Introduction

During the last 35 years, gynecologic laparoscopy has evolved from a limited surgical procedure used only for diagnosis and tubal ligations to a major surgical tool used to treat a multitude of gynecologic indications. Today, laparoscopy is one of the most common surgical procedures performed by gynecologists. For many procedures, such as removal of an ectopic pregnancy, treatment of endometriosis, or ovarian cystectomy, laparoscopy has become the treatment of choice. Compared with laparotomy, multiple studies have shown laparoscopy to be safer, to be less expensive, and to have a shorter recovery time. The advantages of laparoscopy for other procedures, including laparoscopically assisted hysterectomy and the staging and treatment of gynecologic cancers, continue to be elucidated.

History of the Procedure

Laparoscopy was first performed in dogs in the early 1900s by Dr. Georg Kelling, a German surgeon, who called his procedure koelioskopie. While experimenting with the use of air for pneumoperitoneum to stop intraabdominal bleeding, he introduced a cystoscope into the abdomen to view the effects of increased pressure on abdominal organs. Dr. Hans Christian Jacobaeus, a Swedish surgeon, was the first to publish a description of laparothorakoskopie in humans in 1910. He used air pneumoperitoneum and a cystoscope to evaluate the peritoneal cavity of tuberculosis patients with ascites. Shortly thereafter, Dr. Bertram M. Bernheim of the JohnsHopkinsHospital, reported a series of the first human laparoscopy performed in the United States, which he called organoscopy. Early in the 20th century, diagnostic laparoscopy was used by a limited number of general surgeons in place of diagnostic laparotomy, but had a substantial complication rate. Throughout the 1920s and 1930s, advocates of the procedure continued to develop improved laparoscopic equipment, such as pyramidal trocars for port introduction and lenses with a wider angle of view than the 90° afforded by the cystoscope. During this period, Dr. Janos Veress, a Hungarian internist, developed a spring-loaded needle with an inner stylet that automatically converted the sharp cutting edge to a rounded end. The Veress needle continues to be used today to create a pneumoperitoneum.

A major step forward in the development of laparoscopy was the development of safer laparoscopic lighting

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Tubal Sterilization Overview

system in the 1950s. Up until that time, intra-abdominal light was produced by a small electric light bulb at the distal tip of the laparoscope analogous to a bronchoscope. The use of a quartz light rod to transmit light from an external source to the tip of the laparoscope increased brightness and decreased the risk of intra-abdominal burns. This was soon followed by the application of fiber optic technology still used in modern laparoscopes. Dr. Raoul Palmer, a French gynecologist who specialized in infertility, was an early pioneer in the development of laparoscopy in the mid 20th century. In addition to advocating monitoring of intra-abdominal pressure, he expanded the therapeutic use of laparoscopy for such tasks as intra-abdominal electrocoagulation of bleeding sites, puncture of ovarian cysts, and lysis of pelvic adhesions. In 1961, Dr. Palmer described the first laparoscopic retrieval of oocytes, and in 1974 he described the point 3 cm below the last rib in the left midclavicular line. Palmer's point is often used today for left upper quadrant laparoscopic entry.

Dr. Kurt Semm, a German gynecologist who specialized in infertility, was perhaps the most influential early advocate of modern operative laparoscopy. In the 1960s and 1970s, Dr. Semm invented the automatic insufflator, and hundreds of laparoscopic instruments, including a thermocoagulator, loop ligature, and devices for extracorporeal and intracorporeal endoscopic knot tying. He was one of the first proponents of video monitoring for laparoscopy, using a series of lenses and mirrors in an articulated arm to connect the laparoscopic to a ceiling-mounted video camera. He developed laparoscopic techniques for ovarian cystectomy, myomectomy, treatment of ectopic pregnancy, appendectomy and hysterectomy. Despite the work of Dr. Semm and other remarkable pioneers, gynecologic laparoscopy continued to be used primarily for diagnosis and tubal ligations into the 1980s.

A major breakthrough came with the introduction of the solid state video camera for laparoscopy in 1982. With the widespread application of these compact cameras, both laparoscopist and assistants could simultaneously view the operative field on a video screen. By the end of the decade, video-laparoscopy had become standard and operative laparoscopy became widely accepted as a safe and effective surgical approach. Today, operative laparoscopy is routinely used by gynecologists to perform a multitude of procedures, including hysterectomies and incontinence procedures, and for the diagnosis and treatment of gynecologic malignancies.

Problem

Laparoscopy is a hybrid surgical approach that shares characteristics of both minor and major surgery. To patients, laparoscopic procedures often seem to be minor surgery because of the small incisions, relatively small amount of postoperative pain, and short convalescent period. When a laparoscopic procedure involves minimal intra-abdominal surgery (eg, diagnostic laparoscopy, tubal fulguration), both postoperative discomfort and the risk of complications may more closely resemble a minor procedure than a major procedure.

its essence, laparoscopy remains an intra-abdominal procedure. Therefore, it shares all intraoperative and postoperative risks of laparotomy, including infection and injury to adjacent intra-abdominal structures. When major intra-abdominal procedures are performed laparoscopically (eg, hysterectomy), the resultant postoperative pain and morbidity are still significant. However, because a large abdominal incision is unnecessary, the postoperative pain and morbidity are always less significant than similar major surgery performed by laparotomy. Laparoscopic procedures have unique risks, which are related to methods used for the placement of abdominal wall ports and to the pneumoperitoneum required for laparoscopy. The use of energy within the abdominal cavity likewise introduces risk. These risks include injury to bowel, bladder, or major blood vessels and intravascular insufflation. In addition, increased intra-abdominal pressures associated with laparoscopy increase anesthesiarelated risks such as aspiration and increased difficulty ventilating the patient. Although the risk of blood loss is relatively low for most procedures, potentially massive blood loss may occur and is complicated by the fact that control of blood loss may be delayed by the time taken to perform an emergency laparotomy.

Frequency

Laparoscopy is one of the most common surgical procedures performed in the United States today. Approximately half of the 700,000 bilateral tubal sterilizations performed annually in the United States are performed laparoscopically. In addition to diagnostic laparoscopy, operative endoscopy is used to perform common procedures, including removal of ectopic pregnancies, treatment of endometriosis, and lysis of pelvic adhesions. Almost one third of the 600,000 hysterectomies performed annually in the United States are now performed with the aid of a laparoscope. Although the ideal role of laparoscopy in gynecologic surgery continues to be defined, it has become a standard approach for a large number of gynecologic procedures.

Indications

Diagnostic laparoscopy

Frequently, the physician needs to assess the pelvis for acute or chronic pain, ectopic pregnancy, endometriosis, adnexal torsion, or other pelvic pathology. Determination of tubal patency may also be an issue. Usually, a primary port for the laparoscope (also known as the "lens") is placed infraumbilically and a second port is placed suprapubically to probe systematically and observe pelvic organs. If needed, a biopsy specimen can be obtained to aid in the diagnosis of endometriosis or malignancy. If tubal patency is a concern, use of a uterine manipulator with a cannula allows a dilute dye to be injected transcervically (chromopertubation). Diagnostic laparoscopy is usually performed under general anesthesia, with endotracheal intubation to minimize the risk of aspiration. However, if the pressure used for peritoneal insufflation is limited, laparoscopy can be performed under conscious sedation.

Tubal sterilization

Trocar placement is similar to diagnostic laparoscopy. Bipolar electrosurgery, clips, or silastic bands may be used to occlude the tubes at the mid-isthmic portion, approximately 2-3 cm from the cornua. Bipolar surgery desiccates the tube with 3 adjacent passes to occlude approximately 2 cm of tube. The auditory tone now available to verify total resistance has improved the efficacy of bipolar cautery. Pregnancy rates vary by patient age, ranging from 1-3% after 10 years.

Lysis of adhesion

Adhesions may form due to prior infection, such as a ruptured appendix or pelvic inflammatory disease (PID), endometriosis, or previous surgery. Adhesions may contribute to infertility or chronic pelvic pain. The chances of pregnancy after lysis of adhesions is relatively low for most patients, and this type of surgery has been largely supplanted by in vitro fertilization and embryo transfer. Likewise, adhesiolysis is often ineffective in curing chronic pelvic pain, in part because most adhesions rapidly reform after surgery.

Adhesions may be lysed by blunt or sharp dissection. Aquadissection may aid in the development of planes prior to lysing. Any of the power instruments may be used for cutting and coagulation (see Power instruments). Although in experienced hands unipolar electrosurgery is safe, gynecologist use of unipolar electrosurgery, such as with the fine unipolar needle, is generally recommended to be limited to adhesions 1-2 cm from the ureter and bowel due to the unpredictable nature of current arcing. Other power techniques may be safer choices for adhesiolysis near the bowel.

Adhesions may reform after lysis, although this can be reduced with good hemostasis and minimal use of electrocautery. Recently, a 4% icodextrin solution has been shown to decrease adhesion reformation in a controlled trial. Unfortunately, the results of laparoscopic lysis of adhesions have been disappointing in terms of improving pain relief or future fertility.

Treatment of endometriosis

Laparoscopy is the most common procedure used to diagnose and treat endometriosis. Endometriotic lesions may be resected or ablated using any of the power instruments (see Power instruments). Both of these techniques have shown to improve fertility and decrease pelvic pain in multiple well-designed studies.

Treatment of ectopic pregnancy

Laparoscopy is the surgical approach of choice for most ectopic pregnancies. A salpingostomy or salpingectomy may be performed to remove the embryo and gestational sac. Although auxiliary instruments (eg, pretied loops, stapling devices) can be used for the salpingectomy, most commonly, a power instrument (eg, bipolar electrosurgery, ultrasonic scalpel) is used for these procedures (see Power instruments).

Ovarian cystectomy

If a simple ovarian cyst sized 6 cm or larger persists for 2 or more cycles in a premenopausal, nonpregnant female, a cystectomy is indicated. This can be achieved using laparoscopy or laparotomy depending on the cyst size and the likelihood of the presence of malignancy.

The cyst can be removed by a number of techniques. If the cyst is complex, rule out malignancy by looking for signs of ascites; excrescences on the ovary; or implantations on the peritoneal, liver, or diaphragmatic surfaces. If malignancy is not apparent, carefully dissect the cyst, making an effort to remove the cyst intact. A bag may be used to transfer the cyst out of the peritoneal cavity through a 10-mm port, draining the cyst prior to removal of the bag. If any doubt exists, the cyst wall should be sent for frozen section to confirm a benign cyst. If malignancy is found, a laparotomy should be performed. Permanent section and pathological diagnosis are performed on all cysts. Ovarian cysts with septa, internal echoes, or solid tumors are not good candidates for laparoscopy unless a benign cystic teratoma is a strong possibility.

If the cyst ruptures during removal, liberally rinse the peritoneal cavity with Ringer lactate solution. A dermoid cyst is particularly concerning because of contamination of the peritoneal cavity with sebaceous material, causing a chemical peritonitis. However, 2 case series demonstrated that pregnant and nonpregnant women who had an intraoperative spillage of a dermoid cyst followed by extensive peritoneal irrigation did not have increased length of stay or increased incidence of postoperative complications. Fear of seeding the cavity with a malignant tumor has always been present, although recent data suggest that spilling does not alter the prognosis if a staging laparotomy is performed immediately.

Postmenopausal cysts may also be removed by laparoscopy, although with the increased concern for malignancy, an oophorectomy and laparotomy may be more prudent. Physicians who perform a laparoscopy should be comfortable with staging by laparoscopy or laparotomy, and malignancy should be excluded perioperatively.

Oophorectomy

An oophorectomy may be more appropriate in postmenopausal women with a growing or persistent cyst. A tubal pregnancy or large hydrosalpinx with adhesions may also require ovary removal. The power instruments, pretied loops, or stapling devices may be used to occlude the infundibular ligament and safely remove the ovary. Because of ovary size, a retrieval bag is needed to remove the tissue. Options for removing the ovary from the peritoneal cavity include (1) using a 12-mm port and removing the sleeve with the bag or (2) performing a minilaparotomy or colpotomy. If a colpotomy is performed, prophylactic antibiotics should be administered.

Myomectomy

Many women with a symptomatic fibroid uterus prefer myomectomy to hysterectomy in order to preserve fertility or the uterus. If the patient has a pedunculated fibroid, the stalk may be easily incised. However, for intramural fibroids, the risk of bleeding increases. The use of a preoperative gonadotropin-releasing hormone (GnRH) agonist may be considered in patients who are anemic. However, some studies have shown longer operative times and a higher conversion to laparotomy rate associated with the use of GnRH agonists in laparoscopic myomectomy due to difficult cleavage planes. An injection of vasopressin into the uterus may help maintain hemostasis. The defect left by the fibroid must be sutured, which can be difficult laparoscopically for inexperienced practitioners. Barrier techniques may be used to decrease adhesion formation.

The fibroid may be removed by morcellation or colpotomy. Power morcellators are available to expedite the process. To date, laparoscopy has not proven better than laparotomy for the treatment of menorrhagia or infertility. In addition, some concern exists that the risk of subsequent uterine rupture during pregnancy may be greater after myomectomy performed by laparoscopy compared with laparotomy. However, all randomized clinical trials of myomectomy performed by laparoscopy versus laparotomy did not show an increased risk of rupture or poorer reproductive outcomes. These trials were conducted by experts in laparoscopic suturing and in carefully selected patients.

Hysterectomy

Initially, laparoscopy was performed prior to vaginal hysterectomy to restore normal anatomy. However, currently, it is often used in a variety of ways, such as assessing feasibility of a vaginal hysterectomy (when adhesions, endometriosis, or a large fibroid uterus is suggested) and performing some or all of the actual hysterectomy. The 3 basic laparoscopic approaches for hysterectomy are laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy (LH), and laparoscopic supracervical hysterectomy (LSH). Although the basic techniques for each approach are fairly standardized, controversy exists over the risks, benefits, and most appropriate indications of each.

LAVH is the most commonly employed and technically straightforward of the 3 techniques. Using 3-4 ports, the peritoneal cavity is surveyed and lysis of adhesions is performed if necessary. The infundibular or uteroovarian ligaments are occluded and divided, depending on whether the ovaries will be removed. The round ligament is cut in a similar fashion, and the uterovesical peritoneum is incised. Depending on physician preference, the proximal uterine blood supply is occluded and divided laparoscopically. After the uterovesical peritoneum is incised, the physician may also choose to laparoscopically incise the posterior cul-de-sac. The physician then proceeds vaginally for the remainder of the case, dissecting the vesicovaginal septum anteriorly to enter the anterior cul-de-sac, ligating the uterine vessels, removing the uterus and ovaries (if appropriate), and closing the vaginal cuff.

LH, the second approach, is performed initially like the LAVH, except that the entire hysterectomy is performed laparoscopically. The surgeon would choose indications similar to LAVH but would add lack of uterine descent, which would make the vaginal approach impossible. After the infundibular, uteroovarian, and round ligament are occluded and divided, the bladder is dissected off the uterus anteriorly. The ureter is identified and dissected along its entire course, and the uterine vessels and uterosacral ligaments are then occluded and divided. After the posterior cul-de-sac is incised, the specimen is removed vaginally, and the cuff is closed.

LSH is the third approach, being most often promoted for benign indications. The technique begins again as for the LAVH, but proceeds with separating the entire fundus from the cervix after the proximal vessels are divided and the bladder is dissected away from the uterus. A special instrument is used to core-out or cauterize the endocervix, and the uterus is then removed through a 12-mm port abdominally by morcellation or transcervically with a special morcellator. This approach eliminates vaginal and abdominal incisions, with no need to dissect near the uterine artery or ureter. Proponents of LSH advocate that the operating room and recovery time are decreased and risk of both infection and ureteral injury are minimized. However, an increased risk exists for reoperation for cervical bleeding and prolapse. Furthermore, patients must follow the recommendations for regular cervical cytology.

Oncologic procedures

Laparoscopy has long been used in oncology for second-look procedures following surgical and chemical treatment of malignancy. More recently, laparoscopy has also been used for staging, including peritoneal washes with biopsy, partial omentectomy, and pelvic and periaortic lymphadenectomy. Procedures such as laparoscopically assisted radical vaginal hysterectomy have also been used by some gynecologic oncologists.