Ch 26 Gynecologic Endoscopy PDF

CHAPTER 26 Gynecologic Endoscopy Malcolm G. Munro, William H. Parker Laparoscopy Diagnostic Laparoscopy Therapeutic (Operative) Laparoscopy Patient Preparation and Communication Equipment and Technique Complications Hysteroscopy Diagnostic Hysteroscopy Operative Hysteroscopy Endometrial A...

CHAPTER 26 Gynecologic Endoscopy Malcolm G. Munro, William H. Parker Laparoscopy Diagnostic Laparoscopy Therapeutic (Operative) Laparoscopy Patient Preparation and Communication Equipment and Technique Complications Hysteroscopy Diagnostic Hysteroscopy Operative Hysteroscopy Endometrial Ablation Patient Preparation and Communication Equipment and Technique Complications KEY POINTS 1 In gynecology, endoscopes are used most often to diagnose conditions and/or direct surgical procedures by direct visualization of the peritoneal cavity (laparoscopy) or the inside of the uterus (hysteroscopy). 2 When used appropriately, endoscopic surgery offers the benefits of reduced 1414  procedure-related pain, improved cosmetic result, lower cost, and faster recovery. 3 Endoscopic surgery is a highly technical process. Consequently, surgeons must thoroughly understand the function and limitations of endoscopic and related equipment, as well as troubleshooting technical adversity. 4 At the present time, there is no evidence that “robotic” assistance to laparoscopic surgery has any clinical, cost, or cosmetic advantages over laparoscopic surgery. Available evidence is that cost is increased while cosmetic results are not as good based on the location and length of incisions. 5 Laparoscopic gynecologic surgeons should be prepared for the spectrum of pathologic and anatomical situations that may be encountered, considering bowel, bladder, ureter, and vascular structures that may be involved. 6 The patient considering laparoscopic surgery should be properly counseled regarding the potential outcomes, including adverse outcomes, and the risk of conversion to laparotomy. 7 The initial entry into the abdominal/peritoneal cavity must be considered carefully, as it can be associated with a large number of the complications encountered during laparoscopic surgery. The main entry strategies are “open laparoscopy,” often referred to as the Hasson entry, and “closed” entry, which includes preinsufflation using a hollow needle, and “direct entry” techniques where the port is passed through the abdominal wall without prior inflation of the peritoneal cavity. 8 Proper patient selection and intraoperative management are critical for laparoscopic surgery for ovarian cysts. If malignancy is strongly suspected, laparotomy may be preferable. 9 Laparoscopic myomectomy usually requires laparoscopic suturing; thus, more technical skills are needed than with many other endoscopic procedures. 10 Laparoscopic total hysterectomy comprises any removal of the uterus where at least part of the dissection is accomplished laparoscopically, while the remainder, if any, is finished vaginally. 11 Dehiscence and hernia risk appear to significantly increase when the fascial incision created for laparoscopic instrumentation is larger than 10 mm in diameter. 12 The incidence of unintended injuries associated with the use of radiofrequency (RF) electricity can be reduced with a good understanding of electrosurgical principles. Surgeons should always be in direct control of electrode activation and all electrosurgical hand instruments should be removed from the peritoneal cavity when not in use. 13 Patients recovering from laparoscopic surgery usually feel better every day. Pain diminishes, gastrointestinal function improves rapidly, and fever is extremely unusual. Therefore, if a patient’s condition is not improving, possible complications of anesthesia or surgery should be considered. 14 Hysteroscopy is useful as a diagnostic aid by allowing direct evaluation of the endometrial cavity. Diagnostic hysteroscopy is superior to hysterosalpingography in the evaluation of the endometrial cavity, but the diagnostic accuracy of transvaginal 1415  ultrasonography is similar, especially when sonographic contrast is injected into the endometrial cavity. 15 A number of intrauterine procedures can be performed under hysteroscopic direction, including adhesiolysis, sterilization, transection of a uterine septum, resection of leiomyomas and polyps, removal of retained products of conception, and endometrial destruction, usually with RF resection, desiccation, or vaporization. 16 Most diagnostic and operative hysteroscopic procedures can be performed in an office or procedure room setting with minimal discomfort and at a much lower cost than in a surgical center or a traditional operating room. 17 The two major risks of hysteroscopic surgery are perforation, with the potential for damage to surrounding structures such as bowel, bladder, and blood vessels; and the fluid and electrolyte consequences of systemic overload of the fluid distension needed to create an operative field. 18 The risks of perforation can be mitigated by careful attention to access technique and the careful and informed use of intrauterine energy-based systems. 19 Risks of systemic overload of distension media can be minimized with the use of normal saline as the distending medium, and by careful attention to measurement of systemic absorption, a process that is best accomplished using automated fluid management systems. Endoscopic procedures use a narrow telescope, an “endoscope” to view the interior of a viscus or preformed space. Although the first medical endoscopic procedures were performed more than 100 years ago, the potential of this method has been extended to perform a variety of operations. In gynecology, endoscopes are used most often to diagnose conditions or direct the performance of surgical procedures in the peritoneal cavity (laparoscopy) or the inside of the uterus (hysteroscopy). When used appropriately, endoscopic surgery offers the benefits of reduced pain, improved cosmesis, lower cost, and faster recovery. The indications for endoscopic surgery are outlined here, including the technology, potential uses, and complications of laparoscopy and hysteroscopy. Because endoscopic surgery relies so much on technology—distension, lighting, imaging, energy, mechanical instrumentation—surgeons must thoroughly understand the function and limitations of endoscopic and related equipment, and be prepared for troubleshooting technical activity. LAPAROSCOPY The past five decades have witnessed rapid progress and technologic advances in gynecologic laparoscopy. Operative laparoscopy was largely developed in the 1970s, and in the early 1980s, laparoscopy was first used to direct the application 1416 of laser or radiofrequency (RF) electrical energy for the treatment of advanced stages of endometriosis. The use of high-resolution (1), and high definition (HD) video cameras (2) in operative laparoscopy has made it easier to view the pelvis during the performance of complex procedures. Most procedures that were previously performed using traditional laparotomy techniques became feasible with the laparoscope including adnexal procedures such as ovarian cystectomy and removal of ectopic pregnancy; uterine surgery, such as myomectomy and hysterectomy; and pelvic floor reconstructive procedures such as sacral colposuspension. The endoscopic approach may have drawbacks for some patients. Although many laparoscopic procedures reduce the cost and morbidity associated with surgery, others have been replaced by even less invasive procedures, and a few have not been shown to be effective replacements for more traditional operations. The use of microprocessor-assisted laparoscopy permits the surgeon to operate remote from the operative field, in a sitting position, with the so-called “robot” allowing translation of natural hand manipulations to the peritoneal cavity with the specially designed instruments. Evidence suggests that clinical outcomes with and without microprocessor-assisted (“robotic”) laparoscopy are similar, but that the costs associated with the use of this device are greater (3). There is evidence that the cosmetic result—the sum of incision number, length, and location—is less acceptable to patients than standard laparoscopy or even small laparotomies (4–6). As a result, for competent laparoscopic surgeons, use of this device adds nothing to the performance of laparoscopic gynecologic surgery except cost. Diagnostic Laparoscopy The objective lens of a laparoscope can be positioned to allow wide-angle or magnified views of the peritoneal cavity. The clarity and illumination of the optics facilitate greater appreciation of fine details than is possible with the naked eye. For example, laparoscopy is the standard method for the surgical diagnosis of endometriosis and pelvic adhesions because no other imaging technique provides the same degree of sensitivity and specificity. There are limitations to diagnostic laparoscopy. The view of the operative field may be restricted, and if tissue or fluid becomes attached to the lens, vision may be obscured. Soft tissues, intramural myomas, or the inside of a hollow viscus such as the uterus or urinary bladder cannot be visualized or palpated. For assessment of these tissues, an imaging modality, such as ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI), is superior. Because of its ability to view soft tissue, ultrasonography is more accurate than laparoscopy for the evaluation of the inside of adnexal masses. 1417 The intraluminal contour of the uterus can be shown only by hysteroscopy or contrast imaging such as contrast hysterosonography, hysterosalpingography (HSG), or MRI. Transvaginal ultrasonography (TVUS), in combination with serum assays of β-human chorionic gonadotropin (β-hCG) and progesterone, can be used to diagnose ectopic pregnancy, usually allowing medical therapy to be given without laparoscopic confirmation (7). As a result of the advances in laboratory testing and imaging technology, laparoscopy is more often used to confirm a clinical impression than for initial diagnosis. Laparoscopy may disclose abnormalities that are not necessarily related to the patient’s problem. Although endometriosis, adhesions, leiomyomas, and small cysts in the ovaries are common, they are frequently asymptomatic. Thus, diagnostic laparoscopy must be performed prudently, interpreting findings in the context of the clinical problem and other diagnoses. Therapeutic (Operative) Laparoscopy The role of laparoscopy in the operative management of gynecologic conditions has evolved from a curiosity to the recognized standard of care. Many procedures previously performed as traditional laparotomic and vaginal operations are readily performed under laparoscopic direction. Operative laparoscopy has the benefit of shorter hospital stays, less postoperative pain, and faster return to normal activity when compared with procedures performed via laparotomy. These features contribute to a reduction in the “indirect costs” of surgical care including less time away from work, and a diminished need for post discharge supportive care in the home (8). In addition to the general benefits of endoscopic procedures, adhesions are less likely to form with laparoscopic surgery than with laparotomy. Because sponges are not used, the amount of direct peritoneal trauma is reduced substantially, and contamination of the peritoneal cavity is minimized. The reduced exposure to the drying effect of room air allows the peritoneal surface to remain relatively moist and, therefore, less susceptible to injury and subsequent adhesion formation. Despite these advantages, there are potential limitations: exposure of the operative field can be reduced, small instruments are required that must be used through fixed ports, and the ability to manipulate the pelvic viscera is often limited. In some cases, the cost of hospitalization increases, despite a shortened stay, because of prolonged operating room time and the use of more expensive surgical equipment and supplies. Efficacy may be reduced if a surgeon cannot adequately replicate the abdominal operation. In some patients, there is an increased risk of complications, which can be attributed to the innate limitations of laparoscopy, the level of surgical expertise, or both. Laparoscopic gynecologic surgeons should be prepared for the spectrum of pathologic and 1418 anatomic situations that may be encountered, considering the bowel, bladder, ureter, and vascular structures that may be involved. With an adequate combination of ability, training, and experience, operative time is comparable to that of traditional abdominal surgical procedures and complications may be reduced. Tubal Surgery Sterilization Laparoscopic sterilization has been extensively used since the late 1960s and while it can be performed with local anesthetics, it is usually accomplished under general anesthesia. The fallopian tubes can be removed (salpingectomy) or occluded by suture, clips, silastic rings or with RF electrocoagulation, most commonly with a bipolar electrocoagulation instrument (see Chapter 14). When an “operative laparoscope” is used, only one incision is required because the sheath in such a system contains an instrument channel. Otherwise, a second port is needed for the introduction of the occluding instrument. Should bilateral salpingectomy be chosen, up to three ports are needed—one for visualization, and two for manipulation and transection of tissue. Patients generally remain in the hospital only for a few hours; even when general anesthesia is used. Postoperative pain is usually minor and related to gas that remains in the peritoneal cavity (shoulder pain, dyspnea), and in the case of occlusive devices, pain at the surgical site. These effects normally disappear within a few days. The failure rate varies by technique but is about 5.4 per 1,000 woman-years (9,10). Bilateral resection of the fallopian tubes has become a more prevalent technique as a result of some evidence that many malignancies that were categorized as ovarian cancers arise in the fallopian tube, and that salpingectomy can reduce the risk of these malignancies (11). Failure and complication rates are being studied in these patients. The use of laparoscopic tubal sterilization has been impacted by the availability of office vasectomy, effective intrauterine contraception, and the development of office- based hysteroscopic sterilization techniques. Ectopic Gestation Medical therapy with methotrexate is considered first-line therapy for tubal pregnancies that, in addition to contraindications to methotrexate use, meet criteria that may include the following: hemodynamic stability, no cardiac activity, tubal mass smaller than 4 cm as determined by ultrasonography, and an acceptably low β-hCG level (12–14). When surgical therapy is required, ectopic gestation can usually be managed successfully by using laparoscopic salpingotomy, salpingectomy, or segmental resection of a portion of the 1419 oviduct (see Chapter 32) (15,16). Salpingotomy is typically performed with scissors or a RF needle electrode after carefully injecting the mesosalpinx with a dilute vasopressin-containing solution (e.g., 20 international units in 100 mL of normal saline) (Fig. 26-1). For salpingectomy, the vascular pedicles are usually secured with electrosurgical desiccation/coagulation, but it is also possible using ligatures or clips. Tissue is usually removed from the peritoneal cavity through one of the laparoscopic cannulas. When salpingotomy is performed, regardless of the route, there is approximately a 5% chance that trophoblastic tissue remains. In such instances, medical treatment with methotrexate is considered appropriate (see Chapter 32). Consequently, a-hCG levels should be measured weekly until there is confidence that complete excision has occurred (17–19). Ovarian Surgery Ovarian Masses Laparoscopic removal of selected ovarian masses is a well-established technique supported by high-quality evidence (20–22). Proper patient selection is critical for laparoscopic management of adnexal masses because of the possible adverse effect of laparoscopic approaches on prognosis with malignant tumors (23,24). Preoperative ultrasonography is mandatory. Sonolucent lesions with thin walls and no solid components are at very low risk for malignancy and, therefore, are suitable for laparoscopic removal. For postmenopausal women, the measurement of CA125 levels is useful in identifying candidates for laparoscopic management (25,26). Combining age, menopausal status, an ultrasound score, and the serum CA125 level into a “Risk of Malignancy Index” may offer an effective means to identify cysts at high risk for epithelial malignancy (27–29). Lesions with ultrasonographic findings suggestive of mature teratoma (dermoid), endometrioma, hemorrhagic, or other cysts presenting with torsion or other causes of acute pain may be suitable for endoscopic management (30–33). Ovarian tumors should be assessed by frozen histologic section, and any frank malignancy should be managed expeditiously by laparotomy (20,24,26). The technique for performing laparoscopy for oophorectomy and cystectomy is similar to that used for laparotomy (19). Pelvic washings should always be collected immediately after entry into the peritoneal cavity and prior to any surgical dissection. For cystectomy, scissors are used to incise the ovarian capsule, and blunt dissection or pressurized fluid (aquadissection) are used to separate the cyst from the ovary. Surgeons should use energy-based techniques with caution as there is evidence that related damage to the adjacent ovarian cortex could compromise the patient’s “ovarian reserve” (34,35). If oophorectomy is performed, the vascular pedicles are occluded and transected, usually with RF 1420 electrosurgical coagulation and cutting systems, but in some instances with sutures, clips, or linear cutting and stapling devices. This is ideally done by isolating the infundibulopelvic ligament. The ureter should be identified and should be clear of the pedicle to be transected. Cysts that appear to be benign may be drained before extraction through a laparoscopic cannula or, less commonly, a posterior culdotomy. If there is concern about the impact of spilled cyst contents, the specimen should be removed in a retrieval bag inserted into the peritoneal cavity through a laparoscopic port. Some authors describe a minilaparotomy technique, or enlarging one port site incision, to exteriorize the mass, drain it externally without intraperitoneal spill, remove the cyst or ovary, and replace the adnexa into the peritoneal cavity (36). FIGURE 26-1 Laparoscopic salpingotomy for unruptured tubal ectopic pregnancy. A: Bleeding through the fimbriated end results in a hemoperitoneum; (B) after removing clot, the left tube is seen distended with blood and gestational tissue (arrow); (C) the left tube is suspended over the left ovary; (D) dilute vasopressin (20 units in 100 mL of normal saline) is injected between the leaves of the mesosalpinx. A salpingotomy incision is made in the proximal portion of the distended tube (E) using a radiofrequency needle electrode. The ectopic pregnancy is carefully expressed and removed from the fallopian tube (F, G, 1421 and H). The post evacuation appearance of the tube is shown (I). The small incision will heal without the need for sutures. Although previously the ovary was routinely closed after cystectomy, this practice is controversial. Some evidence suggests that suture closure could contribute to the formation of adhesions (37). Other studies, including a RCT, suggest that suture-based closure of the ovary is associated with fewer adhesions than using electrodesiccation alone (38). Other Ovarian Surgeries Ovarian torsion, previously treated by laparotomy and oophorectomy, more often can be managed laparoscopically (39,40). Even if there is apparent necrosis, the adnexa can be untwisted, usually with preservation of normal ovarian function (32,41). If an ovarian cyst is present, as is typically the case, cystectomy may be performed after “detorsion” or, if appropriate, deferred to a later time. Rarely is adnexectomy indicated. Polycystic ovarian syndrome should be treated medically. In rare instances, surgical therapy is indicated to reduce ovarian cortical volume, a technique that can be performed laparoscopically using electrosurgery or laser vaporization to perform ovarian “drilling.” This procedure reduces the volume of ovarian stromal tissue and may lead to a temporary return to normal ovulation (42–44). Although such procedures have been shown to be successful in a number of randomized trials (45), postoperative adhesions form in 15% to 20% of patients, underscoring the need to first exhaust medical treatment options (46,47). Uterine Surgery Myomectomy Laparoscopic myomectomy, requires laparoscopically-directed suturing and, thus, requires more technical skills than many other endoscopic procedures (Fig. 26-2). In addition the procedure requires the performance of morcellation so that the fragments of leiomyoma can be removed through the laparoscopic ports or a small incision. There is high-quality evidence suggesting that, compared to laparotomy, the laparoscopic approach is associated with reduced postoperative pain and fever and a shorter institutional stay (48). While it is possible that microprocessor-assisted (“robotic”) laparoscopic myomectomy may allow more surgeons to suture effectively under laparoscopic guidance, in expert hands there appears to be no benefit to robotic surgery in any measurable perioperative outcome (49,50). Some controversies regarding the appropriateness of laparoscopic myomectomy remain, given concerns about the perceived risks associated with 1422 intraperitoneal morcellation. There have been questions related to the efficacy of the approach, especially as it relates to the treatment of infertility and the symptom of heavy menstrual bleeding (HMB), each of which is thought to be secondary to submucous myomas. Morcellation of leiomyomas following removal from the uterus can be performed via laparotomy or under laparoscopic direction using either hand-held cutting instruments, or, in the instance of laparoscopic technique, with an electrosurgical or electromechanical morcellating system that cuts and extracts the tissue (see Fig. 26-27). Much of the controversy around this technique relates to the potential impact of morcellation in general, and electromechanical morcellation in particular, on the prognosis for patients who have unsuspected leiomyosarcomas. There is no convincing evidence that morcellation adversely impacts the prognosis for these very malignant tumors (51). However, for women undergoing myomectomy, the risk of leiomyosarcoma is extremely low, with a reported incidence ranging from approximately 4/10,000 (52), to 2/1,000 (53) and for myomectomy there is no evidence that one method of morcellation is better than the other with respect to impact on oncologic prognosis (54,55). There is evidence that leiomyoma cells are already present in the peritoneal cavity prior to morcellation (56), a finding that would suggest that the disease has already disseminated prior to myomectomy by any technique (57). 1423 FIGURE 26-2 Laparoscopic myomectomy. This patient has a FIGO type 2–5 leiomyoma (A), and has the symptoms of heavy menstrual bleeding and infertility. An ultrasonic cutting blade is used to make a transverse incision in the fundus (B), and then the leiomyoma is dissected out from the myometrium (C). D: Laparoscopic technique is used to create multiple layers of running suture to close the defect. The leiomyoma is removed from the peritoneal cavity through a laparoscopic port after morcellation. Although there are some well-designed studies evaluating infertility outcomes (Class-1, randomized clinical trials) comparing laparoscopic myomectomy with laparotomy, the sample sizes are relatively small, and the cases are highly selected limiting the size and number of the lesions to be removed (58,59). Nevertheless, fertility outcomes have been shown to be similar with laparoscopy and laparotomy (59–61). These and other trials evaluating perioperative outcomes such as duration of admission, surgical pain, and operative complications demonstrated the laparoscopic approach to be superior (62). Proper patient selection for myomectomy, regardless of route, is extremely important, particularly because, by age 50, the prevalence of leiomyomas may be as high as 70% in Caucasians and over 80% in women of African 1424 ancestry (63). It is relatively easy to mistakenly ascribe symptoms to the presence of leiomyomas. Unless the myoma is adjacent to the endometrium, it is unlikely to contribute to HMB or infertility. The impact of intramural myomas on infertility is not well understood (64). Leiomyomas that cause pressure are often large and may be located so close to vital vascular structures, that their location may preclude the laparoscopic approach even in expert hands. Many women will do well with expectant or medical management, or with procedural alternatives such as uterine artery embolization. The surgeon should freely select a laparotomic approach, either at the outset, or during the procedure if technical limitations put the patient at risk or otherwise compromise the potential relevant clinical outcomes (65). Patients who have pedunculated or subserosal leiomyomas that cause bothersome discomfort or pain in association with torsion are especially good candidates for laparoscopic excision (19,66). Hysterectomy Laparoscopic hysterectomy (LH) encompasses a variety of procedures, including the facilitation of vaginal hysterectomy (VH) with variable extents of endoscopic dissection, supracervical hysterectomy (SCH) by dissection, amputation and mechanical removal of the fundus, and the removal of the entire uterus under laparoscopic direction (67). In most environments, the procedure is performed with a combination of electrosurgical vessel sealing devices and mechanical cutting systems, often incorporated into a single instrument. In some instances, sutures, clips, and linear cutting and stapling devices are employed in the process of dissecting or occluding vascular pedicles. When LH was introduced, complications, while lower than for AH, were higher than in comparison with VH (68). With time, training and experience, this outcome has changed with complication rates of LH and VH becoming similar, while remaining lower than for AH (69–71). One study has demonstrated that hospital readmission rates are even lower with LH compared with all other techniques, including instances where the da Vinci microprocessor device is used to assist the laparoscopic procedure (71,72). The procedural costs of LH are generally greater than either VH or AH (8,73), but it is evident that patients can be safely discharged within hours of surgery for both VH and LH, an approach that further reduces the cost of care (74,75). The surgical costs can be substantially reduced when reusable instruments are employed (76). In addition to reduced institutional stay, most studies show less postoperative pain, and faster postoperative recovery with LH than when hysterectomy is performed via laparotomy (68,77,78). There is evidence that pain scores and quality-of-life measures, including sexual activity and physical and mental functioning, were significantly better for women who underwent hysterectomy via laparoscopy 1425 versus laparotomy (79). These differences were present at 6 weeks following surgery and remained at the 12-month follow-up visit. When the societal benefits of faster return to work or family are considered, the cost of laparoscopic surgery is less (80). Selection of the route of hysterectomy must be done considering the anatomy, the disorder or disease state, the patient’s wishes, and the training and experience of the surgeon. LH offers no advantage for women in whom VH is possible, because the endoscopic approach is more expensive and probably has a higher risk for perioperative morbidity (77). The ideal place for LH is as a replacement for laparotomy (68,81,82). There are relatively few remaining indications for laparotomy-based hysterectomy, an approach, which should be reserved for the minority of women for whom a laparoscopic or vaginal approach is not appropriate. These include: (a) patients with medical conditions, such as cardiopulmonary disease, where the risks of either general anesthesia, or the increased intraperitoneal pressure associated with laparoscopy are deemed unacceptable; (b) where morcellation is known to be or likely to be required and uterine malignancy or hyperplasia is either known or suspected. In instances where a minimally invasive approach such as LH or VH may be considered, hysterectomy via laparotomy may be performed for the following reasons: (a) hysterectomy is indicated but there is no access to the surgeons or facilities required for VH or LH and referral is not feasible; (b) circumstances where anatomy is so distorted by uterine disease or adhesions that a vaginal or laparoscopic approach is not deemed safe or reasonable by individuals with recognized expertise in either VH or LH techniques (76,79,82). For surgeons without the skill and training to perform minimally invasive hysterectomy (either vaginal or laparoscopic), and for benign indications, consideration should be given for referral to a gynecologist with such training (82). Infertility Operations The use of assisted reproductive technology, and, in particular, in vitro fertilization (IVF) and embryo transfer (ET) have, at least for those with financial means, replaced the performance of tubal surgery. However, for many, when infertility occurs secondary to disruption of the normal anatomy or anatomic relationships by an inflammatory process, laparoscopically directed operations used to restore anatomy can be successful and include fimbrioplasty, adhesiolysis, and salpingostomy for distal obstruction (83). Fimbrioplasty is distinguished from salpingostomy because it is performed in the absence of pre- existing complete distal obstruction. Endometriosis associated with adnexal distortion can be treated by laparoscopic adhesiolysis or resection. Whereas there 1426 is no known additional benefit for medical treatment of coexistent active endometriosis, the evidence relating to ablation of minimal and mild endometriosis is mixed (84,85) although when subjected to meta-analytic technique, there is a slight fecundity benefit for those undergoing laparoscopic ablation (86). Adhesiolysis may be accomplished by blunt or sharp dissection with scissors, ultrasonic shears, or an RF electrosurgical electrode. While laser-based instruments have been used, there is no evidence that they provide any additional value over less expensive techniques such as electrosurgery (87–89). The dissecting instruments are usually passed through an ancillary port; when laser energy is used, the channel of the operating laparoscope may be used for this purpose. Although there has been controversy regarding the most appropriate modality for adhesiolysis, these methods are probably equally effective in appropriately trained hands. Laparoscopic operations for the treatment of mechanical infertility are probably equally effective to similar procedures performed by laparotomy. In patients with extensive adhesions, successful outcomes are unlikely regardless of the approach. Consequently, assisted reproductive technologies such as IVF and ET are necessary in these situations (see Chapter 36) (19,83). Endometriosis Endometriosis is an enigmatic disorder whereupon the extent of visible disease frequently is unrelated to the severity of symptoms; frequently it is asymptomatic with other disorders responsible for the patient’s pain or infertility. The endometriosis-related inflammation that can occur may create dense adhesions in the pelvis that involve the uterus, fallopian tubes, ovaries, bladder, ureters (90), bowel, and in particular the rectum and sigmoid colon (91). As a result, the incidence of postoperative complications such as fistula are relatively high (90,92). Consequently, when extensive disease exists, and if removal or reconstruction is indicated, endometriosis becomes a surgical challenge requiring surgeons with a training in retroperitoneal dissection to preserve the integrity of the ureters and bowel, particularly in the cul-de-sac between the rectum and vagina. In many instances, optimal surgical management involves a multidisciplinary approach including urologic and colorectal surgeons. The laparoscopic management of endometriomas parallels that of adnexal masses, although the complex ultrasonographic features of many endometriomas sometimes make it difficult to distinguish them preoperatively from a neoplasm (93). The close attachment of the endometrioma to the ovarian cortex and stroma may make it difficult to find surgical dissection planes, and incomplete removal increases the risk of recurrence. In such instances, there may be a tendency either 1427 to compromise the function of the remaining ovary by attempting complete removal or risk recurrence by leaving part of the endometrioma in place. It is common to find the endometrioma adherent to the posterior uterus, the cul- de-sac, or the pelvic sidewall (Fig. 26-3). In such cases, the surgeon must dissect carefully, protecting the ureter and bowel. A Cochrane review found good evidence that excisional surgery for endometriomas decreases the recurrence rate of the endometrioma, decreases the risk for return of pain symptoms, and in women who were previously subfertile, increases the rate of subsequent spontaneous pregnancy (94). Consequently, where possible, an excisional approach should be the goal. FIGURE 26-3 Removal of left ovarian endometrioma. (A) The endometrioma in the ovary (O), lateral to the uterus (U) is attached to the pelvic sidewall (arrows) over the left ureter. (B and C) After careful drainage and careful dissection the remaining ovary is like a shell. In D the ovary has been sutured closed and the endometrioma removed via a laparoscopic port (inset). Multifocal endometriosis may be treated by mechanical excision or ablation, the latter using coagulation or vaporization with either electrical or laser energy. With proper use, each energy source creates approximately the same amount of 1428 thermal injury (87–89). Endometriosis frequently is deeper than appreciated initially, making excisional techniques valuable in many instances (19,83,95–97). Excisional techniques have been demonstrated superior with respect to postoperative spontaneous pregnancy rates (94) although systematic reviews of randomized trials are somewhat inconsistent (98). Endometriosis cases should be performed by a surgeon skilled in the treatment of endometriosis, whenever possible, in order to adequately treat ovarian and extraovarian disease thereby minimizing the need for further surgery. Pelvic Floor Disorders Laparoscopy can be used to guide procedures to treat pelvic support defects, including culdoplasty, enterocele repair, vaginal vault suspension, paravaginal repair, and retropubic cystourethropexy for urinary stress incontinence. Retropubic cystourethropexy comprises the use of either suture or mesh to attach the anterior vagina to Cooper ligaments, located on the posterior aspect of the symphysis, thereby suspending the proximal urethra in a fashion that treats urinary stress incontinence. In the last decade, the advent of mesh-based midurethral slings placed transvaginally largely superseded laparoscopic retropubic cystourethropexy in the treatment of urinary stress incontinence because of reduced morbidity and cost, with at least equal or superior results (99– 101). There was published evidence supporting the notion that the laparoscopic approach is effective when compared with laparotomy, most commonly the Burch colposuspension (102,103). There has been increased interest in the performance of laparoscopic retropubic cystourethropexy because of concerns related to the use of vaginal mesh. Consequently, the laparoscopic Burch colposuspension has, to some degree, experienced a rebirth (104). For vaginal vault prolapse, particularly that which occurs following hysterectomy, the surgical approaches have included a spectrum of techniques applied either vaginally or abdominally. The laparoscopic technique most commonly performed is sacrocolpopexy, where the vaginal apex is loosely attached to the anterior aspect of the sacrum, usually with mesh secured with suture at either end. There is evidence that the abdominal approaches are superior to those performed vaginally (105–108) and that the laparoscopic technique is associated with equivalent anatomic and functional outcomes at 12 months (109), equivalent “cures” at about 3 years (110), with reduced complications and hospital stay (109,111). Although apical and anterior compartment defects can be successfully corrected via laparoscopy, posterior and perineal defects are best visualized and repaired using vaginal techniques. The laparoscopic treatment of 1429 enterocele and vault prolapse may be useful in patients who require abdominal approaches after failure of a previous vaginal procedure. Because of the anatomical proximity of the pelvic ureter to the uterosacral ligament and anterolateral vagina, bilateral ureteral patency should be confirmed cystoscopically after laparoscopic vaginal vault suspension, enterocele repair, culdoplasty, cystourethropexy, or paravaginal repair. Gynecologic Malignancies For some gynecologic cancers, the role of laparoscopic techniques has been clearly established, while for others, the precise place for endoscopy in surgical management is unclear. High-quality evidence was published in the late 20th and early 21st century supporting the notion that, for endometrial (112–114) and cervical cancer (115,116) clinical outcomes were preserved while cost and morbidity were reduced with the use of laparoscopic technique. Because the value of LH had already been determined, the fundamental issue was the utility of laparoscopic technique for pelvic lymph node sampling, or pelvic lymphadenectomy. Later and larger scale studies suggested that women whose surgeries were facilitated by laparoscopy did as well as those whose surgeries were via laparotomy (117,118). The literature reports the use of microprocessor- assisted laparoscopic surgery, compared with standard laparoscopy, adds to cost and cosmetic impact without improving clinical outcomes for endometrial (119,120) or cervical cancer (121–124). Laparoscopy has been used for “second-look” procedures for ovarian cancer (125), and is being investigated for the staging and treatment of early ovarian malignancy (126–129) and for identifying the resectability of ovarian cancer (130). Microprocessor-based devices that assist the performance of laparoscopy (e.g., da Vinci system) have been employed to facilitate radical hysterectomy for cervical cancer and cytoreduction of ovarian cancer (see Chapter 39) (131,132). Laparoscopy in gynecologic oncology surgery has value without apparent prognostic compromise in properly selected patients. Patient Preparation and Communication The rationale, alternatives, risks, and potential benefits of the selected procedure, compared with alternative medical and surgical management, should be explained to the prospective patient. She should know the likely outcome of expectant management if the procedure was not performed. The expectations and risks of the laparoscopic procedure, and those of any other procedures that may be needed, must be explained. It may be helpful to compare risks and recovery with the same procedure performed via laparotomy. 1430 The risks of laparoscopy include those associated with anesthesia, infection, bleeding, and injury to the abdominal and pelvic viscera. The possibility of conversion to laparotomy, if a complication should occur, or if the procedure cannot be completed via laparoscopy, should be discussed. Infection is uncommon with laparoscopic surgery. For procedures involving extensive dissection, there is a higher risk for visceral injury than if such dissection is not necessary. These risks should be clearly presented in a fashion that includes the possibilities of immediate and delayed recognition of complications, such as ureter or bowel injury. The patient should be given realistic expectations regarding postoperative disability. Because pain and visceral dysfunction normally continue to improve after uncomplicated laparoscopy, the patient should be instructed to communicate immediately any regression in her recovery. For most gynecologic laparoscopic surgical procedures, patients can be discharged on the day of surgery, but the time absent from work or school will depend upon a number of factors including the nature of the surgery, the postoperative response of the patient, and the nature of her work. If there is extensive dissection, or if the surgery lasts longer than 4 hours, hospital admission may be necessary, and the period of disability may be extended. The university professor undergoing adnexectomy for an ovarian mass may be back on the job within a few days; the kindergarten teacher may require 6 weeks or more after a laparoscopic pelvic floor reconstruction, because lifting may compromise the integrity of the repair. It has long been the perception that preoperative mechanical bowel preparation reduces the morbidity of colonic surgery should an injury occur, and improves visualization and exposure of the operative field at laparoscopy. There is now an abundance of high-quality evidence demonstrating that preoperative mechanical bowel preparation does not reduce the morbidity of colonic surgery (133). There exists high-quality evidence from randomized trials demonstrating that mechanical bowel preparation does not improve visualization at gynecologic laparoscopy and may have a number of adverse effects (134–136). Therefore, gynecologic surgeons should abandon routine preoperative bowel preparation to improve visualization. In selected instances, such as in severe endometriosis when cul-de-sac dissection is anticipated, mechanical bowel preparation should be considered. Communication with the family or other designated individuals should be arranged prior to the procedure. The patient should arrange for a friend or family member to be present to discuss the results of the procedure with the physician and to drive her home if she is discharged the same day. Equipment and Technique To facilitate the discussion of laparoscopic equipment, supplies, and techniques, it 1431 is useful to divide procedures into “core competencies,” which are as follows: 1. Patient positioning 2. Operating room organization 3. Peritoneal access 4. Visualization 5. Manipulation of tissue and fluid 6. Cutting, hemostasis, and tissue fastening 7. Tissue extraction 8. Incision management Patient Positioning Proper positioning of the patient is essential for patient safety, operator comfort, and optimal visualization of the pelvic organs. There may be advantages to positioning the patient while awake to reduce the frequency of positioning-related complications. Laparoscopy is performed on an operating table that can be tipped to create a steep, head-down (Trendelenburg) position that allows the bowel to move out of the pelvis to facilitate visualization after the cannulas have been placed. The footrest can be removed or dropped to allow access to the perineum. The patient is placed in the low lithotomy position, with the legs appropriately supported in stirrups and the buttocks protruding slightly from the lower edge of the table (Fig. 26-4). The thighs are usually kept in the neutral position to preserve the sacroiliac angle, reducing the tendency of bowel to slide into the peritoneal cavity. The feet should rest flat, and the lateral aspect of the knee should be protected with padding or a special stirrup to avoid peroneal nerve injury. The knees should be kept in at least slight flexion to minimize stretching of the sciatic nerve and to provide more stability in the Trendelenburg position. The arms are positioned at the patient’s side by adduction and pronation to allow freedom of movement for the surgeon and to lower the risk for brachial plexus injury (Fig. 26-5). Care must be exercised to protect the patient’s fingers and hands from injury when the foot of the table is raised or lowered. After the patient is properly positioned, the bladder should be emptied with an indwelling catheter and a uterine manipulator positioned in the endometrial cavity and secured by an intracavitary balloon or attached to the cervix as appropriate. 1432 FIGURE 26-4 Patient positioning: the low lithotomy position. The patient’s buttocks are positioned so that the perineum is at the edge of the table. The legs are well supported with stirrups, with the thighs in slight flexion. Too much thigh flexion may impede the manipulation of laparoscopic instruments while in the Trendelenburg (head-down) position. 1433 FIGURE 26-5 Operating room organization, stylized view. The patient’s arms are at the sides. The right-handed surgeon stands on the patient’s left. Instruments and equipment are distributed around the patient within view of the surgeon. For pelvic surgery, the monitor should be located between the patient’s legs. Operating Room Organization The arrangement of instruments and equipment is important for safety and efficiency. The orientation depends on the operation, the instruments used, and whether the surgeon is right- or left-handed. An orientation for a right-handed operator is shown in Figures 26-5 and 26-6. For pelvic surgery, the ideal circumstance is to have two television monitors, one positioned above each foot of the patient allowing the surgeon and the primary assistant the opportunity to view the surgical field without having to turn their heads (Fig. 26-6). If only one monitor is available, it is typically placed at or over the foot of the table within the angle formed by the patient’s legs. The right-handed surgeon usually stands by the patient’s left side, but at an angle facing the patient’s contralateral foot. The first assistant is in a mirror image 1434 position on the right side, and an additional assistant for uterine manipulation, if present, sits between the patient’s legs. The nurse or technician and instrument table are typically positioned beside one leg of the patient in a fashion that avoids obscuring the video monitor(s) on the left or right, depending on surgeon preference. The insufflator may be placed on the opposite side of the patient, in front of the surgeon, to allow continuous monitoring of the inflation rate and intra-abdominal pressure. The energy source (e.g., electrosurgical or ultrasonic generator) may be placed on the same side as the surgeon to facilitate positioning of the power cords and foot pedals, although increasingly, foot pedals are not used, and with battery-powered instruments, cables and remote control units are unnecessary. FIGURE 26-6 Operating room organization, photographic view. A: View from the foot of the table. Note the second assistant positioned between the legs of the patient for uterine manipulation. B: View from the head of the table. Peritoneal Access Before any laparoscopic procedure can be performed, the surgeon must successfully access the peritoneal cavity. A pneumoperitoneum must be created, and a primary cannula must be placed to allow introduction of the laparoscope. This initial entry into the abdominal cavity must be considered carefully, as it can be associated with a large number of the complications encountered during laparoscopic surgery (137). Various points on the abdominal wall can be chosen for the initial entry, although the umbilicus is the most common (Fig. 26- 7). 1435 FIGURE 26-7 Laparoscope access sites and vascular anatomy of the anterior abdominal wall. Location of the vessels that can be traumatized when inserting trocars into the anterior abdominal wall. The main entry strategies are “open laparoscopy,” often referred to as Hasson entry, and “closed” entry, which includes “preinsufflation” using a hollow needle to inflate the peritoneal cavity prior to positioning of the initial cannula or port, and “direct entry” techniques where the port is passed through the abdominal wall without prior inflation of the peritoneal cavity. 1436 FIGURE 26-8 Typical insertion sites. In most instances, both the insufflation needle, if used, and the primary cannula are inserted through the umbilicus. When subumbilical adhesions are known or suspected, the insufflation needle may be placed through the pouch of Douglas or in the left upper quadrant after evacuation of the gastric contents with an orogastric tube. Some systems allow the insufflation needle to function to position a cannula for a 2 mm laparoscope (Figure 26-16). 1. Access sites 1437  The site of initial or primary access is generally through the umbilicus. However, there are a number of circumstances where this may not be appropriate or even safe. Such circumstances include pregnancy, the presence of a very large pelvic mass, or when previous surgery has been performed in the lower or mid abdomen. In such instances alternate sites such as the left upper quadrant may be more appropriate (Fig. 26-8). 2. Access techniques After the location for the initial entry has been determined, the surgeon must choose the technique with which to enter the abdomen. Laparoscopic entry can be achieved with the open (Hasson), or closed techniques. While each technique has its advantages and disadvantages, surgeon training and experience probably plays a role in minimizing complications and available evidence suggests that, with respect to risk, there is no overall advantage of one technique over another (137). Surgeons should be familiar with all techniques but should likely adhere to the method with which they have the most experience. The open entry technique, first described by Dr. Harrith Hasson, involves gaining entry into the peritoneal cavity via a small “minilaparotomy” skin incision that is typically about 1.5 cm in length (138). Using careful blunt dissection, the incision is carried down to the fascia which is visualized, grasped, tented-up using surgical instruments, and sharply incised; the peritoneum, if identified separately, is carefully opened to enter the peritoneal cavity. The edges of the fascial incision are tagged with stay sutures, and a cannula of appropriate diameter, fitted with a conical occluder and a blunt obturator (Hasson system) is inserted through the facial incision and fixed in position, using either the stay sutures or an integrated balloon system (Fig. 26-9). After removing the obturator, the laparoscope can be inserted through the cannula, and when proper intra-abdominal placement is visually confirmed, the abdomen can be insufflated. The Hasson entry is most often performed at the umbilicus, but this technique can be used at any appropriate location on the abdominal wall. The closed access approaches comprise the one-stage “direct insertion” technique, and the two-stage approach consists of preinsufflation with a specially designed hollow needle, which (Fig. 26-10) is followed by insertion of the trocar– cannula system. Safe insertion of the insufflation needle (the Veress needle is the reusable version) mandates that the instrument be maintained in a midline, sagittal plane while the operator directs the tip between the iliac vessels, anterior to the sacrum but inferior to the bifurcation of the aorta and the proximal aspect of the vena cava. Because the sacral promontory is commonly covered in part by the left common iliac vein, vascular injury may still occur in the midline below the bifurcation (139). 1438  To reduce the risk of retroperitoneal vascular injury while minimizing the chance of inadvertent preperitoneal insufflation, in women of average or lower weight, the insufflation needle is directed to the patient’s spine at a 45- degree angle. In heavy to obese individuals, this angle may be increased incrementally to nearly 90 degrees, accounting for the increasing thickness of the abdominal wall and the tendency of the umbilicus to gravitate caudad with increasing abdominal girth (Fig. 26-11) (140,141). With one hand used to lift the anterior abdominal wall, the needle’s shaft is held by the tips of the fingers of the dominant hand and then steadily but purposefully guided into position only far enough to allow the tip’s entry into the peritoneal cavity. The tactile and/or auditory feedback created when the needle passes through the facial and peritoneal layers of the abdominal wall may provide guidance and help prevent overaggressive insertion attempts. This proprioceptive feedback is less apparent with disposable needles than with the classic Veress needle. With the former, the surgeon must listen to the “clicks” as the needle obturator retracts when it passes through the rectus fascia and the peritoneum. The needle should never be forced. Regardless of technique, the underlying retroperitoneal vessels are protected ultimately by limiting the depth of insertion of the insufflation needle. 1439 FIGURE 26-9 Open or minilaparotomic (Hasson) access. This technique requires that a minilaparotomy be made in or just below the umbilicus. The Hasson system including the blunt obturator is positioned in the peritoneal cavity using sutures attached to the fascia to hold the device in place. Alternatively, a balloon around the distal tip of the device can be used along with the conical occluder to preserve the pneumoperitoneum. After the needle has been inserted, but before insufflation, the operator should try to detect whether the insufflation needle has been malpositioned in the omentum, mesentery, blood vessels, or hollow organs such as the stomach or bowel. The most direct approach is to use a specially designed insufflation needle that has an integrated cannula through which a small-diameter (e.g., 2 mm) laparoscope can be passed to visualize the point of entry (see Fig. 26-16). Otherwise, indirect methods are necessary. The most accurate test of appropriate needle position is an initial intraperitoneal pressure of less than 8 to 10 mm Hg as measured by the insufflator (142–144). Traditionally, the use 1440 of a syringe attached to the insufflation needle has been used to aspirate potential blood or gastrointestinal contents and there is evidence that this technique has value in determining visceral or blood vessel placement (143). To facilitate this examination, a small amount of saline may be injected via the syringe. Tests that are designed to create negative pressure, such as lifting the abdominal wall to attempt aspiration of a drop of saline placed over the open, proximal end of the needle have been demonstrated ineffective (143). FIGURE 26-10 Insufflation needle. When pressed against tissue such as fascia or peritoneum, the spring-loaded blunt obturator (inset) is pushed back into the hollow needle, revealing its sharpened end. When the needle enters the peritoneal cavity, the obturator springs back into position, reducing the risk of injury to the intra-abdominal contents. The handle of the hollow needle allows the attachment of a syringe or tubing for insufflation of the distention gas. FIGURE 26-11 Umbilicus and weight. Location of the great vessels and their changing relationship to the umbilicus with increasing patient weight (from left to right). The 1441 location of the umbilicus tends to migrate caudally with increasing weight, however, there is considerable variation—the great vessels may, in some instances lie directly below the umbilicus. Intraperitoneal pressure varies with respiration and is slightly higher in obese patients. Another reassuring sign that has not had adequate evaluation is the loss of liver “dullness” over the lateral aspect of the right costal margin. However, this sign may be absent if there are dense adhesions in the area, usually the result of previous surgery. Symmetric distention is unlikely to occur when the needle is positioned extraperitoneally. Proper positioning can be shown by lightly compressing the xiphoid process, which increases the pressure measured by the insufflator. The amount of gas transmitted into the peritoneal cavity should depend on the measured intraperitoneal pressure, not the volume of gas inflated. Intraperitoneal volume capacity varies significantly between individuals. Many surgeons prefer to insufflate to 25 to 30 mm Hg for positioning of the cannulas and there is a body of evidence supporting this approach (142,145). This level usually provides extra volume and enough counterpressure against the peritoneum to facilitate introduction of the cannula, potentially reducing the chance of bowel or posterior abdominal wall and vessel trauma. After placement of the cannulas, the pressure should be dropped to 10 to 15 mm Hg, which reduces the risk of subcutaneous insufflation leading to crepitus and essentially eliminates hypercarbia or decreased venous return of blood to the heart (142,145,146). There is little evidence that it is necessary to create a pneumoperitoneum prior to the insertion of the trocar–cannula system in the absence of pre-existing abdominal wall adhesions. Therefore, in women with no previous surgery, the primary puncture can be performed with a trocar–cannula system, which reduces operating time. This technique is referred to as “direct entry,” which involves the blind insertion of the primary cannula before insufflating the abdomen. Regardless of the technique, preinsufflation or direct entry, the first, or primary, cannula must be of sufficient caliber to permit passage of the laparoscope. The patient should be in an unaltered supine position during placement of the primary cannula. After creating an intraumbilical incision, the abdominal wall is elevated wither using intraperitoneal pressure (20–30 mm Hg), or by affixing Kocher clamps to the fascia. Both hands can be positioned on the device, using one to provide counter pressure and control to prevent “overshoot” and resultant injury to bowel or vessels. The angle of insertion is the same as for the insufflation needle; adjustments are made according to the patient’s weight and body habitus (141). The laparoscope should be inserted to confirm proper intraperitoneal 1442 placement and then the insufflation gas is allowed to flow. Access Cannulas Laparoscopic cannulas (or ports) allow the insertion of laparoscopic instruments into the peritoneal cavity while maintaining the pressure created by the distending gas (Figs. 26-12 and 26-13). Cannulas are hollow tubes with a valve or sealing mechanism at or near the proximal end. The cannula may be fitted with a Luer- type port that allows attachment to hollow tubing connected with the CO2 insufflator. Larger-diameter cannulas (8 to 15 mm) may be fitted with adapters or specialized valves that allow the insertion of smaller-diameter instruments without loss of intraperitoneal pressure. The obturator is a longer instrument of slightly smaller diameter that is passed through the cannula, exposing its tip. Most obturators are called “trocars” because their tip is designed to penetrate the abdominal wall after the creation of an appropriately sized skin incision. Many disposable trocar–cannula systems are designed with a “safety mechanism”—usually a pressure-sensitive spring that either retracts the trocar or deploys a protective sheath around its tip after passage through the abdominal wall. None of these protective devices has been shown to make insertion safer and they all increase the cost of the equipment. Round-tipped obturators are not designed to penetrate the abdominal wall; they serve to facilitate passage of a Hasson cannula into the peritoneal cavity (Fig. 26-9). Some access cannulas require no obturator, relying on a wood-screw design to penetrate the abdominal wall (Fig. 26-13). After the initial cannula (either the Hasson or the closed entry cannula) is successfully placed and the abdomen is insufflated, the surgeon should survey the peritoneal cavity and place additional cannulas under direct vision as necessary. If there are adhesions to the anterior abdominal wall in an area where the surgeon wishes to place a laparoscopic port, adhesiolysis can be performed to allow safe placement of the cannula. 1443 1444 FIGURE 26-12 Disposable access systems. These instruments are designed for single use. A 12-mm internal diameter blunt access system is shown in A. The next device (B) also has a 12-mm internal diameter, but has a deployable blade that is used to cut through the abdominal wall. A smaller-diameter blunt conical device is shown in C while a sharp conical access system is presented in D. Both C and D have a 5.5 mm in inside diameter. A narrow, 2.7-mm diameter cannula is shown in E. The trocar for this system is a long insufflation needle with a spring deployable obturator. Ancillary cannulas are necessary to perform most diagnostic and operative laparoscopic procedures, as they allow the insertion and use of laparoscopic hand instruments such as scissors, probes, and other manipulating devices. Most disposable ancillary cannulas are identical to those designed for insertion of the primary cannula; however, simple cannulas without the so-called “safety mechanisms” and insufflation ports are generally sufficient (Figs. 26-12 and 26- 13). Proper positioning of ancillary cannulas depends on the planned procedure, the nature of the pathologic and associated processes, and a sound knowledge of the abdominal wall vascular anatomy. For the secondary puncture, the patient may be tipped head down (Trendelenburg), allowing the abdominal contents to move away from beneath the incision sites, thus making it unnecessary to lift the abdominal wall during secondary cannula insertion. Alternatively, the intraperitoneal pressure may be maintained at 25 to 30 mm Hg to allow insertion of the secondary cannulas prior to placing the patient in Trendelenburg position. Ancillary cannulas should always be inserted under direct vision because injury to bowel or major vessels can occur. Before insertion, the bladder should be drained with a urethral catheter. The insertion sites depend on the procedure, the disease, the patient’s body habitus, and the surgeon’s preference. For diagnostic laparoscopy, the most useful and cosmetically acceptable site for insertion of an ancillary cannula is in the midline of the lower abdomen, about 2 to 4 cm above the symphysis. The ancillary cannula should not be inserted too close to the symphysis because it limits the mobility of the ancillary instruments and access to the cul-de-sac. Laparoscopic cannulas can become dislodged and slip out of the incision during a procedure. There are a variety of cannulas designed to reduce slippage that include those with threaded exteriors and anchoring systems with balloon tips. The surgeon can prevent slippage by ensuring that the skin incisions are not too large for the cannula. 1445 FIGURE 26-13 Reusable access systems. A: A sharp conical device while B represents a pyramidal-tipped design. C and D (and inset) are images of the so-called EndoTip device that can be positioned in the abdominal wall by simply twisting or screwing it in without the requirement of a trocar. In addition to the suprapubic cannula, placement of bilateral lower– quadrant cannulas is useful for operative laparoscopy, but the superficial and inferior epigastric vessels must be located to avoid injury (Fig. 26-7). Transillumination of the abdominal wall from within permits the identification of the superficial inferior epigastric vessels in most thin women. The deep inferior epigastric vessels cannot be identified by this mechanism because of their location deep to the rectus sheath. The most consistent landmarks are the medial umbilical ligaments (obliterated umbilical arteries) and the exit point of the round ligament into the inguinal canal. At the pubic crest, the deep inferior epigastric vessels can 1446 often be visualized between the medially located umbilical ligament and the laterally positioned exit point of the round ligament. The cannula should be inserted lateral to the vessels if they are visualized. If the vessels cannot be seen and it is necessary to position the cannula laterally, the device should be placed 3 to 4 cm lateral to the medial umbilical ligament or lateral to the lateral margin of the rectus abdominis muscle. If the incision is placed too far laterally, it will endanger the deep circumflex epigastric artery. The risk of injury can be minimized by placing a 22-gauge spinal needle through the skin at the desired location, directly observing the entry through the laparoscope. This provides reassurance that a safe location has been identified and allows visualization of the peritoneal needle hole, which provides a precise target for inserting the cannula. Cannulas should be placed at an angle that is perpendicular to the contour of the abdomen, to ensure that the distance traveled from the skin to the parietal peritoneum is as short as possible. This will reduce the risk of injuries associated with insertion, such as those caused by trocars sliding medially during placement and injuring abdominal wall vessels. A properly angled port will ensure ease of operation when instruments are being introduced through the cannula. Large- diameter devices are more likely to cause injury; therefore, the smallest cannulas necessary to perform the procedure should be used. Ancillary cannulas should not be placed too close together because this hinders optimal mobility of the hand instruments, which compromises access and maneuverability. The incision must be the appropriate size for the cannula that is being placed. It must be of adequate length to allow easy insertion of the device through the skin —a 1-cm long incision is inadequate to allow passage of a 1-cm diameter device. The outside diameter of a cannula is larger than the inside diameter; allowance must be made for the thickness of the material used to create the port. In some instances, this can add two or more millimeters to the device’s outside diameter, and, therefore, increase the required length of the incision. Conversely, if the incision made is too large, in addition to the cosmetic impact, the cannula may slip out during the case, or there may be continuous leakage of the pneumoperitoneum around the cannula. 1447 FIGURE 26-14 Single port access system. Demonstrated is a three-port access system from Medtronic (inset) and a similar device being used intraoperatively through the umbilicus with multiple instruments, including the laparoscope. Single incision laparoscopic surgery refers to a technique where only one multi-instrument laparoscopic port is used to perform the procedure. The single incision is usually made at the umbilicus and about 2.5 to 3 cm in length. The specially designed port is placed in the incision which allows insufflation, introduction of the laparoscope and two or more additional instruments to permit completion of the procedure without additional incisions (Fig. 26-14). Pelosi et al. published the first single incision multiport laparoscopic procedure (147). This technique has certain limitations, given the limited number of access channels and the fact that that the laparoscope and operative instruments are introduced parallel to each other. These issues have been partially addressed with improved instrumentation, such as steerable laparoscopes and hand instruments. With specialized training, surgeons have been able to perform certain types of cases safely and successfully using the single incision technique (148). One drawback to this method may be an increased risk of postoperative umbilical hernia, likely a 1448 result of the larger umbilical incision (149). Visualization During endoscopy, the image must be transferred through an optical system to the eye of the surgeon. Historically, surgeons looked directly through the laparoscope to view the intra-abdominal contents. Virtually all modern laparoscopy is performed using video guidance. Endoscopes Laparoscopes are more than simple telescopes as they serve a dual purpose— transmission of light into a dark and closed cavity and obtaining an image of the operative field. The light is generally transmitted from a cold light source via a fiberoptic cable to an attachment on the endoscope that passes the light to the distal end of the telescope via a peripherally arranged array of fiberoptic bundles. The image is generally obtained by a distally positioned lens and transmitted to the eyepiece via a series of rod-shaped lenses. The eyepiece can be used to directly view the peritoneal contents or can serve as a point of attachment for a digital video camera. Some endoscopes transmit the image by a collection of densely packed fiberoptic bundles. This approach generally diminishes resolution, but allows flexibility of the endoscope, which is of great value for small-caliber telescopes or if the device is designed to be “steerable” with an articulated distal end. Another concept is to position a digital “chip” on the end of the system, which functions as a camera, obviating the need to have any lenses or fibers for transmission of an image. This design is colloquially called “chip-on-a-stick.” A laparoscope with an integrated straight channel, parallel to the optical axis, is called an “operating laparoscope” because the channel permits the introduction of operating instruments. This provides an additional port for the insertion of instruments and the application of laser energy. However, operative endoscopes are of relatively larger caliber than standard laparoscopes. They may have smaller fields of view, thereby presenting increased risks associated with the use of monopolar electrosurgical instruments. Standard, “viewing only” laparoscopes permit better visualization at a given diameter. In general, the wider the diameter of the laparoscope the brighter the image, because increased light- or wider-diameter lenses result in an improved viewing experience for the surgeon. Narrow-diameter laparoscopes are associated with reduced transfer of light into and out of the peritoneal cavity; therefore, they require a more sensitive camera or a more powerful light source for adequate illumination. Previously, ideal illumination was provided by 10-mm diagnostic laparoscopes, but improvements in optics has allowed the 5-mm diameter laparoscope to become the standard in many operating rooms (Fig. 26-15). Very 1449 narrow diameter laparoscopes, 2 mm or less, can provide adequate illumination for many procedures, and with a reduced cosmetic impact (Fig. 26-16). FIGURE 26-15 Laparoscopes. Three 0-degree laparoscopes are shown. From top to bottom, 2-mm, 5-mm and 10-mm diameter. The viewing angle depicts the relationship of the visual field to the axis of the endoscope and typically ranges from 0 to 45 degrees to the horizontal (see Fig. 26-50). The zero-degree scope is the standard for gynecologic surgery. However, the 30-degree angle is invaluable in difficult situations, such as the performance of laparoscopic sacrocolpopexy, some myomectomies, and hysterectomy in the presence of large myomas. Imaging Systems The video camera is usually attached to the eyepiece of the endoscope where it captures the image and transmits it to the camera located outside the operative field, where it is processed, sent to a monitor and, potentially, a recording device (Fig. 26-17). Laparoscopes without an optical path have been introduced, with the sensor located on the distal tip of the endoscope, a design that still requires a remote camera location. The resolution capability of the monitor should be equal to that provided by the camera. Most monitors can display at least 800 horizontal lines of resolution, while HD systems generally possess 1,080 lines and “4-K” devices can resolve up to 2,160 lines. The more light transmitted through the endoscope, the better the visualization. The best available output is achieved from 250 to 300 watts, usually using xenon or metal halide bulbs. Most camera systems are integrated with the light source to vary light output automatically, depending on the amount of exposure required. 1450 Light guides or cables transmit light from the source to the endoscope via a bundle of densely packed optical fibers (fiberoptic). Fiberoptic cables lose function over time, particularly if mishandling breaks the fibers. FIGURE 26-16 “Scout” laparoscope. The 2-mm laparoscope is passed through the 2.7- mm access system from Figure 26-12E. The tubing is connected to inflow gas, usually carbon dioxide. Creation of a Working Space The peritoneal cavity is a potential space, making it necessary to fill it with a gas, typically CO2, to create a working environment. Other approaches are being explored using mechanical lifting systems that allow room air into the peritoneal cavity (150,151), a process called “gasless” laparoscopy. To create a pneumoperitoneum, CO2 is instilled into the peritoneal cavity under pressure by a machine called an insufflator. The insufflator delivers the CO2 from a gas cylinder to the patient through tubing connected to a Luer adaptor on one of the laparoscopic cannulas. Most insufflators can be set to maintain a predetermined intra-abdominal pressure. High flow rates (9 to 20 L/min) are especially useful for maintaining exposure when suction of smoke or fluid depletes the volume of intraperitoneal gas. Intraperitoneal retractors attached to a pneumatic or mechanical lifting system can be used to create an intraperitoneal space much like a tent (150). This “gasless” or “isobaric” technique may have some advantages over pneumoperitoneum, particularly in patients with cardiopulmonary disease (152) or with a potential malignancy. Airtight cannulas are not necessary, and instruments do not need to have a uniform, narrow, cylindrical shape. Consequently, some conventional instruments may be used directly through the incisions. Despite being introduced more than 20 years ago, and with evidence of efficacy (153), gasless laparoscopy has not experienced much of an uptake in gynecology, possibly because of perceived difficulties attaining adequate 1451 exposure. FIGURE 26-17 Laparoscopic “tower” and camera. While many operating rooms now integrate their controllers, light sources, suction irrigation systems, and video monitors into floating platforms, for others the “tower” remains a useful method for positioning and storing the equipment. Here the monitor is on the top, the camera base next, then the light source and image printer. A camera sensor and coupler are shown; the coupler attaches the camera to the eyepiece of the endoscope. 1452 FIGURE 26-18 Uterine manipulators. The manipulator is useful not only to provide access to different aspects of the uterus, but for exposing the adnexa and the cul-de-sac. The manipulator at the top is called the Rumi® (CooperSurgical, Trumbull, CT, USA). It has a vaginal “cup” to help delineate the vagina, particularly useful for hysterectomy, and an occluding balloon that allows maintenance of pneumoperitoneum when a culdotomy is created. The manipulator on the bottom is the Valtchev® (Conkin Surgical Instruments Ltd, Vancouver, BC, Canada), and is entirely reusable. Note the articulation point that, in this case, is creating maximal anteversion of the uterus. Manipulation of Tissue and Fluid Uterine Manipulators Uterine manipulation is an important component of the exposure strategy for most pelvic procedures, especially for myomectomy and hysterectomy. A properly designed uterine manipulator should have an intrauterine component, or obturator, and a method for fixation of the device to the uterus. Articulation of the instrument permits acute anteversion or retroversion, both of which are extremely useful maneuvers. If the uterus is large, longer and wider obturators are used so that the manipulations can be performed more effectively. Two types of uterine manipulators are shown in Figure 26-18. A hollow channel attached to a port allows intraoperative instillation of liquid dye to aid in the identification of the endometrial cavity (during myomectomy) or to demonstrate tubal patency. Grasping Forceps 1453 The forceps used during laparoscopy should, to the extent possible, replicate those used in open surgery. Disposable instruments generally do not have the quality, strength, and precision of reusable forceps (Fig. 26-19). Instruments with teeth (toothed forceps) are necessary to securely grasp the peritoneum or the edge of an ovary for removal of an ovarian cyst. Minimally traumatic instruments designed like Babcock clamps are needed to safely retract the fallopian tube. Tenaculum-like instruments are desirable to retract leiomyomas or the uterus. A ratchet is useful to hold tissue without arduous hand pressure. Graspers should be insulated if unipolar RF instruments are being used to attain hemostasis. FIGURE 26-19 Laparoscopic instruments for grasping and manipulating tissue. A: (top and inset) are 5-mm diameter graspers with a curved tip, often called “Maryland” graspers. Other reusable tips (B) and (C) may be positioned in the same handle as is shown for A. D: is a 10-mm claw grasper while (E) and (F) are 5- and 2-mm manipulating probes respectively. G: is a 2-mm grasping forceps. Suction and Irrigation Devices called “suction-irrigators” can be used to introduce irrigation fluid into the abdomen, and suction it away as needed. A high-pressure mechanical pump allows the fluid to be introduced for irrigation, or for hydro- or “aquadissection.” The device is attached to a wall suction and can be used to clear away any fluid as needed. The cannulas used for suction and irrigation depend on the irrigation fluid used and the fluid being removed. For ruptured ectopic gestations or other procedures in which there is a large amount of blood and clots, large-diameter 1454 cannulas (7 to 10 mm) are preferred. Cannulas with narrow tips are more effective in generating the high pressure needed for hydrodissection. Isotonic fluids should generally be used to minimize the risk of fluid overload and electrolyte imbalance. There is evidence that normal saline is more likely to induce oxidative stress and reduce fibrinolytic activity (154,155), and, perhaps, increase the risk of adhesion formation (156), a circumstance that makes Ringer’s lactate a more appropriate solution (157). Hemostasis, Cutting, and Tissue Fixation Hemostasis can be achieved during laparoscopic surgery using energy sources, sutures, clips, linear staplers, and topical or injectable substances. Cutting can be managed by mechanical means or by using electrical, ultrasonic, laser, or RF energy. Secure apposition or tissue fixation may be accomplished with sutures, clips, or staples. With appropriate training, a skilled surgeon can obtain good results with any combination of these techniques for cutting, hemostasis, and tissue fixation. Studies in animals have not demonstrated any difference in injury characteristics when cutting is performed with either laser or RF energy (87–89) and randomized controlled studies have shown no differences in fertility outcomes (158). Differences in results are more likely to be caused by other factors, such as patient selection, extent of disease, and degree of surgical expertise. Consequently, it is difficult to justify the costs associated with using lasers during laparoscopic gynecologic surgery. Hemostasis Because of the visual, tactile, and mechanical limitations of laparoscopy, prevention of bleeding is important for the conduct of efficient, effective, and safe procedures. RF electricity is the least expensive and most versatile method for achieving hemostasis during laparoscopy and can be applied with either monopolar or bipolar instruments. The current for performing electrosurgical techniques is provided by a device that converts the alternating polarity circuit from a wall source from a frequency of 60 Hz to one in the RF spectrum typically from 300 to 500 KHz (300–500,000 Hz). These devices, some of which are proprietary, can be simple or complex, providing power for monopolar and bipolar instrument (Fig. 26-20). Regardless of the type of system, the process of electrical desiccation and coagulation is best achieved by contacting the tissue and activating the electrode using continuous low-voltage or “cutting” current. With adequate power, typically 30 to 50 watts (depending, in part on the surface area of the electrode[s]), tissue will be heated, desiccated, and coagulated. Blood vessels should be compressed with the blades of the forceps before the electrode is 1455 activated so that the “heat sink” effect of flowing blood is eliminated. This allows the opposing walls of the vessel to bond, forming a strong tissue seal in a process called coaptive coagulation. Bipolar devices can be fitted with a serial ammeter that measures the current flowing through the system. When the tissue between the blades of the forceps is completely desiccated, the device is no longer able to conduct electricity, which can trigger a visual or auditory cue for the surgeon. With generic devices, the surgeon can reduce lateral thermal spread of RF energy by manually pulsing delivery or by simultaneously running irrigation fluid over the pedicle. FIGURE 26-20 RF Electrosurgical generator. Displayed is the Medtronic Valleylab™ FT10 Energy Platform (Medtronic Inc., Minneapolis, MN, USA), a radiofrequency electrosurgical generator designed to be used with a spectrum of monopolar, bipolar, and proprietary bipolar instruments. The device is capable of outputting high-voltage (“coagulation”) and low-voltage (“cut”) waveforms for monopolar instruments as well as a low-voltage waveform for bipolar instruments. 1456 FIGURE 26-21 Reusable bipolar system. The Karl Storz RoBi™ (Karl Storz Endoscopy Americas, Culver City, CA, USA), system comprises a reusable device with changeable cutting and dissecting/coagulating tips displayed on the right. A coagulating tip is seen in the inset. Generic bipolar devices are generally reusable, and some have changeable tips to use in different situations (Fig. 26-21). Automated RF systems comprise proprietary generators that pulse energy and generally proprietary bipolar forceps, often with included mechanical blades designed to cut tissues following coagulation of the tissue (Fig. 26-22). These systems are usually designed such that the generator stops automatically when current is no longer being conducted by the tissue between the blades of the forceps or when the tissue uniformly reaches a temperature predetermined to indicate tissue desiccation and coagulation. Control of superficial bleeding can be achieved with fulguration, the near- contact spraying of tissue with modulated, high-voltage RF waveforms from the “coagulation” side of the electrosurgical generator using a monopolar instrument. Care must be taken to perform laparoscopic fulguration safely, ensuring that the entire shaft of the laparoscopic instrument is well away from bowel. 1457 FIGURE 26-22 Laparoscopic hybrid cutting and sealing devices. (A) Ethicon Endosurgery’s Harmonic Ace®+7 (Ethicon Endosurgery Inc, Cincinnati, OH, USA) LCS and (B) the Medtronic LigaSure™ Maryland. These two devices both cut and coagulate or seal tissue. The ligating cutting shears (LCS) are based on ultrasound technology. The bottom blade oscillates while the top jaw is opened to grasp the tissue and then used by the surgeon to slowly transect and seal the blood vessels in the tissue being transected. The RF bipolar radiofrequency device (B) is the Medtronic 1737 Maryland device that, using electrical impedance, tells the surgeon when the tissue is coagulated. Tissue is transected using a mechanical blade activated by a hand-controlled trigger. 1458 FIGURE 26-23 Laparoscopic suturing instruments. 3-mm and 5-mm diameter laparoscopic needle drivers are displayed in A and C while a knot manipulator is shown in B and inset left. The device is shown transferring a knot into the peritoneal cavity (inset right). Ultrasonic instruments can be used for hemostasis. Those with a forceps-like end effector disperse the mechanical energy in a way that allows the tissue to be heated and coagulated. These so called “ligating-cutting” shears also cut when high pressure is exerted in the handle by the surgeon (Fig. 26-22). Hemostatic clips may be applied with specially designed laparoscopic instruments. Nonabsorbable clips made of titanium are useful for relatively narrow vessels, and longer, delayed absorbable, self-retaining clips are generally preferred for larger vessels, 3 to 4 mm or more. Clips may be of particular value when securing relatively large vessels near an important structure such as the ureter. Laparoscopic suturing is a method of maintaining hemostasis (159–161). Compared with clips or linear staplers, suturing has a relatively low cost of materials, although operating time may be longer. The two basic methods for securing a ligature around a blood vessel are the creation of intracorporeal and extracorporeal knots, depending on where the knot is formed. Intracorporeal knots replicate the standard instrument-tied knot and are formed within the peritoneal 1459 cavity. Extracorporeal knots are created outside the abdomen under direct vision and transferred into the peritoneal cavity by knot manipulators (see Fig. 26-23). Pretied knotted suture loops attached to long introducers, called “Endoloops®,” may be used to secure vascular pedicles. However, care should be taken to make sure that they are tightly secured and that no other tissue is incorporated in the loop. A number of devices that facilitate the formation and tying of knots are available. Various barbed sutures that facilitate laparoscopic suturing by eliminating the need to tie knots are commercially available. The suture contains small barbs along its length that fix the suture in place within the tissue. This is particularly helpful in procedures that require a great deal of suturing, such as laparoscopic myomectomy. Small areas of low-volume bleeding can be treated with topical hemostatic agents. Topical agents such as microfibrillar collagen are available in 5-mm and 10-mm diameter laparoscopic applicators. Fibrin sealants (e.g., Tisseel®) and bovine thrombin and gelatin (Floseal®) can be used. A solution of dilute vasopressin may be injected locally to maintain hemostasis for myomectomy or removal of ectopic pregnancy. Cutting The most useful cutting instruments are scissors (Fig. 26-24). Because it is difficult to sharpen laparoscopic scissors, most surgeons prefer disposable instruments that can be used until dull and then discarded. Scissors are ideal for cutting avascular tissue, or in situations such as adhesiolysis near vital structures where thermal energy must be avoided. Often surgeons need to coagulate a vascular pedicle by sealing the blood vessels, and separate the pedicle by cutting the coagulated area. In this situation, the target tissue can be coagulated using a bipolar instrument, and divided using scissors. Devices that initially coagulate the tissue, then mechanically divide it, have become prevalent, and provide a more efficient option to achieve the same goal. Another mechanical cutting tool is the linear stapler–cutter that can simultaneously cut and hemostatically staple the edges of the incision. These devices are of limited utility in gynecologic laparoscopy because of their high cost, the large dimensions of the instruments, and inability of the staples to secure the large pedicles that exist in the pelvis. Laser and electrical sources of energy manifest their effect by conversion of electromagnetic energy to mechanical energy, which is transformed to thermal energy. Highly focused RF electrical current (high-power or current density), generated by a specially designed electrosurgical generator produces vaporization 1460 or cutting, by raising the intracellular temperature above 100°C resulting in the rapid conversion of water to steam and a massive increase in intracellular volume. This expansion ruptures the already damaged cell membrane resulting in cellular and tissue vaporization into a cloud of steam, ions, and protein particles. If the instrument used to focus the energy is moved in a linear fashion, the result is tissue transection or cutting. Less focused RF energy (moderate current or power density) elevates intracellular temperature, causing desiccation, rupture of hydrogen bonds, and resulting tissue coagulation, but vaporization does not occur. FIGURE 26-24 Laparoscopic mechanical cutting instruments. Demonstrated is a laparoscopic hand instrument with a handle (A), shaft (B), and detachable tips (C). The scissor tips are demonstrated in short straight (D), long curved (E), and hooked (F) designs. Monopolar electrosurgical instruments that are narrow or pointed are capable of generating the high-power densities necessary to vaporize or cut tissue (Fig. 26-25). Continuous or modulated and relatively low-voltage outputs are generally the most effective; for example, 60 watts of ‘pure cutting’ current. For optimal results, the instrument should be used in a noncontact fashion, following (not leading) the energy through the tissue. Laparoscopic scissors are generally of monopolar instruments and are designed to cut mechanically; energy may be applied simultaneously for desiccation and hemostasis when cutting tissue that contains small blood vessels (Fig. 26-23). Laser energy can be focused to vaporize and cut tissue. The most efficient laser-based cutting instrument is the CO2 laser, which has the drawback of 1461 requiring linear transmission because light cannot be conducted effectively along bendable fibers. The potassium-titanyl-phosphate (KTP) and neodymium:yttrium, aluminum, garnet (Nd:YAG) lasers are effective cutting tools. They are capable of propagating energy along bendable quartz fibers but have a slightly greater degree of collateral thermal injury than RF electrical or CO2 laser energy. Because of such limitations and their additional expense, these lasers are of limited value. FIGURE 26-25 Laparoscopic monopolar RF cutting instruments. Shown are a monopolar laparoscopic probe with a hook electrode and four electrodes designed to focally vaporize and/or transect tissue. The needle electrode is seen in A, an L electrode in B, a spatula in C and a hook electrode is demonstrated by D. Ultrasonic cutting is largely accomplished mechanically using a blade that oscillates back and forth in a linear fashion (Fig. 26-22). The oscillation is achieved using a vibrating element located in a handle that oscillates the blade, hook, or one arm of the clamp 55,000 times per second (55 kHz). The distance of the oscillation can be varied and determines the efficiency of the cutting process. The tip of the device cuts mechanically, but there is a degree of collateral thermal tissue coagulation injury that can be used for hemostasis. In low-density tissue, the process of mechanical cutting is augmented by the process of cavitation, in which reduction of local atmospheric pressure allows vaporization of intracellular water at body temperature. Tissue Extraction 1462 After excising tissue, it is necessary to remove it from the peritoneal cavity. Small samples can be pulled through an appropriate-sized cannula with grasping forceps; however, larger specimens may not fit. If the specimen is cystic, it may be drained by a needle or incised, shrinking it to a size suitable for removal through the cannula or one of the small laparoscopic incisions. It is often helpful to place specimens in endoscopic retrieval bags for removal, which help contain the specimen and facilitate its removal from the abdominal cavity in its entirety (Fig. 26-26). If there is any concern for malignancy in an ovarian cyst, all attempts should be made to keep the cyst intact during dissection, and to place the specimen in an appropriately sized bag before drainage and removal, thus preventing spillage of the cyst contents within the abdomen. FIGURE 26-26 Specimen removal bag. This 10-mm diameter system is positioned in the peritoneal cavity. Then, the bag is deployed (insets), allowing the surgeon to place specimens for removal, generally through the port or cannula. More solid tissue, such as leiomyomas or the entire uterus, may be broken up 1463 or “morcellated” into smaller pieces for removal. This may be achieved manually or laparoscopically and can be performed with or without containment in a specimen bag. Manual morcellation refers to the simple process of bringing the excised intra- abdominal specimen up to any opening where it can be reached by the surgeon, and cut into small pieces using scissors or a scalpel, to allow it to be removed. When performing total LH for a large uterus, the vaginal opening can be used to access the specimen for manual morcellation. Some surgeons opt to perform this procedure after placing the uterus into a large specimen bag in order to contain it. In cases of laparoscopic SCH and myomectomy, there is no vaginal incision. Therefore, manual morcellation can be performed using a minilaparotomy, often created by enlarging the umbilical laparoscopic incision to about 3 cm. Alternatively, an incision can be made in the posterior cul-de-sac (posterior colpotomy) to provide access, an approach that has the advantage of being more cosmetically acceptable. Laparoscopic morcellation can be achieved with scissors, ultrasonic equipment, or electrosurgery, but the most efficient technique for laparoscopic morcellation of large solid specimens is the use of electromechanical morcellators. Often referred to as “power morcellators,” these devices utilize a rapidly rotating blade that can quickly core and remove large solid specimens from the abdomen (Fig. 26-27). Concerns have been raised about electromechanical morcellators, based upon the notion that their use may disseminate tumor cells in cases where an undiagnosed uterine malignancy is present. Studies show that among women undergoing hysterectomy or myomectomy for presumed benign leiomyomas, the prevalence of occult malignancy, or undiagnosed uterine sarcoma, is approximately 1 in 500 to 2,500 (162–164). Morcellation of a uterine sarcoma may worsen the patient’s prognosis, although data supporting this notion are limited. Consequently, the FDA issued a warning statement regarding the use of electromechanical morcellation (165). This led many surgeons to limit their use of these devices. Most experts in the field believe that electromechanical morcellation still has a role in gynecologic surgery, allowing us to provide minimally invasive surgical options to women with large benign tumors (166). Various products have been developed to allow electromechanical morcellation to be performed within a contained system using a large specimen bag positioned in the abdomen. These techniques are still being refined, and it is not yet clear if this approach will improve the prognosis for a patient with an inadvertently morcellated malignancy. Although our ability to preoperatively distinguish benign myomas from malignant sarcomas is limited, surgeons must evaluate each patient based on risk 1464 factors and appropriately select low-risk patients as candidates for morcellation. With appropriate patient selection and a thorough informed consent process, women at low risk for cancer can continue to benefit from electromechanical morcellation. Incision Management Dehiscence and hernia risk appear to significantly increase when the fascial incision is larger than 10 mm in diameter (167,168). Closure of the fascia can be performed using special ligature carriers used to position suture under direct laparoscopic vision to prevent the accidental incorporation of bowel into the incisions. An alternative is the use of 5/8 round needles and standard needle drivers. In either instance, the peritoneum should be closed to reduce the risk of Richter hernia. FIGURE 26-27 Solid tissue morcellators. RF based (A) and electromechanical (B). These devices are positioned in the peritoneal cavity and attached to a power generator. The blunt obturator is removed; a grasping instrument inserted through the lumen is used to withdraw the tissue, which is cut by a cylindrical blade (C and D). 1465 Complications Patients recovering from laparoscopic surgery usually feel better every postoperative day. Pain diminishes, gastrointestinal functio