Laparoscopy
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Patient choice, preparation & consent
Check all equipment before operation
Position the patient, catheterize, attach uterine manipulator
Patient choice, preparation and consent
Patient selection includes attention to obesity, past history of midline laparotomy with a risk of anterior abdominal wall adhesions (and certain Pfannenstiel procedures are a risk, e.g. myomectomy, operations for sepsis, ovarian cystectomy), & previous known abdominal sepsis. All patients should be thoroughly examined before the operation & have an ultrasound scan.
All should be advised of the risk of visceral injury, & the possibility of proceeding to laparotomy, & this should be clearly recorded in the notes.
Injury
At laparoscopy, 50% injuries are caused by trocar & cannula & Verres needle insertion & 50% by diathermy/dissection accidents. Avoid this by learning anatomy, patient selection, & entry technique. Learn open entry technique (Hasson’s technique) & Palmer point entry (left costal margin, 3cm down, not discussed here) in patients with previous midline incisions. Avoid diathermy injury by checking for distance from bowel/ureter/bladder & lack of contact to viscera when using diathermy. Diathermize with good vision only.
Always make good records in the notes. Saved images are increasingly used.
Check all equipment before operation
Unlike open surgery, the equipment – laparoscope tower & settings, gas bottle & insufflator (gas machine), camera, scope, Verres needle, trocars & cannulas, instruments – should all be checked by the surgeon.
Position the patient, catheterize, attach uterine manipulator
Make sure the table is horizontal, & that patient’s buttocks are off the bottom of the table, with the lower section dropped/removed. Position the legs in lithotomy, but thighs horizontal, at the level of the patient’s abdomen. If lithotomy pole slings are used, ensure the slings & poles are padded to prevent compression.
Operate with the table as low as possible.
Pass an indwelling catheter if there is any prospect of the procedure taking time, otherwise in-out catheterization will do. Always perform a bimanual examination before proceeding. Place a vulsellum on the anterior lip of the cervix & insert & attach a uterine manipulator. If there might be an ectopic or an early intra-uterine pregnancy insert the manipulator only after the ectopic pregnancy is confirmed by direct vision with the scope.
The Procedure
Incise the umbilicus vertically with a ‘No 15’ bladed scalpel (small blade). Insert the blade just through the skin at the deepest point of the umbilicus flick upwards & outwards. 12mm defect (to fit 10mm trocar & cannula)
- Insert the Verres needle at 700, aim midline. Some surgeons prefer to elevate the anterior abdominal wall at entry. A sensation & a click or two clicks may be felt and heard as the Verres needle pierces the sheath & peritoneum
- Laparoscopy without the Verres is widely practiced. As is entry with main trocars & cannulas that allow vision
- Checking that the Verres needle is in the abdominal cavity & not in the bowel can be done with the hanging drop technique, or elevation of the abdominal wall to hear a ‘hiss’ from the top of the needle, or by saline injection through the needle (no resistance to flow), & finally resistance to the pulling back of the syringe barrel (there is a vacuum in the abdominal cavity) when the syringe is inserted onto the Verres & insufflated water has also not returned brown
- Next, attach the CO2 pipe to the Verres needle, & switch on the gas. The pressure on the monitor should remain in single figures (< or = 7mmHg). If the figure rises a) elevate the abdominal wall, or b) remove & re-insert the Verres needle. The pressure will rise as the abdomen fills to capacity. Fill to 20-25 mmHg for ALL port insertions. If a port comes out half way through the operation
- Only the primary (umbilical) trocar is inserted blind. Learn how to palm the trocar & cannula. Different trocars & cannulas perform differently. Learn how to ‘arm’ them if needed. Then place the index finger along the shaft to prevent too deep insertion. Aim in the midline at 45-700 to the horizontal
- Secondary trocars are usually inserted lateral to the inferior epigastric artery on each side after the artery is identified with the scope, after cutting a 7 mm horizontal incision in the skin. Midline suprapubic is a good alternative – the favoured position for the Filshie clip applicator
- Once the trocars and cannulas are in and operating commences drop the pressure to 15mmHg to prevent a) difficulty ventilating b) hypercapnia c) decreased & unpredictable venous return
Good vision
- If the image is blurred, check the focus, then wipe the telescope tip on bowel or remove & wipe with a swab or alcohol
- Withdraw the scope for a wider view, & at times, push in the scope & zoom in close. Try both.
- Keep the viewed object(s) in the middle of the screen at all times
- The top of the camera always faces the ceiling of the room
- Try to keep the camera still once the view is good
- Uterine elevation & pushing bowel into the upper abdomen with the patient in Trendelenburg will help to reveal anatomy. Elevate the uterus
Operating technique – adhesiolysis, sterilization, ectopics
Adhesiolysis is done as with open surgery – place adhesions on stretch by manipulating with care. Transilluminate adhesions to look for vessels & the boundaries of viscera. Know your anatomy. Inspect thoroughly before cutting or using diathermy
Diathermize once all adjacent structures are free. Do not make contact with other instruments when using diathermy. Diathermy can sometimes be set lower (20-30 Watts) than in open surgery
For sterilization, ensure that the fallopian tube is correctly identified (by the fimbrial end), & that the Filshie clip will occlude the tube completely. Keep the long jaw of the applicator underneath to avoid dropping the clip. Keep the jaws half closed for insertion through the port and manipulation. If in doubt, apply a second clip or recall the patient later for a hysterosalpingogram
For ectopic pregnancies, do a linear salpingotomy with unipolar diathermy on the anti-mesenteric border, & remove the conceptus with graspers or irrigation & retrieve it into a 10 mm secondary port with a ‘toilet seat’ (to take the 5mm grasper) or an artery forceps through the skin or a bag. Alternatively, do a salpingectomy with bipolar diathermy/ligasure/harmonic scalpel to blanch the tube mesentery & then the tube before cutting, with retrieval in the same way. An ‘Endobag’ to remove the tube may be available (others use a sterile rubber glove). If there is blood inside the abdomen, suck it out first as it absorbs light