LAPAROSCOPY

Shenillee Burgess
Reyad Hosein
 Outline
❖ Definition​
❖ Indications: Diagnostic, Therapeutic​
❖ Laparoscopic Procedure​
❖ Advantages & Disadvantages​
❖ Contraindications, Risk Factors​
❖ Complications​
❖ Consent​
❖ Common Procedures​
 Definition

Laparoscopy (Minimally Invasive Surgery) is an

endoscopic operative procedure that allows a
surgeon to gain access to the inside of the abdomen
and pelvis without having to make large incisions in
the skin.​
 Indications

❖ Diagnostic​

❖ Therapeutic​
 Diagnostic

❖ EVALUATION OF INFERTILITY​
❖ Tubal Patency​
❖ Endometriosis​
❖ Peritubal/Perifimbrial Adhesions​
❖ Polycystic Ovaries​
 Diagnostic

❖ EVALUATION OF ACUTE PELVIC PAIN​

❖ Accident To Ovarian Cyst​
❖ Endometrioma​
❖ Ectopic Pregnancy​
❖ Adhesions​
 Diagnostic

❖ EVALUATION OF CHRONIC PELVIC PAIN​

❖ Endometriosis​
❖ Pelvic Inflammatory Disease​
❖ Adhesions​
❖ Ovarian Cyst​
 Therapeutic (4 C’s)
❖ CANCER/TUMOUR​
❖ Ovarian Cyst (Aspiration, Puncture)​
❖ Removal Of Subserosal Fibroids​

❖ CONTRACEPTION​
❖ Tubal Sterilization​
❖ Removal Of Foreign Bodies From Peritoneal Cavity
(IUCD
 Therapeutic

❖ CONCEPTION​
❖ Adhesiolysis​
❖ In-Vitro Fertilization​

❖ COMPLAINTS OF PAIN AND BLEEDING​

❖ Endometriosis (Electrocoagulation, Laser Vaporization)​
❖ Polycystic Ovary Syndrome (Laparoscopic
Electrocautery Drilling Of Ovaries)​
❖ Pelvic Inflammatory Disease​
 Procedure
❖ Under G.A. or L.A.​
❖ Vaginal Preparation:​
❖ Modified Lithotomy position with poles tilted forward.​
❖ Bladder emptied; NG Tube.​
❖ Vagina cleaned and draped.​
❖ Bimanual exam (size, position and mobility of uterus).​
 Procedure
❖ Sims speculum (visualize cervix).
❖ Volsellum or single-toothed tenaculum on anterior lip.
❖ Uterine cannula inserted and locked in position
(Spackman’s or Rubin’s cannula /Humi Uterine
Manipulator).
❖ Speculum removed
 Procedure
❖ Abdominal Preparation:
❖ Cleaned and draped.
❖ 1cm sub or intra umbilical incision/Open Entry.
❖ 45o Trendelenburg position.
❖ Pneumoperitoneum - Verres needle/CO2.
❖ Trocar and cannula inserted at a 600 angle to the skin
towards the sacral promontory
 Procedure

❖ Trocar removed, escaping gas heard.

❖ Laparoscope/light source inserted.
❖ Other ports and instruments eg grasping
forceps, scissors.
❖ Procedure begun.
 End of Procedure
Instruments are removed in reverse order of insertion.​

Return patient to horizontal position; allow gas to escape with

some assistance from abdominal compression.
Withdraw laparoscope and cannula.
Suture incisions.
Remove vaginal instruments.
Advantages (Versus Laparotomy)
❖ Earlier mobilisation​
❖ Shorter hospital stay (1-2 days) ​
❖ More rapid return to work​
❖ Minimal tissue trauma/scarring/adhesions​
❖ Less blood loss​
❖ Lower wound infection rates​
Advantages (Versus Laparotomy)
❖ Less post-op. pain and morbidity​
❖ Better cosmetic appearance - “key-hole surgery”​
❖ Economic​
❖ Procedure can be recorded for the patient’s benefit with video laparoscopy​
 Advantages (Versus HSG)
❖ Painless​
❖ Visualise entire pelvis - diagnose adhesions and
endometriosis​
❖ Visualise fimbrial ends​
❖ Minimal cornual spasm​
❖ Laparoscopy and methylene blue dye insufflation gold
standard for assessing tubal patency​
 Disadvantages
❖ Major’ invasive surgical procedure:
❖ Anaesthetic complications​
❖ Trauma to bowel, bladder, blood vessels
❖ Pelvic adhesions if inadequate haemostasis or infections​
❖ Usually longer intra-operative time​
❖ Large tumours (fibroids/ovarian cysts) can be difficult to remove and may have
to be morcellated and removed in piecemeal fashion.
 Disadvantages
❖ High degree of technical skill and training.​
❖ Equipment tends to be expensive.​

Solutions​
❖ Structured training programme for advanced laparoscopic
skills.​
❖ Development of regional centres for more advanced
surgical cases.​
 Limitations
❖ High degree of technical skill and training.​
❖ Equipment tends to be expensive.​
❖
Solutions
❖ Structured training programme for advanced laparoscopic
skills.​
❖ Development of regional centres for more advanced
surgical cases.​
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 you’re 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