LAPAROSCOPY

Shenillee Burgess
Reyad Hosein
 Outline
Definition
Indications:Diagnostic,Therapeutic
LaparoscopicProcedure
Advantages&Disadvantages
Contraindications,RiskFactors
Complications
Consent
CommonProcedures
 Definition

Laparoscopy(MinimallyInvasiveSurgery)
isanendoscopicoperativeprocedurethat
allowsasurgeontogainaccesstothe
insideoftheabdomenandpelviswithout
havingtomakelargeincisionsintheskin.
 Indications

Diagnostic

Therapeutic
 Diagnostic

EVALUATIONOFINFERTILITY
TubalPatency
Endometriosis
Peritubal/PerifimbrialAdhesions
PolycysticOvaries
 Diagnostic
EVALUATIONOFACUTEPELVICPAIN
AccidentToOvarianCyst
Endometrioma
EctopicPregnancy
Adhesions
 Diagnostic
EVALUATIONOFCHRONICPELVIC
PAIN
Endometriosis
PelvicInflammatoryDisease
Adhesions
OvarianCyst
 Therapeutic (4 Cs)
CANCER/TUMOUR
OvarianCyst(Aspiration,Puncture)
RemovalOfSubserosalFibroids

CONTRACEPTION
TubalSterilization
Removal Of Foreign Bodies From Peritoneal
Cavity(IUCD
 Therapeutic
CONCEPTION
Adhesiolysis
In-VitroFertilization

COMPLAINTSOFPAINANDBLEEDING
Endometriosis (Electrocoagulation, Laser
Vaporization)
Polycystic Ovary Syndrome (Laparoscopic
ElectrocauteryDrillingOfOvaries)
 Procedure
UnderG.A.orL.A.
VaginalPreparation:
ModifiedLithotomypositionwithpolestilted
forward.
Bladderemptied;NGTube.
Vaginacleanedanddraped.
Bimanualexam(size,positionandmobility
ofuterus).
 Procedure
Simsspeculum(visualizecervix).
Volsellum or single-toothed tenaculum on
anteriorlip.
Uterine cannula inserted and locked in
position (Spackmans or Rubins cannula
/HumiUterineManipulator).
Speculumremoved
 Procedure
AbdominalPreparation:
Cleanedanddraped.
1cm sub or intra umbilical incision/Open
Entry.
45oTrendelenburgposition.
Pneumoperitoneum-Verresneedle/CO2.
Trocarandcannulainsertedata600angleto
theskintowardsthesacralpromontory
 Procedure
Trocar removed, escaping gas
heard.
Laparoscope/light source
inserted.
Other ports and instruments eg
graspingforceps,scissors.

 End of Procedure
Instrumentsareremovedinreverseorderof
insertion.

Return patient to horizontal position; allow gas to

escape with some assistance from abdominal
compression.
Withdrawlaparoscopeandcannula.
Sutureincisions.
Removevaginalinstruments.
 Advantages(Versus
Laparotomy)
Earliermobilisation
Shorterhospitalstay(1-2days)
Morerapidreturntowork
Minimaltissuetrauma/scarring/adhesions
Lessbloodloss
Lowerwoundinfectionrates
Advantages(Versus
Laparotomy)
Lesspost-op.painandmorbidity
Bettercosmeticappearance-key-holesurgery
Economic
Procedurecanberecordedforthepatientsbenefitwithvideo
laparoscopy
 Advantages(VersusHSG)
Painless
Visualise entire pelvis - diagnose adhesions and
endometriosis
Visualisefimbrialends
Minimalcornualspasm
Laparoscopyandmethylenebluedyeinsufflation
goldstandardforassessingtubalpatency
 Disadvantages
Majorinvasivesurgicalprocedure:
Anaestheticcomplications
Traumatobowel,bladder,bloodvessels
Pelvicadhesionsifinadequatehaemostasisorinfections
Usuallylongerintra-operativetime
Largetumours(fibroids/ovariancysts)canbedifficulttoremove
and may have to be morcellated and removed in piecemeal
fashion.

 Disadvantages
Highdegreeoftechnicalskillandtraining.
Equipmenttendstobeexpensive.

Solutions
Structuredtrainingprogrammeforadvanced
laparoscopicskills.
Developmentofregionalcentresformore
advancedsurgicalcases.

 Limitations
Highdegreeoftechnicalskillandtraining.
Equipmenttendstobeexpensive.

Solutions
Structuredtrainingprogrammeforadvanced
laparoscopicskills.
Developmentofregionalcentresformore
advancedsurgicalcases.
Contraindications
Absolute contraindications

1) Acute intestinal obstruction associated with a massive (>4 cm) bowel

dilatation, which may obscure the laparoscopic view and increase the
likelihood of bowel injury

2) Uncorrected coagulopathy

3) Trauma with hemodynamic instability or a clear indication of bowel injuries,

such as presence of bile or evisceration
Relative Contraindications.

1. ICU patients who are too ill to tolerate pneumoperitoneum, potential

hypercarbia, or general anesthesia

2. Recent laparotomy (within 4-6 weeks) or extensive adhesions secondary to

previous abdominal surgery and morbid obesity

3. Moderate to severe cardiorespiratory disease

4. Presence of anterior abdominal wall infection (cellulitis or soft-tissue infection)

Risk Factors
Certain factors or conditions may interfere with a laparoscopy. These factors
include, but are not limited to, the following:

Obesity
History of multiple surgeries resulting in adhesions that prevent safe access to
the abdomen with a laparoscope
Blood from an intra-abdominal hemorrhage may prevent visualization with the
laparoscope
Complications
Gas embolism

Because carbon dioxide is used in laparoscopy to create the pneumoperitoneum, a gas

embolization is an uncommon but very serious complication. Embolization usually is caused
by inadvertent placement of the Veress needle in a major vessel prior to insufflation of the
abdominal cavity with carbon dioxide.

Retroperitoneal major vessel injury

Laceration of major abdominal blood vessels is one of the least common but most life-
threatening complications in laparoscopy. Injuries, which present in approximately 3 per
10,000 laparoscopies, may occur during insertion of the Veress or the primary trocar.vessels
such as inferior epigastric,iliac vessels or rarely aorta
Urologic injuries

Injury to the bladder or ureters can occur during trocar placement, use of power instruments,
or stapling or suturing devices. The greatest challenge is recognizing that the injury has
occurred so that the treatment can be performed in a timely manner.

Anaesthetic complications
Incisional hernia

Burns

Parietal Emphysema

Death (3-8 in 10000)

consent
Do you know what a Laparoscopy is and why youre having it?

Laparoscopy is performed to have a look inside of you using a small camera attached to a video screen.
On the day of your operation you will come in early in the morning.

You cant have had anything to eat or drink from the night before.You will be seen by a number of doctors:
the surgeon performing the operation and because we need to put you to sleep for this procedure, his
anaesthetist.The surgeon will talk to you about the operation and make sure you understand what is

involved.Once you have been taken through to the operating room the anaesthetist will you to sleep, and
this will only be for about 20 minutes as this is a simple and quick procedure.

The surgeon will perform the operation by first blowing gas into your stomach, through a small cut, to
make it bigger making it easier to see inside, then making a small cut to allow the camera inside.
After the operation the gas will be let out, the camera removed. You will be bought round from the
anaesthetic in a recovery room and stay in hospital until the late afternoon. If you are feeling well then
someone may come to pick you up and take you home. You must not drive for 24 hours and you must not
be left alone at home overnight.As with any operation there are a number of risks but these are
minimised.

The main risks are: infection, clots and damage to surrounding structures.Infection is minimised by using
sterile instruments, hand washing and gloves.

Clots occur due to immobility but as the operation is short there is a low risk of this. You will be given
some special stockings to help prevent this anyway. It is very unlikely but damage to surrounding
structures may occur such as bowel and bladder but these would be repaired during the operation but he
surgeon, although a separate incision may be required to do this properly. The aim of this operation is to
diagnose the cause of the pain you are having and this benefit outweighs the risks involved.

Any questions?
Common procedures

1) Tubal Sterilization

2) Lysis of adhesions

3) Aspiration and puncture of ovarian cysts

4) Electrocoagulation or laser vaporization of endometriotic deposits

5) Removal of foreign bodies such as IUCD from the peritoneal cavity

6) Laparoscopic electrocautery drilling of the ovaries from PCOS

7) To be notes in oncology and urogynaecology many procedures can be done

with the aid of the laparoscope