CHAPTER 3 Laparoscopy

Introduction

Laparoscopy (Greek lapar meaning flank) is a technique utilized by surgical gynaecologists around the world to great effect. Advances in the technique over the past two decades have revolutionized gynaecological surgery and provided a vastly improved service for patients. At the same time, some of these advances have been associated with considerable controversy, and many opinions are forcefully expressed without much factual basis. This chapter aims to discuss the basics of laparoscopy and its application, providing some of the evidence from the literature where possible.

History

Examination of the body cavities using instrumentation has been practised by clinicians over many centuries. Most of the early techniques involved inspection of the bladder and urethra (Bozzini 1805). Light sources were introduced initially with alcohol flames (Desmoreaux 1865), and subsequently the incandescent light bulb. The first inspection of the peritoneal cavity was through the posterior fornix in the early 20th Century (von Ott 1901). Examination of other cavities was described soon afterwards (Jacobaeus 1910), with carbon dioxide used for insufflation more than a decade later (Zollikoffer 1924). The first diagnosis of an ectopic pregnancy followed (Hope 1937), as did female sterilizations. Veress first reported the spring-loaded insufflation needle as a technique for introducing a pneumothorax in patients with tuberculosis (Veress 1938).

Further advances were relatively slow with few clinicians inspired by the new techniques. The first description of sterilization in English was not until 25 years later (Steptoe 1967). Few therapeutic procedures were performed laparoscopically, although the technique gained widespread support for diagnosis.

The revolution in therapeutic techniques probably started with the report of the first laparoscopic hysterectomy (Reich et al 1989) and, with advances in instrumentation, light sources and camera systems, continued apace throughout the 1990s. However, a few practitioners attempted procedures that were beyond either their surgical training or ability, and responsible bodies rapidly concluded that regulation was required. The Royal College of Obstetricians and Gynaecologists (RCOG) established its training guidelines in 1994 with certification for those trained to perform at different levels. This has been repeatedly modified to bring the UK training into line with practice in other European countries.

Theatre Set-Up

When setting up a theatre for laparoscopic surgery, a number of factors need to be considered. First, both the surgeon and the assistant need to have an excellent view of the operating area. Second, the surgeon needs to be in a comfortable position, and third, the instrumentation needs to be arranged systematically and consistently.

The authors believe that the television screen should be placed between the patient’s legs if the camera is inserted at the umbilicus. Figure 3.1 demonstrates that the view displayed on the screen is in the same direction in which the patient is lying and the surgeon operating. Many experienced surgeons place the television screen directly in front of themselves and behind the assistant. Under these circumstances, the surgeon is operating in a different direction to which he or she is looking; not only is this uncomfortable and ergonomically disadvantageous, but all images have to be transposed through 90 degrees, adding to the difficulties of hand–eye coordination. The additional advantage of placing the monitor between the patient’s legs is that only one screen is required.

Figure 3.1 Theatre set-up is important. The monitor should be in the same plane as the surgical field, i.e. a straight line from the surgeon through the surgical field also passes through the monitor.

The scrub nurse should stand in a consistent position, and instrumentation such as bipolar diathermy, scissors, graspers and suction irrigation should be placed reliably within easy reach of the surgeon. The scrub nurse should be within sight of the television screen, enabling anticipation of the next instrument required. A protective bar placed across the table prevents the assistant’s arm from resting on the upper part of the patient and potentially dislodging the endotracheal tube (Figure 3.2).

Figure 3.2 The patient is positioned flat on the table with legs supported. A bar is placed over the endotracheal tube to protect this from being dislodged and to support the assistant’s arm.

Surgical Team

A coordinated surgical team is essential for safe laparoscopic procedures. An experienced anaesthetist can allow a state of permissive hypercapnia whilst the patient is in a steep Trendelenberg position. Careful positioning on a non-slip mattress decreases the tendency of the patient to slide up the bed. A well-stocked laparoscopic trolley will decrease overall operating time by minimizing the delay whilst staff find the required instruments.

Equipment

Laparoscopic surgeons are totally dependent on their equipment. Any laparoscopic procedure can only be performed safely if clear images are presented to the surgeon. The quality of the image is dependent on the weakest link in a long series of technologically advanced items. It is essential that laparoscopic surgeons are familiar with the function and adjustments of the imaging systems that they use, and it is this complicated equipment that provides the majority of the cost of laparoscopic surgery.

It is primarily the vast improvement in technology that has led to the increase in the number of procedures performed using laparoscopic techniques; however, there is scope for further improvement in laparoscopic equipment and robotics. Three-dimensional viewing systems and automated assistants may enhance the current instrumentation.

The following items are essential.

Trocars

Many different types of trocar are available, which vary in size, length and design of the tip (Figure 3.3). The 12 mm, 10 mm and 5 mm trocars are used most commonly in gynaecological surgery. When performing complicated surgery, there can be many changes of instrument down any individual port. For this reason, the trocars have to be able to grip the abdominal wall, and there are various designs to facilitate this. Some of the more modern trocars have a type of ‘fish scale’, whilst others utilize a screw thread which can grip more effectively but increases the diameter of the incision. The trocar tip can be conical, pyramidal or a single flat blade in design. They create different sized and shaped incisions in the fascia, with the single flat blade and conical dilating tip producing the smallest defect. Optical trocars have a blunt clear dome-shaped tip housing a crescent-shaped blade. They allow a controlled sharp dissection of the abdominal wall layers under direct vision. These trocars can be inserted prior to insufflation and may be useful in obese patients with thick abdominal walls. Trocars may be disposable or reusable. Many laparoscopic surgeons have been persuaded to use disposable trocars because of their constantly sharp tips, the so-called safety devices to retract the tip when through the full thickness of the abdominal wall and to avoid contamination between patients. However, most surgical units find the cost of disposable trocars prohibitive for use with every case.

Figure 3.3 A selection of trocars used in laparoscopic surgery.

Laparoscopes

The laparoscopes most commonly used in gynaecological surgery are of 10 mm, 5 mm or, occasionally, 3 mm diameter. The 10 mm laparoscopes provide the largest images with the optimal illumination, although the new generation of 5 mm laparoscopes can provide an image equal to their 10 mm relatives from only a few years ago. The laparoscope is a high-precision engineered instrument which requires careful handling, both during operations and in the sterilization process between cases. It contains both a fibreoptic bundle for light transmission and a series of lenses to transfer the image back to the eyepiece. Modern laparoscopes consist of a hybrid rod lens system, although the 3 mm laparoscope utilizes a high-quality fibreoptic bundle. The hybrid rod lens system at 3 mm diameter would be too easily damaged. Most surgeons utilize a laparoscope which projects an image that appears at 0 degrees to the shaft of the scope; however, laparoscopes that project an image from 30 or 70 degrees are also available. Although these laparoscopes rarely cause problems for the surgeon, they can cause difficulty in coordination of the image by the assistant who is holding the laparoscope and camera device.

Light source and lead

The weakest link in the endoscopic equipment chain is often the light lead. This fibreoptic cable is often used for months or years after many of its cables are damaged. It also requires careful maintenance and will inevitably require replacement in time. A number of light sources exist and many surgeons still utilize the halogen system, despite the fact that this has been superseded by the more powerful xenon light source.

Camera system

Modern camera systems are an essential part of the laparoscopic surgeon’s equipment. There are few surgeons around the world who continue to operate by looking directly down the eyepiece of the laparoscope, even for minor diagnostic procedures. There is a clear advantage in being able to project the image on to a television screen that is visible to all members of the surgical team. Together with the ergonomic advantages of not having to stoop over the patient, this means that camera systems are now commonplace. The image seen through the eyepiece of the laparoscope is converted into electrical signals by a charge-coupled device housed in the camera head. These electrical signals are then processed by the camera control facility which is, in turn, connected to the television monitor. Cameras may contain one or three charge-coupled devices, each of which is colour specific, recording only one of the three primary colours. Most modern camera systems enable collection of digital images which are projected on to a digital monitor, although hybrid set-ups can co-exist. Some camera heads incorporate remote buttons to allow the operator to control various features of the imaging system, such as taking prints, operating the video recorder or white balancing. Some cameras are autoclavable but the majority of surgeons will place the camera system inside a sterile plastic sheath before connecting to the laparoscope (Figure 3.4).

Figure 3.4 A sterile bag can be used for placement of the camera head and cable.

Recording equipment

The modern laparoscopic surgery theatre should contain a video recorder and still photo facility for the purpose of producing images of any procedure. Many educational and training videos have been produced and are extremely valuable. Patients may appreciate a copy of their operation and some surgeons believe it is important to create a medicolegal record of the procedure for possible future reference. There is no reason why laparoscopic surgery should be treated any differently to open surgery, and surgeons who do not record their procedures on a video can hardly be regarded as neglecting the medical records. Within gynaecology, the majority of medicolegal claims are connected with laparoscopic sterilization, and most surgeons would regard photographs of the clips occluding each fallopian tube to be a sensible precaution.

Television monitor

Many different television monitors are available, but the majority are 20 inches in size. High-definition monitors coupled with a digital camera have led to improvements in display. The monitor should be the last piece of equipment that is adjusted if the image is of poor quality, and is possibly the least important in determining a good view of the surgical field.

Insufflator

As laparoscopic surgical techniques have advanced, there has been a significant improvement in the technology of insufflators. They should provide a maximum flow rate of approximately 35 l/min with continuous monitoring of volume, flow rate and intra-abdominal pressure. Safety devices should ensure that the maximum pressure setting is not exceeded, and most modern insufflators have an alarm to notify the surgeon. Some insufflators additionally provide smoke evacuation, either controlled by the surgeon with a foot pedal or with a direct link through to the diathermy or laser device. The insufflator needs to have simple and easily interpreted display panels. The laparoscopic surgeon will refer to the insufflator when creating the pneumoperitoneum and, at this vital part of the procedure, needs to know where to look for the information he or she is seeking.

Operating instruments

There are innumerable types of operating instruments, and individual surgeons will have their own preferences. Essentially, the instruments can be divided into the jaws, the shaft and the handles. Jaws have been designed which mimic all the instrumentation available for open surgery, plus many others. Examples are shown in Figure 3.5. The shafts may be of 10, 5 or 3 mm diameter and may or may not contain a diathermy attachment. For non-disposable instrumentation, it is often the shaft that is the most difficult part of the instrument to keep clean and maintain. Handles come in a variety of ergonomic designs, according to surgeon preference. Handles may be ratcheted or non-ratcheted in a variety of ways. Most non-disposable instruments have a detachable handle in order to convert an instrument into one with or without a ratchet. Surgeons have their favourite graspers and, as with most situations, it is more important to be familiar with an instrument and to know its limitations than it is to have a wide variety of instrumentation that is less familiar.