More Related Content
Similar to Gynecological Laparoscopy powerpoint slide (20)
Recently uploaded (20)
Gynecological Laparoscopy powerpoint slide
- 2. 2 2 Introduction Introduction During the past few years laparoscopy has During the past few years laparoscopy has become one of the most frequently performed become one of the most frequently performed operations in gynecological departments. Initially operations in gynecological departments. Initially it was used for occlusion of the fallopian tube as it was used for occlusion of the fallopian tube as a simple method of female sterilization and for a simple method of female sterilization and for the diagnosis of pelvic pain and infertility, but the diagnosis of pelvic pain and infertility, but increasingly it is being used for operative increasingly it is being used for operative procedures, which are described in detail in procedures, which are described in detail in different sections of this book. Before embarking different sections of this book. Before embarking on such procedures it is essential that each on such procedures it is essential that each surgeon develops a safe technique for surgeon develops a safe technique for insufflating the abdomen and inserting the insufflating the abdomen and inserting the laparoscope and various ancillary probes and laparoscope and various ancillary probes and instruments. instruments.
- 3. 3 3 Contraindications Contraindications Absolute Absolute Mechanical and paralytic ileus Mechanical and paralytic ileus Large abdominal mass Large abdominal mass Generalized peritonitis Generalized peritonitis Irreducible external hernia Irreducible external hernia Cardiac failure Cardiac failure Recent myocardial infarction Recent myocardial infarction Cardiac conduction defects Cardiac conduction defects Respiratory failure Respiratory failure Severe obstructive airways Severe obstructive airways disease disease Shock Shock
- 4. 4 4 Contraindications Contraindications Relative Relative Multiple abdominal incisions Multiple abdominal incisions Abdominal wall sepsis Abdominal wall sepsis Gross obesity Gross obesity Hiatus hernia Hiatus hernia Ischaemic heart disease Ischaemic heart disease Blood dyscrasias and coagulopathies Blood dyscrasias and coagulopathies
- 5. 5 5 Anesthetic Considerations Anesthetic Considerations Patients are usually admitted on the day Patients are usually admitted on the day of operation, they are given oral of operation, they are given oral benzodiazepine. Intravenous induction of benzodiazepine. Intravenous induction of anesthesia is achieved with propofol and anesthesia is achieved with propofol and muscle relaxation with atracurium. muscle relaxation with atracurium. Endotracheal intubation is used for all Endotracheal intubation is used for all patients since we believe that a laryngeal patients since we believe that a laryngeal mask is inherently unsafe, particularly for mask is inherently unsafe, particularly for prolonged procedures. Analgesia is prolonged procedures. Analgesia is achieved with fentanyl and achieved with fentanyl and metoclopramide is employed as an metoclopramide is employed as an antiemetic. antiemetic.
- 6. 6 6 Patient Preparation Patient Preparation Patient should be fasted and the bladder emptied. Patient should be fasted and the bladder emptied. Shaving is rarely necessary, but if it is it should Shaving is rarely necessary, but if it is it should be done immediately before the operation. be done immediately before the operation. Bowel preparation is necessary if the surgery is Bowel preparation is necessary if the surgery is close to or involving large bowel. close to or involving large bowel. Antibiotic prophylaxis if vagina is opened or there Antibiotic prophylaxis if vagina is opened or there are fluid instillations via the cervix. are fluid instillations via the cervix. Thromboembolism prophylaxis if indicated. Thromboembolism prophylaxis if indicated.
- 7. 7 7 Insufflation of the Abdominal Insufflation of the Abdominal Cavity with CO2 Cavity with CO2 A vertical incision made A vertical incision made deep inside the inferior deep inside the inferior aspect of the umbilicus, aspect of the umbilicus, to to have a nice have a nice scar resulting scar resulting, , deep fascia and parietal deep fascia and parietal peritoneum meet. The peritoneum meet. The Veress needle is inserted, Veress needle is inserted, initially almost at right initially almost at right angles (Figure), and angles (Figure), and advanced through the advanced through the layers of the abdominal layers of the abdominal wall, feeling each layer as wall, feeling each layer as it is penetrated, for about it is penetrated, for about 1cm before angling it 1cm before angling it forwards towards the forwards towards the anterior pelvis. anterior pelvis.
- 8. 8 8 Entry Technique Entry Technique Intraumbilical incision. Veress needle inserted Intraumbilical incision. Veress needle inserted vertically until peritoneum pierced and then vertically until peritoneum pierced and then angled towards the anterior pelvis. angled towards the anterior pelvis. Confirm peritoneal position of needle. Confirm peritoneal position of needle. Insufflate until pressure of 1 Insufflate until pressure of 15 5 mm Hg. mm Hg. Insert primary trocar, withdrawing sharp point Insert primary trocar, withdrawing sharp point when peritoneum is pierced. when peritoneum is pierced. Steep Trendelenburg position once primary trocar Steep Trendelenburg position once primary trocar has been correctly positioned. has been correctly positioned. Check all around umbilical area for any sign of Check all around umbilical area for any sign of damage to bowel. damage to bowel. If bowel has been damaged by the trocar it If bowel has been damaged by the trocar it should be repaired immediately by a laparotomy. should be repaired immediately by a laparotomy.
- 9. 9 9 Insertion of the Umbilical Trocar Insertion of the Umbilical Trocar and Laparoscope and Laparoscope Once inserted, the Once inserted, the trocar is angled trocar is angled almost horizontally almost horizontally and pushed and pushed forwards towards forwards towards the anterior pelvis, the anterior pelvis, taking care to taking care to avoid the major avoid the major vessels as they vessels as they course over the course over the sacral promontory. sacral promontory.
- 10. 10 10 Initial Inspection Initial Inspection Following insertion of Following insertion of the laparoscope the the laparoscope the surgeon should surgeon should perform an anatomic perform an anatomic tour of the pelvis tour of the pelvis The ovarian fossa and The ovarian fossa and posterior surface of posterior surface of the ovary must also the ovary must also be inspected for be inspected for evidence of evidence of endometriosis and endometriosis and subovarian adhesions subovarian adhesions
- 11. 11 11 Insertion of the Second and Insertion of the Second and Third Operative Trocars Third Operative Trocars Placement of Lateral Placement of Lateral Trocars Trocars Positively identify the Positively identify the deep epigastric arteries deep epigastric arteries lateral to the umbilical lateral to the umbilical ligament, which are ligament, which are visualized from visualized from underneath the underneath the peritoneal surface peritoneal surface Insert lateral trocar Insert lateral trocar under direct vision, under direct vision, vertically at first and vertically at first and then guiding it towards then guiding it towards the anterior pelvic the anterior pelvic compartment. compartment.
- 12. 12 12 Diagnostic laparoscopy Diagnostic laparoscopy Frequently, the physician needs to assess the Frequently, the physician needs to assess the pelvis for acute or chronic pain, ectopic pelvis for acute or chronic pain, ectopic pregnancy, endometriosis, adnexal torsion, or pregnancy, endometriosis, adnexal torsion, or other pelvic pathology. Determination of tubal other pelvic pathology. Determination of tubal patency may also be an issue. Usually, the patency may also be an issue. Usually, the camera lens is placed infraumbilically and a camera lens is placed infraumbilically and a second port is placed suprapubically to probe second port is placed suprapubically to probe systematically and observe pelvic organs. If systematically and observe pelvic organs. If needed, a biopsy specimen can be obtained to aid needed, a biopsy specimen can be obtained to aid in the diagnosis of endometriosis or malignancy. in the diagnosis of endometriosis or malignancy. If tubal patency is a concern, use of a uterine If tubal patency is a concern, use of a uterine manipulator with a cannula allows a dilute dye to manipulator with a cannula allows a dilute dye to be injected transcervically (chromopertubation). be injected transcervically (chromopertubation).
- 13. 13 13 Tubal sterilization Tubal sterilization Bipolar electrosurgery, Bipolar electrosurgery, clips, or silastic bands clips, or silastic bands may be used to may be used to occlude the tubes at occlude the tubes at the mid-isthmic the mid-isthmic portion, approximately portion, approximately 3 cm from the cornua. 3 cm from the cornua. Bipolar surgery Bipolar surgery desiccates the tube desiccates the tube with 3 adjacent passes with 3 adjacent passes to occlude to occlude approximately 2 cm of approximately 2 cm of tube. tube. Laparoscopic view of a falopian ring in place
- 14. 14 14 Tubal sterilization Tubal sterilization Laparoscopic view Laparoscopic view of the insertion of a of the insertion of a Filshie clip Filshie clip
- 15. 15 15 LAPAROSCOPIC LAPAROSCOPIC FIMBRIOPLASTY FIMBRIOPLASTY The principle of fimbrioplasty is to restore The principle of fimbrioplasty is to restore the original anatomy of the infundibulum the original anatomy of the infundibulum by treating the phimosis. by treating the phimosis. Section of the adhesions reveals the tubal Section of the adhesions reveals the tubal phimosis. A fine atraumatic forceps phimosis. A fine atraumatic forceps inserted via the contralateral trocar to the inserted via the contralateral trocar to the tube is then cautiously introduced into the tube is then cautiously introduced into the phimosis. By gently opening it, the phimosis. By gently opening it, the adhesions and bridles in the infundibulum adhesions and bridles in the infundibulum can be observed and exposed can be observed and exposed
- 16. 16 16 LAPAROSCOPIC LAPAROSCOPIC SALPINGOSTOMY SALPINGOSTOMY This technique This technique consists of creating a consists of creating a new ostium in cases new ostium in cases where the distal part where the distal part of the tube is totally of the tube is totally occluded occluded (hydrosalpinx). The (hydrosalpinx). The operation comprises operation comprises two phases: incision two phases: incision and eversion and eversion
- 18. 18 18 Laparoscopic Ovarian Surgery Laparoscopic Ovarian Surgery General Principles General Principles All of the general principles described for All of the general principles described for laparoscopic surgery are applied for ovarian laparoscopic surgery are applied for ovarian surgery including: surgery including: Proper selection and preoperative counselling of Proper selection and preoperative counselling of patients. patients. General endotracheal anesthesia. General endotracheal anesthesia. Urinary drainage with a Foley catheter. Urinary drainage with a Foley catheter. Capability to perform immediate laparotomy if Capability to perform immediate laparotomy if necessary. necessary. Uterine manipulator placed inside the uterus. Uterine manipulator placed inside the uterus. Experience in operative laparoscopy. Experience in operative laparoscopy.
- 19. 19 19 Laparoscopic Ovarian Surgery Laparoscopic Ovarian Surgery Technique of Technique of Ovarian Cystectomy Ovarian Cystectomy The ideal site is the The ideal site is the antimesenteric antimesenteric portion of the ovary, portion of the ovary, away from the blood away from the blood vessels of the hilus. vessels of the hilus. Figure Figure- - The cyst wall The cyst wall is grasped through is grasped through the ovarian incision the ovarian incision
- 20. 20 20 Laparoscopic Ovarian Laparoscopic Ovarian Surgery Surgery The cyst wall is The cyst wall is stripped out of the stripped out of the ovary ovary Suture of the ovary Suture of the ovary after cystectomy. after cystectomy.
- 21. 21 21 Laparoscopic Oophorectomy Laparoscopic Oophorectomy Laparoscopic Laparoscopic oophorectomy or oophorectomy or salpingo- salpingo- oophorectomy are oophorectomy are preferred when the preferred when the cyst fills the ovary cyst fills the ovary and in and in postmenopausal postmenopausal women. women.
- 22. 22 22 Endometriosis Endometriosis The endometrioma has typical features, The endometrioma has typical features, which i which include: nclude: Size not more than 12cm in diameter. Size not more than 12cm in diameter. Adhesions to the pelvic sidewall and/or the Adhesions to the pelvic sidewall and/or the posterior broad ligament. posterior broad ligament. 'Powder burns' and minute red or blue spots 'Powder burns' and minute red or blue spots with adjacent puckering on the surface of the with adjacent puckering on the surface of the ovary. ovary. Tarry, thick chocolate-colored fluid content. Tarry, thick chocolate-colored fluid content. In contrast with other ovarian cysts the walls In contrast with other ovarian cysts the walls of the small endometrioma do not usually of the small endometrioma do not usually collapse after opening the cyst, and in the collapse after opening the cyst, and in the absence of fibrosis have the pearl-white absence of fibrosis have the pearl-white appearance of ovarian cortex appearance of ovarian cortex
- 23. 23 23 Endometriosis Endometriosis A typical small A typical small endometrioma with endometrioma with the puckered scar the puckered scar closing the closing the invagination of the invagination of the ovarian cortex. The ovarian cortex. The ovary is rotated and ovary is rotated and manipulated to rest on manipulated to rest on the anterior side of the anterior side of the uterus exposing the uterus exposing the anterior face. the anterior face.
- 24. 24 24 Endometriosis Endometriosis The inside wall is The inside wall is ovarian cortex, ovarian cortex, which has a slightly which has a slightly pigmented pigmented appearance. appearance.
- 25. 25 25 Treatment of ectopic pregnancy Treatment of ectopic pregnancy Laparoscopy is the surgery of choice Laparoscopy is the surgery of choice for most ectopic pregnancies. A for most ectopic pregnancies. A salpingostomy or salpingectomy may salpingostomy or salpingectomy may be used to remove the embryo and be used to remove the embryo and gestational sac. Auxiliary gestational sac. Auxiliary instruments, such as pretied loops or instruments, such as pretied loops or stapling devices, may be particularly stapling devices, may be particularly well suited for the salpingectomy, well suited for the salpingectomy, although any of the power although any of the power instruments work equally well instruments work equally well
- 26. 26 26 Lysis of adhesion Lysis of adhesion Adhesions may form due to prior infection, Adhesions may form due to prior infection, such as a ruptured appendix or pelvic such as a ruptured appendix or pelvic inflammatory disease (PID), inflammatory disease (PID), endometriosis, or previous surgery. endometriosis, or previous surgery. Adhesions may contribute to infertility or Adhesions may contribute to infertility or chronic pelvic pain. Adhesions may be chronic pelvic pain. Adhesions may be lysed by blunt or sharp dissection. lysed by blunt or sharp dissection. Aquadissection may aid in the Aquadissection may aid in the development of planes prior to lysing. development of planes prior to lysing.
- 27. 27 27 Removal of the Myoma Removal of the Myoma The myomas must The myomas must always be extracted to always be extracted to avoid peritoneal avoid peritoneal reimplantation, which reimplantation, which causes postoperative causes postoperative pain, and also to carry pain, and also to carry out histology. The out histology. The myoma may be myoma may be removed through the removed through the suprapubic puncture suprapubic puncture site after enlargement site after enlargement of the incision (20mm) of the incision (20mm) with a one- or two- with a one- or two- tooth tenaculum. tooth tenaculum.
- 28. 28 28 Removal of the Myoma Removal of the Myoma The myoma is The myoma is isolated. isolated. Uterine closure Uterine closure (interrupted (interrupted sutures sutures
- 29. 29 29 CervicaI Cancer- CervicaI Cancer- lymphadenectomy lymphadenectomy Laparoscopic view Laparoscopic view after opening of after opening of the paravesical the paravesical space. space.
- 30. 30 30 CervicaI Cancer- CervicaI Cancer- lymphadenectomy lymphadenectomy Identification and Identification and blunt dissection of blunt dissection of the external iliac the external iliac vein vein T The obturator he obturator pedicle and the pedicle and the internal obturator internal obturator muscle. muscle.
- 32. 32 32 Complications of Laparoscopy Complications of Laparoscopy Peri-operative pulmonary, thrombo-embolic, urinary Peri-operative pulmonary, thrombo-embolic, urinary Anesthetic particularly associated with long Anesthetic particularly associated with long procedures and patients classed as poor anesthetic risk procedures and patients classed as poor anesthetic risk Entering the peritoneal cavity various needle injuries, Entering the peritoneal cavity various needle injuries, trocar injuries trocar injuries, , blood vessels potentially at risk, blood vessels potentially at risk, particularly the bowel, urinary tract and great vessels particularly the bowel, urinary tract and great vessels Insertion of lateral ports injury to epigastric vessels Insertion of lateral ports injury to epigastric vessels should largely be avoided by direct visualization should largely be avoided by direct visualization internally, and lateral ports should be inserted carefully internally, and lateral ports should be inserted carefully under direct vision under direct vision Electrosurgical injuries transmitted heat, open circuit, Electrosurgical injuries transmitted heat, open circuit, faulty insulation, capacitative coupling; faulty insulation, capacitative coupling; Laser injuries (transmitted heat, overshooting of Laser injuries (transmitted heat, overshooting of target) target) Port site complications (hematoma, infection and Port site complications (hematoma, infection and hernia). hernia).