Gynecologic Laparoscopy

During the last 50 years, laparoscopy has evolved from a limited gynecologic surgical procedure used only for diagnosis and tubal ligations to a major surgical tool used for a multitude of gynecologic and nongynecologic indications. Today, laparoscopy is one of the most common surgical procedures performed in many parts of the world.

For many gynecologic procedures, such as removal of an ectopic pregnancy, treatment of endometriosis, ovarian cystectomy, and hysterectomy, laparoscopy has become the treatment of choice. Compared with laparotomy, multiple studies have shown laparoscopy to be safer, to be less expensive, and to have a shorter recovery time. The advantages of the laparoscopic approach for other procedures, including myomectomy, sacral colpopexy, and the staging and treatment of gynecologic cancers, continue to broaden. ^[1]

Laparoscopic techniques have also continued to evolve, primarily as a result of technological advances. In addition to better cameras and instruments, technology has resulted in the development of robotically assisted laparoscopy, and more recently single-port laparoscopy. The relative advantages and disadvantages of these new approaches compared with traditional laparoscopy, as well as their indications, continue to be studied.

Laparoscopy was first performed in dogs in the early 1900s by Dr. Georg Kelling, a German surgeon, who called his procedure koelioskopie. ^[2] While experimenting with the use of air for pneumoperitoneum to stop intra-abdominal bleeding, he introduced a cystoscope into the abdomen to view the effects of increased pressure on abdominal organs.

Dr. Hans Christian Jacobaeus, a Swedish surgeon, was the first to publish a description of laparothorakoskopie in humans in 1910. ^[2] He used air pneumoperitoneum and a cystoscope to evaluate the peritoneal cavity of tuberculosis patients with ascites. Shortly thereafter, Dr. Bertram M. Bernheim of the Johns Hopkins Hospital, reported a series of the first human laparoscopy performed in the United States, which he called organoscopy.

Early in the 20^th century, diagnostic laparoscopy was used by a limited number of general surgeons in place of diagnostic laparotomy, but had a substantial complication rate. ^[3] Throughout the 1920s and 1930s, advocates of the procedure continued to develop improved laparoscopic equipment, such as pyramidal trocars for port introduction and lenses with a wider angle of view than the 90° afforded by the cystoscope. During this period, Dr. Janos Veress, a Hungarian internist, developed a spring-loaded needle with an inner stylet that automatically converted the sharp cutting edge to a rounded end. The Veress needle continues to be used today to create a pneumoperitoneum.

A major step forward in the development of laparoscopy was the development of a safer laparoscopic lighting system in the 1950s. Up until that time, intra-abdominal light was produced by a small electric light bulb at the distal tip of the laparoscope analogous to a bronchoscope. The use of a quartz light rod to transmit light from an external source to the tip of the laparoscope increased brightness and decreased the risk of intra-abdominal burns. This was soon followed by the application of fiber optic technology still used in modern laparoscopes.

Dr. Raoul Palmer, a French gynecologist who specialized in infertility, was an early pioneer in the development of laparoscopy in the mid 20^th century. In addition to advocating monitoring of intra-abdominal pressure, he expanded the therapeutic use of laparoscopy for such tasks as intra-abdominal electrocoagulation of bleeding sites, puncture of ovarian cysts, and lysis of pelvic adhesions. In 1961, Dr. Palmer described the first laparoscopic retrieval of oocytes, and in 1974 he described the point 3 cm below the last rib in the left mid-clavicular line. Palmer's point is often used today for left upper quadrant laparoscopic entry. ^[4]

Dr. Kurt Semm, a German gynecologist who specialized in infertility, was perhaps the most influential early advocate of modern operative laparoscopy. ^[5] In the 1960s and 1970s, Dr. Semm invented the automatic insufflator, and hundreds of laparoscopic instruments, including a thermocoagulator, loop ligature, and devices for extracorporeal and intracorporeal endoscopic knot tying. He was one of the first proponents of video monitoring for laparoscopy, using a series of lenses and mirrors in an articulated arm to connect the laparoscope to a ceiling-mounted video camera. He developed laparoscopic techniques for ovarian cystectomy, myomectomy, treatment of ectopic pregnancy, appendectomy and hysterectomy. Despite the work of Dr. Semm and other remarkable pioneers, gynecologic laparoscopy continued to be used primarily for diagnosis and tubal ligations into the 1980s.

A major breakthrough came with the introduction of the solid state video camera for laparoscopy in 1982. With the widespread application of these compact cameras, both laparoscopist and assistants could simultaneously view the operative field on a video screen. By the end of the decade, video-laparoscopy had become standard and operative laparoscopy became widely accepted as a safe and effective surgical approach. Today, operative laparoscopy is routinely used by gynecologists to perform a multitude of procedures, including hysterectomies and incontinence procedures, and for the diagnosis and treatment of gynecologic malignancies.

In recent years, 3 innovations that have been introduced or reintroduced to the field of laparoscopy: 1) robotic surgery ^[1] , 2) natural orifice transluminal surgery ^[6] , and 3) single incision laparoscopic surgery (SILS). All 3 have their advantages and disadvantages compared to traditional laparoscopy. Of these 3 developing technologies, robotic surgery is having the largest impact on clinical care.

Laparoscopy is a hybrid surgical approach that shares characteristics of both minor and major surgery. To patients, laparoscopic procedures often seem to be minor surgery because of the small incisions, relatively small amount of postoperative pain, and short convalescent period. When a laparoscopic procedure involves minimal intra-abdominal surgery (eg, diagnostic laparoscopy, tubal fulguration), both postoperative discomfort and the risk of complications may more closely resemble a minor procedure than a major procedure.

At its essence, laparoscopy remains an intra-abdominal procedure. Therefore, it shares all intraoperative and postoperative risks of laparotomy, including infection, bleeding and injury to adjacent intra-abdominal structures. When major intra-abdominal procedures are performed laparoscopically (eg, hysterectomy), the resultant postoperative pain and morbidity are still significant. However, because a large abdominal incision is unnecessary, the postoperative pain and morbidity are always less significant than similar major surgery performed by laparotomy.

Laparoscopic procedures have unique risks, which are related to methods used for the placement of abdominal wall ports and to the pneumoperitoneum required for laparoscopy. The use of energy within the abdominal cavity likewise introduces risk. These risks include injury to bowel, bladder, or major blood vessels and intravascular insufflation. In addition, increased intra-abdominal pressures associated with laparoscopy increase anesthesia-related risks such as aspiration and increased difficulty ventilating the patient. Although the risk of blood loss is relatively low for most procedures, potentially massive blood loss may occur and is complicated by the fact that control of blood loss may be delayed by the time taken to perform an emergency laparotomy.

United States statistics

Laparoscopy is one of the most common surgical procedures performed in the United States today. Approximately half of the 700,000 bilateral tubal sterilizations performed annually in the United States are performed laparoscopically. In addition to diagnostic laparoscopy, operative endoscopy is used to perform common procedures, including removal of ectopic pregnancies, treatment of endometriosis, and lysis of pelvic adhesions. Almost two thirds of the 600,000 hysterectomies performed annually in the United States are now performed with the aid of a laparoscope, with or without robotic assistance. Although the ideal role of laparoscopy in gynecologic surgery continues to be defined, it has become a standard approach for a large number of gynecologic procedures.

Diagnostic laparoscopy

Frequently, the physician needs to assess the pelvis for acute or chronic pain, ectopic pregnancy, endometriosis, adnexal torsion, or other pelvic pathology. ^{[7, 8]} Determination of tubal patency may also be an issue. ^[7]  Diagnostic laparoscopy can play an important role in the evaluation of unexplained infertility. ^[9]

Usually, a primary port for the laparoscope (also known as the "lens") is placed infraumbilically and a second port is placed suprapubically to probe systematically and observe pelvic organs. If needed, a biopsy specimen can be obtained to aid in the diagnosis of endometriosis or malignancy. If tubal patency is a concern, use of a uterine manipulator with a cannula allows a dilute dye to be injected transcervically (chromopertubation).

Diagnostic laparoscopy is usually performed under general anesthesia, with endotracheal intubation to minimize the risk of aspiration. However, if the pressure used for peritoneal insufflation is limited, laparoscopy can be performed under conscious sedation.

Tubal sterilization

Trocar placement is similar to diagnostic laparoscopy. Bipolar electrosurgery, clips, or silastic bands may be used to occlude the tubes at the mid-isthmic portion, approximately 2-3 cm from the cornua. ^[10] Bipolar surgery desiccates the tube with 3 adjacent passes to occlude approximately 2 cm of tube. The auditory tone now available to verify total resistance has improved the efficacy of bipolar cautery. Pregnancy rates vary by patient age, ranging from 1-3% after 10 years.

Lysis of adhesion

Adhesions may form due to prior infection, such as a ruptured appendix or pelvic inflammatory disease (PID), endometriosis, or previous surgery. Adhesions may contribute to infertility or chronic pelvic pain. The chances of pregnancy after lysis of adhesions is relatively low for most patients, and this type of surgery has been largely supplanted by in vitro fertilization and embryo transfer. Likewise, adhesiolysis is often ineffective in curing chronic pelvic pain, in part because most adhesions rapidly reform after surgery.

Adhesions may be lysed by blunt or sharp dissection. Aquadissection may aid in the development of planes prior to lysing. Any of the power instruments may be used for cutting and coagulation (see Power instruments). Although in experienced hands unipolar electrosurgery is safe, gynecologist use of unipolar electrosurgery, such as with the fine unipolar needle, is generally recommended to be limited to adhesions 1-2 cm from the ureter and bowel due to the unpredictable nature of current arcing. Other power techniques may be safer choices for adhesiolysis near the bowel.

Adhesions may reform after lysis, although this can be reduced with good hemostasis and minimal use of electrocautery. ^[11] Recently, a 4% icodextrin solution has been shown to decrease adhesion reformation in a controlled trial. Unfortunately, the results of laparoscopic lysis of adhesions have been disappointing in terms of improving pain relief or future fertility.

Treatment of endometriosis

Laparoscopy is the most common procedure used to diagnose and treat endometriosis. ^[12] Endometriotic lesions may be resected or ablated using any of the power instruments (see Power instruments). Both of these techniques have shown to improve fertility and decrease pelvic pain in multiple well-designed studies. A systematic review by Franck et al reported improvements in the quality of sexual life following laparoscopic surgery for endometriosis. ^[13]

Treatment of ectopic pregnancy

Laparoscopy is the surgical approach of choice for most ectopic pregnancies. ^{[14, 15]} A salpingostomy or salpingectomy may be performed to remove the embryo and gestational sac. Although auxiliary instruments (eg, pretied loops, stapling devices) can be used for the salpingectomy, most commonly, a power instrument (eg, bipolar electrosurgery, ultrasonic scalpel) is used for these procedures (see Power instruments).

Ovarian cystectomy

If a simple ovarian cyst sized 6 cm or larger persists for 2 or more cycles in a premenopausal, nonpregnant female, a cystectomy is indicated. This can be achieved using laparoscopy or laparotomy depending on the cyst size and the likelihood of the presence of malignancy.

The cyst can be removed by a number of techniques. ^{[16, 17]} If the cyst is complex, rule out malignancy by looking for signs of ascites; excrescences on the ovary; or implantations on the peritoneal, liver, or diaphragmatic surfaces. If malignancy is not apparent, carefully dissect the cyst, making an effort to remove the cyst intact. A bag may be used to transfer the cyst out of the peritoneal cavity through a 10-mm port, draining the cyst prior to removal of the bag. If any doubt exists, the cyst wall should be sent for frozen section to confirm a benign cyst. If malignancy is found, a laparotomy should be performed. Permanent section and pathological diagnosis are performed on all cysts. Ovarian cysts with septa, internal echoes, or solid tumors are not good candidates for laparoscopy unless a benign cystic teratoma is a strong possibility.

If the cyst ruptures during removal, liberally rinse the peritoneal cavity with Ringer lactate solution. A dermoid cyst is particularly concerning because of contamination of the peritoneal cavity with sebaceous material, causing a chemical peritonitis. However, 2 case series demonstrated that pregnant and nonpregnant women who had an intraoperative spillage of a dermoid cyst followed by extensive peritoneal irrigation did not have increased length of stay or increased incidence of postoperative complications. Fear of seeding the cavity with a malignant tumor has always been present, although recent data suggest that spilling does not alter the prognosis if a staging laparotomy is performed immediately.

Postmenopausal cysts may also be removed by laparoscopy, although with the increased concern for malignancy, an oophorectomy and laparotomy may be more prudent. Physicians who perform a laparoscopy should be comfortable with staging by laparoscopy or laparotomy, and malignancy should be excluded perioperatively.

Salpingo-oophorectomy

Salpingo-oophorectomy may be more appropriate in postmenopausal women with a growing or persistent cyst. Tubes and ovaries are also removed prophylactically in women with a genetic predisposition to ovarian or tubal cancer. ^[18] A tubal pregnancy or large hydrosalpinx with adhesions may also require ovary removal. The power instruments, pretied loops, or stapling devices may be used to occlude the infundibular ligament and safely remove the ovary. Because of ovary size, a retrieval bag is needed to remove the tissue. Options for removing the ovary from the peritoneal cavity include (1) using a 12-mm port and removing the sleeve with the bag or (2) performing a minilaparotomy or colpotomy. If a colpotomy is performed, prophylactic antibiotics should be administered.

Myomectomy

Many women with a symptomatic fibroid uterus prefer myomectomy to hysterectomy in order to preserve fertility or the uterus. If the patient has a pedunculated fibroid, the stalk may be easily incised. However, for intramural fibroids, the risk of bleeding increases. The use of a preoperative gonadotropin-releasing hormone (GnRH) agonist may be considered in patients who are anemic. However, some studies have shown longer operative times and a higher conversion to laparotomy rate associated with the use of GnRH agonists in laparoscopic myomectomy due to difficult cleavage planes. An injection of vasopressin into the uterus may help maintain hemostasis. The defect left by the fibroid must be sutured, which can be difficult laparoscopically for inexperienced practitioners. Barrier techniques may be used to decrease adhesion formation.

The fibroid may be removed by morcellation or colpotomy. The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors. ^[19]  To date, laparoscopy has not proven better than laparotomy for the treatment of menorrhagia or infertility. In addition, some concern exists that the risk of subsequent uterine rupture during pregnancy may be greater after myomectomy performed by laparoscopy compared with laparotomy. However, all randomized clinical trials of myomectomy performed by laparoscopy versus laparotomy did not show an increased risk of rupture or poorer reproductive outcomes. These trials were conducted by experts in laparoscopic suturing and in carefully selected patients.

Hysterectomy

Initially, laparoscopy was performed prior to vaginal hysterectomy to restore normal anatomy. However, currently, it is often used in a variety of ways, such as assessing feasibility of a vaginal hysterectomy (when adhesions, endometriosis, or a large fibroid uterus is suggested) and performing some or all of the actual hysterectomy. ^[20] The 3 basic laparoscopic approaches for hysterectomy are laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy (LH), and laparoscopic supracervical hysterectomy (LSH). Although the basic techniques for each approach are fairly standardized, controversy exists over the risks, benefits, and most appropriate indications of each. ^[21]

LAVH is the most commonly employed and technically straightforward of the 3 techniques. Using 3-4 ports, the peritoneal cavity is surveyed and lysis of adhesions is performed if necessary. The infundibular or uteroovarian ligaments are occluded and divided, depending on whether the ovaries will be removed. The round ligament is cut in a similar fashion, and the uterovesical peritoneum is incised. Depending on physician preference, the proximal uterine blood supply is occluded and divided laparoscopically. After the uterovesical peritoneum is incised, the physician may also choose to laparoscopically incise the posterior cul-de-sac. The physician then proceeds vaginally for the remainder of the case, dissecting the vesicovaginal septum anteriorly to enter the anterior cul-de-sac, ligating the uterine vessels, removing the uterus and ovaries (if appropriate), and closing the vaginal cuff.

LH, the second approach, is performed initially like the LAVH, except that the entire hysterectomy is performed laparoscopically. The surgeon would choose indications similar to LAVH but would add lack of uterine descent, which would make the vaginal approach impossible. After the infundibular, uteroovarian, and round ligament are occluded and divided, the bladder is dissected off the uterus anteriorly. The ureter is identified and dissected along its entire course, and the uterine vessels and uterosacral ligaments are then occluded and divided. After the posterior cul-de-sac is incised, the specimen is removed vaginally, and the cuff is closed.

LSH is the third approach, being most often promoted for benign indications. The technique begins again as for the LAVH, but proceeds with separating the entire fundus from the cervix after the proximal vessels are divided and the bladder is dissected away from the uterus. A special instrument is used to core-out or cauterize the endocervix, and the uterus is then removed through a 12-mm port abdominally by morcellation or transcervically with a special morcellator. Note: The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors. ^[19]  This approach eliminates vaginal and abdominal incisions, with no need to dissect near the uterine artery or ureter. Proponents of LSH advocate that the operating room and recovery time are decreased and risk of both infection and ureteral injury are minimized. However, an increased risk exists for reoperation for cervical bleeding and prolapse. Furthermore, patients must follow the recommendations for regular cervical cytology. 

Oncologic procedures

Laparoscopy has long been used in oncology for second-look procedures following surgical and chemical treatment of malignancy. More recently, laparoscopy has also been used for staging, including peritoneal washes with biopsy, partial omentectomy, and pelvic and periaortic lymphadenectomy. ^{[22, 23]} Procedures such as laparoscopically assisted radical vaginal hysterectomy have also been used by some gynecologic oncologists.

Robotic laparoscopic surgery appears to be changing the approach to many gynecologic cancer cases. The robotic system allows surgeons to perform procedures that previously would have been performed via laparotomy using modified laparoscopic procedures. The robotic system has the advantages of 3-dimensional, high-definition imaging and magnification that improve the topography of the pelvis and the cervicovaginal plane. Fully articulated instruments emulate the full range of motion of a surgeon’s wrists and hands. This enhances the surgeon’s ability to remotely perform fine motor skills such as intricate dissections and intracorporeal suturing that remain difficult during traditional laparoscopy.

Anterior abdominal wall anatomy should receive special attention prior to laparoscopy because many laparoscopic complications result from trocar placement.

Abdominal scars

Previous surgery is associated with a greater than 20% risk of adhesions of bowel or omentum to the anterior abdominal wall, ^[24] For this reason, many laparoscopists adjust their techniques in these patients to minimize the risk of bowel injury. Of special concern are incisional scars immediately adjacent to the umbilicus because bowel adherent underneath the umbilicus may be at risk for injury regardless of the technique used. Although Pfannenstiel and abdominal incisions distant to the umbilicus may also be associated with adhesions, in many laparoscopists' experiences, these incisions appear to represent less of a risk than incisions near the umbilicus.

In addition to location, the width and depth of the scar should be evaluated because a wide or retracted scar may suggest that a postoperative wound infection had occurred. Common wisdom dictates that postoperative infections may be associated with an increased risk of intra-abdominal adhesion formation, although no data are available to support this observation. If the dome of the bladder is involved in the infectious process, it may cause progression of the bladder dome higher behind the anterior abdominal wall, thus increasing the risk of bladder injury at the time of suprapubic trocar placement. ^[25]

Abdominal wall thickness

Although abdominal thickness correlates with patient weight, short stature or truncal obesity may increase abdominal wall thickness out of proportion to patient weight. ^[26] Routine evaluation of the abdominal wall prior to laparoscopy is important because the success of trocar insertion may depend on altering the technique based on abdominal wall thickness.

Umbilicus

The umbilicus should be examined for signs of umbilical hernia. Techniques for trocar insertion should be adjusted, and closure of the defect should be considered. In the absence of incarcerated bowel, the skin over the hernia can be carefully incised and the peritoneal cavity entered using an open technique. Closure of a small defect can be performed with interrupted sutures at the completion of the laparoscopic procedure. For ideal cosmetic results, larger defects may require the assistance of a surgeon experienced in umbilical hernia repair.

Abdominal wall vessels

The anterior abdominal wall contains 2 sets of bilateral vessels: the superficial and the inferior (deep) epigastric vessels. These arteries originate from the femoral and external iliac arteries, respectively, and are accompanied by a large vein in most cases. Immediately above the symphysis pubis, they are both located an average of 5.5 cm from the midline and course slightly more laterally at points more cephalad. In order to avoid injuring these vessels during lateral trocar placement, the superficial vessels should be visualized by transillumination and the inferior vessels should be laparoscopically visualized whenever possible. ^[27] The use of conical trocars (as opposed to pyramidal tipped trocars) can also decrease the risk of injury to these vessels. ^[28]

Determination of absolute contraindications to laparoscopy remains controversial. For years, previous abdominal surgery and intestinal obstruction were regarded as contraindications to laparoscopy because of an increased risk of iatrogenic bowel perforation. However, recent reports suggest that morbidity is lower with laparoscopy compared to laparotomy.

In gynecology, the most commonly suggested contraindication is hemodynamic instability resulting from a ruptured ectopic pregnancy. However, following appropriate fluid resuscitation, laparoscopy is a safe approach.

Another traditional contraindication was pregnancy. In the last few years, several large series have documented the safety of using an open technique for laparoscopy during pregnancy.

Finally, disagreement is ongoing as to whether a known gynecologic malignancy is a contraindication to laparoscopy. Several case reports and series have suggested that laparoscopy may increase the risk of intraperitoneal spread of cancer cells.

Although few absolute contraindications exist for laparoscopy, several risk factors are well appreciated.

Patient risk factors

Patient risk factors are as follows:

• Obesity

  • Obesity is a well-recognized factor that increases the risk of any abdominal surgery. For laparoscopy, increased weight takes on a special significance. Women with a body mass index (BMI) greater than 25 kg/m² are classified as overweight, and those with a BMI greater than 30 kg/m² are considered obese. In an average-sized woman of approximately 160 cm (64 in), these cutoff points correspond roughly to weights of 73 kg (160 lb) and 91 kg (200 lb), respectively.

  • In women who are overweight, and even more so in those who are obese, every aspect of laparoscopy becomes more difficult and potentially more risky. Placement of laparoscopic instruments becomes much more difficult and often requires special techniques. Bleeding from abdominal wall vessels may be more common because these vessels become difficult to locate. Many intra-abdominal procedures become increasingly difficult because of a restricted operative field secondary to retroperitoneal fat deposits in the pelvic sidewalls and increased bowel excursion into the operative field. This second problem is probably related to increased volume of bowel, decreased elevation of a heavier anterior abdominal wall by the pneumoperitoneum, and the inability to place many patients who are obese in steep Trendelenburg position because of ventilation considerations.

  • Recommendations from the American College of Obstetricians and Gynecologists also emphasize that laparoscopy can be more complicated in obese patients, and the risk of conversion to laparotomy is increased in this setting. ^[29]

  • Weight loss prior to elective surgery in patients who are overweight or obese would be ideal. Unfortunately, significant weight loss may take years and, more often than not, is impossible. A more realistic approach is to inform the patient of the increased risk associated with obesity and to limit the extent of advanced laparoscopic procedures that are attempted in patients who are obese. Although no certain weight exists at which laparoscopy is contraindicated, performing surgery in patients weighing more than 136 kg (300 lb) requires skill. In the oncology literature, several reports suggest decreased postoperative morbidity in laparoscopic surgery performed in morbidly obese women for endometrial cancer, especially in the rates of wound infection and wound dehiscence.

• Age

  • Another well-described surgical risk factor is age. As the population ages, more women of increased age will have indications for laparoscopy. Older patients are at increased risk of having concomitant disease processes that affect their perioperative morbidity and mortality.

  • Probably the single most important consideration is age-associated increase in cardiovascular disease. Intraoperative cardiac stress related to anesthesia and the surgery itself may result in sudden cardiac decompensation based on arrhythmia, ischemia, or infarct.

  • Of special importance is the increased susceptibility of elderly persons to hypothermia because the vast majority of patients experience some degree of hypothermia during laparoscopy. In older patients, even mild degrees of hypothermia may increase the risk of cardiac arrhythmia and prolong recovery time.

• Previous abdominal surgery

  • As far as laparoscopic complications are concerned, one of the most important risk factors is a history of previous abdominal surgery. The risk of adhesions of omentum and/or bowel to the anterior abdominal wall after previous abdominal surgery is greater than 20%. Because laparoscopy requires the insertion of sharp instruments into the abdominal cavity, a reasonable assumption is that previous surgery would increase the risk of bowel injury. Thus, strategies have been developed to decrease the risk of bowel injury in patients with previous abdominal surgery.

  • The most common of these strategies is the use of an open technique for laparoscopic trocar placement, as first advocated by Hasson. Open laparoscopy techniques almost certainly decrease the risk of bowel injury distant to the umbilicus. To avoid bowel injury at the site of entry, modifications of the open technique have employed blunt entry of the peritoneal cavity with a hemostat to avoid inadvertently grasping and incising the bowel. In patients with previous laparotomy in which the scar is located at the umbilicus, use of an alternative location for trocar insertion (usually in the left upper quadrant) has been recommended to avoid injury of bowel adherent immediately beneath the umbilicus. The closest organ to the left upper quadrant is the stomach (therefore, an oral gastric tube is recommended before insertion) and the left lobe of the liver. Although clinical trials are limited, this appears to be an acceptable approach.

  • Despite the potential for increased risk of bowel injury after previous laparotomy, some laparoscopists advocate the use of a closed periumbilical trocar insertion techniques in all patients, regardless of a history of previous surgery. One justification is that bowel injury is uncommon (approximately 3 cases per 10,000 procedures) and open laparoscopy does not completely avoid the risk of bowel injury.

Anesthetic risk factors

Anesthesiologists are trained not only in the art of providing anesthesia, but also to serve as consultants. This may be one of the least-used assets available to modern surgeons. Prior to surgery, discuss preparation of any patient with significant health problems with an anesthesiologist. In complex cases, these patients should be seen by an anesthesiologist for optimal preanesthesia preparation. ^[30]

• Time since last oral intake

  • One of the most critical time-dependent aspects of preparation is the degree to which the patient's stomach is empty because both general anesthesia and increased intra-abdominal pressure may increase the risk of regurgitation and resultant aspiration. The appropriate time to wait from the last oral intake until induction of general anesthesia is a much-debated topic. In general, the recommendation is that approximately 6 hours be allowed to elapse between the last intake of solid food and the elective induction of anesthesia. In patients with conditions associated with decreased gastric emptying (eg, diabetes-induced autonomic dysfunction) or in the presence of predisposing factors for regurgitation (eg, sliding hiatal hernia, known reflux), a longer period of fasting may be indicated.

  • Unfortunately, in emergency cases such as ectopic pregnancy or ovarian torsion, general anesthesia may be required despite a period of fasting of less than 6 hours. In these cases, always consult an anesthesiologist. In many cases, steps can be taken to decrease the incidence of aspiration pneumonia, including administration of agents to decrease gastric acidity, such as antacids or histamine receptor antagonists, or the use of drugs that increase gastric emptying, such as metoclopramide.

• Heart disease

  • Preoperative evaluation should include a search for evidence of underlying cardiac disease. With a positive history or physical examination findings suggestive of cardiac disease, preoperative evaluation by both a cardiologist and an anesthesiologist is extremely important. Patients with ischemic heart disease who undergo anesthesia may have decreased cardiac blood return coupled with an increased heart rate that may result in infarction. Laparoscopic-associated metabolic acidosis, respiratory acidosis, and hypothermia may result in arrhythmia in predisposed patients, thus increasing the risk of ischemia even further. Also, the risk of arrhythmia increases with distention of the abdomen, especially in patients who are breathing spontaneously.

  • Finally, patients at risk for congestive heart failure should be evaluated carefully prior to laparoscopy because a decrease in cardiac output may be related to decreased venous return and increased peripheral vascular resistance.

• Pulmonary disease

  • Any patient with a significant history of pulmonary problems should be evaluated by both a pulmonologist and an anesthesiologist prior to laparoscopy. When given an option, laparoscopy is preferable to laparotomy in these patients. The relatively decreased postoperative pain following laparoscopy may result in less ventilatory compromise than laparotomy and thus, fewer problems with atelectasis or pulmonary failure in those with borderline pulmonary function.

  • Special care should be taken during laparoscopy in patients with pulmonary disease. Hypercarbia and decreased ventilation associated with laparoscopy may be especially deleterious in pulmonary patients with chronic respiratory acidosis. In rare cases, pneumothorax and pneumomediastinum have been described as complications of abdominal insufflation. In patients with compromised pulmonary function, even a small intravasation of carbon dioxide could result in significant pulmonary decompensation.