Larcoscopic Surgery; indications and procedure

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.

Larcoscopic

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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