Laparoscopy and Laparoscopic Surgery

REVIEW
Laparoscopy and These can be reduced by thorough pre-operative evaluation. The

learning curve for acquisition of laparoscopic operative skills is
laparoscopic surgery steep and appropriate training in this area is therefore essential.
Laparoscopy versus laparotomy

Frances Powell
The benefits of laparoscopy are well known and many gynae-
Aradhana Khaund cological procedures may now be performed via the minimal
access route. There are a number of advantages to the patient
with laparoscopic surgery versus open surgery including the
Abstract utilisation of smaller skin incisions, reduced post-operative pain
Laparoscopic surgery is an essential component of modern gynaecol- and reduction in post-operative scarring. Less pain leads to the
ogy. It has rapidly evolved from a simple diagnostic technique to a use of less post-operative analgesia, shorter hospital stays and
complex therapeutic surgical option for many gynaecological prob- faster recovery and return to normal activities. Such procedures
lems, both in emergency and elective settings. A sound knowledge are also associated with less intra-operative haemorrhage and
of pelvic anatomy, equipment, entry methods and operative tech- less use of blood transfusions. With a reduction in exposure of
niques is essential for safe and effective laparoscopy. Patient selec- internal organs to the external environment, infection rates are
tion, pre-operative evaluation and counselling are important with also reduced. The cost of complex laparoscopic surgery such as
good communication between surgeons, patients, anaesthetists and hysterectomy compared to open surgery is often greater. This,
theatre staff. Application of optimal laparoscopic ergonomics will however, is off set by shorter hospital stays, quicker recovery
reduce risks to the surgeon. Prompt recognition and management of and return to work.
complications is vital with involvement of other surgical specialities Whist laparoscopic surgery demonstrates clear advantages to
when required. Regular training in minimal access surgery is essential women, a different set of surgical skills is required when
to ensure safe and efficient laparoscopic surgery. A combination of compared to those necessary for open surgery. Laparoscopic
operative experience in theatre and simulation learning is ideal. procedures may be technically more challenging for surgeons
Keywords ergonomics; gynaecology; laparoscopy; laparoscopic with limitation of range of motion at the surgical site, resulting in
surgery; minimal access surgery; simulation; skills acquisition; theatre potential loss of dexterity, less perception of depth and less tactile
layout; training sensation. Visiospatial awareness is essential for laparoscopy and
motor skills may be technically more challenging to learn when
compared to open surgery. Laparoscopy may be more advanta-
Introduction geous in obese women where laparotomy may yield extremely
poor views of the intra-abdominal cavity.
Laparoscopy is a surgical method by which the peritoneal cavity
may be visualised in the absence of a large abdominal incision.
Pre-operative evaluation and patient preparation
The role of laparoscopy in modern gynaecology has expanded
rapidly over the last 25 years, from an initial diagnostic test to Optimal pre-operative evaluation is vital prior to undertaking
one that involves complex therapeutic techniques. The first laparoscopic surgery in order to reduce both anaesthetic and
recorded endoscopic procedure was performed by Kelling in surgical complications and improve surgical outcomes. Risk
1901, in Germany. The first laparoscopy in gynaecology was a factors such as obesity, a low body mass index (BMI), previous
sterilisation procedure performed by Bo €sch in 1936, in surgery, previous intra-abdominal infection, inflammatory bowel
Switzerland. With the development of equipment, including disease and medical conditions must all be considered. A good
electrosurgery, increasingly complex surgery has become history and accurate pre-operative counselling of women are
possible. Development has been particularly rapid since the mid essential.
1980s. Box 1 highlights some relative contraindications to laparos-
Surgical practice in gynaecology has been revolutionised by copy. Few, however, are absolute.
the use of laparoscopic techniques, many of which are now
considered routine. Between 2014 and 2015, more than 72,000
procedures were coded as having been performed laparoscopi- Relative contraindications to laparoscopy
cally by gynaecologists in England. Both recovery times and
length of hospital stays are shorter whilst post-operative pain is C Significant cardiorespiratory compromise
reduced. There are, however, associated risks to be considered. C Obesity
C Diaphragmatic hernia
C Significant intra-abdominal adhesions
C Large pelvic mass
Frances Powell MRCOG Department of Obstetrics and Gynaecology, C Haemodynamic instability or hypovolaemic shock
Wishaw General Hospital, Wishaw, Scotland, UK. Conflicts of C Intestinal obstruction
interest: none declared.
C Some malignant disease
Aradhana Khaund MD MRCOG Department of Obstetrics and C Pregnancy
Gynaecology, Queen Elizabeth University Hospital, Glasgow,
Scotland, UK. Conflicts of interest: none declared. Box 1
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 26:10 297 Crown Copyright Ó 2016 Published by Elsevier Ltd. All rights reserved.
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REVIEW
Adequate discussion between anaesthetic and surgical teams

is essential for women with co-morbidities. The cardiovascular Key factors in optimising laparoscopic ergonomics
changes associated with laparoscopy may be particularly unac-
ceptable for women with significant cardiac and/or respiratory
C Placement of a gel mat under the surgeon’s feet
compromise. In women with previous surgery, the possibility of
C Attention to the number and duration of cases within each theatre
intra-abdominal adhesions should be considered. session
Whilst haemodynamic instability is a relative contraindica- C Optimal positioning of patient to maintain surgeon in a
tion, laparoscopy may provide a number of advantages to open comfortable operating posture
surgery if performed by a gynaecologist with the appropriate C Position theatre assistants appropriately
skills. These include better visualisation of the abdominal cavity, C Maintain operating instruments at elbow height with shoulders
reduced intra-abdominal bleeding secondary to compression relaxed
from the pneumoperitoneum and the ability to control bleeding
C Lower table height after insufflation to maintain ergonomic
effectively with minimal tissue handling. operating surface height
In pregnancy, open surgery has been the tradition for removal
C If using a step, ensure balance is achieved with easy access to
of adnexal cysts. Whilst many still prefer this surgical option, foot diathermy controls
there is growing evidence that laparoscopic surgery is safe in all
C Ensure correct positioning and height of the video monitor to
trimesters, the safest time being the second trimester when avoid neck and eye strain. A downward viewing angle of 15 de-
miscarriage and pre-term labour rates are lowest. grees is recommended with the distance between surgeon and
monitor dependent on the monitor screen size.
Laparoscopic ergonomics C Utilise instruments with maximum ease of manipulation
C Consider arm rests for prolonged procedures
The benefits of gynaecological laparoscopic surgery are well
established, but the effects on the surgeon of performing such Box 2
surgery is rarely reported. Minimisation of risk to the surgeon
may be achieved with optimisation of theatre layout, correct Cameras are usually high definition (HD) providing very clear
positioning of the surgeon and assistant and use of appropriate images with good resolution. The camera incorporates the cam-
instruments. era head, its cable and the camera control unit (CCU). The lens,
Ergonomics is the science of making the environment also known as a coupler, screws on to the camera head and
favourable for the surgeon. Rates of musculoskeletal injury have magnifies the image. Typically, the camera head includes a
increased amongst gynaecologists as the utility of laparoscopic colour bar button, white balance, focus and image capture but-
techniques has increased. Development of more advanced and tons. With improving technology, the use of 3D systems is now
prolonged procedures has also contributed to the situation. Areas more widespread, facilitating improved depth perception.
such as the back, neck, shoulders, proximal upper limbs and Laparoscope diameters vary from 2 to 12 mm whilst the angle
thumbs have been particularly implicated. It is therefore essential of view varies from 0 to 90 degrees. The shaft of the telescope
that the surgeon is as comfortable as possible throughout the contains a quartz lens system with high clarity.
procedure. With appropriate knowledge and training, the oper- The light source is an important component of basic laparo-
ating theatre may be adapted to facilitate optimal operative er- scopic equipment. A fibreoptic cable transmits light via the
gonomics. Box 2 outlines key factors in optimising laparoscopic telescope into the abdomen. All light sources use xenon, halogen
ergonomics. or mercury bulbs. Xenon sources produce optimal illumination.
For standard laparoscopy, a 5 mm diameter cable with a length of
Consent 240 centimetres should be utilised. Light cables should be
Women should be fully informed of the risks and benefits of checked at each use to ensure the fibres remain intact thus
laparoscopic surgery compared to open surgery. Risks directly ensuring optimum light transmission.
related to the entry technique used, visceral damage (damage of The insufflator is an essential part of equipment necessary for
bowel, urinary tract and major blood vessels), infection and the delivery of carbon dioxide (CO2) and subsequent observation
thromboembolism rates, blood transfusion and port site com- of abdominal and pelvic cavities. The latest insufflators incor-
plications (e.g. haematoma formation and post-operative hernia porate a gas-heating system to avoid lowering of body tempera-
formation requiring further surgery) should be discussed. Out- ture. They should have a variable flow rate setting with a range
comes associated with surgery including the surgeon’s experi- of 0e40 litres per minute. Machines have an automatic cut off
ence in the procedure are also relevant. when the set pressure is reached with an alarm sounding at this
All patients undergoing laparoscopic procedures should be point. Carbon dioxide (CO2) is the gas of choice as it is inert, non-
made aware of the risk of conversion to laparotomy and the flammable, non-toxic, readily absorbed into the patient’s circu-
associated longer hospital stay and recovery period. lation with low solubility in body tissues, non-combustible and
odourless. It is also inexpensive and excreted by the lungs and
Equipment kidneys.
All laparoscopic procedures use cannulae to support the
In order to achieve safe and effective surgery, the surgeon must laparoscope/instruments and facilitate access to the peritoneal
have a sound understanding of the basic and specialised equip- cavity. They consist of a hollow cannula and an internal
ment required. removable obturator. Most modern trocars are disposable and
REVIEW
plastic. All have a valve to prevent gas leakage and have a cutting Positioning
or dilating system. Cutting trocars divide tissue as they pass
The patient should initially be placed on the operating table su-
through whilst dilating systems are blunt, separating tissue with
pine with arms tucked in by her sides and legs placed in lithot-
the application of force. Cutting trocars typically have cutting
omy, in padded stirrups. The thigh should be parallel to the
tips; this has led to a reduction in pain and port site bleeding.
abdomen and the knee flexed to 90 degrees. This position pro-
Blunt trocars require more force to insert and can therefore be
vides vaginal access, reduces pressure on the popliteal fossa and
associated with increased vascular injury. Radially expanding
prevents the patient slipping towards the head of the table. The
outer sheaths have also been developed to allow for smaller scars
patient should be flat on the operating table whilst the ports are
and safer trocar insertion. Blunt trocars may be used with an
inserted. As previously discussed, attention should be paid to
optical bladeless entry or when using the open entry technique.
optimal surgical ergonomics. Following port insertion, the pa-
Primary and secondary trocars vary in diameter from 2 to 30 mm.
tient should be placed in a steep Trendelenburg position to allow
The Veress needle has an inner spring loaded blunt obturator.
access to the pelvic organs. Restraint may be provided by padded
It may be disposable or reusable and is used to create a pneu-
shoulder pads. Positioning of monitors is related to surgeon’s
moperitoneum. A lateral hole on the stylet enables CO2 to be
preference. An ideal layout may include a monitor at the patient’s
delivered prior to primary trochar entry. Veress needles are used
feet and a further monitor to each side of the patient, to permit
less frequently as primary trochars have developed. They may be
flexibility for operator and theatre assistants.
useful for benign cyst aspiration during laparoscopic surgery.
Additional equipment such as uterine manipulators, tissue
Anatomy
graspers, scissors, suction-irrigation probes and energy devices
are routinely used in gynaecological laparoscopy. Many dispos- A sound knowledge of anatomy of the anterior abdominal wall
able, semi-reusable and reusable instruments have become and pelvis is essential for safe laparoscopy and limitation of
available. complications. The inferior epigastric artery and ureter are
Tissue dissection may be achieved by both sharp and blunt particularly vulnerable during laparoscopy.
methods and a variety of instruments make this possible. Scis- The primary port is most commonly placed at the umbilicus,
sors may be used in isolation or with an energy source attached. the thinnest part of the abdominal wall, even in obese patients.
Laparoscopic ligation can be performed in a variety of ways. The rectus sheath and peritoneum lie close underneath this.
Pre-tied endoloops may be utilised in addition to intra-corporeal Secondary ports must be placed with care, to avoid the infe-
or extra-corporeal knot tying and use of a self-retaining suture rior epigastric artery which arises from the external iliac artery,
such as the v-loc. Laparoscopic needle holders are required to immediately above the inguinal ligament. It pierces the trans-
facilitate the placement of sutures. versalis fascia as it ascends, entering between the rectus
Electrosurgery is required for many basic and advanced abdominis muscle and the posterior lamella of its sheath. The
laparoscopic procedures. A thorough understanding of energy obliterated umbilical artery, or medial umbilical ligament can be
sources is essential in order to avoid complications. Monopolar identified on the anterior abdominal wall; ports should be placed
electrosurgery is an isolated system where electricity passes lateral to this to avoid the epigastric vessels. Surface landmarks
through the patient and returns to an electrode. In bipolar elec- may also be utilised; ports are inserted 1/3 of the way across a
trosurgery, the two blades, each electrically insulated from each horizontal line from the anterior superior iliac spine to the
other, are the primary and return electrodes. umbilicus.
Cutting is achieved with the utility of high current and low Clear identification of the ureter is important during laparos-
voltage whilst coagulation (a modulated current) is achieved copy as its path places it at particular risk to injury. During
with pulses of current and high voltage. Energy sources may be hysterectomy, the ureter is particularly vulnerable to injury as
applied to standard laparoscopic instruments in order to provide the uterine artery crosses superior to the ureter close to the
an ability to coagulate blood vessels whilst cutting. Lateral lateral fornix of the vagina. Using a uterine manipulator during
spread of bipolar energy is generally limited to 2 mm whilst surgery decreases this risk.
monopolar spread is related to the power utilised and the dura-
tion of application. When using diathermy, the lowest possible Entry methods
power should always be utilised.
Entry into the peritoneal cavity can be performed utilising a
More advanced sealing instruments which combine functions
number of different techniques. There is no clear consensus on
of grasping with a power source to coagulate and divide tissues,
the safest method. The two most common techniques used are
also exist. Mechanical energy devices utilise ultrasound vibration
the closed technique using a Veress needle, and the open or
to cut whilst simultaneously providing haemostasis. Lateral
Hasson technique. More recently, a direct entry approach has
spread of energy is thought to be reduced with these energy
gained popularity.
modalities.
Laser is a relatively more expensive modality. The CO2 laser is Closed entry
most commonly used. It is very precise and associated with the The patient’s bladder should be emptied prior to port insertion to
least thermal injury. It is very effective in achieving vaporisation avoid iatrogenic bladder injury. A small intraumbilical skin is
and cutting, but less so for coagulation. Conversely, lasers with a made through which the surgeon introduces the Veress needle at
short wavelength such as Argon, Neodynium, YAG and KTP right angles to the abdomen, with the operating table in the
have very effective coagulation properties but are less effective in horizontal position. The needle should be tested and the
achieving vaporisation.
REVIEW
abdomen palpated for masses prior to insertion. As the needle tight seal to be made between the skin and trocar thus avoiding
passes through the rectus sheath, resistance is felt as the blunt gas leakage. The obturator is removed, the laparoscope inserted
obturator stylet is forced back exposing the cutting edge which and insufflation commenced. Following removal of the ports at
passes through the sheath and then the peritoneum, into the the end of the operation, the stay sutures are secured to close the
peritoneal cavity. The spring loaded obturator then moves for- defect in the sheath, reducing the risk of port site hernia forma-
ward protecting the abdominal contents from the sharp needle. A tion. This technique is an alternative to closed laparoscopy. It
double click should be audible/felt as the needle passes into the avoids the use of sharp instruments after the initial skin incision
abdominal cavity. Opinion is divided as to whether the anterior and is a useful option for very thin or obese patients.
abdominal wall should be elevated (to lift it away from under-
lying structures) as the needle is passed. Excessive lateral Direct entry
movement of the needle should be avoided to prevent inadver- This technique involves an intraumbilical incision and the use of
tent visceral damage. an optical trocar where the laparoscope is loaded into the pri-
The saline test may be used to assess whether the needle is mary trocar. The trocar is pushed and twisted through the
correctly sited although this is not always accurate with no evi- abdominal wall into the peritoneal cavity under direct vision.
dence to support its routine use. This involves aspiration, to see Once inside the perinoneal cavity, the obturator is removed, the
if any blood, faeces, fluid or pus are aspirated, instillation of laparoscope inserted and a pneumoperitoneum created as
saline to assess for blockage and withdrawal of the syringe to see described previously. This is the most rapid method of entry and
whether saline flows easily. Correct placement of the needle is is an acceptable alternative to the open and closed techniques.
most reliably indicated by the measurement of intra-abdominal Several optical systems have been developed in the last decade.
entry pressure. A reading of 8 mmHg or less with free flow of gas
is reassuring. Secondary trocar placement
Gas should be initially set at a low flow rate (1 litre/minute). Secondary trocars should be inserted under direct vision at 90
Pressure is increased to 20e25 mmHg and flow rate may also be degrees to the skin with an intra-abdominal pressure of 20e25
increased thereafter (e.g. 7e10 litres/minute). The Veress needle mmHg. The inferior epigastric arteries should be visualised and
is withdrawn once a 2e3 litre pneumoperitoneum is achieved. the anterior abdominal wall vessels transilluminated, prior to
The flow rate may be reduced to maintain this and the patient is secondary port placement. They should be placed lateral to the
placed in the Trendelenburg position. The skin excision is then inferior epigastric arteries, minimising the risk of vascular injury
extended vertically to allow passage of the trochar. This should and facilitating a wide operative field. Once the peritoneum has
be in the intraumbilical region, the thinnest part of the abdominal been entered with the trocar tip in vision, the trocar should be
wall where tissues are least vascular and the peritoneum is fixed. directed towards the anterior pelvis immediately. The size, po-
The primary trocar is grasped in the surgeon’s dominant sition and number of secondary ports utilised depend on the
hand, using the index finger along the shaft of the trocar as a operation being performed, the equipment required, the patient’s
buffer to prevent it slipping beyond the depth of the abdominal anatomy, the operator’s arm span and the presence of any
wall. It is inserted at 90 degrees to the skin and then directed adhesions.
towards the pelvis after passing through the abdominal wall. The
trocar is then removed from the port and the laparoscope Special cases
inserted and rotated through 360 degrees, to assess for adhesions The primary port is most commonly inserted at the umbilicus. If,
or damage from needle/trocar insertion. Operating pressure however, there is increased risk of visceral damage due to pre-
should be reduced to 10e15 mmHg at this point. vious surgery or extremes of body habitus (obesity or low BMI)
Formation of a pneumoperitoneum can cause cardiovascular then alternative entry sites should be considered. Following three
compromise by reducing venous return to the heart, leading to failed entry attempts at the umbilicus, an alternative placement
hypotension and bradycardia. The pneumoperitoneum should be of the primary port should be considered.
immediately released if this occurs. Continuous monitoring pCO2 Palmer’s point (named after the French gynaecologist Raoul
is required, especially in obese patients or those with chronic Palmer) lies in the left hypochondrium, in the left mid clavicular
respiratory disease where hyperventilation may not be sufficient line, 3 centimetres below the costal margin. This is an area where
to reduce elevated pCO2. In such cases, the Trendelenburg po- intra-abdominal adhesions are least likely to occur after previous
sition may need to be reversed, the procedure abandoned or surgery, except in cases of previous upper abdominal surgery.
converted to open surgery. A 3 mm skin incision is made and a Veress needle inserted
vertically through the abdominal wall in the usual manner after
Open entry (modified Hasson’s technique) splenomegaly is excluded and the stomach emptied with a naso/
This technique is traditionally preferred by general surgeons and oro-gastric tube. Once a pneumoperitoneum has been achieved,
was first described by Hasson in 1974. An intraumbilical vertical a 5 mm trocar should be inserted and the laparoscope used to
skin incision of approximately 1e2 centimetres is made, long inspect the abdominal cavity. Secondary ports can then be
enough to dissect down to the fascia, grasp and incise the rectus inserted under direct vision and any adhesions dissected to allow
sheath and underlying perinoneum and enter the peritoneal access to undertake the planned surgery. A 5 mm optical trocar
cavity under direct vision. The fascia is secured with a stay su- may be used as an alternative to the Veress needle approach.
ture on each side. Confirmation of opening of the peritoneal Suprapubic primary port insertion is associated with an
cavity is by the visualisation of omentum. A blunt tipped trochar increased risk of bladder damage and pre-peritoneal gas insuf-
is then inserted and the stay sutures secured around it to allow a flation. Passing the Veress needle through the uterine fundus is
REVIEW
associated with ascending infection and may cause bowel injury, umbilicus and peritoneum. Both approaches may be technically
especially if the bowel is adherent to the fundus. Insufflation via challenging.
the Pouch of Douglas is not safe in the presence of deep infil- Women who are young, thin and nulliparous with very well
trating endometriosis where the cul de sac is obliterated and the developed abdominal muscles are at highest risk of vascular
rectum is adherent to the posterior cervix. injury. In such cases, the aorta may lie less than 2.5 centimetres
The risk of adhesion formation is 50% after one previous below the skin. The open technique or Palmer’s point entry are
midline laparotomy and 23% following one lower transverse advised for these women.
incision. Previous peritonitis or inflammatory bowel disease in-
crease the risk of intra-abdominal adhesion formation and sub- Anaesthetic considerations
sequent injury at laparoscopy. In such cases, Palmer’s point
Operative laparoscopy requires muscle relaxation, head down tilt
entry should be considered.
and a sustained pneumoperitoneum. Such conditions make
Port removal general anaesthesia the safest and most preferable option. A
Secondary ports should be removed under direct vision to ensure thorough understanding of the pathophysiological changes
that there has been no inadvertent vessel or visceral injury. On induced by these requirements is necessary in order to optimise
removal of the laparoscope, observation should be made to per-operative care. Regional/local anaesthesia, whilst possible
exclude injury to the bowel at the time of insertion. The gas for the simplest and shortest cases, is not advised. Box 3 outlines
should then be expelled from the abdomen and the primary port the pathophysiological effects of laparoscopy.
removed. Acidosis may be partially corrected by anaesthetic hyperven-
The sheath should be closed when non-midline ports over 7 tilation in the short-term. Haemodynamic changes are more
mm and midline ports over 10 mm have been utilised. The fascia exaggerated in women with severe heart disease, especially in
is closed with a J shaped needle after lifting it away from un- cases of heart failure. These women require more intensive intra-
derlying structures. The skin incisions may be closed with and post-operative monitoring. Pneumoperitoneum (resulting in
interrupted or subcuticular sutures. peritoneal stretching) and manipulation of pelvic organs may
cause vagal stimulation and subsequent bradycardia or bra-
Obese and thin patients dyarrhythmias. In such situations, surgery should be halted with
or without release of intra-abdominal gas whilst atropine is
Obesity (BMI >30 kilograms/metre2) was previously considered
a contraindication to laparoscopic surgery. However, with
increasing experience, excellent outcomes may be achieved in
The pathophysiological effects of laparoscopy
this group of operatively challenging women. With thorough pre-
operative evaluation and planning from anaesthetic and surgical
Haemodynamic Effects (pneumoperitoneum >10 mmHg)
teams, such women who are at a greater risk of complications
C Arterial pressure increases
associated with open surgery may benefit from the minimal ac-
C Cardiac output falls from 10 to 30%
cess approach. Table 1 highlights the advantages and disadvan-
C Heart rate remains unchanged
tages of laparoscopic surgery in obese women.
C Pulmonary and systemic vascular resistance increase
In women who are morbidly obese, the open technique is
recommended for primary trocar entry. If a Veress needle is Effect of CO2
utilised, a deep incision at the base of the umbilicus should be C Dissolves in blood and tissue as carbonic acid leading to acidosis
made. Every effort must be made to ensure that the needle is C Acidosis may be corrected by hyperventilation
inserted vertically, thus minimising the distance between the C Acidosis results in impaired myocardial contractility, myocardial
irritability, pulmonary hypertension and systemic vasodilatation
Ventilatory Changes (pneumoperitineum >10 mmHg)

Advantage and Disadvantages of laparoscopic surgery in C Reduced pulmonary compliance
obese women C Increased pulmonary resistance and ventilation/perfusion
mismatch
Advantages Disadvantages C Increased peak inspiratory pressure
C Decreased lung volume
Faster mobilisation Impaired tolerance to the
Trendelenburg position Metabolic and renal response
Reduced post-operative ileus Difficulty in maintaining a C Pneumoperitoneum results in a 50% decrease in glomerular
pneumoperitoneum filtration rate and urine output. Both are restored with release of
Smaller wounds with reduced Difficult entry to the peritoneal gas
wound infection cavity C The metabolic response is reduced (decrease in acute phase
Reduced post-operative Suboptimal vision of the proteins, leukocytosis and hyperglycaemia)
thromboembolism operative field C No difference in endocrine response and circulation catechol-
Reduced rate of post-operative Suboptimal manipulation of amines, cortisol, rennin and aldosterone compared to open
hernia instruments surgery
Table 1 Box 3
REVIEW
administered and anaesthesia is manipulated. Laparoscopy is

associated with an increased risk of reduced oxygen saturations. Specific complications and their management
The Trendelenburg position exerts further pressure on the dia-
phragm and reduces cardiac pre-load. Inferior epigastric injury
All these effects are increased in elderly and obese women and Controlled by pressure, the insertion of a catheter balloon for tam-
hence, the reasons for laparoscopic surgery being performed less ponade, sutures or diathermy.
frequently in this group of individuals.
Iliac vessel injury
Complications Prompt control and repair. Laparotomy and vascular surgeon input as
appropriate.
Complications in laparoscopic surgery occur at a rate of 1e12.5/
1000 procedures. This varies with the complexity of surgery and Ureteric injury
the experience of the surgeon. Depends on time of presentation. Cystoscopy and pyelogram are
More than half of injuries occur during the entry procedure helpful. Stenting and surgical repair with urology input may be
with the overall risk of serious complications occurring one in required.
1000 cases. Damage to major blood vessels and bowel occurs in
0.9/1000 and 1.8/1000 procedures, respectively. Bladder injury
There is no evidence of difference between Veress needle Recognition from visual inspection, haematuria, air in the catheter
entry and open/direct entry in terms of preventing major bag, urine leakage from trocar incision or oliguria. Cystogram is
vascular or visceral complications. An open technique, however, helpful in diagnosis. Urology input advised. A prolonged in dwelling
is associated with a reduced incidence of failed entry, extraper- catheter is required and surgical repair.
itoneal insufflation and omental injury.
Morbidity and mortality are reduced by the prompt recogni- Uterine injury
tion and treatment of complications. A standard practice of a 360 From instruments. Can manage with observation, pressure, sutures
degree inspection of the abdominal cavity is therefore advised or diathermy.
following laparoscope insertion to allow early pick up of any
trauma. Bowel injury particularly, may not be recognised at the Bowel injury
time of surgery with up to 15% of cases presenting in the post- May be recognised be observation of faecal contents, faecal odour,
operative period. There should be a high index of suspicion in diathermy burn or a haematoma visible on the bowel, post-operative
the patient who is not recovering as quickly after laparoscopic abdominal pain, temperature, vomiting or peritonitis. General sur-
surgery. geon involvement is advised. Management may be with peritoneal
Complications are reduced with experience and good training. lavage and broad spectrum antibiotics, laparoscopy or laparotomy
Surgeons should use the entry technique with which they are with or without bowel repair, resection or colostomy formation.
most comfortable and familiar, recognise when it is not working
and have a safe and practiced back up plan. Good documentation Nerve injury
is essential with clear description of entry techniques utilised. Usually transient and managed conservatively. Sciatic, perineal and
Box 4 outlines specific complications and their management. brachial nerves implicated especially.
Indications Haematoma formation and infection

The indications for laparoscopic surgery in gynaecology have
increased with improving quality of equipment and experience of Incisional hernia e Uncommon. Occurs with port sites >5 mm usu-
surgeons. ally. Managed surgically.
Diagnostic laparoscopy is performed for the investigation of Box 4
pelvic pain. The rate of ‘negative laparoscopy’ where no pa-
thology is identified may be up to 50%. Pre-operative patient
counselling is therefore important. The first line surgical treat- Traditionally, hysterectomy has been performed using an
ment of ectopic pregnancy utilises a laparoscopic approach, even open surgical or vaginal approach. Laparoscopic hysterectomy,
in the presence of rupture, as long as the patient is stabilised however, has become increasingly common. The route of surgery
before surgery. In tubal ectopic pregnancy, salpingectomy is depends on surgical skill, the indication for surgery, contraindi-
most commonly performed, assuming the contralateral tube is cations to a particular method and patient preference. Both
normal in appearance. Salpingostomy is an alternative, where subtotal and total hysterectomy may be performed laparoscopi-
the contralateral tube is damaged. Follow up of serum beta hCG cally, the specimen being retrieved via abdominal ports and
levels is required. vaginally, respectively.
Ovarian cysts are often amenable to laparoscopic treatment. A wide spectrum of endometriotic disease exists, ranging from
Electively, the nature and size of a cyst should be established an incidental finding of mild disease to severe disease causing
before surgery using imaging such as transvaginal ultrasound pain, distortion of pelvic anatomy and secondary problems such
and tumour markers. Ovarian cysts may also present as emer- as subfertility. Laparoscopy is used in the diagnosis and treat-
gencies, requiring prompt surgery for torsion, haemorrhage or ment of endometriosis with the aim of treating or removing
rupture. visible disease and restoring anatomy.
REVIEW
Laparoscopy has a place in the management of gynaecological procedures. It has advantages for patients, surgeons and hospi-
cancers (ovarian, endometrial and cervical). This method may tals. In order to avoid complications, a thorough understanding
provide much better views of the pelvis, including pelvic side of pelvic anatomy, equipment and operative techniques is
walls, when compared to open surgery. The quicker recovery essential. A structured training programme should be available to
resulting from laparoscopic surgery means that patients are often all trainees who perform laparoscopy. A
fit for adjuvant treatment, if required, much more quickly than
had they undergone open surgery. This method is also ideal
when performing laparoscopic bilateral salpingoophorectomy for
Practice points
risk reducing surgery after breast cancer or those with increased
genetic risk.
C Minimal access surgery has significant benefits for patients such
Tubal factors account for 30% of female subfertility. Hydro-
as smaller incisions, shorter hospital stay and quicker recovery
tubation performed at laparoscopy allows assessment of gross
C Optimal patient selection, pre-operative evaluation and patient
tubal anatomy and patency. Laparoscopic bilateral salpingec-
counselling are vital
tomies or “tubal clipping” for hydrosalpinges improves the suc-
C An appreciation of laparoscopic ergonomics is important with
cess rates for assisted conception. Egg retrieval may also be
minimisation of risk to the surgeon
performed laparoscopically if the ovaries are inaccessible
C A sound understanding of anatomy and familiarity with equip-
vaginally.
ment is essential for safe and effective laparoscopy
Ovulatory failure secondary to polycystic ovarian syndrome
C Knowledge of different entry techniques and their pros/cons is
may respond to laparoscopic ovarian drilling, typically following
vital
failure of medical attempts to induce ovulation. Drilling into the
C Special considerations must be applied to obese and thin women
ovary removes some of the androgen secreting stroma and theca
C Anaesthetic considerations and multidisciplinary team working
thus reducing the abnormal ovarian steroid production. Five to
are important components of safe laparoscopy
ten punctures are made in each ovary with monopolar diathermy
C Early recognition of complications associated with laparoscopy
to a depth of 2e4 mm.
and prompt management is essential
C Laparoscopy surgery may be performed in pregnancy, ideally
Training in laparoscopic surgery
during the second trimester
Laparoscopic surgery requires additional skills to those required C Regular training in laparoscopy is essential with incorporation of
for open surgery. Fine motor skills, visiospatial awareness, depth simulation learning
of perception, camera navigation and knowledge of specific in-
struments and equipment are all vital for safe laparoscopy. The
learning curve is steep. Reduction in the numbers of hours spent
by trainees in theatre and the evolving nature of gynaecological
surgery make training by alternative methods essential. The de-
FURTHER READING
livery of simulation training is a means of addressing such issues.
Neiber TE, Johnson N, Lethaby A, et al. Surgical approach to hys-
A blended approach is ideal where theoretical knowledge is
terectomy for benign gynaecological disease (Review) 2009; 2.
combined with simulation learning. The latter may be self-
2009. Issue Art No.: CD003677, www.hscic.gov.uk.
directed, utilising box trainers or virtual reality systems. Learnt
Quinn D, Moohan J. Optimal laparoscopic ergonomics in gynaecol-
skills may then be evaluated through practical and theoretical
ogy. Obstet Gynaecol 2015; 17: p77e82.
assessments, allowing the trainee to reflect and transfer their
Royal College of Obstetricians and Gynaecologists. Green-top
skills to the theatre environment. This training has the potential
guideline. Diagnostic laparoscopy. Consent Advice No. 2.
to enhance laparoscopic skills and confidence of trainees whilst
December 2008, http://bsge.org.uk/guidelines/.
improving safety and efficiency in theatres.
Royal College of Obstetricians and Gynaecologists. Green-top
guideline No. 49. Laparoscopic injuries. 2008, http://bsge.org.uk/
Summary guidelines/.
Minimal access surgery is an essential component of modern
gynaecology where it is the gold standard method for many

Laparoscopy and Laparoscopic Surgery

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REVIEW

Laparoscopy and These can be reduced by thorough pre-operative evaluation. The

Laparoscopy versus laparotomy

Adequate discussion between anaesthetic and surgical teams

Ventilatory Changes (pneumoperitineum >10 mmHg)

administered and anaesthesia is manipulated. Laparoscopy is

Indications Haematoma formation and infection

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