Laparoscopic
surgery
Laparoscopy has revolutionized the investigation and management of women in gynecological practice. Though first described over 90 years ago1 it is really only in the past two to three decades that advances in light delivery systems and camera/video technology have allowed the performance of advanced procedures. The aim of this chapter is to review the indications, procedures, and complications of laparoscopic surgery as applied to women with an abnormal menstrual cycle. Evidence-based recommendations are used where possible.
THE BASICS OF LAPAROSCOPY
Standard laparoscopy is performed under general anesthesia and
involves the creation of a carbon dioxide pneumoperitoneum. The abdomen is
inflated via a Veress needle inserted subumbilically. A 10-mm diameter trochar
is inserted, again in the subumbilical position, and a telescope inserted
through the trochar sleeve to view the internal organs. A uterine manipulator
is passed into the cervix to allow optimal views of the pelvis.The legs are
held in stirrups and the patient put into a steep Trendelenburg’s (head down)
position to displace bowel from the pelvis. One to three 5-mm secondary ports
are placed along the ‘bikini line’ in the suprapubic or iliac fossae areas for
the introduction of graspers, scissors, suction-irrigation or diathermy
instruments. In modern laparoscopy the camera is linked to one or two video
monitors to allow optimum views of the procedure for the surgeon and
assistants. The operation may be recorded on videotape or digital videodisc
(DVD) and kept in the department or, as in Oxford (UK), handed to the patient
for safe-keeping and personal viewing. The latter approach also permits
surgeons in other units to view the operative findings and procedures as the
need dictates.
INDICATIONS FOR LAPAROSCOPIC SURGERY
The indications for surgery with reference to this book include
pelvic pain and/or irregular or heavy menstruation.These symptoms may be due to
pathology of the uterus, tube, ovary, peritoneum or adhesions between these
structures and to the bowel. Surgery may be divided into diagnostic or
operative procedures. A diagnostic laparoscopy is generally performed as a
day-case procedure whilst operative procedures often, but not necessarily,
involve a stay of one or more nights postsurgery.
PROCEDURES
It is fair to say that just about any abdominopelvic operative
procedure can be performed laparoscopically. However, just because a procedure
can be done laparoscopically, it does not follow that it necessarily should be
performed this way. There are, however, a number of advantages of laparoscopy
over laparotomy including reduced pain scores, time in hospital, and time to return
to normal functioning. However, operative time may be increased, equipment
costs are higher, and increased surgical experience may be required.
DIAGNOSTIC LAPAROSCOPY
The aim of a diagnostic laparoscopy is to investigate the
pathological cause of symptoms listed in Table 1. Diagnostic laparoscopies are
usually performed as day-case procedures with women going home 3–4 h after
surgery. If pathology is found the management options are discussed with the
patient before discharge and/or at a later clinic appointment. An alternative approach
is to ‘see and treat’.Women with symptoms suggestive of, for instance,
endometriosis may be asked to give their consent to ablation of small areas of
disease and still go home the same day. In general, it is probably best not to
treat more than minor degrees of endometriosis or adhesions during a diagnostic
laparoscopy. Patients with abdominopelvic pain, randomized to the control arm
of trials examining operative laparoscopy, appear to have some reduction in
pain scores following diagnostic laparoscopy alone that may persist for at
least 12 months. The mechanism for this finding is unclear. Photographic
reinforcement of normal findings in pelvic pain patients has not been shown to
be better than no reinforcement in a randomized controlled trial (RCT).
OPERATIVE LAPAROSCOPY
The term operative laparoscopy encompasses a wide range of
procedures from ablation of a small amount of endometriosis to resection of a
large rectovaginal nodule or total laparoscopic hysterectomy. Consequently, the
risks and benefits of operative laparoscopy vary with the extent, type and
location of disease, the procedure planned, and the expertise of the surgical
team. A prospective study of 25764 laparoscopies performed in 72 Dutch
hospitals during 1994 revealed a complication rate of 2.7/1000 for diagnostic
and 17.9/1000 for operative laparoscopies8. A complication was defined as
any unexpected or unplanned event requiring intra- or postoperative
intervention. Hemorrhage of the epigastric vein and bowel injuries were the
most commonly observed complications. Two deaths occurred. The laparotomy rate
was 3.3/1000. Previous laparotomy and surgical experiencewere identified as
variables associated with risk of complication.
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