Laparoscopy in Gynecology
Laparoscopy
• A surgical procedure that involves insertion
of a narrow telescope-like instrument
through a small incision in the belly button.
• This allows visualization of the abdominal
and pelvic organs.
Laparoscopy literally means, "to look inside the
abdomen".
Laparoscopic surgery
• Laparoscopic surgery, also called minimally invasive surgery
(MIS), bandaid surgery, or keyhole surgery, is a modern surgical
technique in which operations are performed far from their
location through small incisions (usually 0.5–1.5 cm)
Advantages and Disadvantages
of laparoscopy
Advantages :
a) lesser pain Disadvantages:
b) few analgesics a) Longer procedure
c) short hospital stay b) more anaesthesia
d) quick return to daily work c) expensive
e) no scar—no scar hernia d) expertise required
f) good cosmetic
g) less pelvic adhesions.
Laparoscope is a rigid telescope varying in diameter
between 4 and 10 mm and it is 30 cm long, incorporating
an optical system as a means of illumination.
The light is transmitted from an external source to the
distal lens by means of fibreglass cables.
Light source of 300 W is used for illumination of
abdominal cavity. Photography requires light source of
1000 W.
Basics of laparoscopy - Instruments
Verres needle
Used to inflate air/CO2 to the peritoneal cavity
(pneumoperitoneum) through the umbilicus where there
is the thinnest abdominal wall
Basics of laparoscopy - Instruments
Electronic laparoflator: Insufflator
Used to insufflate through the verres needle.
Maintains constant intra-abdominal pressure without exceeding
the safety limit.
Basics of laparoscopy - Instruments
Trocars
Permit access to the intra-peritoneal cavity in which other
instruments can pass.
The trocar used should be adapted to the diameter of the
telescope selected
Telescope
There are different sizes and angles, each with a different use.
They are used to visualize the peritoneal cavity
Camera equipment & Light source
Forceps and scissors
There are two types:
◉ Disposable
◉ Reusable
They can be either atraumatic or grasping foreceps.
Basics of laparoscopy - Procedure
Preparation of the patient:
Inform the patient about the therapeutic benefits and
potential risks (informed consent).
Intestinal preparation: Simple intestinal emptying, for
better viewing and preventing injuries.
Bladder should remain empty throughout the procedure
using a catheter.
Systemic antibiotics should be started a day before
surgery.
Place the patient in the dorsolithotomy position.
diagnostic procedure >> sedation and local anaesthesia
the therapeutic procedure always requires general
anaesthesia because of prolonged time taken
Applications of Laparoscopy
Diagnostic Therapeutic
tool tool
Anterior wall subserous
Diffusely enlarged uterus pedunculated fibromyoma Multiple fibroids—uterus
due to adenomyosis of the uterus. subserous and intramural.
Unruptured tubal
Tubo-ovarian mass. Tubal pyosalpinx
ectopic pregnancy
Endometriosis: Chronic PID: perihepatic Chronic PID: pelvic
peritoneal implant adhesions. adhesions
Abdominal Koch’s Genital Koch’s disease: Genital Koch’s disease:
disease: peritoneal tubercles on the uterine beaded tuberculous
adhesions. serosa. fallopian tube.
Laparoscopic appearance of
endometriosis—manifestations
Major complications
Cardiopulmonary Haemorrhage
arrest Cautery burns to various viscera
gas embolism Sepsis
CO2 causes acidosis Injury to the bowel, small
arrhythmia intestine, blood vessels, bladder
cardiac arrest and ureter with the sharp
instruments and burn injuries
Failure to complete the
procedure
The other complications
Include:
surgical emphysema
haematoma
Hernia at the site of portals with omental protrusion rarely
occurs.
Failed procedure>> Due to adhesions, extensive pelvic
lesions or uncontrolled haemorrhage
Contraindications to Laparoscopy
Generalized peritonitis
Hypovolemic shock
Cardiac and respiratory diseases
Hemoglobin less than 7 g/dL
Uterine size > 12 wks. (puerperal)
Multiple previous abdominal procedures
Umbilical hernia
Extreme body weight
Acute pelvic infection can spread during laparoscopy
abdominal tumour can be injured by the sharp instrument.
Laparoscopy – risk factors
Patient related risk factors
◉ Obesity
◉ Age
◉ Previous abdominal surgery
Anesthetic risk factors
◉ Time since last oral intake
◉ Heart disease
◉ Pulmonary disease
Laparoscopy – Patient related risk factors
Obesity
◉ Laparoscopy becomes more difficult and potentially more risky.
◉ Placement of laparoscopic instruments becomes much more difficult .
◉ Bleeding from abdominal wall vessels may be more common because
these vessels become difficult to locate.
◉ Restricted operative field secondary to retroperitoneal fat deposits in
the pelvic sidewalls and increased bowel excursion into the operative
field
Laparoscopy – Patient related risk factors
Age
◉ Older patients are at increased risk of having concomitant disease
processes that affect their perioperative morbidity and mortality
Previous abdominal surgery
◉ Risk of adhesions of omentum and/or bowel to the anterior
abdominal wall after previous abdominal surgery is greater than 20%.
◉ As laparoscopy requires the insertion of sharp instruments into the
abdominal cavity, a reasonable assumption is that previous surgery
would increase the risk of bowel injury
Reference
Shaw's Textbook of Gynecology 16th Edition
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