Laparoscopic surgery

The generic advantages of avoiding a large laparotomy incision are now well established. For the patient, a laparoscopic procedure is invariably less painful, and recovery and return to full normal activities is more rapid. There are also significant gains in short-term quality of life measures associated with the laparoscopic approach. For the surgeon, improved visualisation offers the opportunity of more precise and accurate surgery. These advantages are usually offset by longer operating times, the use of complex and expensive equipment, and the possibility of new types of complications and increased risk of standard operative morbidity. The aim of this chapter is to identify areas of general technique in which the risks associated with laparoscopic surgery can be minimised while retaining all the advantages of the approach. This is being achieved partly by improved and simplified instrumentation, partly by refinement in techniques, and partly by an increasing awareness of the potential pitfalls of the approach and by adopting strategies to avoid these problems. The majority of gynaecological procedures are already performed endoscopically and all gynaecologists who operate will need to become proficient in these techniques. This chapter outlines techniques for safe laparoscopic entry and safe bipolar diathermy techniques, and describes how to undertake some of the simpler laparoscopic procedures; the evidence supporting these approaches is also presented. Surgical proficiency in safe laparoscopic entry and laparoscopic tubal surgery should lead to the confidence to then undertake more complex procedures.     

Laparoscopic treatment of massive ovarian edema.

Massive ovarian edema is an unusual cause of ovarian enlargement in young girls and women. A woman with the disorder was managed laparoscopically by wedge resection of the ovary. We believe that endoscopic surgery is the appropriate approach for ovarian edema, as it establishes the diagnosis by minimally invasive means and at the same time ensures conservative treatment.     

Laparoscopic gynaecological surgery

Surgical technology has advanced to a level where most gynaecological operations can be performed laparoscopically. Performing laparoscopic surgery requires a degree of surgical skill and structured training is required. A mixture of simulation training and supervised clinical training is required to acquire the skills to perform laparoscopic surgery competently. Attending good quality training courses will enhance the required skills and allow practice of these procedures before attempting these procedures on patients. A patient-centred approach should be adopted when counselling patients pre-operatively, particularly when choosing the route of a procedure. Structured training in technical and non-technical skills is essential.     

Laparoscopic surgery during pregnancy

In the last decade, operative laparoscopic procedures are performed increasingly in both gynecology and general surgery. The major advantages of this newer minimally invasive approach are: decreased postoperative morbidity, less pain and decreased need for analgesics, early normal bowel function, shorter hospital stay, and early return to normal activity. With the advancement of laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy (LC). Other laparoscopic procedures commonly performed during pregnancy include: management of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy. The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and fetus should be taken into account. To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on its safety and exact complication rate. This is due to the few cases reported and the lack of prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases. Finally, most reports in the literature come from centers and surgeons with special interest, experience, and skills in laparoscopy, and their results may not reflect the real complication rates. We have reviewed the pertinent English literature from the last decade. The cumulative experience suggests that laparoscopic surgery may be performed safely during pregnancy, although more studies are needed to establish its exact rate of adverse events.     

Laparoscopic surgery in pregnancy

Each year, roughly 2% of pregnant women will undergo non-obstetrical abdominal surgery. Appendicitis, symptomatic cholelithiasis and adnexal masses are some of the common diagnoses encountered. Pregnancy poses challenges in the diagnosis and surgical management of these conditions for several reasons. Since the 1990’s, laparoscopic surgery has gained popularity and in the past few years has become the standard of care for pregnant women with surgical pathologies. The advantages of laparoscopic surgery include shorter hospital stay, lower rates of wound infection, and decreased time to bowel function. This brief review discusses key points in laparoscopic surgery during pregnancy and highlights studies comparing laparoscopic and open approaches in common surgical conditions during pregnancy.     

Laparoscopic surgery during pregnancy

STUDY OBJECTIVE: To describe the benefits, complications, and safety of laparoscopic surgery during pregnancy. DESIGN: Retrospective case series (Canadian Task Force classification II-2). SETTING: Community academic medical center. PATIENTS: Nineteen pregnant women. INTERVENTIONS: Five (26.3%) appendectomies, seven (36.8%) ovarian cystectomies, five (26.3%) cholecystectomies, one diagnostic laparoscopy (5.3%), and one (5.3%) salpingectomy. In one woman, laparoscopy was converted to exploratory laparotomy to complete a difficult ovarian cystectomy, and a second patient required a minilaparotomy incision to remove the specimen. MEASUREMENTS AND MAIN RESULTS: No preterm labor or adverse perinatal outcome occurred, although one woman had irregular uterine contractions that promptly resolved with tocolytics. One patient delivered at 35 weeks' gestation and the rest carried their pregnancy to term, and all delivered normal infants. No malignancy was found on histopathologic examination of specimens. Hospital stay ranged from 1 to 4 days. CONCLUSION: Laparoscopic surgery can be performed safely in pregnant women. This series adds 19 cases to the approximately 141 reported in the literature. (J Am Assoc Gynecol Laparosc 6(2):229-233, 1999)     

Laparoscopic surgery in endometriosis

Endometriosis (the presence of endometrial glands and stroma outside of the uterine cavity) is a common gynecologic problem affecting 10% of women in the general population, 40% of women with infertility and 60% of women with chronic pelvic pain. Laparoscopy has revolutionized management of women with endometriosis. Diagnosis of endometriosis depends on visualization of endometriotic lesions and histologic confirmation. Endometriotic implants have a multitude of appearances: powder burns, red, blue-black, yellow, white, clear vesicular and peritoneal windows. Diagnostic laparoscopy is often combined with operative procedures to treat manifestations and symptoms of endometriosis. This often includes removal or laser vaporization of endometriotic implants, lysis of adhesions, restoration of normal anatomy and removal or fulguration of ovarian endometriomas (conservative surgery). Severe incapacitating endometriosis, recurrent endometriosis following conservative surgery and symptomatic endometriosis in women not desiring more children is often treated by laparoscopic unilateral or bilateral salpingo-oophorectomy or laparoscopically-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (radical surgery). Endometriosis affecting the appendix, ureters, bladder wall and rectosigmoid colon could be treated with laparoscopic appendectomy, excision of endometriotic implants or laparoscopic colectomy and anastomosis, respectively. Hydrodis-section and use of CO2 super pulsed laser aid in removal of adherent endomeriotic implants without damage to normal underlying structures. Robotic-assisted laparoscopic surgery promises to provide advantages in the management of women with severe endometriosis secondary to 3-dimensional visualization, decreasing surgeon's fatigue and hand tremors and improving surgical precision.     

Laparoscopic robotic gynecologic surgery

The first gynecologic procedure performed with a robot was a tubal anastomosis. This was performed in 1998 with the Zeus robot. Over the past several years other gynecologic procedures have been performed with other robots. Current robotic technology may not be universally applicable to many gynecologists' clinical practice. The field of surgical robotics is evolving at an ever increasing pace, however, and gynecologists need to participate in its development.     

Laparoscopic surgery for gynecologic cancers

In conclusion, laparoscopic techniques are useful for the evaluation and treatment of selected gynecologic malignancies and provide major benefits to patients. The benefits, however, can be expected only from gynecologic oncologists well-versed in advanced laparoscopic techniques. Results must be interpreted cautiously, depending on the laparoscopic expertise of the reporting authors. Numerous questions remain unanswered, particularly those associated with long-term recurrences and survival. The use of laparoscopic procedures for gynecologic malignancies must be considered investigational until adequate long-term survival data are available.     

Laparoscopic surgery in gynecologic oncology

Panoramic retroperitoneal pelviscopy, introduced in 1987 was the first of the laparaoscopic operations used in the field of gyneceologic oncology. It was divised in order to enable the assessment of the pelvic lymph nodes prior to decision making in the management of patients with early cervical cancer. Starting from 1992, laparaoscopic surgery to all fields of gynecologic oncology and all the operations of the classical repertoire were transcribed in the new repertoire. This evolution is not without danger. Direct manipulation of an organ harboring a malignant tumor increases the chances of diffusion of malignant cells. Working with micro-instruments under CO(2) insufflation is likely to favor chances of dissemination. The true place of laparoscopic surgery is, as it has assuredly been since the beginning of its use, in the assessment of tumor surroundings and not in direct manipulation of the organ harboring the tumor. In the cases where imaging clearly shows regional and/or distal spread, it would be better to avoid laparoscopic dissection and retrieval. The most difficult problem in laparaoscopic onco-surgery is not the surgery itself, but in determining in which cases is can be used and in which it cannot.     

Laparoscopic surgery for gynaecological oncology

PURPOSE OF REVIEW: The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the early 1990s. The issue has been very controversial from the beginning, with some justification in view of the possible consequences of faulty cancer surgery. After more than 10 years, long-term follow-up and comparative studies, both of which are required in clinical oncological research, are now available. RECENT FINDINGS: A number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, excluding major exenterative surgery. The use of an extraperitoneal technique for aortic dissections is emerging. New indications, such as radical vaginal trachelectomy, pelvic sentinel node identification, interval debulking surgery of adnexal malignancies, or the liberal use of surgical staging of uterine cancers, have been developed as a direct result of the availability of laparoscopic techniques. SUMMARY: Continuing worldwide interest clearly demonstrates that laparoscopic techniques are now part of the armamentarium of the gynaecological oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay. Combined training in gynaecological oncology and in laparoscopic surgery is, more than ever, mandatory as a means of avoiding the risk of inadequate staging or the mismanagement of pelvic malignancies. The diversity of techniques, including laparotomy, laparoscopy, and vaginal surgery, allows the individualization of surgical approaches, whereby tumour size and local or general conditions can be taken into account.     

Laparoscopic surgery for omental pregnancy

A 16-year-old girl underwent emergency laparoscopic surgery for what was thought to be hematoperitoneum secondary to extrauterine pregnancy. During the operation, omental pregnancy was diagnosed and treated by laparoscopy. According to Studiford's criterion, this case can be classified as a primary omental pregnancy. When performing laparoscopy for suspected tubal pregnancy with no visible pathologic changes on either tube, careful evaluation of the whole abdominal cavity is necessary so as not to overlook an abdominal pregnancy.     

Managing obesity in gynaecological surgery

The incidence of obesity is rising worldwide. This is contributing to an increase in complexity around perioperative care in all surgical specialties including gynaecology. A holistic approach is essential when managing obese women requiring surgery. A multidisciplinary team is strongly advised in the process of selecting women for surgery. Careful emphasis must be placed on pre-operative and postoperative care with focus on prevention of additional complications associated with obesity. Weight management clinics may have an important role in the pre-operative planning stage. It may be safer to defer surgery in selected cases whilst conditions are optimised or cancel surgical options altogether when surgery is deemed too high risk. This may include women with gynaecological cancers who would otherwise be advised surgery. We aim to outline the challenges encountered in the management of obesity in gynaecology and discuss various methods to optimise care when surgery is necessary.     

子宫腺肌病腹腔镜保守手术治疗

子宫腺肌病保守手术的方式包括开腹手术及腹腔镜手术,保守手术治疗主要应用于年龄较轻,有保留子宫要求及生育意愿的女性,腹腔镜下子宫腺肌病保守手术目前更推荐用于局限型子宫腺肌病。腹腔镜手术中常用到子宫壁楔形切除,子宫壁H形切口法、双瓣法、三瓣法等减容手术方式,各种手术方式有其优缺点。任何一种治疗方法需关注的是对临床症状的治疗效果、减少术后复发率、妊娠结局及预防术后妊娠子宫破裂发生。