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Operative Laparoscopy

Overview

Background

Operative laparoscopy has become the standard approach for most common surgeries, including tubal ligation, cholecystectomy, appendectomy, and ovarian cystectomy (see the image below).

Transvaginal extraction of the uterus in total lap

Transvaginal extraction of the uterus in total laparoscopic hysterectomy.

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Currently, technology is so advanced that almost all surgical procedures can be performed laparoscopically. The laparoscopic approach has been gaining popularity for several reasons:

Usually can be performed in the outpatient setting

Shorter hospitalization when admission is necessary

Better cosmetics

Faster recovery and earlier return to normal activity

Less risk of postoperative adhesion formation

The higher cost of the procedure may be outweighed by social benefits, including lack of or shorter hospitalization and earlier return to work.

The video below depicts a single-incision laparoscopic cholecystectomy.

Laparoscopic cholecystectomy. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

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Indications

Almost any gynecologic surgery can be performed laparoscopically in carefully selected patients and in the hands of a skilled minimally invasive surgeon. Advancement in technology and the availability of a wide spectrum of laparoscopic equipment and energy sources have allowed a large variety of surgery to be performed laparoscopically, ranging from simple tubal ligation to complex urogynecologic and oncologic procedures.

Contraindications

Absolute contraindications for operative laparoscopy include the following:

Surgeon’s lack of skills

Inadequately equipped operating room

Shock

Markedly increased intracranial pressure

Retinal detachment

Relative contraindications include:

Compromised cardiopulmonary status

Ventriculoperitoneal shunt

Pregnancy

Large pelvic masses

Technical Considerations

Best Practices

To document correct intraperitoneal placement of the initial trocar, we recommend using serial gas pressure measurement. It has been shown to be the best indicator of correct placement of the initial trocar (100% sensitive for preperitoneal insufflations).

In obese patients or patients with suspected pelvic adhesions, we routinely choose the left upper quadrant site and use the direct entry technique using a 5-mm optical trocar and 5-mm 0-degree scope. We find that the close proximity of this site to the lower rib requires less force to lift the anterior abdominal wall as compared to the umbilical site. This is especially practical in obese patients and can be performed by the surgeon alone without assistance.

Always make sure that a nasogastric or orogastric tube is placed and the stomach is deflated prior to performing a left upper quadrant entry.

Complication Prevention

Preperitoneal insufflation can occur when the Veress needle is mistakenly placed in the preperitoneal space and insufflations are started. This can prevent entry inside the peritoneal cavity and can create a false space with potential injury to the underlying vascular structures. It is one cause of conversion to laparotomy.

Omental emphysema can occur when the Veress needle is inserted into the omentum and appears as gas bubbles within the omentum. It is rarely of clinical consequence. Elevation of CO2 levels has been reported.

Most wound infections are superficial and consists of wound cellulitis. However, more serious infections and wound abscesses rarely occur, especially in the context of a contaminated surgery like pelvic abscesses, ruptured appendix, or bowel injury. Most of these infections are treated conservatively with bedside drainage, wound packing, and antibiotics. Severe necrotizing fasciitis can rarely occur.
The American Congress of Obstetricians and Gynecologists does not recommend prophylactic antibiotics in patients undergoing diagnostic laparoscopy.

Bowel injury can occur during closed-entry or open-entry technique. However, the incidence seems to be the lowest during open entry (0.048%) versus closed entry (0.083%).
The risk of bowel injury increases in the context of bowel adhesions, such as a history of previous surgery, pelvic inflammatory disease, and endometriosis. Bowel injury is concerning because these injury can be missed during the surgery and present postoperatively with peritonitis and sepsis.

Injury to a major retroperitoneal vessel is a catastrophic complication and occurs most commonly during laparoscopic entry when blindly placing the Veress needle or primary trocar through a periumbilical incision.
However, vascular injury can occur regardless of the method of entry because of the short distance between the base of the umbilicus and the major retroperitoneal vessels, which can be as little as 2 cm.
The incidence of major vascular injury ranges between 0.04 and 0.5%.

Accidental placement of the Veress needle and insufflating into a major vein can result in a massive gas embolism. Injuring any of the major vessels can result in fatal exsanguination.

Injury to the deep inferior epigastric vessels can cause subcutaneous hematoma and significant morbidity.

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