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B29. Laparoscopy in gynecology

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Laparoscopy refers to using transperitoneal endoscopy for minimally invasive surgeries. It is widely used in gynaecology and is usually preferred over laparotomy if possible.

You may also read topic 8 in surgery for general information on laparoscopy.

Setup and procedure

Many devices are necessary in laparoscopy:

  • Device to give abdominal access
  • To reach pneumoperitoneum
  • Distension medium (CO2)
  • Optic light source
  • Camera
  • Devices for the operative manipulation

To achieve pneumoperitoneum, the Veress needle is inserted through the umbilicus.

The distension medium is usually CO2, which is administered into the peritoneal cavity until a pressure of 15 mmHg is achieved. Then, the Veress needle is removed, and an automatic insufflator maintains the intraabdominal pressure during the operation.

Different types of optic light sources can be used, depending on the operation.

Operative equipment is inserted into the peritoneal cavity through trocars. These are metallic devices that have a piercing tip which punctures through the abdominal wall. The piercing tip can then be removed, leaving a working channel through which equipment can be inserted. An insufflation valve prevents leakage of gas from the abdomen.

Many operative devices are available. Many of them can be attached to an energy source during operation, to provide electrocauterization, electrocoagulation, etc.

The primary port is placed in the umbilicus. The number and placement of the additional ports depend on the choice of the surgeon. Typically, two or three more ports are placed.

Tissues can be removed through the trocars, usually after being placed in small endobags. They can also be sucked out or removed through the vagina.

Indications

  • Sterilisation (by electrocoagulation of the fallopian tubes)
  • Myomectomy (removal of fibroid)
  • Hysterectomy
  • Salpingo-oophorectomy
  • Ectopic pregnancy
  • Adhesiolysis (removal of intraabdominal adhesions)
  • Ovarian cystectomy
  • Diagnosis and treatment of endometriosis
  • Drainage of tubo-ovarian abscess
  • Treatment of pelvic organ prolapse

Advantages

Compared to open surgery, laparoscopy has certain advantages:

  • Faster recovery
  • Less cosmetic scarring
  • Decreased hospital stay
  • Decreased risk for adhesion and hernia

Disadvantages

  • Long practice is required for laparoscopy
  • Operation may be longer
  • Equipment is more expensive
  • There may be complications related to increased intraabdominal pressure, Trendelenburg position, and the longer duration

Contraindications

  • Uncorrectable coagulopathy
  • Frozen abdomen (adhesions in the peritoneal cavity due to multiple previous laparotomies)
  • Haemorrhagic shock
  • Severe cardiac dysfunction
  • Pregnancy (not a contraindication if the operation is life-saving)

Complications

  • During insertion – injury to vessels, GI tract, bladder
  • During surgical manipulation – laceration of organs, bleeding, GI perforation
  • Due to pneumoperitoneum
    • CO2 embolism
    • Hypercapnia
    • Renal failure
    • PTX
    • Abdominal compartment syndrome