Safe use of electrosurgery is essential to any surgery, including laparoscopic surgery. Electrosurgical units are the most common piece of surgical equipment in the operating room. A clear understanding of the principles of electrosurgery will allow the operating surgeon to avoid inadvertent injury to their patient [1].

Electric current is the movement of electrons and voltage is the force that causes this movement. The electric current is proportional to the voltage and resistance (impedance) in the circuit. Electrosurgical units are composed of the generator, an active electrode and the dispersive pad. The generator transforms the electricity from the power source into electrical energy. The active electrode delivers the electrical energy to the surgical site and can be monopolar or bipolar in nature.

Monopolar electrodes have a single electrode that delivers current that travels to the return electrode through the patient. These electrodes can be in many forms such as scissors, hooks or spatulas. Bipolar electrosurgery utilizes an electrical current that passes through two parallel poles, one of which is positive and the other negative. The flow of current is between the two poles, which are typically graspers. Bipolar energy uses a lower energy waveform because the poles are in close proximity to each other.

The return electrode is commonly known in the operating room as the grounding pad. This provides a large surface area for the current to move from the patient’s tissue back to the electrosurgical generator. This prevents the current from heating and damaging the patient’s skin. Perfect contact between the pad and the patient’s skin is essential to prevent burns. An understanding of the cutting and coagulation settings on the electrosurgical generator is important. Cutting uses a continuous wave form where the energy is concentrated in a small area, resulting in heating of the cells. Coagulation utilizes an intermittent current that produces less heating than the cutting current but produces dehydration of tissue, coagulation of vessels and more lateral spread than the cutting current.

The specific electrosurgical dangers associated with laparoscopic surgery arise when there is transfer of current from instrument to tissue within the abdominal cavity outside the direct view of the surgeon. Whilst operating, the surgeon must pay particular attention to the location of the active electrode (instrument) and the location of other metal instruments in the abdomen. Direct coupling is a phenomenon that occurs when the active electrode comes into contact with another instrument in the surgical field, resulting in transfer of current (and potentially injury) to remote tissue.

Trocar placement

Endoscopic surgery requires transabdominal placement of small metallic or plastic hollow tubes, known as trocars, to enable passage of a variety of operative instruments into the intra-abdominal operative site. The first instrument placed is the Verres needle that allows passage of carbon dioxide to establish a pneumoperitoneum. The Verres needle is approximately 2 mm in diameter. It has a sharp point with a spring-activated retractable blunt protective cover that moves back and forth over the needle. A small skin incision is created either vertically intraumbilically or horizontally infraumbilically to allow insertion of the needle. Once the incision has been created, the surgeon and assistant elevate the abdominal wall. The Verres needle is grasped in its entirety and the tip is placed into the inferior portion of the incision at a point where even in patients with large BMIs, the peritoneum is just a few millimeters away. The needle is advanced through the various layers of the umbilical abdominal wall into the peritoneal cavity. During this blind needle placement, maximum effort is utilized to prevent injury to underlying bowel and vasculature. The needle is advanced and the popping sound and sensation of fascia and peritoneum being pierced are heard and felt by the operator. The needle advancement is then halted. The operator then tests to determine if intra-abdominal placement has been achieved by placing some saline at the outer end of the needle. Lifting the abdominal wall creates a negative pressure and this will draw the saline drop into the abdominal cavity, thus reflecting that a direct, clear connection has been established. Once this process is completed, tubing from the carbon dioxide insufflator is attached to the needle, allowing carbon dioxide to flow into the peritoneal cavity. Percussion of the abdomen will then indicate that the cavity is distended and full of carbon dioxide, again reaffirming the proper placement of the Verres needle.

A second and completely different technique to establish a pneumoperitoneum is to place a trocar under direct vision. An approximate 2 cm intraumbilical incision is created, allowing the operator to tunnel down through the fascia and open the peritoneum directly. Hasson first described this technique [3] and as such, a Hasson trocar is placed into the peritoneal cavity that then allows maintenance of the pneumoperitoneum.

The pneumoperitoneum, independent of technique, allows placement of the laparoscope and the larger diameter trocars that are required for the operative procedures to be performed.

Laparoscopes, with cameras attached, vary in diameter and the trocars used for them must be of similar size. The two traditional scopes used are either 5 mm or 10 mm in diameter. The trocar that houses the camera is usually placed intraumbilically, in a blind fashion, utilizing the sense of pressure release that one feels when the trocar successfully enters the abdominal cavity. Once this trocar is placed, the laparoscope with attached camera may be placed through the hollow trocar into the peritoneal cavity to establish full-magnified vision of the entire cavity. Additional trocars, varying in number and also in diameter, can then be placed under direct vision. The usual trocar diameter for these accessory instruments is 5 mm. These trocars are placed as far lateral as possible from the umbilicus at the level of the umbilicus. Placement of the accessory instrument trocars in this manner allows the instruments to have the best mechanical advantage when operating on the adnexa and the upper uterus. Additional instruments may need to be utilized for retraction, grasping, and gaining access to the cul de sac or the lower retroperitoneum. For these instruments, one or more trocars can be inserted inferiorly at any portion of the lower abdomen that enhances access. Some surgeons have utilized specific anatomic guidelines for the placement of the trocars but in most instances, the additional sites of placement are better dictated by the particular surgical need.

Two most important rules for trocar placement are, first, that one should transilluminate the abdominal cavity to attempt to avoid injuring a major abdominal wall vessel when inserting the trocar, and second, that the camera should be utilized to view the trocar tip completely as it enters the abdominal wall. This is the most successful way of avoiding damage to vascular, bowel or other underlying structures. Occasionally, accessory instruments are used that have 10–12 mm or even 18 mm diameters and there will need to be an expansion of one or more trocar sites to accommodate these larger instruments.

Emergency needle

Whenever laparoscopy is performed, the trocar placement may induce abdominal wall bleeding. Several methods are available to suture this arterial or venous bleeding quickly that allows the safe continuation of the endoscopic procedure. One of the most effective emergency needle systems is the Carter–Thomasen system [4]. This needle can be used for suturing as large a vessel as the inferior epigastric artery and can be effectively utilized even if there is only one accessory trocar placed. This system is also extremely useful for closing the peritoneum and fascia of trocar sites that are 10 mm or greater in diameter. This closure is sufficient to reduce the risk of trocar site hernias.

The laparoscopic approach is being used for a wide range of gynecologic surgeries including, infertility, hysterectomy, adnexal pathology, and myomectomy. During laparoscopy, there is decreased tissue drying and less exposure to environmental contaminants. The magnification afforded by the laparoscope permits the pinpoint application of energy sources and allows access to some areas with less trauma than by laparotomy. Thus, laparoscopic surgery has many other advantages in addition to more rapid recovery and less pain during the postoperative period.

Infertility

In infertile women, the reported incidence of endometriosis is between 5% and 48%. Among patients with severe pelvic pain, endometriosis may be found in up to 80% of cases. Laparoscopic surgery remains the treatment of choice for the diagnosis of endometriosis, especially in its milder forms. Several modalities have been advocated for the treatment of endometriosis: medical therapy, surgery, combined medical and surgical therapy, and in vitro fertilization. Patients with mild disease may conceive without treatment. Therefore, it is more difficult to prove any benefit in these patients. In the surgical treatment of endometriosis, laparoscopy is preferable to laparotomy. Several studies have shown comparable pregnancy rates when laparoscopy is compared to laparotomy. There is no place for medical suppressive therapy alone in the treatment of patients with moderate and severe endometriosis, most of whom have adhesive disease. In these cases, restoration of the normal pelvic architecture is the primary goal of laparoscopic surgery.

The surgical treatment of endometriosis may be divided into three areas: removal of implants, lysis of adhesions, and the excision of endometriomas. Compared to vaporization and coagulation, excision of lesions offers the advantages of providing a histologic diagnosis and assuring complete removal of the disease. In addition, if lesions are vaporized or if coagulation is employed, the char induced may not be distinguished with certainty from the characteristic blue-black implants.

Endometriomas should be excised. Following aspiration, recurrences are common. Suture closure of the ovary is usually not necessary because the edges fall together spontaneously. However, if needed, sutures should not encompass the ovarian cortex in order to reduce the incidence of adhesion formation. After hemostasis has been secured, the ovary is wrapped in Interceed.

Second-look laparoscopy (SLL) following conservative infertility surgery has been performed only after an extended period has elapsed without a pregnancy. Early SLL, performed 1–8 weeks after the initial procedure, is recommended because the early postoperative period is when adhesions that have begun to form or reform are filmy and avascular, making adhesiolysis easy.

In order to assess the impact of adhesions upon fertility, Tulandi et al. used life-table analysis to assess the cumulative pregnancy rates among infertile patients with adnexal adhesions of similar extent [2]. These were 32% and 45% at 12 and 24 months after adhesiolysis but only 11% and 16% at the same time periods in patients who elected not to undergo surgery.

Tubal surgery