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.

Figure 3.5 A selection of laparoscopic scissors, graspers and bipolar diathermy of 5 mm diameter.

Laparoscopic operating equipment is expensive and has a relatively short shelf-life in comparison with open instrumentation. It is essential that any theatre budget takes this into consideration and that laparoscopic surgeons are not asked to continue working with blunt and non-functioning instruments. The more complex problems of decontamination and sterilization of these precision instruments mean that they require careful maintenance by a specialist team.

Site of entry

There are three main sites of entry into the peritoneal cavity. The most common site is at the umbilicus, with some clinicians using a suprapubic approach and others utilizing Palmer’s point (in the mid-clavicular line in the ninth intercostal space).

At the umbilicus, the abdominal wall is at its thinnest. A subumbilical incision is preferred by some clinicians, but there appears to be no logic to this. If the umbilicus is to be used, there is little point in inserting either the Veress needle or primary trocar at a point where the abdominal wall has expanded. In addition, an intraumbilical incision is cosmetically superior (Figure 3.6). The left upper quadrant of the peritoneal cavity is where the fewest intraperitoneal adhesions occur. For this reason, Palmer suggested the ninth intercostal space as an insertion point for insufflation and brief inspection of the peritoneal cavity. A number of clinicians utilize this entry point when they suspect that periumbilical adhesions may be present.

Figure 3.6 An incision is made intraumbilically.

Closed laparoscopy

A vertical incision is made intraumbilically, with the angle of the Veress needle insertion varying according to the body mass index (BMI) of the patient, from 45 degrees in non-obese women to 90 degrees in obese women (Figure 3.7). Most clinicians stabilize the anterior abdominal wall by grasping it with the left hand, while the right hand inserts the Veress needle. Experienced laparoscopists can feel the Veress needle pass through the layers of the anterior abdominal wall, and will usually be able to tell whether the Veress needle is correctly positioned. At this point, a number of techniques have been described to assist in demonstrating that the Veress needle is correctly positioned. A syringe can be used to aspirate from the Veress needle to identify visceral contents. Alternatively, a droplet of water or saline can be placed on the end of the Veress needle and the negative intra-abdominal pressure causes this to be sucked in. A syringe placed on the end of the Veress needle and containing water or saline, but without its plunger, will usually allow the solution to drip into the peritoneal cavity if correctly positioned. Once insufflation is commenced, the filling pressure can be observed and uniform distension of the abdominal cavity can be determined by percussion. In particular, the area over the liver becomes resonant to percussion when pneumoperitoneum is created. ‘Waggling’ of the Veress needle from side to side should be avoided as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels.

Figure 3.7 The Veress needle is placed intraumbilically and directed towards the pouch of Douglas during insertion.

It is important to create pneumoperitoneum of a set pressure rather than volume. The size of the intraperitoneal cavity varies greatly between individuals. The purpose of insufflation is to provide a cushion between the anterior abdominal wall and the important underlying structures when the primary trocar is inserted. Phillips et al (1999) demonstrated that an intraperitoneal pressure of 25 mmHg was necessary in order to maintain the gas bubble during insertion of the primary trocar. It is extremely important that this pressure is then reduced to 15 mmHg or less for the rest of the operation. Ventilation difficulties are not encountered at this initial filling pressure, as the patient is flat and the pressure of this level is only maintained for a short period of time.

Open laparoscopy

The Hasson entry technique was first described in 1971 (Hasson 1971). A vertical incision is placed intraumbilically and the various layers of the abdominal wall are incised using two Langenbeck retractors on either side to assist with visualization. Once the rectus sheath is incised, a suture is inserted on either side of the incision into the sheath. The peritoneum is opened, a blunt Hasson cannula is inserted directly into the peritoneal cavity and insufflation is commenced. A seal is usually created utilizing the sutures in the rectus sheath and tightening around a cone attached to the Hasson cannula.

Comparison of complications

A vast number of laparoscopies using the closed technique have been performed over many years. A collection of over 350,000 procedures has calculated the risk of bowel damage to be 0.4/1000 and the risk of major vessel injury to be 0.2/1000. The most common bowel injury is to the transverse colon, while the most common vascular injury is to the right common iliac artery (Clements 1995).

There are no comparable data on such a large number of patients for open laparoscopy. One rationale of the Hasson technique is to identify intraperitoneal and bowel adhesions at entry into the peritoneal cavity, thus avoiding blind insertion of a trocar into a visceral structure, but this was not supported by a recent Cochrane review (Ahmad et al 2008). More logically, the Hasson technique avoids major vessel damage. Population-based studies are an inappropriate way of comparing the two techniques, as many clinicians only use the open laparoscopy approach if they think there is a danger of intraperitoneal adhesions. They are therefore selecting a high-risk group of patients on which to perform this technique. Studies that have been published with large numbers suggest that bowel damage in the open laparoscopy group is equivalent to that in the closed laparoscopy group (Chapron et al 1998).

Advocates of the open laparoscopy approach maintain that the time taken to achieve pneumoperitoneum is equivalent to that of the closed laparoscopy approach (Pickersgill et al 1999).

Ten percent of patients will have intra-abdominal adhesions, with 5% having severe adhesions containing bowel around the umbilicus. Ninety-two percent of these patients with severe adhesions will have had a previous laparotomy, with the vast majority following midline incisions (Garry 2000). Although not all visceral perforations caused by laparoscopy are the result of negligence, it would seem prudent for clinicians to take previous midline laparotomies into consideration when performing a laparoscopy. It is important that those advocates of closed laparoscopy are able to perform open laparoscopy when their own technique fails. There is currently no conclusive proof that one technique is safer than the other, and a huge randomized controlled trial would be necessary to detect small safety differences between the two techniques.

Laparoscopic suturing

Laparoscopic suturing can be avoided in many procedures, but is an important skill for the advanced laparoscopic surgeon. Many experienced open surgeons are reluctant to pass through the sometimes humiliating learning curve required in order to master suturing techniques. However, it is simply a matter of ‘practice making perfect’ and laparoscopic suturing is an ideal exercise for the simulator.

Sutures are usually introduced through the accessory ports, and care needs to be taken to ensure that the needle is observed for the entire time it is in the peritoneal cavity. Laparoscopic suturing is less forgiving than suturing at open surgery, and this is classically demonstrated with the curved needle. The correct surgical technique is to insert the tip of the needle into the tissue and then rotate the needle through the tissue in an arc that follows the exact curve of the needle. The needle holder needs to be at right angles to the needle in order to fulfil this task. Poor surgical technique at open surgery often involves surgeons pushing a curved needle in a straight line through the tissues, rather than rotating it through.

Some surgeons prefer to use a straight needle when suturing laparoscopically as this passes through the ports more easily. The principle of suture insertion remains the same by passing the needle through the tissues in a direction that mimics the shape of the needle.

Once the suture is appropriately placed, a knot can be tied either intracorporeally or extracorporeally, according to the individual surgeon’s preference and familiarity. Knots of adequate strength can be tied by either method.

Pre-tied sutures

The endo-loop is a simple technique for applying a suture to a pedicle, pushing down a pre-tied knot (Figure 3.8). These pre-tied sutures employ a Roeder knot and are extremely useful either as a time-saving device or for less-experienced laparoscopic surgeons.

Figure 3.8 A pre-tied Roeder knot mounted on a knot pusher. The loop is placed over the pedicle and the knot pushed tight by advancing the plastic pusher.

Stapling

Mechanical stapling devices have helped to revolutionize laparoscopic surgery and encouraged a generation of surgeons to utilize these precision instruments (Figures 3.9 and 3.10). The device usually inserts three lines of carefully arranged titanium staples, either side of a knife tract, which allows the tissue to be divided when the staples are fired. It is an extremely efficient and rapid instrument, but its major disadvantage is its diameter which requires a 12 mm port. They do need to be applied with great care, and the surgeon needs to ensure that only the desired tissue is secured within the jaws of the device. In the use of this instrument, the surgeon has to be particularly aware that the view on the monitor is only provided in two dimensions. The tips of the stapling device must be visualized before firing.

Figure 3.9 The stapling device. The white handle is fixed, the grey lever closes the instrument and the black lever fires the staples and knife.

Figure 3.10 The cartridge of the stapling device shows six rows of titanium staples separated in the centre by the knife tract.

Specimen removal

Many laparoscopic operations are initially straightforward, such as an oophorectomy for a large ovarian cyst. Very often, the most difficult part of the procedure is actually removing the specimen without increasing the size of the incisions in the abdominal wall. A number of devices have been employed in order to make this extraction easier. The most commonly used specimen retrieval system utilizes a bag such as the Endo-catch bag in Figure 3.11. The bag comes pre-folded and springs open once inserted into the abdominal cavity, allowing the specimen to be inserted. The edges of the bag are brought to the surface and the specimen removed without spilling its contents into the peritoneal cavity. A large cyst can be deflated extracorporeally for easy removal.

Figure 3.11 The bag specimen retrieval system. Advancing the white plunger pushes the bag out of the introducer. The wire around the neck of the bag springs open.

For larger cysts and more solid structures, such as fibroids, alternative methods of specimen removal may be necessary. A posterior colpotomy can be extended with ease to 4 or 5 cm diameter without increasing discomfort or recovery time for the patient. Large-volume specimen bags can be inserted through the posterior fornix and wrapped around large ovarian cysts or fibroids. The neck of the bag can be brought through the incision in the posterior fornix, and the specimen either morcellated or deflated through a much larger incision than is required for the abdominal ports. Figures 3.12–3.20 demonstrate the removal of a 7 cm pedunculated fibroid using a posterior colpotomy. Initially, the fibroid is fixed with a suture to avoid it being displaced into the upper abdomen under the influence of gravity once it is disconnected from the uterus (Figures 3.13–3.14). A straightforward Endo-GIA staple disconnects the fibroid from the uterus and the fibroid is brought down to the posterior colpotomy by pulling on the suture (Figures 3.15–3.17). Transvaginally, the posterior colpotomy is extended and the fibroid morcellated to remove the specimen (Figures 3.18 and 3.19). The posterior colpotomy is repaired either vaginally or laparoscopically with precision.

Figure 3.12 This uterus has a pedunculated 7 cm fibroid arising from the left side of the fundus. An instrument can be seen causing an indentation in the posterior fornix.

Figure 3.13 A suture has been introduced through the posterior fornix and is passed through the fibroid to fix the specimen.

Figure 3.14 The suture is returned to the posterior fornix.

Figure 3.15 A staple is placed over the pedicle of the fibroid which is divided.

Figure 3.16 The staple provides an effective haemostatic and excisional device. Despite the patient being in a steep Trendelenburg position, the separated fibroid remains fixed by the suture through the posterior fornix.

Figure 3.17 The view vaginally shows the suture passing through into the peritoneal cavity.

Figure 3.18 The incision in the posterior fornix is enlarged to 3–4 cm.

Figure 3.19 The fibroid is morcellated and removed through the posterior fornix incision.

Figure 3.20 Although morcellated, the fibroid is completely removed without the need to extend the abdominal incisions.

Mechanical morcellators are an alternative way of removing the fibroids or the fundus and body of the uterus if a subtotal hysterectomy is performed. Extreme care needs to be taken with mechanical morcellators as they are dangerous if the wrong tissue is grasped inadvertently. They require considerable patience and are another piece of expensive theatre equipment.

Energy sources

Many energy sources are available for use with laparoscopic instruments. Bipolar and monopolar diathermy are widely available and reliable. The use of lasers is covered elsewhere in this text (see Chapter 4). Newer methods of tissue division and vessel sealing include the Harmonic Scalpel^® and the Ligasure^® system. Progress in this area of technology has allowed many diagnostic laparoscopies to be converted into effective therapeutic treatment.

Gasless laparoscopy

It is possible to operate within the peritoneal cavity without distending it using carbon dioxide (Chin et al 1993, Wood et al 1994). A rigid mechanical support is required in order to elevate the anterior abdominal wall so that the viscera can be identified. The advantages of gasless laparoscopy are the avoidance of insufflators causing possible gas emboli, and the use of simpler trocars. However, most gasless laparoscopy techniques require extra portals in order to insert the mechanical device for visualization. It is not a technique that has become widespread.

Robotic techniques

Robots were first used in humans to carry out a transurethral resection of the prostate in 1991 at Imperial College, London (Davies et al 1997). The controls of modern robots have an intuitive ease of use, and complex manoeuvres such as suturing can be easily mastered. Physiological movement can be digitally subtracted from the camera signal to give a still image on the screen; for example, cardiac pulsation can be dampened down. The surgeon can be remote from the patient, even in another continent. In an era of consumer-driven health care, there is increasing demand for the most up-to-date equipment. Disadvantages of the robot include limited haptic feedback so the operator is unable to gauge the force applied to the tissue. The robot is an expensive and complex piece of equipment requiring careful maintenance, and in the event of a malfunction, the surgeon must be prepared to complete the operation either laparoscopically or as an open procedure. Operations performed robotically include radical prostatectomy, beating heart bypass grafts and radical hysterectomy.

Diagnostic

All gynaecologists perform diagnostic laparoscopies for multiple indications. It is a common investigation for pelvic pain, infertility, assessment of pelvic masses and in trials to assess clinical efficacy of treatment. There is virtually no indication for a diagnostic laparotomy in current medical practice. All clinicians would agree that a diagnostic laparoscopy is a quick, easy and safe way of assessing the peritoneal cavity, while causing minimal discomfort and allowing rapid recovery for the patient.

Therapeutic

If a therapeutic laparoscopic procedure can be performed with ease and without putting the patient in increased danger, there is no question about its efficacy. Clinicians would agree that a diagnostic laparotomy is unnecessary, has a long recovery period and significant minor morbidity. It is therefore logical to extend this principle into the area of therapeutics. There are many procedures that are clearly better performed laparoscopically, and these should be made available to all patients. It is the responsibility of health authorities, hospital administration and local clinicians to ensure that this logical and sensible approach is available for their patients. Examples of procedures that should normally be performed laparoscopically are given in Box 3.2.

Obese and infirm patients recover significantly better after a laparoscopic procedure compared with an open procedure. A high BMI, previously regarded as a relative contraindication, should be viewed as an indication for a laparoscopic approach.

The debate about laparoscopic surgery becomes more involved when examining more complex gynaecological procedures. There is no doubt that the vast majority of procedures can be performed laparoscopically, but not all procedures should be. The dilemma is in determining which patient fits into which category, and that will sometimes depend on the surgeon. This is not the place to discuss at length the use of laparoscopy in various operations. Laparoscopy is merely the route by which a procedure is performed. It is the appropriate operation rather than the route that is perhaps more important.

The debate concerning the route most suitable for a hysterectomy is an excellent example of the difficulties in determining where laparoscopic surgery is best used. For many years, the surgeon has had a choice of the vaginal or the abdominal route for removing a patient’s uterus. The rates of vaginal hysterectomy vary enormously depending on the country in which a patient is treated. However, the circumstances in which a vaginal or abdominal hysterectomy is most suitable are still unclear.

The frequently quoted paper from Dicker et al (1982), where one-third of hysterectomies were performed vaginally, demonstrates a faster recovery time and lower minor morbidity rate by this route. Major morbidity was infrequent in both groups, but considerably higher in the vaginal hysterectomy group. It seems logical that an easy vaginal hysterectomy would have minimal major complications and provide the patient with the shortest recovery period. However, as the procedure becomes more difficult, the possibility of major complications increases. Judging when to dismiss the advantages of shorter recovery and look for the lower major morbidity rate is an issue that has not been standardized.

It is most desirable to perform a vaginal hysterectomy under the easiest circumstances, but when the procedure is extremely difficult, an abdominal hysterectomy is preferable. At some point between these two extremes, the lines cross. Laparoscopic hysterectomy was introduced in an attempt to make some of the more difficult vaginal hysterectomies easier. As a consequence, many patients who would have otherwise had an abdominal hysterectomy were offered a laparoscopic hysterectomy or a laparoscopic-assisted vaginal hysterectomy. The effects of the route of hysterectomy were examined in 1347 women in the eVALuate study (Garry et al 2004). The trial had two arms; one arm compared abdominal with laparoscopic hysterectomy, and the second underpowered arm compared vaginal and laparoscopic routes. The abdominal arm showed a higher risk of complications including ureteric injuries and conversion to laparotomy with the laparoscopic route, but also less pain and a shorter hospital stay. The vaginal arm showed a longer duration of operation with the laparoscopic route compared with the vaginal route. The trial has been criticized for the low number of laparoscopic hysterectomies performed by each surgeon. The complications may have been higher due to the learning curve of the surgeons. In addition, conversion to open surgery was recorded as a major complication, which may have encouraged surgeons to persist against their better judgement.

With a decrease in the number of hysterectomies being performed and significantly reduced surgical experience as a trainee, the opportunity to learn these techniques is limited. The vast majority of gynaecologists performing this surgery are inevitably self-taught. There are no scientifically reproducible data to show which factors should determine whether a patient has a vaginal, laparoscopic or abdominal hysterectomy. Indeed, the indications would be different for individual surgeons with varied surgical expertise; as such, the debate continues.

There will obviously be some instances where one procedure is clearly preferable. Where prolapse exists, a vaginal hysterectomy is preferable. Where multiple intraperitoneal adhesions are expected or ovarian malignancy is diagnosed, an abdominal approach is superior. For most stage I endometrial cancers where the peritoneal cavity needs to be inspected, washings taken, ovaries removed and possibly lymph node sampling performed, a laparoscopic hysterectomy is superior.

As with the majority of situations, the real truth lies somewhere between the two extremes. Clinicians who have avoided learning laparoscopic surgical techniques need to accept that they have significantly improved the care of many patients and should be readily available. Conversely, some of the proponents of laparoscopic surgery need to accept that there is nothing clever about a procedure that results in increased serious morbidity.