Laparoscopy

40 yrs- laparoscopy has evolved from

a limited Surgical procedure used only
for diagnosis and tubal ligations to a
major

surgical

tool

used

for

multitude of gynecologic indications

Today, laparoscopy is one of the most
common

surgical

procedures

performed in many parts of the world.

70% of gynecological surgeries can

be done laparoscopically

THE BASICS

TECHNICAL CONSIDERATIONS

OPERATING ROOM SET-UP

Proper hardware and instruments are needed
Large centers have dedicated laparoscopic OTs
Sufficient back up of instrumentation to cover
for equipment failure.
Automatic table needs frequently change
position of patient in order to enhance exposure
and visualization

Anaesthesia head end

Surgeon stands left of the patient
First assistant-opp. side
Second assistant between patients legs

POSITION

Lithotomy
Thighs in level with trunk
Hips in extension and abduction
Knees slightly flexed
Stirrups low
Arms tucked flushed with body
Buttocks protruding beyond edge of table

Surgeons Stance

Ideal relaxed stature

Tiring

LAPAROSCOPIC
INSTRUMENTION
1. Optical Devices
2. Equipment for creating / maintaining
domain
3. Instruments for Access
4. Operative instruments
5. Energy sources
6. Tissue approximation/ hemostasis
7. Miscellaneous

Optical Devices

Telescope
Camera head
Camera control unit
Light Source
Light Guide Cable
Monitor

Telescope
Optical lens train comprised of precisely
aligned glass lenses and spacers (Rod lens
system)-distal tip-determines viewing angle
Light post-For attachment of light cable to
telescope.
Eyepiece, or ocular lens- attached to camera
to view the images on a video monitor.
Bundles of fibres-carrying light and image

Laparoscopes
Come in various sizes
10mm,5mm,2-3mm
needlescopes(Diagnostic)
Various visualization capabilities
zero degree forward viewing, 30 or 45
degree telescope

Light Source
Halogen or Xenon

Why xenon light source is better?-Light emitted is

more natural and intense - resembles daylight
Halogen - yellow light (colour distortion )
Lamp life meter ,keep spares
Cold light can still burn holes in drapes esp. disposable and burn
patients skin if left on the abdomen.
White balance by making sure white is correct then all the colours
through the spectrum are correct.

Light cable
Transmits light from lamp to laparoscope
There are two types
1) Fiberoptic cable 2) Fluid cable
Fiberoptic cables- flexible but do not transmit a
precise light spectrum
Fluid cables-transmit more light and a complete
spectrum but are more rigid, require soaking for
sterilization and cannot be gas sterilized
Don't bend to acutely as will break fibres
Check-that all the fibres are okay

Optic cables

Video Camera
Solid state silicon computer chip or CCD (chargecoupled device)
Functions as an electronic retina -consists of an
array of light-sensitive silicon elements
Silicon emits an electrical charge when exposed
to light
These charges are amplified, transmitted,
displayed, and recorded
Each silicon element contributes one unit
(referred to as a pixel) to the total image
Resolution or clarity of the image depends on
number of pixels or light receptors on the chip.
Std cameras in use contain 250,000 to 380,000
pixels

CHIP
Single chip camera has a composite
transmission in which three colours,
red, blue and green, are compressed on
a single chip
Three chip camera has a separate chip
for each colour with a higher resolution.

MONITORS
Clarity of image displayed or recorded- depend on
resolution capability of monitor
HD gives better image
Std consumer-grade video monitors- 350 lines of
horizontal resolution
Monitors with about 700 lines are preferred for
laparoscopic surgery.
Two separate monitors on each side of the table
are commonly used for most laparoscopic
procedures.
Use of special video carts for housing the monitor
and other video equipments allows greater
flexibility and maneuverability

RECORDING
For Reviewing and Documentation
Recorder, editor and printer

Insufflator
CO2 Gas of choice- low risk of embolism, low

toxicity

to

peritoneal

tissues,

rapid

reabsorption, low cost and inhibits combustion

because this has the same refractive index as air, so

doesnt distort image

CO2 delivered via automatic, high flow, pressure

regulated device - insufflator.

11/04/16

 Insufflator delives gas at a flow rate of up to 20L / min.

Regulates intra-abdominal pressure and stops delivery of
CO2 when pressure exceeds predetermined level.
Level is usually set at 12-15 mm Hg due to risk of
hypercarbia,

acidosis&

adverse

hemoynamic

and

pulmonary effects at higher pressure.

Insufflator is equipped with an alarm, which sounds when
pressure limit is exceeded-Never ignore any alarm that
sounds during laparoscopic surgery!

Energy Sources

Principles
Current- Electrons flow from one atom to orbit of
an adjacent atom.
Voltage is the force or push that provides
electrons with the ability to travel from atom to
atom.
If electrons encounter resistance, heat will be
produced-The resistance to electron flow is called
impedance
A completed circuit must be present in order for
electrons to flow. A completed circuit is an intact
pathway through which electrons can travel
Current = Flow of electrons during a period of
time, measured in amperes

CAUTERY AND
ELECTROSURGERY
Electrocautery
Refers to direct current (electrons flowing in one direction)
During electrocautery, current does not enter the patients

body. Only the heated wire comes in contact with tissue

Electrosurgery

is alternating current

In electrosurgery, the patient is included in the circuit and

current enters the patients body

 The electrosurgical generator is the source of the

electron flow and voltage.
The circuit is composed of the generator, active
electrode, patient, and patient return electrode
Pathways to ground are numerous but may include
the

OR

table,

stirrups,

and

equipment.

The

patients tissue provides the impedance, producing

heat as the electrons overcome the impedance.

 Standard current alternates at a frequency of

60Hz
Electrosurgical

frequency,

systems

but

can

because

function

current

at

would

this
be

transmitted through body tissue at 60 cycles,

excessive neuromuscular stimulation and perhaps
electrocution would result.
Nerve&muscle

cycles/second

stimulation
(100

kHz),

cease
so

at

100,000

electrosurgical

generator takes 60 cycles current and increases

the frequency to over 300,000 cycles per second.

Bipolar

In bipolar electro surgery, both the

active electrode and return electrode
functions are performed at the site of
surgery.
The two tongs of the forceps perform
the active and return electrode
functions. Only the tissue grasped is
included in the electrical circuit

Monopolar
The active electrode is in the wound. The
patient return electrode is attached
somewhere else on the patient. The
current must flow through the patient to
the patient return electrode to complete
the circuit.
Monopolar Circuit - four components
Generator
Active Electrode
Patient
Patient Return Electrode

Waveforms functions
ESU produce a variety of electrical waveforms
As waveforms change, so will the corresponding tissue effects
Using a constant waveform, like cut the surgeon is able to
vaporize or cut tissue.
Using an intermittent waveform, like coagulationwill produce
less heat. Instead of tissue vaporization, a coagulum is produced.

A blended current is not a mixture of both cutting and

coagulation current but rather a modification of the duty cycle.

High heat produced rapidly causes vaporization. Low heat

produced more slowly creates a coagulum

Safety Considerations during

Electrosurgical laparoscopic surgery

Direct Coupling
Direct coupling occurs when the user
accidentally activates the generator while
the active electrode is near another metal
instrument. The secondary instrument will
become energized. This energy will seek a
pathway to complete the circuit to the
patient return electrode. There is potential
for significant patient injury
So Do not activate the generator while the
active electrode is touching or in close
proximity to another metal object

Insulation Failure
Many surgeons routinely use the coagulation
waveform. This waveform is comparatively
high in voltage.
This voltage or push can spark through
compromised insulation. Also, high voltage
can blow holes in weak insulation.
Breaks in insulation can create an alternate
route for the current to flow. If this current
is concentrated, it can cause significant
injury

Capacitive Coupling
Occurs whenever a non conductor separates two
conductors.
During laparoscopic procedure, an inadvertent
capacitor
maybe
created
by
the
surgical
instruments.
The conductive active electrode is surrounded by
nonconductive insulation. This, in turn, is surrounded
by a conductive metal cannula
A capacitor creates an electrostatic field between the
two conductors and, as a result, a current in one
conductor can, through the electrostatic field, induce
a current in the second conductorI.
In a laparoscopic procedure, a capacitor may be
created by the surgical instruments composition and
placement.

Avoiding Electrosurgical
Complications

Inspect insulation carefully

Use lowest possible power setting
Use a low voltage waveform (cut)
Do not activate in close proximity or direct
contact with another instrument
Use
bipolar
electrosurgery
when
appropriate
Select an all-metal cannula system as the
safest choice -Do not use hybrid cannula
systems that mix metal with plastic

Ultrascision or the Harmonic

Scalpel

Generator (the box)-Adjusts the amount of electrical energy

being delivered and monitors performance.

Transducer- located in the hand piece -This is where electrical

energy is converted to the ultrasonic waves..
Dissection Instrument (peripheral hand piece)
A metallic rod is coupled to the transducer and vibrates at the
prescribed frequency (i.e. 55kHz). The tip of the rod contacts
with the surface tissue.

Advantages over
electrocautery

Dual action of coagulation and cutting

Heat generated is low
No lateral tissue damage
No smoke is produced so visualization is better
No current passes through the patient
eliminating the chance of electrical hazard
Less tissue damage, so less post operative
pain

Instruments for Access

Veress needle
Pneumoperritoneum prior to insertion of trocar
Consists of an outer sharp cutting needle and inner blunt
spring-loaded obturator.
During insertion resistance at the fascia causes the blunt tip
to retract backwards enabling penetration by the sharp outer
needle.
Once the cutting edge penetrates freely into the peritoneal
cavity, the blunt stylet springs forward beyond the cutting
edge preventing injury to intraperitoneal structures.
The inner stylet is hollow with a side hole near its tip to allow
insufflation with air.

Palmers test withdraw -push saline- withdraw

Pressure test ie low intra abdominal pressure
Saline drop test
Moving needle tip

Trocar/Cannula THE
PORT
Outer hollow sheath or cannula that
has a valve to prevent the CO2 gas
from escaping, a side port for
instillation of gas.

Inner removable trocar fits through

the outer sheath and is used while
inserting

the

port

through

the

abdominal wall The trocar has a blade

with a shaft and body.

Trocars
Available in various diameters and sizes
according to requirements
10mm and 5 mm being commonly used
Reducers - available for reusable trocars
to prevent air leakage from the cannula
when smaller diameter instruments are
used.

 Types of Trochars

Cutting
Pyramidal tipped
Flat blade

Non cutting
Pointed conical
Blunt conical
Optical

OTHER LAPAROSCOPIC INSTRUMENTS

-

Dissecting forceps

Grasping instruments

Scissors

Suction irrigation

Clip applicator s

Staples

Sutures / needles

Needle holder

Cautery (mono & bi polar)

Morcellator

1) MARYLAND

2)CURVED DISSECTOR
WITH
LONG BLADES

3) BLUNT DISSECTOR

4)GRASPER

5)GRASPER

6)RIGHT ANGLE

General instruments Design

Reusable three-piece design
Available in different diameters and
length
Choice of handle styles.
Fully rotating 360 sheath.
No hidden spaces that can trap
operative blood and tissue debris.

Scissors

HOOK SCISSORS, single action jaws

METZENBAUM SCISSORS, curved,

length of blades 12-17 mm, widely
used as an instrument for mechanical
dissection in laparoscopic surgery.

STRAIGHT SCISSOR can give

controlled depth of cutting because it
has only one moving jaw.

CLEANING, DISINFECTING AND

STERILIZING OF LAPAROSCOPIC
INSTRUMENTS

DISASSEMBLE
ENZYMATIC SOLUTION
ULTRASONIC CLEANER
SOFT BRISTLED BRUSHES
SOFT DETERGENTS
HLD
AUTOCLAVE ,ETO , PLASMA STERILISER

Surgical aspects

Contraindications
Absolute - Uncontrolled coagulopathies;
patients unfit for General Anesthesia;
generalized
peritonitis;
severe
cardiopulmonary
disease;
uncontrolled
intra-abdominal haemorrhage; abdominal
wall infection; haemodynamic instable
patients.
Relative- pregnancy; previous multiple
abdominal operations; portal hypertension;
severe liver disease. Surgeons experience
and skill are the most affecting factors.

ANAESTHESIA
General anaesthesia usually
Allows anaesthesiologist to manipulate the tidal
volumes

and

respiratory

rates

necessary

to

counteract the respiratory changes resulting from

the pneumoperitoneum and positioning of the
patient.
On the rare occasion, local and/or regional
anaesthesia with intravenous sedation can be
used for certain short procedures.

 Major

POSTOPERATIVE
MANAGEMENT
Post-op problems after lap surgery include

pain &

nausea.
Can be reduced with the appropriate use of various classes of
analgesics (eg. NSAIDS, opioids, etc)
The classical shoulder tip pain can be reduced by removing as
much of pneumoperitoneum as possible at end of surgery

Postoperative nausea and vomiting (PONV) can be reduced by

avoiding over-inflation of the stomach during mask ventilation,
identifying those at risk of PONV, reducing the use of opioid
analgesics where possible and the liberal use of anti-emetics

ENTRY ISSUES

PRIMARY ENTRY
Is the first maneuver to learn and even though seems to be
simple ,is not riskless complications ranging from 0.05 to 0.2%
The most common methods used are:
Veress needle access
Open access using Hassons trocar
Direct trocar insertion
Optical trocar access
Depends on surgeons choice, pt factors and different
situations
Occasionally, it can be difficult especially for obese patients
and it can cause potentially dangerous complications in some
patients

 Small

VERESS NEEDLE
TECHNIQUE
incision is made above or

below the

umbilicus-anterior abdominal wall is lifted up

using a clamp by the surgeon and assistant on
either side of umbilicus to create a negative
abdominal pressure.
The Veress needle is then inserted into the

peritoneal cavity, usually a give can be felt.

Should aim towards the pelvis.
Once inserted and hold in a steady position

CONFIRMATION
Three methods used to test the proper
position
Using a syringe: injection of saline, suction of
air and the drop test.
Subsequently, a low flow insufflation of CO2 is
started with a careful reading of the electronic
insufflator. The intra-abdominal pressure
(around -1 and 4 mmHg) is very important
Also percussion of abdomen over liver and
obliteration of
liver dull sounds, show a
diffusion of the gas into the abdominal cavity.

 Once the intra-abdominal pressure reaches 13-15

mmHg, the needle is removed
The first sharp trocar can be inserted
After port is inserted, a rapid introduction of
telescope is very important to verify correct entry
and to explore the abdominal cavity for injuries
The remaining trocars are placed differently under
direct vision according to the procedure

OPEN (HASSON) TECHNIQUE

To avoid injuries to bowel associated with blind technique,
Hasson proposed this blunt minilaparotomy access.
2 cm incision vertical/curvilinear is made to above or
below umbilicus or differently accordingly to procedure to
be done
The linea alba and the peritoneum is incised under direct
vision.
Once peritoneal cavity is entered, using a finger,gently
explore periumbilical area is suggested to verify any
adhesion.
Then blunt Hassons trocar can be inserted. The trocar is
held in place by two sutures anchored on either side of
the abdominal fascia. The advantage of this technique
include safety- especially in patients with previous
abdominal operations.

DIRECT TROCAR
INSERTION
By experienced and skilled laparoscopic surgeons

form of blind direct insertion

One reason in favor of this technique is in avoiding use of
Veress needle and a double blind puncture of the abdomen.
Involves skin incision- periumbilical skin must be lifted up
using towel clamps on either side and a disposable trocar is
used (trocar must be sharp). The trocar must be held like a
pen avoiding in this way to penetrate too deep. Once trocar
is inserted, an explorative laparoscopy must be carried out
to verify intra-abdominal or retroperitoneal injuries

OPTICAL TROCAR
INSERTION

Disposable or reusable
Very useful in obese or in pts who
underwent previous major abdominal
surgery
A 0 degree telescope is inserted into
the sheath and fixed and using a
rotating movement it is possible to
enter into peritoneal cavity under
direct vision, layer by layer

Correct trocar placement should

provide direct access to the target
organs,
an optimal view of the operative field
and minimize mental and muscular
fatigue.

 CARE AND HANDLING OF

LAPAROSCOPIC INSTRUMENTS
CLEANING, DISINFECTING AND
STERILIZING OF LAPAROSCOPIC
INSTRUMENTS

COMPLICATIONS AND MANAGEMENT

COMPLICATIONS
1. Anaesthetics Complications
2. Complications due to pneumoperitonium
3. Surgical complications
4. Diathermy related injuries
5. Patients factors related complications
6. Post operative complications

 Pre-peritoneal gas insufflation - Commonest complication

Bowel injury- unusual (0. 05%-0.4%) - mainly to bowel adhesionIf Occurs sutured via open laparotomy, minilaparotomy or
laparoscopy.
Choice of how to repair is related to severity of injury, skill and
preference of surgeon.
Other organs, such as stomach and bladder are rarely injured
Vascular injuries (0.03 to 0.05%)-if caused by a blind insertion of
trocar -catastrophic and requires a prompt surgical intervention.
A conventional laparotomy with vascular repair becomes must

Avoid the epigastric vessels

Avoiding complications
Patient positioning
Hyperextension of arms brachial plexus damage
Femoral neuropathy due to flexion at hip & knee
Peroneal nerve injury lateral pressure

Entry
Remember to keep patient flat during trocar entry
Prior surg. consider alternate sites for trocar entry
Beware of very thin or very obese patients
Avoid too deep trocar insertions
Place secondary ports under direct vision
At the end remove laparoscope under direct vision

Electrical energy
Keep tip of monopolar/ bipolar forceps in centre of
screen and clearly visible during activation
Check to see plates in good contact

83

Treatment retroperitoneal
injury

Direct compression over aorta

IV fluids
Laparotomy
Call a vascular surgeon

84

Ureter & Bladder injury

Bladder injury check with dye when in doubt
< 1cm foleys catheter 7-10day
>1cm suture in 2 layers + foleys
Ureter check with cystoscopy

85

Single port laparoscopy (SPA,LESS,SPICES,

SILS,OPUS)

Natural orifice translumenal

endoscopic surgery (NOTES)

Robotic surgery

 It has not changed the nature of disease

The

basic

principles

apply,including

of

appropriate

good

surgery

case

still

selection,

excellent exposure,adequate retraction and a high

level technical expertise
If a procedure makes no sense with conventional
access, it will make no sense with a minimal
access approach

HYSTEROSCOPY
BASICS

HYSTEROSCOPY IS A PROCEDURE
THAT INVOLVES DIRECT VISUAL
INSPECTION OF CERVICAL CANAL
AND UTERINE CAVITY

Hysteroscope
Rigid
Flexible
Contact
Microcolpohysteroscope

Rigid Hysteroscope
Most commonly used
Office & O.T procedure
3.5 to 5 mm
Single Flow / Continuous Flow
7 to 8 mm - Resectoscope

RESECTOSCOPE
Electrosurgical endoscope
Consists of
Inner sheath - which has a common channel
for telescope, distending media and
electrode and
Outer sheath - for the return of distending
media.
Lens is angled towards the electrode for clear
view
Electrode can be ball, barrel, knife, or cutting
loop type.

Resectoscope

Flexible Hysteroscope
Tip can deflected to 120 1600
Costly
Fragile

VersaScope (Office
Hysteroscopy)

1.8 mm diameter
Fibre optic
00 Scope
3.5 mm Diagnostic/Operative
Sheath
5 Fr Electrode/Operative
instruments can pass through the
channel
100 curvature
3600 Rotating collar to visualize the
cornuae

Benefits of Office
Hysteroscopy
No anesthesia
Minimal Learning Curve See One Do One
No cervical Dilatation required so no chances of incompetent os
No speculum or Teneculum is used-no Cervical trauma or
lacerations .

DIAGNOSTIC SHEATHS
Usually 4 5 mm in diameter
Required to deliver distending media into uterine cavity
Telescope fits into the sheath and there is 1mm gap
between sheath and scope through which distending
media is transmitted and controlled by external
stopcock.
Imprecise or loose coupling telescope and sheath
results in leakage of distending medium.

OPERATIVE SHEATHS
It has channels for
a) 3 - 4 mm telescope
b) instillation of medium
c) operating instruments
Types
A) STANDARD OPERATING SHEATH
Single cavity for medium,telescope and
operative tools.
Disadvantage of not being able to
flush the cavity with distending medium
and operating tool manipulation within
the cavity is difficult.

Distension Media
Opens the potential space of uterine cavity
Media Leaves the uterus by
- Cervical leakage
- Tubal leakage
- Intravasation

Media
CO2
Insufflation Pressure
100 120 mm Hg
Flow
30 60 ml / min
= Intrauterine Pressure 40 80 mm Hg
- Diagnostic
- Gas Embolism
- CO2 Intoxication

Media - Fluids
High Viscosity
Dextran (Hyskon)
Low Viscosity
Electrolyte

- Saline
- Ringer Lactose
- 5 -10 % Dextrose
Non Electrolyte - Glycine
- Sorbitol
- Mannitol

Sodium Chloride (0.9%)

- Isotonic
- Conductive
- Laser, Bipolar (Versapoint)
Disadvantages:- Obscure vision if bleeding
- Cannot use standard Monopolar

Glycine (1.5%)
- Hypotonic
- Non conductive
- Better Visualisation
when bleeding
Disadvantages :- Fluid Volume overload
- Hyponatremia
- Metabolised to ammonia
- C.I in Hepatic Insufficiency

Dextran 70
- Non Electrolyte
- Non Conductive
- High Viscous fluid
- Good vision
Disadvantages:- Fluid overload (Deficit 500 ml)
- Allergic Reactions/ Anaphylaxis
- D.I.C
- Destroys instruments

Pressure & Flow

Control

Gravity Fall System

90 100 cm above pts Perineum

give ~ 70 mm Hg

Fluid Delivery /
Monitoring Systems
ADVANTAGE

Pumps

Convenience

Monitoring Early warning

Exact amounts
Evaluating
rapidity

Electronic Suction & Irrigation Pump

Outflow Pressure 75 mm Hg
Flow rate
200 ml/mt
Suction Pressure 0.25 bar

Energy Source
Needle
Monopolar

Hook
Resectoscope

Energy Source
Bipolar

Versapoint

Ball tip
- Precise Vaporisation
Spring tip - Hemostatic vaporisation of large areas
Twizzle tip - Hemostatic Resection & Morcelation

Surgical Instruments
Scissors

- Synechiae, Polyp, Septum

Forceps

Biopsy

Graspers - Foreign bodies

Sterilization of
instruments
Dismantle, clean and put in Glutaraldehyde
solution (cidex) for 20 mts
Only few scopes and instruments are
autoclavable

Procedure
Anesthesia- No Anesthesia,PCB,Mild sedation,SAB,GA

Position- Dorsal Lithotomy

Bladder Emptied

Bimanual Examination

Cervical Dilatation

Indications
Diagnostic hysteroscopy
1. Infertility
- Abnormal
HSG/TVS/SSG
- Unexplained infertility
2. Abnormal uterine bleeding
3. Recurrent spontaneous abortion

Indications
Operative hysteroscopy
1. Submucous fibroid/polyp
2. Intrauterine septum
3. Intrauterine adhesion
4. DUB
5. Cornual block
6. Miscellaneous
- IUCD removal, hysteroscopic sterilisation
- biopsy from intrauterine lesion

Contraindications For
Hysteroscopy
Absolute
- Current / Recent Genital Infection
- Profuse Uterine Bleeding
- Pregnancy
Relative
- Menstruation
- Recent Uterine Perforation
- Invasive Cervical Carcinoma
- Endometrial Adenocarcinoma

Septal resection

VERSA POINT

 Bipolar Technique
Works in Saline
Instant Tissue Vaporization
Contact Technique Enables Continuous visualization
Excellent homeostasis with less or no charring

Complications
1.
2.
3.
4.
5.
6.

Anesthesia
Distension medium
Perforation
Bleeding
Infection
Operator technique

Hysteroscopy when done by

proper technique, incorporating latest
technologies, is a simple, valuable and
precise diagnostic tool in the hands of
Gynecologists.
Seeing is Believing