CHAPTER 26
Gynecologic Endoscopy
KEY POINTS
1 In gynecology, endoscopes are used most often to diagnose conditions and/or direct
surgical procedures by direct visualization of the peritoneal cavity (laparoscopy) or
the inside of the uterus (hysteroscopy).
2 When used appropriately, endoscopic surgery offers the benefits of reduced
1414procedure-related pain, improved cosmetic result, lower cost, and faster recovery.
3 Endoscopic surgery is a highly technical process. Consequently, surgeons must
thoroughly understand the function and limitations of endoscopic and related
equipment, as well as troubleshooting technical adversity.
4 At the present time, there is no evidence that “robotic” assistance to laparoscopic
surgery has any clinical, cost, or cosmetic advantages over laparoscopic surgery.
Available evidence is that cost is increased while cosmetic results are not as good
based on the location and length of incisions.
5 Laparoscopic gynecologic surgeons should be prepared for the spectrum of
pathologic and anatomical situations that may be encountered, considering bowel,
bladder, ureter, and vascular structures that may be involved.
6 The patient considering laparoscopic surgery should be properly counseled regarding
the potential outcomes, including adverse outcomes, and the risk of conversion to
laparotomy.
7 The initial entry into the abdominal/peritoneal cavity must be considered carefully, as
it can be associated with a large number of the complications encountered during
laparoscopic surgery. The main entry strategies are “open laparoscopy,” often
referred to as the Hasson entry, and “closed” entry, which includes preinsufflation
using a hollow needle, and “direct entry” techniques where the port is passed
through the abdominal wall without prior inflation of the peritoneal cavity.
8 Proper patient selection and intraoperative management are critical for laparoscopic
surgery for ovarian cysts. If malignancy is strongly suspected, laparotomy may be
preferable.
9 Laparoscopic myomectomy usually requires laparoscopic suturing; thus, more
technical skills are needed than with many other endoscopic procedures.
10 Laparoscopic total hysterectomy comprises any removal of the uterus where at least
part of the dissection is accomplished laparoscopically, while the remainder, if any,
is finished vaginally.
11 Dehiscence and hernia risk appear to significantly increase when the fascial incision
created for laparoscopic instrumentation is larger than 10 mm in diameter.
12 The incidence of unintended injuries associated with the use of radiofrequency (RF)
electricity can be reduced with a good understanding of electrosurgical principles.
Surgeons should always be in direct control of electrode activation and all
electrosurgical hand instruments should be removed from the peritoneal cavity when
not in use.
13 Patients recovering from laparoscopic surgery usually feel better every day. Pain
diminishes, gastrointestinal function improves rapidly, and fever is extremely
unusual. Therefore, if a patient’s condition is not improving, possible complications
of anesthesia or surgery should be considered.
14 Hysteroscopy is useful as a diagnostic aid by allowing direct evaluation of the
endometrial cavity. Diagnostic hysteroscopy is superior to hysterosalpingography in
the evaluation of the endometrial cavity, but the diagnostic accuracy of transvaginal
1415ultrasonography is similar, especially when sonographic contrast is injected into the
endometrial cavity.
15 A number of intrauterine procedures can be performed under hysteroscopic
direction, including adhesiolysis, sterilization, transection of a uterine septum,
resection of leiomyomas and polyps, removal of retained products of conception,
and endometrial destruction, usually with RF resection, desiccation, or vaporization.
16 Most diagnostic and operative hysteroscopic procedures can be performed in an
office or procedure room setting with minimal discomfort and at a much lower cost
than in a surgical center or a traditional operating room.
17 The two major risks of hysteroscopic surgery are perforation, with the potential for
damage to surrounding structures such as bowel, bladder, and blood vessels; and the
fluid and electrolyte consequences of systemic overload of the fluid distension
needed to create an operative field.
18 The risks of perforation can be mitigated by careful attention to access technique
and the careful and informed use of intrauterine energy-based systems.
19 Risks of systemic overload of distension media can be minimized with the use of
normal saline as the distending medium, and by careful attention to measurement of
systemic absorption, a process that is best accomplished using automated fluid
management systems.
Endoscopic procedures use a narrow telescope, an “endoscope” to view the
interior of a viscus or preformed space. Although the first medical endoscopic
procedures were performed more than 100 years ago, the potential of this method
has been extended to perform a variety of operations. [1] In gynecology,
endoscopes are used most often to diagnose conditions or direct the performance
of surgical procedures in the peritoneal cavity (laparoscopy) or the inside of the
uterus (hysteroscopy).
[2] When used appropriately, endoscopic surgery offers the benefits of
reduced pain, improved cosmesis, lower cost, and faster recovery. The
indications for endoscopic surgery are outlined here, including the technology,
potential uses, and complications of laparoscopy and hysteroscopy.
[3] Because endoscopic surgery relies so much on technology—distension,
lighting, imaging, energy, mechanical instrumentation—surgeons must
thoroughly understand the function and limitations of endoscopic and related
equipment, and be prepared for troubleshooting technical activity.
LAPAROSCOPY
The past five decades have witnessed rapid progress and technologic advances in
gynecologic laparoscopy. Operative laparoscopy was largely developed in the
1970s, and in the early 1980s, laparoscopy was first used to direct the application
1416of laser or radiofrequency (RF) electrical energy for the treatment of advanced
stages of endometriosis. The use of high-resolution (1), and high definition (HD)
video cameras (2) in operative laparoscopy has made it easier to view the pelvis
during the performance of complex procedures. Most procedures that were
previously performed using traditional laparotomy techniques became
feasible with the laparoscope including adnexal procedures such as ovarian
cystectomy and removal of ectopic pregnancy; uterine surgery, such as
myomectomy and hysterectomy; and pelvic floor reconstructive procedures
such as sacral colposuspension. The endoscopic approach may have drawbacks
for some patients. Although many laparoscopic procedures reduce the cost and
morbidity associated with surgery, others have been replaced by even less
invasive procedures, and a few have not been shown to be effective replacements
for more traditional operations.
[4] The use of microprocessor-assisted laparoscopy permits the surgeon to
operate remote from the operative field, in a sitting position, with the so-called
“robot” allowing translation of natural hand manipulations to the peritoneal cavity
with the specially designed instruments. Evidence suggests that clinical
outcomes with and without microprocessor-assisted (“robotic”) laparoscopy
are similar, but that the costs associated with the use of this device are
greater (3). There is evidence that the cosmetic result—the sum of incision
number, length, and location—is less acceptable to patients than standard
laparoscopy or even small laparotomies (4–6). As a result, for competent
laparoscopic surgeons, use of this device adds nothing to the performance of
laparoscopic gynecologic surgery except cost.
Diagnostic Laparoscopy
The objective lens of a laparoscope can be positioned to allow wide-angle or
magnified views of the peritoneal cavity. The clarity and illumination of the
optics facilitate greater appreciation of fine details than is possible with the
naked eye. For example, laparoscopy is the standard method for the surgical
diagnosis of endometriosis and pelvic adhesions because no other imaging
technique provides the same degree of sensitivity and specificity.
There are limitations to diagnostic laparoscopy. The view of the operative
field may be restricted, and if tissue or fluid becomes attached to the lens,
vision may be obscured. Soft tissues, intramural myomas, or the inside of a
hollow viscus such as the uterus or urinary bladder cannot be visualized or
palpated. For assessment of these tissues, an imaging modality, such as
ultrasonography, computed tomography (CT), or magnetic resonance imaging
(MRI), is superior. Because of its ability to view soft tissue, ultrasonography is
more accurate than laparoscopy for the evaluation of the inside of adnexal masses.
1417The intraluminal contour of the uterus can be shown only by hysteroscopy or
contrast imaging such as contrast hysterosonography, hysterosalpingography
(HSG), or MRI. Transvaginal ultrasonography (TVUS), in combination with
serum assays of β-human chorionic gonadotropin (β-hCG) and progesterone, can
be used to diagnose ectopic pregnancy, usually allowing medical therapy to be
given without laparoscopic confirmation (7). As a result of the advances in
laboratory testing and imaging technology, laparoscopy is more often used to
confirm a clinical impression than for initial diagnosis.
Laparoscopy may disclose abnormalities that are not necessarily related to the
patient’s problem. Although endometriosis, adhesions, leiomyomas, and small
cysts in the ovaries are common, they are frequently asymptomatic. Thus,
diagnostic laparoscopy must be performed prudently, interpreting findings in the
context of the clinical problem and other diagnoses.
Therapeutic (Operative) Laparoscopy
The role of laparoscopy in the operative management of gynecologic conditions
has evolved from a curiosity to the recognized standard of care. Many procedures
previously performed as traditional laparotomic and vaginal operations are readily
performed under laparoscopic direction. Operative laparoscopy has the benefit
of shorter hospital stays, less postoperative pain, and faster return to normal
activity when compared with procedures performed via laparotomy. These
features contribute to a reduction in the “indirect costs” of surgical care including
less time away from work, and a diminished need for post discharge supportive
care in the home (8). In addition to the general benefits of endoscopic procedures,
adhesions are less likely to form with laparoscopic surgery than with laparotomy.
Because sponges are not used, the amount of direct peritoneal trauma is reduced
substantially, and contamination of the peritoneal cavity is minimized. The
reduced exposure to the drying effect of room air allows the peritoneal surface to
remain relatively moist and, therefore, less susceptible to injury and subsequent
adhesion formation.
Despite these advantages, there are potential limitations: exposure of the
operative field can be reduced, small instruments are required that must be used
through fixed ports, and the ability to manipulate the pelvic viscera is often
limited. In some cases, the cost of hospitalization increases, despite a shortened
stay, because of prolonged operating room time and the use of more expensive
surgical equipment and supplies. Efficacy may be reduced if a surgeon cannot
adequately replicate the abdominal operation. In some patients, there is an
increased risk of complications, which can be attributed to the innate limitations
of laparoscopy, the level of surgical expertise, or both. [5] Laparoscopic
gynecologic surgeons should be prepared for the spectrum of pathologic and
1418anatomic situations that may be encountered, considering the bowel, bladder,
ureter, and vascular structures that may be involved. With an adequate
combination of ability, training, and experience, operative time is comparable to
that of traditional abdominal surgical procedures and complications may be
reduced.
Tubal Surgery
Sterilization
Laparoscopic sterilization has been extensively used since the late 1960s and
while it can be performed with local anesthetics, it is usually accomplished under
general anesthesia. The fallopian tubes can be removed (salpingectomy) or
occluded by suture, clips, silastic rings or with RF electrocoagulation, most
commonly with a bipolar electrocoagulation instrument (see Chapter 14).
When an “operative laparoscope” is used, only one incision is required because
the sheath in such a system contains an instrument channel. Otherwise, a second
port is needed for the introduction of the occluding instrument. Should bilateral
salpingectomy be chosen, up to three ports are needed—one for visualization, and
two for manipulation and transection of tissue.
Patients generally remain in the hospital only for a few hours; even when
general anesthesia is used. Postoperative pain is usually minor and related to gas
that remains in the peritoneal cavity (shoulder pain, dyspnea), and in the case of
occlusive devices, pain at the surgical site. These effects normally disappear
within a few days. The failure rate varies by technique but is about 5.4 per 1,000
woman-years (9,10). Bilateral resection of the fallopian tubes has become a
more prevalent technique as a result of some evidence that many
malignancies that were categorized as ovarian cancers arise in the fallopian
tube, and that salpingectomy can reduce the risk of these malignancies (11).
Failure and complication rates are being studied in these patients. The use of
laparoscopic tubal sterilization has been impacted by the availability of office
vasectomy, effective intrauterine contraception, and the development of officebased hysteroscopic sterilization techniques.
Ectopic Gestation
Medical therapy with methotrexate is considered first-line therapy for tubal
pregnancies that, in addition to contraindications to methotrexate use, meet
criteria that may include the following: hemodynamic stability, no cardiac
activity, tubal mass smaller than 4 cm as determined by ultrasonography, and an
acceptably low β-hCG level (12–14). When surgical therapy is required,
ectopic gestation can usually be managed successfully by using laparoscopic
salpingotomy, salpingectomy, or segmental resection of a portion of the
1419oviduct (see Chapter 32) (15,16). Salpingotomy is typically performed with
scissors or a RF needle electrode after carefully injecting the mesosalpinx with a
dilute vasopressin-containing solution (e.g., 20 international units in 100 mL of
normal saline) (Fig. 26-1). For salpingectomy, the vascular pedicles are usually
secured with electrosurgical desiccation/coagulation, but it is also possible using
ligatures or clips. Tissue is usually removed from the peritoneal cavity through
one of the laparoscopic cannulas.
When salpingotomy is performed, regardless of the route, there is
approximately a 5% chance that trophoblastic tissue remains. In such
instances, medical treatment with methotrexate is considered appropriate (see
Chapter 32). Consequently, a-hCG levels should be measured weekly until
there is confidence that complete excision has occurred (17–19).
Ovarian Surgery
Ovarian Masses
Laparoscopic removal of selected ovarian masses is a well-established technique
supported by high-quality evidence (20–22). [8] Proper patient selection is critical
for laparoscopic management of adnexal masses because of the possible adverse
effect of laparoscopic approaches on prognosis with malignant tumors (23,24).
Preoperative ultrasonography is mandatory. Sonolucent lesions with thin walls
and no solid components are at very low risk for malignancy and, therefore, are
suitable for laparoscopic removal. For postmenopausal women, the measurement
of CA125 levels is useful in identifying candidates for laparoscopic management
(25,26). Combining age, menopausal status, an ultrasound score, and the serum
CA125 level into a “Risk of Malignancy Index” may offer an effective means to
identify cysts at high risk for epithelial malignancy (27–29). Lesions with
ultrasonographic findings suggestive of mature teratoma (dermoid),
endometrioma, hemorrhagic, or other cysts presenting with torsion or other
causes of acute pain may be suitable for endoscopic management (30–33).
Ovarian tumors should be assessed by frozen histologic section, and any frank
malignancy should be managed expeditiously by laparotomy (20,24,26).
The technique for performing laparoscopy for oophorectomy and cystectomy is
similar to that used for laparotomy (19). Pelvic washings should always be
collected immediately after entry into the peritoneal cavity and prior to any
surgical dissection. For cystectomy, scissors are used to incise the ovarian
capsule, and blunt dissection or pressurized fluid (aquadissection) are used to
separate the cyst from the ovary. Surgeons should use energy-based techniques
with caution as there is evidence that related damage to the adjacent ovarian
cortex could compromise the patient’s “ovarian reserve” (34,35). If oophorectomy
is performed, the vascular pedicles are occluded and transected, usually with RF
1420electrosurgical coagulation and cutting systems, but in some instances with
sutures, clips, or linear cutting and stapling devices. This is ideally done by
isolating the infundibulopelvic ligament. The ureter should be identified and
should be clear of the pedicle to be transected. Cysts that appear to be benign
may be drained before extraction through a laparoscopic cannula or, less
commonly, a posterior culdotomy. If there is concern about the impact of
spilled cyst contents, the specimen should be removed in a retrieval bag
inserted into the peritoneal cavity through a laparoscopic port. Some authors
describe a minilaparotomy technique, or enlarging one port site incision, to
exteriorize the mass, drain it externally without intraperitoneal spill, remove the
cyst or ovary, and replace the adnexa into the peritoneal cavity (36).
FIGURE 26-1 Laparoscopic salpingotomy for unruptured tubal ectopic pregnancy.
A: Bleeding through the fimbriated end results in a hemoperitoneum; (B) after removing
clot, the left tube is seen distended with blood and gestational tissue (arrow); (C) the left
tube is suspended over the left ovary; (D) dilute vasopressin (20 units in 100 mL of normal
saline) is injected between the leaves of the mesosalpinx. A salpingotomy incision is made
in the proximal portion of the distended tube (E) using a radiofrequency needle electrode.
The ectopic pregnancy is carefully expressed and removed from the fallopian tube (F, G,
1421and H). The post evacuation appearance of the tube is shown (I). The small incision will
heal without the need for sutures.
Although previously the ovary was routinely closed after cystectomy, this
practice is controversial. Some evidence suggests that suture closure could
contribute to the formation of adhesions (37). Other studies, including a RCT,
suggest that suture-based closure of the ovary is associated with fewer adhesions
than using electrodesiccation alone (38).
Other Ovarian Surgeries
Ovarian torsion, previously treated by laparotomy and oophorectomy, more
often can be managed laparoscopically (39,40). Even if there is apparent
necrosis, the adnexa can be untwisted, usually with preservation of normal
ovarian function (32,41). If an ovarian cyst is present, as is typically the case,
cystectomy may be performed after “detorsion” or, if appropriate, deferred to a
later time. Rarely is adnexectomy indicated.
Polycystic ovarian syndrome should be treated medically. In rare instances,
surgical therapy is indicated to reduce ovarian cortical volume, a technique that
can be performed laparoscopically using electrosurgery or laser vaporization to
perform ovarian “drilling.” This procedure reduces the volume of ovarian stromal
tissue and may lead to a temporary return to normal ovulation (42–44). Although
such procedures have been shown to be successful in a number of randomized
trials (45), postoperative adhesions form in 15% to 20% of patients, underscoring
the need to first exhaust medical treatment options (46,47).
Uterine Surgery
Myomectomy
[9] Laparoscopic myomectomy, requires laparoscopically-directed suturing
and, thus, requires more technical skills than many other endoscopic
procedures (Fig. 26-2). In addition the procedure requires the performance of
morcellation so that the fragments of leiomyoma can be removed through the
laparoscopic ports or a small incision. There is high-quality evidence
suggesting that, compared to laparotomy, the laparoscopic approach is
associated with reduced postoperative pain and fever and a shorter
institutional stay (48). While it is possible that microprocessor-assisted
(“robotic”) laparoscopic myomectomy may allow more surgeons to suture
effectively under laparoscopic guidance, in expert hands there appears to be no
benefit to robotic surgery in any measurable perioperative outcome (49,50).
Some controversies regarding the appropriateness of laparoscopic
myomectomy remain, given concerns about the perceived risks associated with
1422intraperitoneal morcellation. There have been questions related to the efficacy of
the approach, especially as it relates to the treatment of infertility and the
symptom of heavy menstrual bleeding (HMB), each of which is thought to be
secondary to submucous myomas.
Morcellation of leiomyomas following removal from the uterus can be
performed via laparotomy or under laparoscopic direction using either
hand-held cutting instruments, or, in the instance of laparoscopic technique,
with an electrosurgical or electromechanical morcellating system that cuts
and extracts the tissue (see Fig. 26-27). Much of the controversy around this
technique relates to the potential impact of morcellation in general, and
electromechanical morcellation in particular, on the prognosis for patients who
have unsuspected leiomyosarcomas. There is no convincing evidence that
morcellation adversely impacts the prognosis for these very malignant tumors
(51). However, for women undergoing myomectomy, the risk of
leiomyosarcoma is extremely low, with a reported incidence ranging from
approximately 4/10,000 (52), to 2/1,000 (53) and for myomectomy there is no
evidence that one method of morcellation is better than the other with
respect to impact on oncologic prognosis (54,55). There is evidence that
leiomyoma cells are already present in the peritoneal cavity prior to morcellation
(56), a finding that would suggest that the disease has already disseminated prior
to myomectomy by any technique (57).
1423FIGURE 26-2 Laparoscopic myomectomy. This patient has a FIGO type 2–5 leiomyoma
(A), and has the symptoms of heavy menstrual bleeding and infertility. An ultrasonic
cutting blade is used to make a transverse incision in the fundus (B), and then the
leiomyoma is dissected out from the myometrium (C). D: Laparoscopic technique is used
to create multiple layers of running suture to close the defect. The leiomyoma is removed
from the peritoneal cavity through a laparoscopic port after morcellation.
Although there are some well-designed studies evaluating infertility outcomes
(Class-1, randomized clinical trials) comparing laparoscopic myomectomy with
laparotomy, the sample sizes are relatively small, and the cases are highly
selected limiting the size and number of the lesions to be removed (58,59).
Nevertheless, fertility outcomes have been shown to be similar with
laparoscopy and laparotomy (59–61). These and other trials evaluating
perioperative outcomes such as duration of admission, surgical pain, and
operative complications demonstrated the laparoscopic approach to be superior
(62).
Proper patient selection for myomectomy, regardless of route, is extremely
important, particularly because, by age 50, the prevalence of leiomyomas
may be as high as 70% in Caucasians and over 80% in women of African
1424ancestry (63). It is relatively easy to mistakenly ascribe symptoms to the presence
of leiomyomas. Unless the myoma is adjacent to the endometrium, it is unlikely
to contribute to HMB or infertility. The impact of intramural myomas on
infertility is not well understood (64). Leiomyomas that cause pressure are often
large and may be located so close to vital vascular structures, that their location
may preclude the laparoscopic approach even in expert hands. Many women will
do well with expectant or medical management, or with procedural alternatives
such as uterine artery embolization. The surgeon should freely select a
laparotomic approach, either at the outset, or during the procedure if technical
limitations put the patient at risk or otherwise compromise the potential relevant
clinical outcomes (65). Patients who have pedunculated or subserosal
leiomyomas that cause bothersome discomfort or pain in association with
torsion are especially good candidates for laparoscopic excision (19,66).
Hysterectomy
[10] Laparoscopic hysterectomy (LH) encompasses a variety of procedures,
including the facilitation of vaginal hysterectomy (VH) with variable extents
of endoscopic dissection, supracervical hysterectomy (SCH) by dissection,
amputation and mechanical removal of the fundus, and the removal of the
entire uterus under laparoscopic direction (67). In most environments, the
procedure is performed with a combination of electrosurgical vessel sealing
devices and mechanical cutting systems, often incorporated into a single
instrument. In some instances, sutures, clips, and linear cutting and stapling
devices are employed in the process of dissecting or occluding vascular pedicles.
When LH was introduced, complications, while lower than for AH, were
higher than in comparison with VH (68). With time, training and experience, this
outcome has changed with complication rates of LH and VH becoming similar,
while remaining lower than for AH (69–71). One study has demonstrated that
hospital readmission rates are even lower with LH compared with all other
techniques, including instances where the da Vinci microprocessor device is used
to assist the laparoscopic procedure (71,72). The procedural costs of LH are
generally greater than either VH or AH (8,73), but it is evident that patients can
be safely discharged within hours of surgery for both VH and LH, an approach
that further reduces the cost of care (74,75). The surgical costs can be
substantially reduced when reusable instruments are employed (76). In addition to
reduced institutional stay, most studies show less postoperative pain, and faster
postoperative recovery with LH than when hysterectomy is performed via
laparotomy (68,77,78). There is evidence that pain scores and quality-of-life
measures, including sexual activity and physical and mental functioning, were
significantly better for women who underwent hysterectomy via laparoscopy
1425versus laparotomy (79). These differences were present at 6 weeks following
surgery and remained at the 12-month follow-up visit. When the societal benefits
of faster return to work or family are considered, the cost of laparoscopic surgery
is less (80).
Selection of the route of hysterectomy must be done considering the
anatomy, the disorder or disease state, the patient’s wishes, and the training
and experience of the surgeon. LH offers no advantage for women in whom
VH is possible, because the endoscopic approach is more expensive and
probably has a higher risk for perioperative morbidity (77). The ideal place
for LH is as a replacement for laparotomy (68,81,82).
There are relatively few remaining indications for laparotomy-based
hysterectomy, an approach, which should be reserved for the minority of
women for whom a laparoscopic or vaginal approach is not appropriate.
These include: (a) patients with medical conditions, such as cardiopulmonary
disease, where the risks of either general anesthesia, or the increased
intraperitoneal pressure associated with laparoscopy are deemed
unacceptable; (b) where morcellation is known to be or likely to be required
and uterine malignancy or hyperplasia is either known or suspected. In
instances where a minimally invasive approach such as LH or VH may be
considered, hysterectomy via laparotomy may be performed for the following
reasons: (a) hysterectomy is indicated but there is no access to the surgeons or
facilities required for VH or LH and referral is not feasible; (b) circumstances
where anatomy is so distorted by uterine disease or adhesions that a vaginal or
laparoscopic approach is not deemed safe or reasonable by individuals with
recognized expertise in either VH or LH techniques (76,79,82). For surgeons
without the skill and training to perform minimally invasive hysterectomy (either
vaginal or laparoscopic), and for benign indications, consideration should be
given for referral to a gynecologist with such training (82).
Infertility Operations
The use of assisted reproductive technology, and, in particular, in vitro
fertilization (IVF) and embryo transfer (ET) have, at least for those with financial
means, replaced the performance of tubal surgery. However, for many, when
infertility occurs secondary to disruption of the normal anatomy or anatomic
relationships by an inflammatory process, laparoscopically directed operations
used to restore anatomy can be successful and include fimbrioplasty,
adhesiolysis, and salpingostomy for distal obstruction (83). Fimbrioplasty is
distinguished from salpingostomy because it is performed in the absence of preexisting complete distal obstruction. Endometriosis associated with adnexal
distortion can be treated by laparoscopic adhesiolysis or resection. Whereas there
1426is no known additional benefit for medical treatment of coexistent active
endometriosis, the evidence relating to ablation of minimal and mild
endometriosis is mixed (84,85) although when subjected to meta-analytic
technique, there is a slight fecundity benefit for those undergoing laparoscopic
ablation (86).
Adhesiolysis may be accomplished by blunt or sharp dissection with scissors,
ultrasonic shears, or an RF electrosurgical electrode. While laser-based
instruments have been used, there is no evidence that they provide any additional
value over less expensive techniques such as electrosurgery (87–89). The
dissecting instruments are usually passed through an ancillary port; when laser
energy is used, the channel of the operating laparoscope may be used for this
purpose. Although there has been controversy regarding the most appropriate
modality for adhesiolysis, these methods are probably equally effective in
appropriately trained hands.
Laparoscopic operations for the treatment of mechanical infertility are probably
equally effective to similar procedures performed by laparotomy. In patients with
extensive adhesions, successful outcomes are unlikely regardless of the approach.
Consequently, assisted reproductive technologies such as IVF and ET are
necessary in these situations (see Chapter 36) (19,83).
Endometriosis
Endometriosis is an enigmatic disorder whereupon the extent of visible disease
frequently is unrelated to the severity of symptoms; frequently it is asymptomatic
with other disorders responsible for the patient’s pain or infertility. The
endometriosis-related inflammation that can occur may create dense adhesions in
the pelvis that involve the uterus, fallopian tubes, ovaries, bladder, ureters (90),
bowel, and in particular the rectum and sigmoid colon (91). As a result, the
incidence of postoperative complications such as fistula are relatively high
(90,92). Consequently, when extensive disease exists, and if removal or
reconstruction is indicated, endometriosis becomes a surgical challenge requiring
surgeons with a training in retroperitoneal dissection to preserve the integrity of
the ureters and bowel, particularly in the cul-de-sac between the rectum and
vagina. In many instances, optimal surgical management involves a
multidisciplinary approach including urologic and colorectal surgeons.
The laparoscopic management of endometriomas parallels that of adnexal
masses, although the complex ultrasonographic features of many endometriomas
sometimes make it difficult to distinguish them preoperatively from a neoplasm
(93). The close attachment of the endometrioma to the ovarian cortex and stroma
may make it difficult to find surgical dissection planes, and incomplete removal
increases the risk of recurrence. In such instances, there may be a tendency either
1427to compromise the function of the remaining ovary by attempting complete
removal or risk recurrence by leaving part of the endometrioma in place. It is
common to find the endometrioma adherent to the posterior uterus, the culde-sac, or the pelvic sidewall (Fig. 26-3). In such cases, the surgeon must
dissect carefully, protecting the ureter and bowel.
A Cochrane review found good evidence that excisional surgery for
endometriomas decreases the recurrence rate of the endometrioma,
decreases the risk for return of pain symptoms, and in women who were
previously subfertile, increases the rate of subsequent spontaneous
pregnancy (94). Consequently, where possible, an excisional approach should be
the goal.
FIGURE 26-3 Removal of left ovarian endometrioma. (A) The endometrioma in the ovary
(O), lateral to the uterus (U) is attached to the pelvic sidewall (arrows) over the left ureter.
(B and C) After careful drainage and careful dissection the remaining ovary is like a shell.
In D the ovary has been sutured closed and the endometrioma removed via a laparoscopic
port (inset).
Multifocal endometriosis may be treated by mechanical excision or ablation,
the latter using coagulation or vaporization with either electrical or laser energy.
With proper use, each energy source creates approximately the same amount of
1428thermal injury (87–89). Endometriosis frequently is deeper than appreciated
initially, making excisional techniques valuable in many instances (19,83,95–97).
Excisional techniques have been demonstrated superior with respect to
postoperative spontaneous pregnancy rates (94) although systematic reviews of
randomized trials are somewhat inconsistent (98).
Endometriosis cases should be performed by a surgeon skilled in the treatment
of endometriosis, whenever possible, in order to adequately treat ovarian and
extraovarian disease thereby minimizing the need for further surgery.
Pelvic Floor Disorders
Laparoscopy can be used to guide procedures to treat pelvic support defects,
including culdoplasty, enterocele repair, vaginal vault suspension,
paravaginal repair, and retropubic cystourethropexy for urinary stress
incontinence.
Retropubic cystourethropexy comprises the use of either suture or mesh to
attach the anterior vagina to Cooper ligaments, located on the posterior aspect of
the symphysis, thereby suspending the proximal urethra in a fashion that treats
urinary stress incontinence. In the last decade, the advent of mesh-based
midurethral slings placed transvaginally largely superseded laparoscopic
retropubic cystourethropexy in the treatment of urinary stress incontinence
because of reduced morbidity and cost, with at least equal or superior results (99–
101). There was published evidence supporting the notion that the laparoscopic
approach is effective when compared with laparotomy, most commonly the Burch
colposuspension (102,103). There has been increased interest in the performance
of laparoscopic retropubic cystourethropexy because of concerns related to the
use of vaginal mesh. Consequently, the laparoscopic Burch colposuspension has,
to some degree, experienced a rebirth (104).
For vaginal vault prolapse, particularly that which occurs following
hysterectomy, the surgical approaches have included a spectrum of techniques
applied either vaginally or abdominally. The laparoscopic technique most
commonly performed is sacrocolpopexy, where the vaginal apex is loosely
attached to the anterior aspect of the sacrum, usually with mesh secured with
suture at either end. There is evidence that the abdominal approaches are
superior to those performed vaginally (105–108) and that the laparoscopic
technique is associated with equivalent anatomic and functional outcomes at 12
months (109), equivalent “cures” at about 3 years (110), with reduced
complications and hospital stay (109,111).
Although apical and anterior compartment defects can be successfully
corrected via laparoscopy, posterior and perineal defects are best visualized
and repaired using vaginal techniques. The laparoscopic treatment of
1429enterocele and vault prolapse may be useful in patients who require abdominal
approaches after failure of a previous vaginal procedure. Because of the
anatomical proximity of the pelvic ureter to the uterosacral ligament and
anterolateral vagina, bilateral ureteral patency should be confirmed
cystoscopically after laparoscopic vaginal vault suspension, enterocele repair,
culdoplasty, cystourethropexy, or paravaginal repair.
Gynecologic Malignancies
For some gynecologic cancers, the role of laparoscopic techniques has been
clearly established, while for others, the precise place for endoscopy in surgical
management is unclear. High-quality evidence was published in the late 20th and
early 21st century supporting the notion that, for endometrial (112–114) and
cervical cancer (115,116) clinical outcomes were preserved while cost and
morbidity were reduced with the use of laparoscopic technique. Because the value
of LH had already been determined, the fundamental issue was the utility of
laparoscopic technique for pelvic lymph node sampling, or pelvic
lymphadenectomy. Later and larger scale studies suggested that women whose
surgeries were facilitated by laparoscopy did as well as those whose surgeries
were via laparotomy (117,118). The literature reports the use of microprocessorassisted laparoscopic surgery, compared with standard laparoscopy, adds to cost
and cosmetic impact without improving clinical outcomes for endometrial
(119,120) or cervical cancer (121–124).
Laparoscopy has been used for “second-look” procedures for ovarian cancer
(125), and is being investigated for the staging and treatment of early ovarian
malignancy (126–129) and for identifying the resectability of ovarian cancer
(130). Microprocessor-based devices that assist the performance of laparoscopy
(e.g., da Vinci system) have been employed to facilitate radical hysterectomy for
cervical cancer and cytoreduction of ovarian cancer (see Chapter 39) (131,132).
Laparoscopy in gynecologic oncology surgery has value without apparent
prognostic compromise in properly selected patients.
Patient Preparation and Communication
[6] The rationale, alternatives, risks, and potential benefits of the selected
procedure, compared with alternative medical and surgical management, should
be explained to the prospective patient. She should know the likely outcome of
expectant management if the procedure was not performed.
The expectations and risks of the laparoscopic procedure, and those of any
other procedures that may be needed, must be explained. It may be helpful to
compare risks and recovery with the same procedure performed via laparotomy.
1430The risks of laparoscopy include those associated with anesthesia, infection,
bleeding, and injury to the abdominal and pelvic viscera. The possibility of
conversion to laparotomy, if a complication should occur, or if the procedure
cannot be completed via laparoscopy, should be discussed. Infection is
uncommon with laparoscopic surgery. For procedures involving extensive
dissection, there is a higher risk for visceral injury than if such dissection is not
necessary. These risks should be clearly presented in a fashion that includes the
possibilities of immediate and delayed recognition of complications, such as
ureter or bowel injury. The patient should be given realistic expectations
regarding postoperative disability. Because pain and visceral dysfunction
normally continue to improve after uncomplicated laparoscopy, the patient should
be instructed to communicate immediately any regression in her recovery. For
most gynecologic laparoscopic surgical procedures, patients can be discharged on
the day of surgery, but the time absent from work or school will depend upon a
number of factors including the nature of the surgery, the postoperative response
of the patient, and the nature of her work. If there is extensive dissection, or if the
surgery lasts longer than 4 hours, hospital admission may be necessary, and the
period of disability may be extended. The university professor undergoing
adnexectomy for an ovarian mass may be back on the job within a few days; the
kindergarten teacher may require 6 weeks or more after a laparoscopic pelvic
floor reconstruction, because lifting may compromise the integrity of the repair.
It has long been the perception that preoperative mechanical bowel preparation
reduces the morbidity of colonic surgery should an injury occur, and improves
visualization and exposure of the operative field at laparoscopy. There is now an
abundance of high-quality evidence demonstrating that preoperative mechanical
bowel preparation does not reduce the morbidity of colonic surgery (133). There
exists high-quality evidence from randomized trials demonstrating that
mechanical bowel preparation does not improve visualization at gynecologic
laparoscopy and may have a number of adverse effects (134–136). Therefore,
gynecologic surgeons should abandon routine preoperative bowel preparation to
improve visualization. In selected instances, such as in severe endometriosis when
cul-de-sac dissection is anticipated, mechanical bowel preparation should be
considered.
Communication with the family or other designated individuals should be
arranged prior to the procedure. The patient should arrange for a friend or family
member to be present to discuss the results of the procedure with the physician
and to drive her home if she is discharged the same day.
Equipment and Technique
To facilitate the discussion of laparoscopic equipment, supplies, and techniques, it
1431is useful to divide procedures into “core competencies,” which are as follows:
1. Patient positioning
2. Operating room organization
3. Peritoneal access
4. Visualization
5. Manipulation of tissue and fluid
6. Cutting, hemostasis, and tissue fastening
7. Tissue extraction
8. Incision management
Patient Positioning
Proper positioning of the patient is essential for patient safety, operator
comfort, and optimal visualization of the pelvic organs. There may be
advantages to positioning the patient while awake to reduce the frequency of
positioning-related complications.
Laparoscopy is performed on an operating table that can be tipped to
create a steep, head-down (Trendelenburg) position that allows the bowel to
move out of the pelvis to facilitate visualization after the cannulas have been
placed. The footrest can be removed or dropped to allow access to the perineum.
The patient is placed in the low lithotomy position, with the legs appropriately
supported in stirrups and the buttocks protruding slightly from the lower edge of
the table (Fig. 26-4). The thighs are usually kept in the neutral position to
preserve the sacroiliac angle, reducing the tendency of bowel to slide into the
peritoneal cavity. The feet should rest flat, and the lateral aspect of the knee
should be protected with padding or a special stirrup to avoid peroneal nerve
injury. The knees should be kept in at least slight flexion to minimize stretching
of the sciatic nerve and to provide more stability in the Trendelenburg position.
The arms are positioned at the patient’s side by adduction and pronation to allow
freedom of movement for the surgeon and to lower the risk for brachial plexus
injury (Fig. 26-5). Care must be exercised to protect the patient’s fingers and
hands from injury when the foot of the table is raised or lowered. After the patient
is properly positioned, the bladder should be emptied with an indwelling catheter
and a uterine manipulator positioned in the endometrial cavity and secured by an
intracavitary balloon or attached to the cervix as appropriate.
1432FIGURE 26-4 Patient positioning: the low lithotomy position. The patient’s buttocks
are positioned so that the perineum is at the edge of the table. The legs are well supported
with stirrups, with the thighs in slight flexion. Too much thigh flexion may impede the
manipulation of laparoscopic instruments while in the Trendelenburg (head-down)
position.
1433FIGURE 26-5 Operating room organization, stylized view. The patient’s arms are at the
sides. The right-handed surgeon stands on the patient’s left. Instruments and equipment are
distributed around the patient within view of the surgeon. For pelvic surgery, the monitor
should be located between the patient’s legs.
Operating Room Organization
The arrangement of instruments and equipment is important for safety and
efficiency. The orientation depends on the operation, the instruments used, and
whether the surgeon is right- or left-handed. An orientation for a right-handed
operator is shown in Figures 26-5 and 26-6.
For pelvic surgery, the ideal circumstance is to have two television monitors,
one positioned above each foot of the patient allowing the surgeon and the
primary assistant the opportunity to view the surgical field without having to turn
their heads (Fig. 26-6). If only one monitor is available, it is typically placed at or
over the foot of the table within the angle formed by the patient’s legs.
The right-handed surgeon usually stands by the patient’s left side, but at an
angle facing the patient’s contralateral foot. The first assistant is in a mirror image
1434position on the right side, and an additional assistant for uterine manipulation, if
present, sits between the patient’s legs. The nurse or technician and instrument
table are typically positioned beside one leg of the patient in a fashion that avoids
obscuring the video monitor(s) on the left or right, depending on surgeon
preference. The insufflator may be placed on the opposite side of the patient, in
front of the surgeon, to allow continuous monitoring of the inflation rate and
intra-abdominal pressure. The energy source (e.g., electrosurgical or ultrasonic
generator) may be placed on the same side as the surgeon to facilitate positioning
of the power cords and foot pedals, although increasingly, foot pedals are not
used, and with battery-powered instruments, cables and remote control units are
unnecessary.
FIGURE 26-6 Operating room organization, photographic view. A: View from the
foot of the table. Note the second assistant positioned between the legs of the patient for
uterine manipulation. B: View from the head of the table.
Peritoneal Access
[7] Before any laparoscopic procedure can be performed, the surgeon must
successfully access the peritoneal cavity. A pneumoperitoneum must be created,
and a primary cannula must be placed to allow introduction of the laparoscope.
This initial entry into the abdominal cavity must be considered carefully, as
it can be associated with a large number of the complications encountered
during laparoscopic surgery (137). Various points on the abdominal wall can be
chosen for the initial entry, although the umbilicus is the most common (Fig. 26-
7).
1435FIGURE 26-7 Laparoscope access sites and vascular anatomy of the anterior
abdominal wall. Location of the vessels that can be traumatized when inserting trocars
into the anterior abdominal wall.
The main entry strategies are “open laparoscopy,” often referred to as Hasson
entry, and “closed” entry, which includes “preinsufflation” using a hollow needle
to inflate the peritoneal cavity prior to positioning of the initial cannula or port,
and “direct entry” techniques where the port is passed through the abdominal wall
without prior inflation of the peritoneal cavity.
1436FIGURE 26-8 Typical insertion sites. In most instances, both the insufflation needle, if
used, and the primary cannula are inserted through the umbilicus. When subumbilical
adhesions are known or suspected, the insufflation needle may be placed through the pouch
of Douglas or in the left upper quadrant after evacuation of the gastric contents with an
orogastric tube. Some systems allow the insufflation needle to function to position a
cannula for a 2 mm laparoscope (Figure 26-16).
1. Access sites
1437The site of initial or primary access is generally through the umbilicus.
However, there are a number of circumstances where this may not be
appropriate or even safe. Such circumstances include pregnancy, the
presence of a very large pelvic mass, or when previous surgery has been
performed in the lower or mid abdomen. In such instances alternate sites
such as the left upper quadrant may be more appropriate (Fig. 26-8).
2. Access techniques
After the location for the initial entry has been determined, the surgeon must
choose the technique with which to enter the abdomen. Laparoscopic entry can be
achieved with the open (Hasson), or closed techniques. While each technique has
its advantages and disadvantages, surgeon training and experience probably plays
a role in minimizing complications and available evidence suggests that, with
respect to risk, there is no overall advantage of one technique over another (137).
Surgeons should be familiar with all techniques but should likely adhere to the
method with which they have the most experience.
The open entry technique, first described by Dr. Harrith Hasson, involves
gaining entry into the peritoneal cavity via a small “minilaparotomy” skin incision
that is typically about 1.5 cm in length (138). Using careful blunt dissection, the
incision is carried down to the fascia which is visualized, grasped, tented-up using
surgical instruments, and sharply incised; the peritoneum, if identified separately,
is carefully opened to enter the peritoneal cavity. The edges of the fascial incision
are tagged with stay sutures, and a cannula of appropriate diameter, fitted with a
conical occluder and a blunt obturator (Hasson system) is inserted through the
facial incision and fixed in position, using either the stay sutures or an integrated
balloon system (Fig. 26-9). After removing the obturator, the laparoscope can be
inserted through the cannula, and when proper intra-abdominal placement is
visually confirmed, the abdomen can be insufflated. The Hasson entry is most
often performed at the umbilicus, but this technique can be used at any
appropriate location on the abdominal wall.
The closed access approaches comprise the one-stage “direct insertion”
technique, and the two-stage approach consists of preinsufflation with a specially
designed hollow needle, which (Fig. 26-10) is followed by insertion of the trocar–
cannula system.
Safe insertion of the insufflation needle (the Veress needle is the reusable
version) mandates that the instrument be maintained in a midline, sagittal
plane while the operator directs the tip between the iliac vessels, anterior to
the sacrum but inferior to the bifurcation of the aorta and the proximal
aspect of the vena cava. Because the sacral promontory is commonly covered
in part by the left common iliac vein, vascular injury may still occur in the
midline below the bifurcation (139).
1438To reduce the risk of retroperitoneal vascular injury while minimizing the
chance of inadvertent preperitoneal insufflation, in women of average or
lower weight, the insufflation needle is directed to the patient’s spine at a 45-
degree angle. In heavy to obese individuals, this angle may be increased
incrementally to nearly 90 degrees, accounting for the increasing thickness of the
abdominal wall and the tendency of the umbilicus to gravitate caudad with
increasing abdominal girth (Fig. 26-11) (140,141). With one hand used to lift the
anterior abdominal wall, the needle’s shaft is held by the tips of the fingers of the
dominant hand and then steadily but purposefully guided into position only far
enough to allow the tip’s entry into the peritoneal cavity.
The tactile and/or auditory feedback created when the needle passes through
the facial and peritoneal layers of the abdominal wall may provide guidance and
help prevent overaggressive insertion attempts. This proprioceptive feedback is
less apparent with disposable needles than with the classic Veress needle. With
the former, the surgeon must listen to the “clicks” as the needle obturator retracts
when it passes through the rectus fascia and the peritoneum. The needle should
never be forced. Regardless of technique, the underlying retroperitoneal vessels
are protected ultimately by limiting the depth of insertion of the insufflation
needle.
1439FIGURE 26-9 Open or minilaparotomic (Hasson) access. This technique requires that a
minilaparotomy be made in or just below the umbilicus. The Hasson system including the
blunt obturator is positioned in the peritoneal cavity using sutures attached to the fascia to
hold the device in place. Alternatively, a balloon around the distal tip of the device can be
used along with the conical occluder to preserve the pneumoperitoneum.
After the needle has been inserted, but before insufflation, the operator
should try to detect whether the insufflation needle has been malpositioned
in the omentum, mesentery, blood vessels, or hollow organs such as the
stomach or bowel. The most direct approach is to use a specially designed
insufflation needle that has an integrated cannula through which a small-diameter
(e.g., 2 mm) laparoscope can be passed to visualize the point of entry (see Fig.
26-16). Otherwise, indirect methods are necessary. The most accurate test of
appropriate needle position is an initial intraperitoneal pressure of less than
8 to 10 mm Hg as measured by the insufflator (142–144). Traditionally, the use
1440of a syringe attached to the insufflation needle has been used to aspirate potential
blood or gastrointestinal contents and there is evidence that this technique has
value in determining visceral or blood vessel placement (143). To facilitate this
examination, a small amount of saline may be injected via the syringe. Tests that
are designed to create negative pressure, such as lifting the abdominal wall to
attempt aspiration of a drop of saline placed over the open, proximal end of the
needle have been demonstrated ineffective (143).
FIGURE 26-10 Insufflation needle. When pressed against tissue such as fascia or
peritoneum, the spring-loaded blunt obturator (inset) is pushed back into the hollow needle,
revealing its sharpened end. When the needle enters the peritoneal cavity, the obturator
springs back into position, reducing the risk of injury to the intra-abdominal contents. The
handle of the hollow needle allows the attachment of a syringe or tubing for insufflation of
the distention gas.
FIGURE 26-11 Umbilicus and weight. Location of the great vessels and their changing
relationship to the umbilicus with increasing patient weight (from left to right). The
1441location of the umbilicus tends to migrate caudally with increasing weight, however, there
is considerable variation—the great vessels may, in some instances lie directly below the
umbilicus.
Intraperitoneal pressure varies with respiration and is slightly higher in obese
patients. Another reassuring sign that has not had adequate evaluation is the loss
of liver “dullness” over the lateral aspect of the right costal margin. However, this
sign may be absent if there are dense adhesions in the area, usually the result of
previous surgery. Symmetric distention is unlikely to occur when the needle is
positioned extraperitoneally. Proper positioning can be shown by lightly
compressing the xiphoid process, which increases the pressure measured by the
insufflator.
The amount of gas transmitted into the peritoneal cavity should depend on
the measured intraperitoneal pressure, not the volume of gas inflated.
Intraperitoneal volume capacity varies significantly between individuals.
Many surgeons prefer to insufflate to 25 to 30 mm Hg for positioning of the
cannulas and there is a body of evidence supporting this approach (142,145).
This level usually provides extra volume and enough counterpressure against the
peritoneum to facilitate introduction of the cannula, potentially reducing the
chance of bowel or posterior abdominal wall and vessel trauma. After placement
of the cannulas, the pressure should be dropped to 10 to 15 mm Hg, which
reduces the risk of subcutaneous insufflation leading to crepitus and
essentially eliminates hypercarbia or decreased venous return of blood to the
heart (142,145,146).
There is little evidence that it is necessary to create a pneumoperitoneum prior
to the insertion of the trocar–cannula system in the absence of pre-existing
abdominal wall adhesions. Therefore, in women with no previous surgery, the
primary puncture can be performed with a trocar–cannula system, which reduces
operating time. This technique is referred to as “direct entry,” which involves the
blind insertion of the primary cannula before insufflating the abdomen.
Regardless of the technique, preinsufflation or direct entry, the first, or primary,
cannula must be of sufficient caliber to permit passage of the laparoscope. The
patient should be in an unaltered supine position during placement of the primary
cannula. After creating an intraumbilical incision, the abdominal wall is elevated
wither using intraperitoneal pressure (20–30 mm Hg), or by affixing Kocher
clamps to the fascia. Both hands can be positioned on the device, using one to
provide counter pressure and control to prevent “overshoot” and resultant injury
to bowel or vessels. The angle of insertion is the same as for the insufflation
needle; adjustments are made according to the patient’s weight and body habitus
(141). The laparoscope should be inserted to confirm proper intraperitoneal
1442placement and then the insufflation gas is allowed to flow.
Access Cannulas
Laparoscopic cannulas (or ports) allow the insertion of laparoscopic instruments
into the peritoneal cavity while maintaining the pressure created by the distending
gas (Figs. 26-12 and 26-13). Cannulas are hollow tubes with a valve or sealing
mechanism at or near the proximal end. The cannula may be fitted with a Luertype port that allows attachment to hollow tubing connected with the CO2
insufflator. Larger-diameter cannulas (8 to 15 mm) may be fitted with adapters or
specialized valves that allow the insertion of smaller-diameter instruments
without loss of intraperitoneal pressure.
The obturator is a longer instrument of slightly smaller diameter that is passed
through the cannula, exposing its tip. Most obturators are called “trocars” because
their tip is designed to penetrate the abdominal wall after the creation of an
appropriately sized skin incision. Many disposable trocar–cannula systems are
designed with a “safety mechanism”—usually a pressure-sensitive spring that
either retracts the trocar or deploys a protective sheath around its tip after passage
through the abdominal wall. None of these protective devices has been shown to
make insertion safer and they all increase the cost of the equipment. Round-tipped
obturators are not designed to penetrate the abdominal wall; they serve to
facilitate passage of a Hasson cannula into the peritoneal cavity (Fig. 26-9). Some
access cannulas require no obturator, relying on a wood-screw design to penetrate
the abdominal wall (Fig. 26-13).
After the initial cannula (either the Hasson or the closed entry cannula) is
successfully placed and the abdomen is insufflated, the surgeon should
survey the peritoneal cavity and place additional cannulas under direct
vision as necessary. If there are adhesions to the anterior abdominal wall in
an area where the surgeon wishes to place a laparoscopic port, adhesiolysis
can be performed to allow safe placement of the cannula.
14431444FIGURE 26-12 Disposable access systems. These instruments are designed for single
use. A 12-mm internal diameter blunt access system is shown in A. The next device (B)
also has a 12-mm internal diameter, but has a deployable blade that is used to cut through
the abdominal wall. A smaller-diameter blunt conical device is shown in C while a sharp
conical access system is presented in D. Both C and D have a 5.5 mm in inside diameter. A
narrow, 2.7-mm diameter cannula is shown in E. The trocar for this system is a long
insufflation needle with a spring deployable obturator.
Ancillary cannulas are necessary to perform most diagnostic and operative
laparoscopic procedures, as they allow the insertion and use of laparoscopic hand
instruments such as scissors, probes, and other manipulating devices. Most
disposable ancillary cannulas are identical to those designed for insertion of the
primary cannula; however, simple cannulas without the so-called “safety
mechanisms” and insufflation ports are generally sufficient (Figs. 26-12 and 26-
13).
Proper positioning of ancillary cannulas depends on the planned procedure, the
nature of the pathologic and associated processes, and a sound knowledge of the
abdominal wall vascular anatomy. For the secondary puncture, the patient may be
tipped head down (Trendelenburg), allowing the abdominal contents to move
away from beneath the incision sites, thus making it unnecessary to lift the
abdominal wall during secondary cannula insertion. Alternatively, the
intraperitoneal pressure may be maintained at 25 to 30 mm Hg to allow insertion
of the secondary cannulas prior to placing the patient in Trendelenburg position.
Ancillary cannulas should always be inserted under direct vision because
injury to bowel or major vessels can occur. Before insertion, the bladder
should be drained with a urethral catheter. The insertion sites depend on the
procedure, the disease, the patient’s body habitus, and the surgeon’s preference.
For diagnostic laparoscopy, the most useful and cosmetically acceptable site for
insertion of an ancillary cannula is in the midline of the lower abdomen, about 2
to 4 cm above the symphysis. The ancillary cannula should not be inserted too
close to the symphysis because it limits the mobility of the ancillary instruments
and access to the cul-de-sac. Laparoscopic cannulas can become dislodged and
slip out of the incision during a procedure. There are a variety of cannulas
designed to reduce slippage that include those with threaded exteriors and
anchoring systems with balloon tips. The surgeon can prevent slippage by
ensuring that the skin incisions are not too large for the cannula.
1445FIGURE 26-13 Reusable access systems. A: A sharp conical device while B represents a
pyramidal-tipped design. C and D (and inset) are images of the so-called EndoTip device
that can be positioned in the abdominal wall by simply twisting or screwing it in without
the requirement of a trocar.
In addition to the suprapubic cannula, placement of bilateral lower–
quadrant cannulas is useful for operative laparoscopy, but the superficial
and inferior epigastric vessels must be located to avoid injury (Fig. 26-7).
Transillumination of the abdominal wall from within permits the identification of
the superficial inferior epigastric vessels in most thin women. The deep inferior
epigastric vessels cannot be identified by this mechanism because of their location
deep to the rectus sheath. The most consistent landmarks are the medial umbilical
ligaments (obliterated umbilical arteries) and the exit point of the round ligament
into the inguinal canal. At the pubic crest, the deep inferior epigastric vessels can
1446often be visualized between the medially located umbilical ligament and the
laterally positioned exit point of the round ligament. The cannula should be
inserted lateral to the vessels if they are visualized. If the vessels cannot be seen
and it is necessary to position the cannula laterally, the device should be placed 3
to 4 cm lateral to the medial umbilical ligament or lateral to the lateral margin of
the rectus abdominis muscle. If the incision is placed too far laterally, it will
endanger the deep circumflex epigastric artery. The risk of injury can be
minimized by placing a 22-gauge spinal needle through the skin at the desired
location, directly observing the entry through the laparoscope. This provides
reassurance that a safe location has been identified and allows visualization of the
peritoneal needle hole, which provides a precise target for inserting the cannula.
Cannulas should be placed at an angle that is perpendicular to the contour of
the abdomen, to ensure that the distance traveled from the skin to the parietal
peritoneum is as short as possible. This will reduce the risk of injuries associated
with insertion, such as those caused by trocars sliding medially during placement
and injuring abdominal wall vessels. A properly angled port will ensure ease of
operation when instruments are being introduced through the cannula. Largediameter devices are more likely to cause injury; therefore, the smallest cannulas
necessary to perform the procedure should be used. Ancillary cannulas should not
be placed too close together because this hinders optimal mobility of the hand
instruments, which compromises access and maneuverability.
The incision must be the appropriate size for the cannula that is being placed. It
must be of adequate length to allow easy insertion of the device through the skin
—a 1-cm long incision is inadequate to allow passage of a 1-cm diameter device.
The outside diameter of a cannula is larger than the inside diameter; allowance
must be made for the thickness of the material used to create the port. In some
instances, this can add two or more millimeters to the device’s outside diameter,
and, therefore, increase the required length of the incision. Conversely, if the
incision made is too large, in addition to the cosmetic impact, the cannula may
slip out during the case, or there may be continuous leakage of the
pneumoperitoneum around the cannula.
1447FIGURE 26-14 Single port access system. Demonstrated is a three-port access system
from Medtronic (inset) and a similar device being used intraoperatively through the
umbilicus with multiple instruments, including the laparoscope.
Single incision laparoscopic surgery refers to a technique where only one
multi-instrument laparoscopic port is used to perform the procedure. The single
incision is usually made at the umbilicus and about 2.5 to 3 cm in length. The
specially designed port is placed in the incision which allows insufflation,
introduction of the laparoscope and two or more additional instruments to permit
completion of the procedure without additional incisions (Fig. 26-14). Pelosi et al.
published the first single incision multiport laparoscopic procedure (147). This
technique has certain limitations, given the limited number of access channels and
the fact that that the laparoscope and operative instruments are introduced parallel
to each other. These issues have been partially addressed with improved
instrumentation, such as steerable laparoscopes and hand instruments. With
specialized training, surgeons have been able to perform certain types of cases
safely and successfully using the single incision technique (148). One drawback
to this method may be an increased risk of postoperative umbilical hernia, likely a
1448result of the larger umbilical incision (149).
Visualization
During endoscopy, the image must be transferred through an optical system to the
eye of the surgeon. Historically, surgeons looked directly through the laparoscope
to view the intra-abdominal contents. Virtually all modern laparoscopy is
performed using video guidance.
Endoscopes
Laparoscopes are more than simple telescopes as they serve a dual purpose—
transmission of light into a dark and closed cavity and obtaining an image of the
operative field. The light is generally transmitted from a cold light source via a
fiberoptic cable to an attachment on the endoscope that passes the light to the
distal end of the telescope via a peripherally arranged array of fiberoptic bundles.
The image is generally obtained by a distally positioned lens and transmitted to
the eyepiece via a series of rod-shaped lenses. The eyepiece can be used to
directly view the peritoneal contents or can serve as a point of attachment for a
digital video camera. Some endoscopes transmit the image by a collection of
densely packed fiberoptic bundles. This approach generally diminishes resolution,
but allows flexibility of the endoscope, which is of great value for small-caliber
telescopes or if the device is designed to be “steerable” with an articulated distal
end. Another concept is to position a digital “chip” on the end of the system,
which functions as a camera, obviating the need to have any lenses or fibers for
transmission of an image. This design is colloquially called “chip-on-a-stick.”
A laparoscope with an integrated straight channel, parallel to the optical axis, is
called an “operating laparoscope” because the channel permits the introduction of
operating instruments. This provides an additional port for the insertion of
instruments and the application of laser energy. However, operative endoscopes
are of relatively larger caliber than standard laparoscopes. They may have smaller
fields of view, thereby presenting increased risks associated with the use of
monopolar electrosurgical instruments. Standard, “viewing only” laparoscopes
permit better visualization at a given diameter.
In general, the wider the diameter of the laparoscope the brighter the image,
because increased light- or wider-diameter lenses result in an improved viewing
experience for the surgeon. Narrow-diameter laparoscopes are associated with
reduced transfer of light into and out of the peritoneal cavity; therefore, they
require a more sensitive camera or a more powerful light source for adequate
illumination. Previously, ideal illumination was provided by 10-mm diagnostic
laparoscopes, but improvements in optics has allowed the 5-mm diameter
laparoscope to become the standard in many operating rooms (Fig. 26-15). Very
1449narrow diameter laparoscopes, 2 mm or less, can provide adequate illumination
for many procedures, and with a reduced cosmetic impact (Fig. 26-16).
FIGURE 26-15 Laparoscopes. Three 0-degree laparoscopes are shown. From top to
bottom, 2-mm, 5-mm and 10-mm diameter.
The viewing angle depicts the relationship of the visual field to the axis of the
endoscope and typically ranges from 0 to 45 degrees to the horizontal (see Fig.
26-50). The zero-degree scope is the standard for gynecologic surgery. However,
the 30-degree angle is invaluable in difficult situations, such as the performance
of laparoscopic sacrocolpopexy, some myomectomies, and hysterectomy in the
presence of large myomas.
Imaging Systems
The video camera is usually attached to the eyepiece of the endoscope where it
captures the image and transmits it to the camera located outside the operative
field, where it is processed, sent to a monitor and, potentially, a recording device
(Fig. 26-17). Laparoscopes without an optical path have been introduced, with the
sensor located on the distal tip of the endoscope, a design that still requires a
remote camera location.
The resolution capability of the monitor should be equal to that provided by the
camera. Most monitors can display at least 800 horizontal lines of resolution,
while HD systems generally possess 1,080 lines and “4-K” devices can resolve up
to 2,160 lines.
The more light transmitted through the endoscope, the better the visualization.
The best available output is achieved from 250 to 300 watts, usually using xenon
or metal halide bulbs. Most camera systems are integrated with the light source to
vary light output automatically, depending on the amount of exposure required.
1450Light guides or cables transmit light from the source to the endoscope via a
bundle of densely packed optical fibers (fiberoptic). Fiberoptic cables lose
function over time, particularly if mishandling breaks the fibers.
FIGURE 26-16 “Scout” laparoscope. The 2-mm laparoscope is passed through the 2.7-
mm access system from Figure 26-12E. The tubing is connected to inflow gas, usually
carbon dioxide.
Creation of a Working Space
The peritoneal cavity is a potential space, making it necessary to fill it with a gas,
typically CO2, to create a working environment. Other approaches are being
explored using mechanical lifting systems that allow room air into the peritoneal
cavity (150,151), a process called “gasless” laparoscopy.
To create a pneumoperitoneum, CO2 is instilled into the peritoneal cavity under
pressure by a machine called an insufflator. The insufflator delivers the CO2 from
a gas cylinder to the patient through tubing connected to a Luer adaptor on one of
the laparoscopic cannulas. Most insufflators can be set to maintain a
predetermined intra-abdominal pressure. High flow rates (9 to 20 L/min) are
especially useful for maintaining exposure when suction of smoke or fluid
depletes the volume of intraperitoneal gas.
Intraperitoneal retractors attached to a pneumatic or mechanical lifting system
can be used to create an intraperitoneal space much like a tent (150). This
“gasless” or “isobaric” technique may have some advantages over
pneumoperitoneum, particularly in patients with cardiopulmonary disease (152)
or with a potential malignancy. Airtight cannulas are not necessary, and
instruments do not need to have a uniform, narrow, cylindrical shape.
Consequently, some conventional instruments may be used directly through the
incisions. Despite being introduced more than 20 years ago, and with evidence of
efficacy (153), gasless laparoscopy has not experienced much of an uptake in
gynecology, possibly because of perceived difficulties attaining adequate
1451exposure.
FIGURE 26-17 Laparoscopic “tower” and camera. While many operating rooms now
integrate their controllers, light sources, suction irrigation systems, and video monitors into
floating platforms, for others the “tower” remains a useful method for positioning and
storing the equipment. Here the monitor is on the top, the camera base next, then the light
source and image printer. A camera sensor and coupler are shown; the coupler attaches the
camera to the eyepiece of the endoscope.
1452FIGURE 26-18 Uterine manipulators. The manipulator is useful not only to provide
access to different aspects of the uterus, but for exposing the adnexa and the cul-de-sac.
The manipulator at the top is called the Rumi® (CooperSurgical, Trumbull, CT, USA). It
has a vaginal “cup” to help delineate the vagina, particularly useful for hysterectomy, and
an occluding balloon that allows maintenance of pneumoperitoneum when a culdotomy is
created. The manipulator on the bottom is the Valtchev® (Conkin Surgical Instruments
Ltd, Vancouver, BC, Canada), and is entirely reusable. Note the articulation point that, in
this case, is creating maximal anteversion of the uterus.
Manipulation of Tissue and Fluid
Uterine Manipulators
Uterine manipulation is an important component of the exposure strategy for
most pelvic procedures, especially for myomectomy and hysterectomy. A
properly designed uterine manipulator should have an intrauterine component, or
obturator, and a method for fixation of the device to the uterus. Articulation of the
instrument permits acute anteversion or retroversion, both of which are extremely
useful maneuvers. If the uterus is large, longer and wider obturators are used so
that the manipulations can be performed more effectively. Two types of uterine
manipulators are shown in Figure 26-18. A hollow channel attached to a port
allows intraoperative instillation of liquid dye to aid in the identification of the
endometrial cavity (during myomectomy) or to demonstrate tubal patency.
Grasping Forceps
1453The forceps used during laparoscopy should, to the extent possible, replicate
those used in open surgery. Disposable instruments generally do not have the
quality, strength, and precision of reusable forceps (Fig. 26-19). Instruments with
teeth (toothed forceps) are necessary to securely grasp the peritoneum or the edge
of an ovary for removal of an ovarian cyst. Minimally traumatic instruments
designed like Babcock clamps are needed to safely retract the fallopian tube.
Tenaculum-like instruments are desirable to retract leiomyomas or the uterus. A
ratchet is useful to hold tissue without arduous hand pressure. Graspers should be
insulated if unipolar RF instruments are being used to attain hemostasis.
FIGURE 26-19 Laparoscopic instruments for grasping and manipulating tissue. A:
(top and inset) are 5-mm diameter graspers with a curved tip, often called “Maryland”
graspers. Other reusable tips (B) and (C) may be positioned in the same handle as is shown
for A. D: is a 10-mm claw grasper while (E) and (F) are 5- and 2-mm manipulating probes
respectively. G: is a 2-mm grasping forceps.
Suction and Irrigation
Devices called “suction-irrigators” can be used to introduce irrigation fluid into
the abdomen, and suction it away as needed. A high-pressure mechanical pump
allows the fluid to be introduced for irrigation, or for hydro- or “aquadissection.”
The device is attached to a wall suction and can be used to clear away any fluid as
needed. The cannulas used for suction and irrigation depend on the irrigation fluid
used and the fluid being removed. For ruptured ectopic gestations or other
procedures in which there is a large amount of blood and clots, large-diameter
1454cannulas (7 to 10 mm) are preferred. Cannulas with narrow tips are more effective
in generating the high pressure needed for hydrodissection. Isotonic fluids should
generally be used to minimize the risk of fluid overload and electrolyte
imbalance. There is evidence that normal saline is more likely to induce oxidative
stress and reduce fibrinolytic activity (154,155), and, perhaps, increase the risk of
adhesion formation (156), a circumstance that makes Ringer’s lactate a more
appropriate solution (157).
Hemostasis, Cutting, and Tissue Fixation
Hemostasis can be achieved during laparoscopic surgery using energy sources,
sutures, clips, linear staplers, and topical or injectable substances. Cutting can be
managed by mechanical means or by using electrical, ultrasonic, laser, or RF
energy. Secure apposition or tissue fixation may be accomplished with sutures,
clips, or staples. With appropriate training, a skilled surgeon can obtain good
results with any combination of these techniques for cutting, hemostasis, and
tissue fixation. Studies in animals have not demonstrated any difference in injury
characteristics when cutting is performed with either laser or RF energy (87–89)
and randomized controlled studies have shown no differences in fertility
outcomes (158). Differences in results are more likely to be caused by other
factors, such as patient selection, extent of disease, and degree of surgical
expertise. Consequently, it is difficult to justify the costs associated with using
lasers during laparoscopic gynecologic surgery.
Hemostasis
Because of the visual, tactile, and mechanical limitations of laparoscopy,
prevention of bleeding is important for the conduct of efficient, effective, and safe
procedures. RF electricity is the least expensive and most versatile method for
achieving hemostasis during laparoscopy and can be applied with either
monopolar or bipolar instruments.
The current for performing electrosurgical techniques is provided by a device
that converts the alternating polarity circuit from a wall source from a frequency
of 60 Hz to one in the RF spectrum typically from 300 to 500 KHz (300–500,000
Hz). These devices, some of which are proprietary, can be simple or complex,
providing power for monopolar and bipolar instrument (Fig. 26-20).
Regardless of the type of system, the process of electrical desiccation and
coagulation is best achieved by contacting the tissue and activating the
electrode using continuous low-voltage or “cutting” current. With adequate
power, typically 30 to 50 watts (depending, in part on the surface area of the
electrode[s]), tissue will be heated, desiccated, and coagulated. Blood vessels
should be compressed with the blades of the forceps before the electrode is
1455activated so that the “heat sink” effect of flowing blood is eliminated. This
allows the opposing walls of the vessel to bond, forming a strong tissue seal in
a process called coaptive coagulation. Bipolar devices can be fitted with a serial
ammeter that measures the current flowing through the system. When the tissue
between the blades of the forceps is completely desiccated, the device is no longer
able to conduct electricity, which can trigger a visual or auditory cue for the
surgeon. With generic devices, the surgeon can reduce lateral thermal spread of
RF energy by manually pulsing delivery or by simultaneously running irrigation
fluid over the pedicle.
FIGURE 26-20 RF Electrosurgical generator. Displayed is the Medtronic Valleylab™
FT10 Energy Platform (Medtronic Inc., Minneapolis, MN, USA), a radiofrequency
electrosurgical generator designed to be used with a spectrum of monopolar, bipolar, and
proprietary bipolar instruments. The device is capable of outputting high-voltage
(“coagulation”) and low-voltage (“cut”) waveforms for monopolar instruments as well as a
low-voltage waveform for bipolar instruments.
1456FIGURE 26-21 Reusable bipolar system. The Karl Storz RoBi™ (Karl Storz Endoscopy
Americas, Culver City, CA, USA), system comprises a reusable device with changeable
cutting and dissecting/coagulating tips displayed on the right. A coagulating tip is seen in
the inset.
Generic bipolar devices are generally reusable, and some have changeable tips
to use in different situations (Fig. 26-21). Automated RF systems comprise
proprietary generators that pulse energy and generally proprietary bipolar forceps,
often with included mechanical blades designed to cut tissues following
coagulation of the tissue (Fig. 26-22). These systems are usually designed such
that the generator stops automatically when current is no longer being conducted
by the tissue between the blades of the forceps or when the tissue uniformly
reaches a temperature predetermined to indicate tissue desiccation and
coagulation.
Control of superficial bleeding can be achieved with fulguration, the nearcontact spraying of tissue with modulated, high-voltage RF waveforms from the
“coagulation” side of the electrosurgical generator using a monopolar instrument.
Care must be taken to perform laparoscopic fulguration safely, ensuring that the
entire shaft of the laparoscopic instrument is well away from bowel.
1457FIGURE 26-22 Laparoscopic hybrid cutting and sealing devices. (A) Ethicon
Endosurgery’s Harmonic Ace®+7 (Ethicon Endosurgery Inc, Cincinnati, OH, USA) LCS
and (B) the Medtronic LigaSure™ Maryland. These two devices both cut and coagulate or
seal tissue. The ligating cutting shears (LCS) are based on ultrasound technology. The
bottom blade oscillates while the top jaw is opened to grasp the tissue and then used by the
surgeon to slowly transect and seal the blood vessels in the tissue being transected. The RF
bipolar radiofrequency device (B) is the Medtronic 1737 Maryland device that, using
electrical impedance, tells the surgeon when the tissue is coagulated. Tissue is transected
using a mechanical blade activated by a hand-controlled trigger.
1458FIGURE 26-23 Laparoscopic suturing instruments. 3-mm and 5-mm diameter
laparoscopic needle drivers are displayed in A and C while a knot manipulator is shown in
B and inset left. The device is shown transferring a knot into the peritoneal cavity (inset
right).
Ultrasonic instruments can be used for hemostasis. Those with a forceps-like
end effector disperse the mechanical energy in a way that allows the tissue to be
heated and coagulated. These so called “ligating-cutting” shears also cut when
high pressure is exerted in the handle by the surgeon (Fig. 26-22).
Hemostatic clips may be applied with specially designed laparoscopic
instruments. Nonabsorbable clips made of titanium are useful for relatively
narrow vessels, and longer, delayed absorbable, self-retaining clips are generally
preferred for larger vessels, 3 to 4 mm or more. Clips may be of particular value
when securing relatively large vessels near an important structure such as the
ureter.
Laparoscopic suturing is a method of maintaining hemostasis (159–161).
Compared with clips or linear staplers, suturing has a relatively low cost of
materials, although operating time may be longer. The two basic methods for
securing a ligature around a blood vessel are the creation of intracorporeal and
extracorporeal knots, depending on where the knot is formed. Intracorporeal knots
replicate the standard instrument-tied knot and are formed within the peritoneal
1459cavity. Extracorporeal knots are created outside the abdomen under direct vision
and transferred into the peritoneal cavity by knot manipulators (see Fig. 26-23).
Pretied knotted suture loops attached to long introducers, called “Endoloops®,”
may be used to secure vascular pedicles. However, care should be taken to make
sure that they are tightly secured and that no other tissue is incorporated in the
loop. A number of devices that facilitate the formation and tying of knots are
available. Various barbed sutures that facilitate laparoscopic suturing by
eliminating the need to tie knots are commercially available. The suture contains
small barbs along its length that fix the suture in place within the tissue. This is
particularly helpful in procedures that require a great deal of suturing, such as
laparoscopic myomectomy.
Small areas of low-volume bleeding can be treated with topical hemostatic
agents. Topical agents such as microfibrillar collagen are available in 5-mm and
10-mm diameter laparoscopic applicators. Fibrin sealants (e.g., Tisseel®) and
bovine thrombin and gelatin (Floseal®) can be used. A solution of dilute
vasopressin may be injected locally to maintain hemostasis for myomectomy or
removal of ectopic pregnancy.
Cutting
The most useful cutting instruments are scissors (Fig. 26-24). Because it is
difficult to sharpen laparoscopic scissors, most surgeons prefer disposable
instruments that can be used until dull and then discarded. Scissors are ideal for
cutting avascular tissue, or in situations such as adhesiolysis near vital structures
where thermal energy must be avoided.
Often surgeons need to coagulate a vascular pedicle by sealing the blood
vessels, and separate the pedicle by cutting the coagulated area. In this situation,
the target tissue can be coagulated using a bipolar instrument, and divided using
scissors. Devices that initially coagulate the tissue, then mechanically divide it,
have become prevalent, and provide a more efficient option to achieve the same
goal.
Another mechanical cutting tool is the linear stapler–cutter that can
simultaneously cut and hemostatically staple the edges of the incision. These
devices are of limited utility in gynecologic laparoscopy because of their high
cost, the large dimensions of the instruments, and inability of the staples to secure
the large pedicles that exist in the pelvis.
Laser and electrical sources of energy manifest their effect by conversion of
electromagnetic energy to mechanical energy, which is transformed to thermal
energy. Highly focused RF electrical current (high-power or current density),
generated by a specially designed electrosurgical generator produces vaporization
1460or cutting, by raising the intracellular temperature above 100°C resulting in the
rapid conversion of water to steam and a massive increase in intracellular volume.
This expansion ruptures the already damaged cell membrane resulting in cellular
and tissue vaporization into a cloud of steam, ions, and protein particles. If the
instrument used to focus the energy is moved in a linear fashion, the result is
tissue transection or cutting. Less focused RF energy (moderate current or power
density) elevates intracellular temperature, causing desiccation, rupture of
hydrogen bonds, and resulting tissue coagulation, but vaporization does not occur.
FIGURE 26-24 Laparoscopic mechanical cutting instruments. Demonstrated is a
laparoscopic hand instrument with a handle (A), shaft (B), and detachable tips (C). The
scissor tips are demonstrated in short straight (D), long curved (E), and hooked (F)
designs.
Monopolar electrosurgical instruments that are narrow or pointed are capable
of generating the high-power densities necessary to vaporize or cut tissue (Fig.
26-25). Continuous or modulated and relatively low-voltage outputs are generally
the most effective; for example, 60 watts of ‘pure cutting’ current. For optimal
results, the instrument should be used in a noncontact fashion, following (not
leading) the energy through the tissue. Laparoscopic scissors are generally of
monopolar instruments and are designed to cut mechanically; energy may be
applied simultaneously for desiccation and hemostasis when cutting tissue that
contains small blood vessels (Fig. 26-23).
Laser energy can be focused to vaporize and cut tissue. The most efficient
laser-based cutting instrument is the CO2 laser, which has the drawback of
1461requiring linear transmission because light cannot be conducted effectively along
bendable fibers. The potassium-titanyl-phosphate (KTP) and neodymium:yttrium,
aluminum, garnet (Nd:YAG) lasers are effective cutting tools. They are capable
of propagating energy along bendable quartz fibers but have a slightly greater
degree of collateral thermal injury than RF electrical or CO2 laser energy.
Because of such limitations and their additional expense, these lasers are of
limited value.
FIGURE 26-25 Laparoscopic monopolar RF cutting instruments. Shown are a
monopolar laparoscopic probe with a hook electrode and four electrodes designed to
focally vaporize and/or transect tissue. The needle electrode is seen in A, an L electrode in
B, a spatula in C and a hook electrode is demonstrated by D.
Ultrasonic cutting is largely accomplished mechanically using a blade that
oscillates back and forth in a linear fashion (Fig. 26-22). The oscillation is
achieved using a vibrating element located in a handle that oscillates the
blade, hook, or one arm of the clamp 55,000 times per second (55 kHz). The
distance of the oscillation can be varied and determines the efficiency of the
cutting process. The tip of the device cuts mechanically, but there is a degree
of collateral thermal tissue coagulation injury that can be used for
hemostasis. In low-density tissue, the process of mechanical cutting is
augmented by the process of cavitation, in which reduction of local
atmospheric pressure allows vaporization of intracellular water at body
temperature.
Tissue Extraction
1462After excising tissue, it is necessary to remove it from the peritoneal cavity. Small
samples can be pulled through an appropriate-sized cannula with grasping
forceps; however, larger specimens may not fit. If the specimen is cystic, it may
be drained by a needle or incised, shrinking it to a size suitable for removal
through the cannula or one of the small laparoscopic incisions. It is often helpful
to place specimens in endoscopic retrieval bags for removal, which help contain
the specimen and facilitate its removal from the abdominal cavity in its entirety
(Fig. 26-26). If there is any concern for malignancy in an ovarian cyst, all
attempts should be made to keep the cyst intact during dissection, and to
place the specimen in an appropriately sized bag before drainage and
removal, thus preventing spillage of the cyst contents within the abdomen.
FIGURE 26-26 Specimen removal bag. This 10-mm diameter system is positioned in the
peritoneal cavity. Then, the bag is deployed (insets), allowing the surgeon to place
specimens for removal, generally through the port or cannula.
More solid tissue, such as leiomyomas or the entire uterus, may be broken up
1463or “morcellated” into smaller pieces for removal. This may be achieved manually
or laparoscopically and can be performed with or without containment in a
specimen bag.
Manual morcellation refers to the simple process of bringing the excised intraabdominal specimen up to any opening where it can be reached by the surgeon,
and cut into small pieces using scissors or a scalpel, to allow it to be removed.
When performing total LH for a large uterus, the vaginal opening can be used to
access the specimen for manual morcellation. Some surgeons opt to perform this
procedure after placing the uterus into a large specimen bag in order to contain it.
In cases of laparoscopic SCH and myomectomy, there is no vaginal incision.
Therefore, manual morcellation can be performed using a minilaparotomy, often
created by enlarging the umbilical laparoscopic incision to about 3 cm.
Alternatively, an incision can be made in the posterior cul-de-sac (posterior
colpotomy) to provide access, an approach that has the advantage of being more
cosmetically acceptable.
Laparoscopic morcellation can be achieved with scissors, ultrasonic equipment,
or electrosurgery, but the most efficient technique for laparoscopic morcellation
of large solid specimens is the use of electromechanical morcellators. Often
referred to as “power morcellators,” these devices utilize a rapidly rotating blade
that can quickly core and remove large solid specimens from the abdomen (Fig.
26-27).
Concerns have been raised about electromechanical morcellators, based upon
the notion that their use may disseminate tumor cells in cases where an
undiagnosed uterine malignancy is present. Studies show that among women
undergoing hysterectomy or myomectomy for presumed benign leiomyomas, the
prevalence of occult malignancy, or undiagnosed uterine sarcoma, is
approximately 1 in 500 to 2,500 (162–164). Morcellation of a uterine sarcoma
may worsen the patient’s prognosis, although data supporting this notion are
limited. Consequently, the FDA issued a warning statement regarding the use of
electromechanical morcellation (165). This led many surgeons to limit their use of
these devices. Most experts in the field believe that electromechanical
morcellation still has a role in gynecologic surgery, allowing us to provide
minimally invasive surgical options to women with large benign tumors (166).
Various products have been developed to allow electromechanical morcellation
to be performed within a contained system using a large specimen bag positioned
in the abdomen. These techniques are still being refined, and it is not yet clear if
this approach will improve the prognosis for a patient with an inadvertently
morcellated malignancy.
Although our ability to preoperatively distinguish benign myomas from
malignant sarcomas is limited, surgeons must evaluate each patient based on risk
1464factors and appropriately select low-risk patients as candidates for morcellation.
With appropriate patient selection and a thorough informed consent process,
women at low risk for cancer can continue to benefit from electromechanical
morcellation.
Incision Management
[11] Dehiscence and hernia risk appear to significantly increase when the
fascial incision is larger than 10 mm in diameter (167,168). Closure of the
fascia can be performed using special ligature carriers used to position suture
under direct laparoscopic vision to prevent the accidental incorporation of bowel
into the incisions. An alternative is the use of 5/8 round needles and standard
needle drivers. In either instance, the peritoneum should be closed to reduce the
risk of Richter hernia.
FIGURE 26-27 Solid tissue morcellators. RF based (A) and electromechanical (B).
These devices are positioned in the peritoneal cavity and attached to a power generator.
The blunt obturator is removed; a grasping instrument inserted through the lumen is used
to withdraw the tissue, which is cut by a cylindrical blade (C and D).
1465Complications
[13] Patients recovering from laparoscopic surgery usually feel better every
postoperative day. Pain diminishes, gastrointestinal function improves rapidly,
and fever is extremely unusual. Therefore, if a patient’s condition is not
improving, possible complications of anesthesia or surgery should be considered.
Laparoscopic procedures can be complicated by infections, trauma, hemorrhage,
or by problems associated with anesthetic use. The incidence of infection is lower
than with procedures performed by laparotomy. Conversely, problems associated
with visualization in conjunction with the change in anatomic perspective may
increase the risk of damage to blood vessels or vital structures such as the bowel,
ureter, or bladder.
Anesthetic and Cardiopulmonary Complications
Laparoscopic surgery is generally safe. A review of laparoscopic tubal
sterilization in 9,475 women found no deaths from complications of anesthesia
(169,170). However, the potential risks of general anesthesia include
hypoventilation, esophageal intubation, gastroesophageal reflux, bronchospasm,
hypotension, narcotic overdose, cardiac arrhythmias, and cardiac arrest.
These risks can be enhanced by some of the inherent features of gynecologic
laparoscopy. For example, the Trendelenburg position, in combination with the
increased intraperitoneal pressure provided by pneumoperitoneum, places greater
pressure on the diaphragm, increasing the risk of hypoventilation, hypercarbia,
and metabolic acidosis. This position, combined with anesthetic agents that relax
the esophageal sphincter, promotes regurgitation of gastric content, which can
lead to aspiration, bronchospasm, pneumonitis, and pneumonia. Parameters of
cardiopulmonary function associated with CO2 and N2O insufflation include
reduced PO2, O2 saturation, tidal volume, and minute ventilation and increased
respiratory rate. The use of intraperitoneal CO2 as a distention medium is
associated with an increase in PCO2 and a decrease in pH. Elevation of the
diaphragm may be associated with basilar atelectasis, resulting in right-to-left
shunt and ventilation–perfusion mismatch (171). All of these effects are
manageable and reversible, with contemporary anesthetic techniques (172).
Carbon Dioxide Embolus
Carbon dioxide is the most widely used peritoneal distention medium, largely
because the rapid absorption of CO2 in blood reduces the significance of gas
emboli. However, if large amounts of CO2 gain access to the central venous
circulation, if peripheral vasoconstriction occurs, or if the splanchnic blood flow
is decreased by excessively high intraperitoneal pressure, severe cardiorespiratory
1466compromise may result.
The signs of CO2 embolus include sudden and otherwise unexplained
hypotension, cardiac arrhythmia, cyanosis, and heart murmurs. The end-tidal
CO2 level may increase, and findings consistent with pulmonary edema may
manifest (173). Accelerating pulmonary hypertension may occur, resulting in
right-sided heart failure.
Because gas embolism may result from direct intravascular injection
through an insufflation needle, the proper placement of the insufflation
needle, if used, must be ensured. Although the initial intraperitoneal pressure
may be set at 20 to 30 mm Hg for port placement, it should be maintained at 8 to
12 mm for the rest of the case (174). The risk of CO2 embolus is reduced by
careful hemostasis because open venous channels are the portal of entry for gas
into the systemic circulation. The anesthesiologist should continuously monitor
the patient’s color, blood pressure, heart sounds, heartbeat, and end-tidal CO2 to
allow early recognition of the signs of CO2 embolus.
If CO2 embolus is suspected or diagnosed, the surgeon must evacuate the
CO2 from the peritoneal cavity and place the patient in the left lateral
decubitus position, with the head below the level of the right atrium. A largebore central venous line should be inserted immediately to allow aspiration of gas
from the heart. Because the findings are nonspecific, the patient should be
evaluated for other causes of cardiovascular collapse.
Cardiovascular Complications
Cardiac arrhythmias occur relatively frequently during laparoscopic surgery
and are related to a number of factors, the most significant of which are
hypercarbia and acidemia. Early reports of laparoscopy-associated arrhythmia
were associated with spontaneous respiration; therefore, most anesthesiologists
have adopted the practice of mechanical ventilation during laparoscopic surgery.
The incidence of hypercarbia is reduced by operating with intraperitoneal
pressures at levels less than 12 mm Hg (175).
The risk of cardiac arrhythmia may be reduced by using NO2 as a distending
medium. Although NO2 is associated with a decreased incidence of arrhythmia, it
is insoluble in blood and, therefore, its use may increase the risk of gas embolus.
External lifting systems (gasless laparoscopy) avoid the complication of
hypercarbia and can provide protection against cardiac arrhythmia (176).
Hypotension can occur because of decreased venous return secondary to
very high intraperitoneal pressure, and this condition may be potentiated by
volume depletion. Vagal discharge may occur in response to increased
1467intraperitoneal pressure, which can cause hypotension secondary to cardiac
arrhythmias (176). All of these side effects should be considered when
performing surgery on patients with pre-existing cardiovascular disease.
Gastric Reflux
Gastric regurgitation and aspiration can occur during laparoscopic surgery,
especially in patients with obesity, gastroparesis, hiatal hernia, or gastric
outlet obstruction. In these patients, the airway must be maintained with a
cuffed endotracheal tube, and the stomach must be decompressed (e.g., with
a nasogastric tube). The lowest necessary intraperitoneal pressure should be
used to minimize the risk of aspiration. Patients should be moved out of the
Trendelenburg position before being extubated. Routine preoperative
administration of metoclopramide, H2-blocking agents, and nonparticulate
antacids reduces the risk of aspiration.
Extraperitoneal Insufflation
The most common causes of extraperitoneal insufflation are preperitoneal
placement of the insufflating needle and leakage of CO2 around the cannula sites.
Although this condition is usually mild and limited to the abdominal wall,
subcutaneous emphysema can become extensive, involving the extremities, the
neck, and the mediastinum. Another relatively common site for emphysema is the
omentum or mesentery, a circumstance that may be mistaken for preperitoneal
insufflation.
Subcutaneous emphysema may be identified by the palpation of crepitus,
usually in the abdominal wall. Emphysema can extend along contiguous fascial
plains to the neck, where it can be visualized directly. Such a finding may reflect
mediastinal emphysema, which may indicate impending cardiovascular collapse
(177–180).
The risk of subcutaneous emphysema is reduced by the proper positioning
of the insufflation needle and by maintaining a low intraperitoneal pressure
after placement of the desired cannulas. Other approaches that reduce the
chance of subcutaneous emphysema include open laparoscopy and the use of
abdominal wall lifting systems that make gas unnecessary.
If the insufflation has occurred extraperitoneally, the laparoscope can be
removed and the procedure can be repeated. Difficulty may ensue because of the
altered anterior peritoneum. Open laparoscopy or the use of an alternate site, such
as the left upper quadrant, should be considered. One approach is to leave the
laparoscope in the expanded preperitoneal space while the insufflation needle is
reinserted under direct vision through the peritoneal membrane caudad to the tip
of the laparoscope (181).
1468In mild cases of subcutaneous emphysema, the findings quickly resolve after
evacuation of the pneumoperitoneum, and no specific intraoperative or
postoperative therapy is required. When the extravasation extends to the neck, it
is usually preferable to terminate the procedure because pneumomediastinum,
pneumothorax, hypercarbia, and cardiovascular collapse may result. Following
termination of the procedure, it is prudent to obtain a chest x-ray. The patient’s
condition should be managed expectantly unless a tension pneumothorax results,
in which case immediate evacuation must be performed using a chest tube or a
wide-bore needle (14 to 16 gauge) inserted in the second intercostal space in the
midclavicular line.
Electrosurgical Complications
The incidence of unintended injuries associated with the use of RF electricity can
be reduced with a good understanding of electrosurgical principles.
RF electrosurgery is performed using two electrodes, connected to an
electrosurgical generator. With monopolar instrumentation, one of the electrodes
is used to focus the energy and create one of the electrosurgical effects
(vaporization/cutting or desiccation/coagulation), while the other is a large area
device attached to the patient remotely to diffuse the current (see Fig. 26-29).
Complications of RF electrosurgery occur secondary to thermal injury from
unintended or inappropriate use of the active electrode(s) or, for monopolar
instrumentation, current diversion to an undesirable path, or injury at the site of
the dispersive electrode. Such complications may occur with the use of these
instruments during laparoscopic, laparotomic, or vaginal surgery. Active electrode
injury can occur with either unipolar or bipolar instruments, whereas trauma
secondary to current diversion and dispersive electrode accidents occur only with
unipolar devices. Complications of electrosurgery are reduced by adherence to
safety protocols coupled with a sound understanding of the principles of
electrosurgery and the circumstances that can lead to injury (182). An excellent
source of information regarding the principles and safe use of RF electricity and
other energy sources called Fundamental Use of Surgical Energy (FUSE), created
by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
is available free of charge (183).
Active Electrode Trauma
If a button or foot pedal is accidentally depressed, tissue adjacent to the electrode
of a monopolar instrument will be traumatized. Potential sites of injury include
the bowel, ureter, and other intraperitoneal structures, or, if the electrode lies on
the abdomen, the skin. Injury from direct extension of thermal effect can occur
when the zone of vaporization or coagulation extends to large blood vessels or
1469vital structures such as the bladder, ureter, or bowel. Bipolar instruments, even
those with advanced impedance sensing systems, reduce but do not eliminate the
risk of thermal injury to adjacent tissue (184,185). Therefore, blood vessels
should be isolated before electrosurgical coagulation, especially when they are
near vital structures, and appropriate amounts of energy must be applied to allow
an adequate margin of noncoagulated tissue.
The diagnosis of direct thermal visceral injury may be difficult. If unintended
activation of the electrode occurs, nearby intraperitoneal structures should be
evaluated carefully. The appearance can be affected by several factors, including
the output of the generator, the type of electrode, its proximity to tissue, and the
duration of activation. The diagnosis of visceral thermal injury is often delayed
until signs and symptoms of fistula or peritonitis appear. Because these
complications may not manifest until 2 to 10 days after surgery, patients should
be advised to report any postoperative fever or increasing abdominal pain.
Thermal injury to the bowel, bladder, or ureter that is recognized at the
time of laparoscopy should be managed immediately, taking into
consideration the potential extent of the zone of coagulative necrosis
(186,187). Incisions made with the focused energy from a pointed electrode are
associated with a minimal amount of surrounding thermal injury. Prolonged or
even transient contact with a relatively large-caliber electrode may produce a zone
of thermal necrosis that may be much larger than visually apparent. In such cases,
wide excision or, for example, resection of up to several centimeters of bowel
may be necessary. The choice of route of access for any required surgical repairs
depends in part on the nature of the injury and on the skills and training of the
surgeon.
[12] The incidence of unintended activation injuries can be reduced if the
surgeon is always in direct control of electrode activation and if all
electrosurgical hand instruments are removed from the peritoneal cavity
when not in use. When removed from the peritoneal cavity, the instruments
should be detached from the electrosurgical generator, or they should be stored in
an insulated pouch near the operative field. These measures prevent damage to the
patient’s skin if the electrode is accidentally activated.
Current Diversion
Current diversion occurs during the use of monopolar instrumentation when the
RF circuit follows an unintended path between the active electrode and the
electrosurgical generator. This may occur with insulation defects, direct coupling,
or capacitative coupling. In older, grounded systems, unlikely to be in use in
operating rooms today, current can be diverted if any part of the patient’s body
touches a conductive and grounded object. In any of these situations, if the power
1470density becomes high enough, unintended and severe thermal injury can result.
Insulation Defects
If the insulation coating the shaft of a monopolar electrosurgical instrument
becomes defective, it can allow current diversion to adjacent tissue, that is most
often bowel, potentially resulting in significant injury, in part because such
defects create a zone of high-current density (Fig. 26-28). Therefore, the
instruments should be examined before each procedure to detect worn or
obviously defective insulation. When using monopolar laparoscopic instruments,
the shaft of the device should be kept away from vital structures and, if possible,
totally visible in the operative field.
Direct Coupling
Direct coupling occurs when the activated electrode of a monopolar instrument
touches and energizes another uninsulated metal conductor such as a laparoscope,
cannula, or other instrument. Direct coupling has value for creating hemostasis by
using a grasping instrument to occlude a blood vessel while a separate activated
electrode is placed in contact with the grasping instrument to provide the energy
for desiccation and coagulation. However, unintentional direct coupling can be
disastrous, if an activated electrode touches another noninsulated device that rests
against structures such as bowel or the urinary tract (Fig. 26-29). The risk of
direct coupling can be reduced by eliminating the simultaneous use of
noninsulated instruments and monopolar instruments. Furthermore, the surgeon
should visually confirm that there is no contact with other conductive instruments
before activating a monopolar instrument.
Capacitive Coupling
Capacitance is the ability of a conductor to establish an electrical current in an
unconnected but nearby circuit. An electrical field is established around the shaft
of any activated unipolar instrument (including the cord), a circumstance that
makes the electrode, and the cord, a potential capacitor. This field is harmless if
the circuit is completed through a dispersive, low-power density pathway,
however, if the nearby circuit focuses the energy on tissue, thermal injury can
occur (Fig. 26-30). The figure demonstrates two mechanisms for capacitative
coupling, the cord wrapped around the towel clip results in coupling that can
focus the energy on the skin, and the activated needle electrode by being in close
proximity to the laparoscope can induce current that is focused on the nearby
bowel. This latter mechanism occurs with operative laparoscopes, where the
electrode capacitively couples with the metal casing (188), and with the
somewhat similar “single port” systems where the laparoscope and hand
1471instruments, including monopolar instruments are passed through the same
concentrated array of ports (189).
The risk of capacitive coupling-related complications can be reduced in a
number of ways. First, it is important to avoid the use of hybrid laparoscope–
cannula systems that contain a mixture of conductive and nonconductive
elements. Instead, the use of all-plastic or all-metal cannula systems is preferred.
It may be best to avoid the use of monopolar instruments using operating
laparoscopes or multiport, single site access systems. If a multiport access cannula
or an operating laparoscope is to be used, only bipolar RF instruments should be
used in the operating channel. The surgical team should ensure that towel clips,
potentially in contact with the patient’s skin, are not used to secure monopolar
cables. Surgeons should be careful to avoid juxtaposing instruments between an
activated electrode and tissue. Finally, minimizing the use of high-voltage,
modulated current (“coagulation” current) will reduce the risk of capacitative
coupling.
1472FIGURE 26-28 RF monopolar instrumentation. The electrosurgical generator converts
wall output at about 60 Hz, to radiofrequency waveforms—typically between 300 and 500
KHz. The dispersive electrode defocuses the current, while the “active electrode”, actually
a current focusing electrode, is used to create a tissue effect. The current oscillates between
the two electrodes through the patient.
1473FIGURE 26-29 Current diversion secondary to insulation defects and direct coupling.
These events may occur with the use of monopolar instrumentation when there is a defect
in the insulation (A) or, classically, to contact a conductive instrument that, in turn, touches
other intraperitoneal structures (B). In the example depicted (B), the activated electrode is
touching the laparoscope, and current is transferred to bowel through a small enough
contact point that thermal injury results. Another common target of such coupling is to
noninsulated hand instruments.
1474FIGURE 26-30 Capacitative coupling. All activated RF electrodes emit a surrounding
charge, proportional to the voltage of the current. This makes the electrode as well as the
connecting cables potential capacitors. In general, as long as the charge is allowed to
disperse through the abdominal wall, no sequelae will result. However, if the path between
the active and dispersive electrodes is interrupted, for example by non-contact or “open”
activation, and especially with high voltage current (shown), the current can couple to
1475nearby structures such as a laparoscope conductive cannula or directly to which could be in
contact with bowel.
Dispersive Electrode Burns
Modern electrosurgical units are designed with isolated circuits and impedance
monitoring systems that shut down the machine if dispersive electrode (“patient
pad”) detachment occurs. The use of isolated circuit electrosurgical generators
with dispersive electrode monitors has virtually eliminated dispersive electrode–
related thermal injury. Dispersive electrode monitoring is actually accomplished
by measuring the impedance in the dispersive electrode, which should always be
low because of the large surface area. Without such devices, partial detachment of
the dispersive electrode could result in a thermal injury because reducing the
surface area of the electrode in contact with the skin raises the current density
(Fig. 26-31).
Because a few ground-referenced machines without such safeguards may still
be in use, it is important to know the type of electrosurgical unit used in the
operating room. If the electrosurgical generator is ground referenced and if the
dispersive electrode becomes detached, unplugged, or otherwise ineffective, the
current seeks any grounded conductor, such as electrocardiograph patch
electrodes or the conductive metal components of the operating table. If the
conductor has a small surface area, the current or power density may become high
enough to cause thermal injury.
Hemorrhagic Complications
Great Vessel Injury
The most dangerous hemorrhagic complications are injuries to the great
vessels, including the aorta and the vena cava, the common iliac vessels and
their branches, and the internal and external iliac arteries and veins. The
most catastrophic injuries occur secondary to insertion of an insufflation
needle or the tip of the obturator (trocar) used to position the primary or
ancillary cannulas. The vessels most frequently damaged are the aorta and the
right common iliac artery as it branches from the aorta in the midline. The
anatomically more posterior location of the vena cava and the iliac veins provides
relative protection, but not immunity, from injury (190). After vascular injury,
patients usually develop profound hypotension with or without
hemoperitoneum. In some cases, blood is aspirated through the insufflation
needle before the introduction of the distending gas. In such instances, the
needle should be left in place while immediate preparations are made to
obtain blood products and perform laparotomy. The bleeding frequently will
1476be contained in the retroperitoneal space, which usually delays the diagnosis;
consequently, hypovolemic shock may develop. To avoid late recognition, the
course of each great vessel must be identified before completing the procedure.
Because it is difficult to assess the volume of blood filling the retroperitoneal
space, immediate laparotomy is indicated if retroperitoneal bleeding is
suspected. A midline incision should be made to allow access to the great
vessels. Upon entry into the peritoneal cavity, the aorta and vena cava should
immediately be compressed just below the level of the renal vessels to gain at
least temporary control of blood loss. The most appropriate course of action
depends on the site and extent of injury. Vascular or general surgery consultation
may be necessary to evaluate and repair significant vascular injuries. Although
most of these injuries are small and amenable to repair with suture, some are
larger and require the insertion of a vascular graft. Deaths have occurred as a
result of these injuries.
FIGURE 26-31 Dispersive electrode burns. If the dispersive electrode becomes partially
detached, the current density may increase to the point that a skin burn results.
Abdominal Wall Vessel Injury
The abdominal wall vessels most commonly injured during laparoscopy are
the superficial inferior epigastric vessels as they branch from the femoral
artery and vein and course cephalad in each lower quadrant. They are
invariably damaged by the initial passage of an ancillary trocar–cannula system or
by the introduction of a wider device later in the procedure. The problem may be
1477recognized immediately by the observation of blood dripping along the cannula or
out through the incision. However, the bleeding may be obstructed by the cannula
until it is withdrawn at the end of the operation.
The more serious injuries are those to the deep inferior epigastric vessels,
which are branches of the external iliac artery and vein that course cephalad
but are deep to the rectus fascia and often deep to the muscles. More laterally
located are the deep circumflex iliac vessels, which are not often encountered in
laparoscopic surgery. Laceration of these vessels may cause profound blood loss,
particularly when the trauma is unrecognized and causes extraperitoneal bleeding.
Signs of injury, in addition to blood dripping down the cannula, include
the postoperative appearance of shock and abdominal wall discolorization or
hematoma located near the incision. In some instances, the blood may track to a
more distant site, presenting as a pararectal or vulvar mass. Delayed diagnosis
may be prevented by laparoscopic evaluation of each peritoneal incision after
removal of the cannula.
Superficial inferior epigastric vessel trauma usually stops bleeding
spontaneously; therefore, expectant management is appropriate. A straight
ligature carrier can be used to repair lacerated deep inferior epigastric vessels.
Alternatively, a Foley catheter may be inserted through the cannula, inflated, put
on traction, and held in place with a clamp for 24 hours. If a postoperative
hematoma develops, local compression should be used initially. Open removal or
aspiration of the hematoma should not be undertaken because it may inhibit the
tamponade effect and increase the risk of abscess. However, if the mass continues
to enlarge or if signs of hypovolemia develop, the wound must be explored.
Intraperitoneal Vessel Injury
Hemorrhage may result from inadvertent entry into a vessel or failure of a specific
occlusive technique. In addition to delayed hemorrhage, there may be a further
delay in diagnosis at laparoscopy as a result of the restricted visual field and the
temporary occlusive pressure exerted by CO2 in the peritoneal cavity.
Inadvertent division of an artery or vein is usually evident immediately.
Transected arteries may go into spasm and bleed minutes to hours later, going
unnoticed temporarily because of the limited visual field of the laparoscope.
Therefore, at the end of the procedure, all areas of dissection must be carefully
examined. Carbon dioxide should be vented, which decreases the intraperitoneal
pressure so that blood vessels temporarily occluded by higher pressure can be
recognized.
Gastrointestinal Complications
The stomach, the small bowel, and the colon can be injured during laparoscopy.
1478Mechanical entry into the large or small bowel can occur 10 times more often
when laparoscopy is performed in patients who have had prior intraperitoneal
inflammation or abdominal surgery. Loops of intestine can adhere to the
abdominal wall under the insertion site and be injured (191,192).
Insufflation Needle Injuries
Needle entry into the gastrointestinal tract may be more common than reported
because it may occur unnoticed and without further complication. Gastric entry
may be identified by the increased filling pressure, asymmetric distention of the
peritoneal cavity, or aspiration of gastric particulate matter through the lumen of
the needle. Initially, the hollow, capacious stomach may allow the insufflation
pressure to remain normal. Signs of bowel entry are the same as those for gastric
injury, with the addition of feculent odor.
If particulate debris is identified, the needle should be left in place, and an
alternate insertion site should be identified, such as the left upper quadrant.
Immediately after successful entry into the peritoneal cavity, the site of injury can
be identified. Defects must be repaired immediately by laparoscopy or
laparotomy.
Trocar/Obturator Injuries
Damage caused by a sharp-tipped obturator or trocar is usually more serious than
needle injury. Inadvertent gastric entry usually is associated with stomach
distention because of aerophagia, difficult or improper intubation, or mask
induction with inhalation anesthetic. Most often, the injury is created by the
trocar–cannula system used for primary access. Ancillary cannulas may result in
visceral injury, although placement of these cannulas under direct vision helps to
reduce the risk of injury. The risk of gastric perforation can be minimized with
the selective use of preoperative nasogastric or oral gastric suction when left
upper–quadrant entries are used or when the intubation was difficult. Open
laparoscopy likely has little impact on the risk for gastrointestinal complications,
particularly those related to adhesions to the anterior abdominal wall from
previous surgery. For high-risk patients, left upper–quadrant needle and trocar–
cannula insertion with a properly decompressed stomach are preferable (193–
196).
If the trocar of a primary cannula penetrates the bowel, the condition is
usually diagnosed when the mucosal lining of the gastrointestinal tract is
visualized. If the large bowel is entered, a feculent odor may be noted. However,
the injury may not be immediately recognized because the cannula may not stay
within the bowel or may pass through the lumen. Such injuries usually occur
when a single loop of bowel is adherent to the anterior abdominal wall. The injury
1479may not be recognized until peritonitis, abscess, enterocutaneous fistula, or death
occurs (197,198). Therefore, at the end of the procedure, the removal of the
primary cannula must be viewed either through the cannula or an ancillary
port, a process facilitated by routine direct visualization of closure of the
incision of the primary port.
Trocar-related injuries to the stomach and bowel require repair as soon as
they are recognized. If the injury is small, a trained operator can repair the defect
under laparoscopic direction using a double layer of running 2-0 or 3-0
absorbable sutures. Extensive lesions may require resection and reanastomosis,
which in most instances requires at least a small laparotomy. The preoperative use
of mechanical bowel preparation in selected high-risk cases minimizes the need
for laparotomy or colostomy, but evidence suggests that bowel surgery, if
necessary, may be safely performed in unprepared bowel (199).
Dissection and Thermal Injury
When mechanical bowel trauma is recognized during the dissection, treatment is
the same as that described for trocar injury. Should the injury involve RF
electrical energy, it is important to recognize that the zone of desiccation and
coagulation may exceed the visual area of damage. This is especially true if the
exact mechanism of the thermal injury is unknown or if injury results from
contact with a relatively large surface area electrode that would be more likely to
create a large coagulation injury. Conversely, bowel injury created under direct
vision with a RF needle or blade electrode is associated with little collateral
coagulation effect and, therefore, can be managed similar to a mechanically
induced lesion. Consequently, surgical repair should be implemented considering
these factors, and should include, if necessary, resection of ample margins around
the injury. Thermal injury may be handled expectantly if the lesion seems
superficial and confined, such as is the case when fulguration (noncontact arcing
of high-voltage current) involves bowel. In such instances, the depth of injury is
generally less than half a millimeter. In a study of 33 women with such injuries
who were managed expectantly in the hospital, only 2 required laparotomy for
repair of perforation (200).
Urologic Injury
Damage to the bladder or ureter may occur secondary to mechanical or thermal
trauma incurred during laparoscopic procedures. Ideally, such injury should be
prevented; otherwise, as is the case for most complications, it is preferable to
identify the trauma intraoperatively.
Bladder Injury
1480Bladder injury can result from the perforation of the undrained bladder by an
insufflation needle or trocar, or it may occur while the bladder is being dissected
from adherent structures or from the anterior uterus (201,202). The frequency of
injury is difficult to estimate and varies with procedure. Estimates of the
frequency of unintentional cystotomy associated with LH ranges from 0.4% to
3.2% and appears to be more frequent in the context of a previous cesarean
section (203,204). The injury may be readily apparent by direct visualization. If
an indwelling catheter is in place, hematuria or pneumaturia (CO2 in the catheter
drainage system) may be noticed. A bladder laceration can be confirmed by
injecting sterile milk or a diluted methylene blue solution through a transurethral
catheter. Thermal injury to the bladder, however, may not be apparent initially
and, if missed, can present as peritonitis or a fistula.
Routine preoperative bladder drainage usually prevents trocar-related
cystotomies. Separation of the bladder from the uterus or other adherent structures
requires good visualization, appropriate retraction, and excellent surgical
technique. Sharp mechanical dissection is preferred, particularly when relatively
dense adhesions are present.
Very small-caliber injuries to the bladder (1 to 2 mm) may be treated with
bladder catheterization for 3 to 7 days. If repair is undertaken immediately,
catheterization is unnecessary. When a larger injury is identified, it can be
repaired laparoscopically (201,202,205). If the laceration is near the trigone or
involves the trigone, however, an open procedure should be used. The mechanism
of injury should be taken into consideration in making this evaluation because
electrical injuries often extend beyond the visible limits of the apparent defect. If
a coagulation-induced thermal injury occurred, the coagulated portion should be
excised.
For small lesions, closure may be performed with layers of absorbable 2-0 to 3-
0 sutures. Postoperative catheterization with either a transurethral or suprapubic
catheter should be maintained for 2 to 5 days for small fundal lacerations and for
10 to 14 days for injuries to the trigone. Cystography should be considered before
the urinary catheter is removed.
Ureteral Injury
One of the most common causes of ureteral injury during laparoscopy is
electrosurgical trauma (184,206,207) although ureteral injury can occur after
mechanical dissection, including linear cutting and stapling devices infrequently
used in contemporary gynecologic laparoscopic surgery (207–209). Although
intraoperative recognition of ureteral injury is possible, the diagnosis is frequently
delayed (207,210). Intraoperative diagnosis of ureteral injury may be confirmed
intraoperatively by visual inspection or demonstration of leakage following the
1481intravenous injection of indigo carmine. Alternatively, cystoscopy following the
intravenous injection of indigo carmine, or a similar dye, will generally show
bilateral patency if there is no ureteric injury. Because there is adequate evidence
that this approach may identify the majority of ureteral injuries, contemporary
guidelines recommend routine performance of cystoscopy following LH (211).
Unrecognized ureteral obstruction may present a few days to 2 weeks after
surgery with flank pain and fever with or without signs of peritonitis and
leukocytosis (212). Abdominal ultrasound may be helpful, but a CT urogram can
more precisely identify the site and degree of the obstruction.
Discharge or continuous incontinence is a delayed sign of ureterovaginal or
vesicovaginal fistula. A vesicovaginal fistula can be confirmed by filling the
bladder with methylene blue and detecting dye on a tampon previously placed in
the vagina. With a ureterovaginal fistula, the methylene blue will not pass into the
vagina, but it can be detected with the intravenous injection of indigo carmine.
Knowledge of the course of the ureter through the pelvis is a prerequisite to
reducing the risk of injury. The ureter can usually be seen through the peritoneum
of the pelvic sidewall between the pelvic brim and the attachment of the broad
ligament. Because of variation from one patient to another or the presence of
disease, the location of the ureter can become obscured, making it necessary to
enter the retroperitoneal space. The techniques used for retroperitoneal dissection
are important factors in reducing the risk of ureteric injury. Blunt and sharp
dissection with scissors is preferred, although hydrodissection can be used (213).
The selective placement of ureteral stents may be helpful in reducing the risk of
injury.
Ureteral injury can be treated immediately if it is diagnosed intraoperatively.
Although limited damage may heal over a ureteral stent left in place for 10 to 21
days, repair is indicated in most patients. Laparoscopic repair of ureteric
lacerations and transections has been performed, but most injuries require
laparotomy (206,214).
Incomplete or small obstructions or lacerations may be treated successfully
with a stent placed either using a retrograde or anterograde technique. Urinomas
may be drained percutaneously. If a stent cannot be placed successfully, a
percutaneous nephrostomy should be performed before operative repair is
undertaken. Repair may be accomplished by excision and reanastamosis, or, more
commonly, ureteric reimplantation with or without facilitating procedures such as
a psoas hitch or a Boari flap.
Neurologic Injury
Peripheral nerve injury is usually related to poor positioning of the patient,
excessive pressure exerted by the surgeons, or to port placement (215,216).
1482Positioning the patient in lithotomy while she is awake may decrease this risk
because the woman can determine if any undue pressure or discomfort is
experienced (217). Nerve injury may occur as a result of the surgical dissection.
In the extremities, the trauma may be direct, such as when the common
peroneal nerve is compressed against a stirrup. The femoral nerve or the sciatic
nerve or its branches may be overstretched and damaged by excessive flexion or
external rotation of the hips. The peroneal nerve may be injured by compression if
the lateral head of the fibula rests against the stirrup (217–219). Brachial plexus
injuries may occur secondary to the surgeon or assistants leaning against an
abducted arm during the procedure. If the patient is placed in a steep
Trendelenburg position, the brachial plexus may be damaged because of the
pressure exerted on the shoulder joint. In most cases, sensory or motor deficits are
found as the patient emerges from anesthesia. The likelihood of brachial plexus
injury can be reduced with adequate padding and support of the arms and
shoulders or by placing the patient’s arms in an adducted position (220).
Most injuries to peripheral nerves resolve spontaneously. The time to recovery
depends on the site and severity of the lesion. For most peripheral injuries, full
sensory nerve recovery occurs in 3 to 6 months. Recovery may be hastened by the
use of physical therapy, appropriate braces, and electrical stimulation of the
affected muscles. Open microsurgery should be performed for transection of
major intrapelvic nerves.
Incisional Hernia and Wound Dehiscence
Incisional hernia after laparoscopy has been reported in more than 900 cases
(167,168). The most common defect is dehiscence that develops in the immediate
postoperative period. Hernias may be asymptomatic or may cause pain, fever,
periumbilical mass, obvious evisceration, and the symptoms and signs of
mechanical bowel obstruction. Although no incision is immune to the risk,
defects that are larger than 10 mm in diameter are particularly vulnerable
(168,221,222).
Richter hernias contain only a portion of the diameter of intestine in the defect,
and the diagnosis is often delayed because the typical symptoms and findings of
mechanical bowel obstruction may be absent (223). The initial symptom is
usually pain. These hernias most often occur in incisions that are lateral to the
midline where there is a greater amount of preperitoneal fat creating a potential
space for incarceration. Fever can be present if incarceration occurs, and
peritonitis may result from subsequent perforation. The condition is difficult to
diagnose, requires a high index of suspicion, and may be confirmed with
ultrasonography or CT (224).
In most cases, these occurrences can be prevented by using small-caliber
1483cannulas, where possible, and with routine fascial and peritoneal closure of
defects made by peritoneal access. The risk of inadvertent incorporation of the
intestine into the wound can be reduced by viewing the closure with a smallercaliber laparoscope passed through a narrow-caliber ancillary port. All ancillary
cannulas should be removed under direct vision to ensure that bowel is not drawn
into the incision and that there is an absence of active incisional bleeding.
The management of laparoscopic incisional defects depends on the time of
presentation and the presence and condition of entrapped bowel. Evisceration
always requires surgical intervention. If the condition is diagnosed immediately,
the intestine is replaced into the peritoneal cavity (if there is no evidence of
necrosis or intestinal defect), and the incision is repaired, usually with
laparoscopic guidance. If the diagnosis is delayed or the bowel is incarcerated or
at risk of perforation, laparotomy is necessary to repair or resect the intestine.
Infection
Wound infections after laparoscopic surgery are uncommon; most are minor skin
infections that can be treated successfully with expectant management, drainage,
or antibiotics (225). Severe necrotizing fasciitis can occur rarely. Bladder
infection, pelvic cellulitis, and pelvic abscess have been reported (226).
Laparoscopy is associated with a much lower risk of infection than with
laparotomy or vaginal surgery. Prophylactic antibiotics should be offered to
selected patients (e.g., those with enhanced risk for bacterial endocarditis and
those for whom total hysterectomy is planned). Patients should be instructed to
monitor their body temperature after discharge and to report immediately a
temperature higher than 38°C.
HYSTEROSCOPY
The hysteroscope is an endoluminal endoscope, adapted from the urologic
cystoscope that can be used to directly evaluate the internal topography of the
cervical canal and endometrial cavity (Fig. 26-32) to aid diagnosis or to direct the
performance of a variety of intrauterine procedures. Although the first published
description of a hysteroscopic procedure was in 1869, a polypectomy (227), the
use of hysteroscopy didn’t become common until the last half of the 20th century.
Hysteroscopic lysis of intrauterine adhesions (IUAs) was first described in 1973
(228). The technique of endoscopically guided electrosurgical resection was
adapted from urology to gynecology, initially for the removal of uterine
leiomyomas (229). Hysteroscopic division of uterine septa was originally
developed using a mechanical technique with specially designed scissors (230).
Hysteroscopic destruction of the endometrium, generally termed endometrial
1484ablation (EA), was originally reported using Nd:YAG laser vaporization, but
subsequent innovators used the urologic resectoscope to ablate the endometrium
using electrosurgical coagulation, resection, or vaporization (231–233).
Hysteroscopically guided thermal ablation with heated fluid is a procedure that
has been used since 2002, the only endoscopically guided technique for
“nonresectoscopic” EA (NREA). Developments in the design of endoscopes have
resulted in smaller-diameter instruments that retain the ability to provide a highquality image. Such developments further facilitate the use of hysteroscopy in an
office or procedure room setting using no or local anesthesia.
FIGURE 26-32 Hysteroscopic view of a normal cervical canal (left) and endometrial
cavity (right). On the right, an image of a postmenopausal uterus, the right and left
cornual areas are easily seen. The ecchymosis posteriorly may be due to trauma from
positioning the hysteroscope.
Diagnostic Hysteroscopy
The goal of evaluation of the uterine cavity is either to obtain a sample of the
endometrium, usually for the detection of hyperplasia or neoplasia, or to identify
structural abnormalities; typically, a uterine septum or focal lesions such as
adhesions, polyps, or submucous leiomyomas. Blind endometrial sampling has
been the diagnostic mainstay for the detection of endometrial hyperplasia,
whereas hysteroscopy, HSG, TVUS, contrast sonohysterography (gel or saline
infusion sonography), and MRI are options in the detection and characterization
1485of structural anomalies. [14] Hysteroscopic examination is superior to HSG in the
evaluation of the endometrial cavity (234,235). The diagnostic accuracy of TVUS
is similar, especially when sonographic contrast is injected into the endometrial
cavity, usually intrauterine saline or gel, a procedure called sonohysterography
that, when normal saline is used, is termed saline infusion sonography (SIS)
(236–238). MRI and ultrasound-based techniques have the advantage of allowing
evaluation of the myometrium, whereas office-based hysteroscopy allows
simultaneous division of adhesions, or removal of small polyps and even some
leiomyomas. Diagnostic hysteroscopy provides information not obtained by blind
endometrial sampling (239–244), such as detection of endometrial polyps or
submucous leiomyomas (239,241,244,245) and can allow for the performance of
directed endometrial biopsy (Fig. 26-33). Malignant or hyperplastic polyps or
other localized lesions can be identified with hysteroscopy and removed via
directed excision (242). However, blind curettage remains an effective approach
for the identification of global endometrial histopathology (239,244,246).
The following are potential indications for diagnostic hysteroscopy:
1. Unexplained abnormal uterine bleeding (AUB)
Premenopausal
Postmenopausal
2. Selected infertility cases
Abnormal hysterography or TVUS
Unexplained infertility
Routine assessment prior to ET
“Second look” evaluation following selected uterine surgery cases
3. Recurrent pregnancy loss (RPL)
1486FIGURE 26-33 Hysteroscopically-guided endometrial biopsy. These 5-Fr biopsy
forceps are opened wide just prior to capture of a focal endometrial lesion, likely a polyp.
[16] For many patients, diagnostic hysteroscopy can be performed in an office or
procedure room setting with minimal discomfort and at a much lower cost than in a
surgical center or a traditional operating room (Fig. 26-34). For some, concerns about
patient comfort or a pre-existing medical condition may preclude office hysteroscopy.
Although hysteroscopy can, in many patients, provide more information than blind
curettage, it should be used prudently. For most patients, other diagnostic or therapeutic
measures can be undertaken before, or instead of, diagnostic hysteroscopy. For example, in
women in the late reproductive years with AUB, or for those with postmenopausal
bleeding, transvaginal sonography, and/or office endometrial biopsy or curettage typically
are adequate to evaluate for neoplasia and to provide enough information to support an
initial management strategy. If a satisfactory diagnosis cannot be established, or if bleeding
continues without explanation or response to treatment, further investigation with one or a
combination of ultrasound, endometrial sampling, contrast sonohysterography, or office
hysteroscopy is appropriate. For women in their earlier reproductive years who have AUB,
medical or expectant management may be used initially, depending on the severity and
inconvenience of the bleeding. For those who do not respond to medical treatments such as
oral contraceptives, the performance of TVUS, contrast sonohysterography, or
hysteroscopy with biopsy (Fig. 26-33), can be used for diagnosis (247).
1487FIGURE 26-34 Office-based hysteroscopy under local anesthesia. Here both the
surgeon and the patient can view the image of the endometrial cavity, and the patient can
ask questions in real time. Patient’s typically require no narcotic systemic analgesics, even
if operative procedures are performed.
For women with infertility, HSG is generally the best initial imaging step
because it provides information about the patency of the oviducts. In the presence
of a suspicious or identified abnormality in the endometrial cavity, hysteroscopy
or contrast sonohysterography can be performed to confirm the diagnosis, better
define the abnormality, and perhaps direct the removal of a lesion—if
hysteroscopy is performed. Some experts consider hysteroscopy or contrast
sonohysterography mandatory for such patients because of the frequent
occurrence of false-negative radiologic images in those with intrauterine
anomalies (248). In women with previous IVF failure, there is evidence that
hysteroscopic identification and treatment of these “missed” anomalies improves
pregnancy rates (249). Confirmation of patency of the oviduct is unnecessary in
women who have recurrent abortions; therefore, these patients can be evaluated
primarily with hysteroscopy.
1488Operative Hysteroscopy
A number of intrauterine procedures can be performed under endoscopic
direction, including adhesiolysis, sterilization, transection of a uterine septum,
resection of leiomyomas and polyps, removal of retained products of conception,
and endometrial destruction through Nd:YAG laser vaporization or RF resection,
desiccation, or vaporization. Hysteroscopy may be used to direct the removal of
foreign bodies including embedded intrauterine contraceptive devices (IUDs).
[16] With proper use of local anesthesia, most of these procedures can be
performed in an office setting (250).
Foreign Body
If the string of an IUD is absent, the device often can be removed with a specially
designed hook or a toothed curette (e.g., Novak). When removal is difficult or
impossible, after sonographic confirmation that the device is in the endometrial
cavity, hysteroscopy can be performed using a sheath with an operating channel,
thereby allowing removal with grasping forceps (Fig. 26-35). If the device is not
seen, or if only a portion is visible hysteroscopically, the remainder imbedded in
the myometrium, individualized management is recommended, usually following
additional imaging studies to more precisely identify the location of the device.
1489FIGURE 26-35 IUD in endometrial cavity. This Cu-T-380A copper-based intrauterine
system is easily seen hysteroscopically; if strings are not seen emanating from the cervix,
the hysteroscope can be used to remove the device with 5-Fr grasping forceps.
1490FIGURE 26-36 Transection of a uterine septum (rAFS Class 5A). The leading edge of
the septum is seen close to the internal os (A). Additional anesthesia is injected via a 5-Fr
needle passed through the 5-Fr channel in the operating sheath (B). A bipolar
radiofrequency (RF) needle is used to start the transection (C) that is nearly complete in D.
This procedure was done completely under local anesthesia in an office environment.
Septum
When RPL is associated with a single corpus containing a uterine septum (rAFS
Class V or CONUTA U2), hysteroscopic division of the septum improves
reproductive outcome at a rate comparable to abdominal metroplasty, with
reduced morbidity and cost (see Chapter 33) (251–256). There are fewer data
regarding infertility but there is some evidence that metroplasty does improve
fecundity (257). Confirmation of the external architecture of the corpus is
1491important and can be achieved using either MRI or three-dimensional ultrasound.
One group has described an office method of “see and treat” where dissection is
continued until attainment of two of three criteria (pain, bleeding, the
visualization of myometrial fibers) determine the end-point of septal transection
(258). This procedure can be successfully performed in the office setting using
local anesthesia protocols, with additional ½% lidocaine with 1/200,000
epinephrine directly injected into the septum or into each cornu to capture
innervation from T10 coursing into the corpus alongside the utero-ovarian
ligament. The procedure may be performed mechanically with scissors or with
energy-based techniques such as an electrosurgical knife, needle, or loop (Fig. 26-
36). Because most septa have few vessels, scissors can be used easily, and the
minimal risk for thermal damage is avoided. Properly applied, monopolar, and,
especially bipolar instrumentation is associated with minimal thermal injury.
Endometrial Polyps
Endometrial polyps have been associated with AUB and infertility. Although
such polyps can be removed with blind curettage, many are missed
(239,241,244,245). Therefore, known or suspected endometrial polyps are more
successfully treated with hysteroscopic guidance, which can usually be performed
as an office procedure. For relatively small polyps, hysteroscopy should be used
to direct the use of small-caliber scissors to transect the polyp at the base and
grasping forceps to remove the lesions from the endometrial cavity (Fig. 26-37).
For larger polyps, special polyp snares, electrosurgical needles, a uterine
resectoscope, or an electromechanical tissue removal system, may be used to
sever the stalk and morcellate the lesion. For patients with infertility and
endometrial polyps, it is not clear whether or not polyp number and size are
related to outcome (259). Consequently, removal of all accessible polyps should
be attempted if the process can be completed with minimal trauma.
1492FIGURE 26-37 Endometrial polypectomy. A: The polyp is seen in mid cavity on the
right posterior endometrium. The lesion is transected as close as possible to the
endometrium to minimize the risk of recurrence, but leaving a tiny attachment (B). Forceps
are used to grasp the polyp at the attachment, then twisting it until it detaches from the
endometrium (C). The lesion is pulled through the cervical canal, removing the
hysteroscopic system in the process (D).
1493FIGURE 26-38 FIGO leiomyoma classification system. Seen here in the context of
FIGO’s System 2, the PALM-COEIN system, the leiomyoma system is a subclassification.
For the hysteroscopic surgeon type 0 and 1 lesions are usually removable as long as the
size is reasonable (generally not more than 5-cm diameter); many type 2 tumors can be
removed, but there are limitations and risks. The surgeon must distinguish type 2 from type
2–5 tumors as the latter cannot be removed hysteroscopically.
Leiomyomas
Hysteroscopy may be used to direct the removal of selected submucous
leiomyomas in women with HMB, infertility, or recurrent first trimester
spontaneous pregnancy loss (236,260–266). This approach is limited based on the
location, size, and number of lesions. Preoperative administration of
gonadotropin-releasing hormone (GnRH) agonists may help shrink submucous
myomas, facilitating their complete removal, and may reduce operating time and
systemic absorption of distension media (267–269).
To facilitate evaluation and documentation of the investigation of women
with fibroids, a classification system has been developed that categorizes the
location of leiomyomas in the uterus, including submucous tumors, based on
1494the proportion of the myoma that is in the uterine cavity (Fig. 26-38) (270). In
patients with myomas that are 3 cm or less in diameter and entirely intracavitary
(type 0), excision is relatively easily accomplished, with minimal endometrial
trauma. Type 2–5 lesions require an abdominal approach with laparoscopy or
laparotomy, with suture-based repair of the defect. Small type 0 leiomyomas may
be removed following transection of the stalk with scissors or an electrode
attached to a uterine resectoscope. For larger type 0 lesions, or for type 1
leiomyomas, some combination of dissection of the tumor from the myometrium
and either electrosurgical or mechanical morcellation (Fig. 26-39) will be
necessary to effect removal. For selected type 2 myomas, careful dissection into
the avascular plane interposed between the tumor and the myometrial
pseudocapsule may be attempted, provided that satisfactory ultrasonography or
MRI has demonstrated an adequate margin of myometrium between the deepest
aspect of the lesion and the uterine serosa. In some instances, it may be preferable
to undertake such procedures with laparoscopic monitoring to ensure that the
bowel is not adjacent to the zone of dissection. Increasingly, this type of guidance
can be provided using transabdominal ultrasonography. In some centers, the vast
majority of type 2 tumors are removed under hysteroscopic direction, in an office
setting, using local anesthesia, an incision into the pseudocapsule, careful
dissection, and electromechanical morcellation (Fig. 26-40) (271). Patients should
be counseled that for some type 1 and many type 2 myomas, it may take more
than one procedure to complete excision (261,272). Hysteroscopic myomectomy
of type 1 and 2 tumors should be performed using an accurate fluid management
system, to minimize the risk of fluid overload. The use of intrauterine
prostaglandin F2α has been described to facilitate extrusion of type 2 myomas
(273).
1495FIGURE 26-39 Myomectomy—FIGO type 0 leiomyoma. A: Note that the leiomyoma is
entirely intracavitary and attached to the endometrium/myometrium by a narrow stalk. An
electromechanical morcellator (Myosure®, Hologic Inc Marlborough, MA, USA) has been
introduced and a portion of the tumor has been removed (B); it is almost totally gone in C.
D: The tumor has been totally removed from the anterior wall.
Endometrial Ablation
The symptom of HMB caused by primary endometrial dysfunction (AUB-E) or
ovulatory disorders (AUB-O) (270) that does not respond to oral medical therapy
may be managed by EA using coagulation, resection, or vaporization, provided
the patient is willing to forego future fertility (77). If future fertility is desired, a
levonorgestrel-releasing IUD can provide virtually equal clinical outcomes (274–
276). Ablation may be performed with a Nd:YAG laser (232), or RF
1496electrosurgical desiccation, resection, or vaporization using a uterine resectoscope
(Fig. 26-41) (233,272) or by any of a number of nonresectoscopic techniques,
including those employing thermal balloons, cryotherapy, heated free fluid or
vapor, or RF electrical energy delivered by a bipolar probe (277–281). Many of
these EA devices can be used in the office setting with local anesthetic protocols.
Endometrial resection is an EA technique performed with an electrosurgical
loop electrode to shave the endometrium and superficial myometrium
(231,282,283). Vaporization utilizes specially designed electrodes that are
attached to standard resectoscopes that are capable of destroying large volumes of
tissue without morcellation (272). Endometrial coagulation is achieved with ballor barrel-shaped electrodes that are used to coagulate and desiccate the
endometrial surface to an appropriate depth of about 4 mm (77,233).
Complications of these procedures include fluid overload, electrolyte imbalances
(if nonelectrolytic or even isosmotic media are used), uterine perforation,
bleeding, and intestinal and urinary tract injury (284,285). The risk of uterine
perforation may be reduced by using a combination of resection or vaporization
and electrosurgical ablation; the latter is most suitable for the thinner areas of the
myometrium in the cornu. The preoperative use of GnRH analogs or danazol may
reduce operating time, and GnRH agonists may reduce bleeding and the amount
of fluid absorbed into the systemic circulation (260,286).
For many women, these procedures are successful in reducing or eliminating
menses without hysterectomy or long-term medical therapy (77,287). Success
rates vary and depend on the duration of follow-up and the definition of success.
For many patients, amenorrhea is the goal, whereas for others, it is normalization
of menses. About 75% to 95% of patients are satisfied with the surgical procedure
after 1 year. Reports of amenorrhea rates range from approximately 30% to 90%.
Forty to 50% (depending in part upon the technique) is a useful number to quote
to patients considering the likelihood of postprocedure amenorrhea. The
nonresectoscopic techniques have similar clinical outcomes (288), thus reducing
the need for resectoscopic ablation. The nonresectoscopic approaches all have
limitations defined by the size or configuration of the endometrial cavity. For
those women with HMB who are not suitable for nonresectoscopic techniques
because of large uteri (>12 cm sounded length), resectoscopic EA remains a
viable option (289).
1497FIGURE 26-40 Myomectomy—FIGO type 2 leiomyoma. A: The deep FIGO type 2
leiomyoma can be seen at the uterine fundus. B: A bipolar RF needle is used to
circumscribe the leiomyoma, incising into the pseudocapsule, which “releases” the fibroid
as the myometrium pushes it into the endometrial cavity (C). Either a RF resectoscope, or
here, an electromechanical morcellator is placed into the pseudocapsule (D) and the
leiomyoma is resected (E). The final result (F). This cavity will fill in as the myometrium
expands and as endometrial epithelialization occurs over the next 12 weeks or so.
Anesthesia—local.
The long-term efficacy and impact of ablation or resection on women with
adenomyosis is unknown. Because ectopic endometrium located in the
myometrium inevitably cannot be ablated, there is potential for persisting or
augmented bleeding and pain. There is evidence that EA failures may be more
common in women with AUB-A (290,291). Another factor associated with post
EA pain is a previous tubal occlusion procedure, a circumstance that should be
considered when counseling women about the possible long-term risks of EA
(290,292).
Sterilization
Sterilization can be performed under hysteroscopic guidance, an approach that
eliminates the disadvantages and risks associated with abdominal or laparoscopic
techniques (293). Until recently the only product available, was Essure®, a
system that comprises a nickel-titanium coil with a Dacron filament that could be
inserted relatively quickly in an office or procedure room setting (see Chapter 14).
1498Tubal occlusion resulted from ingrowth of fibrous tissue across the coils, a
process that takes approximately 3 months to complete. Various protocols were in
place, depending on the country, to determine device placement prior to use. In
2018 the product was withdrawn by the manufacturer, the result of patient
concerns about side effects of the procedure.
Synechiae
Asherman syndrome is the presence of adhesions in the endometrial cavity
(IUAs) resulting in infertility or recurrent spontaneous abortion with or without
amenorrhea. If IUA do not occlude the upper cervical canal or lower uterine
segment, these synechiae may be detected on a hysterogram or contrast
sonohysterogram but are best shown with diagnostic hysteroscopy (Fig. 26-42).
Relatively thin, fragile synechiae may be divided with the tip of a rigid diagnostic
hysteroscope (294). Thicker lesions will require division by semi-rigid or rigid
scissors. Because the endometrium has often been substantially damaged, and
difficult to identify, the use of RF energy–based instruments should be minimized
or avoided. Reproductive outcome depends on the extent of the preoperative
endometrial damage (295,296). This is another hysteroscopic procedure that is
amenable to performance in the office, in selected cases, but the surgeon must be
careful to maintain orientation within the endometrial cavity. Simultaneous
intraoperative imaging with transabdominal ultrasound, or, in some institutions,
intraoperative fluoroscopy, is desirable and often necessary in moderate and
severe cases.
1499FIGURE 26-41 Resectoscopic endometrial ablation (REA) techniques. REA can be
accomplished with coagulation using a rolling ball or barrel (shown) and either low or
modulated high-voltage RF outputs; by vaporization using a suitably designed electrode
and high Wattage low-voltage RF waveforms; or using a resection loop and low-voltage
current. In each case, the surgeon’s goal is to treat the entire endometrium—if medically
prepared, the depth should be about 4 mm.
1500FIGURE 26-42 Asherman Syndrome—Isthmical Adhesions. This patient has
amenorrhea associated with localized adhesions at the level of the isthmus. She is operated
upon in the office procedure room using both hysteroscopic and transabdominal
sonographic guidance. On the left, the scissors are seen dividing the adhesions while also
viewed from the ultrasound perspective (center). The endometrial cavity is entered (right)
and the procedure is completed. Some use a stent; we perform a second-look procedure in
4 to 8 weeks.
Patient Preparation and Communication
Diagnostic hysteroscopy procedures traditionally have been performed in the
office or clinic settings. Operative hysteroscopy has usually been performed in an
operating room or hospital outpatient surgical center. In a number of medical
centers, 90% of the operative hysteroscopies are performed in an office procedure
room setting using local anesthesia assisted by ensuring that the environment is
comfortable, even including the use of music (297). The patient should
understand the rationale for the planned procedure, the anticipated discomfort,
potential risks, and the expectant, medical, and surgical alternatives. The nature of
the procedure and the chance of therapeutic success should be explained, and she
should be given a realistic estimate of success based on the operator’s experience.
Diagnostic Hysteroscopy: Risks
The risks of diagnostic hysteroscopy are few, and those complications that occur
rarely have severe consequences (298). The uncommon adverse events that
should be discussed with the patient include perforation, bleeding, and those
related to anesthesia and the distention media. After diagnostic hysteroscopy,
most patients have slight vaginal bleeding, and occasionally, lower abdominal
cramps. Severe cramps, dyspnea, and upper abdominal and right shoulder pain
can develop when CO2 is used as the distension media as it passes through the
fallopian tubes into the peritoneal cavity. Even in an office environment, the
patient should be encouraged to have a friend or relative escort her home.
Operative Hysteroscopy: Risks
Counseling before operative hysteroscopy varies depending on the planned
procedure, type of anesthesia, and procedure location—office or
operating/procedure room. Overall, the risks of operative hysteroscopy are higher
than those of diagnostic hysteroscopy. These increased risks are largely confined
to procedures such as adhesiolysis of severe intrauterine synechiae or resection of
leiomyomas that are either large or extend deeply into the myometrium. These
risks include those associated with anesthesia, intrinsic to all hysteroscopic
procedures, and related to the specific surgical procedure to be performed (298).
1501With any hysteroscopic procedure, air embolus is a possibility, as are
complications associated with the gaseous or fluid distention media used.
Hypotonic distension media may not be tolerated in some patients if there is
significant intravascular absorption, especially in patients with underlying
cardiovascular disease. The patient must be aware of the risks associated with
uterine perforation, which range from failure to complete the procedure to
hemorrhage or damage to the intestines or to the urinary tract. If such
complications occur, laparotomy may be necessary to repair the injury.
Equipment and Technique
The equipment required for hysteroscopy depends on the reason for the
procedure. The surgeon must be knowledgeable about the equipment, its
mechanisms, and the technical specifications to facilitate efficiency, optimal
clinical outcome, and decrease the probability of complications. A typical
hysteroscopy setup for both diagnostic and operative procedures is shown in
Figures 26-43 and 26-44.
Core competencies required for hysteroscopy are as follows:
1. Patient positioning and cervical exposure
2. Anesthesia
3. Cervical dilation
4. Uterine distention
5. Visualization and imaging
6. Intrauterine cutting and hemostasis
7. Other instrumentation
Patient Positioning and Cervical Exposure
Hysteroscopy is performed in a modified dorsal lithotomy position; the patient is
supine, and the legs are held in stirrups. For hysteroscopic procedures performed
while the patient is conscious, comfort must be considered in conjunction with the
need to gain good exposure of the perineum. Stirrups that hold and support the
knees, calves, and ankles permit prolonged procedures. “Candy cane” stirrups
should be avoided for hysteroscopic surgery, especially for conscious patients.
1502FIGURE 26-43 Office hysteroscopy setup. Hysteroscopic procedures are facilitated with
an electric examination table designed to adjust the patient’s position. Distension media
may be positioned on an IV pole, but wide, cystoscopy tubing allows maintenance of
higher intrauterine pressures suitable for viewing and performing simple procedures such
as polypectomy or transcervical sterilization. A light source is necessary and a camera
desirable. The camera is attached to the monitor and may be connected to a printer and/or
video recorder. The camera head is attached to a flexible hysteroscope.
1503FIGURE 26-44 Office hysteroscopy instruments. An assembled continuous flow
operating hysteroscope with a 5.5-mm diameter external sheath is shown connected to
inflow and outflow tubing and an attached medical video camera and light cable. In the
lower right inset are three 5-Fr instruments that can be passed through the operating
channel into the endometrial cavity. From left to right these are biopsy forceps, semi-rigid
scissors, and grasping forceps. In the left inset are bipolar RF instruments. From left to
right these include a “spring tip” for tissue vaporization; a “twizzle tip” for tissue
transection; and a “ball tip” for vessel coagulation.
There are a number of methods whereby the cervix may be accessed.
Historically, a speculum is used, but “vaginoscopic” and occasionally digital
access are additional options applicable to many patients.
When the traditional speculum-based exposure is used for cervical exposure,
the operator should select the smallest speculum possible, particularly when the
procedure is performed under no or local anesthesia. A bivalve speculum hinged
on only one side allows its removal without disturbing the position of the
tenaculum and hysteroscope. Typically, a tenaculum is attached to the cervix;
clinicians can minimize the pain associated with this process by injecting a small
amount of local anesthetic (such as xylocaine 1%) using a spinal needle prior to
grasping the cervix. The use of weighted specula should be avoided in conscious
patients because of the discomfort involved (Fig. 26-45). Dilation may or may not
be required depending on the status of the cervix and the outside diameter of the
hysteroscopic system.
The “vaginoscopic” technique (Fig. 26-45) avoids the speculum, using the
1504hysteroscope to deliver distending media to the vagina, usually allowing visual
access to the external os. Absent cervical stenosis and provided a narrow enough
hysteroscopic system, access to the endometrial cavity can usually be
accomplished with overall comfort greater than that associated with the traditional
technique (299). Such an approach can be additionally useful—even essential—
for virginal women, or others for whom a speculum is inappropriate or
uncomfortable.
Anesthesia
The anesthetic requirements for hysteroscopy vary greatly, depending on the
patient’s level of anxiety, the status of her cervical canal, the procedure, and the
outside diameter of the hysteroscope or sheath. In some patients, diagnostic
hysteroscopy is possible without anesthesia, especially if the patient is parous or
if narrow-caliber (<3 mm in outside diameter) hysteroscopes and sheaths are used
(299). For large-diameter hysteroscopic systems, pain caused by cervical dilation
may be reduced with the preprocedural use of oral or vaginal misoprostol, or by
inserting a laminaria “tent,” in the cervix 3 to 8 hours before the procedure.
Laminaria are thin rods of natural (“slippery elm”) or synthetic construction that,
when passed through the internal os, expand over several hours thereby dilating
the cervix. If laminaria are left in place too long (e.g., longer than 24 hours), the
cervix may overdilate, which is counterproductive for CO2 insufflation.
For most diagnostic and many operative procedures, effective uterine
anesthesia is obtained using local anesthetic techniques, permitting the
hysteroscopy to be done in an office procedure room. Paracervical block may
be the most effective (300). Following exposure of the cervix with a vaginal
speculum, a spinal needle can be used to instill about 3 mL of 0.5% to 1%
lidocaine into the anterior lip of the cervix to allow attachment of a tenaculum to
allow manipulation of the exocervix. While the exact location and depth of the
injection varies with providers and studies, the uterosacral ligament location
(about 4-mm deep at approximately at the 4- and 8-o’clock positions as one looks
at the cervix) has been demonstrated successful (301). Care must be taken to
avoid intravascular injection. An alternative technique is the use of an
intracervical block where the anesthetic agent is injected evenly around the
circumference of the cervix, attempting to reach the level of the internal os. The
efficacy of this approach is unclear (300). Recognizing the complex innervation
of the uterus, alternative or additional topical anesthesia may be applied to the
cervical canal or to the endometrium, or both, using anesthetic spray, gel, or
cream. It is unclear how effective these approaches are, because many of the
study protocols seemed to allow inadequate time between application and
initiation of the procedure (302). A number of options have been published
1505including instillation of 5 mL of 2% mepivacaine into the endometrial cavity with
a syringe or the application of similar amounts of 2% lidocaine gel. Many
operative procedures can be performed with these techniques combined, if
deemed necessary, with the oral or intravenous use of anxiolytics or analgesics.
The use of such systemic agents mandates continuous monitoring of blood
pressure and oxygenation, and the availability of appropriate resuscitative staff
and equipment. An important component of the optimal use of local anesthesia is
to allow sufficient time between injection or application of the agents and the
commencement of the procedure. While injectable local anesthetic agents such as
lidocaine and mepivacaine may have an onset of action of 2 to 3 minutes, it may
take up to 15 to 20 minutes to obtain a maximal effect. If local anesthesia is not
deemed appropriate, regional or general anesthesia may be used in the context of
a surgical center or operating room.
1506FIGURE 26-45 Hysteroscopic access. In many instances, the hysteroscopic system can
be passed into the vagina (vaginoscopic access, top panel), the external os visualized
endoscopically, and then advanced into the endometrial cavity without a tenaculum or
cervical dilation. The more traditional approach of tenaculum and cervical dilation is
necessary if the cervical canal is stenotic or substantially narrower than the outside
diameter of the hysteroscopic system.
Cervical Dilation
1507In many instances, and particularly in vaginally parous women, dilation of the
cervix will be unnecessary, especially if narrow-caliber hysteroscopic systems are
used. Sometimes dilation will be necessary. Although a seemingly simple
process, cervical stenosis, or suboptimal technique can result in perforation that
compromises the entire procedure. If the objective lens of the endoscope cannot
be placed in the endometrial cavity, the hysteroscopy cannot be done. The process
of dilation should be undertaken carefully, respecting the orientation of the cervix
to the axis of the vaginal canal (version) and that of the corpus to the cervix
(flexion). In difficult circumstances, simultaneous ultrasound may be valuable,
and difficult dilation may be facilitated directly with the hysteroscope.
There are a number of options available to facilitate cervical dilation. There is
high-quality evidence that prostaglandin E1 (misoprostol) administered 400 μg
orally or 200–400 μg vaginally, approximately 3 to 24 hours before the procedure
facilitates cervical dilation (303–306). This may have more utility for
postmenopausal women (307) who require estrogenization, with a vaginal
preparation, administered daily for 2 weeks before the procedure (308).
Intraoperatively administered intracervical vasopressin (0.05 U/mL, 4 cc at 4 and
8 o’clock) substantially reduces the force required for cervical dilation (309).
Regardless of the circumstance, the cervix should be dilated as atraumatically as
possible. It is best to avoid using a uterine sound because it can traumatize the
canal or the endometrium, causing unnecessary bleeding and uterine perforation.
The best approach may be to use the hysteroscope, not a dilator or sound, to
explore the cervical canal, a circumstance that generally facilitates visually guided
entry into the endometrial cavity. Should actual obstruction be encountered, the
use of scissors to divide adhesions, or transabdominal ultrasound to guide
advancement of the hysteroscopic is generally successful.
Uterine Distention
Distention of the endometrial cavity is necessary to create a viewing space. The
choices include CO2 gas, high-viscosity 32% dextran 70, and several lowviscosity, electrolyte free fluids, including 1.5% glycine, 3% sorbitol, 5%
mannitol and dextrose in water, and 0.9% normal saline. A pressure of 45 mm Hg
or higher is generally required for adequate distention of the endometrial cavity
and to visualize the tubal ostia. To minimize extravasation, the pressure used
should be the lowest possible to provide adequate exposure, and to stay below the
mean arterial pressure (310). For each of the fluids, there are several methods
used to create this pressure by infusion into the endometrial cavity.
Sheaths
Rigid hysteroscopes are fitted to an external sheath before they are passed into the
1508endometrial cavity through the cervical canal. The design and diameter of the
sheath reflect the dimensions of the endoscope and the purpose of the instrument.
Typical diagnostic combinations have a sheath slightly wider than the telescope,
allowing infusion of the distention media. Operative sheaths have additional
channels, to permit the passage—introduction and removal—of distention media,
and the insertion of surgical instruments, such as RF electrodes or semi-rigid
scissors, biopsy devices, or grasping forceps. These sheaths are usually 5 to 8 mm
in diameter, and some allow continuous flow of distention media in and out of the
endometrial cavity (Fig. 26-46).
FIGURE 26-46 Hysteroscopic sheaths. A: A simple “diagnostic” sheath, with only one
inflow channel (In), but no outflow and no instrument channel. B: A continuous flow
system with two separate sheaths connected together. One sheath is responsible for inflow
(In) and one for outflow (Out), a circumstance that does much to maintain a clear field,
particularly if there is blood or debris. There is a separate instrument channel (IC). C: A
single piece continuous flow sheath with integrated inflow and outflow channel, and an
instrument channel (IC).
Media
CO2 provides an excellent view for diagnostic purposes, but it is unsuitable for
operative hysteroscopy and for diagnostic procedures when the patient is bleeding
because there is no effective way to remove blood and other debris from the
1509endometrial cavity. To prevent CO2 embolus, the gas must be instilled by an
insufflator that is specially designed for the procedure—the intrauterine pressure
is kept below 100 mm Hg, and the flow rate is maintained at less than 100
mL/min.
Normal saline is a useful and safe medium for RF-based procedures that do not
require monopolar RF resectoscopes. Even if there is absorption of a substantial
volume of solution, saline typically does not cause electrolyte imbalance.
Therefore, saline is a good fluid for minor procedures performed in the office.
The development of bipolar RF instrumentation for hysteroscopic surgery has
allowed the application of saline as a distending medium in even more advanced
and complex procedures.
Viscous solutions of 32% dextran 70 are useful for patients who are bleeding,
because they do not mix with blood. However, dextran solutions are expensive, of
limited availability and tend to “caramelize” on instruments, which must be
disassembled and thoroughly cleaned in warm water immediately after each use.
Anaphylactic reactions, fluid overload, and electrolyte disturbances can occur.
For standard operative hysteroscopy with monopolar RF resectoscopes, lowviscosity, nonconductive fluids such as 1.5% glycine, 3% sorbitol, and 5.0%
mannitol are used most often. These solutions can be used with standard,
monopolar RF instrumentation because there are no electrolytes to disperse the
current and impede the electrosurgical effect. Each of these media is inexpensive
and readily available, usually in 3-L bags suitable for continuous-flow
hysteroscopy. Because each fluid is electrolyte-free, extravasation into the
systemic circulation can be associated with electrolyte disturbances. Compared
with 1.5% glycine or 3.0% sorbitol, 5% mannitol is iso-osmolar, and it functions
as a diuretic, an advantage when performing resectoscopic surgery. Regardless of
the electrolyte content of the fluid distending media, systemic “absorption”
must be monitored continuously, or frequently (every 5 minutes), by
collecting outflow from the sheath and subtracting it from the total infused
volume. Frequently the manufacturer fills the bags with more than the 3 L, which
makes accurate calculation of absorbed volume especially difficult (311). There
exist a number of machines designed to provide continuous feedback to the
surgeon regarding the degree of negative fluid balance (Fig. 26-47). Absorbed
volumes of electrolyte free solutions that are greater than 1 L mandate the
intraoperative measurement of electrolyte levels. The risk of fluid overload is
reduced by the judicious restriction of intravenous fluid by the anesthesiologist.
The administration of an appropriate dose of furosemide should be considered,
and the surgeon should plan for the expeditious completion of the procedure. If
there is more than a preset limit (1.0 to 1.5 L of electrolyte free extravasated
fluid, or 2.0 to 2.5 L of normal saline), the procedure should be stopped.
1510Excessive circulating sorbitol may cause hyperglycemia, and large volumes of
glycine may elevate levels of ammonia in the blood (312).
FIGURE 26-47 Fluid management system. Hysteroscopic fluid management systems
combine a pump that delivers fluid to the endometrial cavity with a system for calculating
the amount of fluid that is absorbed systemically—the deficit. The bags of fluid are hung
(A) and connected to the pump (B) that delivers the media via tubing (C) to the inflow
channel of the hysteroscopic system (D). Then, the fluid is either systemically absorbed
through blood vessels or the peritoneal cavity via fallopian tubes, or collected from the
outflow channel of the hysteroscope (E), the underbuttocks drape (F) and, if available,
floor suction (G), into containers at the base of the system (H).The collected fluid is
weighed by an electronic scale (I) and the microprocessor system converts this weight to
volume that, when subtracted from the measured infused volume by the microprocessor,
allows the “deficit” to be displayed on the screen in mL (J).
Media Delivery Systems
Syringes can be used for office diagnostic procedures and are especially good for
infusing dextran solution. The syringe can be operated by the surgeon and is
either connected directly to the sheath or attached by connecting tubing. Because
1511this technique can be tedious, it is suited only for diagnostic hysteroscopy and
simple operations such as polypectomy or IUD retrieval.
For low-viscosity fluids such as normal saline, continuous hydrostatic pressure
is effectively achieved by elevating the vehicle containing the distention media
above the level of the patient’s uterus. The achieved pressure is the product of the
width of the connecting tubing and the elevation—for operative hysteroscopy
with 10-mm tubing, intrauterine pressure ranges from 70 to 100 mm Hg when the
bag is between 1 to 1.5 m above the uterine cavity.
FIGURE 26-48 Flexible hysteroscope. This flexible hysteroscope uses optical fibers for
both light and optical transmission has an integrated fluid channel for delivery of media
and a 3.5-mm outer diameter and can be articulated (inset) to provide a better view in the
cornua or for the uterine sidewalls. The “post” to connect the system to the remote “cold”
light source is in the lower right. These hysteroscopes are not suitable for surgical
procedures because they both lack an operating channel and the continuous flow system
needed to keep the field clear.
A pressure cuff may be placed around the infusion bag to elevate the pressure
in the system. Caution must be exercised, because this technique causes
increasing extravasation if intrauterine pressure rises above the mean arterial
pressure.
A variety of infusion pumps are available, ranging from simple devices to
instruments that maintain a preset intrauterine pressure. Simple pump devices
1512continue to press fluid into the uterine cavity regardless of resistance, whereas the
pressure-sensitive pumps reduce the flow rate when the preset level is reached,
thereby impeding the efflux of blood and debris and compromising the view.
Virtually all media management systems designed for hysteroscopic use allow the
surgeon to preset an intrauterine pressure. Such pressure management is usually
based on measurements in the remote machine, so data may be delayed and
somewhat inaccurate. The development of more sensitive and accurate pressure
management systems is a remaining need.
Imaging
Endoscopes
Hysteroscopes are available in two basic types—flexible and rigid. Flexible
hysteroscopes (Fig. 26-48) are self-contained in that they do not require a sheath
—the single integrated channel is used to transmit gas or fluid to the endometrial
cavity for distention. As a result, these instruments are generally of smaller
diameter than rigid systems. They can be designed to be “steerable” allowing
angled viewing. Flexible hysteroscopes utilize fiberoptic bundles rather than
lenses to transmit the image to the observer, have lower resolution than rigid
instruments of a similar diameter and typically do not have a channel with a
caliber suitable for most hand instruments. For other uses, rigid hysteroscopes are
more durable and provide a superior image. The most commonly used
hysteroscopes are 3 to 4 mm in outside diameter, although those using fibers can
be made smaller than 2 mm in diameter.
Rigid endoscopes require an angled (foreoblique) lens to provide a field of
view useful for operative hysteroscopy. In addition to 0-degree versions, they are
commonly used in 12- to 15-degree, and 25- to 30-degree models (Fig. 26-49).
The surgeon must be aware of the difference between the viewing angle and the
long axis of the endoscope to facilitate passage through the cervical canal (Fig.
26-50). The 0-degree telescope provides a panoramic view and is best for
diagnostic procedures, although it is the standard lens used for the hysteroscopic
electromechanical and similar systems. Hysteroscopes with 25- to 30-degree
angles are most often used for cannulation of the fallopian tubes or placement of
sterilization devices. Twelve- to 15-degree designs are a suitable compromise
useful for diagnosis and most operative procedures. The utility of endoscopes
with more extreme foreoblique views may be offset by the tendency of
instruments to leave the visual field on full extension.
Light Sources and Cables
Adequate illumination of the endometrial cavity is essential. Because it runs from
a standard 110- or 220-volt wall outlet, the light source requires no special
1513electrical connections. For most cameras and endoscopes, the element must have
at least 150 watts of power for direct viewing and preferably 250 watts or more
for video and operative procedures (313).
FIGURE 26-49 Rigid hysteroscopes. Demonstrated are a 12-degree (bottom) and a 30-
degree (top) foreoblique variety.
1514FIGURE 26-50 Rigid endoscope optics. A: When the 0 degrees hysteroscope is inserted
into the cervix the cervical canal is generally central (top) and the direction of insertion is
aligned with the viewing angle. When a 12-degree lens is inserted with the axis of the
endoscope aligned with that of the cervix, the canal will be seen to be anterior (middle), a
circumstance that becomes more extreme with a 30-degree viewing angle to the point that
only the cervical sidewall is seen (bottom). B. Adjusting the viewing angle to see the
cervical canal for the 12-degree and the 30-degree lenses is shown. This maneuver
1515demonstrates the location of the canal, but for insertion the axis must be oriented as in A.
Imaging
Although diagnostic hysteroscopy may be performed with direct visualization, it
is best to use video guidance for prolonged operations. Video imaging is
important for teaching and recording pathology and procedures. The camera must
be sensitive because of the narrow diameter of the endoscope and the frequently
relatively dark background of the endometrial cavity, particularly when it is
enlarged. For procedures at increased risk for perforation, such as lysis of
adhesions or when dissection deeply invades the myometrium, simultaneous
transabdominal ultrasound imaging can be used (Fig. 26-51).
Image Documentation
A small video camera can be used to coordinate the procedure with the operating
room team and to teach or monitor the performance of trainees. Video imaging
has utility for the patient when hysteroscopic surgery is performed without
sedation, facilitating their understanding of the pathology, if present, and the
procedure performed. It allows the acquisition of still or video images for future
reference or teaching, although it is important to preserve patient anonymity, or
privacy, depending on the nature and purpose of the recorded material. Several
video recording formats are available, each with inherent advantages and
disadvantages. High-definition digital cameras provide high-quality video still
images and high-resolution digital video, suitable for publication or teaching.
Intrauterine Cutting and Hemostasis
The instruments available for use through operative hysteroscopes include
electrosurgical instruments, mechanically operated biopsy, grasping, cutting, and
punch-biopsy devices. These tools are narrow and flexible enough to navigate the
1- to 2.3-mm diameter operating channel (Fig. 26-44). The value of mechanical
devices is often limited by their small size and relatively flimsy construction. The
biopsy forceps can be used to sample targeted lesions, the scissors to divide
adhesions, dissect myomas and transect polyps, and the grasping forceps to
remove small polyps or intrauterine devices. Some operative hysteroscopes are
designed to allow passage of fibers for the conduction of Nd:YAG laser energy,
although this modality has generally been superseded by electrodes that provide
similar or superior functionality at reduced cost.
1516FIGURE 26-51 Simultaneous hysteroscopic and transabdominal ultrasound imaging.
For procedures at enhanced risk for uterine perforation, the use of transabdominal
ultrasound can provide the surgeon with a view of both the endometrial cavity and the
myometrium and serosa. The fluid in the endometrial cavity provides a contrast medium
that facilitates sonographic identification of the intrauterine instruments.
The uterine resectoscope is like the one used in urology and is designed to
apply RF electrical energy in the endometrial cavity (Fig. 26-52). An
understanding of the principles of electrosurgery is mandatory for safe and
effective use of this instrument. By sliding the “working element,” one of a
variety of electrode tips can be manipulated back and forth within the cavity.
Tissue can be divided with a pointed electrode, excised with a loop, or desiccated
with a rolling ball or bar. An electrode with multiple tips or edges can be used to
vaporize tissue, provided high-power generator outputs are used. For monopolar
resectoscopes clear operative field is maintained by the continuous flow of
nonconductive distending media in and out of the cavity. Although basic design
modifications have made the resectoscope more useful in gynecology, extraction
1517of resected fragments is time-consuming. The most effective approaches include
“trapping” of fragments between the electrode and the distal tip of the endoscope,
or the periodic use of a uterine curette, or polyp forceps, inserted after removal of
the resectoscope. One company has introduced a system that aspirates the
fragments as they are made. Alternatively, much of the myoma or endometrium
can be vaporized, thereby minimizing the need for periodic but time-consuming
removal of tissue “chips.” If vaporization is used, it is important to obtain
representative samples of the endometrium or myoma for pathologic analysis.
Resectoscopes are available in both monopolar and bipolar designs. The
advantages of bipolar systems—decreased electrosurgical injuries, and, because
saline can be used, reduced risk of fluid and electrolyte complications, and
increased tolerance for systemic media absorption—are increasingly making them
the best choice for surgeons and patients.
The problem of tissue removal has been partially addressed by using an
alternative design to the resectoscope. These hysteroscopic morcellation, or
“tissue removal” devices are based on the design of an orthopedic endoscopic
“shaver.” They comprise a hollow cannula and a distal fenestration or “window”
that is repeatedly opened and closed with a reciprocating blade that “chops” the
target tissue as it is aspirated through the window into the suction channel (Fig.
26-53). These devices are particularly useful for large polyps and FIGO type 0
and many type 1 leiomyomas, but require additional dissecting techniques for
many deeper type 1 and type 2 fibroid resection (271) (Fig. 26-40).
FIGURE 26-52 Resectoscope. The assembled resectoscope is shown, with two electrodes
in the foreground. Manipulation of the electrode is via the white handle in the proximal
portion of the device.
1518FIGURE 26-53 Electromechanical morcellator. These systems have their own
proprietary hysteroscope system with an offset eyepiece (right) to allow for one of the
rigid hollow probes (bottom) to be inserted. The probe is connected to a motor drive
(center) that is activated by depressing a footpedal (upper left) that activates both an
oscillating blade and suction. The blade transects the tissue, and the suction transports it to
a collecting sac in the fluid management system.
Other Instrumentations
For any hysteroscopic procedure, it is necessary to have available a cervical
tenaculum, dilators, uterine curette, and appropriate-sized vaginal specula. When
using the resectoscope, it is helpful to have a modern, solid-state, isolated circuit
electrosurgical generator capable of delivering modulated and nonmodulated RF
current. The simultaneous use of transabdominal ultrasound is often necessary to
aid in difficult uterine access situations, or to assist in guiding the performance of
adhesiolysis or myomectomy of type 2 leiomyomas. Laparoscopy or laparotomy
may be necessary for emergencies secondary to uterine perforation.
1519Complications
The primary potential risks of positioning a hysteroscopic system in the
endometrial cavity solely for viewing (“diagnostic hysteroscopy”) are limited to
cervical trauma and uterine perforation. Other adverse events such as infection,
excessive bleeding, and complications related to the distention media are
extremely uncommon when the procedure is short, and does not involve
instrumentation of the myometrium (0%–1%) (298). The risks of operative
hysteroscopy are related to one of five aspects of the procedure performed:
(a) anesthesia; (b) distention media; (c) perforation; (d) bleeding; and (e) the
use of energy (284,298).
Anesthesia
Local anesthetic protocols typically include the intracervical or paracervical
injection of 0.5% to 2% lidocaine or mepivacaine solution, with or without a local
vasoconstrictor such as adrenaline. The risk of overdosage is minimized by
ensuring that intravascular injection is avoided and by not exceeding the
maximum recommended doses (lidocaine, 4 mg/kg; mepivacaine, 3 mg/kg). The
use of a dilute vasoconstrictor such as epinephrine 1/200,000 reduces the amount
of systemic absorption of the agent, virtually doubling the maximum dose that
can be used and facilitates the onset of action of local anesthetic agents (314).
Complications of intravascular injection or anesthetic overdose include allergy,
neurologic effects, and impaired myocardial conduction. Allergy is characterized
by the typical symptoms of agitation, palpitations, pruritus, coughing, shortness of
breath, urticaria, bronchospasm, shock, and convulsions. Treatment measures
include administration of oxygen, isotonic intravenous fluids, intramuscular or
subcutaneous adrenaline, and intravenous prednisolone and aminophylline.
Cardiac effects related to impaired myocardial conduction include bradycardia,
cardiac arrest, shock, and convulsions. Emergency treatment measures include the
administration of oxygen, intravenous atropine (0.5 mg), intravenous adrenaline,
and the initiation of appropriate cardiac resuscitation. The most common central
nervous system manifestations are paresthesia of the tongue, drowsiness, tremor,
and convulsions. Options for therapy include intravenous diazepam and
respiratory support.
Distention Media
[17] The other major complication associated with hysteroscopic procedures
is excessive absorption of media, a risk that can be minimized with careful
attention to technique.
1520Carbon Dioxide
Because carbon dioxide is highly soluble in blood emboli that occur are
usually clinically insignificant. However, in rare instances, CO2 emboli may
result in serious intraoperative morbidity and even death (315–317). These
risks can be eliminated by avoiding the use of CO2 with operative procedures, or
minimized by ensuring that the insufflation pressure is always lower than 100 mm
Hg, and that the flow rate is lower than 100 mL/min. The insufflator used must be
especially designed for hysteroscopy; it is difficult to set laparoscopic insufflator
flow rates below 1,000 mL/min.
Dextran 70
Dextran 70 is a hyperosmolar medium that, albeit rarely, can induce an allergic
response, or coagulopathy (318,319). Similar to other types of distention media if
sufficient volumes are infused, there is a risk of vascular overload and heart
failure (320,321). Because dextran is hydrophilic, it can draw 6 times its own
volume into the systemic circulation. Consequently, the volume of this agent
should be limited to less than 300 mL. There is little use of dextran 70 because of
the limited supply of the solution.
Low-Viscosity Fluids
The low-viscosity fluids—1.5% glycine, 3% sorbitol, and 5.0% mannitol—are
commonly used, largely because of their low cost, compatibility with monopolar
electrosurgical instruments, and availability in large-volume bags. Should these
electrolyte-free, and usually hypotonic, media be absorbed to excess in the
systemic circulation, they can create serious fluid and electrolyte disturbances a
potentially dangerous complication which can result in pulmonary edema,
hyponatremia, heart failure, cerebral edema, and death. These issues combine to
support the notion that, where possible, it is best to use systems that can function
in normal saline or similar solutions. While the risk of fluid overload remains,
patients will tolerate a larger volume of systemic absorption without the risk of
electrolyte imbalance and related complications. There exist a number of
published guidelines describing the steps required to reduce the risk of fluid
overload at the time of hysteroscopy, but those from the AAGL are the most
current (322).
1. Before undertaking anything but simple operative procedures using these
agents, baseline serum electrolyte levels should be measured. Women with
cardiopulmonary disease should be evaluated carefully. While high-quality
studies have suggested that the selective preoperative use of agents such as
1521GnRH agonists may reduce operating time and media absorption (323,324),
another, equally well-designed trial, did not reach the same conclusions (325).
Intracervical injection of 8-mL dilute intracervical vasopressin (0.01 U/mL)
immediately prior to surgery has been shown effective at reducing the amount
of systemic absorption of distending media (326). The duration of this effect
may be limited to approximately 20 to 30 minutes so repeat dosing at suitable
intervals may be useful.
2. In the operating room, media infusion and collection should take place in a
closed system to allow accurate measurement of the “absorbed” volume. [19]
The volume should be measured continuously with a device specifically
designed for the purpose. If such a system is not available, volume should be
calculated every 10 minutes by support staff who are trained in these
calculations and unencumbered by duties that may interfere with this task. If
such “manual” methodology is used, it is important to understand that
available evidence suggests that there is a great deal of variability and
inaccuracy with such techniques (327).
3. The lowest intrauterine pressure necessary for adequate distention should be
used to complete the operation, if possible at a level that is below the mean
arterial pressure. A good range is 70 to 80 mm Hg, which can be achieved
with a specially designed pump or by maintaining the meniscus of the infusion
bag 1 m above the level of the patient’s uterus.
4. When using electrolyte free media, deficits of more than 1 L require
repeat measurement of serum electrolyte levels and consideration of the
dose of intravenous furosemide appropriate to the patient’s renal
function. When such a deficit exists, the procedure should be completed
expeditiously. If the deficit reaches a preset limit (no more than 1.5 L), the
procedure should be terminated, and a diuretic such as mannitol or furosemide
should be used as needed. The maximum deficit allowed when normal saline
is used, is approximately 2.5 L. Regardless of the media, small patients, or
those with cardiovascular compromise will typically have a lower tolerance
for fluid deficits, a circumstance that mandates setting a lower limit for
systemic absorption and, consequently, termination of the procedure (328).
Perforation
Perforation may occur during dilation of the cervix, positioning of the
hysteroscope, or because of the intrauterine procedure itself. [18] The risks of
perforation can be reduced by careful attention to the techniques used to access
the endometrial cavity, and by careful use of energy-based systems.
With complete perforation, the endometrial cavity typically does not distend,
and the visual field is generally lost. When perforation occurs during dilation of
1522the cervix, the procedure must be terminated, but, because of the blunt nature of
the dilators, usually there are no other injuries. If the uterus is perforated by the
activated tip of a laser, electrode, or an activated electromechanical tissue
removal device, there is a risk for bleeding or injury to the adjacent viscera.
Therefore, the operation must be stopped, and laparoscopy or laparotomy
should be performed. Injury to the uterus is relatively easy to detect with a
laparoscope. However, mechanical or thermal injury to the bowel, ureter, or
bladder is more difficult to the extent that laparoscopy is frequently inadequate to
make a complete evaluation. If the patient’s condition is managed expectantly,
she should be advised of the situation and asked to report any symptoms of
bleeding or visceral trauma such as fever, increasing pain, nausea, and vomiting.
Bleeding
Bleeding that occurs during or after hysteroscopy results from trauma to the
vessels in the myometrium or injury to other vessels in the pelvis. Myometrial
vessels are more susceptible to laceration during resectoscopic procedures that
require myometrial dissection for procedures such as endometrial resection or
FIGO type 1 or type 2 myomectomy.
In planning operations that involve deep resection, anemic patients should be
treated medically, if possible, with agents such as ulipristal acetate or a GnRH
agonist, if necessary, while oral or intravenous iron is used to replenish iron
stores. An alternative approach, perhaps suitable for nonanemic patients is
obtaining and storing autologous blood before surgery.
The risk of bleeding may be reduced by the preoperative injection of diluted
vasopressin into the cervical stroma (326). The risk of injury to the branches of
the uterine artery can be lowered by limiting the depth of resection in the lateral
endometrial cavity near the uterine isthmus, where ablative techniques should be
considered. When performing myomectomy, identification and dissection of the
pseudocapsule, totally or largely eliminates myometrial injury and related
bleeding. When bleeding is encountered during resectoscopic procedures, the ball
electrode can be used to desiccate the vessel electrosurgically. Intractable
bleeding may respond to the injection of diluted vasopressin or to the inflation of
a 30-mL Foley catheter balloon or similar device in the endometrial cavity (260).
Thermal Trauma
Thermal injury to the intestine or ureter may be difficult to diagnose, and
symptoms may not occur for several days to 2 weeks. Therefore, the patient
should be advised of the symptoms that could indicate peritonitis.
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