laparoscopy

Laparoscopy in gynecology:

the single most important change in gynaecological surgical practice over the last 20– 30 years is endoscopic surgery.
Laparoscopy allows visualization of the peritoneal cavity. This involves insertion of a needle called a Veress needle into a suitable puncture point in the umbilicus. This allows insufflation of the peritoneal cavity with carbon dioxide gas so that a larger instrument can be inserted. The majority of instruments used for diagnostic laparoscopy are 5 mm in diameter, and 10 mm instruments are used for operative laparoscopy. More recently, a 2 mm laparoscope has become available.
Equipments for laparoscopy:
1. laparoscopes
2. veress needle
3. trocars and cannulae
4. laparoscopic insufflator
5. suction/irrigation pump
6. ancillary instruments (disposable and nondisposable instruments available for laparoscopy of various designs and sizes)
7. light source and light lead
8. camera and monitor system
9. electrosurgical generator
10. laser
11. photo and video documentation


Advantages of laparoscopy over the laparotomy in general:
less postoperative pain, shorter hospital stay and quicker return to normal activity, It may also result in less adhesion formation than an open procedure,

Indications for laparoscopy (diagnostic and therapeutic uses):

• Suspected ectopic pregnancy in case of uncertain diagnosis clinically, treated by either Salpingectomy (removal of the tube and gestational sac ) or salpingotomy (opening of the tube and removal of the gestational sac only) via laparoscopy.

* Laparoscopy is regarded as the gold standard for diagnosis of PID:
Laparoscopy should be performed if the clinical diagnosis is uncertain, drainage of an abscess might be required, or there is no improvement after 24-48 hours of intravenous antibiotic treatment.

• Undiagnosed pelvic pain, dysmenorrhoea and chronic pelvic pain (Following laparoscopy, about two-thirds of women will be found to have no pathology)

* Laparoscopy allows direct visualization of endometriotic lesions and the possibility of biopsy of suspicious areas and also staging of the disease in terms of
the extent of adhesions and the number and size of lesions. It also allows for concurrent therapy at the same time in the form of diathermy or laser
treatment in selected cases.

• Subfertility: Laparoscopy under general anaesthetic : direct visualization of the pelvic organs. Tubal patency is then tested by instilling methylene blue through the cervix and observing the spillage of the dye from the fimbrial ends.

• In the technique of gamete intrafallopian transfer (GIFT), a laparoscope is used to transfer the eggs and sperm to the fimbrial part of the Fallopian tube

• Sterilization, Sterilization is most commonly performed by laparoscopy which enables women to be admitted to hospital as a day case.
And reversal of sterilization is also possible using laparoscopy.

* Operative laparoscopy can be used to perform ovarian cystectomy or oophorectomy

* there are certain indications for laparoscopy in pelvic mass:
• Uncertainty about the nature of the mass
• Staging for ovarian malignancy
• Adnexal torsion

• ovarian tumour suitable for laparoscopic surgery are:
- age less than 35 years (possibility of ovarian cancer is low)
- ultrasound shows no solid component
- simple ovarian cyst
- endometrioma

Complications of laparoscopy:

Complications are uncommon, but include:
Intraoperative: Bowel injury, Vascular injur y, Bladder injury (The bladder is always emptied prior to the procedure to avoid bladder injury), Ureteric injury
Surgical emphysema, Anaesthetic complications
Post operative: Unrecognized visceral or vascular injury, Venous thromboembolism, Infection, Port site hernia

Absolute and relative contraindications
1- Mechanical or paralytic bowel obstruction
2- Generalized peritonitis
3- Diaphragmatic hernia
4- Major intraperitoneal haemorrhage (e.g. shock)
5- Severe cardiorespiratory disease
6- Massive obesity
7- Inflammatory bowel disease
8- Large abdominal mass
9- Advanced pregnancy
10- Multiple abdominal incisions
11- Irreducible external hernia