Gynecologic Laparoscopy

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Chapter 44 Gynecologic Laparoscopy

William W. Hurd, Janice Duke, Tommaso Falcone

INTRODUCTION

During the past 25 years, gynecologic laparoscopy has evolved from a limited surgical procedure used only for diagnoses and tubal ligations to a major surgical tool used to treat a multitude of surgical conditions. In fact, laparoscopy has become one of the most common surgical procedures performed in the United States today. For many gynecologic procedures, such as removal of ectopic pregnancies and the treatment of endometriosis, the cost/benefit ratio is well-established, particularly in terms of expense and safety. For other procedures, including laparascopy-assisted hysterectomy and treatment of gynecologic cancers, the relative risks and benefits of the laparoscopic approach are still being determined.

This chapter gives an overview of the history and modern use of laparoscopy. Laparoscopic complications and specific laparoscopic techniques are considered in subsequent chapters.

HISTORY

The first experimental laparoscopy (ceolioscopy) was performed by Dr. Georg Kelling in Berlin in 1901; Kelling placed a cystoscope into the abdomen of dogs to evaluate the ability of insufflated air to stop gastrointestinal hemorrhage.¹ Dr. Hans Christian Jacobaeus of Sweden published the first description of laparothoroscopy in 1910 as a technique to evaluate patients with peritoneal tuberculosis. However, laparoscopy made little headway into clinical practice until after World War I. It took until the 1960s for laparoscopy to be accepted in the United States and Europe as a safe and valuable surgical procedure.

For many years, gynecologic laparoscopy was performed almost exclusively for diagnostic purposes and for sterilizations. By the 1970s, the role of laparoscopy had expanded to include lysis of adhesions and treatment of endometriosis.² The technology and equipment advanced over the next three decades such that laparoscopy is now used for a wide variety of procedures ranging from treatment of ectopic pregnancies and ovarian cysts to hysterectomy, incontinence procedures, and management of gynecologic malignancies.

GENERAL TECHNIQUES FOR LAPAROSCOPY

Primary Trocar Placement

For many years, the standard techniques used for creating a pneumoperitoneum and placing a laparoscopic port into the abdomen were either a closed technique or an open approach. In the past decades multiple alternative approaches and locations have been reported. The four most common approaches are:

1. Standard closed technique (Veress needle insufflation followed by primary trocar insertion)

2. Direct trocar insertion (no insufflation prior to trocar insertion)

3. Open laparoscopy

4. Left upper quadrant insertion technique.

Both reusable and disposable instruments are commonly used. The ultimate safety of many of the newer techniques and instruments has not yet been determined.

Standard Closed Technique: Veress Needle and Primary Trocar Insertion

The standard closed technique was used almost exclusively for decades and continues to be widely used today. Both the Veress needle and primary trocar are blindly placed through a periumbilicar incision into the peritoneal cavity. Using this approach with reusable instruments, the combined risk of injuring retroperitoneal vessels, bladder, or bowel has been found to be less than 1 in 1000 cases.³ This approach has become the gold standard against which all other techniques are judged.

For the standard technique, the patient is placed in a horizontal position and the abdominal wall is elevated by manually grasping the skin and subcutaneous tissue. This is done to maximize the distance between the umbilicus and the retroperitoneal vessels. An alternative method used to elevate the abdominal wall is to place penetrating towel clips at the base of the umbilicus.

In a woman of ideal weight (body mass index [BMI] <25kg/m²) or only slightly overweight (BMI 25 to 30kg/m²), the lower anterior abdominal wall is grasped and elevated, and the Veress needle is inserted toward the hollow of the sacrum at a 45-degree angle (Fig. 44-1).⁴ In the thinnest patients in this group, the retroperitoneal vessels are much closer to the abdominal wall and the margin for error is reduced, with as little as 4 cm between the skin and these vessels. In the obese patient (BMI >30kg/m²; weight usually greater than 200 pounds), a more vertical approach, approximately 70 to 80 degrees, is required to enter the peritoneal cavity because of the increased thickness of the abdominal wall.

Figure 44-1 Changes in the anterior abdominal wall anatomy with weight. Diagram of representative sagittal views derived from magnetic resonance and computed tomographic imaging for patients in three groups. A, Ideal weight (body mass index [BMI]<25 kg/m²) B, Overweight (BMI 25–30 kg/m²). C, Obese (BMI >30 kg/m²). An 11.5-cm Veress needle is superimposed on each view for comparison.

(Adapted from Hurd WW, Bude RO, DeLancey JOL, et al: Abdominal wall characterization by magnetic resonance imaging and computed tomography: The effect of obesity on laparoscopic approach. J Reprod Med 36:473–476, 1991.)

Verification that the Veress needle tip is in the peritoneal cavity is done by a number of methods, including the hanging drop test, injection and aspiration of fluid through the Veress needle, and close observation of intra-abdominal pressure during carbon dioxide insufflation. After a pneumoperitoneum has been created, the Veress needle is removed and the primary port trocar (most commonly 5 or 10 mm in diameter) is placed at an angle identical to that used for the Veress needle.

Direct Trocar Insertion

Direct trocar insertion is a technique whereby the primary trocar is inserted without the Veress needle being previously inserted and insufflating the abdomen with carbon dioxide.⁵ The primary trocar is inserted at an angle similar to that described for the closed technique. The peritoneal cavity is then insufflated with carbon dioxide through the umbilical port. This technique decreases the risk of extraperitoneal insufflation by allowing the surgeon to confirm intraperitoneal placement of the primary trocar before insufflation. Although small randomized studies have not demonstrated an increased risk of injuries, some series suggest that this technique might increase the risk of bowel injury.^5,⁶ Further large studies are required.

Open Laparoscopy

Open laparoscopy, first described by Dr. Harrith Hasson in 1971, refers to creating a small incision in the abdomen and placing the port through the incision without using a sharp trocar.^7,⁸ The skin and anterior rectus fascia are incised with a scalpel and the peritoneal cavity is bluntly entered with a Kelly or Crile forceps. A laparoscopic port with a blunt-tipped trocar is then placed into the peritoneal cavity. For the Hasson technique, fascial sutures are used to help maintain a pneumoperitoneum.⁷ This method almost completely avoids the risk of retroperitoneal vessel injury and is preferred by many laparoscopists for this reason. Although open laparoscopy does not entirely avoid the risk of bowel injury, many laparoscopists use this approach in an effort to decrease this risk in patients with previous abdominal surgery suspected of having adhesions.

Left Upper Quadrant Technique

This approach was developed for use in patients with previous abdominal surgery with suspected or known periumbilical bowel adhesions. It is performed by using a left upper quadrant site to place both the Veress needle and primary laparoscopy port into the abdomen. This point, sometimes referred to as Palmer’s point, is in the midclavicular line beneath the lower rib margin.

It is important to know the anatomy of the left upper quadrant before using this technique. The most important organs that are closest to this site are the stomach and left lobe of the liver.⁹ Although a small series has shown the risk of complications to be small, the relative risk of complications with this technique remains to be demonstrated by a large study.¹⁰

Placement of Secondary Ports

Secondary ports are required to perform most gynecologic laparoscopy procedures today. After identifying the inferior epigastric vessels by visualizing them intra-abdominally through the laparoscope, one to three secondary ports are placed, depending on the procedure.¹¹ A midline port may be placed 3 to 4 cm above the pubic symphysis. Lateral ports are placed approximately 8 cm from the midline and above the pubic symphysis to avoid the inferior epigastric vessels (Fig. 44-2).¹² This lateral site corresponds to McBurney’s point in the right lower quadrant, and is approximately one-third the distance from the anterior iliac crest to the pubic symphysis (see Fig. 44-2). An additional lateral port for the principal surgeon is required for most operative laparoscopy cases. The site chosen is typically at the level of the umbilicus lateral to the rectus muscle. This site offers the surgeon comfortable use of both hands and allows access to most areas of the pelvic or abdominal cavity.

Figure 44-2 Ideal port sites in relation to the deep and superficial vessels of the anterior abdominal wall.

Secondary ports are placed with sharp trocars under direct laparoscopic visualization to avoid injuring intraperitoneal structures. These trocars should be placed directly into the peritoneal cavity without tunneling. After removal, the intra-abdominal gas pressure is reduced to observe for signs of hemorrhage indicative of abdominal wall vessel injury. If the port diameter is 10 mm or greater, the fascia and peritoneum should be closed with a full-thickness suture to reduce the risk of subsequent herniation.

Removal of Ports and Port Site Closure

At the time of port removal, several measures have been advocated in an effort to minimize patient risk. Secondary ports should be removed under direct visualization to detect any bleeding that might have been masked by the port or the intra-abdominal pressure. Certainly, any port with stabilizing threads should be rotated counterclockwise for removal, because forcefully pulling out the sleeve without rotation might actually enlarge the fascial defect.

All carbon dioxide used for pneumoperitoneum should be allowed to escape before removal of the umbilical port. Not only will this minimize subsequent shoulder pain, but it will also avoid pushing bowel into the incision sites as residual gas escapes. Some surgeons recommend elevating and shaking the abdominal wall at the umbilicus to dislodge any bowel or omentum that might have partially lodged in the umbilical site, because there is no way to visualize this area after removal of the laparoscope.

It has become clear that large port sites are at a small but undeniable risk for subsequent bowel herniation if not securely closed.¹³ Furthermore, patients with ascites or in whom intra-abdominal fluid has been placed for chemotherapy or adhesion prevention are at risk of postoperative leakage through the port site. For these reasons, it is recommended that all extra-umbilical port sites be surgically closed when a trocar greater than 8 mm in diameter was used for port placement or if repeated removal and replacement of the port has enlarged the fascial defect. Although the risk of herniation at the umbilicus appears to be extremely rare, some surgeons recommend closing the fascia at this site as well.

Closure of a midline port incision is relatively straightforward, because the anterior and posterior rectus fascial sheaths fuse in the midline. The fascia can be grasped with a Kocher forceps and closed with interrupted absorbable suture under direct visualization.

Closure of lateral ports is more of a challenge because the fascia is clearly divided into sheaths. Closure of only one fascial sheath puts the patient at risk of herniation of bowel between the sheaths, often referred to as a Spigelian hernia (see Chapter 45). For this reason, methods have been designed to simultaneously close both layers.

When closing secondary ports, it is imperative to do so under direct laparoscopic visualization to avoid bowel injury. One of several transabdominal suture guides are used to place interrupted absorbable suture through both the anterior and posterior fascial sheaths, usually incorporating the peritoneum as well. However, even this technique does not completely prevent subsequent herniation.¹⁴ For this reason, any painful bulge appearing beneath a laparoscopic port site should be evaluated ultrasonographically to detect bowel herniation.

POWER INSTRUMENTS

Power instruments are often used during laparoscopy because suture ligation, the most common hemostatic method used during laparotomy, is difficult to perform laparoscopically. Electrocoagulation was perhaps the first power instrument used during laparoscopy.² This instrument is heated by passing electrical current through the tip of a grasping instrument, which is then used to coagulate tissue.

In the past 30 years, other methodologies have been developed, most notably electrosurgery. Unipolar electrosurgery passes current through the patient to cut or coagulate tissue. Bipolar electrosurgery was developed in an effort to minimize the risk of inadvertent injury to adjacent tissue, particularly the bowel. Bipolar electrosurgery offers an increased margin of safety because the electrical current is confined to the tip of the instrument, but the cutting ability is reduced. Lasers offer a precise, rapid, and accurate method of thermally destroying the tissue; however, hemostatic effects are lessened and lasers are costly. The ultrasonic scalpel is an ultrasonically activated instrument that moves longitudinally at a rate of 55,000 vibrations per second and is able to cut tissue and coagulate small vessels without heat or electrical energy. Tips available for this instrument include grasper/scissors, a hook blade, and a ball tip. These instruments are discussed in more depth in Chapter 45.

Techniques for Large Vessel Occlusion

Occlusion and division of large vessels, such as ovarian and uterine vessels, is an important part of many advanced gynecologic laparoscopy procedures such as hysterectomy and oophorectomy. Traditional suturing with intracorporeal or extracorporeal knot tying for this purpose is relatively slow and difficult for many laparoscopists. Originally, these large vessels were laparoscopically occluded with pretied suture loops or linear stapling devices. With experience, it has been found that these large vessels can be effectively occluded with power sources, including bipolar electrosurgery and the ultrasonic grasper. When occluding the uterine artery during hysterectomy, most of these techniques are associated with a risk of ureter injury.

LAPAROSCOPIC PROCEDURES

Diagnostic Laparoscopy

Laparoscopy is an invaluable method for assessment of the pelvis in women with acute or chronic pain and in women suspected of having an ectopic pregnancy, endometriosis, adnexal torsion, or other pelvic pathology. In most cases, the laparoscope is placed through an infra-umbilical port and a probe is placed through a second suprapubic port to manipulate the pelvic organs, if only a diagnostic laparoscopy is performed. However, for operative laparoscopy other than the simplest procedures the suprapubic port is not useful and is quite uncomfortable. If operative laparoscopy is performed, the accessory trocars should be placed in the right and left lower quadrants. For advanced laparoscopy, an accessory trocar at the level of the umbilicus lateral to the rectus abdominis muscle will allow the principal surgeon to operate comfortably and have access to the pelvis. If tubal patency is a concern, a dilute dye can be injected transcervically, a procedure termed chromopertubation.

Before initiating any surgery, the peritoneal cavity should be thoroughly inspected using a systematic approach. With the surgeon controlling the movement of the laparoscope, each quadrant of the abdomen and then the pelvis should be carefully inspected. The spleen is usually difficult to see except in thin women (Fig. 44-3). Care should be taken to inspect the appendix, omentum, peritoneal surfaces, stomach, surface of the bowel, diaphragms, and liver (Figs. 44-4 and 44-5).¹⁵ If any suspicious lesions are observed, fluid should be obtained for cytology (pelvic washings) before prior to biopsying the lesion for frozen section.

Figure 44-3 Anatomy of the left upper abdomen.

Figure 44-4 Subdiaphragmatic adhesions of Fitz-Hugh–Curtis syndrome. These two physicians, Dr. Curtis in 1930 and Dr. Fitz-Hugh in 1934, described the relationship between adhesions and gonococcal infection.

Figure 44-5 Liver hemangioma.

Tubal Sterilization

Laparoscopy is one of the most commonly used techniques for permanent sterilization in the world (see Chapter 28). Original laparoscopic techniques used electrocautery or electrosurgery to coagulate the midportion of the tubes. Other techniques, including clips and Silastic bands, have gained popularity. The pregnancy rates vary by age of the patient, ranging from 1% to 3% after 10 years.¹⁶

Lysis of Adhesion and Tubal Reconstructive Surgery

Adhesions are usually the result of previous pelvic infections secondary to pelvic inflammatory disease or a ruptured appendix, endometriosis, or previous surgery. These adhesions may contribute to infertility or chronic pelvic pain. Lysis of adhesions is performed bluntly or by sharp dissection using scissors or a power source. Extreme caution should be used if adhesions less than 1 cm from the ureter or bowel are lysed using unipolar electrosurgery because of the unpredictable nature of current arcing. The other power techniques, such as the ultrasonic scalpel, may be a better choice for adhesiolysis near bowel for surgeons who do not have experience with unipolar cautery.

Tubal reconstructive surgery is still performed even in the era of in vitro fertilization (IVF) and is almost exclusively performed laparoscopically. Fertility-enhancing procedures include adhesiolysis, fimbrioplasty, and terminal neosalpingostomy. Before and during these procedures, chromopertubation is carried out to document proximal tubal patency by injecting dilute indigo carmine dye through the cervix using a cannula. Laparoscopic surgery is performed using the principles of microsurgery to avoid tissue damage, including delicate handling of tissues, and minimal use of electrosurgery for hemostasis.

Patients with mild tubal disease and preservation of fimbria have excellent pregnancy rates after laparoscopic surgery. Although these patients remain at risk for subsequent ectopic pregnancy, the risk of multiple gestations associated with IVF is avoided for patients who subsequently achieve a viable intrauterine pregnancy.

Unfortunately, adhesions often reform after lysis. Multiple techniques have been used in an effort to decrease reformation (see Chapter 52). Gentle tissue handling and good hemostasis also appear to be important. Barrier methods have been shown in clinical trials to decrease adhesions, but have yet to be proven to improve pain relief or future fertility.

Fulgarization of Endometriosis

Laparoscopy is the primary surgical approach used to treat endometriosis. Endometriosis lesions may be resected or ablated, using scissors or any of the power instruments. These treatment approaches have been shown to improve fertility and decrease pelvic pain (see Chapter 49).

Ectopic Pregnancy Treatment

Laparoscopy has become the surgical approach of choice for most ectopic pregnancies ¹⁷ (see Chapter 48). The embryo and gestational sac are removed either through a longitudinal incision (linear salpingostomy) or by removing a part of the tube (salpingectomy). Even a ruptured tubal pregnancy can be treated laparoscopically, as long as the patient is hemodynamically stable.

Ovarian Cystectomy and Oophorectomy

Ovarian pathologic conditions, including cysts, commonly result in a gynecologic complaint such as pain. The underlying pathology ranges from physiologic and self-limiting functional cysts to ovarian torsion and other benign conditions, to ovarian malignancy. Ovarian cysts are usually characterized ultrasonographically and treated when necessary by laparoscopy or laparotomy, depending on the size of the cyst and the level of suspicion for malignancy (see Chapter 50).¹⁸ The most important concept in adnexal surgery is to avoid spilling the cyst contents whenever possible.

Myomectomy

Many women with a symptomatic fibroid uterus prefer a myomectomy over hysterectomy to preserve fertility or the uterus (see Chapter 46).¹⁹ In some cases, myomectomy can be performed laparoscopically. The challenges in the case of intramural myomas are related to hemostasis, effective closure of the resulting myometrial defect, and removal of the specimen from the abdomen. Vasopressin can be injected into the uterus to help maintain hemostasis. The excised fibroid can be removed by morcellation or culpotomy. Power morcellators are available to expedite the process. Barrier techniques may be used to decrease subsequent adhesion formation. Some early case series have reported increased risk of subsequent uterine rupture during pregnancy after laparoscopic myomectomy compared to those performed by laparotomy.²⁰ However, several randomized clinical trials have shown no increased risk in expert hands.²¹ A totally laparoscopic approach should be attempted only by gynecologists skilled in laparoscopic suturing.

Laparoscopic Uterine Nerve Ablation for Pelvic Pain

Many women have severe dysmenorrhea that is unresolved despite medical management, but wish to maintain future childbearing potential. In these patients, two laparoscopic approaches have been attempted with some success. Laparoscopic uterosacral nerve ablation (LUNA) is performed by stretching and dividing each uterosacral ligament using electrosurgery or laser alone or in combination with scissors. Care must be taken to avoid injuring the ureters. This procedure has been shown to have some temporary success, but a recent Cochrane review has questioned the validity of this procedure.²²

Laparoscopic presacral neurectomy is a second approach for central pain. This technically challenging procedure is performed by careful retroperitoneal dissection between the common iliac artery on the right and the inferior mesenteric artery where it crosses over both left common iliac artery and vein on the left. The superior hypogastric plexus, which includes the presacral nerves, is dissected from the left common iliac vein and periosteum of sacral promontory and a 2- to 3-cm segment is resected. Surgical risks include vascular complications, and long-term risks, such as constipation, are more common than with LUNA. Although both LUNA and laparoscopic presacral neurectomy appear to give some patients at least temporary relief from central pain, many clinicians believe that there is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhea, regardless of cause.²²

Hysterectomy

Laparoscopic hysterectomy, first described by Dr. Harry Reich in 1992, is commonly performed today.²³ The three basic laparoscopic approaches for hysterectomy are laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy. Although the basic techniques for each of these approaches are fairly standardized, controversy exists over the risks, benefits, and most appropriate indication of each.

Laparoscopic-assisted Vaginal Hysterectomy

LAVH is the most commonly employed and technically straightforward of the three procedures. Using three to four ports, the peritoneal cavity is surveyed and lysis of adhesions is performed if necessary. Then the infundibulopelvic or utero-ovarian ligaments are occluded and divided, depending on whether the ovaries will be removed. The round ligament is divided, the uterovesicle peritoneum is incised, and the bladder dissected from the anterior uterus. This step results in an increased risk of bladder injury compared to either abdominal or vaginal hysterectomy. At this point, the uterine arteries laparscopically are sometimes occluded and divided, although this is associated with an increased risk of ureter injury compared to either abdominal or vaginal hysterectomy. Finally, the posterior cul-de-sac is incised.

The surgeon proceeds vaginally for the remainder of the case, dissecting the vesicovaginal septum anteriorly to enter the anterior cul-de-sac, ligating the uterine vessels if not previously done, removing the uterus and ovaries if appropriate, and closing the vaginal cuff.

Laparoscopic Hysterectomy

Laparoscopic hysterectomy, the common second approach, is performed initially like the LAVH, except that the entire hysterectomy is performed laparoscopically. This approach is often used when there is little or no uterine descent, which makes the vaginal approach unfeasible.

After the infundibulopelvic (or utero-ovarian) and round ligament are occluded and divided, the bladder is dissected away from the anterior uterus. The ureters are identified, and the uterine vessels and uterosacral ligaments are occluded and divided. The posterior cul-de-sac is incised, the vagina is circumferentially separated from the cervix, and the specimen is removed vaginally. The cuff is closed laparoscopically or vaginally.

Supracervical Hysterectomy

The supracervical hysterectomy is a third common laparoscopic approach to hysterectomy for benign indications.²⁴ The technique begins in a manner identical to LAVH and laparascopic hysterectomy. However, before dissecting the cervix, the fundus is transected at the uterocervical junction. To minimize residual cyclic vaginal bleeding and decrease the risk of developing cervical dysplasia or cancer, the glandular tissue endocervix is cored out or cauterized. The uterine specimen is removed through a 12-mm abdominal port using a power morcellator.

This approach eliminates both the vaginal and abdominal incision, thus decreasing the risk of infection. The risk of ureteral injury is also decreased, because the procedure stops above the level of the internal os. However, a risk of subsequently developing cervical dysplasia or cancer remains due to the presence of the cervical stump. For this reason, routine Pap smears are required, and some patients will require additional surgery related to cervical abnormalities. Furthermore, at least two randomized clinical trials have failed to show superior results in bladder function or sexual function.^25,²⁶ These studies did show a higher reoperation rate for bleeding and prolapse.

Although small trials have tried to assess the value of laparoscopic hysterectomy, a large multicenter, randomized trial that compared laparoscopic with abdominal hysterectomy and laparoscopic with vaginal hysterectomy has provided insight into the role of this procedure.²⁷ The study confirmed that the laparoscopic approach offers no advantage over the vaginal approach. It also confirmed that the laparoscopic approach is associated with less postoperative pain, shorter hospital stay, and faster convalescence compared with the abdominal approach. It demonstrated that the laparoscopic approach was associated with a slightly higher risk of urinary tract injury. The shorter length of hospitalization with laparoscopic hysterectomy offset some of the additional costs incurred by longer operating room times and the expense of disposable instruments.²⁸