Overview of laparoscopic surgery
Thomas G Stovall, MD
William J Mann, Jr, MD
INTRODUCTION — The laparoscope is as an essential diagnostic and therapeutic operative tool. The broader issues related to laparoscopy and the surgical techniques that are common to many gynecologic laparoscopic procedures will be reviewed here. Specific uses of laparoscopy are discussed in the individual topic reviews on each entity.
ROLE OF LAPAROSCOPY IN GYNECOLOGIC SURGERY — Laparoscopic surgical procedures are usually performed in an effort to replicate procedures that have been successful at laparotomy. Potential advantages of laparoscopy over laparotomy include shorter operative time (for some, but not all, procedures), smaller scar, faster recovery, decreased adhesion formation, and decreased cost [1-3]. A meta-analysis of 27 randomized clinical trials comparing operative laparoscopy to laparotomy for benign gynecological conditions found the overall risk of minor complications (eg, fever, wound or urinary tract infection) was lower in women undergoing laparoscopic procedures (RR 0.55, 95 percent CI 0.45 to 0.66) while the risk of major complications (pulmonary embolus, transfusion, fistula formation, major additional unplanned surgery) was the same in both groups .
However, just because a procedure can be preformed using a laparoscope connected to a video monitor does not necessarily mean that it should be. As an example, cumulative ongoing pregnancy rates in subfertile women with anovulation and polycystic ovarian syndrome are similar after primary treatment with ovarian drilling or medical ovulation induction . The place for laparoscopically assisted vaginal hysterectomy, as opposed to traditional abdominal or vaginal hysterectomy, and the place of laparoscopic myomectomy versus abdominal myomectomy, in a gynaecologic surgeon's armamentarium are also unclear. (See "Vaginal hysterectomy", section on Laparoscopic-assisted vaginal hysterectomy and see "Myomectomy", section on Laparoscopic myomectomy).
PATIENT POSITIONING — The woman is placed in a supine position while general anesthesia is administered. A bladder catheter is useful to avoid bladder distension, which increases the risk of bladder perforation and may obscure the operative field. After insertion of trochars, she is then tilted into Trendelenburg's position (20- to 45-degree angle) to assist with displacement of the bowel from the pelvis. The procedure can be performed by placing her in a dorsal lithotomy position using candy-cane type stirrups or Allen stirrups (Edgewater Medical Systems, Mayfield Heights, OH), or with the patient lying flat with legs spread to allow access to the vagina. The buttocks should be at the edge of the table. Operator preference and the scope of the intended procedure determine the optimal position.
INSTRUMENTATION — Almost all instruments available for laparotomy are now available for use at laparoscopy. (See "Surgical instruments for gynecologic surgery"). However, because the instruments must fit through a 3- to 20-mm port and must be of sufficient length to reach the pelvis, specialized instruments have been devised. Virtually all instruments are available in a reusable, disposable, or hybrid form (part of the instrument is disposable and part is reusable). Disposable instruments are typically less cost effective, although they have the advantage of always being available, and the cutting edges are always sharp. Situations occasionally arise where a laparotomy instrument may be used directly through a lower portal. There are also techniques evolving in which the operator's sleeved hand may be introduced into the abdomen during the procedure.
Telescopes — Telescopes for laparoscopy are of two basic types, those with and those without an operative channel .They range in size from 3 to 12 mm, and have straight or angled lenses. The 0-degree lens provides a panoramic view of the pelvis and is preferred by most gynecologic surgeons, although angled 30-, 45-, and 135-degree lenses assist in evaluating the anterior abdominal wall or working around masses. The choice of telescope is generally based upon operator preference. The larger the caliber of the telescope, the greater the number of fiber bundles contained therein, and the higher the quality of the video picture. The optics of the smaller scopes are rapidly improving.
Telescope warmers are used by some surgeons to reduce fogging during the procedure. Antifog solutions are also very successful. Three-dimensional systems are under evaluation.
Light source — The application of fiberoptic technology has allowed a greater intensity of light to be delivered to the laparoscope and into the abdomen. Light transmission is improved as the number of fibers, size of the cable, and the power of the light source all increase. In contrast, illumination is reduced at each junction in the system, such as the use of a beam splitter or when there is an operating port. Transmission is also reduced if the optic cables are damaged or broken.
Cannulas and trocars — Cannulas are available in diameters from 3 to 12 mm to accommodate laparoscopes and instrumentation of all sizes .They are equipped with either a trumpet or flapper valve to prevent gas leakage. The cannula also helps to control the depth of trochar insertion.
Trocars have either a pyramidal or conical tip and, for closed procedures, should be sharp enough to produce the force necessary to penetrate the abdominal wall. With open laparoscopy, the trochar is inserted directly into the peritoneal cavity so a sharp tip is not required. Most trocars are constructed with a hollow channel with openings at the tip and at the top of the instrument. This creates a rush of gas when the peritoneal cavity is penetrated by the trocar; the instrument does not need to be passed into the abdomen beyond this point. Blunt trocars and transparent tips allowing visualization during insertion have been developed (optical-access trocars), but experience with them is limited .
Uterine cannula — The uterine cannula is used to manipulate the uterus and thereby facilitate visualization of and access to pelvic structures. Most cannulas also permit injection of a dye solution (chromopertubation) to assess tubal patency. A variety of uterine manipulators are available. The most widely used are the Cohen cannula and the Hulka uterine manipulator.
A uterine cannula should not be used when:
- The uterus is absent
- Anomalies exist that prevent exposure of or access to the cervix
- The woman is a prepubescent female
- An intrauterine pregnancy is suspected
- The procedure planned includes oocyte recovery.
A sponge stick, or examining hand, may be positioned in the vagina in the absence of the uterus.
Pneumoperitoneum needle — The Veress needle is the pneumoperitoneum needle used most frequently. This needle has two working parts: an outer needle with a sharp beveled edge, and an inner, spring-loaded, retractable blunt shaft that extends beyond the end of the needle point. As soon as the peritoneum is penetrated, the blunt shaft is propelled forward by the spring-loaded mechanism beyond the sharp tip, thus making the instrument a blunt-tipped instrument. Positioning of the needle can be confirmed by demonstration of generated negative pressure by lifting the abdominal wall or freely injecting saline. Preperitoneal insufflation of gas will distort the abdominal cavity and pelvic structures and may make operative laparoscopic procedures prohibitively difficult or impossible. Therefore, proper placement of the Verres needle can be the most important aspect of a laparoscopic procedure. Proponents of open laparoscopy do not use these instruments, favoring surgical incision into the peritoneal cavity, and direct placement of the trochar, followed by insufflation.
Grasping instruments — Grasping forceps have been designed for tissue manipulation. Some are broad and flat, while others are finer and made for delicate tissue handling. Toothed forceps are used to put traction on tissue that is to be removed, such as for grasping ovarian cysts and leiomyomas. Forceps with pointed ends are used for tissue dissection and surgical plane development. Ratcheted and non-ratcheted varieties exist.
Atraumatic tissue-grasping instruments have double action and curved jaws and are operated by either a scissors or a spring handle. A disposable Babcock-type atraumatic grasper with a ratcheted scissors handle can be particularly useful in handling adnexal structures. Biopsy forceps may double as grasping instruments, but can be traumatic to the tissue.
Cutting equipment — Scissors are available with blades of different sizes and shapes, such as hook scissors, curved-blade scissors, and scissors with straight blades or with teeth. Monopolar current can be attached to scissors to enhance cutting and coagulation. For most cutting needs, hooked scissors are a practical instrument because the jaw is designed to hold tissue until the cut is made. Sawtooth scissors hold tissue in a similar manner, but have no particular advantage over the hooked scissors.
Other cutting equipment includes various types of laser energy and electrosurgical needle tip electrodes. A bipolar instrument that combines both tissue desiccation and cutting in one instrument is also available. The unipolar J-hook electrode and the hook electrode are designed with an irrigation/suction tube that adds to their versatility.
Laparoscopic scalpels resemble a small #11 scalpel and may be inserted through either a primary or a secondary operative port. The scalpel can be attached to unipolar cautery. Harmonic scalpels which use sound waves to dessicate tissue are also available.
Suturing — Suturing techniques using laparoscopic instrumentation are the same as those in open laparotomy. The needle and tissue graspers are, by necessity, small enough to fit through the operative ports. Needle-holders are designed with locking jaws and are controlled by either an axially aligned or a spring-assisted scissors handle. The jaws of the needle-holder are strong and their approximation is exact to allow the instrument to be used for intracorporeal knot-tying.
Tissue can be reapproximated using either a straight or curved needle. The needle is first placed down the trocar and grasped with a laparoscopic needle holder. The needle is then passed through the tissue that is to be approximated, grasped, and brought out through the trocar. A simple half-hitch knot is then created and pushed into place with a knot-pusher. A square knot is made by tying another half-hitch and sliding it down to secure the knot in place . One of several methods that can be used to create a surgical knot using an intracorporeal suturing technique. Both extracorporeal and intracorporeal knot-tying can be performed with instruments. Use of these instruments requires a hand-eye coordination that can only be made efficient with practice; the instrument manufacturers have designed training devices for this purpose.
Pre-tied surgical loops are designed to be placed over structures with pedicles and then tightened in place. These are especially useful for removal of the ovary or fallopian tube. Once in place, the suture tag is cut and, most commonly, a second loop is placed to secure hemostasis.
Staples — Stapling as a laparoscopic surgical technique can be used for a variety of procedures such as hysterectomy, oophorectomy, appendectomy, bowel reanastomosis and resection, and to obtain hemostasis of bleeding vessels. Disposable clip appliers containing both absorbable and nonabsorbable staples are available for laparoscopy.
An endoscopic stapler places six rows of titanium staples 3.0 cm in length and simultaneously divides the stapled tissue. The staples compress the tissue to either 1.5 or 1.0 mm, depending upon the cartridge selected.
Suction and irrigation — Suction and irrigation are important for all types of laparoscopic surgery. Irrigation is used for removal of char or for visualization when bleeding is encountered. Irrigation can also be used for hydrodissection and creation of tissue planes.
A variety of suction instruments have been designed that are adequate for removal of irrigation fluid, or intraperitoneal air and smoke. A large-bore device is best for removal of blood clots when brisk bleeding is encountered and also for passing laser fiber. Suction/irrigation devices offer a combination of cautery or needle tip electrodes.
Video — Video monitors allow the surgeon and the remainder of the operating team to visualize the procedure. The camera is attached to the telescope and white-balanced before being placed into the abdominal cavity. Earlier cameras used beam splitters to allow the surgeon to look down the telescope as well as operate from the video monitor. This is really not necessary and decreases the quality of the picture obtained.
Generally, two monitors are used for pelvic laparoscopy, with one video being placed at the foot and the second placed across the operating table from the surgeon. Whether a permanent videotaped copy of the procedure should be made is controversial. Some surgeons prefer to provide a copy to the patient while others believe that it is not necessary and potentially increases the surgeon's liability. Photos may also be taken.
Tissue removal — Tissue morcellators are used for reduction of large masses into smaller fragments to assist with tissue removal. Tissue bags can be used for tissue isolation before or after morcellation. The bags can be removed through a secondary trocar.
Tissue dilators are used for stretching a 10-mm port to a 20-mm port. This technique can be very helpful for tissue removal. A colpotomy incision can also be an effective alternative to tissue removal through a secondary trocar; colpotomy is especially useful for removal of larger tissue pieces or ovarian masses. A corkscrew device is screwed into myomas to remove them through a colpotomy incision or through a minilaparotomy incision. Finally, one can enlarge a port incision to remove tissue.
PLACEMENT OF THE VERESS NEEDLE AND TROCARS — The Veress needle is usually placed intraumbilically. It also may be introduced in the area located midway between the pubic symphysis and the umbilicus, immediately supraumbilically at the midline, at the lateral border of the rectus muscle at either the left or right McBurney's point, or at the lateral border of the rectus muscle two finger breadths below the left costal margin. Transfundal  and posterior vaginal fornix  insertions have also been employed. A left upper quadrant, or even left intercostal insertion, may offer safer access in women who have had prior laparotomies.
A small incision is made just large enough to accommodate the needle, principal trocar, and cannula. The sacral promontory and aorta are palpated, and the length of needle necessary to reach the peritoneal cavity is estimated. The Veress needle is grasped between the finger and thumb of the right hand. The surgeon's right hand rests on the woman's abdomen and the tip of the needle is inserted through the skin incision. The left hand can then grasp the lower abdomen and elevate the tissue. The Veress needle is advanced at a 45-degree angle toward the hollow of the pelvis and, as it penetrates the peritoneum, the displaced hub of the needle will click against the top, indicating that penetration of the peritoneum has occurred. Two "pops" occur: first, the fascia and second, the peritoneum. Controlled insertion of the Veress needle helps to prevent injuries to the structures of the posterior abdomen and retroperitoneum.
Proper placement should be confirmed by connecting a 10-mL syringe containing 4 mL of normal saline to the Veress needle. The plunger is withdrawn to make sure that no blood appears in the needle, indicating a vessel injury, and that no bowel contents are obtained, suggesting a bowel injury. The saline is then injected. If the needle is correctly positioned, there will be no recovery of saline on aspiration and the plunger will snap when it is released, due to the negative pressure created. An alternative method is referred to as the hanging drop method. A drop of saline is placed at the open end of the needle and the abdomen is then elevated; the negative pressure created should cause the drop of water to be sucked in to the abdominal cavity.
Insufflation — The gas line is connected and the gas turned on after verification that the Veress needle or primary trocar is intraabdominal. The pressure should not be greater than 15 mmHg. If this is the case, the abdominal wall should be grasped and gently elevated. This will dislodge any omentum that has lodged against the needle opening. The angle of the needle, if used, should be increased and the needle rotated to free the opening. If none of these maneuvers reduces the increased pressure to an acceptable level, the needle should be removed and replaced.
If gas pressures are normal at 1 L/min, liver dullness to percussion will be lost after 45 to 60 seconds. Once liver dullness disappears, the rate of gas flow can be increased. Typically, 2 to 4 liters of gas will be required, with the necessary volume somewhat dependent upon the depth of anesthesia and the patient's size. When the abdomen has been sufficiently insufflated, the flow of gas is stopped and the pneumoperitoneum needle removed. Increased intraabdominal pressure and stimulation of the neurohumoral vasoactive systems during insufflation decrease venous return, preload, and cardiac output and increase heart rate, mean arterial pressure, and systemic and pulmonary vascular resistance. In otherwise healthy patients (ASA 1 or 2), these changes are not dangerous when intraabdominal pressure does not exceed 15 mmHg .
Carbon dioxide (CO2) gas, which is typically used to create the pneumoperitoneum, causes hypercapnia and respiratory acidosis. Monitoring of end-tidal CO2 concentration is mandatory and minute volume of ventilation should be increased in order to maintain normocapnia .
The European Association for Endoscopic Surgery clinical practice guideline on pneumoperitoneum for laparoscopic surgery concluded the following interventions effectively reduced pain after laparoscopy in randomized controlled trials :
- Reducing intraabdominal pressure
- Using other insufflation gases, such as nitrous oxide, helium, or argon
- Lowering the insufflation rate
- Warming and humidifying the insufflation gas
- Removal of residual intraabdominal gas at the end of operation
- Intraperitoneal instillation of fluids
- Intraperitoneal instillation of anesthetics
- Reducing the size of trocars
- Injecting anesthetics into the trocar sites
- Omitting drains, if possible
Primary trocar placement — The appropriate trocar for the laparoscope size should be chosen before insertion. The trocar should be grasped with the third finger placed against the shaft for better control. The trocar and cannula are introduced subcutaneously for a distance of 2 to 3 cm and then the angle of introduction is increased to 45 degrees towards the hollow of the sacrum. The proper depth of insertion is identified when a rush of gas from the peritoneal cavity is heard. The trocar is partially retracted and the cannula advanced for 1 to 2 cm to ensure that it is adequately placed within the peritoneal cavity. The trocar is then removed and the telescope introduced. Excessive pressure to overcome skin or fascial resistance can lead to uncontrolled trochar entry into the abdomen and injury to posterior abdominal or retroperitoneal structures. Enlarging the obstructing incision is preferable to increasing the force placed on the instrument. Placing one's body weight or shoulder into the trochar to obtain insertion is mentioned only to condemn it.
Direct trocar insertion is another method that can be used. The insertion technique is the same, except the pneumoperitoneum needle is not used, an incision is made sharply into the peritoneal cavity under direct vision, and no gas is insufflated until after the intra-abdominal location has been confirmed.
Multiple studies have been done comparing direct trocar insertion with the use of a Veress needle followed by trocar insertion (indirect method) [10-17]. Both methods are equally safe in terms of bowel and major blood vessel injury, but injuries related to the pneumoperitoneum needle can occur and are directly related to placement of the needle. The use of the direct entry method has been shown to decrease the amount of intra-abdominal gas required and reduces operative time with laparoscopic sterilization .
Secondary trocar placement — The secondary trocar should be placed in a well-controlled fashion under direct visualization. A suprapubic trocar can be placed centrally about two finger breadths above the symphysis pubis. The bladder should be emptied before this trocar is inserted and we prefer to leave a bladder catheter in place throughout the surgical procedure.
Lateral lower pelvic ports are helpful in many cases. The trocar should be placed lateral to the deep inferior epigastric vessels. Transillumination of the abdominal wall will often identify these superficial vessels and aid in trocar placement. These trocars should be placed under direct visualization. If bleeding is encountered, a variety of suture passers have been devised to aid with suture ligation to control bleeding.
Veress needle insertion can also be done in the left ninth intercostal space, anterior axillary line in patients with known extensive adhesions, or if abdominal insufflation cannot be accomplished through the umbilicus. The trocar is then inserted at the left costal margin in the midclavicular line.
Closure of trocar incision — Many surgeons recommend reapproximation of the fascial defects created at laparoscopy to prevent bowel herniation. However, multiple studies have shown that closure of the fascial defect does not in and of itself guarantee that a hernia will not form. Most authors believe the fascial defect should be closed if an extra umbilical port greater than 10 mm is used. Fascial reapproximation may be accomplished in a variety of ways. Ideally, the fascia is directly visualized using army-navy or similar type retractors, grasped with an Allis or Kocher clamp, and sutured. A number of specialized instruments have been devised and include the Grice suture needle (Ideas for Medicine, Clearwater, FL), the Carter-Thomason needle-point suture passer (Advanced Surgical Education, San Clemente, CA), the EndoClose instrument (U.S. Surgical Corporation, Norwalk, CI), and the Reverdin suture needle (Aesculap, Tuttlingen, Germany) [18,19].
Incisional bowel herniation after laparoscopy may be related to more complicated procedures that require multiple ancillary ports, larger diameter ports for specimen removal, and operative instrumentation, such as stapling devices. Increased operative times and greater tissue manipulation may also lead to fascial weakening. The use of fascial screws increases the incision size and may result in greater fascial tissue damage. A survey of members of the American Association of Gynecologic Laparoscopists reported 933 hernias from an estimated 4,385,000 laparoscopic procedures (incidence 21 per 100,000 procedures) . Eighteen percent of these hernias occurred despite fascial closure. Similar findings were reported in a multicenter retrospective review that identified 19 herniations despite an attempt to close the fascia at the initial surgery in 9 of 19 cases (43 percent) . Another multicenter study of 3,560 operative laparoscopies found six incisional hernias (incidence 0.17 percent) . It appears that the risk of herniation is greater for extra-umbilical sites and with use of a 12-mm trocar (3.1 percent) than with a 10-mm trocar (0.23 percent).
EXAMINATION — The pelvis should be examined methodically, including the anterior, posterior, and lateral abdominal walls; cul-de-sac; uterus, adnexae, and supporting ligaments; pelvic sidewalls; rectosigmoid; and the course of the ureter and pelvic vessels. The laparoscope lens should be kept clean, focused, and in a position that gives the best view of the target field. The uterine cannula and probes are used to manipulate abdominal and pelvic organs to provide optimum examination of all peritoneal surfaces. Irrigation and suction will help to keep the field free of debris. Adhesions that obscure exposure can be lysed using the cutting equipment described above.
COMPLICATIONS — Conditions that increase the risk of complications from laparoscopy include extensive bowel distention, very large pelvic or abdominal masses, cardiac decompensation, extensive pelvic/intraabdominal adhesions, and diaphragmatic hernia. Patients with these conditions are often better served with a nonlaparoscopic surgical approach.
As with other surgical procedures, the number of complications appears to be related to the surgeon's experience and the number of procedures performed. One study surveyed 181 urologic surgeons at three and 12 months following completion of a laparoscopy course that included didactic lectures, live case presentations, simulator training, and a live-animal laboratory . Surgeons who performed procedures without additional training were threefold to fivefold more likely to have at least one complication at three and 12 months, respectively, than surgeons who sought additional training. In addition, those surgeons in a solo practice or those with a variable surgical assistant were 7.74 and 4.80 times more likely to have had a complication. Therefore, formal training and didactic lectures are important , but do not substitute for continued operating room experience with a more experienced laparoscopist. In addition, procedures on patients who have had prior surgeries or intraabdominal disease (endometriosis, pelvic inflammatory disease) are associated with a higher risk of complications than simple procedures in women without this past history.
In one survey, the incidence of entry access injury was 5 per 10,000 to 3 per 1000 procedures . Bowel and retroperitoneal vascular injuries comprised 76 percent of all injuries and almost 50 percent of small and large bowel injuries were unrecognized for at least 24 hours. The type and proportion of organ injury during entry was: small bowel (25 percent), iliac artery (19 percent), colon (12 percent), iliac or other retroperitoneal vein (9 percent), secondary branches of a mesenteric vessel (7 percent), aorta (6 percent), inferior vena cava (4 percent), abdominal wall vessels (4 percent), bladder (3 percent), liver (2 percent), other (less than 2 percent).
Vascular injury — The most common site of vascular injury is the inferior epigastric vessels. These vessels may be punctured during secondary trocar placement, but this can be avoided by placement of the secondary trocar lateral to the rectus muscles and/or by transillumination of the lower abdominal wall. Dissection on the pelvic side wall or loss of a vascular pedicle also may cause significant bleeding.
Anatomy — A study describing the vasculature of the abdominal wall using computed tomography (CT) found that the lateral trocar should be placed approximately 8 cm from the midline and at least 5 cm above the symphysis to minimize the risk of vessel injury . Another series evaluated the abdominal wall anatomy of 33 women using CT and magnetic resonance imaging to determine the best placement of the Veress needle and primary trocar for avoiding injury to the retroperitoneal vessels . In the nonobese patient, the needle could be inserted at a 45-degree angle through the base or lower margin of the umbilicus with little risk of major vessel injury. In the obese patient, however, the trocar could be inserted at 45 degrees, but placement should begin through the base of the umbilicus. In a subsequent study, the same authors showed that the umbilicus was located at or cephalad to the aortic bifurcation and cephalad to where the left common iliac vein crosses the midline .
Repair — Mild bleeding can be identified using probing instruments and an irrigator-aspirator. These sites may be coagulated or fulgurated.
If moderate to heavy bleeding occurs, a 4x4x12 cm damp sponge can be placed in the peritoneal cavity through a 10 mm trochar, and used as a lap pad would be utilized during open surgery. Pressure can be applied with this sponge, and often will control the problem, or at least allow time for considering further steps.
A variety of techniques have been described for suture ligation of bleeding vessels. The most common include using fascial closure needles under laparoscopic guidance to pass the suture lateral and medial to the vessels. Trying to cauterize these vessels is usually ineffective
Perforation of the aorta or vena cava is a life-threatening event that fortunately is very rare. One review of 16 cases of great-vessel injury reported that 14 of the 16 injuries resulted from Veress needle injury and resulted in two deaths .
Delayed bleeding from trochar sites has been seen, with significant drops in hemoglobin and large abdominal and flank ecchymoses.
Bowel injury — Injury to the bowel may result from electrosurgical injury, insertion of the pneumoperitoneum needle, or placement of the laparoscopic trocar. Injuries due to the pneumoperitoneum needle can be managed conservatively and generally do not require any treatment. By comparison, the vast majority of trocar punctures require suture reapproximation, while burn injuries require resection of 1 to 2 cm of viable tissue around the injury site to ensure that the area represents tissue that has not been damaged [30-36]. If bowel injuries occur, the resected loop of bowel should be examined; cytologic changes associated with electrothermal injuries can be identified.
The demonstration of free intra-abdominal air on an upright abdominal radiograph has been used to diagnose a ruptured intraperitoneal viscus. This radiographic sign is generally not helpful after laparoscopic surgery because approximately 40 percent of patients will have more than 2 cm(2) of free air at 24 hours postlaparoscopy, despite lack of any clinical evidence of bowel perforation . However, increasing amounts of intraabdominal air during a period of observation warrants concern. After laparoscopy, intestinal injury must be suspected based upon clinical presentation in a woman with increased pain or fever following surgery. Ileus after laparoscopy is not normal, and warrants thorough patient evaluation.
Urinary tract injury — Injury to the urinary tract during laparoscopy usually occurs to the bladder during secondary trocar insertion. This injury can be minimized by placement of the secondary trocar under direct visualization and by making certain that the bladder is emptied before trocar placement.
Thermal injury to the bladder generally results from dissection during laparoscopic hysterectomy or with dissection and destruction of endometriosis [38-41]. As with bowel injuries, no treatment is generally required if the bladder is punctured with a pneumoperitoneum needle. In contrast, a perforation due to trocar injury should be sutured if recognized at the time of the initial surgery. If not recognized, the patient generally presents with urinary ascites, abdominal pain, and distension accompanied by fever, chills, oliguria, nausea, and vomiting. These patients will have markedly elevated blood urea nitrogen (BUN) and creatinine concentrations and respond to aggressive hydration and bladder drainage. Cystoscopy is rarely indicated; these types of injuries will heal spontaneously and do not require surgical repair.
Ureteral injury is becoming more common as a result of increasing numbers of laparoscopic-assisted vaginal hysterectomies being performed, although ureteral injury can occur during other operative laparoscopic procedures as well [42-45]. Ureteral identification is the only means of preventing injury. (See "Complications of gynecological surgery", section on Ureteral injuries). Delayed fistulas have been described, presumably due to thermal injury.
Neuropathy — Peripheral neuropathy may occur postoperatively, primarily from nerve compression as a result of faulty patient positioning. (See "Complications of gynecological surgery", section on Neuropathies).
Port site metastasis — Port site metastasis refers to cancer growth in the trocar site after laparoscopic oncology surgery. It occurs after approximately 1 to 2 percent of laparoscopic procedures performed in the presence of intraperitoneal malignancy; this rate is comparable to the rate of wound metastasis after laparotomy . Purported mechanisms include hematogenous spread or direct contamination by tumor cells, secondary effects from pneumoperitoneum, and surgical technique. These mechanisms have been reviewed in detail elsewhere . Although it is not clear whether port site metastases can be prevented, a number of preventive measures have been suggested, such as avoidance of laparoscopy in patients with advanced intraperitoneal malignant disease and instillation of agents to prevent tumor growth.
CREDENTIALING — Credentialing (ie, approving a surgeon to perform a particular surgical procedure) is not new and has been discussed in a variety of forums since laparoscopy became commonplace. The purpose is to ensure high quality health care provided by competent surgeons. Credentialing involves a review of the procedures performed, the quality of the procedures, as well as the indications and patient selection criteria that the surgeon. Interest in credentialing comes from residency programs, malpractice insurance companies, third-party payers, government health agencies, and consumer advocacy groups.
Numerous pitfalls can occur during the credentialing process. For example: Who is the first to be credentialed? How often will it take place? Will the credentialing be procedure specific or technique driven? What will be done with the surgeon who is currently performing the procedures but does not pass the credentialing process? What are the acceptable rates of complications for the various operative procedures? The Society of Reproductive Surgeons has published credentialing guidelines for laparoscopic surgery [47,48]. Stratification of laparoscopic procedures has been proposed by the Society of Reproductive Surgeons and the American Fertility Society. These guidelines can be used as a resource for individual facilities to use in establishing their own quality assurance and credentialing processes.
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