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Laparoscopy in gynecology

INDICATIONS

Indications for laparoscopic cystectomy include serous, mucous, dermoid and endometriotic cysts. The internal wall of the endometriotic cyst, the complete dissection of which from the ovarian cortex could be difficult, can also be vaporized with the CO2 laser.

The indications for laparoscopic oophorectomy usually include large endometriotic cysts and benign ovarian cysts in patients aged over 40 years. The laparoscopic aspiration of unilocular, smoothwalled, translucent ovarian cysts remains controversial.
The main concern is spillage of malignancy.
 


Thorough preoperative evaluation of the patient, combining ultrasonography of ovarian tumors with the measurement of tumor markers, may greatly improve the accuracy of diagnosis of ovarian malignancy. Moreover, laparoscopy is, in the first place, used as a diagnostic tool whereby the pelvis and the abdominal cavity are thoroughly evaluated.



The ovaries are inspected carefully to ensure that the
cyst wall is smooth and that there is no vegetation. The interior wall of the cyst can also be carefully
examined, and a biopsy with frozen histological evaluation can be carried out. In a retrospective study of 226 patients reported that the diagnosis of malignant tumors by laparoscopy was 100% accurate. The anatomopathological examination of specimens in benign conditions was neverwrong. They concluded that laparoscopy is a reliable way of diagnosing the type of ovarian cyst.

SURGICAL PROCEDURES

  The procedure is performed under general anesthesia. After the induction of a pneumoperitoneum, a 12-mm trocar is inserted subumbilically. The laparoscope is connected to a video camera. Three 5-mm trocars are systematically inserted suprapubically: one in the midline approximately 3 cm above the symphysis pubis, and the other two a few centimeters on either side, taking care to avoid the epigastric vessels.

The initial phase of the laparoscopy is purely diagnostic. First, the abdominal cavity is inspected thoroughly and a peritoneal sampling is sent for cytology. The ovaries are examined carefully in order to exclude the presence of excrescences or other evidence suggesting malignancy. It is important to differentiate between organic and functional cysts during laparoscopy; 10–20% of functional cysts do not disappear after 3 months of treatment with combination oral contraceptive pills containing 50 μg of ethinylestradiol.



Intraperitoneal cystectomy

The utero-ovarian ligament is grasped with an atraumatic forceps introduced on the side of the tumor, in order to expose the ovary completely. The first step consists of making an incision in the ovarian cortex with the scissors or with the CO2 laser. The incision must be made in the ovarian cortex overlying the cyst, and it must be long enough to permit a straightforward cystectomy. In some cases, the cyst is first aspirated and the liquid examined. The interior wall of the cyst can be checked by introducing the laparoscope into the ovarian cyst. If there is any intracystic vegetation, a biopsy with frozen histological evaluation can be carried out before a decision is made whether to perform a cystectomy or oophorectomy. In fact, ideally, the cyst should be removed intact from the ovary, without aspirating any of the contents.




  The second step is separation of the ovarian cyst capsule from the surrounding ovarian cortex. The ovarian cyst is held using an atraumatic forceps and the ovarian cortex is grasped with another forceps placed close to the ovarian cyst. By traction and countertraction, the dissection is easily carried out and the cyst is removed. The surgeon must constantly observe the tissue tension, and the grasping forceps must be moved often in order to apply the traction in just the right place to avoid tearing the ovary.

At the ovarian hilus, the dissection is often more difficult, but nevertheless, dissection should continue until the cyst is completely removed from the ovary. Thereafter, the interior ovarian surface is examined and rinsed. Hemostasis is usually achieved spontaneously but, if necessary, bipolar coagulation can be used. However, aggressive electrocoagulation can be the cause of ovarian destruction and premature ovarian failure. Generally, there is no bleeding and the ovary is left to
heal without suturing. Indeed, the ovarian edges approximate spontaneously. In cases of large cysts
where approximation does not occur spontaneously, closure can be undertaken using the following techniques.

Suturing

The ability to suture during laparoscopy was initially developed by Semm and Mettler. Loop ligation using the endoloop or Roeder loop is most often used as an adjuvant to hemostasis, and as a classic ligature in the case of salpingo-oophorectomy or oophorectomy. With the advent of endoligature and the intra- and extracorporeal operative knotting techniques, classic methods used at laparotomy were introduced in endoscopic surgery and have become a mainstay.

The intracorporeal knotting technique has been recommended by Semm and Mettler for fine ovarian sutures. Two lowerabdominal puncture sites are necessary, and, through these, laparoscopic needle holders are introduced to manipulate the suture, needle and involved tissue. The suture material used is 4-0 or 6-0 polydioxanone.
 



Clips


Clips can also be used for closing the ovarian cortex after cystectomy. The clip is of medium to large size and is made of titanium, an inert, non-reactive metal (Autosuture (Endo Hernia); Ethicon). Three to four clips are applied using the 10-mm clip applicator; this is usually sufficient to achieve ovarian closure. For ovarian surgery, a titanium clip is preferred to one made of polydioxanone material.

Fibrin sealant

  Fibrin sealant is useful in controlling microvascular or capillary bleeding from ruptured or surgically dissected tissue. It is particularly beneficial during surgery in patients with increased bleeding tendencies. It might also be used to seal tissue with different kinds of biomaterials. Thus, fibrin sealant has a place in all surgical disciplines for the purposes of tissue sealing, hemostasis and support of wound healing. There seem to be a few drawbacks, such as the risk of viral transmission; however, the benefits of combining fibrin sealing with modern-day surgery far outweigh any known risks. For the optimal use of fibrin sealant, the application technique should meet the following requirements:

 

  • The sealant components should be fully dissolved and kept at a temperature of 37°C (which is easy

with the Fibrinotherm system)

  • The wound surfaces should be as dry as possible (although application to wet surfaces is feasible)
     
  • The components should be mixed thoroughly on application
     
  • The thrombin and aprotinin concentrations may be adjusted to the purpose of application
     
  • The sealant should be applied as a thin film through a catheter introduced into one of the trocars

     
  • After clotting has occurred, further mechanical stresses should be avoided for about 3–5 min. The edges of the ovarian cortex are approximated with atraumatic forceps (Figure 17.12)


Laparoscopic oophorectomy

In most cases, the tube is removed with the ovary intact unless a previous salpingectomy has been performed. Different methods of laparoscopic oophorectomy have been described. The initial technique described the placement of pre-tied loop ligatures16; three chromic endoloop sutures were placed around the ovary and the tube and pulled tight. The ovary was then cut away from its pedicle, cut into strips and removed laparoscopically. The second method of laparoscopic oophorectomy was
bipolar coagulation with excision.


This technique involved four punctures, with traction on the adnexum. A bipolar coagulation forceps was then used to coagulate the ovarian pedicle.After total desiccation of the tissue, 5-mm scissors or the CO2 laser were used to cut. Successive portions of the meso-ovarium and mesosalpinx were treated in a similar fashion, and the proximal tube and ovarian ligament were also coagulated and cut. Once the tube and ovary had been separated, they were removed laparoscopically using a LapSac. Recent studies have shown equally good results using tissue desiccation with bipolar coagulation followed by excision without ligatures.

The most recent technique for laparoscopic oophorectomy is the automatic laparoscopic stapling device. Disposable stapling instruments for laparoscopic surgery are now available. The Multifire GIA surgical stapler (United States Surgical Corporation, Newark, NJ, USA) is readily available and is proving to be effective for appendicectomy, hysterectomy and adnexectomy. A staple cartridge 3 cm in length is fired across the infundibulopelvic vessels. Two triple-staggered lines of titanium staples are automatically placed, with a knife cutting between them. In most cases, two firings of the automatic stapling device are necessary to accomplish removal of the tube and ovary. They are then extracted in a similar way to that used in other laparoscopic techniques. The automatic stapling device reduces operating time, but is nevertheless more expensive than bipolar coagulation.

In certain cases, it is impossible to use pre-tied ligatures as the primary method, because the ovary adheres too strongly to the side-wall to allow placement of the ligature around the adnexa. In such cases, dissection and bipolar coagulation are necessary before beginning the oophorectomy. Similarly, the automatic stapling device, which is 12 mm in diameter, cannot be placed around the whole adnexa; it must be mobile and free before the automatic stapling device can be used17. Hydrodissection, blunt probing, scissors and judicious use of bipolar coagulation are necessary in certain cases to mobilize the ovary for laparoscopic removal using any of the three techniques described. Aggressive ovariolysis increases the risk of ureteral or bowel injury, or severe bleeding.

The absence of ovarian adhesiolysis before oophorectomy can lead to the incomplete removal of all functional ovarian tissue. The endoloop sutures must be placed below the ovary, to avoid trapping ovarian tissue in the pedicle. Persistent ovarian remnant syndrome after laparoscopic oophorectomy has been described by several authors.

Cyst and adnexa removal

There are several techniques for the removal of a cyst or of the adnexa.
After enucleation from the ovaries or after oophorectomy, the tissue is grasped with the grasping forceps introduced through the operating channel of the laparoscope and removed from the abdominal cavity. Such removal can be performed only in cases of small ovarian cysts or after aspiration of the cyst. However, in cases where spillage should be avoided at all costs (septated cysts or CA125 > 35 IU/ml), an impermeable bag can be used (LapSac; Ethicon or Cook).

The bag is introduced through a second puncture trocar. The cyst or the ovary with the intact cyst is placed in the bag, which is closed by pulling its drawstring. The bag is raised to just beneath the abdominal wall and a needle is introduced into the bag in order to aspirate the cyst and decompress it. Then the bag is removed without spillage from the abdominal cavity through a 2-cm suprapubic incision. In some cases, the tissue is grasped directly with an instrument introduced through a suprapubic incision, without using a bag. Theoretically, removing the cyst through a puncture site could lead to a surviving ovarian remnant in the abdominal wall.

Nezhat et al. have not observed this phenomenon in their 1–3-year follow-up of patients who underwent this technique of cyst wall removal. However, Canis (personal communication) has recently reported induced endometriosis at the trocar site after removal of an endometriotic cyst through the abdominal wall. A metastatic tumor has been reported in three cases on the anterior abdominal wall at the trocar site, following biopsy of ovarian cancer.

It is suggested that any suspicious ovarian tissue must be removed from the abdomen while avoiding direct contact with the abdominal incision. In cases of large dermoid cysts, the cyst can be placed in the cul-de-sac of Douglas using a grasping forceps. A colpotomy incision is made and the cyst is then removed intact or aspirated through the vagina: a needle is directed through the vagina for cyst decompression.

The thick cyst contents can be evacuated by introducing the suction cannula into the cyst after making an incision of 5–6mm. When the mass is small enough, it can be pulled through the vaginal incision. Copious vaginal and intraperitoneal irrigation with antiseptic solution is performed after cyst removal. In our department, a colpotomy incision is made through the vagina and the overlying peritoneum using scissors. Reich suggests that a posterior colpotomy incision using the CO2 laser or electrosurgery through the cul-de-sac of Douglas into the vagina is preferable to a vaginal incision, because complete hemostasis is obtained while making the colpotomy incision.

The anatomic relationship between the rectum and the posterior vagina must be confirmed before making the laparoscopic colpotomy incision, to avoid cutting the rectum. Reich uses an instrument placed in the uterus for elevation and anteversion. The posterior vaginal fornix is identified by placing a wet sponge in a ring forceps just behind the cervix. A rectal probe can also be used to ensure that the rectum is out of the way.

In 2006, the surgical management of ectopic pregnancy should be carried out using laparoscopy. The place of laparotomy is limited to rare cases of extremely severe, acute rupture when no competent laparoscopic surgeon is available. In this chapter we discuss in turn the technical aspects of the various techniques, the indications for surgical treatment and the influence of choice of treatment on the subsequent results.

TECHNICAL ASPECTS

The laparoscopic conservative treatment of ectopic pregnancy was reported by Manhes and Bruhat more than 25 years ago. Some improvements to the initial technique were made in the 1980s3. Since then, the technique has not been substantially modified. The first report of the radical procedure was published by Dubuisson et al. in 19874. It has not been greatly modified since then. In the following section we underline some aspects of the operative technique used to prevent the risk of
complications.

Conservative treatment

Despite some descriptions of success, ‘milking’ of the tube must be avoided in all cases where a hematosalpinx is found. In our first publications, we emphasized that ‘milking’ was complicated by persistent trophoblast in 25% of cases, versus 5% when a salpingotomy was performed. Twenty-five years later, this position has not changed, and explains partially the high failure rate reported in some series. The salpingotomy must be as non-traumatic as possible. Scissors section, CO2 laser section or monopolar electrosection are the best methods, although there are no data to support one above another.

The most common technique is monopolar electrosection, because it is the easiest and cheapest method. The crucial point is to avoid large coagulation of the tubal wall, which can lead to a tuboperitoneal fistula. Therefore, it must be achieved with a fine electrode and a cutting current. The electrode must not be pressed on the tube, but rather should just touch it slightly to increase the power density. The speed of movement along the incision must be sufficiently fast to maximize the cutting effect and limit the collateral coagulation. Bipolar coagulation is forbidden for this step.

The salpingotomy must be carried out at the internal part of the hematosalpinx. The trophoblast is located there, and the distal part contains generally only clots. Aspiration of the trophoblast must be performed with a suction device that is at least 7 mm in internal diameter. With a narrower device, the risk of partial removal of the trophoblast increases.

The high rate of failure in some compression of the mesosalpinx for at least 5 minutes.A preventive injection of vasoconstrictive drugs (Pitressin, ornithinevasopressin) is an elegant and efficient alternative when permitted. The salpingotomy must not be sutured. In the initial study3, suturing was not performed for technical reasons. Later on, it was proved that suturing the tube increases therisk for obstruction and decreases postoperative fertility, and that the tubal scar quality is better without a suture.

Salpingectomy

In the initial study, thermocoagulation was used. This has been replaced by bipolar or even monopolar coagulation. No data support a difference in the use of any of these technologies, even though bipolar cautery is generally considered to be less dangerous. There is no difference in the direction of the salpingectomy: it can be carried out from the isthmus to the infundibulopelvic ligament or vice versa. Extraction of the tubes from the abdominal cavity must be done in an endobag or through a culdotomy, rather than pulling the tube through a trocar incision.