJ. Chronic obstructive pulmonary disease. N Engl J Med 2000;343:269–280. 244. Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet 2007;369:1553– 1564. 245. Weinacker AB, Vaszar LT. Acute respiratory distress syndrome: physiology and new management strategies. Annu Rev Med 2001; 52:221–237. 246. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004;351:327–336. 247. Anonymous. Demography of dialysis and transplantation in Europe, 1984. Report from the European Dialysis and Transplant Association Registry. Nephrol Dial Transplant 1986;1:1–8. 248.


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Gynecology_Novak. 247. Anonymous. Demography of dialysis and transplantation in Europe, 1984. Report from the European Dialysis and Transplant Association Registry. Nephrol Dial Transplant 1986;1:1–8. 248. Blumberg A, Weidmann P, Shaw S, et al. Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. AmJ Med 1988;85:507–512. 249. Lewis SL, Van Epps DE. Neutrophil and monocyte alterations in chronic dialysis patients. Am J Kidney Dis 1987;9:381–395. 250. Hellem AJ, Borchgrevink CF, Ames SB. The role of red cells in haemostasis: the relation between haematocrit, bleeding time and platelet adhesiveness. Br J Haematol 1961;7:42–50. 251. Remuzzi G. Bleeding disorders in uremia: pathophysiology and treatment. Adv Nephrol Necker Hosp 1989;18:171–186. 252. Janson PA, Jubelirer SJ, Weinstein MJ, et al. Treatment of the bleeding tendency in uremia with cryoprecipitate. N Engl J Med 1980;303:1318–1322. 253.


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Gynecology_Novak. 252. Janson PA, Jubelirer SJ, Weinstein MJ, et al. Treatment of the bleeding tendency in uremia with cryoprecipitate. N Engl J Med 1980;303:1318–1322. 253. Mannucci PM, Remuzzi G, Pusineri F, et al. Deamino-8-darginine vasopressin shortens the bleeding time in uremia. N Engl J Med 1983;308:8–12. 254. Stoelting R, Dierdorf S. Renal disease. In: Stoelting R, Dierdorf E, eds. Anesthesia and co-existing disease. New York: Churchill Livingstone, 1993:289–312. 255. Tonelli M, Pannu N, Manns B. Oral phosphate binders in patients with kidney failure. N Engl J Med 2010;362:1312–1324. 256. Hostetter TH, Olson JL, Rennke HG, et al. Hyperfiltration in remnant nephrons: a potentially adverse response to renal ablation. JAm Soc Nephrol 2001;12:1315–1325. 257. Miller R. Pharmacology of muscle relaxants and their antagonists. New York: Churchill Livingstone, 1986. 258.


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Gynecology_Novak. 257. Miller R. Pharmacology of muscle relaxants and their antagonists. New York: Churchill Livingstone, 1986. 258. Mazze R. Anesthesia for patients with abnormal renal function and genitourinary problems. New York: Churchill Livingstone, 1986. 259. Roth F, Wuthrich H. The clinical importance of hyperkalaemia following suxamethonium administration. Br J Anaesth 1969;41:311– 316. 260. Silberman H. Renal failure and the surgeon. Surg Gynecol Obstet 1977;144:775–784. 261. Bullock ML, Umen AJ, Finkelstein M, et al. The assessment of risk factors in 462 patients with acute renal failure. Am J Kidney Dis 1985;5:97–103. 262. Hou SH, Bushinsky DA, Wish JB, et al. Hospital-acquired renal insufficiency: a prospective study. Am J Med 1983;74:243–248. 263. Meyer RD. Risk factors and comparisons of clinical nephrotoxicity of aminoglycosides. Am J Med 1986;80:119–125. 264.


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Gynecology_Novak. 263. Meyer RD. Risk factors and comparisons of clinical nephrotoxicity of aminoglycosides. Am J Med 1986;80:119–125. 264. Shusterman N, Strom BL, Murray TG, et al. Risk factors and outcome of hospital-acquired acute renal failure. Clinical epidemiologic study. Am J Med 1987;83:65–71. 265. Lameire NH. Contrast-induced nephropathy—prevention and risk reduction. Nephrol Dial Transplant 2006;21:i11–i23. 266. Bush HL Jr, Huse JB, Johnson WC, et al. Prevention of renal insufficiency after abdominal aortic aneurysm resection by optimal volume loading. Arch Surg 1981;116:1517–1524. 267. Cebul RD, Beck JR. Biochemical profiles. Applications in ambulatory screening and preadmission testing of adults. Ann Intern Med 1987;106:403–413. 268. Batchelder BM, Cooperman LH. Effects of anesthetics on splanchnic circulation and metabolism. Surg Clin North Am 1975;55:787– 794. 269. Maze M, Bass NM. Anesthesia and the hepatobilliary system.New York: Churchill Livingstone, 2000. 270.


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Gynecology_Novak. 269. Maze M, Bass NM. Anesthesia and the hepatobilliary system.New York: Churchill Livingstone, 2000. 270. Child C, Turcotte JG. Surgery and portal hypertension. In: Child C, ed. The liver and portal hypertension. Philadelphia, PA: WB Saunders, 1964:1–85. 271. Mansour A, Watson W, Sahyani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 1997;122:730–736. 272. Telem DA, Schiano T, Goldstone R, et al. Factors that predict outcome of abdominal operations in patients with advanced cirrhosis. Clin Gastroenterol Hepatol 2010;8:451–458. 273. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464–470. 274. Malinchoc M, Kamath PS, Gordon FD, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000;31:864–871. 275.


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Gynecology_Novak. 274. Malinchoc M, Kamath PS, Gordon FD, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000;31:864–871. 275. Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. Nat Clin Pract Gastroenterol Hepatol 2007;4:266– 276. 276. Terblanche J. Sclerotherapy for prophylaxis of variceal bleeding. Lancet 1986;1:961–963. 277. Lamont J. The liver. In: Vandam L, ed. To make the patient ready for anesthesia: medical care of the surgical patient. Menlo Park, CA: Addison Wesley, 1984:47–66. 278. Blamey SL, Fearpm KC, Gilmour WH, et al. Prediction of risk in biliary surgery. Br J Surg 1983;70:535–538. 279. Czaja AJ, Summerskill WH. Chronic hepatitis. To treat or not to treat? Med Clin North Am 1978;62:71–85. 280.


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Gynecology_Novak. 279. Czaja AJ, Summerskill WH. Chronic hepatitis. To treat or not to treat? Med Clin North Am 1978;62:71–85. 280. Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006;55(RR-16):1–33. 281. Liaw YF, Sung JJ, Chow WC, et al. Lamivudine for patients with chronic hepatitis B and advanced liver disease. N Engl J Med 2004;351:1521–1531. 282. Marcellin P, Heathcote EJ, Buti M, et al. Tenofovir disoproxil fumarate versus adefovir dipivoxil for chronic hepatitis B. N Engl J Med 2008;359:2442–2455. 283. Keam SJ, Cvetkovic RS. Peginterferon-alpha-2a (40 kD) plus ribavirin: a review of its use in the management of chronic hepatitis C mono-infection. Drugs 2008;68:1273–1317. 284.


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Gynecology_Novak. 283. Keam SJ, Cvetkovic RS. Peginterferon-alpha-2a (40 kD) plus ribavirin: a review of its use in the management of chronic hepatitis C mono-infection. Drugs 2008;68:1273–1317. 284. Chiang PP. Perioperative management of the alcohol-dependent patient. Am Fam Physician 1995;52:2267–2273. 285. Matloff D, Kapkan MM. Gastroenterology. In: Molitch M, ed. Management of medical problems in surgical patients. Philadelphia, PA: FA Davis, 1982:219–252. 286. Wiklund RA. Preoperative preparation of patients with advanced liver disease. Crit Care Med 2004;32(Suppl):S106–S115. 287. O’Leary JG, Yachimski PS, Friedman LS. Surgery in the patient with liver disease. Clin Liver Dis 2009;13:211–231. Malcolm G. Munro Andrew I. Brill William H. Parker Positioning the insufﬂation needle and the primary cannula are best accomplished with the patient in an unaltered horizontal position.


Gynecology_Novak

Gynecology_Novak. Malcolm G. Munro Andrew I. Brill William H. Parker Positioning the insufﬂation needle and the primary cannula are best accomplished with the patient in an unaltered horizontal position. Proper patient selection is critical for laparoscopic management of ovarian cysts because of concerns about an adverse effect on prognosis with malignant tumors. Laparoscopic myomectomy often requires laparoscopic suturing; thus, more technical skills are needed than with many other endoscopic procedures. Laparoscopic hysterectomy comprises any removal of the uterus where at least part of the dissection is accomplished laparoscopically while the remainder, if any, is finished vaginally. Dehiscence and hernia risk appear to significantly increase when the fascial incision is larger than 10 mm in diameter.


Gynecology_Novak

Gynecology_Novak. Dehiscence and hernia risk appear to significantly increase when the fascial incision is larger than 10 mm in diameter. The incidence of unintended electrosurgical activation injuries can be reduced if the surgeon always remains in direct control of electrode activation and if all electrosurgical hand instruments are removed from the peritoneal cavity when not in use. Patients recovering from laparoscopic surgery usually experience daily improvement. Pain diminishes, gastrointestinal function returns rapidly, and fever is extremely unusual. Therefore, if a patient’s condition is not improving, possible complications of anesthesia or surgery should be considered.


Gynecology_Novak

Gynecology_Novak. Endoscopy is a procedure that uses a narrow telescope to view the interior of a viscus or preformed space. Although the first medical endoscopic procedures were performed more than 100 years ago, the potential of this method was realized only recently. Endoscopes are used to perform a variety of operations. In gynecology, endoscopes are used most often to diagnose conditions by direct visualization of the peritoneal cavity (laparoscopy) or the inside of the uterus (hysteroscopy). When used appropriately, endoscopic surgery offers the benefits of reduced pain, improved cosmesis, lower cost, and faster recovery. The indications for endoscopic surgery are outlined here and described in more detail in the appropriate chapters. The technology, potential uses, and complications of laparoscopy and hysteroscopy are summarized here.


Gynecology_Novak

Gynecology_Novak. The past four decades have witnessed rapid progress and technologic advances in gynecologic laparoscopy. Operative laparoscopy was developed in the 1970s, and in the early 1980s, laparoscopy was first used to direct the application of electrical or laser energy for the treatment of advanced stages of endometriosis. The use of high-resolution, and, more recently, high-definition video cameras in operative laparoscopy made it easier to view the pelvis during the performance of complex procedures (1,2). Most procedures that previously were performed using traditional techniques are feasible with the laparoscope, including adnexal procedures such as ectopic pregnancy and ovarian cystectomy; uterine surgery, such as myomectomy and hysterectomy; and reconstruction of the pelvic ﬂoor, such as retropubic urethropexy and sacral colposuspension. The endoscopic approach may have drawbacks in some patients. Although many laparoscopic procedures appear to reduce the cost and morbidity associated


Gynecology_Novak

Gynecology_Novak. urethropexy and sacral colposuspension. The endoscopic approach may have drawbacks in some patients. Although many laparoscopic procedures appear to reduce the cost and morbidity associated with surgery, others were replaced by even less invasive procedures, and a few were not effective replacements for more traditional operations. The use of microprocessor-assisted laparoscopy allows the surgeon to operate remotely from the operative field, in a sitting position, with the “robot” allowing translation of natural hand manipulations to the peritoneal cavity with the specially designed instruments. The value of this and other techniques and indications for operative endoscopy are still under investigation and constantly in a state of evolution.


Gynecology_Novak

Gynecology_Novak. Diagnostic Laparoscopy The lens of a laparoscope can be positioned to allow wide-angle or magnified views of the peritoneal cavity. The clarity and illumination of the optics allow a better appreciation of fine detail than is possible with the naked eye. Laparoscopy is the standard method for the diagnosis of endometriosis and adhesions because no other imaging technique provides the same degree of sensitivity and specificity.


Gynecology_Novak

Gynecology_Novak. There are limitations to laparoscopy. The view of the operative field may be restricted, and if tissue or ﬂuid becomes attached to the lens, vision may be obscured. Soft tissues, intramural myomas, or the inside of a hollow viscus cannot be palpated. For assessment of these tissues, an imaging modality, such as ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI), is superior. Because of its ability to view soft tissue, ultrasonography is more accurate than laparoscopy for the evaluation of the inside of adnexal masses. The intraluminal contour of the uterus can be shown only by hysteroscopy or contrast imaging such as saline infusion sonography, hysterosalpingography, or MRI. Ultrasonography, in combination with serum assays of β-human chorionic gonadotropin (β-hCG) and progesterone, can be used to diagnose ectopic pregnancy, usually allowing medical therapy to be given without laparoscopic confirmation (3). As a result of the advances in blood tests and


Gynecology_Novak

Gynecology_Novak. (β-hCG) and progesterone, can be used to diagnose ectopic pregnancy, usually allowing medical therapy to be given without laparoscopic confirmation (3). As a result of the advances in blood tests and imaging technology, laparoscopy more often is used to confirm a clinical impression than for initial diagnosis.


Gynecology_Novak

Gynecology_Novak. Laparoscopy may disclose abnormalities that are not necessarily related to the patient’s problem. Although endometriosis, adhesions, leiomyomas, and small cysts in the ovaries are common, they are frequently asymptomatic. Thus, diagnostic laparoscopy must be performed prudently, interpreting findings in the context of the clinical problem and other diagnoses.


Gynecology_Novak

Gynecology_Novak. The role of laparoscopy in the operative management of gynecologic conditions is evolving. Many procedures previously performed as traditional abdominal and vaginal operations are feasible or even readily performed under laparoscopic direction. Operative laparoscopy has the benefit of shorter hospital stays, less postoperative pain, and faster return to normal activity. These general features of laparoscopic procedures contribute to a reduction in the “indirect costs” of surgical care, including less time away from work and a diminished need for postdischarge supportive care in the home (4). In addition to the other benefits of endoscopic procedures, adhesions are less likely to form with laparoscopic surgery than with laparotomy. Because sponges are not used, the amount of direct peritoneal trauma is reduced substantially, and contamination of the peritoneal cavity is minimized. The reduced exposure to the drying effect of room air allows the peritoneal surface to remain more moist


Gynecology_Novak

Gynecology_Novak. trauma is reduced substantially, and contamination of the peritoneal cavity is minimized. The reduced exposure to the drying effect of room air allows the peritoneal surface to remain more moist and, therefore, less susceptible to injury and adhesion formation.


Gynecology_Novak

Gynecology_Novak. Despite these advantages, there are potential limitations: exposure of the operative field can be reduced; instruments are small and can be used only through fixed ports; and the ability to manipulate the pelvic viscera is limited. In some cases, the cost of hospitalization increases, despite a shortened stay, because of prolonged operating room time and the use of more expensive surgical equipment and supplies. Efficacy may be reduced if a surgeon cannot adequately replicate the abdominal operation. In some patients, there is an increased risk of complications, which can be attributed to the innate limitations of laparoscopy, the level of surgical expertise, or both. With an adequate combination of ability, training, and experience, however, operative time is comparable to those of traditional abdominal surgery and complications may be reduced.


Gynecology_Novak

Gynecology_Novak. Tubal Surgery Sterilization Laparoscopic sterilization has been used extensively since the late 1960s, and while it can be performed with local anesthetics, it is usually accomplished under general anesthesia. The fallopian tubes can be occluded by suture, clips, silastic rings, or with radiofrequency electrocoagulation, most commonly with a bipolar electrocoagulation instrument (see Chapter 10). When an “operative laparoscope” is used, only one incision is required because the sheath in such a system contains an instrument channel. Otherwise, a second port is needed for the introduction of the occluding instrument. Patients generally remain in the hospital only for a few hours; even when general anesthesia is used. Postoperative pain is usually minor and related to gas that remains in the peritoneal cavity (shoulder pain, dyspnea), and in the case of occlusive devices, pain at the surgical site. These effects normally disappear within a few days. The failure rate is about 5.4 per


Gynecology_Novak

Gynecology_Novak. the peritoneal cavity (shoulder pain, dyspnea), and in the case of occlusive devices, pain at the surgical site. These effects normally disappear within a few days. The failure rate is about 5.4 per 1,000 woman-years (5,6). The use of laparoscopic tubal sterilization was impacted by the availability of office vasectomy, effective intrauterine contraception, and the development of office-based hysteroscopic sterilization techniques, discussed later in this chapter.


Gynecology_Novak

Gynecology_Novak. Ectopic Gestation Medical therapy with methotrexate is considered first-line therapy for tubal pregnancies that meet criteria that may include the following: no cardiac activity, tubal mass smaller than 4 cm as determined by ultrasonography, and β-hCG level less than 10,000 (7,8). When surgical therapy is required, ectopic gestation can usually be managed successfully by using laparoscopic salpingotomy, salpingectomy, or segmental resection of a portion of the oviduct (see Chapter 20) (9,10). Salpingotomy is performed with scissors, a laser, or an electrosurgical electrode after carefully injecting the mesosalpinx with a dilute vasopressincontaining solution (20 U in 100 mL of normal saline). For salpingectomy, the vascular pedicles are usually secured with electrosurgical desiccation or coagulation, but it is possible using ligatures or clips. Tissue is usually removed from the peritoneal cavity through one of the laparoscopic cannulas.


Gynecology_Novak

Gynecology_Novak. When salpingotomy is performed, regardless of the route, there is about a 5% chance that trophoblastic tissue remains. In such instances, medical treatment with methotrexate is appropriate (see Chapter 20). Consequently, β-hCG levels should be measured weekly until there is confidence that complete excision occurred (11–13).


Gynecology_Novak

Gynecology_Novak. Ovarian Surgery Ovarian Masses Laparoscopic removal of selected ovarian masses is a well-established technique supported by high quality evidence (14–16). Proper patient selection is critical for laparoscopic management of adnexal masses because of the possible adverse effect of laparoscopic approaches on prognosis with malignant tumors (17,18). Preoperative ultrasonography is mandatory. Sonolucent lesions with thin walls and no solid components are at very low risk for malignancy and, therefore, are suitable for laparoscopic removal. For post-menopausal women, the measurement of CA125 levels is useful in identifying candidates for laparoscopic management (19,20). Combining age, menopausal status, an ultrasound score, and the serum CA125 level into a “risk of malignancy index” seems to offer an effective approach to the identification of cysts at high risk for epithelial malignancy (21–23). Lesions with ultrasonographic findings suggestive of mature teratoma (dermoid), endometrioma,


Gynecology_Novak

Gynecology_Novak. an effective approach to the identification of cysts at high risk for epithelial malignancy (21–23). Lesions with ultrasonographic findings suggestive of mature teratoma (dermoid), endometrioma, or hemorrhagic or other cysts presenting with torsion or other causes of acute pain may be suitable for endoscopic management (24–27). Ovarian tumors should be assessed by frozen histologic section, and any frank malignancy should be managed expeditiously by laparotomy (14,18,20).


Gynecology_Novak

Gynecology_Novak. The technique for performing laparoscopy for oophorectomy and cystectomy is similar to that used for laparotomy (13). For cystectomy, scissors are used to incise the ovarian capsule, and blunt dissection or aqua dissection is used to separate the cyst from the ovary. If oophorectomy is performed, the vascular pedicles are occluded and transected, usually with radiofrequency electrosurgical coagulation and cutting systems, but in some instances with sutures, clips, or linear cutting and stapling devices. The ureter should be identified and should be clear of the pedicle to be transected. Cysts that appear to be benign may be drained before extraction through a laparoscopic cannula or, less commonly, a posterior culdotomy. If there is concern about the impact of spilled cyst contents, the specimen should be removed in a retrieval bag inserted into the peritoneal cavity through a laparoscopic port. Some authors describe a minilaparotomy technique, or enlarging one port site incision, to


Gynecology_Novak

Gynecology_Novak. should be removed in a retrieval bag inserted into the peritoneal cavity through a laparoscopic port. Some authors describe a minilaparotomy technique, or enlarging one port site incision, to exteriorize the mass, drain it externally without intraperitoneal spill, remove the cyst or ovary, and then reintroduce the adnexa into the peritoneal cavity (28).


Gynecology_Novak

Gynecology_Novak. Although in the past the ovary routinely was closed after cystectomy, this practice may be unnecessary and could contribute to the formation of adhesions (29). There is controversy about this point as at least one randomized clinical trial (class 1) suggested that suture-based closure of the ovary is associated with fewer adhesions than using electrodesiccation alone (30). Ovarian torsion, previously treated by laparotomy and oophorectomy, often can be managed laparoscopically (31,32). Even if there is apparent necrosis, the adnexa can be untwisted, usually with preservation of normal ovarian function (26,33). Performing a cystectomy at the same time that the ovary is untwisted greatly reduces the likelihood that ovarian function will be maintained. Rarely is adnexectomy indicated.


Gynecology_Novak

Gynecology_Novak. Polycystic ovarian syndrome can be treated laparoscopically using electrosurgery or laser vaporization to perform ovarian “drilling.” This procedure reduces the volume of ovarian stromal tissue and may lead to a temporary return of normal ovulation (34–36). Although such procedures were successful in a number of randomized trials, postoperative adhesions form in 15% to 20% of patients, which underscores the need to first exhaust medical treatment (37–39). Laparoscopic myomectomy, although feasible, may be difficult to perform because proper closure of the myometrium requires laparoscopically directed suturing and, thus, requires more technical skills than many other endoscopic procedures. While it is possible that microprocessor-assisted (robotic) laparoscopic myomectomy may allow more surgeons to suture effectively under laparoscopic guidance, in expert hands there appears to be no benefit to robotic surgery in any measurable perioperative outcome (40).


Gynecology_Novak

Gynecology_Novak. There remain some questions regarding the efficacy of laparoscopic myomectomy, especially as it relates to the treatment of infertility and heavy menstrual bleeding, each of which are thought to be secondary to submucous myomas. Although there are some well-designed randomized clinical trials evaluating infertility outcomes comparing laparoscopic myomectomy to that performed by laparotomy, the sample sizes are still relatively small, and the cases are highly selected, limiting the size and number of the lesions to be removed (41,42). In these trials, fertility outcomes were similar between the laparoscopic and the laparotomic approaches. These and other trials evaluating perioperative outcomes, such as duration of admission, surgical pain, and operative complications, found the laparoscopic approach to be superior (43).


Gynecology_Novak

Gynecology_Novak. Proper patient selection for myomectomy, regardless of route, is extremely important, particularly because, by age 50, the prevalence of leiomyomas may be as high as 70% in whites and 80% in women of African ancestry (44). It is relatively easy to mistakenly ascribe symptoms to the presence of leiomyomas. Unless the myoma involves the endometrial cavity, it is unlikely to contribute to heavy menstrual bleeding or infertility; the impact of intramural myomas on infertility is not well understood (45). Leiomyomas that cause pressure are often large and may be located near vital vascular structures that may preclude the laparoscopic approach even in expert hands. Many women will do well with expectant or medical management or with procedural alternatives such as uterine artery embolization. The surgeon should freely select a laparotomic approach, either at the outset or during the procedure, if technical limitations put the patient at risk or otherwise compromise the potential relevant


Gynecology_Novak

Gynecology_Novak. The surgeon should freely select a laparotomic approach, either at the outset or during the procedure, if technical limitations put the patient at risk or otherwise compromise the potential relevant clinical outcomes (46). Patients who have pedunculated or subserosal leiomyomas that cause bothersome discomfort or pain in association with torsion are especially good candidates for laparoscopic excision (13,47).


Gynecology_Novak

Gynecology_Novak. Laparoscopic hysterectomy encompasses a variety of procedures, including the facilitation of vaginal hysterectomy with variable extents of endoscopic dissection, supracervical hysterectomy by dissection, amputation and mechanical removal of the fundus, and the removal of the entire uterus under laparoscopic direction (48–50). In most environments, the procedure is performed with a combination of electrosurgical vessel sealing devices and mechanical cutting systems, often incorporated into a single instrument. In some instances sutures, clips, and linear cutting and stapling devices are employed in the process of dissecting or occluding vascular pedicles.


Gynecology_Novak

Gynecology_Novak. Compared to vaginal hysterectomy, there is a slightly higher risk of complications with laparoscopic hysterectomy, but this risk is probably lower than for abdominal hysterectomy (51). As experience is gained with laparoscopic hysterectomy, these outcomes may approach those of vaginal hysterectomy. The procedural costs of laparoscopic hysterectomy are greater than either vaginal or abdominal hysterectomy but can be dramatically reduced when reusable instruments are employed (4,52). Most studies show less postoperative pain, shorter hospital stays, and faster postoperative recovery with laparoscopic hysterectomy than with abdominal hysterectomy (51,53). There is evidence that pain scores and quality-of-life measures, including sexual activity and physical and mental functioning, were significantly better for women who underwent laparoscopic versus abdominal hysterectomy (54). These differences were present at 6 weeks following surgery and remained at the 12-month follow-up visit. When


Gynecology_Novak

Gynecology_Novak. better for women who underwent laparoscopic versus abdominal hysterectomy (54). These differences were present at 6 weeks following surgery and remained at the 12-month follow-up visit. When the societal benefits of faster return to work or family are considered, the cost of laparoscopic surgery is significantly less (4).


Gynecology_Novak

Gynecology_Novak. Selection of the route of hysterectomy must be done considering the anatomy, the disorder or disease state, the patient’s wishes, and the training and experience of the surgeon. Laparoscopic hysterectomy offers no advantage for women in whom vaginal hysterectomy is possible because the endoscopic approach is more expensive and probably has a higher risk for perioperative morbidity (51). The ideal place for laparoscopic hysterectomy is as a replacement for abdominal hysterectomy.


Gynecology_Novak

Gynecology_Novak. Outside of physician training, there are relatively few remaining indications for abdominal hysterectomy, which should be reserved for the minority of women for whom a laparoscopic or vaginal approach is not appropriate, including (i) patients with medical conditions, such as cardiopulmonary disease, where the risks of either general anesthesia or the increased intraperitoneal pressure associated with laparoscopy are deemed unacceptable; or (ii) where morcellation is known or likely to be required and uterine malignancy is either known or suspected. For both laparoscopic and vaginal hysterectomy the reasons include: (i) hysterectomy is indicated but there is no access to the surgeons or facilities required for vaginal or laparoscopic hysterectomy and referral is not feasible; or (ii) circumstances where anatomy is so distorted by uterine disease or adhesions that a vaginal or laparoscopic approach is not deemed safe or reasonable by individuals with recognized expertise in either


Gynecology_Novak

Gynecology_Novak. circumstances where anatomy is so distorted by uterine disease or adhesions that a vaginal or laparoscopic approach is not deemed safe or reasonable by individuals with recognized expertise in either vaginal or laparoscopic hysterectomy techniques (52,54). For surgeons without the skill and training to perform minimally invasive hysterectomy (either vaginal or laparoscopic), for benign indications, consideration should be given for referral to a gynecologist with such training.


Gynecology_Novak

Gynecology_Novak. Infertility Operations When infertility occurs secondary to disruption of the normal anatomy or anatomic relationships by an inﬂammatory process, laparoscopically directed operations used to restore anatomy include fimbrioplasty, adhesiolysis, and salpingostomy for distal obstruction (55). Fimbrioplasty is distinguished from salpingostomy because it is performed in the absence of preexisting complete distal obstruction. Endometriosis associated with adnexal distortion can be treated by laparoscopic adhesiolysis. Whereas there is no known additional benefit of medical treatment of coexistent active endometriosis, the evidence relating to ablation of minimal and mild endometriosis is mixed, although when subjected to meta-analytic technique, there is a slight fecundity benefit for those undergoing laparoscopic ablation (56–58). Laparoscopy is used for procedures in which gametes (gamete intrafallopian transfer) or zygotes (zygote intrafallopian transfer) are placed into the fallopian


Gynecology_Novak

Gynecology_Novak. laparoscopic ablation (56–58). Laparoscopy is used for procedures in which gametes (gamete intrafallopian transfer) or zygotes (zygote intrafallopian transfer) are placed into the fallopian tube after oocytes are removed either via ultrasound-or laparoscopically guided technique.


Gynecology_Novak

Gynecology_Novak. Adhesiolysis may be accomplished by blunt or sharp dissection with scissors, ultrasonic shears, or an electrosurgical electrode. There is no evidence that laser-based instruments provide any additional value over less expensive techniques such as electrosurgery (59–61). The dissecting instruments are usually passed through an ancillary port; when laser energy is used, the channel of the operating laparoscope may be used for this purpose. Although there is controversy regarding the most appropriate modality for adhesiolysis, these methods are probably equally effective in appropriately trained hands.


Gynecology_Novak

Gynecology_Novak. Laparoscopic operations for the treatment of mechanical infertility are probably equally effective to similar procedures performed by laparotomy. In patients with extensive adhesions, successful outcomes are unlikely regardless of the approach. Consequently, assisted reproductive technologies such as in vitro fertilization and embryo transfer are necessary in these situations (see Chapter 32) (13,55).


Gynecology_Novak

Gynecology_Novak. Endometriosis The laparoscopic management of endometriomas parallels that of adnexal masses, although the ultrasonographic complexity of endometriomas sometimes makes it difficult to distinguish them preoperatively from a neoplasm (62). The close attachment of the endometrioma to the ovarian cortex and stroma may make it difficult to find surgical dissection planes, and incomplete removal increases the risk of recurrence. In such instances there may be a tendency either to compromise the function of the remaining ovary by attempting complete removal or to risk recurrence by leaving part of the endometrioma in place. A Cochrane review found good evidence that excisional surgery for endometriomas decreases the recurrence of the endometrioma, decreases the recurrence of pain symptoms, and in women who were previously subfertile, increases subsequent spontaneous pregnancy (63). Consequently, where possible the excisional approach should be the goal. Multifocal endometriosis may be treated


Gynecology_Novak

Gynecology_Novak. women who were previously subfertile, increases subsequent spontaneous pregnancy (63). Consequently, where possible the excisional approach should be the goal. Multifocal endometriosis may be treated by mechanical excision or ablation, the latter using coagulation or vaporization with either electrical or laser energy. With proper use, each energy source creates about the same amount of thermal injury (59–61). Endometriosis frequently is deeper than appreciated initially, making excisional techniques valuable in many instances (64,65).


Gynecology_Novak

Gynecology_Novak. Pelvic Floor Disorders Laparoscopy can be used to guide procedures to treat pelvic support defects, including culdoplasty, enterocele repair, vaginal vault suspension, paravaginal repair, and retropubic cystourethropexy for urinary stress incontinence. Although these conditions can be treated vaginally, the laparoscopic approach may offer benefits, particularly with retropubic urethropexy. There is some evidence that the laparoscopic approach is effective when compared with the traditional methods, but, in most instances, vaginal or laparoscopic mesh-based techniques seem to be the most frequently used approaches (66,67). Using the same surgical principles applied during traditional pelvic ﬂoor repair, laparoscopy promises better access to key anatomical landmarks and potentially more accurate suture placement (68). Whereas apical and anterior compartment defects can be successfully corrected via laparoscopy, posterior and perineal defects are best visualized and repaired using


Gynecology_Novak

Gynecology_Novak. accurate suture placement (68). Whereas apical and anterior compartment defects can be successfully corrected via laparoscopy, posterior and perineal defects are best visualized and repaired using vaginal techniques. The laparoscopic treatment of enterocele and vault prolapse may be useful in patients who require abdominal approaches after failure of a previous vaginal procedure. Because of the anatomical proximity of the pelvic ureter to the uterosacral ligament and anterolateral vagina, bilateral ureteral patency should be confirmed cystoscopically after laparoscopic vaginal vault suspension, enterocele repair, culdoplasty, cystourethropexy, or paravaginal repair.


Gynecology_Novak

Gynecology_Novak. Gynecologic Malignancies The role of laparoscopy in the management of gynecologic malignancy is not clearly established (69–71). A study performed by the Gynecology Oncologic Group showed that laparoscopic management of presumed stage I endometrial cancer was feasible (72). Larger-scale studies suggest that women treated with a laparoscopic approach do not fare worse than those treated via laparotomy (73,74). The potential for laparoscopic lymphadenectomy fostered a resurgence of interest in vaginal radical hysterectomy for stage I carcinoma of the cervix. Laparoscopy is being investigated for the staging of early ovarian malignancy and for second-look surgery (75,76). The rationale, alternatives, risks, and potential benefits of the selected approach should be explained to the prospective patient. She should be advised concerning the likely outcome of expectant management if the procedure was not performed.


Gynecology_Novak

Gynecology_Novak. The expectations and risks of diagnostic laparoscopy, and those of any other procedures that may be needed, must be explained. It may be helpful to compare risks and recovery with the same procedure performed via abdominal surgery. The risks of laparoscopy include those associated with anesthesia, infection, bleeding, and injury to the abdominal and pelvic viscera. The possibility of conversion to laparotomy if a complication should occur or if the procedure cannot be completed via laparoscopic surgery should also be discussed. Infection is uncommon with laparoscopic surgery. For procedures involving extensive dissection, there is a higher risk for visceral injury. These risks should be clearly presented in a fashion that includes both the possibilities of immediate and delayed recognition. The patient should be given realistic expectations regarding postoperative disability. Because pain and visceral dysfunction normally continue to improve after uncomplicated laparoscopy, the


Gynecology_Novak

Gynecology_Novak. The patient should be given realistic expectations regarding postoperative disability. Because pain and visceral dysfunction normally continue to improve after uncomplicated laparoscopy, the patient should be instructed to communicate immediately any regression in her recovery. After diagnostic or brief operative procedures, patients can be discharged on the day of surgery and usually require 24 to 72 hours off work or school. If extensive dissection—a major surgical procedure performed laparoscopically—is necessary or if the surgery lasts longer than 4 hours, hospital admission may be necessary, and the period of disability may then be as long as 10 to 14 days.