Diagnostic and Operative Laparoscopy



Diagnostic and Operative Laparoscopy


Stephanie Delgado

Tamisa Koythong

Xiaoming Guan



GENERAL PRINCIPLES



Definition



  • Minimally invasive surgery began in obstetrics and gynecology with laparoscopy and has now become ubiquitous, led by advances in technology and its popularity with patients and clinicians because of improved pain scores and reduced length of stay.


  • Minimally invasive gynecologic surgery (MIGS) is an important part of the diagnosis and management in a number of areas within obstetrics and gynecology. These include the following:



    • Abdominal cerclage


    • Ectopic pregnancy including cervical, cesarean scar, and niche pregnancy


    • Sterilization


    • Pelvic organ masses, torsion, and/or bleeding (uterus/tubes/ovaries)


    • Acute and chronic pelvic pain


    • Pelvic floor and urologic conditions (bladder and ureters)


    • Pelvic masses (both malignant and benign)


    • Bowel surgery for endometriosis


  • In this chapter, we review the suggested workup and preoperative planning for common gynecologic procedures and review a step-by-step guide for performing the most common laparoscopic surgeries.


Physical Examination



  • The abdominal examination is an important part of the preoperative assessment of a patient scheduled for MIGS. It is essential to note that scars and/or hernias will affect the placement of the laparoscopic port sites.


  • Table 3.6.1 reviews how to perform a detailed pelvic examination.


  • When evaluating patients who have chronic pelvic pain and/or endometriosis, it is important to isolate the distribution and origin of referred pain. Figure 3.6.1 shows our targeted physical examination of patients with pelvic pain.


Nonoperative Management



  • Before proceeding with MIGS, we recommend considering nonoperative options as shown in Table 3.6.2.


  • Although MIGS has been used for managing acute conditions such as bleeding, ectopic pregnancy and acute abdomen, these are cases that should only be considered by highly experienced surgeons under individualized circumstances.


IMAGING AND OTHER DIAGNOSTICS



  • Imaging modalities are important in the evaluation, diagnosis, and surgical planning for MIGS procedures.



    • Transvaginal ultrasound is usually the primary imaging modality employed in the diagnosis of common gynecologic pathologies, and it helps to identify and quantify structural causes of abnormal uterine bleeding and adnexal pathology.


    • Saline-infused sonohysterography (SIS) allows a more specific assessment of the intrauterine cavity, including identification of endometrial polyps and staging of endometrial myomas.


    • Magnetic resonance imaging (MRI) may be useful to identify adenomyosis, deeply invasive endometriosis (nodules, rectal, and extrapelvic involvement) and can provide a more detailed evaluation of uterine fibroids (particularly when considering the feasibility of a laparoscopic myomectomy).






















  • Endometrial biopsy should always be part of the workup of a patient older than 45 years with abnormal uterine bleeding to rule out malignant or premalignant pathology (American College of Obstetricians and Gynecologists [ACOG] recommendation (1)).



    • In women younger than 45, a biopsy should be obtained in the setting of additional risk factors (i.e., obesity, unopposed estrogen exposure, nulliparity, or polycystic ovarian syndrome), failed medical management, and persistent abnormal bleeding.


    • In women with persistent postmenopausal bleeding or those with inconclusive endometrial biopsy results, diagnostic hysteroscopy should be considered before surgical management.


PREOPERATIVE PLANNING



  • Preoperative planning is important to:



    • Address the postoperative expectations of the surgery


    • Describe the procedure in detail


    • Review the potential complications and risks


    • Discuss the postoperative recovery


    • Allow the patient to be able to make an informed decision



      • Informed consent should cover the indications, alternatives, and risks of surgery, and allow time for patient discussion.


    • Improve patient outcomes and satisfaction


  • Preoperative evaluation includes a review of the following:



    • Medical history: Including all medical comorbidities and prior surgery


    • Physical examination: A detailed physical and pelvic examination as previously reviewed. This allows the provider to determine not only the indicated surgery but also the route of surgery (i.e., vaginal, laparoscopic, or abdominal).


    • Laboratory findings: Pertinent preoperative labs include a pregnancy test, blood count, creatinine, and testing for genital tract infections. If there is reason to suspect other conditions (bleeding diatheses, endocrine disorders, or electrolyte abnormalities), appropriate tests should be ordered.


    • Imaging studies: Review of all available imaging is recommended preoperatively to help plan port site placement, especially in patients with high body mass index (BMI), large volume pathology, and during pregnancy.


    • Preanesthetic testing: Important for planning of intra- and postoperative anesthesia/analgesia


    • Blood loss preparation: Many gynecologic procedures are performed because of vaginal bleeding. When possible, preoperative anemia should be addressed using medical management such as administration of orally (PO) or intravenous (IV) iron replacement therapy, and assessment of the need for blood transfusions before surgery. Although MIGS has a low risk of significant blood loss, this is always a possibility and should always be appropriately addressed preoperatively.


    • Lifestyle adjustments, when possible, are important adjunctive steps:



      • Encouraging smoking cessation: Discontinuing tobacco use before surgery has been shown to decrease the risk of postoperative wound and pulmonary complications.


      • Optimizing blood glucose levels preoperatively: Blood glucose levels should be optimal before elective surgery to avoid intra- and postoperative complications including wound healing, pulmonary infections and adverse reactions to anesthesia.



        • The recommendation is a perioperative glucose average of <200 mg/dL for patients without diabetes.


        • For patients with diabetes, daily glucose logs and glycated hemoglobin (A1c) can be used to determine ideal preoperative glycemic control.


  • Perioperative prevention of wound infection:



    • The rate of superficial postoperative incisional infections is affected by the route of surgery, with a rate of 2.3% to 2.6% after total abdominal hysterectomy via laparotomy versus a rate of 0.6% to 0.8% after laparoscopic hysterectomy (2).


    • Deeper infections including vaginal cuff or pelvic abscesses have been reported in 0.5% to 1.2% of all cases, regardless of surgical approach. The pathogens involved are mostly from the endogenous flora of the skin or vagina and include both aerobic and anaerobic bacteria.


    • Table 3.6.3 shows the risk factors for surgical site infection.


    • Strategies to prevent wound infection (ACOG guidelines (2)) include the following:



      • Treating any active infections before attempting surgery


      • Clipping hair around the surgical site










      • Optimizing perioperative glucose levels


      • Showering with an antimicrobial soap the night before surgery


      • Using a preoperative surgical skin preparation with a chlorhexidine-alcohol base.


    • Antibiotic prophylaxis is recommended when:



      • Entry into the bowel or vagina is anticipated


      • All hysterectomies


      • Dosage: 2 g of cefazolin given within 1 hour of incision



        • For a patient weighing >120 kg, the recommended dose is 3 g.


        • Cefazolin is re-dosed every 4 hours or when estimated blood loss exceeds 1,500 cc.


    • For routine diagnostic or operative laparoscopy, antibiotic prophylaxis is not recommended (2).


SURGICAL MANAGEMENT


Positioning



  • Laparoscopic gynecologic procedures are typically performed with the patient in lithotomy position with both arms tucked by the patient’s side (see Figure 3.6.2).



    • When positioning a patient in the lithotomy position, it is important to be sure that there is no nerve compression (see “Complications” section in this chapter for more details).


    • Tucking the patient’s arms allows the surgeon more space for better ergonomics and operating comfort. To tuck the arms properly, soft foam or cushioning should be placed under the patient’s arm to avoid nerve compression at the elbow. The arm should be in a neutral position with the thumb facing up and the hand protected.


  • Institution of the Trendelenburg position following initial entry into the abdomen is very helpful because it causes the small bowel to move into the upper abdomen, allowing better access and visualization of the pelvis. The change in position of the patient should only be carried out after the initial port has been placed so that the bowel can be displaced under direct visualization, which helps avoid injury.


Approach



  • The best approach to laparoscopic surgery has to be individualized because, although there are obvious general principles, port placement must be driven by many factors including, but not limited to, the underlying pathology, equipment available, provider preference, and patient condition.








Procedures and Techniques


Laparoscopy Entry and Port Placement



  • Entry and port placement is the most important step in proceeding with laparoscopic surgery.


  • There are three main methods for laparoscopic entry:



    • Open (Hasson)


    • Closed (Veress)


    • Direct entry under visualization


  • No one method is superior to the others, and it is important to be familiar with all three methods so that the best method can be individualized as needed.


  • When starting a procedure, it is always important to assure the patient is flat and that her stomach is not distended.


  • Initial port placement is generally at the umbilicus where the tissue thickness between the skin and peritoneal cavity is the least. This factor is especially important in obese patients.



    • If there is a concern because of large intra-abdominal pathology or adhesions from prior surgery, entry is recommended at Palmer point that is located in the left upper quadrant (LUQ) 2 cm below the costal margin at the midclavicular line.


    • A supraumbilical entry is also an alternate entry point.


  • Open (Hasson) Technique



    • A 10-mm incision is made on the skin, usually periumbilically. Using blunt dissection, the subcutaneous fat and tissue are distracted to the level of the fascia.


    • Kocher clamps are then placed on the fascia which is incised to the point of entry into the pre-peritoneum. Stay sutures are then placed at the apices of the fascia, and they will be used to assure that the port remains in place once it is inserted.



    • The peritoneal cavity is then entered bluntly or sharply through the exposed peritoneum, and the blunt-ended trocar (Hasson) is placed through the opening and secured with the stay sutures. The tubing for the carbon dioxide gas is then attached and the abdomen is insufflated to the desired pressure.


  • Closed (Veress) Technique



    • The umbilical stump is grasped and everted. A 5-mm stab incision is then made with an 11-blade scalpel into the everted stump. A Veress needle is then introduced into the abdomen via this incision, and its entry is confirmed with a saline drop test or a low-pressure test.



      • If the Veress needle is correctly placed within the peritoneal cavity, saline should flow through the Veress needle without resistance and the intra-abdominal pressure should be <7 mm Hg.


    • After safe peritoneal cavity entry is confirmed, the abdomen is insufflated to the desired pressure, usually 15 mm Hg, and maintained at that pressure in a stable manner. The Veress needle may then be removed.


    • The initial port and camera may then be introduced.



      • A 0.5-mm scope is placed within a 5-mm Optiview trocar.


      • The trocar is then placed into the prior incision.


      • Using gentle rotational force, the port is advanced, under direct vision with the camera, into the abdomen through the layers of the abdominal wall.


  • Direct Entry



    • Direct entry has the advantages of avoiding complications associated with the Veress needle, which include inadvertent insufflation of CO2 into the preperitoneal space.



      • The umbilical stump is everted, and a 5-mm incision is made at the base of the umbilicus.


      • A 0.5-mm laparoscope within a 5-mm Optiview trocar is then placed into the incision.


      • Using downward rotational force, the trocar traverses the various layers of the abdominal wall until it reaches the peritoneal cavity.


      • Once entry into the peritoneal cavity is confirmed, the insufflation tubing is then connected and the abdomen is distended to the desired pressure.


  • After entry into the peritoneal cavity, additional ports may then be placed depending on the pathology and the surgery being contemplated. Usually, two to three additional ports are placed in the left and right lower quadrants.



    • Care must be taken to avoid the inferior epigastric vessels when placing the lateral ports. Tech Figure 3.6.1 demonstrates the standard location of additional port sites, typically 2 cm above and 2 cm medial to the anterior superior iliac spine.


  • The patient is placed in a steep Trendelenburg position, and the pelvis is visualized along with the area in which the surgery is to be performed.

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Sep 8, 2022 | Posted by in OBSTETRICS | Comments Off on Diagnostic and Operative Laparoscopy

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