Laparos PDF

MANUAL OF GYNECOLOGICAL
LAPAROSCOPIC SURGERY
IInd Edition
Prof. Luca MENCAGLIA, M.D.

Scientific Head of the Centro Oncologico Fiorentino (CFO),
Florence,I taly
Dr. Luca MINELLI, M.D.
Head of Department of Gynecology and Obstetrics
Sacro Cuore General Hospital, Negrar, Italy
Prof. Arnaud WATTIEZ, M.D.
Head of Department of Gynecology and Obstetrics
Faculty of Medicine, University Hospital of Strasbourg, France
Co-authors:
Elizabet ABDALLA Fabio IMPERATO

Paulo AYROZA Mario MALZONI
Department of Gynecology and Obstetrics, Malzoni Medical Center Villa dei Platani,
Medical School of the Santa Casa University Avellino, Italy
of So Paulo, Brazil
Carlo TANTINI
Fabrizio BARBIERI Department of Gynecology and Obstetrics,
Stefano LANDI Hospital of Cecina, Italy
Department of Gynecology and Obstetrics,
Sacro Cuore General Hospital, Negrar, Italy Daiana TONELLOTTO
Barra DOr Hospital, Rio de Janeiro, Brazil
Cristiana BARBOSA
Sabrina CONSIGLI Beatrice VIDELA
Emmanuel LUGO Leopoldo Carlos VIDELA
Centro Oncologico Fiorentino, Callao Surgical Institute,
Florence, Italy Buenos Aires, Argentina
4 Manual of Gynecological Laparoscopic Surgery
Manual of Gynecological Laparoscopic Surgery

IInd Edition
Prof. Luca MENCAGLIA, M.D.
Scientific Head of Centro Oncologico Fiorentino,
Florence, Italy
Dr. Luca MINELLI, M.D.
Head of Department of Gynecology and Obstetrics,
Prof. Arnaud WATTIEZ, M.D.
Head of Department of Gynecology and Obstetrics,
Faculty of Medicine, University Hospital of Strasbourg,
Strasbourg, France
Correspondence Addresses:
Prof. Dr. Luca Mencaglia 2013
, Tuttlingen, Germany
Centro Oncologico Fiorentino, Printed in Germany, ISBN 978-3-89756-405-3
Via Ragionieri, 101, 50019 Sesto Fiorentino, Firenze, Italy P.O. Box, D-78503 Tuttlingen, Germany
Phone: +39/05553010 Phone: +49 7461/14590
E-mail: [email protected] Fax: +49 7461/708-529
Web: www.centrocologicofiorentino.it E-mail: [email protected]
Dr. Luca Minelli
Direttore U.O. di Ginecologia e Ostetricia, Editions in languages other than English and German are
Ospedale Sacro Cuore, Negrar Verona in preparation. For up-to-date information, please contact
Via Don A. Sempreboni, 5
, Tuttlingen, Germany, at the address given
37024 Negrar (VR), Italy above.
Prof. Dr. Arnaud Wattiez
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Manual of Gynecological Laparoscopic Surgery 5
Contents
I Instrumentation and Operating Room Setup

Cristiana Barbosa and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
II Use of Electricity in Laparoscopy
Paulo Ayroza and Elizabet Abdalla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
III Ergonomics in Laparoscopy
Arnaud Wattiez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
IV Gynecologic Laparoscopic Surgical Anatomy
Cristiana Barbosa, Arnaud Wattiez and Luca Mencaglia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
V Suturing Techniques in Gynecologic Laparoscopy
Daiana Tonellotto, Paulo Ayroza, Arnaud Wattiez and Luca Mencaglia . . . . . . . . . . . . . . . . . . . 73
VI The Role of Diagnostic Laparoscopy and Transvaginal Endoscopy (TVE) in Infertility
and Assisted Reproduction Technology (ART)
Emmanuel Lugo, Carlo Tantini and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
VII Techniques of Laparoscopic Tubal Sterilization
Emmanuel Lugo and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
VIII Laparoscopic Tubal Surgery
Emmanuel Lugo and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
IX Laparoscopic Management of Ectopic Pregnancy
Cristiana Barbosa and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
X Laparoscopic Surgery for Symptomatic Endometriosis
Luca Mencaglia, Arnaud Wattiez and Sabina Consigli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
XI Laparoscopic Management of Deep Endometriosis
Luca Minelli and Stefano Landi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
XII Technique of Laparoscopic Myomectomy
Stefano Landi and Luca Minelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
XIII Laparoscopic Treatment of Adnexal Masses
Mario Malzoni and Fabio Imperato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
XIV Laparoscopic Management of Borderline Ovarian Tumors
Paulo Ayroza and Elizabet Abdalla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
XV Laparoscopic Hysterectomy
Arnaud Wattiez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
XVI Laparoscopic Surgery of the Pelvic Floor
Arnaud Wattiez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
XVII Laparoscopic Surgical Staging of Endometrial Carcinoma
Fabrizio Barbieri and Luca Minelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
XVIII Laparoscopic Pelvic and Lumbo-aortic Lymphadenectomy
Fabrizio Barbieri and Luca Minelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
XIX Complications in Laparoscopic Surgery
Leopoldo Carlos Videla Rivero and Beatrice Videla Rivero . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Recommended Set for Gynecological Laparoscopic Surgery . . . . . . . . . . . . . . . . . . . . . . . 227
12.0 High Frequency

Electrosurgical Units
The AUTOCON II 400 is a versatile, state-of-the-art high
frequency electrosurgical unit designed for both unipolar
and bipolar electrosurgical applications. The operational
parameters of various cutting and coagulation settings can
be preselected on the frontpanel display, thus providing
the user with a highly accurate and reproducible method
to obtain good results. Exact fine-tuning in 1 W-steps is
enabled for procedures that require maximum precision at
very low power. Up to 8 hemostatic effects for unipolar and
bipolar cutting, each with up to 370 W output, permit optimal
control of coagulation and the intended surgical effect. In
the bipolar coagulation mode, the autostart function auto-
matically activates the coagulation current as soon as the
Fig. 47 electrode has touched the tissue with both branches. The
The high frequency electrosurgical unit AUTOCON II 400, various safety circuits of the unit provide a very high level of
(KARL STORZ Tuttlingen, Germany).
safety for both the patient and staff. Software-supported test
programs ensure easy and rapid servicing. The color touch-
screen with its modern and user-friendly design allows for
easy operability, maintenance and cleaning (Fig. 47).
13.0 Laser Systems

The most commonly used type of laser is the CO2 laser, which impact on the outcome of the laser treatment, such as the
is also considered to be the most precise which causes the inherent absorption characteristics / wavelength of the laser
least thermal injury. Even though the CO2 laser is considered system specifically selected for the intended application, spot
to be highly efficient in terms of tissue vaporization, cutting or size, power density, mode of delivery (contact/ no contact)
excision, but has only minimal coagulating properties. Lasers and exposure time (intermittent or continuous).
with a short wavelength such as Argon, Neodymium:Yttrium-
Aluminum Garnet (Nd:YAG) and KTP 532 lasers (Potassium In summary, each of the various laser systems available on
Titanyl Phosphate; KTiOPO4, KTP) have good coagulating the market has a specific clinical application. Laser generators
properties but are less efficient in terms of vaporization. The are much more expensive than electrosurgical systems, and
degree and extent of thermal damage produced by laser there are many safety aspects, such as the potential risk of
irradiation depends on the structure, water content, pigmen- cumulative thermal effects, burns due to inappropriate expo-
tation and the state of tissue perfusion. In addition, user- sure and retinal damage, that speak against the widespread
determined operational parameters can have a considerable use of laser technology.
14.0 Ultrasonic Dissection and Coagulation Systems

The use of ultrasonic energy for cutting and coagulation is an in liver surgery). High power settings can be applied to cleave
alternative to electrosurgery. Ultrasound is the unique energy the loose surrounding tissues by frictional heat while simulta-
form that allows both cutting and coagulation of tissues neously coagulating the wound margins (frequently applied in
without exposing the patient to the risks associated with the colon surgery). High-power ultrasonic dissection can cause
application of high frequency current. The major benefit of collateral damage by excessive generation of heat. However,
this alternative technique is that only a minor degree of lateral in view of the high level of operational reliability and safety
heat-induced tissue damage occurs. Ultrasonic systems that feasible with this alternative technology, the anticipated
are operated at low power settings cleave water-containing advances in the further development will certainly make it a
tissues through cavitation sparing organized structures of low valuable tool in the future.
water content without coagulating vessels (frequently applied
16.0 Suture Techniques

Advanced laparoscopic procedures can be performed safely
and effectively only if the surgeon or gynecologist has gone
through the initial stages of surgical training and has gained
an adequate level of proficiency in intracorporeal suturing and
knot tying techniques. Laparoscopic suturing and knot tying
should be practiced on a good quality endotrainer with an
experienced tutor. There are two suturing methods: the intra-
corporeal and the extracorporeal technique. The major steps
of the intracorporeal technique are: introduction of the needle
and intraabdominal suturing, placement of suture ligatures,
knot tying, either extracorporeal or intracorporeal.
Intracorporeal suturing techniques involve that each knot
is formed and tied inside the cavity with the aid of needle
holders. There are many different types of needle holders
Fig. 51 that essentially vary in handle design and tip configuration
The SZABO-BERCI Needle Holder PARROT-JAW with straight (Figs. 5152). In our opinion, intracorporeal knots should
handle and adjustable ratchet. be reserved to experienced surgeons, because advanced
procedures require a good command of microsurgical suture
techniques. Once an adequate level of proficiency in intracor-
poreal suture and ligature has been achieved, the surgeons
conversion rate will certainly decrease.
a b
Fig. 52a Fig. 52b
Various needle holders with curved jaws. The KOH Macro Needle Holder with curved jaws, ergonomic
pistol handle and disengageable ratchet.
As the term denotes, extracorporeal suturing and knot tying

is performed outside the body cavity. Once the tissue is
sutured, the needle is removed through the trocar cannula
and the suture is completed extracorporeally. In this case, a
knot tier is required. Even though pre-tied loops are available
in the market, surgeons-in-training should learn the basic
skills of extracorporeal knot tying. For extracorporealknotting
various types of knot pushers can be used. Knot pushers
are of either closed-jaw or of open-jaw type (Fig. 53). For
a trainee who has strong convictions to pursue a surgical
career it is essential to make every effort to perfect his/her
skills to achieve an adequate level of proficiency in suturing
techniques. The correct extracorporeal Roeder knot is very
useful. For major or safety sutures, e.g., for ligature of a uterine
vascular pedicle in hysterectomy, the extracorporeal Roeder
knot is necessary. To push the knot, a specific open-jaw knot
pusher is used. The endoloop is the oldest device used for
laparoscopic-guided ligature; it is a loop with a pre-formed Fig. 53
Knot tier for extracorporeal knotting. The close-up views show the
slipknot that can be positioned around the structure that various types of open-end, and closed-end tip design.
needs to be removed.
In some cases, a laparoscopic clip applicator may be neces-
sary. In minimally invasive surgery, surgical clips are used for
tissue approximation. Most of them are made of pure titanium
or of titanium alloys. Surgical clips are easy to apply and can
be left inside the abdominal cavity. After a few weeks, the
clip is covered by fibrous tissue. The jaw of the clip appli-
cator should be located perpendicular to the wound site
before deploying the clip, the surgeon should take care that
both jaws are in view. Two clips are usually deployed over
the structure that needs to be secured. One clip is deployed
over the tissue which the surgeon wants to remove to prevent
spillage of fluid. The clips should not be applied very close to
each other.
17.0 Extraction Bag

Disposable extraction bags are very important to prevent
contamination of the abdominal wall during extraction of
specimens from the abdominal cavity (Fig. 54). Extraction
protected by an endoscopic bag is mandatory to obviate the
risk of benign dissemination (e.g., in the case of endometriosis,
ectopic pregnancy, and benign ovarian cysts), spillage during
removal of a benign teratoma, risks of infection (pyosalpinx),
and risks of malignant dissemination (suspected cysts). The
extraction bag must be very strong so that it can resist the
force that is exerted by the surgeon while pulling it through a
small opening.
Fig. 54
Disposable extraction bag.
18.0 Morcellator Systems

An electronic or manual morcellator can be used for The removal of large portions of tissue may also be accom-
piecemeal removal of large specimens, such as fibroids or the plished with the aid of endoscopic cold knives introduced
uterus during laparoscopic hysterectomy, and particularly, through a minimal abdominal incision or vaginal puncture.
supracervical hysterectomy (Figs. 55a, b). The fully These shielded blade carriers permit endoscopic insertion
autoclavable ROTOCUT G1 morcellator is an efficient and and application of cold knives in the abdominal cavity. There
time-saving alternative to previous systems. Rapid removal is a great variety of extraction devices on the market. One,
of large tissue segments is facilitated by the highly efficient that should be mentioned is the vaginal extractor. It allows
cutting performance of the disposable cutting blades, which intra-abdominal specimens to be retrieved via the vagina,
can be changed intraoperatively. The blades are available while maintaining the integrity of the pneumoperitoneum
in sizes of 12-mm or 15-mm. Optimal weight distribution and, therefore, endoscopic-assisted retrieval under optimal
and direct activation ensure a straight-forward and smooth viewing conditions. During laparoscopic myomectomy, it is
operation. A specially designed trocar sleeve protects tissue essential to have a screw- or spiral-tipped instrument that
from inadvertent blade contact. The powerful ROTOCUT G1 allows for proper fixation and removal of subserous or intra-
has a direct drive motor that produces a maximum speed mural fibroids (Fig. 56).
of 1200 rpm, minimizing the amount of effort required of
surgeons and reducing procedure times. The control unit
that optimizes Rotocuts performance is the UNIDRIVE
S III, which is compatible with all previous generations of
KARL STORZ morcellators.
Fig. 55 a Fig. 55 b
The morcellator system ROTOCUT G1, laparoscopy set. The hollow shaft motor of the ROTOCUT G1 mocellator is used in
conjunction with the control unit UNIDRIVE S III.
Fig. 56
Myoma fixation instrument with screw-shaped tip.
19.0 Uterine Manipulators

Various instruments and auxiliary devices may be used for diagnostic assessment or surgical interventions. The uterine
mobilizing or stabilizing the uterus and adnexae during both manipulator is of crucial importance because it facilitates
diagnostic and operative laparoscopic surgery. visualization of the pelvic organs and permits endoscopically-
A uterine manipulator is used in the majority of advanced controlled injection of methylene blue in the case of chromo-
laparoscopic-assisted gynecological procedures, be it for pertubation for assessment of tubal patency (Figs. 5759).
Fig. 57 Fig. 58
The TINTARA uterine manipulator (KARL STORZ Tuttlingen, Proper placement of the uterine manipulator.
Germany).
Fig. 59
The CLERMONT-FERRAND uterine manipulator
20.0 Operating Room Setup and Preparation of the Patient

Endoscopic surgery requires a perfect technological environ- Patients must be informed of the therapeutic benefits and
ment. Knowledge of the instruments and operating room all potential risks (informed consent). The possibility that
setup is essential for optimizing the workflow of endoscopic a laparotomy may be required must always be mentioned.
procedures and the facilitating the interaction between Intestinal preparation is often useful. Bowel preparation can
surgeons, medical personnel, and all areas inside and outside minimize the need for an accessory port to retract the bowel.
of the hospital. A well organized operating room is not only Its purpose is to empty the small intestine and facilitate vision
an essential prerequisite for the successful outcome of lapa- by flattening the intestinal loops and pushing them out of the
roscopy, but also reduces costs. The operating room should way. In all cases associated with an increased inherent risk of
be large enough to accommodate the necessary equipment. intestinal injury is (endometriosis of the rectovaginal septum or
Before starting surgery, it is necessary to check the instru- major adhesiolysis), preoperative bowel preparation is more
mentation, particularly the insufflation unit, as well as the complete and resembles the preparatory measures applied
high frequency surgery unit and the suction-irrigation system. prior to bowel surgery. Before being admitted to the operating
The number of persons forming the surgical team depends room, the patient should always void. The full urinary bladder
on the surgical indication. As a rule, one assistant and one may be inadvertantly perforated during insertion of the Veress
surgical nurse are sufficient. Certain procedures require an needle or trocar. If gynecological surgery or any general
additional assistant (Fig. 60). It is essential that all members lower abdominal surgery is planned (such as hernia repair or
of the surgical team (including the surgeon) be trained and adhesiolysis) it is advisable to insert a Foley catheter. If any
capable of solving all technical problems which could occur upper abdominal procedure has been scheduled, it is good
before and during the intervention. practice to have a nasogastric tube in place.
!
@
Fig. 60
Schematic drawing of the room setup illustrating the optimal arrangement of the surgical team and equipment during gynecological
laparoscopic procedures. ! operating surgeon; @ first assistant; # second assistant; $ scrub nurse; % anaesthesiologist.
21.0 Patient Positioning

Positioning of the patient is also important for the successful The assistant seated between the legs of the patient watches
outcome of surgery. The patient is placed in a low dorso- the hand movements of the surgeon on the monitor and
lithotomic position (gynecological position) with her legs should maintain traction in the appropriate direction with the
positioned to provide vaginal access (Fig. 61). The patients handle of the uterine manipulator.
legs should be comfortably supported by padded obstetric
knee braces or Allen stirrups to minimize the risk of deep vein Proper make-up assignement of the surgical team is also a
thrombosis (Fig. 62). The Trendelenburg position should be basic prerequisite for the successful outcome of any laparo-
used only after the main trocar has been inserted, because scopic operation. In the majority of cases, the surgeon stands
the Trendelenburg position brings the sacral promontory, and on the left side of the patient. A surgeon who is left handed,
therefore the major vessels (bifurcation of the aorta and left should stand to the right of the patient during creation of
common iliac vein) into the axis of trocar insertion. In gyneco- the primary port. This facilitates inserting the Veress nee-
logical laparoscopic procedures or if laparoscopy is to be dle or primary trocar towards the pelvis with the dominant
performed together with hysteroscopy, the patient should be hand. The camera assistant should be positioned opposite
positioned in the lithotomy position which enables an assis- to the surgeon, but it is always recommended to have two
tant to stand between the patients legs allowing for free video monitors, one for the surgeon, and one for the camera
access to the lower abdomen (Fig. 63). In these procedures, assistant and other members of the surgical team. If only one
the surgeon needs to use a uterine manipulator for proper monitor is available, it should be located between the legs of
visualization of the female reproductive organs. the patient.
Fig. 61
Correct preoperative placement of the patient on the operating table
in low dorsolithotomic position.
Fig. 63
Placement of the patient in low dorsolithotomic
position enables proper manipulation of the
laparoscopic instruments via the accessory ports.
Fig. 62
The legs are gently placed in well-padded boot-type stirrups for
routine deep vein thrombosis prophylaxis.
22.0 Maintenance and Sterilization

Professionals in charge of cleaning, decontamination, sterili- Disposable instruments are not designed to be cleaned in a
zation, and inspection of surgical instruments, devices, similar way as their reusable counterparts, e.g., the c
and implants should be adequately trained so that they series of dismantling instruments. Reusable surgical instru-
are fully aware of the delicacy and cost of endoscopic ments must be safely cleaned and sterilized immediately after
equipment. Setting up the operating room prior to surgery surgery. Instruments must be dismantled prior to cleaning.
includes testing the camera equipment, the light source, the After decontamination, every small piece and recess must be
insufflation unit and CO2 tanks, the suction-irrigation system cleaned and dried with water and compressed air. For lenses
and taking great care the bipolar and unipolar electro- and telescopes, alcohol or special soap should be used. The
coagulation system. majority of up-to-date instruments are designed for steam
Because of the importance of having optimized instrument heat sterilization (autoclaving). Other validated sterilization
management quality and economy, KARL STORZ has procedures currently in use:
developed the EndoProtect1 service, consisting of modular Sterilization via autoclave is the most widely used and
services that ensure the optimal deployment of instruments inexpensive method. In the case of endoscopes and instru-
sets in the hospital, the replacement of instruments and their ments expressly manufactured and sold as autoclavable,
proper and careful handling by personnel. Also a database- sterilization cycles of 121C for 20 minutes, or 134C for
supported management and monitoring system is offered 7 minutes are used.
for the entire range of instruments in offices and hospitals. Gas sterilization with ethylene oxide is generally considered
This new system is the KARL STORZ instrument manage- to be the ideal method of sterilization, because it acts at a
ment platform, which enables each individual instrument to relatively low temperature and is not detrimental to endo-
be accurately registered using a special data matrix code and scopic instrumentation. Unfortunately, the technique is
rapid, error-free identification with a scan camera. relatively expensive and time-consuming (72 hours prior
Disposable instruments shall not be resterilized for reuse in to reuse of instruments). Therefore, only a few centers use
laparoscopic surgery because such practice is associated gas sterilization, because multiple sets of laparoscopic
with an elevated risk of pathogen transmission compared instruments should always be held available.
to the effectiveness of cleaning and sterilization procedures
applied to reusable instruments.
Recommended Literature:
MENCAGLIA L, WATTIEZ A: Manual of Gynaecological
Laparoscopic Surgery. (2000); Endo-Press Tuttlingen,
Germany
HULKA J, REICH H: Textbook of laparoscopy,
Third edition (USA). (2002); 5356, 6981, 276283
Chapter II
Use of Electricity in Laparoscopy
Paulo Ayroza and Elizabet Abdalla
Medical School of the Santa Casa University of So Paulo, Brazil
Electrosurgical unit
Return plate
1.0 History
The therapeutic use of heat in the treatment of human beings O An electrosurgical generator was used for the first time in
has been known for a very long time. The Egyptians used the operating room by Cushing in 1926. Although he was
cauterization to treat tumors three thousand years B.C. not the first to try it, William Bovie was the one responsible
Four hundred years before the Christian era, Hippocrates for developing the modern concept of electrosurgery.
discussed the use of heat to treat diseases. In this context, O In 1934, Werner described tissue coagulation using high
he described the use of cauterization to treat joint problems frequency electrical energy. This concept represented an
and haemorrhoids. He also recommended applying seven or important step forward in surgery and is still used widely
eight little pieces of heated iron to the hemorrhoid to arrest today.
bleeding. However, it was only at the start of the 20th century
that Koch described cauterization using electricity. In this The use of electrosurgical energy in laparoscopy dates from
technique, an electric current heated the tip of a forceps and the 1960s when gynecologists were the first to use laparos-
the hot metal was applied to the tissue to cauterize it. In 1878, copy for minor surgical procedures such as tubal sterilization.
Koch also described the first tubal sterilization by means of At the start, there were some mishaps, which discouraged the
cauterization with a wire heated by an electric current. use of the monopolar modality of electrosurgery for the next
two decades. Technical developments led to the production
In fact, there is a great difference between electrocautery and of new electrosurgical generators and laparoscopic instru-
electrosurgery. In the former, electricity heats a metal instruments specially designed for this modality. Thus, at the end of
ment, which is then applied to the tissue. In electrosurgery, the 1980s, electrosurgery came back to fill an indispensable
the opposite occurs, with the current producing heat as it space in gynecological endoscopy.
passes through the tissue.
Electrosurgery is the most frequently used form of energy in
Electrosurgery developed in the 20th century. It causes the all branches of surgery. In 1995, Odell demonstrated how the
electric current to pass through the body, producing heat use of electrosurgery in laparoscopy optimizes the proce-
due to tissue impedance. Unlike cauterization, during electro- dures, reducing operation time and blood loss.
surgery the forceps does not heat to the point of burning but
is limited to transmitting the electric current to the tissues. Over the years, some doubts have emerged regarding possible
The development of electrosurgery passed through various injuries caused by heat in healthy tissue. In 1982, Riedel and
periods and various discoveries were made. It is worth Semm described the risks of inappropriate use of electro-
recalling how a few concepts that are today regarded as very surgery and they emphasized the need for appropriate
simple were established. monitoring of this technique.
O Experiments with static electricity, which began in 1786, Various studies have analyzed injuries caused to the tissues
used direct current, also known as galvanic current, which by monopolar and bipolar electrocoagulation. In 1995, with
produced muscle contractions. different devices, Baggish and Tucker evaluated histologically
the extent of necrosis caused by monopolar and bipolar
O The specific current induction developed by Faraday electrocoagulation.
and Henry was integrated in 1891 by DArsonval, who
described the use of high frequency current to counteract
muscle contractions.
2.0 Principles of Electrosurgery

Several properties of electricity must be understood in order O Voltage: the force that drives the current or flow of
to understand electrosurgery. Electrons orbit the nucleus of electrons, measured in volts.
an atom. When the electrons flow from one atom to the orbit O Resistance: obstacle to the flow of current, measured in
of an adjacent atom, there is a flow of current. Voltage is the ohms (resistance = impedance).
force or push that provides electrons with the ability to
travel from atom to atom. If the electrons encounter resis- The following principles apply specifically in electrosurgery:
tance, heat is produced. The resistance to the flow of electrons O The electrosurgical generator (ESG) is the source of the
is called impedance. A complete (or closed) electrical circuit electron flow and voltage.
is required to make electrons to flow through. In other words,
only an uninterrupted pathway allows electrons to circulate.
O A monopolar circuit consists of the generator, an active
electrode, the patient and the patient return electrode.
The common terms used to describe the principles of electro-
surgery include:
O There are numerous pathways to ground for leakage
current and these may include the OR table, stirrups, staff
O Current: flow of electrons in a certain period of time, members and equipment.
measured in amperes.
O The patients tissues provide the impedance, producing
heat when the electrons overcome the impedance.
2.1 Various Forms of Electric Current

Various forms of electric current are associated with surgical ions can flow in the direction corresponding to their polarity
applications. and in this way the concentration of ions can increase in
direct relation with the intensity and duration of the electric
O Direct current (DC): the electron exchange occurs
current. To avoid the electrolytic effect, electrosurgery uses
continuously in a single direction. This type of current can
alternating current, where the constant reversal of polarity
be used in medicine for therapeutic purposes (for example,
reduces the potential damage caused by polarization.
acupuncture and pain electrotherapy).
O Pulsed current: a relatively high amount of energy is O Faradic effect: when passing through the tissue, the
discharged at short intervals. This is useful for nerve electric current can stimulate the nerve endings, inducing
stimulation, for example, in electromyography. reactions such as muscle contraction and pain. This is
caused by the frequency of the electrical current; low
O Alternating current (AC): the electron exchange between frequencies in particular stimulate nerve endings.
the two electrodes is bidirectional. This is the electric
current used in electrosurgery. The modern concept of electrosurgery involves using a
high frequency electric current to avoid the negative effects
When an electric current flows through biological tissue, the of neuromuscular stimulation. Since nerve and muscle
following effects can be observed: stimulation ceases at 10,000 cycles/second (10 kHz), electro-
O Thermal effect: as electricity passes through the tissue it surgery can be performed safely at radio frequencies above
generates heat, which is the only effect desired in electro- 100 kHz. An electrosurgical generator produces a 60-cycle
surgery. The amount of heat generated depends on the current and increases the frequency to over 300,000 cycles
intensity of the electric current, the resistance of the tissue per second. At this frequency, electrosurgic al energy
and the duration of current flow. can pass through the patient with minimal neuromuscular
stimulation and no risk of electrocution.
O Electrolytic effect: when a direct electric current passes
through a tissue with a high electrolyte concentration, it Monopolar electric current reaches the human body through
can cause polarization of the electrolytic compounds. The an active electrode and leaves it through a neutral electrode.
2.2 Waveform
An electrical wave has a sine form that can be modified, currents but rather a variation of the duty cycle. Moving from
resulting in waves with different forms and different effects. blend 1 to blend 3, the duty cycle is reduced progressively.
Two types of electrical wave are normally used in electro- A lower duty cycle produces less heat. Consequently,
surgery: blend 1 is able to vaporize tissue with minimal hemostasis
O Non-modulated (Fig. 1), also called pure wave, obtained whereas blend 3 is less effective at cutting but provides
using a free alternating current of continuous form, which maximum hemostasis.
is responsible for the cutting effect. It can also be used for The only variable that determines whether a waveform vapo-
coagulation. rizes tissue or causes coagulation is the rate at which heat is
O Modulated (Fig. 2), so called because this waveform produced. A high amount of thermal energy released rapidly
produces some modifications in frequency and amplitude. induces vaporization, whereas a low amount released more
This waveform is used especially for coagulation. slowly induces coagulation. Any one of the five waveforms
(non-modulated, modulated and the 3 blends) can accom-
O A third waveform, the so-called blended current, can plish both tasks by modifying the variables that influence the
be used. This is not a mixture of cutting and coagulation tissue effect.
Fig. 1 Fig. 2
Pure or unmodulated wave form. Modulated electrical wave.
2.3 Use of the thermal effect in electrosurgery

High frequency surgery uses the thermal effect caused by the Coagulation
passage of an electric current through the tissue. There are For coagulation a low current density is usually applied so
two basic methods of thermal tissue destruction: cutting and that the tissue temperature increases slowly giving the water
coagulation. enough time to evaporate. Meanwhile, the tissue undergoes
Cutting thermal coagulation. In this process, the heat first causes
coagulation of the connective tissue, denaturing proteins
When a high current density is applied to a tissue, the heating but preserving cellular architecture. After that an amorphous
of the intracellular fluid from 37 to 100 C is so fast that there coagulum is formed when disintegration is complete. This is
is no time for the water to evaporate. The resulting vapor indicated by the visual effect of carbonization. The gradual
pressure leads to explosion of the cellular membranes. This cellular retraction that occurs during thermal hemostasis
phenomenon is called vaporization. The separation of tissues allows the closure of small vessels. The result is creation of
by means of heat can be used to cut and has many advan- a coagulum rather than cellular vaporization. In order to over-
tages compared to mechanical cutting (for example, minor come the high impedance of air, the coagulation waveform
bleeding and minimal coagulation effect at the incision). This has significantly higher voltage than the cutting current. Use
modality is more powerful and generally less penetrating. of a high voltage coagulation current has implications during
When used with fine electrodes, it allows precise cutting with minimally invasive surgery.
minimal coagulation. It can also reduce operating times. With
thicker or wider electrodes the contact area and also the Electrosurgical desiccation occurs when the electrode is in
potential for thermal injury are increased. direct contact with the tissue. Desiccation is achieved most
efficiently with the cutting current. By touching the tissue with
To obtain a suitable cutting effect, the generator must be the electrode, the current density is reduced. Less heat is
activated before the electrode touches the tissue. A layer generated and no cutting action occurs. The cells dry out and
of vapor and carbon particles is created between the form a coagulum rather than vaporize and explode.
electrode and the tissue to create a current pathway. The
electrosurgical cutting effect is similar to dissection without Some surgeons cut with the coagulation current. Likewise, it
touching the tissue. If the electrode is used slowly or is is possible to coagulate with the cutting current by holding the
held stationary, the risk of thermal damage to the tissue is electrode in direct contact with the tissue. It may be necessary
increased. to adjust power settings and electrode size to achieve the
desired surgical effect. The advantage of coagulating with the
The electrosurgical cutting effect is used on vascular tissue cutting current is that a much lower voltage is used.
such as in adhesiolysis and also for peritoneal endometriosis
resection.
2.4 Different Electrosurgery Modalities

By modalities of electrosurgery is meant the way the
electrical current is applied to the tissue. High frequency
electrical current can traditionally be applied with two different
modalities: monopolar or bipolar. While tissue separation is
obtained mostly with the monopolar technique, coagulation
can be obtained with both modalities.
Monopolar: monopolar is the most commonly used electro-
Electrosurgical unit surgical modality due to its versatility and clinical effective-
ness. In monopolar electrosurgery, the active electrode is at
the surgical site. The patient return electrode is elsewhere on
the patients body. The current passes through the patient
Return plate as it completes the circuit from the active electrode to the
patient return electrode (Fig. 3).
Fig. 3
Monopolar modality.
Bipolar: in bipolar electrosurgery, the two tines of the forceps

perform the functions of both the active electrode and
the return electrode at the site of surgery. Only the tissue
grasped by the forceps is included in the electrical circuit.
Because the return function is performed by one tip of the
forceps, a patient return electrode is not needed. The current
passes through the tissue held by the forceps and returns
directly to the electrosurgical unit without getting into contact
with other tissues. In this case, the damage produced in
the tissues is limited and the risk of thermal injury in distant
tissues is infinitely lower (Fig. 4).
The bipolar modality presents some advantages compared to
the monopolar:
O The current flow through tissue is restricted to the area
between the two jaws of the electrode, which is under Electrosurgical unit
the direct vision of the surgeon. In the monopolar tech-
nique, the current passes through many tissues outside the Fig. 4
surgeons visual control before it can return to the electro- Bipolar modality.
surgical generator.
O The risk of thermal injuries in distant tissues due to direct
contact of instruments, faulty insulation or diffusion of the
electrical current is reduced in the bipolar technique.
O The risk of interference with other electronic equipment,
(ECG, pacemakers and others) connected to the patient at
the same time, is lower.
3.0 Electrosurgery: General Safety Aspects

3.1 Grounded Electrosurgical Systems
When it is understood that the electrical current is essentially This would put patients at risk of burns at an alternative site
a continuous flow of electrons with an entry and exit site, it because:
is easy to understand that the current must return to some O the current follows the easiest and most conductive path,
place along some pathway. The place is the unit and the
pathway is the return plate. Through the phenomenon known O any grounded object can complete the circuit, not just the
as current division, the current can split and follow more electrosurgical generator,
than one path to ground. The circuit to ground is completed O the surgical environment offers many alternative routes to
whether it travels the intended electrosurgical circuit to the ground,
patient return electrode or to an alternative ground.
O if the resistance of the alternative path is sufficiently low
and the current flowing to ground in that path is sufficiently
concentrated, an accidental burn may occur at the alter-
native grounding site.
3.2 Isolated Electrosurgical Systems

If the circuit to the patient return electrode is interrupted, an Patient return electrodes are not inactive or passive.
isolated generator will deactivate the system because the The only differences between the active electrode and the
current cannot return to its source. Generators with insulated patient return electrode are their size and relative conductivity.
circuits reduce the risk of burns at alternative sites but do not The quality of the conductivity and contact area at the plate/
protect the patient from burns caused by the return electrode. patient interface must be maintained to prevent injury at the
Historically, patient return electrode burns have accounted for return electrode site.
70% of the injuries reported during the use of electrosurgery.
3.3 Patient Return Electrodes

O Function of the patient return electrode. It should be recalled that the only difference between the
The function of the patient return electrode is to collect active electrode and the patient return electrode is their
and remove current from the patient safely. A return elec- relative size and conductivity. If the electrons are concen-
trode burn occurs when the heat produced over time is trated at the active electrode, a lot of heat is produced. If
not safely dissipated by the size or conductivity of the this current is dispersed over a comparatively large patient
patient return electrode. return electrode, little heat is produced.
If the surface contact area between the patient and the return
O Ideal return electrode contact with current dispersion. electrode is reduced or if the impedance of that contact is
The ideal patient return electrode safely collects current increased, a dangerous condition can develop. In the case
delivered to the patient during electrosurgery and carries of a reduced contact area, the current flow is concentrated
that current away. To eliminate the risk of current density, in a smaller area (Fig. 6). This causes an increase in the
the plate should present a large contact area to the temperature of the return electrode. If the temperature of
patient associated with low impedance (Fig. 5). It should the return electrode increases sufficiently, the patient may
be placed on conductive tissue as close as possible to the sustain a burn. Many factors can cause an increase in
operative site. impedance, including excessive hair on the contact surface,
adipose tissue, bony prominences, the presence of liquid,
poor adhesion and scar tissue.
Fig. 5 Fig. 6
The return electrode plate provides an adequate contact area. If the plate contact is faulty, the density of the return current
increases dangerously and with it the risk of local burns.
O Check the plate site, which should be a well vascularized are equipped with patient plate monitoring, which actively
muscle mass. Avoid irregular bony contours and bony monitors the amount of impedance at the patient/plate
prominences. The incision site, patient positioning and any interface because there is a direct relationship between this
other equipment connected to the patient should also be impedance and the contact area. The system is designed
considered. to deactivate the generator before an injury can occur if
it detects a dangerously high level of impedance at the
O Patient electrode plate monitoring. patient/plate interface.
Contact quality monitoring was developed to protect
patients from burns due to inadequate contact of the return In order to work properly, such generators must use a patient
electrode. Plate site burns are caused by a decreased return electrode that is compatible. This type of electrode is
contact area at the return electrode site. New generators divided into two separate areas.
3.4 Direct Coupling

Direct coupling occurs when the user accidentally activates patient return electrode. There is a potential risk of significant
the generator while the active electrode is near another metal patient injury. The generator should not be activated while the
instrument. The secondary instrument will become energized. active electrode is touching or in close proximity to another
This energy will seek a pathway to complete the circuit to the metal object.
3.5 Insulation Failure

Many surgeons routinely use the coagulation current. This The surgeon can obtain the desired coagulation effect
waveform has a relatively high voltage. This voltage or without high voltage, simply by using the cutting current
push can spark across an area of compromised insulation. while holding the electrode in direct contact with tissue. This
Moreover, high voltage can blow holes in weak insulation. technique will reduce the likelihood of insulation failure. Recall
Breaks in insulation can create an alternative route for the that coagulation can be obtained with the cutting current by
current to flow. If this current is concentrated, it can cause holding the electrode in direct contact with tissue, thereby
significant injury. lowering the current density. By lowering current density the
rate at which heat is produced is reduced, allowing effective
coagulation with the cutting current.
3.6 Capacitative Coupling during Laparoscopy

Metal trocar system Plastic trocar system
A capacitor is not a part labeled capacitor in an electrical Capacitance cannot be entirely eliminated with an all-plastic
device. It occurs whenever a nonconductor separates two cannula. The patients conductive tissue completes the
conductors. During laparoscopy an inadvertent capacitor definition of a capacitor. Capacitance is reduced, but is not
may be created by the surgical instruments. The conductive eliminated.
active electrode is surrounded by nonconductive insulation.
This, in turn, is surrounded by a conductive metal trocar. Hybrid trocar system
A capacitor creates an electrostatic field between the two The worst case occurs when a metal cannula is held in
conductors and, as a result, a current in one conductor can, place by a plastic anchor (hybrid cannula system). The metal
through the electrostatic field, induce a current in the second cannula still creates a capacitor with the active electrode.
conductor. In laparoscopy a capacitor may be created by the However, the plastic abdominal wall anchor prevents the
composition and placement of the surgical instruments. current from dissipating through the abdominal wall. The
capacitative coupled current may exit from adjacent tissue on
its way to the patient return electrode. This can cause signi-
ficant injury.
4.0 Recommendations for Avoiding Electrosurgical Complications

in the Patient During Operations
The majority of potential problems can be avoided by following these simple guidelines:
O Inspect all the insulation carefully O Do not activate in an open circuit

O Use the lowest possible power setting O Do not activate in close proximity to or direct contact
O Use a low voltage waveform (cutting) with another instrument
O Use brief intermittent activation rather than O Use bipolar electrosurgery where possible
prolonged activation O Select an all-metal trocar system as the safest option
and do not use hybrid trocar systems that combine
metal with plastic.
Recommended Reading
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scissors compared with monopolar devices. 22. NIELSEN PH, NYLAND MH, ISTRE O, MAIGAARD S,
Fertil Steril 1995; 63: 4226 et al: Acute tissue effects during transcervical
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bipolar coagulation. J Neurosurg 1991; 75: 14851 23. O CONNOR JL, BLOOM DA: William T. Bovie and
4. BHLER K, KATO K, KLESSEN C, KOCH R, et al.: electrosurgery. Surgery 1996; 119: 3906
Die temperatur-geregelte bipolare Elektrokoagulation 24. ODELL RC: Electrosurgery: principles and safety issues.
Zent bl Gynkol,1991; 113: 71322 Clin Obstet Gynecol 1995; 38: 6102
5. CORSON SL: Electrosurgical hazards in laparoscopy.
JAMA 1974; 227: 12613 25. PEREIRA FEL: Degeneraes. Morte celular. Alteraes
do interstcio. In: BRASILEIRO FILHO, G.;
6. CUSHING H: Electrosurgery as an aid to the removal PITTELLA, J.E.H.; PEREIRA, F.E.L.; BAMBIRRA, E.A;
of intracranial tumors. Surg Gynecol Obstet 1928; 47: BARBOSA, A.J.A Bogliolo Patologia. 5 ed. Rio de
75184 Janeiro, Guanabara Koogan 1996,. p.4681.
7. CURCIE DJ, CRAELIUS W: The role of thermal feedback 26. RAPPAPORT WD, HUNTER GC, ALLEN R, LICK S,
in electrosurgical tissue heating. Tech Health Care 1995; et al.: Effect of eletrocautery on wound healing in midline
i 3: 1116 laparotomy incisions. Am J Surg 1990; 160: 61820
8. Di GIOVANNI M, VASILENKO P, BELSKY D:
Laparoscopic tubal sterilization. The potential for 27. RIEDEL HH, SEMM K: An initial comparison of
thermal bowel injury. J Reprod Med 1990; 35: 9514 coagulation techniques of sterilization. J Reprod Med
1982; 27: 26 17
9. FARNWORTH TK, BEALS SP, MANWARING KH,
TREPETA RW: Comparison of skin necrosis in rats by 28. RIEDEL HH, LEHMANN-WILLENBROCK E, MECKE H,
using a new microneedle electrocautery, standard-size AHMELS E: Histologische und enzymhistochemische
needle electrocautery and the shaw hemostatic scalpel. Untersuchungen am Kaninchenuterushorn nach
Ann Plast Surg 1993; 31: 1647 anwendung unterschiedlicher Koagulationsmethoden.
Zent bl Gynkol 1990; 112: 189205
10. GIORDANO BP: Dont be a victim of surgical smoke.
AORN J 1996; 63: 52022 29. RYDER RM, HULKA JF: Bladder and Bowel injury after
11. GOLDWYN RM: Bovie. The man and the machine. electrodesiccation with Kleppinger Bipolar forceps.
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12. GROSSKINSKY CM, RYDER RM, PENDERGRASS HM, 30. SODERSTROM RM: Principles of Eletrosurgery During
HULKA JF: Laparoscopic capacitance: A mystery Endoscopy. In:Sammarco MJ, Stovall TG, Steege JF.
measured. Am J Obstet Gynecol 1993; 169: 16325 Gynecologic Endoscopy. Baltimore, 1996,
Williams & Wilkins, p. 17992.
13. HOGLAN M: Potential Hazards from electrosurgery
plume. Recomendations for surgical smoke evacuation. 31. SEMM K: Endocoagulation: A new and completely safe
Can Oper Room Nurs J 1995; 13: 106 medical current for sterilization. Int J Fertil 1977; 22: 238
14. HUKKI J, LIPASTI J, CASTREN M, PUOLAKKAINEN P, 32. SIGEL B, DUNN MR: The mechanism of blood vessel
et al: Lactate dehydrogenase in laser incisions. Laser closure by high frequency electrocoagulation.
Surg Med 1989; 9: 58994 Surg Gynecol Obstet 1965; October: 82331
15. KAPLUN A, ARONSON M, HALPERIN B, GRIFFEL B: 33. TUCKER RD, STASZ PS, KRAMOLOWSKY EV: A simple
Cellular events in adhesion formation due to Thermal and inexpensive method for measuring electrosurgical
Trauma. Eur Surg Res 1984a; 16: 13640 variables. Biomed Instrum Tech 1989; 23: 547
16. KAPLUN A, GRIFFEL B, HALPERIN B, ARONSON M: 34. TUCKER RD, KRAMOLOWSKY EV, PLATZ CE: In vivo
A model for adhesion formation by thermal injury in the effect of 5 french bipolar and monopolar electrosurgical
abdominal cavity of the mouse. Eur Surg Res 1984b; probles on the porcine bladder. Urol Res 1990;
16: 1315 18: 29 14
17. KOCKS J: Eine neue Methode der Sterilisation der Frau. 35. TUCKER RD, BENDA JA, MARDAN A, ENGEL T:
ZBL Gynk 1878; 2: 617 The interaction of electrosurgical bipolar forceps and
18. LEVY BS, SODERSTROM RM, DAIL DH: Bowel injuries generators on an animal model of fallopian tube
during laparoscopy. Gross anatomy and histology. J sterilization. Am J Obstet Gynecol 1991; 165: 4439
Reprod Med 1985; 30: 16872
36. VECK S: An introduction to the principles and safety of
19. LUCIANO AA, WHITMAN G, MAIER DB, RANDOLPH J, electrosurgery. Br J Hosp Med 1996; 55: 2730
et al: A comparison of thermal injury, healing
patterns, and postoperative adhesion formation 37. VOYLES CR, TUCKER RD: Education and engineering
following CO2 laser and electromicrosurgery. solutions for potencial problem with laparoscopic
Fert Steril 1987 48: 10259 1987 monopolar electrosurgery Am J Surg 1992; 164: 5762
20. LUCIANO AA: Power sources. Obstet Gynecol Clin N 38. WERNER R: Sterilisierung der Frau durch
Am 1995; 22: 42343 Tubenverkochung. Chirurg 1934; 6: 8435
Chapter III
Ergonomics in Laparoscopy
Arnaud Wattiez
Strasbourg University Hospital
Strasbourg, France
The operating column should be arranged in such a way

that the surgeon can see the insufflator and electrosurgical
generator while the suction/irrigation unit, video equipment
etc. do not have to be in sight.
The operating room must be well-illuminated for safety
reasons. This will help in finding the instruments faster or
performing unusual tasks. A good video system is of crucial
importance.
Once the patient is positioned, the movability of all members
of the operating team should be assessed. The patient should
be placed relatively far down on the operating table to allow
the full range of movements for the manipulator. The legs
should be flexed and abducted enough to give the second
assistant enough room but not so much as to interfere with
the other surgeons (Fig. 4). The arms should be alongside
the body. For obvious reasons, this is often disputed by the
Fig. 4 anesthetists, who prefer to have easy intravenous access,
Position of the patient on the operating table. continuous blood pressure and oxygen saturation monitoring
etc. We believe, that there should be no compromise such
as having the arm on the surgeons side alongside the
patient and the other at a right angle to the body because
the ergonomics and comfort of the assistant are fundamental.
Great attention must be paid to make sure that cables and
tubes are not intertwined behind the surgeons in order to
avoid wasting time in disconnecting them every time the
surgeons change places. Letting the assistant perform some
of the operating steps is an alternative to changing places,
which can be used in small operating rooms.
The number, position and quality of the screens are extremely
important. A clear view will enhance the precision and
% speed of surgery. A clear image of appropriate size reduces
eyestrain if the screen is placed at a distance of 0.6 to 6 times
the screens diameter. The screens should not be situated
so high as to necessitate acrobatic neck movements, but
not so low that the view of the screen is impeded. Ideally,
laparoscopic pelvic surgery requires that there be two
screens close to the patients legs (Fig. 5).
!
@
Fig. 5
The position of the two monitors allows the surgical team and the nurse to see the screen.
! operating surgeon; @ first assistant; # second assistant; $ scrub nurse; % anaesthesiologist.
Hysterectomy Myomectomy
a 1 Trocar 10 mm, 234 Trocar 5 mm b 13 Trocar 10 mm, 24 Trocar 5 mm

Fig. 6a, b
Trocar ports in the case of a bulky uterus.
3.1 Position of the Primary Trocar

Virtuality has the great advantage that the image can be trocar. If the trocar is in sub-xyphoid position, the uterus will
assessed and changed, if the visual field is inadequate. For look smaller and vital structures (such as the uterine arteries)
example, during hysterectomy, after inserting the primary will appear in a better position to allow vision (Fig. 6). Another
trocar, a mass blocking the view from side to side may be option is to change from a 0-straight forward laparoscope to
found in the case of a bulky uterus. There are three solutions a 30-forward-oblique scope to enable surgery on the uterine
to this situation. The first is to give a GnRH analogue for 3 arteries or the utero-sacral ligaments. By virtualizing the
months and then re-operate. The second is to convert to difficulties, operating times can be reduced.
laparotomy. The third solution is to change the position of the
3.2 Accessory Trocars

The number of trocars: four hands are usually available for
surgery (if optic robots are not used) so the time dedicated to
placing more than four trocars is wasted time. The surgeon
involved in the pre-operative planning must carefully consider
and set up the points of trocar insertion. We normally use
four trocars for all laparoscopic procedures including adnexal
surgery (Fig. 7). Using this method systematically is helpful
in anticipating the procedure and reducing operating times.
On the other hand, adding a fifth trocar can be justified if this
facilitates or shortens the operation.
The position of the trocars: did you ever stop to think
why laparoscopic instruments are 43 cm in length? The
abdominal wall acts as a lever for the trocar. The balance
between force (= fatigue) and precision depends on the ratio
between the intra-abdominal and the extra abdominal part of
the instrument: the more the ratio is shifted in favor of the
extraabdominal part, the more precision will be gained, but
the greater length means larger movements of the hands,
which brings on fatigue more rapidly. Unfortunately, many
consider this ratio to be constant although it is not.
Fig. 7
Positioning the trocars for 4 hands.
Fig. 8 Fig. 9
Introduction of the accessory trocar. Topographical anatomy of vessels and organs relative to the trocars
angle of insertion.
The afore-mentioned ratio can be altered easily by shifting the Other ergonomic rules, which may shorten operating times,
point of trocar insertion away from the operating field (e.g. are: placing two lateral trocars in a triangle with the primary
cranially in the midline during pelvic operations). trocar, never introducing more than one trocar parallel to the
Consequently, the trocar site must be different for delicate primary trocar, taking into account the axis of work and angles
procedures such as tubal surgery and for those requiring of approach (especially while suturing), etc. Remember,
force such as myomectomy or Burchs operation. The most that the right lower quadrant trocar is usually controlled by
efficient balance is achieved when the ratio is 1:1, because the assistant, so the assistants parameters as well as the
the hand can feel the pressure of the tissue and the force anticipated function and level of the port must be considered
exerted. With any other ratio, this feeling is lost. This is why during pre-operative planning. Letting the assistant perform
it is important to take your time to plan each point of trocar some tasks that are better performed from his side (e.g. right
insertion; this time is not wasted. Symmetrical insertion is not uterine artery coagulation during hysterectomy) eliminates
important. the need for the surgeon to change sides.
3.3 Type of Trocar and Mode of Insertion

There are many trocar types available today; each surgeon should be inserted not in the direction of the pelvis but at a
must be familiar with those that best answer his needs. A very right angle to the skin, the muscles and the aponeurosis, as
important property that is often forgotten is being able to shown in Figs. 8 and 9. We use disposable trocars with valves
introduce instruments into the trocar without looking away that permit suturing without CO2 leakage. Other surgeons,
from the screen. For this to happen, the trocar must be at who frequently apply monopolar electrosurgery during which
a right angle to the skin when there is no instrument inside a lot of smoke is generated, prefer a trocar with a valve that
it and it must have a wide opening. This means that trocars allows to connect a smoke evacuation system.
3.4 Trocar Size

Using 5 mm-instruments in a 11-mm trocar with a reducer between the trocar and the reducer. This condition inherently
will impair precision of handling. When an instrument of entails imprecision. It is better to begin the operation with
appropriate size is used, the contact point between the trocar 5 mm-trocars and change to 11 mm-trocars when a 10
and the abdominal wall corresponds with the pivot point, mm-instrument is needed. Changing the trocar to 11 mm
whereas the use of an instrument of smaller diameter involves for suturing is not done automatically and depends on the
that there are two contact points with the trocar (in the number of sutures. If the need arises to make four or less
reducer and at the trocar tip). A third contact point is located sutures, it is preferable to maintain the small incisions for
between the trocar and the abdominal wall, and between the faster suturing although it is essential to change the trocar if a
trocar and the reducer. As a result, there are two pivot points, greater number of sutures is required.
one between the trocar and abdominal wall, and the other
4.0 Instrumentation
4.1 Multifunctional Instruments
The three basic actions are dissection, hemostasis and the non-dominant hand can cut (mechanically or electri-
cutting. All of these actions can be performed easily when cally), coagulate by use of monopolar technique, lateralize
multifunctional instruments are used (such as bipolar forceps and dissect. Thus, the surgeon is able to perform nine
or monopolar scissors) in the following order: different actions and rarely needs to change instruments
The surgeon holds the bipolar forceps in one hand and so as to enable performing a specific action. There are
other acceptable ways of holding laparoscopic instruments
curved scissors, connected to the monopolar electrosurgical
provided this is done logically.
generator, in the other. In this way, the dominant hand is
able to dissect, grasp, apply traction and coagulate while
4.2 Maintenance of Instruments

Appropriate, fully functioning instruments shorten operating clean instrument to be used at all times without delay. Every
times and prevent complications. Scissors must always cut surgeon must be responsible for checking the condition of
properly and bipolar forceps must always be kept clean. the instruments in use to ensure their effective function.
Having a second bipolar forceps readily available allows the
5.0 Surgical Strategy

Surgical strategy must be logical and strict but always modi- needs to be overcome, and probably could have been antici-
fiable. It should be decided upon during the first few minutes pated through careful strategy planning. An operation with
of the operation immediately after examining the operating a lot of stops, changes and pauses is much slower than a
field. It is not rare to see surgeons start on one side and then planned operation. Because of its special nature, laparos-
change sides when faced with an obstacle that frequently copy requires that a few basic rules be observed.
5.1 Strict Hemostasis

Bleeding interferes with surgical maneuvers. In laparotomy This is why strict and meticulous hemostasis is essential in
and vaginal surgery the management of minor bleedings laparoscopy. Meticulous dissection and coagulation, anato-
without hemodynamic significance may be delayed with the mical cleavage planes, perfect knowledge of anatomy
temporary placement of a suction tube nearby. This is not and good proficiency in bipolar coagulation are the basic
the case in laparoscopy, because the technique depends competences needed to translate the appropriate laparo-
completely on boundary conditions such as video camera scopic strategy into practice.
and lighting system, confined working space, the few
operating ports and the inherent difficulty associated with the
need for changing instruments.
5.2 Do not Irrigate (Apply Only Suction) !

This statement may sound strange to many laparoscopic O loss of electrical efficiency when an electrolyte solution is
surgeons because lavage has been used extensively for over used
20 years. It is clear, that there are situations which require O spread of the liquid throughout the abdominal cavity, which
lavage, such as in the event of extensive hemorrhage or at the is particularly hazardous in the presence of malignancy,
end of the surgery, but lavage also has disadvantages: infection and dermoid cysts.
O loss of exposure: the operating space is reduced when Finally, suction and lavage are time-consuming procedures.
it is filled with liquid and pneumoperitoneum pressure
decreases when it is suctioned out. Light is absorbed and To avoid lavage, the surgeon must follow a surgical strategy
reflected by the liquid that allows to avoid situations where the use of irrigation is
indispensable.
O loss of anatomical planes due to tissue edema
5.3 Correct Position of the Laparoscope

The lack of a third dimension becomes more obvious when close to the distal lens of the laparoscope in order to align the
the image is distant and at the periphery of the screen. The needle correctly.
tip of the instrument must be kept as close as possible to the Since red absorbs colors, blood should be aspirated as soon
center of the screen. When suturing distant structures such as possible as it reduces brightness.
as the levator ani, one should try to keep the needle holder
5.4 Optimal Use of Accessory Trocars

Trocars should never be used to mobilize an organ that Alternative strategies include:
obscures vision. This can be the case with the sigmoid during O tilting the operating table,
prolapse surgery, with the adnexa during excision of a recto-
vaginal nodule and may also occur during uterovaginal O suspension to the abdominal wall
prolapse surgery afterr subtotal hysterectomy. If a trocar is O the use of an uterine manipulator.
used to mobilize these organs, it is lost for surgery along with
the aid of the assistant who assumes a static role and may These measures, applied at the beginning of the operation,
lose his/her concentration. It also constitutes a source of risk take a few seconds and can save precious time during
and harm when it is outside the operating field. surgery.
6.0 Selecting Information

During laparoscopy the surgeon should select the essential For methodological reasons, information is divided into
information required for the work and ignore what is not useful on-screen and off-screen information.
as it may interfere with the concentration. By doing so the
surgeon is able to anticipate difficulties, as will be explained
below.
7.0 Surgeons Ergonomics and Convenience

During lengthy operations the surgeon suffers from muscular In laparoscopy as in laparotomy, the hands must be in the
strain and fatigue. This can cause errors and slowness. middle of the operating field. In other words, the screen must
Research has shown that muscles can work for hours if they be aligned in the same visual direction as the operating field. If
employ 15% of their maximum strength but they will fatigue if this is not the case, the surgeon will be operating at a different
they use more power. In a recent study, we demonstrated that angle from the one shown on the screen. This will impair
highly proficient surgeons, aware of surgical ergonomics, use orientation and can result in protracted, clumsy movements,
about 15% of the muscle strength of their arms and shoulders and prolonged duration of surgery.
while less experienced surgeons use a higher percentage of The axis between the screen, the surgeons hands and the
their muscular strength. Application of ergonomic principles surgeons eyes should be kept as straight as possible. The
reduces the amount of muscle power applied during surgery, greater the shift, the greater is the distortion of the movements.
which will reduce fatigue and enhance safety and operating We can draw two lines, one between the surgeons eyes and
times. the screen, and one between his eyes and hands. The greater
The operating table position and height are of great impor- the angle between those lines, the more distorted are the
tance in laparoscopic surgery. The table should be low directions. The distortion is very noticeable at angles greater
enough for the surgeon and allow a proper working position then 60 degrees. In case of a right angle (90), e.g., from the
to reduce fatigue. The correct arm position should be with the patients right, the instrument must be pushed in order to
arm lying alongside the chest with the elbow at an angle of 90 achieve a movement to the left. This lack of orientation makes
degrees or more. The height of the abdomen should also be the surgeons movements slow and imprecise.
considered. Since most operating tables are manufactured To sum up, two screens positioned nearby the patients legs
for laparotomy, it is often necessary to use a foot support, should be used during pelvic operations, as shown in Figs.
which must be wide enough for the surgeons feet and the 10 and 11.
pedals.
Main table Screen 2nd Screen

Screen Videocamera 2nd Videocamera
Videocamera Cold light 2nd Cold light source
Cold light source Irrigation-suction source Myoma morcellator
CO2 insufflator system for CO2 insufflator 1st Coagulator
ISC and LPS Second 2nd Coagulator
Vaginal tray Second Assistant
Assistant 2nd monitor
2nd camera Instrument tray Irrigation-suction
Instrument tray 2nd light source system for
myoma Scrub nurse ISC and LPS
Scrub nurse morcellator
Instrument Instrument
1st coagulator pockets
pockets 2nd coagulator
Operating surgeon First Assistant
Operating surgeon First Assistant
Anesthesiologist
L R L R
Anesthesiologist
Anesthesia unit
Anesthesia unit
Fig. 10 Fig. 11
Operating room set up. Alternative operating room setup.
8.0 Quality of the Image

To obtain good quality information from the video screen, and a 21-inch flatscreen monitor. The screen must be coupled
the best possible video technology should be used. In short, directly to the video camera via the best available connection
we use IMAGE1 (KARL STORZ Tuttlingen, Germany) or a (RGB, YC or PAL/NTSC). If RGB is not available, the cables
3-CCD video camera connected to a xenon cold light source should be as short as possible.
9.0 Staff Training

Staff training and regular equipment checks are obvious instrument in the right trocar opening at the right time, who is
though often overlooked measures for speeding up surgery. always ready for the next step and who has the needle holders
To reduce operating times, it is very important to have an loaded inside a trocar before suturing begins, allowing the
active and well-trained theater nurse who holds the trocar surgeon to keep his eyes on the screen.
straight while instruments are changed, who puts the right
10.0 Preoperative Preparation

O Bowel preparation: a low fiber diet for 7 days prior to O All of the equipment used for laparoscopic surgery,
surgery will assist good exposure of the operative field. including more rarely used instruments such as cysto-
Properly prepared bowels take up less space, are easier scopes, ureter catheters and instruments for intestinal
to retract and slide into the pelvis less. On the other hand, surgery, should be readily available within a short time.
preparation with liquids the evening before surgery fills Special procedures and personnel, such as needed, e.g.,
the bowel with liquid and has the opposite effect. For this for the frozen section technique, must be available on
reason, we do not recommend this type of preparation if standby.
opening the intestine is unlikely, as in the case of simple
hysterectomy.
Chapter IV
Gynecologic Laparoscopic
Surgical Anatomy
Cristiana Barbosa1, Arnaud Wattiez2
and Luca Mencaglia1
1
Centro Oncologico Fiorentino, Florence, Italy
2
Strasbourg, France
1.0 Introduction
Laparoscopy allows a highly magnified and close-up view of
the abdominal and pelvic cavity, making it possible to visualize
and study the anatomical structures and pelvic spaces that in
the past were difficult to visualize at laparotomy.
2.0 Anterior Abdominal Wall 2.1 Anatomical Area

The anterior abdominal wall is the entrance to the abdominal The anterior abdominal wall is bounded superiorly by the
cavity. The anterior abdominal wall is usually traversed blindly xiphoid process medially and by the inferior margin of the
so knowledge of the anatomy is crucial to avoid any compli- intercostal cartilages of the 7th to 10th ribs. Inferiorly, it is
cations while doing so. limited by the pubic symphysis and laterally by the inguinal
ligament and the anterior superior iliac spine.
2.2 Layers of the Anterior Abdominal Wall

Rectus
Cutis abdominis muscle Subcutaneous fat
The anterolateral abdominal wall consists of muscle and
fascia. From the skin to the peritoneal cavity, there are various
layers: the skin, subcutaneous fat, the anterior layer of fascia
covering the rectus abdominis muscles medially, the external
oblique muscles laterally and the internal oblique and trans-
versus abdominis laterally.
The external oblique is the most superficial of the muscles
and the transversus is the deepest in the anterolateral
abdominal wall.
Transversalis fascia: covers the posterior layer of the rectus
sheath and the transversus abdominis muscle.
Peritoneum Fascia The preperitoneal space: contains connective tissue and fat.
Peritoneum: The internal part of the parietal peritoneum is
Fig. 1 in contact with the internal organs thanks to the negative
Drawing of the various anatomical layers of the anterior abdominal pressure inside the abdominal cavity.
wall.
2.3 The Umbilicus

Rectus
Umbilicus abdominis muscle
The umbilicus is located in the midline, usually 2 to 2.5 cm
below the level of the tubercles of the iliac crests. The
umbilicus is at the level of the intervertebral discs of L3 and
L4.
The bifurcation of the abdominal aorta into the right and left
common iliac arteries is located a few centimetres below
the umbilicus. The left common iliac vein crosses in front of
the body of the fifth lumbar vertebra and behind the aortic
bifurcation.
In slim patients, the distance between the anterior abdominal
wall and the large vessels is short so attention must be
Peritoneum Fascia redoubled when the principal trocar is being introduced.
Fig. 2
Drawing of the abdominal wall at the level of the umbilicus.
It is also necessary to pay attention to the superficial blood The umbilicus is the most suitable site for introducing the
supply of the umbilicus, which is usually in the form of a circle primary trocar and the Veress needle because the anterior
to the right of the umbilicus. Because of this, the umbilical abdominal wall here contains less subcutaneous tissue and
incision is preferably made on the left. does not contain any muscle, and the distance between the
skin and peritoneum is shortest.
The difference between the fascia above and below the
umbilicus must be recalled. In the upper part, the posterior However, the umbilicus, entered through its upper part, is
layer of the internal oblique fascia and the aponeurosis of the location of choice for open laparoscopy, a technique
the transversus abdominis muscle pass behind the rectus preferred by some and favoured by general surgeons.
abdominis muscles, while the anterior layer of the internal
The peritoneal layer is adherent with the layers above so
oblique fascia passes in front. Below the umbilicus, all the
once the fascia has been identified, clamped and incised, it
fasciae pass together anterior to the rectus abdominis
is easy to open the serosa bluntly and enter the abdominal
muscles (Figs. 1, 2). These anatomical relations are important
cavity using a round-tipped Hasson trocar.
when the Veress needle is introduced during laparoscopy. In
fact, if it is introduced in or below the umbilicus, a distinct This technique is indicated in patients who have previously
tactile sensation is felt when the fascia and peritoneum is undergone pelvic and/or abdominal surgery or where post-
crossed. If it is introduced above the umbilicus, lateral to the inflammatory adhesions are suspected because it allows
midline, passage through the anterior fascia, posterior fascia direct inspection of the structures beneath the trocars entry
and peritoneum can be felt distinctly. site.
2.4 Muscle Wall

The rectus abdominis muscles can be identified in the intersections, which divide the rectus muscles into segments
muscle wall. They are located lateral to the midline from the at the level of the xiphoid process, the umbilicus and between
xiphoid process to the border of the pubic symphysis. They these two points.
are divided centrally by the linea alba, which is a tendinous The external oblique muscle is located lateral to the rectus
raphe forming a central groove between the rectus muscles. abdominis muscle between the lateral part of the lower ribs
The lateral angle of the rectus abdominis muscle is called the and the iliac crest. The inferior margin of its fascia forms the
semilunar line. The rectus abdominis muscles have tendinous inguinal ligament.
2.5 Blood Supply of the Anterior Abdominal Wall

The anterior abdominal wall has a deep and superficial The deep vascular system is formed by the superior
blood supply. The superficial vascular network is formed epigastric artery, the inferior epigastric artery and by the deep
by the superficial epigastric artery, the superficial cirumflex circumflex iliac arteries and their corresponding veins. The
iliac artery and the corresponding veins. These vessels are superior epigastric artery is a branch of the internal thoracic
branches of the femoral artery, which emerge caudal to artery while the inferior epigastric artery is a branch of the
the inguinal ligament. The epigastric artery runs medial to external iliac. They are found beneath the rectus abdominis
the rectus abdominis muscles, while the circumflex artery muscles.
is lateral. These vessels can be seen by transillumination,
especially in thin patients (Figs. 34).
Fig. 3 Fig. 4
View of the superficial blood supply of the abdominal wall by Drawing of the superficial blood supply of the abdominal wall which
transillumination (insert picture showing the external view). can be visualized by transillumination.
3.0 The Uterus

The uterus is located deep in the pelvic cavity. It is pear- The uterus is about 7.5 cm in length, 5 cm in its transverse
shaped and divided into two parts: the upper part, the body, diameter and about 2.5 cm thick. It weighs about 3040 gr
is bulkier and the lower part consists of the cervix (Fig. 5). in nulliparous and 70 gr in multiparous women. It is located
Between these two parts, a transitional zone known as the between the bladder anteriorly and the rectosigmoid poste-
uterine isthmus is identified; this corresponds to the internal riorly. Its upper part is suspended from the round ligaments,
os of the cervix. while the inferior part is held by the vesicouterine ligaments,
The long axis of the uterus corresponds to the axis of the the parametria and the uterosacral ligaments bilaterally,
pelvic wall. Since the organ is mobile, its position varies with which form the retinaculum uteri or paracervical ring.
the possible alterations in the distension of contiguous organs The shape, size, weight and position of the uterus vary
such as the bladder and rectum. There is usually an angle of according to the different periods of the womans life.
100 to 120 between the body and cervix. If this is anterior,
it is defined as uterine anteversion, while it is described as
retroversion when it is posterior.
Fig. 5
Uterus, view of the fundus.
3.1 The Uterine Corpus

The body of the uterus becomes gradually smaller from the
fundus toward the isthmus, The anterior wall is covered by
the visceral peritoneum, which is continuous with the vesical
peritoneum anteriorly, forming the vesicouterine space.
The posterior wall is convex and covered by the visceral
peritoneum which continues inferiorly to cover the cervix and
upper vagina. The tubes and round ligaments, which fix the
uterus to the wall of the pelvis, emerge bilaterally from the
upper and lateral ends of the uterine body. The utero-ovarian
ligaments emerge posteriorly. These three structures are
covered by a layer of peritoneum, which passes from the
lateral margin of the uterine wall to the wall of the pelvis and is
called the broad ligament (Fig. 6).
Fig. 6
Broad ligament of the uterus.
The tubes, the round ligaments, the utero-ovarian ligaments,

vessels and nerves are located between the anterior and
posterior leaves of peritoneum of the broad ligament (Fig. 9).
The portion of the broad ligament below the tube is called
the mesosalpinx. The insertion of the broad ligament on the
lateral wall of the pelvis has a concave border, known as the
pelvic infundibulum, traversed by the ovarian vessels and
nerves.
The round ligaments arise from the lateral part of the uterus
and pass through the broad ligaments below and anterior
to the tubes above the iliac vessels, then course through
the internal inguinal ring to traverse the inguinal canal and
terminate in the labia majora. They are about 1012 cm in
length and are formed by muscle fibers mixed with fibrous
tissue arising from the uterus. Vessels and nerves run in the
round ligaments.
Fig. 9
Right anterior broad ligament.
4.0 Vessels and Nerves

4.1 The Uterine Artery
The uterine artery arises from the anterior trunk of the internal Anatomical variations of the uterine artery are uncommon.
iliac (or hypogastric) artery. It crosses the medial part of the Just 1% of patients have two uterine arteries on one side
levator ani muscle and enters the uterus at the level of the while the presence of two uterine veins for each artery is a
cervix. It provides the blood supply to all of the uterus. It constant finding. Pelage et al. in 1999 demonstrated that the
has a wavy course. In the cervix, it is located 2 cm above blood supply to the uterus could originate from the ovarian
and anterior to the ureter to which it supplies a small branch artery or from the artery of the round ligament. On the other
(Fig. 10). hand, it is more common for the blood supply to the ovary
From its cervical insertion, it ascends tortuously along the to originate from the uterine artery in about 24% of woman.
lateral wall of the uterus between the two layers of the broad The uterine artery usually arises from the hypogastric artery,
ligament as far as the tubes. It then extends as far as the but it may also arise from the vaginal artery or middle rectal
ovarian hilum where it terminates in an anastomosis with the artery.
ovarian artery. It gives descending branches to the cervix
and vagina, which anastomose with branches of the vaginal
artery.
Fig. 10
Uterine artery.
To prevent injury to the ureter during hysterectomy, the O The uterine artery is coagulated at the level of the isthmus
following is advisable: and at the point where it passes between the cervix and
O Use of a uterine manipulator sturdy enough to elevate and the body of the uterus.
lateralize the uterus with the aim of exposing the angle O Knowledge of the principles of electrosurgery is essential
where it meets the uterine artery. Incorrect exposure of for preventing the potential risk of ureter injuries. In
the uterine artery can easily lead to injuries to the ureter particular, the use of bipolar electrosurgery with suitable
when the artery is divided, ligated or coagulated by use of instruments is recommended.
bipolar electrosurgery. O The anatomical proximity of the ureter to the pelvic infun-
O Fenestration of the broad ligament, which allows the ureter dibulum requires great care during adnexectomy when
to be moved, which is located very close to the posterior ligating or coagulating this ligament, especially in the case
leaf of the peritoneum. of adhesions or pelvic endometriosis.
O Adequate dissection of the posterior leaf of the broad O Where possible, always visualize the ureter by trans-
ligament is essential to better visualize and localize the illumination, as described above.
uterine artery and vein.
6.0 The Pelvic Vessels

For the pelvic surgeon, knowledge about the anatomy of the
pelvic vessels is crucial regarding the proportions of pelvic
organs and the caliber of these vessels. Surgical compli-
cations involving these vessels inevitably produce major
hemorrhage.
6.1 Aorta, Inferior Vena cava and Bifurcation

The aorta descends in the retroperitoneal space to the left of
the midline. At the level of the fourth lumbar vertebra, it divides
into three branches: two large lateral ones, the common iliac
arteries, and medially a smaller terminal branch, the middle
Fig. 18
sacral artery. Right ovarian artery and right pelvic infundibulum.
The ovarian artery arises directly from the anterolateral part
of the aorta at the level of the vertebral bodies of L2 and L3,
caudal to the origin of the renal arteries. The ovarian artery
Another important artery that originates directly from the aorta
has an oblique and lateral retroperitoneal course. On the left it
is the inferior mesenteric artery, which supplies the left half of
traverses the psoas muscle and on the right the inferior vena
the transverse colon, all the descending colon, the sigmoid
cava. The ovarian artery crosses the external iliac vessels
and part of the rectum. The mesenteric artery originates from
2 cm inferior to the ureter. The smaller branches supply the
the aorta 34 cm superior to the bifurcation of the common
ureter and uterine tubes and finally anastomose with the
iliac arteries. It then crosses the left common iliac artery and
uterine artery at the level of the uterine body.
continues in the pelvis as superior hemorrhoidal artery, which
The ovarian vessels, lymphatics and related nerve endings descends between the layers of the sigmoid and terminates
are located in the pelvic infundibulum (Fig. 18). in the superior part of the rectum.
Fig. 19 Fig. 20
Common iliac arteries and inferior vena cava. Principal vessels at the level of the sacral promontory.
6.2 The Inferior Vena cava

The inferior vena cava is a large venous trunk, which drains Perforation or injury of the large vessels during introduction
the subdiaphragmatic part of the human body as far as the of the Veress needle or primary trocar is of low incidence,
right atrium. The abdominal portion of the inferior vena cava but nonetheless one of the most feared and dangerous
has a caliber of 22 mm and is 20 cm long (Fig. 19). complications of laparoscopic surgery. The major risk factors
The inferior vena cava is located to the right of the lumbar contributing to the occurence of this complication are low
spine. It is formed by the union of the right and left common intra-abdominal pressure, insufficient pneumoperitoneum,
iliac veins at the level of the fifth lumbar vertebra. The left of rapid or uncontrolled entry, incorrect position of the operating
the two branches of the common iliac vein is of major impor- table or a patient with a very large abdominal girth. It must be
tance to the pelvic surgeon because this crosses the midline recalled how important close attention is during this phase as
very close to the sacral promontory (Fig. 20). Injury to this a good third of complications of laparoscopic surgery occur
vein can occur when the primary trocar is introduced through during introduction of the Veress needle or primary trocar.
the umbilicus or during surgical maneuvers at the level of the
sacral promontory.
6.3 The Iliac Arteries

The abdominal aorta divides into two branches, the common
iliac arteries, to the left of the body of the fourth lumbar
vertebra. They are about 5 cm long and divide in turn into the
external and internal iliac arteries bilaterally.
The right common iliac artery is retroperitoneal with the
small intestine, sympathetic nerves and the ureter anterior
to it. Posteriorly are the bodies or the fourth and fifth lumbar
vertebrae, the terminal part of the two common iliac veins and
the start of the inferior vena cava. Laterally, the right common
iliac vein and the psoas major muscle can be identified. The
left common iliac vein passes medially.
The left common iliac artery is retroperitoneal with the small
intestine, sympathetic nerves and superior hemorrhoidal
artery in front of it, and at this point it is crossed by the
Fig. 21 ureter. The bodies of the fourth and fifth lumbar vertebrae are
The iliac vessels and psoas muscle.
posterior. The left common iliac vein runs medial to the psoas
major muscle (Fig. 21).
The branches of the common iliac arteries provide the blood
supply to the ureter, psoas muscle, lymph nodes and perito-
neum.
6.4 The Median Sacral Artery

This artery arises from the posterior part of the aorta, a little
above its bifurcation. It courses in the midline anterior to
the lumbar vertebr, sacrum and coccyx. It supplies small
branches to the rectum. In front of the sacrum it anastomoses
with the lateral sacral arteries. It is crossed by the left common
iliac vein.
The median sacral artery and the left common iliac vein may
be accidently injured by surgical maneuvers at the level of the
sacral promontory. In the case of promonto-sacral surgery,
it is advisable to make a true and proper fenestration of the
retroperitoneum. A small retroperitoneal incision is made and
after a short time, distension with CO2 allows these vessels to
be visualized better and identified (Fig. 22).
Fig. 22
The sacral vessels at the level of the promontory.
6.5 The External Iliac Artery

The common iliac artery divides into internal and external. The
external iliac artery is bigger and passes obliquely and lateral
to the border of the psoas muscle (Fig. 23). It then enters the
inguinal canal where it tapers and is called the femoral artery.
At its origin it is crossed by the ovarian vessels and, in some
cases, by the ureter. The round ligament crosses it at the end
of its course before it enters the inguinal canal. The external
iliac vein runs below the artery together with numerous
vessels and lymph nodes that are located along its course.
Fig. 23
Left external iliac artery.
6.6 The Branches of the External Iliac Artery

Apart from the small branches to the psoas muscle, it divides
into two large branches, the inferior epigastric artery and the
deep circumflex iliac artery.
The inferior epigastric artery arises from the medial part of the
external iliac artery, 1 cm above the inguinal ligament. It forms
a curve anterior to the subperitoneal tissue of the medial
border of the internal inguinal ring, crosses the transversalis
fascia and runs upward towards the rectus abdominis
muscles and posterior fascia, finally dividing into numerous
branches. Below the umbilicus, it anastomoses with the
superior epigastric artery, a branch of the internal mammary
artery, and with the inferior intercostal arteries (Fig. 24). This
artery produces a prominence in the parietal peritoneum,
known as the lateral umbilical fold. It supplies the rectus
abdominis muscle and the anterior abdominal wall and gives Fig. 24
a branch to the round ligament. Inferior epigastric artery.
Fig. 27 Fig. 28
Obturator fossa. Superior vesical artery.
The obturator artery is an important anatomical boundary toward the lower part of the greater sciatic foramen. It
during lymphadenectomy along the external iliac artery. It is supplies the piriformis muscle, the coccygeus and levator ani
accompanied by the obturator nerve and vein. It is located with the rectal vessels.
deeply and laterally in the pelvis toward the upper part of The vaginal artery arises from the internal iliac artery in a
the obturator foramen on both sides. Inside the obturator common trunk with the uterine artery and middle rectal artery.
foramen, the nerve runs more laterally compared to the artery The ureter crosses it posteriorly and from this point the artery
(Fig. 27). The artery passes through the obturator foramen and descends in the direction of the vagina medial to the ureter. It
divides into an anterior and posterior branch. The obturator ends in the middle third of the vagina in small anastomosing
artery is related laterally to the obturator fascia and medially branches and supplies all of the vagina.
to the ureter. Anatomic variants of this vessel are common
and to identify it the umbilical artery and external iliac artery The superior vesical artery arises from the proximal part of the
are used as reference points as the obturator artery is located anterior trunk of the internal iliac artery and supplies numerous
between these two vessels. branches to the upper part of the bladder and ureter.
The middle rectal (or hemorrhoidal) artery descends lateral to The middle vesical artery is a branch of the superior vesical
the rectum in the pararectal space. It supplies the rectum and artery and supplies the base of the bladder (Fig. 28).
anastomoses with the superior and inferior rectal arteries. The inferior vesical artery normally arises in common with the
The internal pudendal artery is the smallest of the terminal middle hemorrhoidal artery or the vaginal artery. It supplies
branches of the internal iliac and supplies the external the base and inferior part of the bladder and the trigone.
genitalia and perineum. It passes downward and external The posterior branches of the internal iliac or hypogastric
to the inferior part of the greater sciatic foramen, behind the artery:
sciatic spines, and leaves the pelvis through the coccygeus
and piriformis muscles. It then crosses the sciatic spine and The iliolumbar artery is a branch of the posterior trunk and
inferior pubic ramus to terminate in the middle of the fascia passes behind the obturator nerve and external iliac vessels
of the urogenital diaphragm and the area of the clitoris. In its toward the medial border of the psoas major muscle, where it
course it is accompanied medially by the pudendal nerve, divides into a lumbar branch and an iliac branch.
the inferior rectal nerve and the inferior gluteal vessels and The lateral sacral arteries are branches of the posterior trunk,
laterally by the sciatic nerve, the inferior gluteal nerve and the normally two in number, one superior and one inferior, which
internal obturator nerve. descend to the lateral border of the sacrum.
The inferior gluteal artery is the most important of the terminal The superior gluteal artery goes to the gluteal area, running
branches of the internal iliac (hypogastric) artery. It descends behind the lumbosacral trunk at the level of the first sacral
anterior to the nerves of the sacral plexus and piriformis nerve and leaving the pelvis through the piriformis, dividing
muscle, posterior to the internal pudendal artery and passes into a superficial and deep branch.
7.0 The Pelvic Spaces

7.1 The Pararectal Space
The pararectal spaces are lateral to the rectum bilaterally.
They are located posterior to the base of the broad ligament,
which forms the anterior boundary of these spaces. The
lateral boundary is formed by the ureter and internal iliac
artery. The base consists of the puborectalis muscle (part of
the levator ani). This space contains the uterosacral ligament
laterally, which passes posteriorly in the direction of the
sacrum (Fig. 29).
Laparoscopic operations for uterine prolapse or endo-
metriosis of the rectovaginal septum are procedures require
a solid knowledge of the anatomy of these spaces. Correct
dissection of the pararectal space is of crucial importance
Fig. 29 Pararectal space. to prevent iatrogenic injury to the vesical and rectal nerve
plexuses, which cross this space.
7.2 The Paravesical Space
The paravesical space is located anteriorly at the base of This space contains, from medial to lateral, the obliterated
the broad ligaments bilaterally. The medial boundary is the umbilical artery, the obturator artery and vein and the
bladder, the lateral boundary is the internal obturator fascia obturator nerve, together with lymph nodes and lymphatic
while its inferior boundary consists of the fibres of the iliococ- vessels (Figs. 3031). The paravesical space is particularly
cygeus muscle, which terminate in the tendinous arch of the important in pelvic lymphadenectomy.
levator ani.
Fig. 30 Fig. 31
Paravesical space. Lateral view of the paravesical space: the internal obturator muscle,
puborectalis muscle and the two tendinous arches can be seen.
7.3 Space of Retzius

The space of Retzius or retropubic space is located between
the posterior part of the pubic bone and Coopers ligament,
which is its anterior boundary. The anterior part of the
bladder is the posterior boundary of this space. The lateral
boundary is formed by the internal obturator muscle and it
is continuous posteriorly with the vesicovaginal space. The
floor of the space of Retzius is the pubocervical (paravaginal)
fascia, which is inserted into the tendinous arch (connective
tissue located medial to the insertion of the iliococcygeus
muscle) in the internal obturator fascia (Fig. 32).
Fig. 32
Space of Retzius.
7.4 The Vesicovaginal Space
This space is found between the anterior part of the vagina

and the posterior part of the bladder. It contains the
bladder trigone and the vesicovaginal fascia. It is bounded
laterally by the vesicouterine ligaments or vesical pillars
(Fig. 33). The inferior vesical arteries and veins and ureters
pass beneath the pillars toward the bladder neck.
This space is also virtual and it is dissected during
hysterectomy to free the bladder; the surgeon must avoid
lateral dissection because of the risk of ureter injury.
7.5 The Rectovaginal Space

Fig. 33
The recto-vaginal space is another virtual space located Vesicovaginal space.
between the posterior part of the vagina and the anterior part
of the rectum. It begins at the medial junction of the utero-
sacral ligaments and the pouch of Douglas. It is bounded
laterally by the iliococcygeus muscles of the levator ani.
7.6 The Presacral Space
This is located posterior to the parietal peritoneum in front of

the vertebral column at sacral level. It is bounded posteriorly
by the anterior longitudinal ligament, the sacral promontory
and the sacrum (Fig. 34). The right lateral boundary is the
right common iliac artery and the right ureter. On the left are
found the left common iliac artery, left ureter and the inferior
mesenteric artery and vein. It contains fat and the presacral
nerves, which receive multiple afferent and efferent connec-
tions from the sympathetic, parasympathetic and somatic
system of the sacral nerves. Dissection of this space is
necessary when presacral neurectomy is performed.
Fig. 34
Presacral space.
Recommended Reading
1. DUBREUIL-CHAMBARDEL, L: (1925) Trait des 4. PELAGE JP, LE DREF O, SOYER P, JACOB D,
Variations du System Artriel Variations des Artres du KARDACHE M, DAHAN H, LASSAU JP, RYMER R:
Pelvis et du Membre Inferieur, Masson et Cie., Paris Arterial anatomy of the female genital tract: veriations
and relevance to trascatheter embolization of the uterus.
2. GASPARRI F, MASSI GB: (1976) Trattato italiano di
AJR Am J Roentgenol.1999 Apr;172(4): 98994.
ginecologia
3. PELAGE JP, LE DREF O, JACOB D, SOYER P,
ROSSIGNOL M, TRUC J, PAYEN D, RYMER R:
Uterine artery embolization: anatomical and technical
considerations, indications, results, and complications
J Radiol. 200 Dec;81 (12 Suppl): 186372.
Chapter V
Suturing Techniques in
Gynecologic Laparoscopy
Daiana Tonellotto1, Paulo Ayroza2,
Arnaud Wattiez3 and Luca Mencaglia4
1
Barra DOr Hospital, Rio de Janeiro, Brazil
2
Medical School of the Santa Casa University of So Paulo, Brazil
3
Strasbourg University Hospital, Strasbourg, France
4
1.0 Ergonomics
To make suturing easier it is important for the surgeon to instruments by the hands and fingers. The arms must be
adopt as ergonomic a position as possible. relaxed and the elbows beside the trunk.
The surgeon must be at a height where the angle between It is extremely important that all of the surgical team is
his upper arm and forearm is > 90 degrees. It must be borne arranged correctly around the table and that the surgeons
in mind that the patients abdominal wall is distended by the line of vision (eye-monitor) always passes between the
pneumoperitoneum and is further elevated by the Trendelen- surgeons hands.
burg position and also that the surgeons hands are situated Moreover, for correct ergonomics during laparoscopic
about 20 cm higher because of the presence of the trocars suturing, the trocar ports should be positioned relative to the
and instruments. If the operating table cannot be lowered tissue to be sutured to take into account as far as possible
sufficiently, the surgeon may use a footrest to assume the the hand holding the needle holder, the plane of suturing and
correct position. the angle of incidence between needle and tissue.
Suturing techniques in laparoscopy do not require large
movements of the trunk and arms but only control of the
2.0 Suturing
Suturing is defined as any surgical step intended to approxi- This type of suture has certain advantages: if a knot comes
mate the edges of a tissue that is discontinuous with its undone, this is not enough to cause suture dehiscence, it is
anatomical planes. Its function can be mechanical (opposing well tolerated by the tissues because less foreign material is
the forces that tend to separate the wound edges), joining present and, in the event of infection, it prevents this from
different anatomical planes together or isolation (preventing spreading to the entire wound following the course of the
bacterial contamination). suture. At the same time, however, it must be borne in mind
that it takes longer compared to a continuous suture, is less
Essentially there are two traditional suturing techniques:
hemostatic and provides relatively lower resistance.
O interrupted
Continuous suture allows approximation of the edges with
O continuous an uninterrupted series of stitches using one thread. It can
be a straight line, and in this case the suture is stopped by a
Interrupted (noncontinuous) sutures are placed to approxi-
knot at either end, or circular (also called purse-string), where
mate the wound edges, placing individual sutures equidistant
the knot is tied with the two ends of the suture. For this type
from each other.
of suture, it is preferable to use a smooth and flexible thread.
The interrupted suture can be simple, when the purpose The advantage of the continuous suture is that it is fast and
is simply to approximate the tissue, double (two simple provides optimal tensile strength retention but the disadvan-
sutures without breaking the continuity of the thread) when tage is that if a suture gives way, this is more likely to produce
hemostasis is also desired or inverting when it is necessary to dehiscence of the entire suture and in the event of infection, it
invaginate the tissue more deeply. favors spread along the suture.
3.0 Materials
1 3 The materials used in the traditional suturing technique are
/4 circle /8 circle
1 needles and suture threads.
/2 curve
Skin and muscles

Ophthalmic (surgery of the Skin suture
3.1 Surgical Needles
eyes and muscles
Surgical needles are available in six different geometric forms:
1 5
/2 circle /8 circle straight straight, curve, circle, circle, 3/8 circle, 5/8 circle and
they are distinguished by the type of point: rounded, conical,
Suture of the skin and diamond point and by the body: circular, oval, triangular,
intestine lancet, hexagonal (Figs. 12).
General, gynecologic and Urology
vascular surgery
Fig. 1
Types of suture needles.
Cross section Cross section

Angle
subtended
Needle
point
Tissue trauma Length of chord
Tissue trauma
s
diu Needle
Ra diameter
Needle
Body of
length
needle
Fig. 2a Fig. 2b Fig. 3

Needles with a cylindrical cross section And triangular cross section (two cutting The maximum length of needles used in
(tissue with little resistance). edges for highly resistant tissue. laparoscopy is the size of the arc, which
can vary from 27 to 36 mm.
In general, semicircular round-bodied surgical needles with a

conical tip with a length varying according to the tissue being
sutured are used almost exclusively (Fig. 3).
In the case of tissues with a firm consistency, some surgeons
prefer to use needles with all three edges of the tip cutting but
round-bodied (taper cut) which penetrate more easily without
causing excessive trauma.
Straight surgical needles can be used transparietally to
suspend tissues such as the intestine, ovaries and vaginal
vault with the aim of improving exposure of the operative field
(Figs. 46).
Fig. 4
The intestine is anchored to the abdominal wall by means of a
suspensory suture. The peri-intestinal fat is transfixed with a straight
needle.
Fig. 5 Fig. 6
The intestine is anchored to the abdominal wall by means of a The intestine is anchored to the abdominal wall for the duration of
suspensory suture. The abdominal wall is transfixed. the operation by means of a suspensory suture.
The most important physical properties of a suture material Polyester (Dacron). Commercial names: Ethibond (polyester
are: coated with polybutylate), Mersilene (polyester), Micron
O tensile strength retention: ability of a thread to oppose (polyester covered with silicone). Non-absorbable synthetic
traction monofilament suture.
O smoothness: force necessary to make a suture glide in a Advantages: optimal tensile strength retention
tissue. Strictly correlated with the friction coefficient of the low reactivity
suture material good flexibility
O elasticity: capacity of a suture to elongate under traction optimal smoothness
O capillarity: physical property by which molecules of liquid Disadvantages: asepsis of the tissue
are induced to move inside a tube independently of gravity removal of the sutures if infected
O hydrophilia: chemical phenomenon denoting the greater Polyester, because of its smoothness and non-absorbability,
or lesser affinity for water of various materials finds its greatest use in surgery of the pelvic floor.
O flexibility: property by which a suture is capable of Monocryl (polyglecaprone 25). Absorbable synthetic mono-
supporting acute angulation without breaking or opposing filament suture.
excessive resistance Advantages: high tensile strength retention
O plasticity: this is the lack of recovery of the initial dimen- absorbable
sions of the suture after forced lengthening Disadvantages: low knot retention
O handling: this is a property that cannot be measured
50% absorbed in 7 days
with instruments but is a special and subjective quality Particularly indicated for suturing delicate tissues such as the
assessed only by the surgeons hand; it is the resultant of tube and ovary as it produces less tissue reaction.
all the physical properties described above.
Polypropylene Commercial names: Prolene, Surgilene.
The sutures most commonly used in laparoscopy are:
Non-absorbable synthetic monofilament suture.
Vicryl (Polyglactin 910). Braided absorbable synthetic suture.
Advantages: good knot retention
Also produced in a form coated with calcium stearate to
optimal smoothness
make it water-repellent and more rigid.
low tissue reaction
Advantages: optimal handling optimal tissue resistance
good knot retention versatile applicability
predictable absorption Disadvantages: memory
very versatile low flexibility
minimal tissue reaction knot tying difficult with bigger suture
Disadvantages: braided and capillary diameters
retention reduced in the presence of urine Small-diameter material is used for vascular sutures while
Vicryl is the most commonly used suture in gynecologic larger diameters are used for temporary suspension of the
laparoscopy because of its optimal handling and versatility. ovaries or sigmoid.
4.0 Instrumentation
To speed up and facilitate as much as possible the suturing
process, perfect knowledge of the required laparoscopic
instruments is essential.
4.1 Trocars
The trocar allows various types of laparoscopic devices to be The trocars have different types of valves:
passed into and used in the abdominal cavity. O multifunctional valve: this is opened by pressure exerted
The 6-mm trocars allow finer and more precise move- by an external plunger
ments so 5-mm instruments are usually employed; however, O automatic valve flaps: this opens automatically when the
needles are introduced and removed more easily through instrument is pushed against it
11-mm trocars. It is therefore possible to use a 11-mm
trocar with reducer although 1113 mm trocars are O silicone leaflet valve: with a membrane, bicuspid or
currently available that do not require reduction from 13 to tricuspid shape
6 mm because they come with a special valve, though this When suturing, attention should be paid to the type of
is extremely fragile and easily damaged when needles are trocar valve; the silicone leaflet valve remains open when
passed through it. When suturing delicate small structures two sutures are passed inside it, causing gas to leak. When
such as the ureter or tube, where it is preferable to use using extracorporeal knots, trocars with a tricuspid valve are
3-mm instruments, 3.9-mm trocars can be used. therefore preferable.
a b
Figs. 8a, b
Needle holders with straight and curved handles.
4.2 Needle holders

The needle holder is the fundamental instrument for laparo- handle, lightweight and sturdy at the same time. They must
scopic suturing as it must carry the needle, place the stitch allow the needle to be grasped firmly but also to scale the
and tie the intracorporeal knot (Fig. 8). force while the suture is being manipulated.
There are different versions depending on the handle design There are needle holders capable of straightening the needle
(curved, straight), opening and closing ratchet mechanism but they have the disadvantage of not allowing any variation
(central position, right, left), stitch (straight, curved, single of the angle of impact on the tissue being sutured.
or double) and jaws but in general, they must all be easy to
4.3 Assistant Needle Holder

The assistant needle holder is the instrument that assists the
needle holder in placing the suture (Figs. 910).
In general, a second needle holder is used to allow good
control of the needle and at the same time allow both hands
to be used equally. Any forceps can be chosen as assistant
needle holder, preferably with flat jaws that allow both the
suture and the tissues to be grasped securely.
Fig. 9
Needle holder and assistant needle holder.
a b c
Figs. 10ac
Jaws of different needle holders.
4.4 Knot Pusher

The knot pusher is an instrument that allows a previously
tied extracorporeal knot to be introduced into the abdominal
cavity. There are different knot pushers (Fig. 11) depending
on the type of knot: simple half hitch, Roeder.
Fig. 11
Knot pusher.
4.5 Scissors
The scissors used to cut suture material must not be the same
as those used for dissection because they are extremely
delicate.
Using dissecting scissors to cut suture material can result in
a dramatic decrease of their cutting performance. This effect
becomes even more evident at an earlier stage if the scissors
are used in combination with electrosurgical instruments.
Scissors vary according to the design of the blades: straight,
curved, hooked. Hooked scissors are preferable for cutting
sutures (Fig. 12).
Fig. 12
Different types of laparoscopic scissors.
5.0 Insertion and Removal of the Needle from the Abdominal Cavity
The insertion and removal of the needle depend on its shape can be introduced in 6-mm trocars up to 12 mm in length, in
and size, and not least, on the trocar size. 11-mm trocars up to 28 mm, in 13-mm trocars up to 34 mm
Straight needles can be inserted in any type of trocar or even and in 15-mm trocars up to 40 mm in length (Figs. 1315).
directly through the abdominal wall, while curved needles
a b c
Figs. 13ac
The sequence demonstrates how the needle and finally protrudes from the distal
holder is inserted in the cannula (a) opening of the 13-mm trocar (c).
a b c
Figs. 14ac
Sequence demonstrating loading of the
suture and thus of the needle inside the
cannula.
a b
Figs. 15ad
Sequence demonstrating the subsequent
insertion of the cannula loaded with suture
c d
and needle inside the trocar.
Figs. 16a, b
When the length of the needle exceeds the
inner diameter of the cannula, this can pose
problems of its own, such as the needle
a b
becoming impacted inside the cannula.
During insertion and removal of the needle from the of the suture, then withdraw the needle holder from the trocar
abdominal cavity, constant videoendosopic monitoring of the until the needle is located about 10 cm from the distal end of
port in use is mandatory, because there is always a risk of the the trocar; at this point, the needle holder is reinserted in the
needle becoming impacted in the valve and dropping into the trocar and the suture is grasped about 3 cm from the swage
abdominal cavity (Fig. 16). of the needle. The needle holder, needle, suture and trocar
The ideal would be to use trocars with an automatic valve. can then be introduced into the abdominal wall, seeking to
There are specific introducers on the market, which are find the correct route.
inserted in the trocars and allow the needle to be passed To remove the needle, apart from the methods described
through safely. above, taking care not to mount the needle in the needle
The needles can be introduced directly through the cutaneous holder but handling it by the suture to provide it with some
ports but with the risk of iatrogenic injury to the abdominal freedom of motion, it is possible to straighten the needle in
wall, bleeding and subcutaneous emphysema. To do this, it the abdominal cavity using two needle holders so that it can
is necessary to remove the trocar from the abdominal wall, be removed directly through the 6-mm trocar but with the risk
introduce the needle holder in the trocar and pick up the end of breakage of the needle itself or of the needle holders.
6.0 The Stitch

The stitch is one of the most difficult steps in laparoscopic orientation of the needle to be changed from forward to back
suturing. or vice versa.
It is always necessary to refer to the ideal stitch which is The assistant needle holder will be able to perfect the angle
obtained when the angles between the wound, needle and between needle and needle holder with traction on the suture
needle holder are each 90 degrees and the suture line is close to the swage or small pushes on the tip of the needle.
parallel to the needle holder. To come as close as possible to The same maneuver may be performed by the same needle
this situation, there are three variables: holder supporting the needle on sufficiently rigid tissue.
O choice of principal needle holder (central or lateral trocar) After locking the needle by closing the needle holder, it is
O straight or reverse mounting of the needle in the needle then possible to place the stitch. The movement transmitted
holder to the needle holder and needle must consist of rotation only
(Figs. 1723).
O angle between the needle and needle holder
If it is desired to place the suture more deeply it is possible
Once the needle has been introduced into the abdomen and
to externally rotate the wrist or move the grip of the needle
the principal needle holder has been adjusted relative to the
holder as far as possible toward the swage.
suture plane, the needle is mounted in the needle holder
without locking at the level of its maximum curve. At this When the needle is extracted from the tissue, one should
point the assistant needle holder, grasping the suture 2 cm attempt to grasp the needle with the needle holder imme-
from the needle swage, causes the needle to rotate forward diately, avoiding letting it drop and losing time required for
or backward through 180 degrees, in this way allowing the repositioning.
P is the axis of rotation of the needle holder A = ALPHA = 90

F is the central axis of the opening in the tissue B = BETA = 0
T is the plane of the needle G = GAMMA = 90
Fig. 17 Fig. 18
Coordinates of the suture plane. Suture angles.
A = ALPHA = 90
B = BETA = 0
G = GAMMA = 90
Fig. 19 Fig. 20
Ideal suture angles. Modifications of the suture angle: tip opened 110.
The Roeder knot is tied as follows: The Weston knot is made with
O A first half knot is tied, O an initial half knot
O the active strand of the suture makes three turns around O the active strand is first wrapped around the passive strand
both strands of the previously formed loop, of the previously formed loop
O the active strand makes a second half knot on the passive O then twisted around both strands of the loop, making the
strand of the loop, active strand pass through the loop that has just been
O the knot is tightened. made
It is important to avoid crossing the two strands of the knot by

O and finally the active strand passes from anterior to
asking the assistant to place a finger on the trocar to separate posterior in the loop closest to the surgeons hands
the two ends of the suture. It is pushed into the abdomen by simply pulling the passive
This knot is secure and easy to tie with a good sliding capacity strand and locked pulling the two ends in opposite directions.
and at the same time optimal holding strength so it provides As with the Roeder knot, it is important to keep the two ends
a high level of safety when ligating vascular pedicles (Figs. of the suture separate. This is a knot with optimal smoothness
2831). but the holding strength of the knot is not optimal especially
with suture sizes less than zero.
Fig. 28 Fig. 29
The stitch is placed in sequence. The margins are approximated by the knot.
Fig. 30 Fig. 31
Suture placed at the infundibulum. Final outcome of the suture.
8.0 Intracorporeal Knots

To tie an intracorporeal knot, it is important to perform the The result should be a surgical knot defined classically as
following steps in order: a succession of half knots and/or half hitches in which the
O the needle holder picks up the suture 2 cm from the swage last should be the reverse of the previous one. However, the
and moves it from the opposite side with respect to the first must be a double half knot, that is, a half knot made by
needles exit point, passing above the suture hole passing the end of the suture twice through the same loop;
this prevents the knot from becoming slack while the next is
O the assistant needle holder wraps twice around the suture being tied.
after which it grasps the end of the suture
In this step it is very important never to mount the needle in
O the two ends are then pulled in opposite directions with the the needle holder because this is associated with the risk of
two needle holders to pull the first square knot taut. iatrogenic injure to adjacent organs.
O the maneuver can be repeated with a single turn each time
until the surgical knot is complete (Figs. 32, 33).
Fig. 32 Fig. 33
Preparation of the knot. Preparation of the knot.
Fig. 34 Fig. 35
Intracorporeal knot-tying depends on correct preparation. The line of the suture (green line) allows the knot to be tied rapidly.
9.0 Endoloop
There are ready-made loops that can be used in laparoscopy loop for making a fishermans knot. The free end is mounted
for hemostasis of vascular pedicles and pedunculated in a plastic guide tube and caught at the detachable proximal
fibromas. end of the guiding tube. If it is not possible to use a trocar with
They are available in Vicryl, Prolene and PDS and usually a silicone leaflet valve, an adaptor must be used to prevent
employ the Roeder knot. The guiding aid in which the suture gas leakage. After placing the loop around the tissue that is to
runs also acts as knot pusher. be ligated, the proximal end of the guiding tube is broken off
and used to exert traction on the free end of the thread while
The endoloop, used for ligatures, is a variation of the Roeder the distal part of the tube is used to push the knot.
knot suitable for tonsillectomy operations. This is a preformed
Recommended Reading
1. AL FALLOUJI M: Making loops in laparoscopic surgery: 10. HANNA GB, FRANK TG, CUSCHIERI A: Objective
state of art. Surg Laparosc Endosc 1993; 3(6):47781 assessment of endoscopic knot quality. Am J Surg
1997; 174(4):4103
2. BABETTY Z, SUMER A, ALTINTAS S: Knot properties
of alternating sliding knots. J Am Coll Surg 1998;186 11. KADIRKAMANATHAN SS, SHELTON JC, HEPWORTH
(4):4859 CC, LAUFER JC, SWAIN CP: A comparison of the
strength of knots tied by hand and at laparoscopy.
3. BONARDINI L, ROSATO S: Suture e fili chirurgici,
J Am Coll Surg 1996;182(1):4654
Ed Mediche Italiane, 1989
12. LUKS FI, DEPREST J, BROSENS I, LERUT T:
4. BROWN RP: Knotting technique and suture materials,
Extracorporeal surgical knot. J Am Coll Surg 1994;
Br J Surg 1992;79(5):399400
179(2) :2202
5. DORSEY JH, SHARP HT, CHOVAN JD, HOLTZ PM:
Laparoscopic knot strength: a comparison with 13. MEDINA M: Analysis and physics of laparoscopic
conventional knots. Obstet Gynecol. 1995 Oct;86 intracorporeal square-knot tying. JSLS 2005;9(1):
(4 Pt 1):53640. 11321.
6. EMAM TA, HANNA GB, KIMBER C, DUNKLEY P, 14. ROMEO A, MINELLI L: Manuale dei nodi e delle
CUSCHIERI A: Effect of intracorporeal-extracorporeal tecniche dannodamento in laparoscopia, EGES
instrument length ratio on endoscopic task performance Edizioni, Verona, 2006
and surgeon movements. Arch Surg 2000; 135(1):625
15. SHARP HT, DORSEY JH, CHIVAN JD, HOLTZ PM: The
7. FREDE T, STOCK C, RENNER C, BUDAIR Z, effect of knot geometry on the strength of laparoscopic
ABDEL-SALAM Y, RASSWEILER J: Geometry of slip knots. Obstet Gynecol 1996;88(3):40811
laparoscopic suturing and knotting techniques.
16. TRIMBOS JB, RIJSSEL EJ, KLOPPER PJ: Performance
J Endourol 1999; 13(3):1918
of sliding knots in monofilament and multifilament
8. GOMEL V, TAYLOR PJ: Laparoscopia ginecologica. suture material. Obstet Gynecol 1986; 68(3): 42530
Diagnostica e chirurgia, UTET, 1998
17. VAN RIJSSEL EJ, TRIMBOS JB, BOOSTER MH:
9. HANNA GB, SHIMI S, CUSCHIERI A: Optimal port Mechanical performance of square knots and sliding
locations for endoscopic intracorporeal knotting. knots in surgery: comparative study, Am J Obstet
Surg Endosc 1997; 11(4):397401 Gynecol 1990;162(1):937
Chapter VI
The Role of Diagnostic Laparoscopy and
Transvaginal Endoscopy (TVE) in Infertility and
Assisted Reproduction Technology (ART)
Emmanuel Lugo1, Carlo Tantini2 and Luca Mencaglia1
2
Hospital of Cecina, Italy
1.0 Introduction
Exploring the peritoneal cavity and visualizing its organs procedures applying either technique, general anesthesia is
is essential in the diagnosis of female pelvic pathology, nearly always necessary in our experience.
especially in the case of infertility or pelvic pain of non-specific
etiology. Diagnostic laparoscopy provides a panoramic view of the
pelvis not feasible by transvaginal endoscopy (TVE) and
The pelvis can be visualized endoscopically by diagnostic facilitates switching to endoscopic surgery in the event
laparoscopy or transvaginal endoscopy. of pelvic pathology. From the surgical point of view, trans-
Both techniques have benefits and drawbacks so that it is not vaginal endoscopy has certain limitations. With the aid of
possible to choose definitively between them. In summary, a 30-hysteroscope and fluid medium for distension of the
it can be stated that both are minimally invasive endoscopic peritoneal cavity, the transvaginal approach undisputably
techniques that require general anesthesia in the vast majority provides some absolutely unique angles of vision and types
of cases (even if performed as day surgery) and the use of a of images. Nonetheless, it must be said, that TVE allows
fully equipped operating room. Although many authors have salpingoscopy of the distal tubal segment to be performed
suggested the use of local anesthesia for these outpatient only in selected cases.
2.0 Laparoscopic Diagnosis

Diagnostic laparoscopy is indicated in infertile patients if tubo- diagnosis between a septate uterus and bicornuate uterus so
peritoneal pathology is suspected to be the primary cause it must always be supplemented by diagnostic laparoscopy
of inhibited female reproduction. Among the most common or transvaginal ultrasound.
indications are suspected tubal defects or irregularities on the
hysterosalpingogram, previous abdominal surgery suggesting Diagnostic laparoscopy is also indicated in infertile patients to
the tentative diagnosis of adhesions, and signs of endome- exclude the presence of pelvic pathology when 1st level ART
triosis or hydrosalpinx on ultrasound. Diagnostic laparoscopy procedures for a period of 68 months did not yield a positive
allows conversion to open surgery and immediate surgical result. Laparoscopy must be scheduled during ovulation or
treatment of any unexpected pelvic pathology prior to initiating the second phase of the cycle and must always be combined
Assisted Reproductive Technology (ART) procedures. with diagnostic hysteroscopy to evaluate the condition of
the uterine cavity and allow endometrial biopsy sampling, if
Laparoscopy combined with diagnostic hysteroscopy is needed.
therefore considered the gold standard for the assessment of
the pelvis and female reproductive tract. Even in the case of The diagnostic measures above must be performed with
Mullerian malformation, the combined use of laparoscopy and utmost care and precision to prevent iatrogenic trauma to the
hysteroscopy is ideal for a definite diagnosis since it allows tissue being examined. Modern technology allows minimally
assessment of the exterior contour of the uterine corpus. invasive diagnostic laparoscopy by use of miniaturized
In fact, hysteroscopy on its own does not allow differential telescopes, instruments and trocars.
a b
Figs. 1a, b
Laparoscopes with diameters of 1 mm, 2 mm, 5 mm and 10 mm.
Fig. 2 Fig. 3 Fig. 4

Panoramic view of the pelvis. Endoscopic view of the tube and ovary. Endoscopic view of the ovary.

The left tube is positioned prior to Injection of methylene blue dye. Abnormal dilatation of the tube,
chromopertubation. sactosalpinx or hydrosalpinx.
Fig. 8 Fig. 9
Salpingitis of the isthmus. Appendix.
However, the surgeon must be readily prepared for endoscopic-

guided surgical treatment of any pathology encountered
during the diagnostic session.
Diagnostic laparoscopy is normally performed as day surgery
with the patient being discharged on the same day (Figs. 19).

Positioning on the operating table involves the cooperation Normally, diagnostic laparoscopy is performed through a
of the awake patient. The patient must be placed in gyneco- double access:
logical position with her arms close to the body and her O periumbilical port for the laparoscope and videocamera;
legs placed in stirrups, avoiding positions that might cause
compression of the plexuses or peripheral nerves. In addition, O along the midline of the lower abdomen for the atraumatic
the legs must be positioned low to prevent interference with forceps needed to manipulate the pelvic organs.
the surgeons maneuvers conducted through the lateral The diameter of the trocars varies according to the diameter
ports. It is preferable to use a uterine manipulator to facilitate of the chosen instruments and laparoscope.
viewing the pelvic organs and for injecting methylene blue
dye for chromopertubation.
3.0 Anesthesia
Diagnostic laparoscopy can be performed under both local In the case of general anesthesia, agents that guarantee rapid
and general anesthesia. recovery can be used so that the patient can be discharged
Various authors have suggested using local anesthesia with a few hours after the procedure. In this case, too, local
periumbilical skin infiltration and intravenous sedation. In this infiltration anesthesia applied to the trocar insertion area has
case it is vitally important to keep abdominal distension very proven to be useful to reduce postoperative pain.
low with insufflation of 12 liters of CO2 at the most to avoid
pain caused by abdominal distension and problems related
to spontaneous respiration.
4.0 Instrumentation
O 5 mm-laparoscope and videocamera O Veress needle
O Insufflation system O Atraumatic grasping forceps
O Xenon cold light source O Suction / irrigation system
O 6 mm-trocar O Uterus manipulator
5.0 Technique
Pelvic endoscopy allows visual inspection of the peritoneal O Minilaparoscopy is performed with a laparoscope, 3 mm
cavity and the female genital tract involved in the reproductive or even 1.2 mm in diameter. The laparoscope may be
process. introduced through the Veress needle; the atraumatic
An extensive diagnostic laparoscopy must include full grasping forceps (diameter 3 mm) may be used through
visualization of the entire peritoneal cavity, a panoramic view a second port. The principal technical problem in this
of the pelvis and pouch of Douglas, the peritoneal liquid, the particular case is related to the extremely reduced diameter
uterosacral ligaments, thorough inspection of the ovarian and of the laparoscope which provides only low-level lighting
tubal surfaces (including the fimbriae) and chromopertubation. conditions in the operative field, even given the use of a
xenon light source. It is therefore necessary to keep the
Various types of instruments can be used for laparoscopy in laparoscope close to the area to be inspected to obtain
infertile patients: enough light. In addition, this type of laparoscope is
O Traditional laparoscopy, performed by using 5 mm- or particularly fragile and delicate (Figs. 1012).
10 mm-laparoscopes, provides optimal visibility at
relatively low expenditures. The second port is a 5 mm-
trocar through which an atraumatic grasping forceps can
be used.
8.0 Patient Selection Criteria

This method is indicated mainly for infertile patients or those and to exclude the presence of pathology in the pouch of
with pelvic pain. Douglas. The purpose of the technique is to visualize and
Potential indications for diagnostic TVE: assess the relationships between the tubes and ovaries, the
mucosa of the fimbria and ampulla, presence of adhesions or
O Diagnostic assessment of infertility pelvic endometriosis and tubal patency (Figs. 1416).
O Visualization of the pelvis after conservative medical The contraindications to this technique are an intact hymen,
therapy or surgical treatment. a particularly narrow vagina, vaginal infection, obliteration of
O Pain mapping the pouch of Douglas or the presence of prolapsed structures
O Diagnostic assessment of patients with pelvic in the pouch of Douglas, retroverted uterus and hemoperito-
endometriosis neum.
O Study of tubal and ovarian physiology Emergency situations, such as acute pelvic inflammation
O Early diagnosis of extrauterine pregnancy or ectopic pregnancy with hemoperitoneum are not indica-
tions for TVE because the presence of adhesions or hemor-
O Visualization of the appendix rhage can severely impede visibility. Undoubtedly, TVE and,
Initially, bimanual vaginal examination and transvaginal ultra- in particular, transvaginal salpingoscopy are useful modalities
sound are performed to assess the position of the uterus for diagnostic purposes.
Fig. 14 Fig. 15 Fig. 16

Tubo-ovarian adhesion. Microadhesions. Microadhesions.
9.0 Anesthesia
Various authors have reported that this technique can be the maneuvers to visualize the pelvic organs are quite painful
performed under local anesthesia, suggesting a routine demanding for general anesthesia in the vast majority of
outpatient setting. Unfortunately, this is possible only in cases.
selected cases with a particularly high pain threshold since
10.0 Technique
Transvaginal endoscopy is usually performed from the cervix are infiltrated with 1.8 ml of local anesthetic (articaine
seventh day of the cycle onwards. After placing the patient 40 mg with epinephrine 0.006 mg/ml), and the posterior lip is
in dorsal lithotomy position and vaginal disinfection with then grasped with a Pozzi forceps and placed under traction.
aqueous chlorhexidine solution, the procedure commences At this point, a trocar needle system designed particularly for
with a diagnostic hysteroscopy. A 30-hysteroscope (diam. this technique is used; the device consists of a type of Veress
2.7 mm with a 3.5 mm-sheath) is introduced into the vagina. needle (length 25 cm) (Fig. 17), a dilator and an external trocar
The vaginal walls are gently expanded by continuous inflow of diameter 3.9 mm, which are put together before starting the
of normal saline solution up to a maximum pressure of procedure. The system is positioned in the midline 1015 mm
120 mmHg. After identification of the cervix, the hysteroscope below the insertion of the posterior vaginal wall on the cervix.
is introduced into the cervical canal and a traditional The release button of a trigger mechanism is actuated which
diagnostic hysteroscopy is performed. causes the Veress needle to penetrate the vaginal wall. This
modality reduces pain and allows the vagina to be perforated
To carry out TVE, after insertion of a Collin speculum in the without traction. Finally, the distal tip of the needle and
vagina, the posterior vaginal fornix and the posterior lip of the dilating sheath are located in the pouch of Douglas.
The Veress needle and dilating sheath are then removed

and the same endoscope used for diagnostic hysteroscopy
is introduced through the trocar. Once, the correct intra-
abdominal position of the hysteroscopes distal tip has been
visually confirmed, continuous flow of prewarmed saline
solution (37 C) can be started.
Unlike traditional laparoscopy, it is not possible to obtain a
panoramic view, so it is appropriate to proceed with imaging in
the standard manner. The examination begins with localizing
the posterior surface of the uterine corpus. The adnexae are
then visualized by on-axis rotation of the hysteroscope and
movements to the right and left. Once, the ovary and utero-
ovarian ligament have been identified, the tubal isthmus and
ampulla are identified and inspected gradually advancing
toward the fimbrial tubal portion. The posterior surface of the
uterine corpus serves as a guide for moving the endoscope to
the contralateral side where the same procedure is repeated. Fig. 17
Finally, the pouch of Douglas and uterosacral ligaments are Preparation of instrumentation used for transvaginal endoscopy.
thoroughly inspected (Figs. 1820).
Tubal patency is assessed similarly to traditional laparoscopy
by injection of methylene blue dye via a no. 14 Foley catheter
previously placed in the uterine cavity (Fig. 21).
Fig. 18 Fig. 19 Fig. 20

Posterior surface of the uterine corpus. Ovarian fossa. Surface of the ovary.
a b c
Figs. 21a-c
Chromopertubation.
11.0 Salpingoscopy
With sufficient experience in the technique, it is possible Inflow of saline is continued throughout the procedure as
to perform salpingoscopy of a few centimeters of the this allows the intestine and tubo-ovarian structures to
distal tubal segment. The ampulla and the proximal tubal remain floating. The volume of liquid required for distension
ostium are identified and the endoscope is then inserted. varies from 200 to 400 ml depending on the duration of
The infundibulum is easily identified by its characteristic the examination (average time 45 min). At the end of the
concentric folds. The endoscope is gradually advanced and, procedure, the liquid is evacuated via the trocar. The point of
as a result of the reduced inflow of saline, the ampulla is trocar insertion in the vaginal fornix rarely requires suturing,
distended until the longitudinal folds come into view. Visuali- unless there is bleeding.
zation of the folds and intra-tubal microanatomy is continued
while the endoscope is withdrawn slowly. Canalization of the
abdominal tubal ostium is easier in the post-ovulatory phase
when the fimbriae are more congested and stiff (Figs. 2224).
Fig. 22 Fig. 23 Fig. 24

Fimbriae. Infundibulum of the Fallopian tube. Major and minor folds.
12.0 Complications
The needle-dilator-trocar system used for TVE has been To keep to a minimum the potential risk of bleeding in the
specially designed to reduce to the minimum accidental vagina, it is advisable not to incise the vaginal mucosa but
injuries which may occur during insertion of the instrument. to insert the appropriate-sized needle directly, dilating the
Moreover, the use of this special TVE instrumentation set is vagina a second time and using a vasoconstricting agent
capable to prevent iatrogenically-induced sequelae, such in combination with the local anesthetic. In fact, minimal
as pelvic infections, rectal or intestinal perforation, bleeding bleeding can give rise to serious problems in terms of
of the vaginal fornix or injury of the posterior surface of the unimpeded vision, hence it follows that this complication
uterine corpus. should be avoided.
13.0 Post-operative Follow-up

The patient is informed of the possibility of watery or bloody mycin 500 mg/day for 3 days). The patient can be discharged
vaginal discharge and is advised not to use intra vaginal at the end of the procedure or when she has adequately
tampons and to abstain from sexual intercourse for one day. recovered from general anesthesia.
Prophylactic antibiotic medication is administered (azithro-
Recommended Reading
1. DURRUTY G, VERA C, MACAYA R, BIANCHI M, 5. GORDTS S, CAMPO R, BROSENS I: Microciruga
MANZUR A: Resultados de la salpingoneostoma endoscpica en medicina reproductiva. Cuadernos de
laparoscpica en infertilidad por hidrosalpinx. medicina reproductiva. Pellicer Antonio. Primera edicin.
Departamento de Obstetricia y Ginecologa, Unidad de Madrid (Espaa). 2002. 8 (1): 5572
Reproduccin Humana, Hospital Clinico Pontificio.
Universidad Catlica de Chile.Revista chilena de 6. HULKA and REICH: Textbook of laparoscopy. (USA).
obstetricia y ginecologa. Santiago (Chile). 2002. 67(6): 2002. (1): 285300
488493
2. GOMEL V: Reproductive surgery. Departament of 7. LEVINE R: Laparoscopic tubal Sterilization. A practical
Obstetrics and Ginecology. Faculty of Medicine. manual of Laparoscopy. A clinical Cook book. Kentucky
University of British Columbia. Vancouver (Canada). (USA). 2002. (1): 107114
2005. Minerva. 57:218
8. MARCONI G., VILELA M., GOMEZ RN, BUZZI J.,
3. GOMEL V, ZOUVES C: Laparoscopa quirrgica en las De ZUNIGA I, QUINTANA R: Salpingoscopia.
enfermedades de las trompas. Ciruga Laparoscpica Cuadernos de medicina reproductiva. Pellicer Antonio.
en Ginecologa. Soderstrom. Segunda edicin Marban. Primera edicin. Madrid (Espana). 2002. 8 (1): 213237
(Philadelphia) 1999. (1):8795.
4. GORDON AG: Tubal Endoscopy. Consultant 9. YOUNG E, VAN TRILLO: Hidrosalpinx e Infertilidad.
Gynaecologist, BUPA Hospital Hull and East Riding, Cuadernos de medicina reproductiva. Pellicer Antonio.
Lowfield Road, Anlaby,Hull HU10 7AZ. 2004 Primera edicin. (Madrid) 2002. 8 (1): 89100
Chapter VII
Techniques of Laparoscopic
Tubal Sterilization
Emmanuel Lugo and Luca Mencaglia
1.0 Introduction
Female surgical sterilization is the most widely employed methods, all of the abdominal cavity can be visualized
method of family planning in the world and the laparo- panoramically and the procedure is usually performed as
scopic technique is currently used the most. The historical day surgery. In most cases, the period of convalescence is
development of this technique dates from the 1970s with short, which explains the widespread patient acceptance
Rioux and Corson. After that came Kleppinger (bipolar), Lay of laparoscopic techniques. Anesthesia is normally general,
and Yoon (silastic rubber ring), Hulka and Clemens (plastic especially in industrialized countries. In a few cases, patients
clip), Semm (endocoagulator), up to Filshie who in 1996 receive spinal and/or epidural anesthesia. The best form of
suggested the use of a titanium clip with a silicone rubber anesthesia is certainly local anesthesia since it is safer, more
lining and a kind of memory function. Basically, all the economical and without late effects, and can be combined
laparoscopic techniques are simple, they do not leave with a sedative and antiemetic.
an external scar, the costs are lower compared to other
2.0 Patient Selection

Potential candidates for tubal sterilization are women who any other major gynecologic disease. According to the
want an irreversible method of contraception or those for whom literature, the main contraindications relating to the technique
pregnancy itself constitutes a risk factor of potential clinical are adhesions following multiple laparotomies, severe
significance. The sterilization procedure can be performed obesity, previous history of peritonitis or salpingitis and any
during or outside the postnatal period. Today, clinicians other pelvic disease. Ileus and large abdominal tumors are
have the choice among a wide range of endoscopic tech- reported in association with a high rate of complications and
niques and it is possible to choose the most suitable time failures. Severe cardiopulmonary disease or dysfunction can
for sterilization. There are a few contraindications, obviously be generic contraindications to tubal sterilization and to the
apart from the presence of a gynecologic malignancy or creation of a pneumoperitoneum.

The patient should be placed in gynecologic position with Laparoscopic tubal sterilization is normally performed via
the legs positioned so as not to interfere with maneuvers the following three ports:
performed through the lateral trocar ports. An uterine O periumbilical primary port, for laparoscope and video
manipulator should be used to facilitate vision and exposure camera
of the fallopian tubes. The Trendelenburg position makes
the procedure easier. O two other lateral ports in the lower quadrant of the
abdomen, used for grasping forceps holding the tube and
the instrument required for tubal sterilization. The trocar
size varies according to the instruments required.
4.0 Instrumentation
O 5 mm laparoscope and videocamera O 5 mm atraumatic grasping forceps
O Insufflator O 5 mm scissors
O Electrosurgical unit
O Xenon light source
O Suction/irrigation system for irrigation and
O 6 mm trocar hydrodissection
O Veress needle O Uterine manipulator
5.0 Technique
There are various techniques of tubal sterilization, which or laparoscopy approach has been found to account for
employ electricity, heat or mechanical devices. Surgical recanalization in up to 4% of cases. For this reason, mere
interruption of the tubes by transection via a laparotomy transection with scissors is not recommended.
5.1 Unipolar Electrocoagulation

This is probably the most widely employed method and has a tissue between the jaws of the forceps. The tissue damage
very low failure rate. A panoramic view of the operating field extends 0.5 1 cm laterally. The tube becomes whitish and
is imperative before proceeding to sterilization. A distorted the passage of electrons through the tissue leads to cellular
video image and the loss of overall vision that can occur if the vaporization and creates a clean cutting effect.
distal lens of the laparoscope is too close to the operating field
can confuse even the most experienced laparoscopist. After It is appropriate to coagulate about 3 cm of tube. Further
removing the intestine from the operating field, the junction applications are frequently required to achieve this effect;
zone between the proximal and midtubal segments is grasped they should be toward the medial part of the tube, that is, in
to dislodge it from the pelvic cavity toward the anterior the direction of the uterine body to avoid electrical injury to
abdominal wall. Once, the fimbriae have been visualized the bowel close to the distal segment or tubal fimbriae.
and the forceps is in correct position, the electrosurgical unit
can be connected (Fig. 1) to the grasping forceps (Fig. 2), a The tube must be viewed from all sides to confirm that coagu-
precaution that prevents inadvertent pedal activation, which lation is appropriate. Missed spots in the coagulated target
might cause electrical injury to a vital intra-abdominal organ. area can be coagulated again. At least 0.5 cm of the adjacent
In general, a power of 50 W is sufficient to induce complete mesosalpinx should also be coagulated, thus cutting off the
tubal occlusion by unipolar electrocoagulation of the tubal vascular supply.
Fig. 1 Fig. 2
The high frequency electrosurgical unit AUTOCON II 400, Grasping forceps.
Fig. 3 Fig. 4
Various types of bipolar forceps. Point where sterilization is performed using bipolar high frequency
current.
5.2 Bipolar Electrocoagulation

The principles of the bipolar mode represent an extremely The isthmic tubal portion must be grasped with the bipolar
important element in techniques of female sterilization. Even if forceps (Fig. 3) approximately 2 cm from the uterine cornu
the macroscopic appearance of a tube coagulated by bipolar (Fig. 4) so as not to cause injury to the uterine corpus. The
energy can appear the same as that coagulated by means HF electrosurgical unit should be set to a power no greater
of unipolar energy, it must be considered that the depth of than 25 W using direct current. 2 or 3 applications are often
destruction and lateral extension of the thermal trauma is required to achieve coagulation of a 3 cm tubal segment.
certainly reduced, so the maneuver has to be performed In the literature there is still controversy whether or not to
for a longer time to achieve the same effect. In reality, the transect the tube following coagulation.
outcome of any method of electrocoagulation, unipolar or
bipolar, depends more on the length of the tubal segment
destroyed than on the number of applications. Most authors
consider that coagulation of a tubal segment of at least 3 cm
is necessary.
5.3 Thermal Sterilization

The Waters instrument is used for thermal sterilization or real Another instrument, suggested by Kurt Semm, is called
cauterization. This is a thermal hook, which resembles the the Semm Endotherm. This consists of a type of forceps
resistance of a toaster, sheathed in a heat-resistant plastic coated with Teflon, which produces a temperature of
protector. The hook is used to grasp the tube and pull it 120 C to 160 C and performs cauterization of the tubal
inside the plastic protector where the energy can be activated segment during an exposure time of 6090 seconds. The
to induce thermal damage to the tissue. However, the extent area of thermal injury is limited to the width of the forceps so
of tissue destruction is less than 1 cm. repeated applications are required to achieve coagulation of
2 to 3 cm of tube.
5.4 Mechanical Devices

Tubal sterilization with Yoon rings Various complications have been reported with this technique,
Inbae Yoon first published successful occlusion of the the majority associated with possible injury to the posterior
fallopian tubes using a silastic ring in 1974. This technique mesosalpinx and with hemorrhage. Rigid or large tubes can
was then adapted to operative laparoscopy with an applicator be divided by the applicator and bleed. The bleeding can be
8 mm in diameter, which allows a tubal segment to be lifted controlled with bipolar coagulation.
up with a pronged forceps inside the applicator sheath and
the silastic ring to be put on (Figs. 57).

Tubal sterilization with Yoon rings. Detailed view of the site of tubal Methylene blue test following tubal
sterilization with Yoon rings. sterilization.
Sterilization with Clips

This method offers the greatest reversibility since only a
few millimeters (Fig. 8) of the tube are damaged, if properly
applied in the isthmic portion. Therefore, the technique can
be recommended in women under 30 years who request
sterilization. The clips that have proven effective are Filshie
and Hulka-Clemens clips. The Filshie clips are made of
titanium coated on the inside with silicone, while the Hulka-
Clemens clips are made of 3 mm Lexan plastic with jaws
articulated by a small metal spring.
An operative laparoscope designed for clip application is
available although the clip can be applied through a second
port using an applicator. Application through a second port
also facilitates exposure, rotating from one side to the other.
The clip must be applied at an angle of 90 in the isthmic
tubal segment 2 or 3 cm from the uterine cornu. Application
of the clip to a different part of the tube can be ineffective Fig. 8
Hulka-Clemens clip.
due to the diameter of the tubal lumen which may not be
occluded completely while pinched between the jaws of the
clip. Following application, the clip remains closed owing
to a spring mechanism. It is always necessary to reconfirm
proper placement of the clip. If residual tubal patency is
suspected, a second clip should be applied.
6.0 Postoperative Care

The patients are usually discharged 2 to 6 hours after the
surgical procedure. It is advisable to give postoperative
analgesia to prevent pain due to acute necrosis of the tissue
following ring / clip application.
Recommended Reading
1. HULKA AND REICH: Textbook of laparoscopy. (USA). 3. SODERSTROM M. RICHARD, RIOUX JACQUES:
2002. (1): 285300 Esterilizacin laparoscpica. Ciruga laparoscpica en
ginecologa. Philadelphia (USA).1999. (1): 183196
2. LEVINE RONALD: Laparoscopic tubal Sterilization. A
practical manual of Laparoscopy. A clinical Cook book.
Kentucky (USA). 2002. (1): 107114
Chapter VIII
Laparoscopic Tubal Surgery
Emmanuel Lugo and Luca Mencaglia
104 Manual of Gynecologic Laparoscopic Surgery
1.0 Introduction
The most recent technical developments provide surgeons between 37 and 43 years. Moreover, the indication for laparos-
working in the field of infertility with ever more sophisti- copic tubal reconstructive surgery is inversely proportional to
cated and effective methods of surgical reconstruction the extent and severity of the tubal damage. In other words,
including endoscopic procedures. On the other hand, the typical patient for surgical laparoscopy will be young,
it should be borne in mind that the outcomes of assisted with tubal damage of modest degree and preferably located
reproduction technology (ART) procedures are improving distally. However, it should be noted that adequate decision-
constantly, raising the question of whether surgical repair of making often calls for diagnostic laparoscopy in view of the
a tubal defect may be useful. In practice, if tubal damage is inherent limitations of other diagnostic techniques such as
suspected or confirmed, it is necessary to decide whether to hysterosalpingography or transvaginal ultrasound, which
directly proceed to ART procedures or to diagnostic laparos- do not allow definitive assessment in the majority of cases.
copy and endoscopic surgical treatment of confirmed tubal Another crucial factor influencing the choice between recon-
infertility. This decision is influenced by a range of secondary structive tubal surgery and ART procedures is the logistical
factors, such as the patients age, presence of other and economic factor, since the latter requires the patient to
pathology or changes in semen quality. Younger patients with be close to specialized and highly reliable centers, where the
distal tubal occlusion should consider surgery first and then costs are usually high.
ART, whereas ART procedures should start directly in women
2.0 Preoperative Assessment

The diagnostic follow-up in couples with infertility problems more than 20% of cases. In all infertile women, cervical
must be performed within a short time and should be and vaginal swabs are advisable to detect the presence of
as non-invasive as possible for emotional reasons. They micro-organisms commonly responsible for pelvic inflam-
should include a complete clinical history, transvaginal matory disease such as Chlamydia trachomatis, Neisseria
ultrasound with sonohysterosalpingography and diagnostic gonorrheae and Mycoplasma hominis.
hysteroscopy with the goal of assessing the uterine cavity Diagnostic laparoscopy should be performed in all patients
accurately. with a high probability of pelvic or tubal pathology.
The possible presence of pelvic inflammatory disease (PID)
should be considered; this can lead to tubal infertility in

The classical position for gynecologic laparoscopy is surgeon. Two accessory 6-mm trocar ports are usually
lithotomy with uterine manipulator, including the option to required, one in each lower abdominal quadrant.
change to the Trendelenburg position if required by the
4.0 Instrumentation
O 5-mm or 10-mm laparoscope and video camera O 5-mm scissors
O Laparoinsufflator O Suction/irrigation system for irrigation and
O Electrosurgical unit hydrodissection
O Xenon light source O Bipolar forceps
O 6-mm or 11-mm trocars
O Veress needle O Laparoscopic suturing instruments
O 5-mm atraumatic grasping forceps O Uterine manipulator
Fig. 2 Fig. 3
Dense pelvic adhesions. Hydrosalpinx and ovarian cyst.
Fig. 4 Fig. 5
Large hydrosalpinx. Lysis of uterine adhesions can cause bleeding.
Fig. 6 Fig. 7
Preparation for chromopertubation. Chromopertubation.
Fig. 12 Fig. 13
Periovarian adhesions. Adhesiolysis by use of scissors.
Following complete lysis of adhesions, the tubo-ovarian through the trocar cannula which is left in place until the
abscess must be aspirated and drained (Figs. 1213). aspirated liquid is completely clear. Assessment of the tube
Aspiration is performed with a laparoscopic suction tube or will permit a decision on whether or not removal is indicated.
by introducing a 510 mm trocar through the abdominal wall, At the end of the procedure, it is important to introduce a
perforating the wall of the abscess and aspirating it through drain (e.g., Jackson-Pratt) into the pelvis. The drain should be
the trocar. Once the purulent liquid has been completely removed 24 to 48 h after the operation.
evacuated, copious lavage is performed with Ringer lactate
7.0 Reconstructive Laparoscopic Tubal Surgery

The fallopian tubes can be occluded proximally or distally, salpingitis isthmica nodosa and/or genital tuberculosis, which
i.e., at the fimbrial ends. The condition can coexist with by definition is associated with severe tubal damage, rule
peri-adnexal adhesions. Tubal blockage can also be out the option of reconstructive laparoscopic surgery, mainly
correlated with an inflammatory process or a medical history because they are considered to have a poor prognosis
of surgical interruption. Reconstructive surgery is feasible regarding the predictable degree of functional recovery (Figs.
only in cases of a minor, circumscribed damage, and if 1415).
possible, not bilateral. Some pathological findings, such as
Fig. 14 Fig. 15
Salpingitis isthmica nodosa. Uterine tuberculosis.
7.1 Fimbrioplasty
Fimbrial phimosis (agglutination of the fimbriae) often coexists gradually opening the jaws. The maneuver must be repeated
with peri-adnexal adhesions and is repaired by laparoscopy. several times, changing the direction in which the forceps is
The intrauterine pregnancy rate after laparoscopic opened. Manipulation of the tissues must be very gentle to
fimbrioplasty varies between 40% and 48% depending on avoid bleeding (Figs. 1622).
its severity and extent, with an extrauterine pregnancy rate Rarely, even though the fimbrial ends appear normal, proximal
ranging between 5% and 6%. In cases where the mucosal stenosis can be found at the abdominal opening of the tube
folds are densely adherent or in the presence of ampullary (prefimbrial phimosis). This stenosis can be diagnosed by
mucosal adhesions, the prognosis is very poor. chromopertubation only. The surgical management involves
The principle of fimbrioplasty is anatomical and functional dissecting along the antimesenteric border of the tube from
repair of the infundibulum. To visualize the phimotic region, the fimbriae as far as the distal ampulla, traversing the area
it is often necessary to perform perioperative chromo- of stenosis. Dissection is performed by use of electrosurgery.
pertubation to distend the tube. Surgical repair can be As a final step, the site of repair is sutured with a very fine
achieved with a fine atraumatic grasping forceps, introducing suture (6/0).
the closed tip into the area of phimosis extremely careful and
Fig. 16 Fig. 17 Fig. 18

Introduction of forceps into the phimotic Opening the jaws of the forceps. Normal appearance of the abdominal tubal
ostium of the tube. ostium at the end of the procedure.
Fig. 19 Fig. 20
Hydrosalpinx with fimbrial phimosis. Methylene blue injection for perioperative chromopertubation.
The management of hydrosalpinx is based essentially on the Once adnexal adhesiolysis has been completed, the tube
quality of the tubal mucosa: should be distended by transcervical instillation of methylene
blue dye using the uterine manipulator. In the area of
O For thin-walled hydrosalpinx with normal mucosa and
occlusion, scar tissue can frequently be found. The target site
without mucosal adhesions, salpingostomy via the laparo-
of the cross- or star-shaped neo-ostium should be located at
scopic approach is indicated. The majority of pregnancies
the thinnest and most avascular area possible, which usually
occur within the first year post-operatively.
corresponds to the original site of the ostium. The cruciate
O For thin-walled hydrosalpinx with focal adhesions, either incision at this level is made using scissors, electrosurgery
reconstructive surgery or ART procedures are indicated. or by laser application with the aim of creating eversion of
Reconstructive surgery in these cases is associated with an the mucosa of the distal tubal portion. Closed atraumatic
increase in the risk of extrauterine pregnancy. grasping forceps can be introduced in the opening to gently
incise the margins of the neo-ostium. To make the margins
O For thin-walled hydrosalpinx with extensive mucosal evert properly, fine bipolar forceps may be used at low current
adhesions (> 50% of the mucosal folds), ART procedures setting; this is performed by touching the serosa at the base
only are indicated, more specifically in vitro fertilization. of the margins previously created to induce shrinking and
Many authors, including ourselves, regard it as appropriate simultaneous eversion. If the tubal wall is thick, sero-serous
in these cases to perform laparoscopic salpingectomy sutures can be placed alternatively with atraumatic sutures
because this has been found to considerably improve the (Vicryl 57/0).
outcomes of ART.
In conclusion, the surgical procedure to create a neo-ostium
In the presence of adnexal adhesions, diagnostic laparo- involves two steps, incision and eversion:
scopy is followed by adhesiolysis with gentle maneuvers
using closed atraumatic forceps in the case of filmy and
O To create the neo-ostium, two to four 12 cm incisions
avascular adhesions; if they are dense and vascular, it is are made parallel to the longitudinal mucosal folds, in an
advisable to use bipolar coagulation and scissors. The avascular area.
tubo-ovarian ligaments must be exposed to confirm patency O Eversion is obtained with various techniques, such as
of the fimbriated tubal portion. If the tube is fixed to the ovary, bipolar coagulation of the serosa or placement of a few
the two structures must be separated. sutures.
7.3 Tubo-tubal Anastomosis

True pathological occlusion of the proximal tube necessitates The proximal end of the tube is distended by means of
a microsurgical procedure with tubo-cornual re-anasto- transcervical injection of methylene blue, which facilitates
mosis, which can be performed laparoscopically. Laparo- localization of the occluded segment of the proximal tube. At
scopic techniques of tubal anastomosis have recently been this point, a cut is made at the level of the occlusion using
described in patients who had a previous history of tubal laparoscopic scissors. It is very important to avoid damage
sterilization. The image magnification properties of video- to mesosalingeal vessels. The tubal segment is separated
endoscopy and the unique angles of vision offered by modern from the mesosalpinx by electrosurgery. Hemostasis of the
laparoscopes, together with the option of bringing the video tubal segment of tube is accomplished by electrocoagulation
image close to the operating field, provides advantages (microelectrode) of the most important bleeding points.
superior to traditional microsurgery. Continuous irrigation allows even small bleeding points to
The major application of laparoscopic microsurgery is be visualized rapidly. The distal tubal segment is prepared
tubo-tubal anastomosis regardless of its site and regardless in a similar way so that there is no difference or asymmetry
of whether it is done because of the presence of occlusion or between the two stumps to be anastomosed. In this case,
to reverse previous tubal sterilization. The surgical technique too, transcervical instillation of methylene blue can be used
of tubo-tubal anastomosis does not vary from the laparotomy to facilitate delineating the margins. The two stumps are then
approach with a traditional microscope. In the case of approximated and sutured in two layers. The first layer joins
adhesions, salpingo-ovariolysis is first performed. This is the endotubal epithelium and muscle and the second joins
followed by infiltration of the mesosalpinx in the area chosen the serosa. The distal suture must be placed at the antimes-
for the anastomosis with 1 or 2 ml of a solution of vasopressin enteric border, and can be placed perfectly on the other
to reduce bleeding and facilitate accurate hemostasis. stump also.
Recommended Reading
1. DURRUTY G, VERA C, MACAYA R, BIANCHI M, 4. GORDON A G: Tubal Endoscopy. Consultant
MANZUR A: Resultados de la salpingoneostoma Gynaecologist, BUPA Hospital Hull and East Riding,
laparoscpica en infertilidad por hidrosalpinx. Lowfield Road, Anlaby, Hull HU10 7AZ. 2004
Departamento de Obstetricia y Ginecologa, Unidad de
5. HULKA and REICH: Textbook of laparoscopy. (USA).
Reproduccin Humana, Hospital Clinico Pontificio.
2002. (1): 285300
Universidad Catlica de Chile. Revista chilena de
obstetricia y ginecologa. Santiago (Chile). 2002. 67(6): 6. MARCONI G, VILELA M, GOMEZ RUEDA N, BUZZI J,
488493 DE ZUNIGA I, QUINTANA R: Salpingoscopia.
Cuadernos de medicina reproductiva. Pellicer Antonio.
2. GOMEL V: Reproductive surgery. Departament of
Primera edicin. Madrid (Espana). 2002. 8 (1): 213237
Obstetrics and Ginecology. Faculty of Medicine.
University of British Columbia. Vancouver (Canada). 7. YOUNG E, VAN TRILLO: Hidrosalpinx e Infertilidad.
2005. Minerva. 57:218 Cuadernos de medicina reproductiva. Pellicer Antonio.
Primera edicin. (Madrid) 2002. 8 (1): 89100
3. GOMEL V, ZOUVES CG: Laparoscopa quirrgica en las
enfermedades de las trompas. Ciruga Laparoscpica
en Ginecologa. Soderstrom. Segunda edicin Marban.
(Philadelphia) 1999. (1):8795.
Chapter IX
Laparoscopic Management
of Ectopic Pregnancy
Cristiana Barbosa and Luca Mencaglia
1.0 Introduction
Implantation of the zygote outside the uterus occurs in
approximately 1 in 200 pregnancies and the incidence
appears to be increasing. This increase in ectopic pregnancy
correlates with the high incidence of sexually transmitted
disease, delayed median age of first pregnancy and improved
accuracy of diagnosis.
The most common site of ectopic pregnancy is at the
ampullary tubal portion where fertilization normally occurs
(Fig. 1) and then, less frequently, other parts of the tube, the
cervix, the ovary and the abdominal cavity.
All variants of extrauterine pregnancy can be treated by
a minimally invasive approach in the majority of cases. In
the last decade, laparoscopic surgery has become very
widespread in both gynecology and general surgery. The
main advantages of the minimally invasive approach are
reduced postoperative morbidity, less postoperative pain,
and accordingly, less analgesic medication, early resumption Fig. 1
of intestinal activity, reduced length of hospital stay and a Ectopic gestation in the ampullary tubal segment.
rapid return to normal activity.

The clinical picture includes nausea, amenorrhea, lower should raise the suspicion of extrauterine pregnancy. The
abdominal pain, cramps and abnormal uterine bleeding. most recent generation of ultrasound allows visualization
Pain in the shoulder raises the suspicion of tubal rupture with and localization of the gestational sac before the sixth week
hemoperitoneum. Diagnostic preoperative assessment must in 98% of cases. The presence or absence of a gestational
include the history and bimanual gynecologic examination sac on transvaginal ultrasound should be correlated with the
(which is able to diagnose an adnexal mass in 50% of pregnancy week and the serum levels of beta-HCG.
cases). However, early diagnosis of ectopic pregnancy can Other useful tests in diagnosing ectopic pregnancy are:
be made with the combination of transvaginal ultrasound endometrial thickness (cut off < 8mm), sonohysterography,
and measurement of the serum beta-HCG. The sensitivity color Doppler and blood progesterone level (cut off 17.5 ng/
of beta-HCG allows the diagnosis to be made only 1015 ml). Unfortunately, progesterone is not of use in patients who
days after ovulation. The growth curve of this hormone is have undergone induction of ovulation.
abnormal in 46% of patients. A delayed increase in beta-HCG
3.0 Positioning of the Patient

The patient is positioned on the table in the classic gyneco- 5 mm-or 10 mm-laparoscope with the primary trocar intro-
logic position. An intrauterine manipulator and Foley bladder duced at the umbilicus. Two accessory 6 mm-ports in the
catheter can be used. right and left iliac fossa and a 6 mm suprapubic port for the
grasping forceps, bipolar forceps and suction cannula.
4.0 Instrumentation
Laparoscope, diameter 5 mm or 10 mm Atraumatic grasping forceps
Videocamera Scissors
Microprocessor-controlled insufflation system Suction and irrigation system
Electrosurgical unit Monopolar hook electrode
Xenon cold light source Bipolar forceps
Trocars, diameter 6 mm or 11 mm Disposable extraction bag
Veress needle Uterine manipulator
5.0 Surgical Technique

5.1 Evacuation of the Hemoperitoneum
A 5 mm suction cannula is usually sufficient for evacuating The surgical management essentially involves partial or total
the hemoperitoneum. If the tube has ruptured and/or the salpingectomy, however, depending on each individual case,
patient is in shock with a large hemoperitoneum, an 11 mm- preservation of the organ may well be the approach of choice.
trocar may be used to introduce the suction tube.
5.2 Salpingectomy
Extensive tubal dilatation is not necessarily an absolute requesting sterilization, in the case of persistent bleeding
contraindication to laparoscopic treatment. Unilateral or after salpingotomy, when the beta HCG > 100,000 mU/ml, in
bilateral adhesiolysis is often performed in the same setting. the case of recurrent tubal pregnancy and in the case of tubal
Salpingectomy is the method of choice in women who pregnancy > 5 cm.
abandoned the desire for future pregnancies or in the case Following evacuation of the hemoperitoneum, the bipolar
of tubal rupture. Other indications for salpingectomy are forceps and scissors are introduced into the abdominal cavity
extrauterine pregnancy following failed sterilization, in a to coagulate and dissect the tube and mesosalpinx (Figs.
blocked tube, in a previously reconstructed tube, in a woman 2, 3).
Fig. 2 Fig. 3
Electrocoagulation of the tube and mesosalpinx. Electrosurgical dissection of the mesosalpinx.
The tube containing the gestational sac is then removed from the laparoscope, final inspection of the abdominal cavity is
the peritoneal cavity through the 11 mm-umbilical port with recommended because in some cases, while grasping the
the aid of forceps located in the suprapubic port. However, tube for removal, the product of conception may slip out
it is preferable to use an endobag for removing the tube unnoticed which requires either aspiration with a suction tube
and product of conception (Fig. 10). After reinsertion of or extraction by use of forceps.
Because of its high metabolic rate, the trophoblast requires is often easier to make a small incision for evacuation of a
oxygen and the cells cannot withstand anoxia. It is most distinct, large-sized intraluminal ectopic pregnancy of friable
probable that vasopressin, by reducing the oxygen supply consistency, compared to one of small size and poorly
for about an hour, has fatal consequences for the trophoblast visible in the thickness of the tubal wall. The preferred route
that has inadvertently left behind, reducing by a factor of five for removing the product of conception with or without the
the 15% risk of persistence of ectopic pregnancy in the case tube is through the 11-mm umbilical port. Alternatively, it can
of conservative salpingotomy. Use of vasopressin is contrain- be reduced piecemeal by use of a biopsy forceps or suction
dicated in patients with ischemic heart disease. cannula. In a few cases, it is advisable to use an extraction
bag for removing the product of conception.
Incision and evacuation: with an unipolar knife electrode
introduced through the 6 mm port, a 12 cm incision is The salpingotomy incision usually does not require suturing.
made in the antimesenteric tubal wall at the site of maximum Seromuscular suturing will be necessary only if the incision is
distension, using a cutting or blended current (20 or 70 W). very large or in the case of mucosal eversion.
In general, it is possible to identify the different layers of the
tubal wall: serosa, muscularis externa and mucosa. Hemostasis: if there is bleeding from the incision margins or
site of implantation, hemostatic tamponade can be applied
If the product of conception cannot be localized when the with grasping forceps prior to electrocoagulation, laser appli-
serosa is incised at the point of maximum dilation, it will cation or placing a suture. Often, 5 minutes of compression
be necessary to incise the still intact muscularis externa are sufficient for hemostasis. Even elevating the adnexa out
and mucosa to advance to the lumen of the tube. Once the of the pelvis can produce the same result as by compressing
ectopic pregnancy, which is usually of very friable consis- the vessels of the mesosalpinx.
tency, has been identified, it can be evacuated by aspiration.
If a mass surrounded by clot is encountered, the product of Arterial bleeding can be present after removal of blood clot.
conception must be delivered through the tubal incision with In this case, the best hemostatic effect can be achieved by
the aid of pressurized irrigation or with grasping or biopsy selective and targeted use of bipolar coagulation forceps,
forceps (Figs. 410). particularly if combined with continuous irrigation. Diffuse
venous bleeding, especially from the site of implantation in
The site of implantation and the tubal incision are then the muscle layer in the case of extraluminal location, can be
irrigated, making sure that the liquid introduced through the controlled readily with electrocoagulation. The superficial
salpingotomy incision drains from the fimbrial end and vice eschar in the extraluminal space does not interfere with
versa. normal healing of the tubal epithelium.
Transcervical instillation of methylene blue will allow demon-
Following removal of an ampullary pregnancy, uncontrollable
stration of tubal patency.
bleeding can occur. In such cases, an endoloop may be used,
It should be borne in mind that when the ectopic pregnancy is which is removed after 510 minutes; this makes it possible
located in the extraluminal space, it is possible that the tubal to localize and coagulate the source of bleeding. In severe
surface exhibits dilation without intraluminal involvement. It cases, the mesosalpingeal vessels can be ligated selectively.
Fig. 9 Fig. 10
Linear incision. Removal of the product of conception.
5.4 Partial Salpingectomy

Partial laparoscopic salpingectomy can be attempted to the tube and corresponding mesosalpinx with subsequent
preserve the tube in the case of failed salpingotomy, tubal removal of the tubal segment through the umbilical port.
rupture, isthmic pregnancy, distal interstitial pregnancy or Alternatively, to avoid thermal (but not ischemic) injury,
recurrent tubal pregnancy. two endoloops, and if required, bipolar coagulation can be
The procedure involves coagulation with bipolar forceps applied to complete hemostasis.
followed by division of both ends of the distended part of
5.5 Extirpation of Tubal Pregnancy through the Fimbrial End

Extirpation of the tubal pregnancy through the fimbrial end, authors have reported excellent results when the pregnancy
tubal aspiration or tubal abortion without salpingotomy are is located in the fimbrial portion, these techniques are not
procedures that involve removal of the product of conception commonly recommended, neither by way of laparoscopy nor
located at the fimbrial end or distal tubal segment. This by laparotomy.
is accomplished by aspiration or use of grasping forceps The technique may be applied in selected cases of intra-
operating from inside or outside, gently pushing the product luminal ectopic pregnancy not yet visible (invasion of the
of conception until it is extruded. In certain cases tubal muscularis and serosa has not yet occurred) by introducing
abortion has already occurred. the suction tip into the tube from the distal ostium and
Since many ectopic pregnancies have actually not implanted instillation of liquid, that acts mechanically to dislodge and
in the intraluminal tubal portion, this type of procedure is often expel the product of conception into the peritoneal cavity
associated with incomplete removal of the trophoblast and eliminating the need for making an incision in the tubal wall.
damage to the tubal wall. For this reason, even though some
5.6 Extraluminal Ectopic Pregnancy

This occurs when the ectopic gestation while growing rapidly Occasionally, it is possible to infiltrate 360 of the space
infiltrates the tubal wall until occupying the space between between serosa and muscularis. In this case, after removing
the muscularis externa and serosa. In the majority of cases, the trophoblast and achieving hemostasis with the aid of
as soon as the serosa is incised at the point of maximum compression or electrocoagulation, the surgeon canconclude
distension, the gestational sac slips out without the need to the operation and follow the patient carefully with serial beta
enlarge the opening. Irrigation in this case will not produce HCG measurements. Methotrexate can be considered as
a flow of liquid from the distal part of the tube. Rarely, the possible adjuvant treatment.
surgeon will be faced with the dilemma of having to enter the
tubal lumen which should be avoided as much as possible.
5.7 Interstitial or Cornual Ectopic Pregnancy

Interstitial ectopic pregnancy can be treated laparoscopically In both laparotomy and laparoscopy, the approach is
by electrosurgical resection of the uterine cornu. This proce- piecemeal resection of the uterine cornu using cutting or
dure will allow the greater part of the tube to be preserved blend current (Figs. 1014). The technique is very similar to
on the one hand, but on the other hand, the complete myoma removal. Hemostasis must be obtained with bipolar
destruction of the interstitial part will make it highly probable coagulation and hydrodissection of the tissue planes using
that any anastomosis will fail. Coagulation of the ascending pressurized normal saline.
branch of the uterine artery and utero-ovarian arteries can be
necessary to achieve good hemostasis. Use of vasopressin is
not considered in this case.
Fig. 11 Fig. 12
Laparoscopic view of cornual pregnancy. The cornual pregnancy is incised with an unipolar needle electrode.
Fig. 13 Fig. 14
Expressing a cornual pregnancy with two forceps. Appearance after removal of the cornual pregnancy.
Rupture of a tubal pregnancy has always been considered a The laparoscopic bipolar forceps is capable of coagulating
contraindication to the laparoscopic approach even though even large uterine or ovarian vessels. Alternatively, ligature
removal of a ruptured tube can be accomplished easily with an endoloop may be employed. After achieving
with bipolar coagulation. There is controversy about the hemostasis, the tube or part of it is removed. Rupture of
management of patients with hemodynamic instability. In an interstitial pregnancy may also be treated with simple
this case, hemorrhage must be arrested at once and the tube coagulation of the uterine and ovarian vessels but this
removed as quickly as possible. The majority of surgeons approach is associated with a higher risk of persistent and
prefer to manage the situation by emergency laparotomy. recurrent ectopic pregnancy.
5.8 Ectopic Ovarian Pregnancy

Ectopic ovarian pregnancy, when diagnosed, must be treated on laparoscopy. With monopolar forceps, the ovarian surface
like any ovarian cyst of unknown origin and must therefore is incised along its major axis at the point where the neofor-
be enucleated intact through a small incision in the ovarian mation appears most superficial. The trophoblastic material
cortex. Ovarian function usually remains unchanged. An can then be dissected and removed, using a suction/irrigation
ovarian pregnancy should be suspected when the serum system. The gestational sac is usually removed as a whole
levels of beta HCG exceed 6000 mU/ml, ultrasound shows an and suturing of the ovarian parenchyma is not necessary.
empty endometrial cavity and tubal pregnancy is not found
5.9 Ectopic Abdominal Pregnancy

Ectopic abdominal pregnancy is a rare event and accounts can be treated readily by laparoscopy if this is done early and
for 1.1% of all ectopic pregnancies. Since it is a condition if the pregnancy does not involve vascular structures that
with high maternal and fetal morbidity and mortality, early can cause uncontrollable bleeding. In the case of abdominal
diagnosis using transvaginal ultrasound, magnetic resonance pregnancy with a live fetus, the approach must be by
imaging and laparoscopy is essential. It is a condition that laparotomy.
6.0 Methotrexate
In selected cases, medical treatment with methotrexate previous surgery, diffuse adhesions, contraindications to
can be as effective as laparoscopic surgery. However, the anesthesia, cornual pregnancy or failure of surgical treatment.
possible side effects associated with methotrexate therapy Medical treatment is indicated if the levels of beta HCG are
can adversely affect patient compliance to a higher degree between 5000 and 10000 mU/ml and the diameter of the
than the surgical treatment option. As regards infertility, adnexal swelling is less than 4 cm. Methotrexate should be
the prognosis after ectopic pregnancy does not appear administered locally or systemically by intramuscular injection
to correlate with the characteristics of the extrauterine of 1 mg/kg or 50 mg/m2. Patients with a hematocrit < 35%
pregnancy but rather with the patients age and medical should take ferrous sulfate 325 mg twice daily.
history. Medical treatment is to be preferred in patients with
7.0 Postoperative Follow-up Care

Patients may be discharged a few hours after the surgery. to exclude the persistence of trophoblastic tissue. If the level
The bladder catheter is removed at the end of the operation. is not below 20 mU/ml, the test is repeated two weeks later
Antibiotic medication should be administered postoperatively. and if it is still positive, the patient should undergo further
The first serum beta-HCG test is performed on the second medical or surgical treatment. Persistent trophoblastic tissue
day and the reduction compared to the preoperative value can be treated successfully with methotrexate, ensuring that
should be at least 70%. The test is repeated after seven days any anemia present is treated preventively.
Chapter X
Laparoscopic Surgery for
Symptomatic Endometriosis
Luca Mencaglia1, Arnaud Wattiez2 and Sabina Consigli1
1
2
Strasbourg University Hospital, Strasbourg, France
1.0 Laparoscopic Surgery for Symptomatic Endometriosis

Introduction
Endometriosis is the presence of endometrial glands and treatment, many variables must be considered, such as age
stroma in an heterotopic location. Endometriosis is a of the patients, extent of disease, degree of symptoms, and
progressive, debilitating disease that affects 1015% of desire for immediate or deferred fertility. In most instances the
women during their reproductive years. Among gyneco- indications for therapy include pain or infertility or both, and
lo gical disorders, endometriosis is second only after the treatment may be surgical or medical, or a combination
uterine myomas in frequency, and accounts for 25% of all of both.
laparotomies performed by gynecologists. In the planning of

The diagnosis of endometrioma is revealed by the presence the aid of laparoscopy and histological examination of biopsy
of ovarian cyst fluid that can be suspected by transvaginal specimens. Unfortunately, blood serum levels of anti-endo-
and transabdominal ultrasound (TU) and physical metrial antibodies, placental proteins PP 14 and CA 125
examination. The most common symptoms are infertility marker do not have sufficient sensibility or specificity to be
and/or pelvic pain which should facilitate establishing routinely used for diagnostic evaluation. Diagnostic preope-
the final diagnosis. However, the diagnosis of peritoneal rative examination must include in all patients a thorough
endometriosis is confirmed only by direct visualization with history-taking, physical examination and TU.

Classical gynecological laparoscopic position, with intra- artery ligament. If a third accessory trocar is needed, this is
uterine manipulator. Two accessory 6 mm trocars should placed in the midline, suprapubically.
be used, one in either quadrant, medial to the umbilical
4.0 Instrumentation
O Laparoscope and video camera
O 5 mm grasping forceps
O Scissors
O Bipolar or unipolar HF electrosurgery unit or laser
system
O 6 mm trocars
O Suction-irrigation system for hydrodissection
5.0 Technique
The surgical treatment options for endometriosis are radical O complete adhesiolysis, with restoration of normal
or conservative surgery. The aims of conservative surgery tuboovarian relationship to enhance fertility potential;
are: O relief of pain;
O removal of both typical and atypical endometriotic O minimize the risk of disease recurrence.
implants;
O complete removal of endometriotic cysts
(endometrioma)
Fig. 1 Fig. 2
Typical red spot of peritoneal endometriosis. Black spots of peritoneal endometriosis.
6.0 Laparoscopy
6.1 Diagnostic Laparoscopy
The first stage of the procedure involves exploring the pelvic
anatomy and mapping out the extent of disease and the
location and boundaries of the bladder, ureter, colon, rectum,
utero sacral ligaments and major blood vessels.
6.2 Operative Laparoscopy

Peritoneal implants may be coagulated using unipolar or
bipolar electrosurgery, vaporized by laser application or may
be excised (Figs. 12).
The hydrodissection technique permits treatment of endo-
metriotic implants on the ureter or major vessels without
causing any damage to these structures (Figs. 35). Fig. 3
Atypical peritoneal endometriosis.
Fig. 4 Fig. 5
Atypical peritoneal endometriosis. Atypical peritoneal endometriosis.
Fig. 6 Fig. 7
Ovarian implants of endometriosis. Small ovarian endometrioma.
Initially, a small port is made into the retroperitoneum using Ovarian Endometriosis
either the laser or scissors. Ringers lactate or saline solution Ovarian implants of endometriosis or small endometrioma of
is injected next to the lesion to create a protective cushion less than 2 cm in diameter may be cauterized, resected by
of fluid between the lesion to be excised and the underlying laser application or excised using scissors, biopsy forceps or
ureter, bladder or blood vessels. Excision of large endo- electrodes (Figs. 67).
metriotic implants is superior to coagulation or vaporization
because the technique is not associated with problems For endometrioma larger than 2 cm in diameter, the first step
related to contamination by smoke and combustion residues. of the procedure involves adhesiolysis of the ovary on the
An additional advantage is, that it allows for the collection of posterior leaf of the broad ligament. In most cases, the cyst
specimen for histological diagnosis. is ruptured during this step, which requires that the liquid be
aspirated immediately to prevent pelvic contamination.
The cystic cavity is repeatedly irrigated with a suction-
irrigation tube (Figs. 89).
Fig. 8 Fig. 9
Large ovarian endometrioma. Aspiration of ovarian endometrioma.
Fig. 10 Fig. 11
Bilateral ovarian endometriomas. Right ovarian endometrioma.
Examine the cystic wall for malignant lesions. Drainage of the Adnexectomy
cyst must be followed by removal of the capsule to prevent Adnexectomy could be necessary even in fertile patients
recurrences. The capsule of the cyst must be separated from when endometriosis has infiltrated most of the parenchyma.
the surrounding ovarian stroma and removed by grasping After coagulation with a bipolar forceps, the proximal
its base with forceps and pulling it away from and out of the portion of the tube and of the uteroovarian ligament must be
ovarian capsule (Figs. 1013). dissected with scissors. In addition, the infundibulo-pelvic
Exposure of the right plane will permit blunt dissection ligament is coagulated and dissected applying traction to
by applying contralateral traction with two 5 mm-forceps. the ovary with grasping forceps. Therefore, the mesosalpinx
If stripping of the capsule is incomplete or difficult to should be completely dissected, after coagulation, to liberate
accomplish, the residual part must be eradicated by laser the adnexa and to extract it by use of a disposable bag.
application or electrocoagulation.
Presurgical treatment with GnRH analogues is useless in
ovarian endometriomas, because it is not effective in reducing
the size and volume of cysts and not even in facilitating the
surgery.
Fig. 12 Fig. 13
Stripping of the endometriotic capsule. Blunt dissection of the endometriotic capsule.
Adhesiolysis
Adhesiolysis may be performed using hydrodissection,
scissors, CO2 laser or atraumatic forceps. Before cutting
the tissue it is important to mobilize and identify the relevant
anatomical structures. Mechanical dissection with forceps
or hydrodissection is not associated with any thermal effect,
therefore this technique should be preferred.
Cul-de-sac obliteration is an important problem. It suggests
rectovaginal involvement, with deep endometriosis and dense
adhesions, and significant distortion of the regional anatomy
involving bowel, vaginal apex, posterior cervix, ureter, and
major blood vessels (Fig. 14).
To facilitate localization of anatomic landmarks and identi-
fication of tissue planes, we usually place a loaded sponge
forceps in the posterior fornix, and, if necessary, insert a
rectal probe. In difficult cases, ureteral probes can be placed
Fig. 14
Severe endometriosis with adhesions. preoperatively (Figs. 1516).
Fig. 15 Fig. 16
Intestinal endometriotic nodule. Intestinal endometriotic nodule with stenosis.

According to the difficulties encountered during surgery, administration of GnRH analogues, Danazol or Gestrinone to
patients should be discharged 24 to 48 hours after surgery. prevent recurrences, to reduce pelvic pain and to facilitate
Mild narcotic analgetics are usually sufficient to control subsequent induction of ovulation in infertile patients.
postoperative pain. Postoperative therapy may include
Chapter XI
Laparoscopic Management of
Deep Endometriosis
Luca Minelli and Stefano Landi
Department of Gynecology and Obstetrics
1.0 Introduction
Endometriosis is a highly debilitating disease that affects is the case in oncologic surgery better with excision en
mainly women of childbearing age, characterized by bloc (Redwine) and restoration of the anatomy, removal of
symptoms such as pelvic pain, dysmenorrhea, painful adhesions.
defecation, dysuria and infertility. To date, all medical treat- Although it is difficult to know the real incidence of deeply
ment options directed toward suppression of the disease infiltrating endometriosis, in a study on 132 patients, covering
and the pain associated with endometriosis have had similar the predefined depth of endometriotic infiltration, we found
effects in terms of symptom alleviation. None of them have deeply infiltrating lesions in 33%. Involvement of the gastro-
proven long-term efficacy. Interruption of medical treat- intestinal tract is present in about 336% of women affected
ment is associated with a high risk of recurrence. However, by endometriosis and 50% of these are affected by severe
evidence-based data suggest that complete laparoscopic disease. The gastrointestinal predilection sites are the rectum
excision of the endometriosis offers good long-term results and sigmoid, accounting for 7285% of cases. This means
with regard to the degree of regression, especially in those that to ensure complete removal of the disease and thus
patients with severe and debilitating symptoms. The surgical improve the outcome in terms of quality of life, surgery on
treatment of endometriosis should aim at removing all visible the bowel with or without bowel resection can be necessary.
areas of endometriosis . with margins free from disease as
2.0 Instrumentation
O 10-mm laparoscope with 3 CCD videocamera O Bipolar scissors with electrosurgical unit
O One 11-mm trocar O Suction and irrigation system
O Two 6-mm trocars O Dissecting forceps (Schnaider)
O One 11/6 mm reducer O Grasping forceps (Dorsey)
O Bipolar forceps O Maxon sutures with straight needle

Pre-operative assessment of endometrial implants plays Instrument-aided investigations are essential: transvaginal
a key role in the decision-making on the most effective ultrasound, ultrasound of the bladder and ureters, double-
strategy planning, possibly with the assistance of a general contrast enema, CA 125 and CA 199. As an alternative to the
surgeon or urologist. Our pre-operative assessment contrast enema, transrectal ultrasound can be performed but
comprises a questionnaire, physical work-up, instrumen- this requires specific instruments.
taided investigations and serum markers. Particular attention All patients should have stopped treatment with progestogens,
is paid to the patients history and symptoms, such as GnRH agonists or the contraceptive pill 34 months before
dysmenorrhea, pelvic pain, dyspareunia, painful defecation, surgery. If intestinal involvement is suspected, specific
covered by a specific questionnaire and assessed on a 10 preoperative preparation is necessary.
point analog scale: 0 = absent 10 = unbearable. In addition,
Preparation begins 24 hours beforehand. When intestinal
rectal and vaginal examinations are performed. Rectal
surgery is highly likely, the patient must take 40 ml of
examination allows the physician to reach 2.5 cm into the
Phosfo-Lax orally, diluted in a glass of water, followed by
pelvis and assess a good portion of the rectal mucosa (about
1 liter of water at 2 p.m. and then at 4 p.m., or else 2 liters of
78 cm of the rectums length of 11 cm), palpate any masses
Selg-Esse 1000 in the morning and 2 liters in the afternoon
and assess the thickness of the recto-vaginal septum and and 40 Mylicon tablets at once. Antibiotic prophylaxis consists
the nodular structure of the uterosacral ligaments. Rectal of 2g of cefazoline at induction of anesthesia followed by 1g
examination has a failure rate of 1764% and is not sufficient 3 times a day and metronidazole 500 mg 3 times a day for
on its own to diagnose deep endometriosis. Factors that can 3 days. If intestinal involvement and thus intestinal surgery
influence the diagnosis are the type of lesion, the depth of are ruled out, an enema is administered on the day prior to
infiltration, the dimensions and the site of the lesion. Even if surgery and 2g of cefazoline are given with induction of anes-
the examination is performed under general anesthesia, the thesia as antibiotic prophylaxis. A Foley catheter is left in the
sensitivity remains very low; its function as a screening test bladder throughout surgery and until the patient is able to
is limited and always requires another test for confirmation. reach the toilet independently (usually on day 1 after surgery).
Accurate data regarding co-involvement of the bladder and After spontaneous urination, the post-voiding residual urine
bowel cannot be obtained with a simple rectal and vaginal is measured until it is less than 100 cc in two successive
examination and a negative examination does not rule out measurements. If the post-voiding residual urine remains
involvement of these organs. The validity of the examination significant for more than 34 days after surgery, the patient is
may be improved if performed during menstruation. discharged after being instructed in self-catheterization.
Before starting the operation, the patient usually has a second prevention. In these cases, a drain is left in place close to the
vaginal and rectal examination under anesthetia. anastomosis for 812 hours. The drain is usally removed after
Laparoscopy begins with the creation of a pneumoperito- the first bowel movement. In general, a nasogastric tube is
neum using a Veress needle through the umbilicus, insertion not required. During postoperative day 1, the patient is given
of the 11-mm umbilical trocar for the laparoscope and continuous epidural analgesia through an elastomeric pump,
placement of two accessory 6-mm ports lateral to the inferior after which analgesia is replaced by 100 mg of ketoprofen
epigastric vessels bilaterally and a third 6-mm suprapubic and 100 mg of tramadol i.m. or 0.3 mg of buprenorphine
port. Complete resection of endometriotic lesions is achieved s.c., as required. Intravenous fluids are administered on the
by use of bipolar scissors. In general, if bowel surgery is day of the operation and the next day patients can start to
required, this is performed by a general surgeon specialist take food orally with a gradual increase in diet. The patients
assisted by one of the two gynecological surgeons. At the are discharged without a special diet. Prior to surgery, the
end of the operation, copious lavage of the peritoneal cavity patients are informed of the potential risks and benefits of the
is performed with 5001000 ml of Ringers lactate solution procedure by a written informed consent form.
and 4% icodextrin solution is left in the abdomen for adhesion
4.0 The Surgical Technique

The type of surgery depends on the depth of invasion and
the topographic distribution of endometriosis. The classical
steps of the technique are as follows:
The laparoscopic procedure begins with laparoscopic
inspection of the pelvic anatomy and systematic mapping of
the endometriotic lesions (Figs. 13).
Fig. 1
Mapping of adhesions and endometriotic lesions.
Fig. 2 Fig. 3
Endometrioma with diffuse adhesions and lesions. Endometriotic lesions on the peritoneum.

Adhesions involving the ovary and the tube. Adhesions to the pelvic wall. Adhesions between the abdominal wall and
intestine.
The caecum must always be inspected for the presence of included. Our standard method is to remove endometriomas
endometriotic implants which could not be confirmed by completely without coagulating or vaporizing superficial
preoperative double-contrast enema. peritoneal implants to be sure that there is no deep endo-
The operation proceeds with adhesiolysis, drainage and metriosis.
stripping of endometriomas, excision of endometriotic Adhesions can be removed with various techniques but
implants and other parietal implants, making sure that we prefer to use mechanical dissection with cold or bipolar
adequate healthy margins of retroperitoneal tissue are scissors (Figs. 46).
Traction and blunt dissection can assist greatly in mobilizing

and localizing structures that must be separated. We
recommend avoiding hydrodissection and use of liquids
because lavage of the peritoneum is much more difficult when
distended with CO2. In case of hermorrhage, application of a
suction tube or a dry gauze pledget is recommended.
Very small endometriomas can be coagulated but in general,
the stripping technique is preferred to avoid recurrence
(Figs. 711).
Fig. 7
Bilateral endometrioma.
Fig. 8 Fig. 9
Endometrioma of multilobular appearance. Ovarian endometrioma with adhesions.
Fig. 10 Fig. 11
Giant endometrioma. Giant endometrioma of the right ovary.
Fig. 12 Fig. 13
Appearance of the endometrioma capsule. Following incision, the contents are aspirated and the cavity of the
cyst is irrigated.
The first step is to mobilize the ovary from the posterior leaf
of the broad ligament to which it frequently forms dense
adhesions. In the majority of cases, the cyst ruptures during
this maneuver, which requires, that the chocolate-colored
fluid be aspirated promptly. Ensuingly, the cavity of the cyst
is irrigated several times. The cyst capsule is removed by
grasping the margin of the fenestration and stripped off from
the ovarian stroma to which counter-traction is applied with
a 5-mm forceps. The correct plane of dissection is chosen
when the capsule appears white or slightly yellow without
red streaks; this allows bloodless dissection without any
hemorrhage (Figs. 1214).
Fig. 14
The adjacent cyst capsule is removed by stripping.
Following stripping, meticulous and highly selective coagu-

lation is required, holding the ovary with a forceps and
visualizing each bleeding site by dripping saline on the base
of the cyst. The capsule is extracted by use of a disposable
bag. Very often, the ovary adheres to the pelvic wall and the
peritoneum underneath can obscure additional endometriotic
implants. These lesions must also be excised. It must be
taken into account that the retroperitoneal fibrosis caused by
the overlying adhesions frequently involves the ureter which
often necessitates careful ureterolysis. Many endometriotic
cysts are fixed to the ipsilateral uterosacral ligament by dense
adhesions so the entire adhesion area between the cyst wall
and the uterosacral ligament is removed en bloc.
In rare cases, adnexectomy is required. It is usually possible
to maintain to some extent the ovarian follicular reserve and
function. When surgery is performed on the ovaries, they
are suspended temporarily at the end of the operation using Fig. 15
non-absorbable 2/0 polypropylene sutures that are removed At the end of the surgery, the pelvic cavity is completely denuded of
on the third postoperative day, as described by Abuzeid. This peritoneum.
procedure allows better access to the pouch of Douglas and
prevents formation of adnexal adhesions to sites of the pelvic
cavity that were denuded of peritoneum (Fig. 15). Every adhesion of fibrous or fat tissue between the rectum
and the lateral pelvic wall is gradually divided until the bowel
Starting from the pelvic area, the ureters and large vessels are
has been sufficiently mobilized.
localized and the ureter is then exposed down to the muscle
wall following its course in the pelvis until healthy tissue is In this way, the entire endometriotic nodule remains adherent
reached. If endometriosis extends deeply and laterally in to the anterior wall of the bowel forming a single mass with
the uterosacral cardinal ligament, it is sometimes necessary the uterosacral ligaments and obliterated cul-de-sac. Where
to sacrifice branches of the internal iliac artery, usually the the disease invades the posterior vaginal fornix, the vagina is
uterine artery, or expose it as far as the intersection with opened. In the case of endometriotic infiltration of the vaginal
the ureter. In extreme cases, the ureteric muscularis can be mucosa itself, a vaginal approach can be useful to delineate
invaded by endometriosis, leading to partial constriction. In and mobilize the nodule by digital dissection prior to initiating
these cases, resection of the involved segment of the ureter laparoscopic dissection; this follows the posterior lip of the
may become necessary, followed by reanastomosis. cervix first and then the vaginal incision, making sure that all
of the vaginal lesion is included in the mass adherent to the
The basic principle is to liberate the obliterated cul-de-sac by
bowel.
en-bloc excision of the deep pelvic endometriosis.
Bowel surgery is performed at this point and can involve
The line of resection in healthy non-fibrosed peritoneum
superficial, partial thickness, full thickness or segmental
starts laterally and runs parallel to the base of the uterosacral
resection. Given the frequent involvement of the submucosal
ligament. The area is then exposed by blunt dissection. A
layer, to ensure complete excision of the endometriosis we
transverse incision is made at the uterine isthmus superior to
recommend full thickness or segmental intestinal resection.
the point of adherence to the bowel, and is carried down-
We consider superficial peeling or peeling of the mucosa
wards along the posterior cervical wall with intrafascial
only in selected cases.
dissection. The plane of dissection is continued caudally
as far as the rectovaginal septum so that the healthy rectal Even if full thickness bowel resection can be performed
wall can be liberated from the endometriotic nodule. The stepwise while the nodule is excised from the bowel and
uterosacral ligaments are resected at the site of insertion in sutured in double layers, we consider the use of a linear stapler
the cervix. As it is often difficult to find the correct planes positioned perpendicular to the bowel axis is extremely safe
of dissection, it is necessary to operate behind the nodule. and, beyond that, not expensive (Figs. 1620).
Fig. 16 Fig. 17
The rectum is densely adherent to the uterine corpus obliterating the Adhesiolysis and exposure of the deep rectovaginal endometriotic
cul-de-sac. nodule.
Fig. 18 Fig. 19
The nodule is completely excised. En bloc excision of the endometriotic lesion.
Fig. 20
Bowel resection with introduction of a transanal stapler.
The bowel segment invaded by the endometriotic nodule device is introduced transanally to complete the procedure.
is grasped with a forceps while positioning a linear stapler Occasionally, for rectosigmoid lesions, a segmental bowel
and firing precisely below the nodule. The technique is resection through a Pfannenstiel minilaparotomy with end-to-
limited in that it can be used only for small-sized lesions end hand-sewn anastomosis is performed under direct visual
(< 3 cm) and if the reduction in bowel lumen is less than 50%. control.
To completely remove an anterior rectal lesion smaller than
3 cm, which would require an ultralow resection (up to 6 cm Alternatively, the proximal bowel segment can be exteriorized
from the anal sphincter), we suggest the use of a circular transvaginally, resected and placed in the anvil of the circular
stapler (CEEA) as described by H. Reich. The nodule is trans- stapler. After completing the end-to-end anastomosis the
fixed perpendicular to the bowel axis in such a way that it vagina is closed laparoscopically and an omental flap is
can be pushed between the anvil and the body of the circular created and interposed between vagina and colon to prevent
stapler which has been inserted through the anal canal. the two sutures from getting into contact. The integrity of the
anastomosis is tested by filling the pelvic cavity with saline
When transanal resection is planned, after placing a fourth and insufflating air into the rectum while the more proximal
trocar in the right upper outer quadrant, the bowel is mobilized part of the sigmoid is occluded mechanically with forceps.
laparoscopically using an ultrasonic scalpel (Ultracision).
In our experience of 600 cases of complete excision of
The involved bowel segment is exposed, safeguarding the advanced endometriosis, we have found negative effects
mesentery and the vessels close to the intestinal wall. The fat is on the bladder, rectum and sexual activity. In this respect,
stripped away from the healthy distal bowel segment, exposing the results of studies recently published by Thomassin and
the intact muscularis propria through 360 degrees so that the Darai, do not correspond with our own. There may be various
sutures for colorectal anastomosis can be placed very safely rationales for this inconsistency. However, all authors agree
with the circular stapler using the Knight-Griffen technique. A on the significance of sparing the pelvic nerve plexuses.
linear endoscopic stapler is then applied with a safety margin
of 1 cm away from the nodule in the healthy distal bowel. The autonomic pelvic nerves in fact provide neurogenic
Then, the proximal segment of rectosigmoid colon with the control of the rectum, bladder and sexual area (vaginal
endometriotic nodule at its stapled end is extracted through lubrication and sweating). Among position-related iatrogenic
the suprapubic port, which is prophylactically extended. The nerve injuries, the inferior hypogastric plexus is most often
bowel segment involved is transected at about 1 cm proximal affected during excision of endometriotic nodules from
to the endometriotic mass. The anvil of the circular stapler the uterosacral ligaments and the lateral adjacent area. To
is secured with a purse string suture to the distal bowel reduce to a minimum the risk of inadvertent nerve injury at
opening and reintroduced into the abdominal cavity. Next, a this level the best safeguard is to observe certain rules that
28 or 32 mm circular end-to-end anastomosis (CEEA) stapling will be described below.
4.1 Protection of the Sympathetic Mesorectum Nerve Fibers; Superior Hypogastric Plexus,
Hypogastric Nerves and Lumbosacral Sympathetic Trunk
The superior hypogastric plexus is formed by sympathetic fully and reach the inferior part of the mesorectum as far as
nerve fibers lying in the presacral space at the level of the the rectal wings, the pararectal fossae must be unified in
promontory, covered by peritoneum and by the anterior layer the retrorectal space by blunt dissection as far as the space
of the visceral pelvic fascia. The right and left hypogastric known as The Holy Plane of Heald located in the midline;
nerves originate from this plexus and descend 810 cm lateral when this has been identified, the posterior and lateral
to the mesorectum in the visceral pelvic fascia following the mesorectal fascia is preserved by dissecting the loose and
cranio-caudal course of the ureter. These nerves can be relatively avascular connective tissue between the visceral
localized by opening the peritoneum at the level of the sacral mesorectal fascia and the parietal endopelvic fascia. The
promontory to gain access to the presacral space. Blunt medial and distal segments of the hypogastric nerves adhere
dissection of the loose adipose tissue in the rectosacral to the mesorectum fascia at this level and can be injured if
space as far as the rectosacral fascia allows identification of they are not exposed. Dissection is continued as far as the
the superior hypogastric plexus and the hypogastric nerves floor of the pararectal spaces, always staying close to the
close to the sacrum and distant from the mesorectum, which rectum to preserve the superior hypogastric plexus and the
is drawn ventrally and caudally with the rectum. If this is done, hypogastric nerves medially and cranially, and the ganglia
innervation is preserved completely during dissection of the and lumbosacral sympathetic trunks laterally and dorsally,
upper part of the mesorectum. To mobilize the rectosigmoid close to the sacrum.
4.2 Protection of the Sympathetic Fibers of the Inferior Mesorectum:

the Inferior-most Aspect of the Hypogastric Nerves and
the Proximal Aspect of the Inferior Hypogastric Plexus
It is extremely important to localize and lateralize the by the proximal aspect of the inferior hypogastric plexus.
hypogastric nerves and their connections to the proximal It is not always easy to identify the hypogastric nerves in
part of the inferior hypogastric plexus. After opening the the presacral space because their thickness varies greatly
retroperitoneum of the presacral space and prior to initiating (47 mm), they are completely surrounded by fatty tissue and
dissection of the uterosacral ligaments and rectal pillars, they sometimes give off multiple nerve fibers. However, clear
the thin and delicate lateral part of the visceral presacral identification, exposure and preservation of these nerves
pelvic fascia between the prerectal space and the pararectal are feasible through laparoscopy and should always be
space is mobilized and lateralized carefully. This lateral part attempted.
is crossed by the hypogastric nerves, the anterior branches At this level, they run from lateral to medial in a cranio-
of the sacral sympathetic trunks, the parasympathetic caudal direction approximately 20 mm to 5 mm inferior to the
pelvic splanchnic nerves and more ventrally and caudally ureter.
4.3 Protection of the Splanchnic Nerves and of the Medial and Inferior Aspects
of the Hypogastric Plexus in the Inferior Mesorectal Spaces
The parasympathetic innervation of the pelvic organs, continue with the medial efferent bundle of the pelvic plexus
rectosigmoid and anal canal is provided by the splanchnic up to the lateral or anterolateral surface of the rectum. In a
nerves which originate from the S2S4 sacral roots. recent study, Ercoli showed, that the pelvic splanchnic nerves
35 branches originate from the pelvic splanchnic nerves 34 are at high position-related risk of iatrogenic injury because
and 12 cm laterally and inferior to the pouch of Douglas; they are in close proximity to these ligaments in 70% of
they perforate the endopelvic fascia, cross the ventral cases. Proper identification of the splanchnic nerves at their
aspect of the piriformis muscle and then converge with the origin from the sacral roots allows safe dissection of the rectal
terminal branches of the ipsilateral hypogastric nerve about wings and the inferior mesorectal planes.
1 cm ventral to the inferior hypogastric plexus. The plexus is Always keeping the parasympathetic nerves under vision
located bilaterally in the presacral aspect of the endopelvic allows the nerve fibers to be kept distant from the debulking
fascia between the posterior vaginal fornix and the rectum planes.
in the ventral part of the lateral rectal ligaments. When the
inferior-most aspect of the posterolateral parametrium is Moreover, by following their course until they converge with
involved by endometriosis, it is resected sparing the dense the hypogastric nerves it is possible to localize the origin of
connective tissue and the fatty tissue surrounding the the pelvic plexus, caudal to the course of the deep uterine
nerve fibers of the cranial and medial aspect of the inferior vein, particularly the efferent branches and the visceral
hypogastric plexus. Ideally, the plane of dissection should not afferent branches of the uterus, vagina and bladder. During
enter the space, similar to the keel of a boat, which is located bowel resection, after excision of the mesosigmoid with
between the anterolateral planes of the mesorectum and the sparing of the innervation described above, only selective
rectal wings. A surgical anatomical reference point that we neuroablation of a small quantity of nerve fibers of the medial
use to separate the lateral parametrium and the vascular part efferent bundle of the pelvic plexus is performed, directed
(ventral and cranial) of the nerve (dorsal and caudal) is the medially towards the rectum and traversing the mesorectum.
deep uterine vein. In fact, only the rectal fibers of the resected segment of bowel
are transected, minimizing rectal denervation.
The lateral ligaments of the rectum run close to the splanchnic
nerves in 30% of cases, cross the pelvic plexus and then
4.4 Protection of the Caudal Aspect of the Inferior Hypogastric Plexus

The distal aspect of the inferior hypogastric plexus is located dissected. It is necessary to divide the pubocervical fascia
in the posterior part of the vesico-uterine ligament, lateral and consisting of the cranial and caudal part of the vesico-uterine
caudal to the distal ureter. To preserve it, after preparing the and vesico-vaginal ligaments at the point where its reflection
ureteric tunnel and the so-called space of Morrow medial will form the ureteric tunnel. In this way, the surgeon gains
and central to the ureter, the lateral aspect of the nerves and safe access to the paravaginal space.
the medial vascular part of the vesico-uterine ligament are
Chapter XII
Technique of Laparoscopic Myomectomy
Stefano Landi and Luca Minelli
1.0 Introduction
The traditional criteria for the surgical management of uterine As regards its benefits and the low risk of complications, LM
fibroids are infertility, recurrent abortions, obstetric can be considered a valid alternative to myomectomy via
complications, abnormal contour of the abdominal wall, laparotomy even though it remains a challenging technique.
abdominal and pelvic pain, abnormal uterine bleeding and In expert hands, LM appears to provide the same results as
menorrhagia attributable to fibroids. In addition, women who myomectomy via a laparotomy approach in terms of fertility
reject hysterectomy because they wish to maintain fertility and pregnancy and has a definite advantage with regard to
potential can choose this type of surgery. the risk of postoperative adhesions. Regarding recurrence
There are still no clear indications with regard to the evaluation, the results are unclear but it is probably similar
laparoscopic approach but laparoscopic myomectomy (LM) with both techniques.
has been broadly accepted recently. Certainly, there are technical limitations in LM so preoperative
The technique of LM does not differ from that of laparotomy. assessment of the patients is extremely important.
2.0 Patient Selection Criteria

Analysis of the largest series published in the literature so far In a retrospective study of 426 women, four independent
shows that LM is used in cases of one or two myomas about factors were found to correlate with the risk of conversion to
5 cm in diameter. The controversy about the number and an open procedure: myoma size larger than 5 cm, intramural
size of myomas that can be managed by laparoscopy has myoma, anterior location and preoperative use of GnRH
not yet been resolved. The generally considered limits are 3 agonists. No mention was made on the number of myomas
myomas and a diameter of 8 cm or a uterus corresponding in which could represent a bias in the selection of patients.
size to a 16 weeks gestation and a myoma measuring 12 cm. Although this predictive model, which uses ultrasound for
In the literature, Nezhat reported on a myomectomy 15 cm in three of the four criteria, has not been validated, it allows us
diameter. In our view, patient selection largely depends on to state that preoperative ultrasound assessment can be of
the experience of the surgical team. As a matter of course, we instrumental value. In our department, patients are accepted
decide not to perform LM in the presence of a large number for LM only after detailed ultrasound examination in the early
of myomas (more than 510) because the procedure would proliferative phase.
become extremely long, small myomas may be missed and It has been suggested that intramural fibroids that reach the
there may not be sufficient space for suturing the uterine uterine cavity can be a contraindication to LM because of
walls if the organ has been subjected to multiple incisions. In intra- and postoperative bleeding and inadequate multilayer
our experience, the size is secondary to the number of myo- closure of the endometrium/myometrium. However, other
mas when deciding on whether a patient meets the selection studies have demonstrated the safety of this procedure even
criteria of LM. in the case of intramural myomas.
3.0 Preoperative Use of GnRH Analogs

There are many reasons for avoiding the preoperative use of that use of tibolone as add-back therapy does not change
GnRH analogs: the efficacy in terms of operation times and rate of blood loss
compared to the GnRH analog alone.
O possible delay in the diagnosis of leiomyosarcoma
O increase in hyalinization phenomena Preoperative use of GnRH analogs in patients undergoing
myomectomy would appear to increase the risk of recurrence
O prolongation of operation times
and a recent study by Rossetti confirms the negative effect on
O difficulty in localizing the cleavage planes
recurrence. A possible explanation was given by Fedele who
O obliteration of the myoma-myometrium boundary reported an increase in recurrence rate for small myomas
O increased incidence of conversions (< 1.5 cm) after GnRH analog treatment, stating that the
However, there is a prospective study by Zullo in 1998, which reason is probably to be found in the simple fact that they
found that the use of analogs for two months prior to surgery were missed during myomectomy rather than recurrence as
produced low blood loss, shorter operating time, an increase such.
in red blood cells, hemoglobin and postoperative iron in all A reduction in the size of the myomas has also been reported
cases except markedly hypo-echogenic fibroids where there with preoperative administration of GnRH antagonists and of
was an increase in operating times. The same author states mifepristone (progesterone antagonist).
5.1 Injection of up to 40 ml of 9-arginine Vasopressin at a Concentration of 0.6 U/ml

in Saline into the Pedicle or Body of Each Myoma
The use of vasoconstrictive agents has been shown to be 20 ml of saline. Its period of activity is 2030 minutes and
as effective in laparoscopy as in laparotomy. They allow should be metabolized before the end of surgery. Use of
faster and easier enucleation with occasional use of bipolar the vasoconstrictor is often not well tolerated and cases of
electrosurgery for hemostasis, and above all, they reduce bronchoconstriction, urticaria, anaphylactic reaction and
blood loss and thus the need for transfusions. In our myocardial infarction have been reported. When used, this
experience, the real advantage is that they provide a clear must be under the strict control of the anesthetists.
view of the operative field. Unfortunately, the use of vaso-
During laparoscopic myomectomy, one case of hypertension
constrictors is not permitted in many European countries.
followed by hypotension after 35 ml at 0.6 U/ml, one case
Traditionally, Por-8 (8-ornithine vasopressin), a synthetic
of pulmonary edema after 10 ml at 0.5 U/ml and one case of
derivative of vasopressin, a strong vasoconstrictor with
transitory hypertension after 70 ml at 0.05 U/l of Por-8 have
weak antidiuretic effects, has been used for many years but
been reported.
is no longer commercially available. Subsequently, some
authors suggested using glypressin (triglycyl-lysine vaso- Recently, use of bupivacaine hydrochloride 0.25% + 0.5 ml
pressin, triglycyl-vasopressin), which is usually employed of epinephrine (1/2 ampoule of 1 mg/ml) has been shown
to treat bleeding esophageal varices. It is an analog of to be effective and safe in reducing hemorrhage, operating
antidiuretic hormone with about 3% of the antidiuretic time and time required for myoma enucleation. The problem
effect of vasopressin. The theoretical advantage is that it is that the constrictive effect lasts for 56 hours so there is
does not cause constriction of the coronary arteries as it is a hypothetical risk of not obtaining accurate hemostasis
a pharmacologically inactive drug precursor that must be with delayed postoperative bleeding and tissue damage
biotransformed to lysopressin (4060 minutes) by endo- and due to the prolonged hypo-oxygenation. The hypothesis
exopeptidases in the liver and kidney. that bupivacaine produces compensatory vasodilatation has
yet to be demonstrated. Methylergometrine maleate and
Pitressin (8-arginine vasopressin), a derivative of vaso- sulprostone should be used only in study protocols as their
pressin, is used widely in the United States. In the past, it safety and efficacy in gynecologic surgery have yet to be
was used in different concentrations, even up to 20 U in demonstrated.
Fig. 2 Fig. 3
Injection of up to 40 ml of 9-arginine vasopressin at a concentration Injection of up to 40 ml of 9-arginine vasopressin at a concentration
of 0.6 U/ml in saline into the myoma pedicle. Remember always to of 0.6 U/ml in saline into the body of a myoma.
aspirate prior to administration of the vasoconstrictive agent to make
sure that it is not injected in a blood vessel.
One to three injections per myoma may be necessary between the myoma and pseudocapsule; hydrodissection
(Figs. 2, 3). A few seconds after injection, the myometrium can also be useful. If the liquid escapes through a previously
begins to turn pale. If excessive resistance is encountered made needle opening, this confirms that the hydrodissection
during injection it is better to draw back the needle until cannula is in the proper cleavage plane.
the resistance disappears, which signifies that the needle is
5.2 Myometrial Incision with Unipolar Hook Electrode or Scissors

Using Pure High-Power Cutting Current
A linear or elliptical incision (Fig. 4) for very large or peduncu- Koh suggests ultralateral placement of the ports with two
lated myomas should be made over the myoma. The standard working trocars, both on the right side. With the traditional
incision is vertical (oblique in the case of an anterior myoma) set-up of the sites of trocar insertion, the incision should be
at the level of the most prominent part of the myometrium oblique in the case of anterior myoma in line with the needle
and is carried down to the surrounding pseudocapsule until holder located in the lateral port. In the case of fundal or
the pearly structure of the myoma is exposed (Fig. 5). Even if posterior myoma, the incision must be vertical in line with
the arteries and arterioles of the myometrium have a trans- the needle holder, which in this case will be in the suprapubic
verse course, a vertical incision is preferred because suturing port so that the needle can be passed deeply in the myome-
is more effective and easier to accomplish. Reduced blood trium (Figs. 67).
loss has been reported with transverse incision of the uterus.
Fig. 4 Fig. 5
Elliptical incision in a pedunculated myoma by use of a unipolar Myometrial incision at the level of the most prominent part of
hook electrode (60-watt cutting current). An elliptical incision is the myometrium with a unipolar hook electrode using a 60-watt
advantageous because the very thin myometrium would be too cutting current. The assistant is using a suction cannula to
difficult to suture. aspirate and maintain clear vision of the operating field.
Fig. 6 Fig. 7
Anterior myoma: the line of incision should be aligned on-axis with Anterior myoma (lateral view): the incision cannot be aligned
the needle holder placed in the lateral port. on-axis with the needle holder in the suprapubic port because
the needle would not be able to penetrate deeply into the
myometrium.
When placing the myometrial incision, the surgeon must producing a sharp and clean cut with minimal lateral diffusion
limit the use of electrocautery. Many cases of uterine rupture of energy. In theory, the ideal choice would be a cold surgical
after leiomyoma coagulation or simple unipolar cauterization knife. In the case of intraligamentary myomas, the first step
have been reported. Bipolar electrosurery may be applied is to incise the broad ligament to assist in spontaneous
selectively to the blood vessels. Hemostasis must be protrusion.
achieved preferably by means of endoscopic suture and the
Pedunculated myomas are resected with unipolar scissors
use of vasoconstrictive agents. The ultrasonic scalpel is used
and then sutured like intramural or subserous myomas. An
by some surgeons. Stringer was the first to use it for LM and
endoloop positioned around the myoma pedicle can help to
its use for uterine incision appears to be as effective as the
reduce bleeding before starting to suture.
knife electrode; however, it appears to produce greater tissue
damage compared to the unipolar mode using 35 watt for However, we advise against only using two endoloops
cutting and 30 watt for coagulation. We prefer to use a 3060 because they slip off the pedicle easily, producing major
watt unipolar hook electrode with unblended cutting current secondary bleeding.
5.3 Enucleation of the Myoma

After identification of the cleavage plane, the myoma is coagulated with the bipolar forceps; hemostasis should be
enucleated, pulling it with a 10 mm tenaculum or spiral-tipped achieved by suture and vasoconstrictive agents. An effort
fixation instrument inserted through the suprapubic port, must be made not to enter the endometrial cavity to avoid
exerting countertraction and performing dissection with a the formation of synechiae or iatrogenic adenomyosis. We do
sturdy forceps and with a suction cannula (Figs. 8, 9). Given not recommend suture of the endometrial cavity to prevent
proper identification and exposure of the cleavage planes, adenomyosis as reported by Koh, but antibiotic prophylactic
the myoma can be removed without any bleeding vessels. cover for two days and diagnostic hysteroscopy at the end
Traction should allow the myoma to be rotated toward the of the operation are worthwhile. Small adjacent myomas can
anterior abdominal wall (in the case of anterior myoma) so be enucleated by tunnelling through the previous incision
that the point of insertion of the fixation instrument should be (Figs. 10, 11) making sure that formation of hematomas is not
as low as possible in the fibroid. Only significant bleeding is facilitated.
Fig. 8 Fig. 9
Enucleation of the myoma. The myoma is enucleated by pulling and The handle of the spiral-tipped fixation instrument is pulled towards
rotating the fibroid with a spiral-tipped fixation instrument inserted the patients feet along an imaginary arc so as to apply traction to
through the suprapubic port, applying countertraction and using the myoma.
blunt dissection with a strong forceps and a suction cannula. In the
case of major bleeding, the surgeon may use the bipolar forceps.
Fig. 12
Schematic drawing of a figure-of-eight zigzag suture that has proven
effective and safe in our series. The suture line is usually placed with
an intracorporeal knot.
13 14
15 16
Figs. 1316
Interrupted figure of eight sutures with Serafit 0 are used to As shown, each individual suture requires four steps starting from
obliterate the bed of the myoma and ensure hemostasis. the right side and is then tied intracorporeally.
We use interrupted figure of eight sutures to approximate

the bed of the myoma and ensure correct hemostasis (Figs.
1316). The serosa is closed with a continuous inverting suture
(Figs. 1719) or interrupted inverting sutures. The sutures are
placed with a 36 needle slightly straightened (maximum size
of needle that can be introduced through a 15 mm trocar) or
with a size 27 curved needle. If there is abundant myometrium,
it is possible before closure to trim the excess to allow normal
reconstruction of the uterus. However, since involution of
the hypertrophic myometrium takes place spontaneously
in the first weeks post myomectomy it is advisable to avoid
removing myometrial tissue as much as possible.
17 18
Figs. 1719
The superficial layer is approximated with a continuous inverting
PDS 0 or 2/0 suture.
O inverting suture on the right side of the incision
O inverting suture on the left side
O final result
19 The assistant cuts the suture and the surgeon can remove the
needle from the abdomen via the 15 mm subprapubic trocar.
5.5 Morcellation
Use of an electromechanical morcellator to remove the This technique should prevent the Swiss cheese effect of
myomas is obligatory. We recommend activating the perforating the myoma with a number of holes, loss of the
blade of the morcellator inside a trocar with an oblique end fragments in the pelvis, repeated grasping of the myoma with
(Figs. 20, 21). In this way, with simple traction the myoma forceps and thus loss of time.
is peeled like an orange into a few or even no fragments.
5.6 End of the Procedure
The peritoneal cavity must be irrigated copiously with intestinal obstruction following formation of adhesions. A
Ringer lactate to obtain correct hemostasis and remove all device to avoid the formation of adhesions is to suture the
the fragments; leaving a small piece of myoma can cause suprapubic fascial defect under vision.
Fig. 20 Fig. 21
Activation of the blade of the morcellator inside a trocar with an Correct position of the blade relative to the end of the trocar:
oblique end: the myoma is rotated and peeled like an orange the blade must be in about the middle of the oblique part of the
without the aid of the assistant and with the production of very trocar.
few fragments.
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Chapter XIII
Laparoscopic Treatment
of Adnexal Masses
Mario Malzoni and Fabio Imperato
Malzoni Medical Center Villa dei Platani
Avellino, Italy
1.0 Introduction
In recent years, minimally invasive laparoscopic surgery has of this type of procedure. In fact, accidental rupture of the
changed the therapeutic management of adnexal masses thin ovarian cyst capsule in patients with missed diagnosis
to such an extent, that it can be considered the standard of proven malignancy can involve intraoperative spillage of
therapeutic option. tumor cells. The objection to laparoscopic surgery for ovarian
tumors is based on the hypothesis, that a missed stage IA
Despite several very promising publications suggesting the ovarian cancer could transform into a stage IC tumor (FIGO
increasing diagnostic value of ultrasonography and color classification) which would require adjunctive chemotherapy.
Doppler, the preoperative diagnosis of malignant lesions
provides too many false-positive results. Laparoscopy is of However, does the incidence of intraoperative spillage
significant value in the diagnostic assessment of adnexal constitute a prognostic risk factor that could adversely
masses in that it allows for elective biopsy and histopatho- affect the patients survival? In patients with stage I ovarian
logic evaluation including the option of ovarian tumor removal. cancer, some authors consider that this risk factor is not
significant compared to others, e.g., the histological tumor
However, the rate of confirmed malignancy in patients with type. According to other authors, spiallage does not seem
adnexal masses ranges from 0.3 to 1.2% (Tab. 1) and the to adversely affect the patients prognosis provided that
publication of case histories describing undetected ovarian copious lavage is performed and the patient is treated by
cancers treated via laparoscopy has given rise to criticism surgery within a week of the laparoscopy.
Tab. 1 Tab. 2
Diagram showing the experience of the authors with laparoscopic Laparoscopic management of ovarian cancer.
management of adnexal masses.
2.0 Indications
It is very difficult to define the limits of laparoscopic surgery. A tumor laparoscopically completely without compromising the
few authors state that laparoscopic management is indicated extent (Tab. 2).
only for adnexal masses that present without any signs of In our experience, nearly all adnexal masses can be treated
malignancy, while for other study groups, this can include laparoscopically. This is because of the methods dual role:
ovarian cancer at an early stage. An expert laparoscopist, diagnostic and therapeutic.
after diagnosing that the lesion is malignant, could stage the
2.1 Functional Ovarian Cysts

Functional ovarian cysts tend to undergo spontaneous or Corpus luteum Cysts
drug-induced remission (suppressive hormonal therapy) These are due to fluid collection inside the corpus luteum
within 8 weeks. Persistence of the cysts is an indication for at the end of ovulation (Fig. 2). They are roundish cystic
laparoscopy. swellings, which rarely exceed 4 cm in diameter. The outer
surface is yellowish in color. The serous-hemorrhagic contents
Follicular Cysts vary in color from brownish red, if recent, to serous when
These develop because of accumulation of follicular liquid they are older. The internal surface is smooth, sometimes
following distention of a Graafian follicle. They vary in size up with remnants of adherent fibrous blood clots. They nearly
to a diameter of 56 cm (< 10 cm) and are unilateral, unilocular always undergo spontaneous regression. In these cases, a
and thin-walled. They are characterized by a smooth outer corpus albicans cyst can be seen on the surface of the ovary,
surface, which is translucent and whitish-gray in color (Fig. 1). consisting of fibrous collagen.
The contents are lemon yellow in color. The internal surface is
smooth and shiny and greyish in color.
Manual of Gynecologic Laparoscopic Surgery 153
2.2 Epithelial Cysts

Serous Cysts
These are the most frequent of all benign ovarian cysts, and
are predominantly unilateral and unilocular with thin, smooth
walls. Their diameter is usually less than 15 cm. The outer
translucent surface is covered with a fine vascular network
(Fig. 3). The internal surface can appear smooth and shiny
(simple cystadenoma) or projecting as papillary structure
(papillary cystadenoma). Sometimes, the outer surface also
has numerous papillary proliferations (surface papilloma of
the ovary). If the serous epithelium has an abundant stromal
component, that is, at least a quarter of the tumor mass is
solid and fibromatous, this is called a cystadenofibroma.
Mucinous Cysts
Fig. 1
Less frequent than the previous ones, they are usually Functional ovarian cyst.
unilateral, pedunculated and thus very mobile with a diameter
that can reach 3050 cm or even more (giant cystadenomas).
They are usually multilocular with cystic cavities of varying
sizes, separated by fine fibrous septa, complete and
incomplete (Fig. 4). The contents are usually fluid, mucinous,
clear and fibrous.
Fig. 2
Corpus luteum.
Fig. 3 Fig. 4
Serous ovarian cyst. Mucinous ovarian cyst.
Endometriomas
These are due to endometriosis located on the ovary;
please refer to the specific chapter regarding manage-
ment. The outer surface is irregular and yellowish white
with numerous areas of dark brown (Fig. 5). The bloody
contents make them difficult to distinguish from functional
hemorrhagic cysts.
2.3 Germinal Cysts

Dermoid Cysts
Typically, they are found with a higher frequency in young
women presenting as cystic swellings with a doughy
consistency, yellowish white in color and opaque. They are
filled with fatty, semisolid, sebaceous material mingled with
Fig. 5 hairs and/or skin, bone, cartilage, and all tissues deriving
Endometrioma. from the three embryonic (ectodermal, mesodermal and
endodermal) layers can be present. They are usually
thick-walled and 610 cm in diameter, but can reach 15 cm
(Fig. 6). Dissection of dermoid cysts is usually attempted
while preserving the integrity of the cystic capsule. If
accidental rupture and ensuing spillage of the cyst contents
into the peritoneal cavity occurs, it is necessary to remove
the spilled material carefully (sebum, hairs, etc.) to prevent
the incidence of chemical peritonitis.
Ovarian Struma
These are usually unilateral and multilocular, with a
diameter of 68 cm. The contents are colloidal. They
consist of highly specialized mature thyroid tissue.
2.4 Inclusion Cysts

Parovarian / Tubal Cysts
These intraligamentous cysts, which develop between the
leaves of the broad ligament, can reach a considerable size
Fig. 6 and can deform the adjacent tube. On the other hand, the
Ovarian dermoid cyst or mature teratoma. ovary appears healthy. They usually arise from embryonic
remnants of the mesonephric or wolffian system (primitive
kidney), present in the thickness of the broad ligament.
More specifically, they derive in the majority of cases from
the cranial part of the mesonephric system close to the
ovarian hilum (epoophoron or parovarium), rarely from
the caudal part of the mesonephric system immediately
below the point of insertion of the utero-ovarian ligament
(paroophoron). They appear as cystic unilateral and
unilocular thin-walled swellings, ovoid or roundish in shape,
sometimes of considerable size, containing clear fluid (Fig. 7).
Their removal requires careful dissection to avoid iatrogenic
injuries to the ureter and uterine pedicle, which may have
been displaced by the cyst and have an atypical course. It is
therefore advisable to identify both structures.
Fig. 7
Parovarian cyst.
The peritoneum is incised with Metzenbaum scissors in an

area distant from the tube (Fig. 8). The margin of the peritoneal
incision is grasped with a fine grasping forceps and the layer
of cleavage between the peritoneum and the cyst is identified.
Then, the cyst is dissected bluntly from the loose connective
tissue with the scissors by opening and closing the blades.
2.5 Inflammatory Cysts

Pyosalpinx
This is a collection of purulent exudate in the lumen of the
uterine tube due to complete occlusion of its ostium as a
result of purulent salpingitis. The tube appears considerably
distended, full of a thick creamy exudate that is greenish
yellow in color. The tubal wall is usually thickened and closely
adherent to adjacent organs.
Fig. 8
Hydrosalpinx Visualization of the peritoneum to be incised for removal of the
paratubal cyst.
This is a collection of serous fluid in the lumen of the uterine
tube because of complete occlusion of its distal ostium as a
result of a weak and/or chronic inflammatory tubal process.
The tube appears distended and full of clear fluid, 25 cm
in diameter, with a smooth pinkish white surface and thin,
transparent walls (Fig. 9). In the presence of hydrosalpinx,
the outcomes of reconstructive surgery performed by laparo-
scopic approach are not encouraging in terms of pregnancy
rate. Therefore, in these cases, an assisted reproduction
technology (ART) program is the method of choice. In fact,
in the decision-making process, whether or not to refer the
patient to an ART program, some authors suggest removing
the affected tube as a prophylactic measure, performing
salpingectomy (Fig. 10) or alternatively, cauterizing the intra-
mural and isthmic tubal portion.
Tubo-Ovarian Abscess (TOA)
The infectious process presents with a collection of purulent
exudate involving the tube and nearby ovary as a result of
salpingo-oophoritis. It usually originates from chronic and
advanced stages of salpingitis. In patients with TOA, the
adnexae assume the appearance of a complex mass, in Fig. 9
Hydrosalpinx.
which it is no longer possible to distinguish the two adjacent
organs, which is why a single swelling, irregularly elongated
and red-brown in color (Fig. 11) is visible at laparoscopy.
Fig. 10 Fig. 11
Left salpingectomy. Tubo-ovarian abscess.
Laparoscopic management of TOA involves aspiration and Ovarian Torsion

drainage of all purulent collections of the mass. A sample Torsion of the adnexa at the site of its pedicle is a surgical
of the material is sent for bacteriological work-up. Next, the emergency. It is more frequently found in an ovary with
abdominal and pelvic cavities are carefully irrigated with concomitant cyst formation. In patients with suspected
saline. Adhesiolysis is performed to release the reproductive ovarian torsion, and if diagnostic confirmation can be
organs from the inflammatory process. At this point, the provided promptly, the immediate therapeutic management
case is evaluated clinically and a decision is made on how involves detorsion of the pedicle for restoration of normal
toproceed. At times, it is sufficient simply to eliminate the anatomical conditions. After surgical detorsion, the ovary is
source of infection, but other times an organ-preserving inspected to confirm that blood flow has been re-established
approach is not feasible. In this case, it is mandatory that and the organ has regained its normal color.
adnexectomy be performed. Finally, intraperitoneal tube
drains are placed.
2.6 Solid Ovarian Masses

Ovarian Fibroma Benign Brenner Tumor
This is the most frequent connective-tissue tumor (5%) This surface epithelial-stromal tumor of transitional cells
growing from the ovarian cortex. It affects mainly women over (resembling urinary bladder epithelium) is of very rare
40 years of age, with a mean of 55 years. Generally unilateral, occurrence; it affects mainly women in the fifth and sixth
it appears as a solid or mixed solid-cystic mass and is mobile decade. Usually unilateral, it appears as a solid, hard and
and sometimes pedunculated. The outer surface can be both encapsulated mass. The outer surface is greyish white in
smooth and nodular and appears brownish white in color. It is color. Complete surgical excision of the benign Brenner
often associated with ascites or ascites and pleural effusion tumor appears to be curative.
(Demons-Meigs syndrome) which regresses after surgical
removal.
3.0 Diagnosis
Before a patient undergoes laparoscopic surgical treatment
of an adnexal mass, it is necessary to exclude the presence
of cancer. Nonetheless, laparoscopic inspection alone of the
adnexae often allows the surgeon to make a benign-malig-
nant differentiation (Fig. 12).
3.1 History
The physician must ask the woman about any menstrual
irregularities and the presence of any urinary or bowel
disturbances.
Pelvic pain is the most frequent symptom although asymp-
tomatic patients are not rare. In fact, it is only when the cysts
reach a considerable size and produce pain in the ipsilateral
iliac fossa that they become apparent and spur the patient to Fig. 12
Multilocular ovarian cyst.
consult a doctor.
Rarely, the pelvic pain can present as an acute abdomen, In advanced malignant disease, patients complain of abdo-
secondary to rupture of a cyst or ovarian torsion. minal distension, swelling, constipation, nausea and anorexia.
3.2 Clinical Examination

Before the procedure, a local physical examination is carried Benign Adnexal Mass
out. The adnexa or adnexae may be tender to both superficial It can be considered benign when a unilateral, mobile swell-
and deep palpation. Deep palpation reveals the outline, ing with a smooth surface is found on examination.
consistency, increased volume and mobility of the adnexal
mass. Adnexal Mass Suspicious for Malignancy
A fixed mass with irregular margins, possibly bilateral, raises
the suspicion of a malignant ovarian neoplasm.
3.3 Transvaginal Ultrasound

Transvaginal ultrasound contributes greatly to the preoperative Benign Adnexal Mass
assessment of an adnexal mass. The ultrasonic characteristics that suggest a benign nature
of the lesion include: size < 6 cm, unilocular structure, homo-
geneous contents, absence of internal proliferations and
septa (possibly thin ones, < 2-3 mm), presence of smooth Adnexal Mass Suspicious for Malignancy
walls and well-defined margins. Dermoid cysts can contain The presence of bilateral masses with irregular margins,
hyperechogenic structures such as bone and cartilage. multiple thick intracyst septa (> 4 mm), papillary projections,
Hemorrhagic cysts can contain internal echoes of variable solid areas and the presence of ascites raise the suspicion of
intensity, both focal and diffuse. a malignant ovarian neoplasm.
3.4 Color Doppler

Recently, use of color Doppler has made it possible to Benign Adnexal Mass
visualize the vascular patterns of adnexal masses based Benign lesions tend to be less vascularized, with isolated
on the pathophysiological reasoning that malignant tumors vessels, mainly located peripherally, which have an increased
are characterized by rapid growth and contain new vessels. blood flow impedance (RI >0.55).
The muscle layer of the walls of these vessels is reduced
so resistance to blood flow is low. Quantification of the
Adnexal Mass Suspicious for Malignancy
blood flow impedance and the presence, distribution and
architecture of neovascularization inside the adnexal mass A lesion can be considered malignant when there is a new
can be utilized in the differential diagnosis of these lesions. vasculature network centrally at the level of the septa, and
However, color Doppler studies can give false-negative proliferations, arranged anarchically and abnormal in form
results due, for example, to areas of avascular necrosis in (dilated vessels, arteriovenous shunts) with reduced flow
malignant tumors. Conversely, complex adnexal masses with impedance (RI <0.45).
a solid and vascularized part (dermoid cysts, Brenner tumors)
can give false-positive results.
3.5 Tumor Markers

Prior to the surgical procedure, specific tumor markers should The most widely available tumor marker test is measurement
be measured: CEA, CA 19-9, CA 125, aFP. Because of their of CA 125. Levels greater than 35 U/ml are arbitrarily regarded
low specificity and sensitivity, the tumor markers may only be as positive. However, specificity is lower in women of child-
used as an adjunct measure for predictive purposes that can bearing age, since some adnexal or peritoneal conditions
help to differentiate benign from malignant adnexal masses. (PID, endometriosis) and menstruation increase the levels.
3.6 CT and MRI

Adjunctive imaging modalities are often used in an attempt instrumental investigations are not necessary. Sometimes,
to improve diagnosis. However, measurement of CA 125 MRI is indicated to assess tumor infiltration and abdomino-
serum levels, transvaginal ultrasound and color Doppler have pelvic CT for lymph node assessment.
an acceptable sensitivity and specificity, so that additional
3.7 Intra-operative Assessment

Laparoscopic findings suspicious for malignancy are ovary (Fig. 13) and the presence of suspicious peritoneal
papillary and/or solid lesions on the outer surface of the implants (Fig. 14).
Fig. 13 Fig. 14
Laparoscopic appearance of ovarian cancer on intra-operative Peritoneal implants suspicious for malignancy.
inspection.
4.0 Surgical Therapy

Faced with this type of disease, the choice must not be
between laparoscopy and laparotomy but between conser-
vative and non-conservative treatment. Surgical therapy must
thus be tailored to the individual case, applying the basic
principle of preserving as much ovarian tissue as possible.
The advantages of laparoscopy are obvious when applied to
establish a differential diagnosis in terms of the benign/malig-
nant nature of the adnexal mass. In young women who wish
to preserve their fertility, laparoscopy allows intraoperative
biopsies to be taken from the ovarian surface without causing
rupture of the cyst. The histological result will decide the
definite surgical therapy.
In the presence of a suspicious adnexal mass, intraopera-
tive laparoscopic assessment may assist in choosing the
type of abdominal incision, which should extend from the
xiphoid process to the pubic symphysis in the presence of Tab. 3
a malignant neoplasm. Both accurate tumor staging and Surgical management of ovarian cancer.
debulking surgery (Tab. 3) require a midline incision. , this
pathology should be treated only in tertiary centers where of ovarian cancers are stage III and IV when diagnosed
oncologic surgery is performed as a matter of routine, and and require conversion to laparotomy to allow adequate
where adequate treatment can be ensured. In fact, two thirds debulking.
4.1 Aspiration
General Principles to rupture, which occurs frequently (Fig. 15). Above all, cyst
aspiration facilitates cystectomy by reducing the tension of
Simple puncture and aspiration of the cyst should be avoided the cyst and allows inspection of its internal walls.
since this is associated with an increase in recurrence rate.
Aspiration is recommended only for dysfunctional cysts. The suction cannula is introduced directly into the cyst on
the antimesenteric side after immobilizing the ovary, grasping
Aspiration is often performed prior to cystectomy. En-bloc the ovarian ligament with an endoclinch grasping forceps
enucleation of an endometrioma, a mucinous cyst or (Fig. 16). It is sometimes sufficient to compress the ovary
ovarian lesion larger than 10 cm is very difficult to manage against the uterus. After removing the cyst contents with a
laparoscopically. Under the aforementioned conditions, it suction cannula, the cyst cavity is lavaged. It is then possible
is preferable to perform controlled prophylactic aspiration to introduce the laparoscope through the opening to assess
rather than risk accidental spillage of the cyst contents due the inner surface.
Fig. 15 Fig. 16
Prophylactic aspiration of a giant ovarian cyst. Grasping the ovarian ligament with an endoclinch forceps and
exposure of the antimesenteric margin.
4.2 Cystectomy
General Principles
Complete enucleation of the cyst with minor trauma to the
residual ovarian parenchyma is advised in young patients
of fertile age with epithelial, germinal and inclusion cysts.
In addition, cystectomy allows full histological examination.
It is surprising how often it is possible even with large cysts
to preserve sufficient ovarian tissue around the hilum to
restore ovarian anatomy satisfactorily. If an adequate blood
supply can be ensured, full recovery of organ function can be
anticipated.
Technique in brief
To improve exposure of the adnexae, a uterine manipulator
must be applied. The ovary is then mobilized by lysis of the
Fig. 17
paraphysiological adhesions to the rectosigmoid. Using a The utero-ovarian ligament is grasped, the ovary is elevated and the
suction-irrigation cannula, the ovary is released from the ovarian cortex is then incised.
posterior leaf of the broad ligament (ovarian fossa). The utero-
ovarian ligament is then grasped with an endoclinch forceps
to elevate and rotate the ovary.
To enucleate the cyst with the capsule intact, a small incision
is made with unipolar scissors contralateral to the ovarian
hilum until the wall of the cyst is reached (Fig. 17). From the
incision margin, the ovarian cortex together with the very thin
stroma is grasped using an atraumatic Dorsey or Matkowitz
grasping forceps. The plane of cleavage between the capsule
and ovary is identified by opening and closing the blades
of the round-ended curved scissors (Fig. 18). The fibrous
adhesions between the wall of the cyst and the ovarian
tissue are dissected (Fig. 19). The blood vessels supplying
the cyst are coagulated with bipolar forceps. Detachment is
completed using the blunt tip of the suction/irrigation cannula.
The incision in the ovarian cortex is then extended to allow
removal of the intact cyst (Fig. 20).
Fig. 18
Identification of the plane of cleavage by opening and closing the
blades of the round-ended scissors.
Fig. 19 Fig. 20
Dissection of fibrous adhesions between the cyst capsule and the Adequate incision of the ovarian cortex allows removal of the intact
ovary. cyst.
In other cases (endometrioma, mucinous cyst), enucleation

of the cyst is preceded by controlled prophylactic
aspiration of the cyst contents. After this step, it is useful
to incise the cyst capsule and ovarian cortex with cold
scissors. Two atraumatic grasping forceps are used to
exert traction and countertraction to the incision margins.
In this way it is possible to discriminate the proper cleavage
plane located between the aforementioned structures
(Fig. 21). The cyst capsule is then detached from the
ovarian parenchyma by stripping (Fig. 22). This part of the
operation is performed with the aid of two instruments,
a Manhes forceps for a deep firm grip of the cyst and a
toothed atraumatic forceps for the ovarian tissue, which
must not be damaged. Hemostasis of the ovarian bed is
obtained with a bipolar coagulation electrode (Fig. 23).
Protruding ovarian tissue is coagulated with bipolar forceps
Fig. 21 to invert the margins of the cortex and reduce the potential
Identification of the proper cleavage plane for enucleation of the risk of adhesion formation. If the ovarian margins overlap,
endometrioma. this is usually left to heal by primary intention without the
need for suturing so that it closes spontaneously. In this
way, the incidence of postoperative adhesions can be
limited (Fig. 24). If the ovarian cortex does not tend to
reapproximate spontaneously, one or two absorbable
monofilament sutures can be placed to reconstruct the
cortex. The sutures are transfixed and tied inside the ovary.
This is followed by repeated irrigation with saline for full
peritoneal toilet.
Fig. 22
Cystectomy with the stripping technique.
Fig. 23 Fig. 24
Hemostasis of the ovarian bed using a bipolar coagulation electrode. Overlapping ovarian margins.
4.3 Oophorectomy
General Principles
Oophorectomy is indicated in young patients only if a
conservative approach is not feasible due to insufficient
residual ovarian tissue.
Technique in brief
After mobilizing the ovary, the ovarian pedicle is first
coagulated and then divided. To achieve coagulation of larger
vascular pedicles, it is preferable to use bipolar forceps with
adequately wide jaws. The mesovarium and mesosalpinx are
then coagulated and divided starting at the uterine side and
proceeding toward the fimbrial tubal portion. The tube, which
should be preserved, must be protected from iatrogenic
injury.
Fig. 25
Exposure of the ureter.
4.4 Adnexectomy
General Principles
Adnexectomy is reserved for postmenopausal patients.
In addition, the decision to remove the tube together with
the ovary is indicated where the tube is also infiltrated by
the pathology. However, removal of the entire adnexa is
frequently performed because it is easier.
Technique in brief
The adnexa is elevated with a certain degree of traction. This
avoids accidental injury to the lateral walls of the pelvis and to
the underlying retroperitoneal structures.
The course of the ureter should always be identified. The
ovarian vessels and common iliac vessels cross the ureter at
its junction with the superior pelvic aperture. Descending in
the pelvis, it runs inside the broad ligament just beside the
uterosacral ligament. If it is not possible to identify the ureter
clearly through the peritoneum, it is necessary to incise the Fig. 26
peritoneum to access the retroperitoneal space and expose Skeletonization of the infundibulo-pelvic ligament.
it (Fig. 25).
The next step involves fenestration of the posterior leaf
of the broad ligament to mobilize the ureter away from the
infundibulo-pelvic ligament. Next, the infundibulo-pelvic
ligament is coagulated with the aid of bipolar forceps and
transected by use of a cold knife. This can be accomplished
more effectively if preceded by adequate vascular pedicle
skeletonization (Fig. 26). The utero-ovarian ligament and the
tubal isthmus are then coagulated and divided (Fig. 27).
The uterine vascular pedicles should always be inspected at
the end of surgery as they can bleed when the hemostatic
effect of positive intra-abdominal pressure has subsided.
Fig. 27
Left adnexectomy.
5.0 Guidelines for the Management

of Suspicious Adnexal Masses
The standard approach in the laparoscopic management
of suspicious adnexal masses includes cytology testing of
peritoneal fluid, inspection of the abdominal and pelvic cavity
combined with peritoneal biopsy, adnexectomy avoiding-
rupture of the capsule, extraction of the operative specimen
with the aid of an endobag without morcellation of solid
areas, and frozen section.
5.1 Cytology Testing

General Principles
Fig. 28
Intraperitoneal washing for cytology testing.
To distinguish benign from malignant lesions, cytology testing
of the peritoneal fluid is performed. The cytolgoy samples of
peritoneal fluid are taken with a suction needle attached to
a syringe at the start of the procedure when the peritoneal
fluid is free from blood. If the peritoneal fluid is insufficient,
washing is performed, that is, the pelvis and abdomen are
irrigated with saline (Fig. 28).
5.2 Inspection of the Peritoneal Cavity

and Biopsy Sampling
General principles
Inspection of the abdominal and pelvic cavity (Fig. 29) to look
for neoplastic lesions is completed with peritoneal biopsy
of suspicious areas. When the peritoneal cavity appears
normal (diaphragm, liver, intestine, omentum, peritoneum)
random biopsies must be taken. On the other hand, if areas
suspicious for malignant neoplastic lesions are detected (Fig.
30), the diagnosis of ovarian carcinoma stage III can be made.
The procedure is converted immediately to laparotomy.
Fig. 29
Inspection of the peritoneal cavity.
Technique in brief
The suspicious peritoneal area is grasped with forceps to
obtain a sufficient amount for histological assessment. When
this fold of tissue has been grasped, the peritoneal margin is
incised. This gives access to the retroperitoneal space, which
is dissected bluntly. Bleeding ceases spontaneously or can
be controlled with bipolar coagulation.
Fig. 30
Neoplastic lesions suspected for malignancy.
5.3 Endobag
General Principles
In patients with ovarian tumors, even of low malignancy,
extraction of the operative specimen can favor the dissemi-
nation of malignant cells, particularly implantation at the point
of trocar insertion. To reduce this risk, endoscopic bags are
used with the aim of protecting the abdominal wall (Fig. 31).
During extraction of the specimen, morcellation to reduce
the size of the solid tissue and facilitate the maneuver is not
advisable because of the increased risk of dissemination of
malignant cells. It follows that in the presence of suspicious
adnexal masses with a diameter greater than about 78 cm,
the laparoscopic approach is contraindicated. However,
despite the use of these two precautions, cases of metastasis
at the point of trocar insertion have been described (port-site
recurrences, PSR). Fig. 31
Laparoscopic extraction bag.
Technique in brief
To introduce the endobag, the accessory trocar (6 mm) is
removed, the accessory skin incision is extended to 10 mm ovarian lesion, frozen section should not be included in the
and the bag cannula is introduced through the parietal port. criteria used for setting up the individual therapeutic strategy,
After placing the extracted material in the bag, the edges of whether conservative or ablative. In these cases, it is
the endobag are pulled outside the wall and clamped with preferable to perform adnexectomy and thereby prevent the
two Klemmer forceps. To allow passage of the bag with risk of neoplastic dissemination because of a false-negative
its contents through the abdominal wall, it is sometimes frozen section result. Young patients with an adnexal mass
necessary to aspirate the cyst contents. with a small solitary lesion are an exception; these can be
biopsied.
Frozen Section On the other hand, biopsy with frozen section is essential in
Frozen section has been reintroduced by laparoscopist to re-staging and avoids reoperation which is poorly acceptable
reduce the incidence of unnecessary conversions. for the patient.
However, frozen section diagnosis of ovarian tumors is Where frozen section is not available, any ovarian lesion
difficult and has a false-negative rate of 5%, with the majority suspected for malignancy at laparoscopy, must be removed
due to inadequate sampling by the surgeon or pathologist. intact by adnexectomy. The type of subsequent treatment will
Thus, in the presence of a laparoscopically suspicious be decided after surgery.
Chapter XIV
Laparoscopic Management of
Borderline Ovarian Tumors
Paulo Ayroza and Elizabet Abdalla
Medical School of the Santa Casa University of
So Paulo, Brazil
1.0 Introduction
Among all gynecologic diseases, the topic of ovarian Nevertheless, it is not at all unusual to find statements of
tumors is perhaps one of the most controversial with regard authors in the literature advising against laparoscopic
to diagnosis, classification, and treatment modalities. treatment of benign ovarian cysts such as endometriomas
Undoubtedly, this reflects the great significance of this and dermoid cysts.
disease among female patients. Whether benign or not, all There are numerous reports in the literature justifying the
ovarian tumors must be examined thoroughly. Functional use of laparoscopy as a diagnostic and therapeutic tool for
cysts may regress within months, whether or not any benign ovarian tumors. In the authors group, use a routine
medication is used. On the other hand, nonfunctional tumors diagnostic protocol is used, which requires that all patients
tend to persist and require an accurate workup. with ovarian tumors are submitted to clinical and laboratory
Since the advent of the laparoscopic technique many work-up (clinical examination, transvaginal ultrasound, and
years ago, we have been able to identify benign cysts and serum marker levels), followed by laparoscopy.
subsequently treat them laparoscopically. Today, it is
even possible to manage by laparoscopy some ovarian
malignancies that required laparotomy until a few years back.
Fig. 1 Fig. 2
Bilateral ovarian endometriotic cysts. Ovarian endometriotic cyst.
Fig. 3 Fig. 4
Large ovarian cyst and uterine myomas. Functional ovarian cyst.
During the laparoscopic procedure, we recommend that examination has demonstrated to be effective in the detection
a strict protocol for the pelvic examination be observed of all ovarian malignancies.
to ensure the highest level of security. The laparoscopic
appearance of ovarian cysts can be highly variable depending Laparoscopic surgery has shown to be a safe and helpful
on their nature (endometriosis, functional, teratoma, etc.), modality for both ovarian cystectomy and oophorectomy
which is why visual inspection plays a vital role in establishing or adnexectomy in that it provides all benefits of minimally
a definitive diagnosis and differentiating between malignant invasive surgery while at the same time preserving patient
or borderline lesions (Figs. 18). safety and fertility.
Our routine use of this protocol over the past 15 years has Which steps should be taken when ovarian malignancies
resulted in a false-negative rate of 0.5%. This means, that or borderline tumors are detected is more controversial.
in 99.5% of patients, the result of our clinical investigation The main question is whether these tumors may be treated
proved to be correct. The method of laparoscopic visualization laparoscopically. In this chapter, we will discuss only
of ovarian cysts in conjunction with intraoperative histological borderline ovarian tumors.
Fig. 5 Fig. 6
Solid ovarian cyst. Bilateral ovarian teratoma.
Fig. 7 Fig. 8
Surface proliferations of an ovarian borderline tumor. Surface proliferations of an ovarian borderline tumor.
2.0 Borderline Ovarian Tumors

(Tumors of Low Malignant
Potential)
Our goal is to perform laparoscopically a good oncologic
procedure
Paulo Ayroza Ribeiro
Borderline ovarian tumors are a subset of epithelial ovarian
tumors, which have a very favorable prognosis. The univer-
sally accepted treatment is surgical removal of the tumor
and histological examination. However, the postoperative
management protocol is highly controversial. To date,
no medical therapy has been shown to clearly improve
outcomes.
In 1929, Taylor first described a subset of ovarian tumors
Fig. 9
Ovarian borderline lesion. that he termed semi-malignant. Although these lesions had a
more favorable prognosis than other ovarian cancers, it was
not until the early 1970s that they were classified separately
as borderline tumors.
One woman in 55 (1.8%) develops some form of ovarian
cancer in her lifetime. Approximately 90% of these cancers
are tumors of epithelial origin. If benign lesions are included,
epithelial tumors account for 60% of all ovarian tumors.
Borderline tumors account for approximately 15% of all
epithelial ovarian tumors. The mean age of occurrence is
approximately 10 years below that of women with ovarian
cancer of distinctly malignant nature. Predisposing factors
believed to be associated with borderline tumors include oral
contraceptive use, menarche, age at first pregnancy, age at
first delivery, menstrual history, smoking and family history
of ovarian cancer. None of these factors, however, has been
shown to be statistically significant.
Borderline ovarian cancer is staged according to the FIGO
classification of ovarian cancer. Many clinicians combine
stages II to IV when assessing prognosis. Another common
Fig. 10 component of staging is the description of the type of
Borderline tumor of cerebroid appearance. implants as these have significant prognostic value.
Fig. 11 Fig. 12
Multilobulated borderline ovarian cyst. Removal of a borderline tumor: coagulation of the mesovarium with
a bipolar instrument.
In contrast to epithelial ovarian carcinoma, its true malignant

counterpart, borderline ovarian tumors are often detected at
an early stage, and this is probably one of the factors that
encourage the clinician to opt for conservative treatment
and also to use laparoscopy as a therapeutic tool.
The etiology of the disease remains unclear because of the
small number of cases and the lack of randomized controlled
studies. The two major histologic tumor subtypes are serous
and mucinous, with the serous subtype being more common.
Other far less common tumors include clear cell and endo-
metrioid forms. Serous tumors are presumed to originate
from the germinal epithelium. Mucinous tumors do not have a
clearly defined origin. Many authors consider that borderline
tumors occupy an intermediate position between their benign
and frankly malignant counterparts.
These tumors, like other ovarian tumors, are difficult to
Fig. 13
detect clinically until they are advanced in size or stage. The Removal of a borderline tumor: division of the mesovarium.
most common presenting symptoms are abdominal pain,
abdominal distension and the presence of an abdominal
mass. Approximately 23% of patients are completely asymp-
tomatic.
Surgery is always indicated when a complex ovarian mass
is discovered, except in special cases when the patient has
clinical contraindications to surgery. Preoperative diagnosis
of borderline tumors is extremely rare, if not impossible, and
they are nearly always believed to be benign or malignant
ovarian masses. The use of laparoscopy as an early diagnostic
tool is particularly recommended as it allows differential
diagnosis between benign, malignant and borderline tumors
(Figs. 911).
As mentioned above, preoperative diagnosis is very difficult, if
not impossible. Measurement of certain parameters, such as
cancer antigen 125 (CA125) is of little diagnostic value as they
are not specific for borderline tumors. Imaging studies using
transvaginal color Doppler ultrasound have been suggested
to assess the malignant potential of ovarian masses. The
detection rate from intratumoral blood flow characteristics in Fig. 14
borderline tumors is similar to that of malignant neoplasms, Removal of borderline tumor: transection of the round ligament and
tube.
Fig. 15 Fig. 16
Exposure of the appendix. Exposure and double ligature of the appendix before dividing it.
i.e. 90% and 92%, respectively. Doppler indices, such as the from benign lesions. The number of cell layers, percentage of
resistance (RI) and pulsatility indices (PI) are also significantly mitoses and nuclear atypia are the criteria which are used to
reduced in carcinoma and borderline ovarian tumors as define these tumors.
compared to benign tumors. While useful in some situations, Approximately 25% of borderline tumors have cell
this modality is not currently part of the standard work-up. proliferations on the outer surface of the lesion, with no
In terms of specifity and sensitivity its diagnostic value is not evidence of growth from the inner surface. Of these,
sufficient, i.e., it cannot be recommended as a screening approximately 90% develop peritoneal implants. Only
tool in the normal patient population. CT scanning and MRI 4% of cases with peritoneal implants do not have surface
studies may be also useful in the pre-operative work-up. proliferation. Peritoneal implants are described as invasive or
As with other malignant neoplasms, staging is performed noninvasive. Noninvasive implants are glandular or papillary
surgically. Many sources recommend complete staging proliferations with cell detachments.
if a borderline tumor is found. Current guidelines include As regards surgical treatment, complete excision of the lesion
biopsy specimens of the pelvic peritoneum (pouch of Doug- must be achieved if at all possible. Secondary procedures,
las, pelvic wall and bladder peritoneum) and abdominal such as appendectomy, can be performed at the same
peritoneum (paracolic gutters and diaphragmatic surfaces). surgery (Figs. 1219). Comprehensive staging, as described
Some authors also suggest biopsy of the omentum, intestinal above, should be a part of every operation of this type. Even
serosa and mesentery, and retroperitoneal lymph nodes though the stage may or may not affect future treatment, it
(pelvic and para-aortic). is of significant prognostic value and, therefore, is of high
The histologic appearance of borderline tumors is quite relevance for both clinician and patient. In 77% of patients
complex because it is not always easy to differentiate them with invasive peritoneal implants, noninvasive implants
are also found. Surgical excision and full staging decrease
the risk of biopsy error, which could result in an inaccurate
diagnosis and prognosis. Some authors have concluded that
fertility-preserving surgery can be offered to patients with
stage IA disease with serous or mucinous tumors.
The optimal treatment of early-stage borderline ovarian tumors
is controversial. Only a few randomized trials evaluating
adjuvant treatment for this disease have been published. A
Norwegian study concluded that stage I borderline tumors
should not receive any adjuvant treatment.
Surgical laparoscopy can be used in cases where the tumor
is limited to the ovary without any sign of dissemination.
In the past, various authors maintained that laparoscopic
management of borderline ovarian tumors should be reserved
for early-stage disease but that this was associated with a
high risk of recurrence, especially due to an increased rate
Fig. 17 of cyst rupture with possible dissemination of potentially
Removal of borderline tumor: the operating field at the end of the neoplastic cells.
surgery.
Fig. 18 Fig. 19
Removal of borderline tumor: extraction in plastic bag. Invasive peritoneal implants.
In a recent study, a French group stated that conservative remove the tumor without any rupture. In these situations we
treatment and cyst rupture occurred more frequently in the recommend the use of plastic extraction bags when removing
laparoscopy group than in the laparotomy groups. Staging the cysts to prevent any spillage into the peritoneal cavity
was incomplete more often in the laparoscopy group than or port site. Furthermore, in some instances, we perform
in the laparoconversion and laparotomy groups. They enucleation of the entire tumor inside the bag.
concluded that the laparoscopic management of borderline
Some groups maintain that conservative surgery remains a
ovarian tumors is associated with a higher rate of cyst rupture
therapeutic option in selected patients with borderline ovarian
and incomplete staging. It is known that recurrence is more
tumors. Even if the rate of new lesions/recurrence is relatively
frequent after conservative treatment or incomplete initial
high with laparoscopy, especially in patients treated with
staging, whatever the surgical approach.
simple ovarian cystectomy, mortality from cancer remains
This study emphasizes the importance of FIGO staging in low. Many patients are able to conceive and carry a normal
borderline tumors. The majority of laparoscopic surgeons pregnancy to term after conservative surgery.
are more conservative by nature and have a background
in infertility, and this may have a negative influence on the In most instances, laparoscopic surgery is curative for
quality and radicality of surgery. In the case of borderline patients with stage I disease. If the tumor is unilateral and
tumors, the surgeon must combine accurate knowledge of there is still some healthy ovarian tissue, unilateral cystectomy
oncologic aspects with the reproductive concepts of fertility can be performed with preservation of the healthy part of
preservation. Bearing this in mind, it will be possible to offer the ovary; however, inspection of the cyst capsule for signs
all the benefits of laparoscopic surgery even in the area of of rupture should be performed before resection. If it is not
oncology. feasible to preserve healthy ovarian tissue, oophorectomy or
salpingo-oophorectomy should be performed.
As stated by our authors, surgeons still can provide repro-
ductive surgery solutions for these patients. Conservative Because of the possible association between borderline
laparoscopic management of borderline ovarian tumors is ovarian tumors and peritoneal implants, the peritoneum
a potentially safe alternative for young women who want should be explored carefully. Peritoneal assessment must
to retain their fertility potential. Fertility and pregnancy be must be performed with great care. Any suspicious
outcomes remain excellent in these women. Preliminary data peritoneal lesion detected at laparoscopy, should be biopsied
suggest, that the recurrence rate following pregnancy was for histology (invasive or noninvasive) and then removed
not influenced by this approach. surgically. The histological type is of significant prognostic
value.
An important contribution to this topic was also offered by an
Italian group suggesting that the laparoscopic management Most of the complications of this disease are caused by the
of borderline ovarian tumors should be reserved for masses operation itself, adjunctive therapy and by recurrence.
not greater than 5 cm. When conservative therapy is desired, From the results in the literature, it is apparent that it is
they recommend removal of the entire affected ovary. difficult to give an accurate prognosis for an individual patient
Furthermore, they suggest that if the neoplasia is bilateral, without full surgical staging. In one study of stage I disease,
cystectomy could be allowed in women who wish to preserve all recurrences occurred in patients who were inadequately
fertility, although they are at high risk of recurrence. staged. Many, if not all, of these patients probably did not
One of the most important complications of laparoscopic actually have stage I disease.
surgery in oncologic situations is port-site metastasis. In Pathologic diagnosis is difficult to confirm by frozen section.
a recent study, the authors concluded that unlike port-site Borderline tumors are correctly diagnosed by frozen
metastasis in other gynecologic malignancies, the prognosis section in 5886% of cases, depending on the experience
in patients with a port-site implant after laparoscopic of the pathologist. In one very large study, frozen section
management of borderline ovarian tumors is excellent. The indicated probable malignancy in 94% of cases subsequently
treatment of this complication is surgical resection. diagnosed as borderline tumors. Thus, the proper operation
It is important to emphasize that independent of the and staging procedures should have been performed during
technique employed in these cases, suspicious ovarian cysts the initial surgery in most cases, even though diagnosis by
should never be punctured. Extreme care must be taken to frozen section was not completely accurate.
Recommended Reading
1. ATALLAH D, MORICE P, CAMATTE S, et al: Place et 7. MANEO A, VIGNALI M, CHIARI S, COLOMBO A, et al:
rsultats de lexamen extemporan dans la stratgie Are borderline tumors of the ovary safely treated by
chirurgicale des tumeurs pithliales malignes et la laparoscopy? Gynecol Oncol 2004; 94: 387-92
limite de la malignit de lovaire. Gynecol Obstet Fertil
8. MORICE P, CAMATTE S, LARREGAIN-FOURNIER D,
2004; 32 651-6, 2004
THOURY A, et al: Port-Site implantation after
2. CHARLES L, ALGARA A, RAMREZ P, FLORES C: laparoscopic treatment of borderline ovarian tumors.
Manejo Laparoscopico del Tumor Ovarico Limitrofe Obstet & Gynecol 2004; 104: 1167-1170
(Borderline). Analisis de la Literatura y Presentacion
de un Caso. Ginecol Obstret Mex 2001; 69: 355-358 9. MORRIS RT, GERSHENSON DM, SILVA EG, FOLLEN
M, et al: Outcome and reproductive function after
3. DARAI E, TEBOUL J, FAUCONNIER A, SCOAZEC JY, conservative surgery for borderline ovarian tumors.
et al: Management and outcome of borderline Obstet & Gynecol 2000; 95: 541-547
ovarian tumors incidentally discovered at or after
laparoscopy. Acta Obstet Gynecol Scand 1998; 10. TROPE C, KAERN J, VERGOTE IB, et al.
77: 451-7 Are borderline tumors of the ovary overtreated both
4. FAUVET R, BOCCARA J, DUFOURNET C, PONCELET C, surgically and systematically? A review of four
et al.: Laparoscopic management of borderline prospective randomized trials including 253 patients
ovarian tumors: results of a French multicenter study. with borderline tumors. Gynecol Oncol 1993; 51:
Ann Oncol 2005; 16: 403-10 236-243,
5. GREEN AE, SOGOR L: Borderline Ovarian Tumor 11. SERACCHIOLI R, VENTUROLI S, COLOMBO FM,
e-medicine.com GOVONI F, et al: Fertility and tumor recurrence rate
after conservative laparoscopic management of
6. KOERN J, TROPE CG, ABELER VM: A retrospective
young women with early-stage borderline ovarian
study of 370 borderline tumors of the ovary treated at
tumors. Fertil Steril 2001; 76: 999-1004
the Norwegian Radium Hospital from 1970 to 1982.
Cancer 1993; 71: 1810-1820
Chapter XV
Laparoscopic Hysterectomy
Arnaud Wattiez
Strasbourg, France
1.0 Introduction
Hysterectomy is currently the most frequently practised there has been a significant increase in the numbers of
surgery not related to pregnancy in women. In the United laparoscopic hysterectomies over the past ten years; in the
States alone about 600,000 operations are carried out per United States the percentage was 0.3% in 1990 and 9.9%
year. in 1997. Some authors report a high rate of complications
Historically, the first surgical approach for hysterectomy was during laparoscopic hysterectomy: 5.8%11.5% for all
abdominal, carried out in 1843 by Charles Clay in Manchester, complications taken together and a rate of 2.2%2.7% for
England. The alternative to the abdominal route has always major complications. These statistics have led certain schools
been the vaginal route: the first vaginal hysterectomy was of surgery to limit strictly the indication for the laparoscopic
reported by Soranus of Ephesus in 120 BC. Apart from this approach in hysterectomy. The figures are often distorted by
historical curiosity, the vaginal approach has certainly always incorrectly selecting patients who are obese or have a large
been the route of choice, if possible with abdominal hysterec- uterus; moreover, the experience of the surgeon is of funda-
tomy being the alternative when the vaginal approach proves mental importance, particularly during the learning period.
not feasible. More recent studies have shown that after a period of training
of about thirty hysterectomies, the rate of complications
This surgical approach remained unchanged until 1988 when is equivalent to that using other approaches. The average
Harry Reich, in Kingston, carried out the first laparoscopic duration of surgery is also comparable to that required for the
hysterectomy. The first procedure described was laparos- vaginal route in the hands of an expert surgeon.
copic assisted vaginal hysterectomy (LAVH), followed by
supracervical laparoscopic subtotal hysterectomy (SLH) and It is true to say, that nowadays there is no major contra-
finally total laparoscopic hysterectomy (TLH). Over recent indication to the laparoscopic approach in hysterectomy,
years various types of instruments have been produced to not even the dimensions of the uterus; indeed, provided
facilitate TLH, in particular the uterine manipulator, which we proper application of the technique, successful laparoscopic
introduced in 1995. hysterectomy of a very bulky uterus is possible using different
types of morcellators and laparoscopic instruments.
Today, there are many indications for laparoscopic hysterec-
tomy. In benign conditions, it has major advantages, for A surgeons lack of experience and dexterity nevertheless
example in uterine fibromatosis and in the treatment of remain relative contraindications. It is evident, that choosing
genital prolapse, as the first stage of promontory fixation. the laparoscopic approach depends on the surgeons
Malignant conditions now also benefit from the laparoscopic experience and the level of difficulty of each individual
approach, particularly endometrial cancer and, in the hands case. Finally, it is incorrect to unduly extend the length of
of an experienced surgeon, cancer of the uterine cervix. the procedure, thus exposing the patient to excessively
Nevertheless, even today in the United States, only 1015% prolonged anesthesia.
of hysterectomies are carried out by laparoscopy, and The only absolute contraindication is the size of the uterus in
most are only laparoscopic-assisted vaginal hysterectomies the case of endometrial carcinoma, as it is essential to remove
(LAVH). The ACOG (American College of Obstetrics and the uterus intact in the presence of neoplasia. However, this
Gynecology) indications state that, in order to choose the is of fairly rare occurence since endometrial carcinoma is
approach, the anatomy of the patient and the surgeons mostly found in a uterus of normal dimensions.
experience of the different techniques must be considered.
Indeed, most surgeons still prefer the laparoscopic-assisted Finally, if general anesthesia is absolutely contraindicated, the
approach to a totally laparoscopic technique. However, vaginal route may be proposed as a suitable alternative.
2.0 Operating Room Setup

2.1 The Patient
Both arms are arranged alongside the body; this avoids the only from the tip of the coccyx); this position is very important
risk of brachial plexus injury due to the position of the surgeon since it facilitates manipulation of the uterus and, conse-
or assistant. The right arm must be well protected. The use quently, exposure of the tissues.
of shoulder braces is advisable especially if an extreme Each leg will be semiflexed to free a conical manipulation
Trendelenburg position is required. area.
A bladder catheter should be in place throughout the proce- The operating fields are disinfected and adequately draped
dure. for both a vaginal and abdominal approach, allowing the
The patient is placed at the edge of the table (ideally, the soft surgeon to perform uterine manipulations under strict aseptic
perineal parts will be off the table and the patient will lie on it conditions.
2.2 The Surgical Team

The surgeon is on the patients left; he/she operates with both impeding the surgeons view and to ensure effective presen-
hands and should stand upright with both elbows close to the tation.
body, the line of sight passing between both hands. A scrub nurse will be particularly useful when sutures are
The first assistant will be to the right; he/she holds the camera being placed; she is positioned on the surgeons left.
with the non-dominant hand and operates the instrument The table, fitted with stirrups, should be lowered as far as
positioned in the pelvic port. possible to allow the surgeon to adopt a correct ergonomic
The second assistant will be positioned between the patients angle for his arms. One video screen should be positioned by
legs; his/her function is to assist in exposing the operating the patients right foot for the surgeon and another screen by
field to the surgeon. He/she should be seated to avoid the patients left foot for the first assistant.
3.0 Hysterectomy Technique

3.1 Positioning the Trocars
The choice of trocars and their placement depends on the it penetrates deep into the muscle and anastomoses with
technique used, the size of the uterus, cost and availability. the internal mammary artery. In most cases, this artery is
Once the patient is anesthetized, the surgeon conducts a clearly set off against the contour of the umbilical artery;
clinical examination. Vaginal inspection allows the size of the O the lateral edge of the rectus abdominis muscle: this
uterus to be determined. This influences the position of the border is essential, because the port must be placed
trocars. At the same time uterine mobility is assessed. outside the muscle;
The distance betwenn umbilicus and symphysis pubis must O the area of the oblique muscles: a triangular-shaped area
measure at least 30 cm. If this distance is shorter or if the beyond the lateral edge of the rectus abdominis muscle.
uterus is large, the central operating trocar will be inserted The thickness in this area is reduced, with only a few
through the umbilical port and an 11 mm-trocar will be placed muscle fibres;
in the midline between the xiphoid process and the umbilicus O the anterior superior iliac spine situated about 3 cm
for the laparoscope. outside the oblique muscle area.
The primary trocar is usually inserted through the umbilical The lateral accessory ports are placed in the centre of
port. Once the laparoscope with coupled video camera the oblique muscle area. These two trocars are 6 mm in
has been passed through this port, the operating surgeon diameter. We prefer to use lightweight plastic disposable
visually determines the size of the uterus and confirms uterine trocars. They have the advantage of remaining straight in
mobility by use of the manipulator. Access to the adnexa and the abdominal wall, facilitating single-handed insertion of
the pouch of Douglas is also assessed. The upper quadrants operating instruments. The trocar valve allows sutures to be
of the abdominal cavity should be systematically explored. placed with a minimum of gas loss. At this point, the use of
Next, the lateral accessory ports are placed. Special attention a high flow insufflation unit (2030 L/min.; e.g., KARL STORZ
must be paid to the following anatomical landmarks: THERMOFLATOR) is especially recommended to maintain
O the epigastric pedicle: a branch of the iliac pedicle, clear vision even in the case of gas loss (vaginal opening and
emanating from the parietal surface at the level of the deep sutures).
inguinal ring. It continues upwards on the deep surface of Once the lateral ports are in place, the third accessory port
the rectus abdominis muscle. At the level of the umbilicus, is created. This port does not need to be placed below
the horizontal line between the two lateral ports. Ideally, it important during the procedure. In fact, if the ports are placed
should be slightly higher than this line giving the surgeon a at a higher level and the operating field is limited during the
more ergonomic working position and a greater variety of different stages of the procedure, the laparoscopic technique
working angles for use of operating instruments. The distance may also be applied easily even in the case of a very large
between the operating trocar and the camera trocar must be uterus.
as great as possible and should never be less than 8 cm. The diameter of the central port varies depending on the
If the uterus is bulky or if the distance between the umbilicus technique applied. A 6 mm trocar is sufficient for techniques
and the pubis symphysis is short, the umbilical port is used using solely electrosurgical coagulation and sutures.
for the operating instruments, and another port is placed The use of atraumatic forceps, mechanical suturing devices
superiorly. or 10 mm-clip applicators requires the use of a 10/12 mm
One ergonomic criterion that must be observed during trocar. In this case, the umbilical entry site for the central
laparoscopy is bringing together the eye-instrument axis; trocar is advisable.
consequently, the size of the uterus becomes relatively less
3.2 The Uterine Manipulator

The role of the uterine manipulator must be completely under- The distal tip of the manipulator insert can be deflected
stood in the particular context of laparoscopic surgery. In at varying angles (0 to 90 relative to the main axis of the
laparoscopy the access routes are limited and therefore each device); deflection is controlled with the main handle.
time an operator handles an instrument to expose tissues an
access route is lost. Correct use of the uterine manipulator Inserting the manipulator into the uterus requires cervical
allows tissues to be well exposed, thus leaving the operating dilatation up to bougie no. 9. The device is locked into the
trocars free during the procedure. zero position and the manipulator insert is screwed in as far
as the anatomical base guard. The anatomical base itself can
In detail the manipulator permits: be inserted into the cervical os, elevating the axis of flexion as
O mobilization of the uterus (pulsion, lateral movements, far as the interior of the cervix.
anteversion, retroversion, on-axis rotation); The second component of the manipulator is the manipulator
O good visualization of the vaginal fornices (allowing their rod. For good visualization of the fornices the insert can be
identification while keeping the ureter clear); rotated through 360 exposing the whole circumference of
O sealing of the pelvic aperture while opening the vagina; the vagina. As it is made from a non-conductive material, it
can be exposed to unipolar current without risk of an electric
O possible help in morcellating a large uterus at the end of
arc. The manipulator insert is available in various lengths and
the procedure;
widths fitting all kinds of vaginal shapes. The lockable handle
O visualization of the vaginal cuff and sealing to facilitate at the proximal end of the longitudinal axis allows the mani-
vaginal closure. pulator insert to be controlled precisely. The position of the
The uterine manipulator plays an even more essential role proximal manipulator rod matches with the distal orientation
when the hysterectomy is difficult. This may be the case with of the insert. In this way, the assistant maintains constant
a large uterus, when correct use of the uterine manipulator visual control of the position of the manipulator insert. The
will allow the procedure to be carried out with the best tissue combination of active deflection of the manipulator tip and
exposure and a significant reduction in surgical risks. on-axis rotation via the manipulator rod helps in reducing
iatrogenic injuries to the ureter during laparoscopic hysterec-
Various uterine manipulators are available. We use a manipu- tomies.
lator with a threaded distal tip which is screwed into the
uterus. The threaded tip is chosen depending on the size Finally, the device has a sealing system consisting of 3 soft
of the uterus. Non-threaded tips are used in the case of plastic discs; this has the advantage of not obstructing
malignant disease and these are simply advanced into the the vagina during final manipulations facilitating posterior
uterus. opening of the vagina.
3.3 The Role of the Operating Team

The surgeon, located to the left of the patient, controls the The scissors can be connected to the unipolar electrosurgical
instruments introduced through the central and left operating unit. It is advisable to use grasping bipolar forceps which
ports. The first assistant located to the right controls the permit to combine as many functions as possible in the same
camera and the instrument placed in the right trocar. The instrument. The operating surgeon thus has various functional
second assistant situated between the legs of the patient options available to his two hands: on the left, manipulation,
is seated and mobilizes the uterus by operating the uterine grasping and electrocoagulation; on the right, dissection,
manipulator. mechanical dissection and electrocoagulation.
The surgeon usually begins the procedure by inserting bipolar The assistant inserts forceps, usually atraumatic forceps, in
forceps into the left trocar and scissors into the central trocar. the right trocar.
3.4 The Round Ligaments

The first part of the procedure is the same for hysterectomy was exposed, made up of the juxtaposition of two anterior
both with and without adnexectomy. It consists of and posterior peritoneal layers of the broad ligament. This
coagulation and division of the round ligaments, followed area appears grey owing to the presence of CO2 and an
by opening of the vesicouterine space with dissection of the empty space under the posterior leaf of the broad ligament.
bladder. The surgeon should coagulate the round ligament at the
The second assistant mobilizes the uterus to the right without center of this triangle. In this way, the surgeon keeps a safe
anteflexion, applying a well-measured thrust. The surgeon distance from the adnexal vein and limits the risks of bleeding.
grasps the left round ligament at its origin anterolateral to The round ligament is divided in the midline by intermittent
the uterus and exerts traction to the right and upwards. This coagulation and section. It should be noted that an arteriole
reveals a triangle bordered by the round ligament at the top, is sometimes present behind the ligament, and this must be
iliac vessels laterally, and adnexal vein medially. By placing carefully coagulated (Figs. 13).
the round ligament under tension, the center of this triangle
Fig. 1 Fig. 2
Transection of the round ligament. Transection of the round ligament after bipolar coagulation.
Fig. 3
A fenestration is created in the leaf of the broad ligament.
3.5 Dissection of the Vesicouterine Pouch

Once the round ligament has been transected, the access to and slightly retroverted while the first assistant grasps the
the vesicouterine space is open. prevesical peritoneum in the midline. It is grasped 1 cm
The first assistant now directs traction downwards to provide below the junction of the peritoneum and the uterine serosa.
a clear view and access to this space. The surgeon should It must be divided in a plane strictly perpendicular to the
then divide the vesicouterine peritoneum by simple traction. uterus while the latter is pushed firmly upwards to avoid any
He introduces his two instruments into the prevesical iatrogenic visceral injury. Ideally, the bipolar forceps, resting
space taking care to remain in contact with the peritoneum on the uterine isthmus, grasps the peritoneal falx and it is
above; then, separating the instruments, he opens the then divided with scissors in the same plane as far as the
space progressing downwards and inwards. The peritoneal isthmus.
capillaries are gradually coagulated. The peritoneum is This action together with the momentum applied to the
divided using cold scissors or by coagulation and cutting in uterus automatically reveals the plane of vesicovaginal
one step if the scissors are connected to the unipolar electro- dissection once the incision has been made. When this plane
surgical unit. This dissection should stop about 1 cm from is reached, blunt dissection of the bladder is carried down-
the midline. wards. The two internal bladder pillars are put under tension
At this point the second assistant moves the uterus towards by upward traction on the bladder and are coagulated and
the surgeon, while the first assistant grasps the round dissected.
ligament as close as possible to the wall. Traction to this This space must be dissected carefully especially in the case
ligament applied outwards and upwards creates the triangle of previous surgery, in particular previous cesarean section.
described above. In these cases the first assistant must elevate the prevesical
The same technique is employed to reach about 1 cm from peritoneum well while the second assistant pushes the
the midline. At this point the uterus is pushed upwards uterus. The surgeon must create a plane which is strictly
Fig. 4 Fig. 5
Identification of the vesicouterine fold. The vesicouterine fold is elevated prior to being incised.
Fig. 6 Fig. 7
Complete division of the vesicouterine peritoneum. Identification of the vesical pillars.
perpendicular to the uterus. During dissection of the left peritoneum too close to the bladder. To prevent this error,
vesicouterine peritoneum, care must be taken as the the uterus must be well centred and pushed slightly down-
surgeon, on the patients left, has a tendency to dissect the wards by the second assistant (Figs. 47).
3.6 Fenestration of the Broad Ligaments

The surgeon now fenestrates the broad ligaments on the appear grey, indicating that the intestine is not interposed
right and left. The uterus is again elevated and mobilized to behind it. The peritoneal leaf is opened by blunt dissection or
the right, putting the left adnexa under tension. The surgeon is divided. Once the opening has been made, the surgeons
carefully coagulates the capillaries of the broad ligament to two instruments are introduced into the fenestration which is
separate the posterior leaf of the broad ligament. This should enlarged by divergent traction.
3.7 Treatment of the Adnexae

Hysterectomy without Adnexectomy Today other instruments are also available which coagulate
The opening is extended towards the uterosacral ligaments. and cut simultaneously, either using ultrasound or
In a total hysterectomy, it is extended towards the suspen- radiofrequency. They can be helpful, especially in difficult
sory ligament of the ovary. Indeed, once the fenestration has hysterectomies, but using the bipolar modality is still the
been created, the ureter is found on the external side of the classic technique of choice.
window (against the wall). Whatever technique is chosen to
detach the adnexa or the suspensory ovarian ligament, the Hysterectomy with Adnexectomy
ureter is not endangered. The first assistant should grasp the ovary and put the suspen-
In a hysterectomy without adnexectomy, the adnexa may be sory ligament of the ovary under traction. The surgeon then
coagulated and divided where it merges with the uterus by a coagulates and divides the ligament close to the ovary. Once
succession of bipolar coagulations followed by division. For the vascular pedicle has been divided and before completing
effective coagulation, it is preferable to set the power at 35 division of the ligament, the traction is slightly reduced and
watts and to increase exposure time. any hemostasis completed. Once division is complete and
the ligament has retracted, absolute hemostasis must be
In hysterectomy without adnexectomy linear cutting staplers confirmed.
are most appropriate. In this case, a blue cartridge should
be used (closed staple size equal to 1.5 mm). The stapler is Adequate venous hemostasis must always be secured to
best introduced via a 12 mm trocar situated in a high central order to avoid problems related to impeded vision, which can
position. As a general rule, a single cartridge is sufficient for lengthen the duration of surgery.
the adnexal transection. Often a residual peritoneal adhesion
must be lysed to complete the transection.
3.8 Treatment of the Uterine Artery

Once the problem of the adnexa has been resolved, the then as follows: the uterine arteries can be seen with behind
uterine vascular pedicles are dissected. The objective is to them the vaginal fornix freed from the cardinal ligament.
produce an anatomical situation which separates the ureter
The surgeon then moves to the front of the uterine pedicle.
from the pedicle of the uterine artery. The first step is posterior
The uterus is slightly retroverted and pushed firmly upwards.
dissection. The uterus is first pushed upwards and to the
Starting from the internal pillar of the bladder, all the tissue in
right. The first assistant grasps the stump of the left round
front of the uterine pedicle is coagulated and divided.
ligament and applies traction to it which is directed inwards.
At the end of this procedure the uterine pedicle stands out on
In a total hysterectomy it may be preferable to apply traction the lateral surface of the uterine isthmus, between the vaginal
to the adnexa. The surgeon applies traction to the posterior fornices to the front and rear. The dissection is complete
peritoneum by introducing the bipolar forceps between the apart from the pedicle and the ureter is clearly visible.
posterior peritoneum and the base of the parametrium. The The same technique is used on the opposite side. The uterus
forceps moves in contact with the peritoneum towards the is moved to the left and the first assistant pulls the uterus
left cardinal and uterosacral ligaments. The peritoneum is towards the left via the stump of the round ligament. On this
separated by back-and-forth movements, releasing the parts side, the angle of approach of the surgeons instruments is
of the parametrium which are moved clear. The peritoneum is often inadequate and, consequently, a risk of injury to the
then coagulated and divided. ureter can arise. To avoid this risk, the arrangement of instru-
ments has to be changed: the bipolar forceps is given to the
Progression continues towards the uterosacral ligament. first assistant, the scissors are in the center and the forceps
In the process the cardinal ligament is coagulated and cut, is moved to the left. The surgeon puts traction on the uterus
releasing the arch of the uterine artery which is isolated. The via the stump of the right round ligament and the assistant
uterosacral ligament is sectioned in its turn. This step can carries out the same dissection as that carried out by the
be made easier by anteflexion of the uterus. The situation is surgeon on the left. The surgeon retains control of the pedal.
In this way, the right and left uterine pedicles are treated. At O since coagulation makes the tissue resistant to the passage
the end of this step the ureters are at least 4 cm away from of current, this tissue should be resected and coagulation
the ascending branch of the uterine artery where hemostasis carried out again on non-coagulated tissue.
will occur. Technically, the assistant draws the uterus towards the right
The uterine artery and vein can be dealt with using various by means of the left arterial pedicle while the manipulator is
techniques. The first hysterectomies were carried out using pushed firmly upwards and to the right. Using the bipolar
bipolar coagulation for the uterine vessels. The large number forceps in the left lateral trocar, the surgeon grasps the
of cases treated successfully has demonstrated the efficacy mass of the uterine pedicle at the level of the ascending
of this technique. The only risk is electrical tissue damage branch. After global coagulation, the surgeon concentrates
extending to the ureter. on the superficial layers which are then incised using little
The rules to be observed to avoid injuries of the ureter are: scissor cuts. The pedicle is thus incised gradually. This
produces perfect coagulation of the veins of the periarterial
O issection as previously described so that the uterine vessels uterine plexus and the artery is more easily seen and in turn
are dissected clear in front, to the sides and behind; coagulated and transected.
O coagulation should be applied only to the ascending branch Once the artery has been divided, the surgeon should
of the uterine artery; continue with dissection in front and behind to lower the
O the time of exposure to coagulation should be as brief as pedicle beyond the boundary of the vaginal fornix. This is
possible. Short repeated coagulation is preferable to long thus a true interfascial hysterectomy. During this step the last
sustained coagulation; parts of the cardinal ligament are coagulated and divided.
Fig. 8 Fig. 9
Anatomic view of the uterine artery and relations with the ureter. Identification by careful dissection of the site where the uterine
artery crosses the ureter.
Fig. 10 Fig. 11
Identification of the relations between the ureter and uterine artery. Identification of the uterine artery and hemostatic suture.
The same procedure is used for the right pedicle. For the
safety of the ureter it is important that the assistant uses the
bipolar forceps. He can approach the pedicle perpendicular
to the ascending portion and thus decrease the risk of injury
to the ureter. Naturally, the surgeon retains control of the
pedal.
The uterine pedicles may also be dealt with using ligatures
or clips. Ligatures have the advantage of not requiring
complete dissection of the artery. Once the dissection of
the pedicle has been completed as described above, a
0 Vicryl suture attached to a curved 30 mm needle is passed
through. It is simpler to pass from front to back of the pedicle
on the left and from back to front on the right. The needle
should penetrate from the dissected vaginal angle at the front
and emerge in the posterior angle to avoid loading too much
vagina behind the vessels. This would involve a risk of cutting
the suture during subsequent interfascial dissection. Fig. 12
Skeletonization of the uterine artery and extracorporeal laparoscopic
suture.
Fig. 13 Fig. 14
The suture is applied to the vascular pedicle. Laparoscopic suture is preferable to bipolar coagulation if the
uterine artery cannot be skeletonized perfectly.
15 16
Figs. 1516
Coagulation with bipolar forceps is an optimal alternative for
occluding the uterine artery.
In this case intracorporeal sutures seem to be contraindicated

and it is preferable to use extracorporeal sutures, either
half-hitches or Roeder knots. However, after cutting and
isolating the uterine pedicle it is sometimes necessary to
place a second ligature using an endoloop.
The use of sutures for the uterine pedicles seems to be

particularly indicated in the case of a bulky uterus both for
controlling hemostasis better and for reducing the risk of
injury to the ureter, which is a major risk when the uterus is
very large.
The use of clips requires dissection of the whole surface of

the artery. There are two possible solutions: remaining with
the ascending branch or starting at the point where the artery
moves away from the uterus.
For the ascending branch, repeated coagulation of the Fig. 17

peripheral veins around the artery should be carried out; In some cases, the openings of the uterine vessels can be
then, by dividing them successively, the artery is exposed identified perfectly.
and clipped. Away from the uterus, the artery and vein are
more easily separated. Dissection should be carried out with In all cases the clip should be closed under visual control. The
as little coagulation as possible due to the proximity of the artery should be only partially blocked to confirm the efficacy
ureter. of the clip (Figs. 817).
3.9 Opening and Division of the Vagina
At this point in the operation the uterus is no longer Usually the incision is started from the anterior vaginal wall.
vascularised and becomes pale. The uterine manipulator rod, At the start the surgeon is equipped with the bipolar forceps
which is turned through 360, shows that the uterine pedicles on the left and disposable scissors in the centre. For the
have been dissected lower than the vaginal fornices. incision the scissors are connected to the monopolar current.
The sealing ceramic cylinder of the manipulator is advanced The first assistant uses a suction cannula to aspirate blood
into the vagina, after being lubricated with gel or vaseline oil. and evacuate the smoke generated by the high frequency
The three silicone seals that can be mounted to the cylinder current. The second assistant manipulates the uterus using
should be inside the vagina. The surgeon must open the the rod to expose the various parts of the vagina to the
vagina through 360. The more the vagina is open the more surgeon for division.
the second assistant loses control of the uterus with the He does this by rotating the rod in the same direction as the
manipulator. division. It is important that the rod should be rotated before
Fig. 18 Fig. 19
Dividing the vagina with the high frequency unipolar electrode. The incision follows the porcelain margin of the uterine manipulator.
Fig. 20 Fig. 21
After vaginal extraction of the uterus, the opening must be sutured. Laparoscopic suture of the vaginal opening.
the surgeon has completed the division as far as the angle During division, it may be necessary for the surgeon to move
of the rod. If this is not the case, the rod will escape from the the scissors to the left trocar to gain better access for dividing
edge of the fornix and penetrate into the abdominal cavity. the fornix (Figs. 1820).
Correct repositioning of the manipulator rod may thus result
in loss of the pneumoperitoneum.
3.10 Extraction of the Uterus and Vaginal Closure

Once the uterus has been freed, if it is of normal size, it is because the vaginal approach requires the patient to be
easily extracted via the colpotomy. The second assistant repositioned, which involves a loss of time. For laparo-
draws the uterus into the vagina; in this way, the pneumoperi- scopic suturing, a glove filled with gauze swabs placed in the
toneum seal is maintained and the edges of the vagina are vagina is the best means of maintaining the pneumoperito-
presented for closure. neum. Suturing is usually carried out with a no. 0 or 1 thread,
attached to a curved 3036 mm needle. The surgeon inserts
On the other hand, if the uterus is large, it must be morcellated
the needle straight into the needle holder of the left trocar.
before extraction. Morcellation may be performed via the
He pierces the upper lip of the vagina in the centre of the
vaginal or laparoscopic routes, using a laparoscopic scalpel
colpotomy which is presented by the assistant. He then holds
with a retractable blade. The uterus is either hemisected or
this lip by half rotating the needle upwards. The assistant
morcellated and can then be extracted through the vagina.
then presents the posterior edge of the vagina which is in
The vagina may be closed via the vaginal or laparoscopic turn pierced. It is essential to transfix the vagina completely
approach. Normally the laparoscopic approach is preferable to produce total haemostasis. The surgeon repeats this
22 23
Figs. 2223
The two uterosacral ligaments are anchored with the laparoscopic
vaginal suture.
operation to produce an X suture. As a rule, extraction of the advisable to use two semicontinuous sutures which will then
thread poses no problem. This suture is placed on the right be joined in the middle of the suture. It is also advisable in this
and left. There are thus two X sutures taking in the center and case, to strengthen the vaginal vault by including the end of
then the angle of the colpotomy on either side. the uterosacral ligaments in the suture.
In some cases a third central X stitch may be made which
A final lavage completes the operation. Bleeding of the vaginal
also includes the ends of the uterosacral ligaments to provide
section is carefully dealt with using bipolar current. The
better support for the vaginal vault. Removal of the uterus or
ureters can then be checked. Peristalsis is not a guarantee of
the intravaginal glove acts as a test of the seal.
their integrity, but the combination of an absence of dilatation
We prefer to use extracorporeal sutures for closing the vagina, and presence of peristalsis means that the risk of injury is
but intracorporeal sutures may also be used. In this case, it is unlikely (Figs. 2123).
4.0 Subtotal Hysterectomy

In general we prefer total hysterectomy, except where the division may be performed in various ways. We prefer to use a
hysterectomy is associated with the management of a uterine cold scalpel with an endoscopic blade holder. Closure of the
prolapse or a suprapubic suspension operation. uterine cervix is carried out with interrupted Vicryl 0 stitches.
In any case, in a subtotal hysterectomy the cervix is divided
at the isthmus after dealing with the uterine arteries. This

Antibiotic Treatment Period of Foley catheterization
All patients receive a single dose of antibiotics during the This is continued only for the duration of the operation except
operation. Postoperative treatment is not systematic in our in cases with associated subpubic suspension.
experience. We only treat infections confirmed after taking
samples and an antibiogram. Length of hospital stay
This varies from 2 to 3 days.
Prevention of Postoperative Thrombophlebitis
Our patients systematically receive prophylactic antithrom- Postoperative Hygiene
botic treatment. Low dosis heparin is started on the day of
In the postoperative period, the patient should avoid effort,
admittance prior to surgery and is continued for 15 days.
at least for the first month. Sexual activity should not recom-
mence until after the first postoperative check-up, one month
after surgery.
6.0 Conclusions
We started to perform total laparoscopic hysterectomy in regarded as a basic procedure for a gynecological surgeon,
1989, but only in 1995, with the introduction of the uterine it should be considered an advanced procedure if performed
manipulator, did our technique become standardized and through the laparoscopic approach. This does not indicate
reproducible. The operating technique is now well estab- any real difficulty in the procedure but rather a poor under-
lished and this surgical guide, in our opinion, should allow standing of laparoscopic surgical technique which should
a laparoscopic hysterectomy to be carried out completely nowadays be an integral part of the basic knowledge of the
safely. A final consideration is that even if hysterectomy is gynecological surgeon.
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CANIS M, BOTCHORISHVILI R, MAGE G, POULY JL, (7432): 134.
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M, BOTCHORISHVILI R, POULY J, MAGE G, BRUHAT
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6. WATTIEZ A, COHEN SB, SELVAGGI L: Laparoscopic FAUCONNIER A, FERNANDEZ B, BREART G,
hysterectomy. Curr Opin Obstet Gynecol. 2002 Aug; DUBUISSON JB: Hysterectomy techniques used for
14(4):417-22. Review. benign pathologies: results of a French multicentre
study. Hum Reprod. 1999 Oct; 14(10):2464-70.
7. CHAPRON C, DUBUISSON JB, ANSQUER Y: Total
laparoscopic hysterectomy. Indications, results, 21. DAVIES A, HART R, MAGOS A, HADAD E, MORRIS R.:
and complications. Ann N Y Acad Sci. 1997 Sep 26; Hysterectomy: surgical route and complications. Eur J
828:341-51. Review. Obstet Gynecol Reprod Biol. 2002 Sep 10; 104(2):
8. CHAPRON C, DUBUISSON JB: Total hysterectomy: 148-51.
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of laparoscopy Gynecol Obstet Fertil. 2000 Sep; aspects of laparoscopic hysterectomy. Acta Obstet
28(9):672-8. Gynecol Scand. 2001 May; 80(5):383-91. Review.
9. CHAPRON C, DUBUISSON JB.: Ureteral injuries after
23. HERTEL H, KOHLER C, MICHELS W, POSSOVER M,
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TOZZI R, SCHNEIDER A.: Laparoscopic-assisted
15(3):733-4.
radical vaginal hysterectomy (LARVH): prospective
10. COSSON M, LAMBAUDIE E, BOUKERROU M, QUERLEU evaluation of 200 patients with cervical cancer.
D, CREPIN G.: Vaginal, laparoscopic, or abdominal Gynecol Oncol. 2003 Sep; 90(3):505-11.
hysterectomies for benign disorders: immediate and
early postoperative complications. Eur J Obstet 24. LYONS TL.: Laparoscopic supracervical hysterectomy.
Gynecol Reprod Biol. 2001 Oct; 98(2):231-6. Obstet Gynecol Clin North Am. 2000 Jun; 27(2):441-50.
Review.
11. DONNEZ J, SQUIFFLET J, JADOUL P, SMETS M:
Results of evaluate study of hysterectomy techniques: 25. MALZONI M, PERNIOLA G, HANNUNA K, IUELE T,
high rate of complications needs explanation. BMJ. FRUSCELLA ML, BASILI R, EBANO V, MARZIANI R.:
2004 Mar 13; 328(7440):643. A review of 445 cases of laparoscopic hysterectomy:
12. KOH CH.: A new technique and system for simplifying benefits and outcome Clin Ter. 2004 Jan; 155(1):9-12.
total laparoscopic hysterectomy. J Am Assoc Gynecol 26. MEEKS GR, HARRIS RL.: Surgical approach to
Laparosc. 1998 May; 5(2):187-92. hysterectomy: abdominal, laparoscopy-assisted, or
13. KOH LW, KOH PH, LIN LC, NG WJ, WONG E, HUANG vaginal. Clin Obstet Gynecol. 1997 Dec; 40(4):886-94.
MH: A simple procedure for the prevention of ureteral Review.
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27. PARKER WH.: Total laparoscopic hysterectomy.
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Obstet Gynecol Clin North Am. 2000 Jun; 27(2):
14. KOVAC SR, BARHAN S, LISTER M, TUCKER L, 43140. Review.
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15. AL-JUBOURI MA.: Laparoscopic assisted vaginal 29. WOOD C.: The AAGL classification system for
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Chapter XVI
Laparoscopic Surgery
of the Pelvic Floor
Arnaud Wattiez
Strasbourg, France
1.0 Introduction
The laparoscopic management of uterine prolapse began the outstanding quality of videoendoscopic images and the
in our department in 1991 and there has been considerable positive pressure of the pneumoperitoneum have granted
development in the technique since then. It was initially access to anatomical spaces that were hitherto very difficult
limited to faithful reproduction of the techniques employed to reach and allows surgical repair under direct visual control.
at laparotomy but numerous complementary features were
added subsequently, allowing us to deal with any circum- The results, which were encouraging overall, are now excellent
stances that arise during female prolapse surgery. owing to repair surgery that is perfect from the anatomical
aspect and provides exceptional functional results.
The common benefits of the laparoscopic approach, such as
rapid postoperative recovery and short hospitalization, were The only issue that remains to be resolved is to simplify this
soon surpassed by the innovative aspect of this technique. technique so that it can be performed in acceptable operating
Indeed, the combined effects of various factors mainly, times.
2.0 Preoperative Workup

Preoperative workup must be particularly careful and precise. compartment. Standard clinical examination must attempt
Only a thorough evaluation of all defects that need to be to define the degree of prolapse involving the uterus,
treated will allow surgical repair in a single operative session bladder and rectum. Lateral cystocele with the vaginal rugae
and minimize the risks of postoperative functional sequelae preserved must be distinguished from central cystoceles
and recurrences. with elimination of the vaginal rugae. The former is due to
detachment of the vagina from the tendinous arc of the pelvic
fascia while the latter is due to a break of the vesicovaginal
2.1 Assessment of Uterine Prolapse fascia. A systematic exploration must make sure that any
Diagnosis of all the defects is the crucial moment of the enterocele is detected. The muscular tonus of the levator ani
clinical workup. It is essential to stage the defects for each muscles must be assessed in terms of quality and quantity.
3.0 Preparation of the Patient

Preparation of the patient is essential to obtain optimum 3.2 Vaginal Estrogens
results from this type of surgery. Preparation of the vaginal
tissues to promote healing and bowel preparation to optimize Administration of vaginal estrogens for at least a month prior
the endoscopic space are particularly useful. to the operation is useful for improving vaginal nutrition.
Improvement of vaginal nutrition will allow better and faster
healing.
3.1 Bowel Preparation
The purpose of this preparation is to empty the bowel so that 3.3 Vaginal disinfection
the loops of intestine can be better seen and to deflate and
flatten them to increase intra-abdominal space. However, Vaginal disinfection is particularly important and must be
it can also be useful in the event of accidental bowel injury. carried out the evening before the operation by vaginal lavage
Preparation begins with a classical low-fiber diet for the five with an antiseptic solution and administration of a Betadine
days prior to surgery. Two evenings before the operation, a vaginal ovule. The abdominal wall is also disinfected. After
laxative Xprep enema is administered. Finally, lavage of the a shower, the evening before the operation, the patients
lower bowel is performed the evening before surgery. This pubic hair is shaved and the abdominal wall and inside the
chronological order is particularly important in order to avoid umbilicus are cleaned and disinfected with an antiseptic
anal leakage on the operating table during surgery, which solution. Finally, immediately before surgery, a solution of
exposes the patient to a greater risk of infection. Betadine is applied prior to sterile draping.
4.0 Positioning of the Patient

Laparoscopic surgery is often long and difficult. Optimizing the acromion prominence, avoiding compression of cervical
the surgical technique and reducing operating times require muscles. Attention must also be paid to the position of the
ergonomic management of the operation, and correct patients hands to avoid compression of the fingers. In some
arrangement of the patient is fundamental. cases, a warming system is used to prevent sudden drops in
the patients body temperature.
The patient must be positioned well down the table the better
4.1 Anesthesia
to allow movements of the uterine manipulator. The greater
General anesthesia with endotracheal intubation is usually the possibilities for moving the uterine manipulator, the better
employed. Muscle relaxation is necessary only where it is not will be the exposure of the different organs during surgery.
possible to obtain sufficient distension of the abdominal wall The abdominal wall and vagina are disinfected carefully and
with a pneumoperitoneum of 12 mmHg. General anesthesia the operation area is prepared prior to introduction of the
can be combined with locoregional epidural or spinal Foley catheter and uterine manipulator. It is imperative that
anesthesia to improve the postoperative course. the perineal region is sterile and accessible to the surgeon,
who should perform a vaginal or rectal examination during
the operation and position the uterine manipulator.
The patient is placed in dorsal decubitus with the legs apart
and semi-flexed. This position allows three surgeons to take 4.3 Bladder Catheterization
up position: The operating surgeon is situated on the left of An indwelling no. 18 Foley catheter is placed. The balloon is
the patient. The first assistant stands opposite to the surgeon inflated with 15cc of saline and the catheter is placed under
on the right side of the patient, and the second assistant traction to make it easier to demonstrate the bladder neck.
is positioned between the patients legs. The patients two The catheter is connected to a collecting bag which is placed
arms are placed alongside her body to avoid injuries of the in visible position so that the urine can be monitored (volume,
brachial plexus. Shoulder braces are placed at the level of color, presence of air in the bag).

5.1 Clinical Examination 2 The inter-iliac distance. Suturing is facilitated by the
position of the trocars. A short patient will mean that the
It is absolutely essential to reassess the uterine prolapse on trocars are positioned higher to gain space.
the operating table as soon as the patient is anesthetized. This
reassessment under anesthesia can provide new information 3 The obesity of the abdominal wall must be assessed
that may modify the operative strategy. The assessment because the trocars are easier to position where the wall
is performed with the aid of vaginal dilators and will allow is thinner. However, more elastic areas should be avoided
evaluation of the line of the vagina and better distinction of because of the difficulty if they need to be reinserted.
its upward and downward movements. This will also allow a 4 The laxity of the peritoneum will give an idea of the
better assessment of the retrovaginal space and its mobility. operation space and the positioning of the trocars will
In the event of hysterectomy, assessment of the size and therefore depend on this.
mobility of the uterus will allow correct choice of trocar
positions.
5.3 Placement of Trocars
In general, 4 trocars are necessary, three suprapubic
5.2 Appearance of the Abdomen (6 mm) and one umbilical (11 mm). The first trocar, 11 mm in
The patients general build and the appearance of the diameter, is normally positioned at umbilical level. Following
abdomen determine the organization of the surgical field and internal inspection and comparison of the size of the uterus
the placement of the trocars. The ergonomics of the operative and the patients build, the final position of this trocar is
maneuvers will depend on this. defined. If the size of the uterus is normal or below normal
and the pubis-umbilicus distance is sufficient, this trocar will
Numerous aspects must be considered: be used for the laparoscope; if, on the contrary, the uterus is
1 The patients build. The first thing to consider is the large and the pubis-umbilicus line is short, this trocar will be
distance from the umbilicus to the pubic symphysis, the central operating port. In the great majority of cases, the
which will determine the distance between the umbilical position is therefore as follows: three suprapubic trocars and
and suprapubic trocars. The latter, in particular, must one umbilical trocar.
be placed sufficiently high up to allow access to the
promontory and the space of Retzius and allow the vari-
ous sutures to be placed. If the patient is of short stature,
the camera trocar must be placed in supraumbilical posi-
tion and the suprapubic trocar is placed at umbilical level.
1 Suprapubic trocars: we prefer to use mtp disposable 2 The umbilical trocar is a simple reusable trocar, which
6 mm trocars. They have the advantage of being light and holds the laparoscope. In fact, this model has a valve,
transparent and being threaded on the outside, which which can be lowered for introducing the laparoscope; this
ensures that they are stable in the abdominal wall; they allows the distal lens to be kept clean during introduction
have a star-shaped valve which prevents gas leakage so it is an economic factor with regard to efficient use of
even during suturing. Their cost is also acceptable. The operating time. If the umbilical entry site is used as central
lateral trocars are placed anterior to the anterior superior port for operating instruments, we prefer the use of a
iliac spine, two fingers medial to the spine and lateral to disposable trocar with a removable reducer attached to
the outer border of the rectus abdominis muscle. They the proximal end of the trocar.
are passed through the oblique and transverse abdominal In the classical situation (three suprapubic trocars and one
muscles. At this level, the thickness of the abdominal wall umbilical trocar), we prefer to begin the operation with three
is usually reduced which facilitates the maneuvers. The 6 mm trocars for dissection and then replace the central
central trocar is positioned along the pubis-umbilicus trocar for suturing (after the hysterectomy is complete).
line more or less in the middle. The minimum distance
between the umbilical primary port and the central port
is 6 cm. In any case, it should be positioned below a line
joining the two outer trocars.
6.0 Organization of the Operating Field

6.1 Positioning of the Uterine Manipulator
The CLERMONT-FERRAND uterine manipulator is essential prepared because the surgeon must be able to manipulate
for demonstrating the uterus. It allows the uterus to be mobi- under completely aseptic conditions.
lized in all its axes: advance motion, anteversion, retroversion, After demonstrating the cervix, hysterometry gives the size
lateralization and flexion of the uterus forwards and laterally. of the uterus so that the appropriate manipulator insert can
It also permits: be selected. The cervix is dilated with Hegar dilators up to
O exposure of the vaginal cul de sac size 8. With the manipulator locked in zero position, a twisting
O maintenance of the pneumoperitoneum motion is applied to push the device through the cervical os
O sealing of the vagina after extraction of the uterus until the threaded part of the insert is completely within the
The device comprises a series of concentric rods. The central cervical canal. At the end of this maneuver, the handle locking
rod is threaded at the distal end, which is inserted in the mechanism must be on the right.
uterus. The manipulator inserts are available in various sizes Most of the time, the manipulation movement must be
to match the size of the uterus. The threaded distal end of preceded by a pushing movement in the direction of the
the insert can be deflected by use of the manipulator handle. patients head. This is because anteversion of the uterus is
Outside this rod there is a sealing ceramic cylinder, which achieved by a combination of two movements: pushing the
can rotate through 360 degrees to allow exposure of the uterus and anteversion by lowering the handle. In this way,
cul-de-sac. This cylinder can be mounted with three silicone the uterosacral ligaments are placed under tension and the
seals. Once hysterectomy is complete, the manipulator with cul-de-sac of the pouch of Douglas is exposed. The adnexae
its silicone seals is pushed toward the vaginal vault preventing are exposed the same way with a movement of pushing and
gas loss and making sure that pneumoperitoneum will be lateral deflection of the handle towards the patients legs,
maintained. which are in gynecologic lithotomy position.
The CLERMONT-FERRAND manipulator must be positioned The dilator can be pushed any time and allows correct
when the patient is asleep and the operation area has been exposure of the vaginal cul-de-sac.
6.2 Fixation of the Intestine

At the start of the operation, organization of the operation The sigmoid is elevated with the aid of forceps and the suture
field is highly important to achieve stability and exposure is tied on the outside. The same can be done with a curved
without the assistants intervention. The pouch of Douglas is needle introduced into the abdomen; the sigmoid fat is trans-
exposed by fixing the sigmoid to the abdominal wall. For this fixed and the needle is then brought out again through the
maneuver, we use two different techniques. The first employs same trocar and the suture is then tied. A Reverden needle is
a nylon suture with a straight needle, which is introduced then used to bring the sutures out transparietally always more
through the abdominal wall about 5 cm above the left lateral or less 5 cm above the left lateral trocar and they are fixed
trocar. The needle then passes through the parasigmoid fat using a forceps. In the same way, following hysterectomy,
from one side of the sigmoid to the other and then comes the vagina or remaining cervix can be suspended from the
out again through the abdominal wall through the same hole. anterior wall using a Reverden needle.
6.3 Division of the Insertion of

the Uterosacral Ligaments
The insertion of the uterosacral ligaments can be divided
at the start of the operation. Culdoplasty commences from
this point. They can be divided simply by touching them with
bipolar coagulation or better with a suture.
7.0 Surgical Strategy Planning

The strategic order of the surgical steps is important and the 7.1 Hysterectomy
phases of dissection must first be distinguished from the
phases of fixation. Classically, the uterus is left in position to avoid opening the
vagina with the risk of infecting the mesh. This technique is
O Phases of Dissection. The chronological order is as
possible by the laparoscopic route; the spaces are dissected
follows: dissection of the promontory, right lateral peri-
with sparing of the round ligaments and with the meshs
toneal dissection, the rectovaginal space followed by
crossed by the broad ligaments. The current trend is to
hysterectomy, during which vesical dissection is pushed
perform total or subtotal hysterectomy. In our experience
far downwards. This order is logical. Dissection of the
subtotal hysterectomy has proven better because the vagina
promontory first is essential and to do this, an increased
is not opened. In the case of total hysterectomy, the vaginal
Trendelenburg position is important, which is often
vault is closed in two layers.
possible only at the start of the operation. Once this
dissection is complete, the patient can be placed level As stated above, the essential difference compared with
if required by the anesthetist. Dissection of the spaces a simple hysterectomy is the chronology of the operating
where the meshes will be placed is made easier by the phases. When treating a prolapse, dissection of the
presence of the manipulator, which assists access to rectovaginal and vesicovaginal spaces needs to be performed
the different spaces; this is therefore performed prior to first, and the uterus is removed only after all these spaces
hysterectomy. have been dissected.
O Phases of Fixation. The posterior mesh is fixed first
and culdoplasty is performed before the mesh is fixed 7.2 Preoperative Antibiotic Prophylaxis
anteriorly. Low peritonization is then carried out until half
of the right peritoneal opening is closed. At this point, the Our patients usually receive preoperative antibiotic prophy-
need for Burch colposuspension is assessed. laxis consisting of an injection of a recent generation
O If the classical technique is desired with suspension cephalosporin; this is repeated if the operation takes more than
of the bladder neck before fixation of the mesh to the 4 hours.
promontory, the meshs are left free until the Burch proce-
dure and any vaginal repair are performed. More often, it is
fixed to the promontory; this is followed by peritonization
and cervical suspension is then performed in a further
step.
8.0 Operative Technique

8.1 Dissection of the Sacral Promontory
The surgical approach to the promontory is best made
when the patient is in increased Trendelenburg position after
displacing the loops of intestine and fixing the sigmoid to
the abdominal wall. A position between L5-S1 or the upper
part of S1 is identified, where the common anterior vertebral
ligament can be viewed. The middle sacral artery and vein
are exposed and coagulated if necessary. In obese patients
or those with a low aortic bifurcation, dissection begins from
the left common iliac vein. The promontory is identified by
instrumental palpation. After identifying the right ureter and
the inferior border of the left common iliac vein, the posterior
prevertebral parietal peritoneum is drawn upwards by the
assistant and incised vertically towards the right ureter starting Fig. 1
from the promontory. Once the peritoneum has been opened, Panoramic view of the pelvis.
Fig. 2 Fig. 3
Identification of the right ureter. Incision of the peritoneum at the level of the sacral promontory.
the pneumoperitoneum gas enters the retroperitoneal space,

providing an initial dissection. The organs adherent to the
posterior plane remain fixed while movable structures are
moved away from the promontory (Figs. 14).
8.2 Incision of the Right Lateral Peritoneum

The dissection follows a vertical axis as far as the cul-de-
sac of the Douglas pouch. In the course of this dissection,
attention should be paid to the internal iliac vein, which is
crossed, and to the area of the uterosacral ligament, which
is usually difficult to dissect. This incision, which is made to
enable peritonization of the mesh, must free the ureter. This is
mobilized from the peritoneum to gain tissue so that the mesh
can later be covered without stretching the ureter.
8.3 Dissection of the Rectovaginal Space Fig. 4

Identification of the various structures at the level of the sacral
The junction of the uterosacral ligaments with the uterus is promontory.
divided. The rectum is elevated and at the same time stretched
towards the sacrum by the assistant with the aid of intestinal
point, the surgeon turns again towards the rectum to identify
forceps. The peritoneum is put under tension, coagulated
the rectopubic bundles of the levator ani muscles. At the end
and then divided two centimeters above the insertion in the
of the dissection, it is important that the levator ani muscles
uterus. Dissection continues as far as the posterior vaginal
(pubococcygeus, puborectalis, and iliococcygeus) can be
wall which facilitates the access to the rectovaginal junction.
identified. The dissected space is bounded by:
Dissection is carried downward remaining in contact with
the vagina anteriorly until the perineal body is reached. At O the levator ani muscles and the pelvic wall laterally
this point, dissection is directed laterally towards the pelvic O the perineal body inferiorly
wall where the subobturator area is reached. In this lateral
area, the median rectal vessels will be found and can be left
O the vagina anteriorly
intact or coagulated depending on the space available. At this O the rectum posteriorly (Figs. 58).
8.4 Hysterectomy
The technique of hysterectomy is as follows: O Integrity of the adnexae may be preserved or not,
O Placement of the uterine manipulator depending on the patients age. The utero-ovarian ligament,
tube and adnexal vessels are coagulated and dissected if
O The various phases of dissection are part of the preparation the adnexae are to be spared, whereas the lumbo-ovarian
of the bed required for placing the mesh: the vesicovaginal ligament is coagulated and dissected if the adnexae are to
and rectovaginal space. be removed.
O Coagulation and division of the round ligaments and
dissection of the lateral vesical spaces. Fenestration of the O Bladder dissection is taken lower than normal to facilitate
posterior leaf of the broad ligament. placement of the mesh.
Fig. 5 Fig. 6
Dissection of the rectovaginal space. Identification of the levator ani muscles.
Fig. 7 Fig. 8
Posterior dissection complete. Left levator muscles.
O Dissection of the posterior leaf of the broad ligament as far O Extraction of the uterus via the vagina
as the origin of the uterosacral ligaments. O Two-layer suture of the vagina: the first layer takes only
O Identification of the uterine pedicles, which are coagulated the vaginal mucosa and the second approximates the
with bipolar forceps or ligated with 0 Vicryl. pericervical fascia. A 0 Vicryl suture is used. These
twolayers are essential to protect the mesh against
O Intrafascial dissection with coagulation of the cervico- contamination of vaginal origin.
vaginal vessels. If total hysterectomy is being performed, O If a subtotal hysterectomy is being performed, the cervix
Halbans fascia must be identified to allow closure in two
is divided at the level of the isthmus after coagulating the
planes.
uterine vessels. Division of the cervix can be performed
O Opening of the vagina through 360 under the guidance of in various ways. We prefer to use a cold knife held in an
the uterine manipulator. endoscopic blade holder.
8.5 Fixation of the Posterior Mesh

The posterior portion of the mesh is fixed first. should never be total but should rather be a partial closure of
Once the hysterectomy has been completed, it is convenient the inter-levator hiatus. This closure is more or less complete
to suspend the vagina to the anterior abdominal wall so depending on the situation. It will constitute the low support
that the assistants instrument is more readily available for point where the vagina will be attached. Once the mesh
suturing. has been stretched between the left-side and right-side
puborectalis muscles, the hiatus between the mesh and the
Each of the levator ani muscles is included in the suture using vagina is closed by suturing the mesh to the vaginal wall at
Ethibond 0 on a 30 mm-needle. The mesh is fixed on both the level of the perineal body.
lateral sides. At this point, myorrhaphy is performed; this
Fig. 9 Fig. 10
Placement of the suture in the right puborectalis muscle. The left levator muscle is picked up with the needle.
Fig. 11 Fig. 12
Fixation of the mesh on the right. Caudal and posterior fixation is complete.
Fig. 13 Fig. 14
Fixation of the posterior mesh to the cardinal ligaments and vagina. Boundary of posterior fixation.
The mesh will then be stretched on the posterior wall of the posterior part of the vagina to minimize the risk of transfixing
vagina and attached to the cardinal ligaments with non-ab- the vagina. Once the mesh has been fixed posteriorly, a
sorbable sutures (Ethibond 0). We avoid sutures in the Mc Call culdoplasty is performed (Figs. 914).
8.6 Culdoplasty
The aim of culdoplasty is to re-establish the normal anatomical needle and then, after identifying the ureter, the cardinal
relationship between the rectum and vagina by repositioning ligament is fixed particularly carefully, followed by the mesh
the rectum more superiorly and restoring tension for the and the vagina. The knot is tied when this is complete. The
vagina towards the back. This can be performed with or same steps are repeated on the contralateral side. When this
without Douglasectomy and with one or two absorbable repair has been completed, the vagina resumes its anatomical
sutures (Ethibond 0). The first step is to pick up the most position so upward traction is no longer necessary.
cranial or posterior part of the uterosacral ligament with the
8.7 Anterior Fixation of the Mesh

The mesh is stretched in the anterior vesicovaginal cavity. If The mesh is fixed to the anterior vaginal wall with absorbable
the uterus is spared, the two straps of the mesh are passed sutures which must not transfix the full thickness of the wall:
through the windows made in the posterior leaf of the broad Ethibond 2/0 with 18 mm curved needle. The knots are tied
ligament. These are fixed behind the isthmus with a flat knot with half-hitches made using the extracorporeal technique.
in the deperitonized area at the start of the rectovaginal 4 to 6 sutures will be needed (Figs. 1517).
detachment.
Fig. 15 Fig. 16
Fixation of the anterior mesh. High fixation of the anterior mesh.
Fig. 17
Junction laterally of the anterior and posterior meshs.
Fig. 18 Fig. 19
Start of low peritonization. End of low peritonization.
8.8 Low Peritonization

At vaginal level the purpose of the peritonization is to exclude inner margin of the lateral incision. Using the same suture,
the mesh from the abdominal cavity, placing the bladder over this procedure is repeated on the right side. A series of
the prosthesis. The surgeon begins with a 0 Vicryl suture half-hitches tie the purse string to close the peritoneum and
with 30 mm curved needle in the prevesical peritoneum, then provide suspension of the bladder (Figs. 1819).
the bladder pillar, the lateral vaginal peritoneum and then the
8.9 Sacral Colpopexy

Sacral colpopexy involves fixing the anterior and posterior Once the sutures have been placed, slight traction is applied
portions of the mesh to the promontory or anterior vertebral to confirm that they are anchored firmly.
ligament with two sutures of Ethibond and a 30 mm-curved The mesh needs to be fixed in position. When all the
needle or with staples or Tacker. corrections have been made, the mesh will be stretched
The needle must remain discernable by transparency on the promontory and fixed at this level. The surgeons
including only the fibrous layer of the aponeurosis to reduce experience is extremely important at this point (Figs. 2021).
to a minimum the risk of spondylodiscitis.
8.10 High Peritonization

The mesh must be completely retroperitoneal in position. for ease of suturing. An adequate number of half-hitches is
A continuous suture joins the outer and inner layers of the used for closure.
lateral peritoneal incision. We use a 0 Monocryl suture with These steps conclude the anterior part. It may also be
30 mm curved needle. The smoothness of this suture makes necessary to open the space of Retzius (Figs. 2223).
Fig. 20 Fig. 21
Placement of the suture in the promontory. Fixation of the mesh to the promontory.
Fig. 22 Fig. 23
High peritonization. Peritonization completed.
8.11 Opening the Space of Retzius

In the case of a transperitoneal approach, the procedure to penetrate the space of Retzius. This space is completely
begins with identification of the landmarks: avascular and is dissected with simple divergent traction. The
O Pubis pneumoperitoneum aids in opening the space. Remaining in
contact with the aponeurosis, a series of tissue layers must
O Coopers ligament be passed until the fatty tissues anterior to Coopers ligament
O Superior margin of the bladder dome where the urachus indicate that the superior boundary of the space of Retzius is
originates reached.
The peritoneum is incised above the bladder dome. The Coopers ligament is localized bilaterally. At this point, the
incision must be horizontal, from one umbilical artery to space of Retzius is easily opened down to the tendinous arc
the other. The assistant applies downward traction to the of the pelvic fascia. The dissection must reach the obturator
peritoneum using forceps, while the surgeon draws the plane foramina.
vertical with the right hand and incises it with monopolar The vaginal walls are palpated with the aid of a finger
scissors held in the left hand. placed in the vagina. The bladder margin is highlighted by
The urachus is coagulated and transected while the surgeon the presence of a vein running along it, which must then be
proceeds along a vertical plane towards the abdomin al carefully separated from the vagina appearing pearly white
wall. The umbilico-prevesical aponeurosis must be passed (Figs. 2425).
Fig. 24 Fig. 25
Identification of the upper border of the bladder. Space of Retzius.
8.12 Paravaginal Repair

The positive pressure of the pneumoperitoneum allows is closed using separate stitches or a running suture of
visualization of the paravaginal defect which is nearly always Ethibond 0 on a 18 mm-needle. This suture should run from
present with high-grade prolapse. It appears as a herniation the pubo-urethral ligaments anteriorly to the ischial spine
between the vaginal wall and the tendinous arc of the pelvic posteriorly. Repair can be uni- or bilateral.
fascia. If there is indeed a paravaginal hernia, the defect
8.13 Burch Colposuspension

Following this repair, colposuspension is performed. The preserve a certain degree of firmness. In the event of bleeding
suture employed is Ethibond 3.5 (0) with a 26 mm needle. after the first passage, an X suture can be placed. In the case
The suture passes through Coopers ligament from above of promontory fixation, a single suture per side is placed and
downwards and then through the vagina from within the tension is reduced. Where paravaginal repair has also
outwards, ensuring that the full thickness of the wall is not been performed, this will necessitate hypercorrection of the
transfixed. Transfixion of the vagina must be wide enough to cervical suspension.
8.14 Peritonization
This must always be performed in full. The aim is to prevent
loops of intestine from becoming trapped in the space
of Retzius. We use Vicryl 0 with a 46 mm curved needle.
Closure is achieved with three passes from right to left and we
join this to the high and low peritonization with half-hitches.
9.0 Final Procedures 10.0 Postoperative Care

9.1 Uterine Morcellation 10.1 Antibiotic Therapy
Morcellation is required in the case of subtotal hysterectomy. We do not use this systematically but treat infections only as
We use the Rotocut Morcellator (KARL STORZ, Tuttlingen, they are identified and according to the antibiogram.
Germany). The uterus, which is normally small, is cut
into strips 10 mm in diameter and removed and sent for
histological examination. 10.2 Prevention of Postoperative phlebitis
All of our patients receive antithrombotic prophylaxis, which
starts on the evening of the operation and continues for 15
9.2 Release of Fixation Sutures
days postoperatively.
The previously suspended intestine is released and hemo-
stasis is ensured.
10.3 Foley Catheter
The catheter is left in for at least 24 hours depending on the
9.3 Peritoneal Toilet
patients age and mobilization. When it is removed, urinalysis
This is best performed with Ringer lactate. Any blood clots and urine culture are performed routinely and antibiotic
are aspirated and careful hemostasis is performed. At the end therapy is started if necessary.
of the procedure, the Ringer lactate must be completely clear.
10.4 Duration of Hospital Stay

9.4 Cystoscopy
3 to 5 days
The ureters are checked repeatedly during the procedure:
after hysterectomy, after peritonization and after Burch
suspension. These repeated controls make it possible that 10.5 Postoperative Period
any iatrogenic injury caused by operating maneuvers can The postoperative period should be quiet, avoiding undue
be immediately detected and thus allow for a more accurate effort and excessive weights.
repair. The color of the urine and air filling the collecting bag
are important checks if bladder or ureter injury is suspected. The diet is normal with plentiful hydration to reduce the
constipation that is nearly always present in the first
The role of cystoscopy is controversial. Some authors 3 postoperative weeks. Sexual activity can be resumed after
perform it systematically and others only in case of doubt, but 6 weeks.
in all cases, the indications should be broad. It will confirm
the patency of the ureter orifices and thus ureter integrity.
11.0 Conclusions
Laparoscopy allows to combine the benefits of prolapse of expert surgeons, the duration is about 2 hours. Certainly,
repair via laparotomy with the low morbidity of the vaginal studies of long-term efficacy and reliability are still needed to
approach. Operating times are long initially but in the hands fully assess the value of this technique.
Recommended Reading
1. AMELINE A, HUGUIER J: La suspension postrieure du 9. CAUBEL P, LEFRANC JP, FOULKES H, PUI A,
disque lombo-sacr : techniques de remplacement des BLONDON J: Traitement par voie vaginale des
ligaments utro-sacrs par par voie abdominale. prolapsus gnitaux rcidivs. J Chir, 1989 ; 126 :
Gynecol Obstet, 1957 ; 56 :9498 446470
2. RANDALL C: Surgical treatment of vaginal inversion. 10. ADDISON WA, TIMMONS C, WALL LL,
Obstet Gynecol, 1971;38: 327332 LIVENGOOD CH: Failed abdominal sacral colpopexy:
observations and recommendations. Gynecol Obstet,
3. NICHOLS D, MILLEY P: Significance of restauration 1989; 74: 480842.
of vaginal depth and axis. Obstet Gynecol, 1970; 36:
251255 11. QUERLEU D, PARMENTIER D, DELODINANCE P:
Premiers essais de la coelio-chirurgie dans le traitement
4. HOFF S, MANELFE A, PORTET R; GIROT C: Promonto- du prolapsus gnital et de lincontinence urinaire
fixation ou suspension par bandelettes transversales ? deffort. In : Les troubles de la statiques pelviennes.
Etude compare de ces deux techniques dans le Blanc., boubli, Baudrant E., DErcale C. : 219 pages,
traitement des prolapsus gnitaux. Ann Chir, 1984 ; Arnette. Paris Ed p 155158.
38 : 363367.
12. WATTIEZ A, BOUGHIZANE S, ALEXANDRE F, CANIS M,
5. BAKER KR, BERESFORD JM, CAMPBELL C: MAGES G, POULY JL, BRUHAT MA: Laparsocopic
Colposacropexy with Prolene Mesh. Gynecol Obstet, procedures for stress incontinence and prolapse.
1990; 171: 5154 Current Opinion in Obstetrics and Gynecology. A.
DeCherney and Stuart Cambell Editors. 1995, Vol 7,
6. ROBERT HG: Nouveau trait de techniques
n 4, 31721.
chirurgicales gyncologiques. Masson et Cie, 1969,
820 pages, p 128130. 13. WATTIEZ A, AIMI G, FINKELTIN F, CANIS M, POULY
JL, POMEL C, GERARD CH, MAGE G, BRUHAT MA:
7. ADDISON WA, LIVENGOOD CH, SUTTON GP,
Cure chirurgicale des prolapsus velico-uterins par voie
PARKER RT: Abdominal sacral colpopexy with
coelioscopie exclusive Gunaikeia, 1997, 2, 2, 505
Mercilene mesh in the. retroperitoneal position in the
management of posthysterectomy vaginal vault 14. WATTIEZ A, CUCINELLA G, GIAMBELLI F, MENCAGLIA L:
prolapse and enterocele. Am J Obstet Gynecol, 1985; Laparoscopic burch procedure for retropubic
15: 140146 colposuspension. It J Gynecol Obstet 1997, 9, 3, 1147.
8. SUTTON JP, ADDISON WA, LIVENGOOD CH, 15. WATTIEZ A, CANIS M, MAGE G, POULY JL, BRUHAT MA:
HAMMOND CB: Life threatening hemorrhage Promontofixation dans le traitement des prolapsus :
complicating sacral colpopexy. Am J Obstet Gynecol intrt et technique de la voie coelioscopique.
1981; 140 : 836837 Le Journal de Coeliochirugie. 1999, 31, 711.
Chapter XVII
Laparoscopic Surgical Staging
of Endometrial Carcinoma
Fabrizio Barbieri and Luca Minelli
extent. For instance, the extent of lymphadenectomy has metrial carcinoma. Laparoscopy has been shown to be
not yet been defined: biopsy of the pelvic and lumbo-aortic capable of implementing all steps of the surgical staging
lymph nodes, systematic pelvic and lumbo-aortic lymph- system in accordance with the FIGO guidelines.
adenectomy or removal only of enlarged lymph nodes. If, on
Numerous studies have shown that with laparoscopic
the one hand, pelvic and lumbo-aortic lymphadenectomy is
surgery the incidence of postoperative complications such as
essential for correct staging, on the other hand it does not
pyrexia, paralytic ileus and wound infection is reduced; the
appear to influence overall survival (at present there is only
duration of hospitalization is also reduced with an early return
one meaningful scientific study published by Kilgore et al in
to normal activity.
1995 that supports the therapeutic value of LND).
The first study of laparoscopic treatment of endometrial carci-
As stated above, the operative staging procedure usually noma was published in 1990. In the following period, various
includes total extrafascial hysterectomy, bilateral adnexec- authors demonstrated the feasibility of laparoscopic surgical
tomy, intraperitoneal exploration / cytological washing and staging taking into account potential limiting factors related to
lymphadenectomy. In the majority of cases, pelvic lymphade- patient (anatomy, body mass index, presence of adhesions)
nectomy is sufficient; however, the lumbo-aortic lymph nodes and surgeon (experience and training) factors. Subsequently,
would be removed in the following situations: positive pelvic a single randomized study with a short follow-up period
lymph nodes, ovarian metastases and clear cell or serous reported that laparotomy and laparoscopy were equivalent in
papillary histological type. For many authors, intraoperative terms of overall survival and disease-free survival.
pathological assessment can provide guidance on whether
to go ahead with lymphadenectomy particularly based on In recent years, therefore, entirely laparoscopic or vaginally
infiltration of the myometrium. assisted laparoscopic surgical staging has become more
and more widespread for the first stages of endometrial
During the past 10 years numerous studies have assessed carcinoma. Obviously, it is extremely important for the
the value of the laparoscopic approach as compared to surgeon to have a profound knowledge of both laparoscopy
traditional laparotomy in the staging and treatment of endo- and gynecologic oncology.
2.0 Preoperative Management

When endometrial carcinoma is suspected clinically, usually that the correct surgical management and any adjunctive
because of abnormal uterine bleeding, it must be confirmed therapy can be planned. In 80% of cases, there is no clinical
by endometrial histology. Where endometrial biopsy cannot evidence of extrauterine disease so the only tests needed are
be performed in an outpatient setting because of stenosis chest radiograph and routine preoperative laboratory tests.
of the cervical canal or poor patient compliance, it must be However, transvaginal ultrasound and/or MRI scan are useful
carried out under general anesthesia. for assessing myometrial infiltration and can indicate cases at
Although they are insufficient for diagnosis, gynecological risk of metastatic spread. If the liver function tests are altered
examination and transvaginal ultrasound must be performed or advanced-stage disease is suspected, imaging procedures
to rule out concomitant adnexal pathology. such as MRI, computed tomography (CT) and abdominal
and pelvic ultrasound can be useful in tracing metastases. In
Cytological examination of the endocervix and ectocervix can patients with characteristic symptoms of disease in certain
exclude the presence of cervical pathology. organs, cystoscopy, contrast enema, cerebral CT or bone
Given the confirmed diagnosis of endometrial carcinoma, scan may be necessary.
the next step is to determine the extent of the disease so
3.0 Surgical Technique

In the majority of cases, total laparoscopic extrafascial
hysterectomy with bilateral adnexectomy and pelvic lymph-
adenectomy is sufficient. In a few cases, radical laparoscopic
hysterectomy may be indicated (Figs. 112 and Tab. 1).
Fig. 1 Fig. 2
Laparoscopic incision of the vaginal wall. External iliac artery and vein. External iliac lymph nodes.
Fig. 3 Fig. 4
Internal iliac lymph nodes located medial to the external iliac Sampling of an internal iliac lymph node.
vessels.
Fig. 5 Fig. 6
The external iliac artery and vein, and the internal iliac lymph nodes. After sampling the lymph nodes the external iliac artery and vein,
The internal iliac artery is visible. the uterine artery and internal iliac artery can be localized.
Fig. 7 Fig. 8
The uterine vessels are distinct anatomical landmarks that highlight The ureter can be followed laterally as far as the pelvis where it
the boundary between the paravesical space anteriorly and the crosses the uterine artery.
pararectal space posteriorly.
Fig. 9 Fig. 10
The ureter can be skeletonized safely. Opening the rectovaginal space between the cul-de-sac and the
uterosacral ligaments.
Uterine artery
Obturator vessels
Internal iliac artery

(hypogastric artery)
Ureter
Fig. 11 Diagram 1
Coagulation of the origin of the uterine artery with bipolar forceps. Exposure and occlusion of the uterine artery by coagulation at its
origin, the anterior division of the internal iliac artery.
4.0 Conclusions
The problems emphasized most frequently with the laparo- Laparoscopic Port-site Metastases
scopic approach are: Recurrence at the port-site following laparoscopic surgery
has been described for all types of gynecologic cancers,
Peritoneal Dissemination even in patients with early disease. The incidence has not
Thanks to the studies by Vergote and Possover, it has been yet been accurately assessed because surgeons often do
demonstrated fully that there is no significant statistical not achieve long-term patient follow-up and this type of
difference between laparotomy and laparoscopy with regard recurrence is often considered to be of little prognostic value
to the incidence of positive peritoneal cytology. It should be in the presene of concomitant distant metastases. In the
stressed that in both series the uterine manipulator was not literature, the incidence is 2.3% with gynecologic carcinomas
used and the tubes were coagulated at the start to avoid and as regards endometrial cancer, a recent review reports 4
intraoperative dissemination. Finally, it has been shown that cases of port-site metastasis in patients with laparoscopically
positive peritoneal cytology on its own is not an unfavorable staged endometrial carcinoma. Numerous hypotheses
prognostic factor. about promoting factors have been proposed: the pneu-
moperitoneum, carbonic anhydride, the pathway effect,
Recurrence in the Vaginal Vault the local immune system, the surgical technique and also
trocar contamination. It is essential to emphasize that there
Numerous studies have shown that there is no increase in
is nothing at present to explain whether the cause of these
vaginal vault recurrence in patients with laparoscopically
metastases is linked to the particular aggressiveness of the
staged endometrial cancer.
tumor or to laparoscopic surgery per se.
Some authors report a reduced incidence of port-site metas-
tases with peritoneal closure and/or surgical repair of the
incision site.
Recommended Reading
1. BEREK J, HACKER NF: Practical gynecologic oncology. 4. VAISBUCH E, DGANI R, BEN-ARIE A, HAGAY Z: The role
Third edition 2000. Ed Lippincott Williams and Wilkins. of laparoscopy in ovarian tumors of low malignant
Philadelphia potential and early-stage ovarian cancer. Obstet Gynecol
2. BENEDET JL, BENDER H, JONES H, NGAN HY, Surv. 2005 May;60(5):32630
PECORELLI S: FIGO staging classifications and clinical 5. AGOSTINI A, ROBIN F, JAIS JP, AGGERBECK M,
practise guidelines in the management of gynecologic VILDE F, BLANC B, LECURU F: Peritoneal closure
cancer. Int J Gynecol Obstet 2000, 70:20962 reduces port site metastases. Surg Endosc 2002,
3. RAMIREZ PT, FRUMOVITZ M, WOLF JK, LEVENBACK C: 16:289-91
Laparoscopic port-site metastases in patients with 6. KILGORE LC, PARTRIDGE EE, ALVAREZ RD, et al:
gynecological malignancies. Int J gynecological Adenocarcinoma of the endometrium: Survival
malignancies 2004, 14:10707 comparisons of patients with and without pelvic node
sampling. Gynecol Oncol 1995, 56:29-33
Chapter XVIII
Laparoscopic Pelvic and
Lumbo-aortic Lymphadenectomy
Fabrizio Barbieri and Luca Minelli
Fig. 3 Fig. 4
The external iliac vessels are excised to the level of the deep Identification of the origin of the uterine artery.
circumflex iliac vein.
Fig. 5 Fig. 6
Dissection of the prevesical space. Exposure of the external iliac vessels from the lateral pelvic wall.
Fig. 7 Fig. 8
En bloc removal of the external iliac lymph nodes. Removal of the obturator lymph nodes.
Surgical landmarks:
1. round ligament (antero-superficial) A retroperitoneal approach has also been described. This
2. infundibulo-pelvic ligament ( medial superficial) would have certain advantages for exposure of the operative
field because the bowel is within the peritoneum and because
3. genitofemoral nerve (lateral and medial)
of the reduced incidence of adhesions (a major advantage
4. external iliac vessels (lateral and medial) especially in patients who must have radiotherapy) but at the
5. obliterated or blind umbilical artery (caudal and medial) expense of a greater incidence of lymphocele, which can be
6. Coopers ligament (deep caudal and lateral) reduced by opening the peritoneum of the paracolic gutters
7. uterine artery (medial) at the end of the operation.
8. ureter (medial)
9. obturator muscle (dorsomedial)
10. internal iliac vessels (superficial dorsal)
11. lumbosacral plexus (deep dorsal)
5.2 Lumbo-aortic Lymphadenectomy
Left lumbar lymph nodes: above, lateral to and below the aorta. The ureter is localized and pushed laterally. The
the aorta precaval and paracaval lymph nodes are dissected starting
to the right of the common iliac artery and continuing as far
Intermediate lymph nodes: between the aorta and the as the right ovarian vein using bipolar forceps. If the lymph
inferior vena cava nodes are positive or there is right ovarian cancer, the lymph-
adenectomy is extended as far as the renal vessels.
Right lumbar lymph nodes: above, lateral to and below
the inferior vena cava For dissection to the left of the aorta, the camera is rotated
through 180 and the first surgeon stands at the patients
The first surgeon is at the patients right to remove the left right side. After identifying the ipsilateral ureter and inferior
para-aortic lymph nodes, and at the left to remove the right- mesenteric artery and elevating the mesosigmoid being
sided and pelvic nodes. careful to preserve the superior hypogastric plexus the left
Following creation of the CO2 pneumoperitoneum, an 11 mm para-aortic, presacral and common iliac lymph nodes are
umbilical port is placed, with three 6-mm ports in the right and removed (inframesenteric lymphadenectomy). In the case of
left iliac and suprapubic regions, and another 11-mm port in left ovarian carcinoma, the lymphadenectomy is extended
the left hypochondrium, which is used to apply traction to the as far as the left renal vein, removing the entire infundibulo-
bowel and to extract the lymph nodes with an endobag. pelvic ligament as far as its origin but sparing the inferior
Lymphadenectomy begins in the right para-aortic region by mesenteric artery.
making an incision in the peritoneum covering the uppermost In patients at high risk of lymph node recurrence or with
part of the ipsilateral iliac artery. ovarian tumors, the lymphadenectomy is extended to the
The video camera is orientated so that the aorta and inferior region between the aorta and the inferior vena cava as far as
vena cava appear horizontal with the inferior vena cava above the renal vessels (infrarenal lymphadenectomy).
6.0 Sentinel Lymph Node

The sentinel lymph node is the first node in the lymphatic Sentinel lymph node sampling can be indicated in the case
system draining lymph from the primary tumor. If this lymph of malignant melanoma, breast cancer and carcinoma of
node is not invaded by metastasis, all other lymph nodes the vulva. The procedure can be performed laparoscopically
should be tumor-negative. The sentinel lymph node can be for surgical staging of other gynaecologic tumors such as
identified by peritumor injection of blue dye, which usually endometrial and cervical cancer. In early-stage cervical
stains the first draining lymph node, or by a peritumor carcinoma, in particular, biopsy sampling of the sentinel
injection of a radioactive tracer (e.g., technetium 99), which lymph node allows frozen section analysis for determination
diffuses and accumulates in the sentinel lymph node where it of the lymph node status. The metastasic status of the SN
can be visualized with a gammacamera. can help to triage patients between radiochemotherapy or
radical hysterectomy, thus reducing morbidity and post-
operative hospitalization.
Chapter XIX
Complications in
Laparoscopic Surgery
Leopoldo Carlos Videla Rivero
and Beatrice Videla Rivero
Callao Surgical Institute
Buenos Aires, Argentina
As in ablative laparoscopic surgery, it is essential to restore a few subjective aspects. There is no single answer to the
the anatomical conditions as much as possible and to place question which of the given options in terms of technique
sutures appropriately. In surgery for infertility, the use of could be best for the laparoscopic approach: the best
microsurgical techniques is highly important. surgical technique is the one the surgeon is familiar with and
the best surgical maneuver is the one that he controls best.
The first laparoscopic access merits a separate paragraph.
The surgeon should have a good command of the technique
This is the step in laparoscopic surgery that requires
to be applied. Besides, there are further aspects that should
particular care. Creation of the first port can be accomplished
be considered: the way how the technique is performed, the
by establishing the pneumoperitoneum with the Veress
surgeons experience with the technique, conviction of its
needle and using the open laparoscopy technique, with
surgical usefulness, its choice and safety in performing it, and
direct insertion of the abdominal trocar or by use of a specific
finally the personal competences and aspects of technical
optical trocar that allows constant visual control. However, all
feasibility as related to the infrastructure available.
of these techniques involve the inherent risk of complications.
Those, associated with the first laparoscopic access are the
The technique that is most universally employed and
risk of perforating or injuring vessels or organs during entry
accepted in gynecologic laparoscopic surgery, especially in
and the possibility of a viscus remaining incarcerated in the
Europe, is the one with the Veress needle, which is followed
incision during removal which entails a postoperative wound
by the classical safety maneuvers, intra-umbilical incision and
hernia.
introduction of a trocar with a conical tip. Introduction of the
Although the first laparoscopic access route offers various accessory trocars for the instruments is carried out under
alternatives, the surgeons choice is often influenced by visual control (Figs. 19).
Fig. 1 Fig. 2
Introduction of the Veress needle. Safety test performed with syringe and normal saline.
Fig. 3 Fig. 4
Assessment of intra-abdominal pressure by applying cephalic traction Introduction of the first intra-umbilical trocar.
to the anterior abdominal wall.
Fig. 5 Fig. 6
Removal of the conical trocar with the cannula left in place. Insertion of the laparoscope with coupled video camera.
a b c
Figs. 7ac
Sequence showing the passage of the laparoscope through the first trocar under visual
control.
a b c
Figs. 8ac
Sequence demonstrating the insertion of the second trocar. This is always performed under
visual control.
copies performed by surgeons at different levels of training/

Surgical laparoscopies 2.711
stages of the learning curve, with an incidence of 381
Complications 28 (1.03%)
complications (2.06%) (Tab. 5), 54 of which were reported as
potentially lethal (0.29%). Tab. 8
Gynecology Service, University of Buenos Aires Hospital Clinic,
Argentina.
Total complications 381 (2.06%)
O Extraperitoneal insufflation 118 Surgical laparoscopies 1,261

O Hematoma of the abdominal wall 80 Complications 10 (0.79%)
O Vascular injury 72
O Infection 34 3 postoperative hemorrhages
O Postoperative bleeding 21 O 2 at the vaginal vault, hysterectomy
O Connected with anesthesia 16 O 1 from the myomectomy bed
O Urologic injury 14
O Intestinal injury 10 1 intestinal injury
O Transitory nerve paralysis 5 O first trocar
O Pericholecystitis 3
O Hematoma of the vaginal vault 3 3 injuries of the bladder
O Hyperthermia (48 h) 2 O 1 during Burch suspension
O Chemical peritonitis (dextran) 2 O 1 during hysterectomy
O Hypothermia 1 O 1 during myomectomy
Tab. 5
Argentine Laparoscopic Surgery Society.
2 vascular injuries
O 1 first trocar, mesenteric artery
O 1 epigastric vein, second port
The Ibero-American Gynecologic Endoscopy Society SIAEGI
in 2002 on the occasion of its IX Congress in Quito, Ecuador
1 fistola uretero-vaginale
collected the Latin American records of laparoscopic compli-
O during radical hysterectomy
cations in Argentina and Chile (Tab. 6).
Tab. 9
Gynecology Service of Private Institute specializing in Endoscopic
Argentina Surgery, Buenos Aires, Argentina.
5,183 cases 42 complications 0.81% (LC Videla Rivero)
Chile
2,140 cases 16 complications 0.74% (C Miranda)
Surgical laparoscopies 2,140
Tab. 6
Ibero-American Gynecologic Endoscopy Society SIAEGI.
Complications 16 (0.74%)
As institutional and personal publications, we present a few O 2 injuries of the aorta (first trocar)
case series with the percentage of complications. In some O 3 injuries of the ureter or bladder
cases the complications that occurred are listed (Tab. 711). O 3 injuries of the intestine
O 1 related to anesthesia
O 1 intraoperative hemorrhage
Surgical laparoscopies 2,401 O 1 epigastric artery hemorrhage
Complications 10 (0.42%) O 5 postoperative
O 1 injury of the aorta Tab. 10

O 1 injury of the ureter University of Chile Hospital Clinic, Santiago de Chile.
O 1 injury of the bladder
O 1 postoperative hemorrhage + brachial plexus
O 1 immunologic peritonitis (dextran)
O 1 nerve compression with paresis of the lower limb Surgical laparoscopies 2,500
O 1 pericholecystitis Total complications 38 (1.5%)
O 1 injury of the ileum (fistula) Major complications 0.25%
O 1 hematoma of the vault Death or serious consequences 0
Tab. 7 Tab. 11
LC Videla Rivero Private Gynecology Service. Gynecology Service, Lagomaggiore Hospital, Mendoza, Argentina.
a b
Figs. 10 ad
Sequence demonstrating iatrogenic injury
of the aorta during introduction of the first
c d trocar (immediate conversion) in 1995.
a b c
Figs. 11ac Sequence demonstrating accidental injury of the right ureter during endometrioma removal, 1987.
a b c
Figs. 12 ac Sequence demonstrating iatrogenic injury to the external iliac artery during surgery for deep endometriosis, 2004.
Q Intraoperative complications O 1 chemical peritonitis in 1998. In conservative adnexal

O 3 injuries of the bladder in 1996, 1997 and 2004, the first surgery, it is customary to leave dextran in the peri-
during total hysterectomy, the second during a Burch toneal cavity to prevent the formation of adhesions.
suspension. Dealt with in all cases by laparoscopic This high molecular weight polymer can provoke a
suture and indwelling catheter in the postoperative peritoneal reaction known as chemical peritonitis. It
period. Good recovery (Fig. 13). was treated by laparoscopy with aspiration of 10 l
ascitic fluid and lavage with saline. The patient made
O 1 uterine hemorrhage in 1993 during laparoscopic
a good recovery (Figs. 1718).
hysterectomy. Due to nonavailability of bipolar forceps,
the injury was repaired laparoscopically by hemostatic O 1 injury of the ileum in 2003 which turned into an ileal
suture of the left uterine artery. Good recovery (Fig. 14). fistula on the second postoperative day. After laparo-
O 1 hypotension of anesthetic origin tomy, the patient made a good recovery.
Q Postoperative complications O 1 umbilical herniation in 1994. A week after laparo-

scopy when the sutures were being removed, the
O 1 injury common peroneal nerve (lateral popliteal patient had umbilical herniation with prolapse of the
sciatic nerve) with paresis of the right lower limb for 3 omentum. The umbilical hernia was repaired after
months. Occurred in 1990 following excision of a large resection of the omentum and the patient made a
myoma by colpotomy and consequent compression. good recovery.
The patient made a full recovery (Fig. 15).
O 1 pericholecystitis in 1991 following rupture of a
dermoid cyst and spillage of its contents in the
peritoneal cavity. The patient presented with an
acute abdomen in the right hypochondrium known
as pericholecystitis. The complication resolved with
simple medical treatment (Fig. 16).
Figs. 13 a, b
Sequence demonstrating iatrogenic injury
of the bladder, injection of methylene blue
and suture, 1994. a b
Figs. 14 a, b
Sequence demonstrating bleeding from
the left uterine artery during hysterectomy,
1993. a b
Figs. 15 a, b
Sequence demonstrating iatrogenic injury of
the sciatic nerve during extraction of myoma
a b
via colpotomy, 1993.
Figs. 16 a, b
Sequence demonstrating pericholecystitis
a b
after rupture of a dermoid cyst, 1993.
Figs. 17 a, b
Sequence demonstrating a patient with
a b
dextran in the peritoneal cavity, 1988.
Fig. 18
Second-look laparoscopy in the patient with
chemical peritonitis due to dextran, 1988.
9.0 Module for Recording Data on Complications in

Gynecologic Endoscopic Surgery (endogin.net)
The following is a module which is used on the www.endo- in which individuals, teams, institutions and scientific
gin.net website to classify and document the complications associations can participate. When the data have been
that can occur in laparoscopic surgery. The specific aim of collected according to our module, it will be possible to have
the module is to simplify data collection. It can also form part precise qualitative and quantitative consistency regarding the
of a multicenter project for collecting data via the Internet, incidence of complications according to time and place.
Diagnosis of the complication electrosurgery Importance of the complication

During surgery burns Q
Q major, potentially lethal
light source and laparoscope
Q During hospitalization Q minor
Q After discharge burns
various Resolution of the complication
Within 3 days
After 3 days CO2
Q phase of resolution
operating lamp
immediate
Type of complication electrical equipment
deferred
Q Q route of resolution
Anesthesiological Site of the complication
related to the anesthesia itself laparoscopy
related to the surgical procedure

Q Abdominal wall hysteroscopy
emphysema laparotomy
Q Related to the access route hematoma vaginal
laparoscopic
infection Q surgical team
hysteroscopica
eventration same team
THL
Q with gynecologic consultation
laparotomy Urinary
ureter with multidisciplinary consultation
vaginal
bladder with a different team
Q Related to the surgical procedure Q
Q
hospital admission
hemorrhage Vascular in the same place as the surgery
small vessels
without blood transfusion normal
large vessels
with blood transfusion intensive therapy
infection Q Neural transferred to a different center
general plexuses of greater complexity
O septicemia motor immediate
O peritonitis sensory deferred
local sympathetic Q re-operation
O surgical wound parasympathetic number
O urinary nerves route of operation
collection Q laparoscopic
Intestinal
O abdominal
stomach hysteroscopic
O pelvic
intestine laparotomy
O retroperitoneal
colon vaginal
mechanical injury
Q radiologic
ileus
Uterine
Q procedure performed
perforation
torsion description
synechiae
adhesion
hematometra
obliteration Progress of the complication
pyometra
traumatic injury
Q without consequences
metrorrhagia
perforation Q with consequences
division Q Tubes slight
laceration section
moderate, interfering with ordinary life
electrosurgical injury removal
disabling
Q Operating room and instruments unilateral
type of consequence
operating table bilateral
description
nerve compression Q Ovary Q lethal
joint injuries removal
muscle injuries unilateral Analysis of the complication

stretching of plexuses bilateral Q Description
10.0 Conclusions
To sum up, it can be concluded that complications exist knowledge of how they can be avoided. However, the best
and are inherent in surgical practice. In laparoscopic surgery treatment of complications is intraoperative.
there are complications specific to this technique. The From 1998 to 2005 in the gynecology service of the Callao
complications are usually due to a sum of factors, which Surgical Institute in Buenos Aires, the complication rate
should be analyzed and discussed even if this often appears was 10/1261 (0.79%) and the rate of major complications
to be difficult for surgeons. We must accept the idea that it was 3/1261 (0.23%). In a French multicenter study, the
is essential to communicate our complications in order to percentages were similar, with 0.89% for complications in
contribute to a better knowledge of them. Classification and general and 0.220.34% for major ones. A few studies have
an appropriate record of these events will improve under- reported higher percentages.
standing. The best way to prevent complications is surgical
Recommended Reading
1. BARBOSA C: Manual Ilustrado de Cirurgia Videolapa- 14. MIRANDA CS, CARVAJAL A: Complication of operative
roscopica em Ginecologia Texto e atlas. 1998; Cap 10, Gynecological Laparoscopy. Journal Society
Livraria e Editora RevienteR Ltda. Laparoscopic Surgeons 2003 Jan-Mar; 7(1):538.
2. BATEMAN BG, KOLP LA, HOEGER K: Complications of 15. NEZHAT C, CHILDERS J, NEZHAT F, NEZHAT C.H,
laparoscopy-operative and diagnostic. Fertility and SEIDMAN D.S: Major retroperitoneal vascular injury
Sterility 1996; 66: 3035. during laparoscopic surgery. : Hum-Reprod. 1997 Mar;
12(3): 4803
3. BONGARD F, DUBECZ S, KLEIN S: Complications of
therapeutic laparoscopy. Current Problems in Surgery 16. NORDESTGAARD AG, BODILY KC, OSBORNE RW,
1994: 862924 BUTTORFF JD: Mayor vascular injuries during
laparoscopic procedures. The American Journal of
4. CANDIANI M, CANIS M, LUCIANO A, MARANA R, Surgery 1995; 169: 543545
MENCAGLIA L, WATTIEZ A, ZUPI E: Testo Atlante di
Chirugia Laparoscopica in Ginecologia. 1997; Cap.7.1, 17. PETERSON HB, HULKA JF, PHILLIPS JM: American
Poli industria Chimica SpA. Edicione fuori commercio. Asociation of Gynecoligic Laparoscopists 1988
Mosby Doyma Italia Srl. Milano, Italia Menbership Survey on Operative Laparoscopy.
The Journal of Reproductive Medicine, 586598.
5. CHAPRON CM, PIERRE F, LACROIX S, QUERLEU D,
18. Primera Ctedra de Ginecologia, Hospital de Clnicas
LANSAC J, DUBUISSON J-B: Major vascular injuries
Universidad de Buenos Aires: Memoria anual de 1994
during gynecologic laparoscopy. J Am Coll Surg 1997;
185:46165. 19. QUERLEU D: y col. (conversiones) Gynecol. Endosc.
2:36, 1993.
6. GARRY R, PHILLIPS G: How safe is the laparoscopic
approach to hysterectomy? Gynaecological Endoscopy 20. QUERLEU D, CHAPRON C: Complications of
1995, 4:7779. gynecologic laparoscopic surgery. Current Opinion in
Obstetrics and Gynecology 1995, 7: 257261
7. GARRY R, PHILLIPS G: How safe is the laparoscopic
approach to hysterectomy? Gynaecological Endoscopy. 21. SADEGHI-NEJAD H, KAVOUSSI LR, PETERS CA:
1995; 4:7779. Bowel injury in open technique laparoscopic cannula
placement. Urology 1996; 43:55960.
8. HASSON HM: Open laparoscopy as a Method of
Access in Laparoscopic Surgery. Gynaecological 22. SARROUF J: Complicaciones en Laparoscopia- 2002,
Endoscopy, 1999; 8:35362 XIV Congreso Peruano de Obstetricia y Ginecologia
Lima, Per en: Docencia, www.endogin.net.
9. HASSON HM: Open laparoscopy: In Gynecology and
23. SEMM K: Cutting versus conical tip designs
Obstetrics, J.J. Sciarra, Ed., Harper & Row, Philadelphia,
Endosc-Surg-Allied-Technol. 1995 Feb; 3(1): 3947
1992, Vol. 6, Ch.44, p.18.
24. TERNAMIAN A M: Laparoscopy without trocars.
10. HILL DJ: Complications of the laparoscopic approach. Surg-Endosc. 1997 Aug; 11(8): 8158
Bailliers Clin Obstet Gynaecol 1994; 8:86579.
25. VANCAILLIE TG: Active electrode monitoring. How to
11. LEHEMANN-WILLENBROCK E, RIEDEL HH, MECKE H prevent unintentional thermal injury associated with
AND SEMM K: Pelviscopy/Laparoscopy and its Compli- monopolar electrosurgery at laparoscopy. Surg-Endosc.
cations in Germany, 1949-1988; The Journal of Repro- 1998 Aug; 12(8): 100912
ductive Medicine 37(8): 671677, Ref 10, Ago 1992.
26. VIDELA RIVERO LC. ORTIZ J: Encuesta sobre Compli-
12. LIU C.Y: Laparoscopic Hysterectomy and Pelvic Floor caciones en Ciruga Laparoscopica. Revista de la Socie-
Reconstruction. 1996; Cap 15, Blackwell Science Inc. dad Argentina de Ciruga Laparoscopica. 1995, 2: 1621
13. MENEIRO M, MELOTTI G, MOURET PH: Ciruga 27. VIDELA RIVERO LC: Base de datos de Complicaciones
Laparoscopica. 1996; Cap2:3438, Editorial Mdica en Endoscopia Ginecolgica 2005,
Panamericana. www.endogin.net.
Recommended Set
for Gynecological Laparoscopic Surgery
Basic Instrument Set for Gynecological Laparoscopic Surgery
26003 AA HOPKINS II Straight Forward Telescope 0, 38361 ON RoBi Grasping Forceps,

enlarged view, diameter|10|mm, length|31|cm, CLERMONT-FERRAND model, rotating, dismantling,
autoclavable, fiber|optic light transmission with connector pin for bipolar coagulation,
incorporated, color code: green double action jaws, fenestrated,
with especially fine atraumatic serration,
26120 JL VERESS Pneumoperitoneum Needle, size 5 mm, length 36 cm
with spring-loaded blunt stylet LUER-Lock,
38361 MD RoBi KELLY Grasping Forceps,
autoclavable, diameter 2.1 mm, length 13|cm CLERMONT-FERRAND model, rotating, dismantling,
30103 MC Trocar, with conical tip, insufflation stopcock, with connector pin for bipolar coagulation,
multifunctional valve, double action jaws, especially suitable for dissection,
size 11 cm, working length 10.5 cm, size 5 mm, length 36 cm
color code: green, 26173 BN Suction and Irrigation Tube, anti-reflex surface,
including: with two-way stopcock, for single hand control,
Trocar only, with conical tip size 5 mm, length 36 cm
Cannula, without valve, with insufflation stopcock 30675 ND MANHES High Frequency Needle, for splitting
and coagulation, insulated, with connector pin for
Multifunctional Valve, size 11 mm
unipolar coagulation, length 31 cm
30160 MC 3 x Trocar, with conical tip, insufflation stopcock, 26775 UF Coagulating and Dissecting Electrode,
multifunctional valve, L-shaped, with connector pin for unipolar
size 6 mm, working length 10.5 cm, coagulation, size 5 mm, length 36 cm
color code: black,
26775 UE Coagulating and Dissecting Electrode,
including: spatula-shaped, blunt with connector pin for
Trocar only, with conical tip unipolar coagulation, size 5 mm,
Cannula, without valve, working length 36 cm
with insufflation stopcock 26005 M Unipolar High Frequency Cord, with 5 mm plug for
Multifunctional Valve, size 6 mm HF unit, models KARL|STORZ AUTOCON system
(50, 200, 350), AUTOCON II 400 (111, 115) and Erbe
30160 S 3 x Thread Sleeve, for trocar size|6|mm,
type ICC, length 300 cm
color code: black
26176 LE Bipolar High Frequency Cord, to KARL|STORZ
33351 ME CLICKLINE MANHES Grasping Forceps, rotating, Coagulator 26021|B/C/D, 860021|B/C/D, 27810|B/C/D,
dismantling, insulated, with connector pin for 28810|B/C/D, AUTOCON system (50, 200, 350),
unipolar coagulation, with irrigation connection for AUTOCON II 400 system (111, 113, 115) and
cleaning, single action jaws, width of jaws 4.8 mm, Erbe-Coagulator, T- and ICC-row, length 300|cm
with multiple teeth, for atraumatic and accurate
39301 C Plastic Container for Sterilizing and Storage of
grasping, size 5 mm, length 36 cm two Telescopes, perforated, with transparent lid,
33361 ON CLICKLINE Grasping Forceps, rotating, dismantling, with silicone telescope holder, external dimensions
without connector pin for unipolar coagulation, (w|x|d|x|h): 520|x|90|x|45|mm
single action jaws, with especially fine serration, 39301 CH Silicone Telescope Holder, for two telescopes,
fenestrated, size 5 mm, length 36 cm up to size 10 mm, i.|e. for use with plastic containers
39301 B to D
33351 SN CLICKLINE SCHNEIDER Lymph Node Grasping
Forceps, rotating, dismantling, insulated, 26173 SP 2 x SZABO-BERCI Needle Holder PARROT-JAW,
with connector pin for unipolar coagulation, single with|diamond coated jaws, straight handle,
action jaws, atraumatic, size 5 mm, length 36 cm with ratchet, for use with trocars size 6|mm,
length|33|cm, for use with suture material
33351 ML CLICKLINE KELLY Dissecting and Grasping 2/0 4/0, needle size SH (Ethicon), EN-S|(Ski),
Forceps, rotating, dismantling, insulated, V|20 (USSC)
with connector pin for unipolar coagulation, 26596 CL CICE Knot Tier, CLERMONT-FERRAND model,
double action jaws, size 5 mm, length 36 cm for|extracorporeal knotting, size|5|mm, length 36|cm
34351 MA CLICKLINE Scissors, rotating, dismantling, insulated, 26168 D Uterine Manipulator, CLERMONT-FERRAND model,
with connector pin for unipolar coagulation, complete
double action jaws, length of blades 17 mm,
26168 TN Uterine Manipulator, TINTARA model, complete
serrated, curved, spoon-shaped blades, size 5 mm,
length 36 cm 26175 BL Myoma Fixation Instrument, screw-shaped,
size|5|mm

38361 ML RoBi KELLY Grasping Forceps,
CLERMONT-FERRAND model, rotating, dismantling, 26 7130 18 ROTOCUT G1, diameter 12 mm/15 mm cutter, for
with connector pin for bipolar coagulation, laparoscopic application for use with UNIDRIVE S III
double action jaws, especially suitable for dissection, 495 NCS Fiber Optic Light Cable, extremely heat-resistant,
size 5 mm, length 36 cm diameter 4.8 mm, length 250 cm
Trocars and Accessories

Size 6 mm, 11 mm
30103 MC Trocar, with conical tip, insufflation stopcock,

multifunctional valve,
size 11 cm, working length 10.5 cm,
color code: green,
including:
Trocar only, with conical tip
Cannula, without valve,
with insufflation stopcock
330160 MC Trocar, with conical tip, insufflation stopcock,

multifunctional valve,
size 6 mm, working length 10.5 cm,
color code: black,
including:
Trocar only, with conical tip
Cannula, without valve,
with insufflation stopcock
30160 S Thread Sleeve, for trocar size|6|mm,

color code: black
TINTARA Uterine Manipulator
26168 TN
26168 TN TINTARA Uterine Manipulator, complete

including:
26168 TNB
Handle
Working Insert, size|4.0|mm,
length|50|mm
26168 TNC length|50|mm
length|80|mm
Tube Support
26168 TND
Optional Accessories:
26168 TNF Working Insert, size 4 mm, length 40 mm,
for use with 26168 TN
n
26168 TNF
26168 TNS Pertubation Tube,
n with LUER-Lock Tube Connector 600008
26168 V Uterine Tenaculum Forceps, length 22 cm
Myoma Fixation Instrument
26175 BL
26175 BL Myoma Fixation Instrument, screw-shaped,

size|5|mm
ROTOCUT G1 Morcellator
26 7130 18 ROTOCUT G1, diameter 12 mm/15 mm cutter,

for laparoscopic application, for use with UNIDRIVE S III
including:
1x Hollow shaft motor
1x Obturator, with blunt tip, diameter 12 mm
1x Same, diameter 15 mm
1x Trocarbush, askew, diameter 12 mm
1x Handle, laparoscopic
1x Cutter, laparoscopic, diameter 12 mm
1x Protective cap, diameter 12 mm
1x Motor valve, diameter 12 mm
1x Sealing cap, for single use, 10 pieces
1x CLICKLINE Tenaculum Forceps, diameter 12 mm
1x Spacer, package of 5 pcs
Maintenance and care of the motor components (Rotocut G1, EC-motor),

must be carried out with the universal spray 280052 B+C).
Please order separately.
Accessories
Cleaning Adaptor for ROTOCUT G1
Manual Cleaning
26 7130 80 Cleaning Adaptor with cone adaption for cleaning pistol

for fast and easy manual rinsing or drying of hollow shaft motor
ROTOCUT G1 26 7130 30
Machine Cleaning
26 7130 81 Cleaning Adaptor with LUER-Lock connector for cleaning

machine for fast and easy mechanically rinsing of hollow
shaft motor ROTOCUT G1 26 7130|30
Accessories
Tray system for cleaning, sterilization and storage of ROTOCUT G1 Morcellator
system for laparoscopic use.
Special features:
Ensures a suitable, validated reprocessing of the ROTOCUT G1
morcellator system
Combined or separate use of trays
Lid with opening for cleaning adaptor
Mechanical cleaning and disinfection is facilitated by cleaning ports
Safe transport and handling during routine use in the OR and CSSD (Central Sterile Supply Department)
Protection of the whole ROTOCUT G1 system during transportation, cleaning and storage
39510 G Wire Tray System for ROTOCUT G1,

for cleaning, sterilization and storage of
one ROTOCUT G1 Morcellator system,
including:
Base Tray
Upper Tray
Lid
External dimensions (w x d x h):
535 x 250 x 210 mm
(ROTOCUT G1 articles not included)
39510 GA Bottom Level to wire tray system 39510 G

(forceps level), external dimensions
(w x d x h): 535 x 250 x 100 mm
39510 GB Upper Level to wire tray system

39510 G (motor level),
external dimensions (w x d x h):
535 x 250 x 100 mm
39510 GL Lid for wire tray system 39510 G,

with handles,
external dimensions (w x d):
530 x 250 mm
(can be mounted either on Base Tray
or on Upper Tray)
IMAGE 1 HUB HD
FULL HD Camera Heads
22 2200 55-3 50 Hz IMAGE 1 H3-Z

60 Hz Three-Chip FULL HD Camera Head
max. resolution 1920 x 1080 pixels, progressive scan, soakable,
gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens,
focal length f = 15 31 mm (2x),
2 freely programmable camera head buttons
22 2200 55-3
Specifications:
IMAGE 1 FULL HD Camera Heads H3-Z
50 Hz 22 2200 55-3 (50/60 Hz)
60 Hz
Image sensor 3x 1/3" CCD chip
Pixel output signal H x V 1920 x 1080
Dimensions (w x h x l) 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15-31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
n 22 2200 56-3 50 Hz IMAGE 1 H3-P Three-Chip

60 Hz FULL HD Pendulum Camera Head
with pendulum system and fixed focus, max. resolution 1920 x 1080
pixels, progressive scan, soakable, gas- and plasma-sterilizable,
focal length f = 16 mm, 2 freely programmable camera head buttons,
for use with color systems PAL/NTSC
22 2200 56-3
Specifications:
IMAGE1 FULL HD Camera Heads H3-P

50/60 Hz 22 2200 56-3 (PAL/NTSC)
Image sensor 3x 1/3" CCD chip
Pixel output signal H x V 1920 x 1080
Dimensions (w x h x l) 35 x 47 x 88 mm
Weight 226 g
Optical interface pendulum system,
fixed focus f = 16 mm
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
For use with IMAGE 1 HUB HD Camera Control Unit SCB 22 2010 11U1xx and IMAGE1 HD
Camera Control Unit SCB 22 2020 11U1xx
IMAGE 1 HUB HD
n
FULL HD Camera Heads autoclavable
22 2200 61-3 50 Hz IMAGE 1 H3-ZA

autoclavable, max. resolution 1920 x 1080 pixels, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom
Lens, focal length f = 15 31 mm (2x), 2 freely programmable camera
22 2200 61-3 head buttons, for use with color systems PAL/NTSC
22 2200 60-3 50 Hz IMAGE 1 H3-FA

autoclavable, max. resolution 1920 x 1080 pixels, progressive scan,
soakable, gas- and plasma-sterilizable, fixed focus,
focal length f = 17 mm, 2 freely programmable camera head buttons,
22 2200 60-3 for use with color systems PAL/NTSC
Specifications:
IMAGE 1 FULL HD Camera Heads H3-ZA H3-FA

50 Hz 22 2200 61-3 (50/60 Hz) 22 2200 60-3 (50/60 Hz)
Image sensor 3x 1/3" CCD chip 3x 1/3" CCD chip
Pixels output signal H x V 1920 x 1080 1920 x 1080
Dimensions (w x h x l) 39 x 49 x 100 mm 39 x 49 x 93 mm
Weight 299 g 261 g
Optical interface integrated Parfocal Zoom Lens, fixed focus f = 17 mm
f = 15-31 mm
Min. sensitivity F 1.4/1.17 Lux F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor standard eyepiece adaptor
Cable non-detachable non-detachable
Cable length 300 cm 300 cm
For use with IMAGE 1 HUB HD Camera Control Unit SCB 22 2010 11-1xx and
TM
IMAGE 1 HD Camera Control Unit SCB 22202011-1xx
39301 Z3TS Plastic Container for Sterilization and Storage

of camera heads IMAGE1 H3-Z, H3-ZA and H3-FA,
autoclavable, suitable for use with steam, gas and
hydrogen peroxide sterilization, Sterrad compatible,
external dimensions (w x d x h): 385 x 255 x 75 mm
Please note: The instrument displayed is not

included in the plastic container.
Only camera heads marked autoclave can be
placed in the tray for steam sterilization.
n 39301 PHTS Plastic Container for Sterilization and Storage

of camera heads IMAGE1 H3-P and H3-ZI,
autoclavable, suitable for use with steam, gas and
hydrogen peroxide sterilization, Sterrad compatible,
external dimensions (w x d x h): 385 x 255 x 75 mm
Please note: The instrument displayed is not

included in the plastic container.
Only camera heads marked autoclave can be
placed in the tray for steam sterilization.
Electronic CO2-ENDOFLATOR with KARL STORZ SCB
26 4305 20-1
26 4305 08-1 Electronic CO2-ENDOFLATOR SCB

including:
Electronic CO2-ENDOFLATOR
with KARL STORZ SCB
power supply: 100 240 VAC, 50/60 Hz
Mains Cord
Silicone Tubing Set, sterilizable
Universal Wrench
SCB Connecting Cable, length 100 cm
* CO2/N2O-Gas Filter, sterile, for single use,
package of 10
Subject to the needs of the customer,
additional accessories must be ordered
and acquired separately.
Please note: For fully utilizing maximum insufflation capacity of

the Electronic ENDOFLATOR SCB the use of
KARL STORZ HiCap Trocars is recommended.
For additional information see catalog LAPAROSCOPY.
*For
) This product is marketed by mtp.
additional information, please apply to:
mtp medical technical promotion gmbh,
Take-Off Gewerbepark 46,
D-78579 Neuhausen ob Eck
E-mail: [email protected]
Cold Light Fountain XENON 300 SCB
20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 125 VAC/220 240 VAC, 50/60 Hz
including:
Mains Cord
Silicone Tubing Set, autoclavable, length 250 cm
20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028 XENON Spare Lamp, only,
300 watt, 15 volt
Fiber Optic Light Cable
495 NCS Fiber Optic Light Cable,

with straight connector, extremely heat-resistant,
diameter 4.8 mm, length 250 cm
AUTOCON II 400 SCB

20 53520x-12x AUTOCON II 400
with KARL STORZ SCB
including:
Mains Cord
20 535201-125 AUTOCON II 400 High-End, Set SCB,

power supply 220 - 240 VAC, 50/60 Hz,
HF connecting sockets: Bipolar combination,
Multifunction, Unipolar 3-pin + Erbe,
Neutral electrode combination 6.3 mm,
jack and 2-pin, System requirements:
SCB R-UI Software,
Release 20090001-43 or higher
including:
AUTOCON II 400 with KARL STORZ SCB
Mains Cord
Recommended Accessories for Equipment Cart
29005 TBG Isolation Transformer,

2000 VA, with 8 IEC-sockets,
8 potential earth connectors,
230 VAC (50/60 Hz)
29005 TBG
29003 IW Earth Leakage Monitor,

for mounting at equipment cart,
for usage with isolation transformer
29005 TBG and 29003 TBK
29003 IW
29005 KKM Special Power Cord,

29005 KKM length 100 cm,
with IEC-plug and socket,
with UL-approval,
for usage with isolation transformer
29005 TBG and 29003 TBK
29005 MZD Monitor Holding Arm,

height and side adjustable,
swiveling and tilting,
centrally mountable, swivel range 190,
overhang 300 mm,
load capacity max. 15 kg,
with monitor fixation VESA 75/100,
for usage with equipment cart 29005 DRB
29005 MZD
Notes:

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MANUAL OF GYNECOLOGICAL

Prof. Luca MENCAGLIA, M.D.

Elizabet ABDALLA Fabio IMPERATO

Manual of Gynecological Laparoscopic Surgery

I Instrumentation and Operating Room Setup

12.0 High Frequency

13.0 Laser Systems

14.0 Ultrasonic Dissection and Coagulation Systems

16.0 Suture Techniques

As the term denotes, extracorporeal suturing and knot tying

17.0 Extraction Bag

18.0 Morcellator Systems

19.0 Uterine Manipulators

20.0 Operating Room Setup and Preparation of the Patient

21.0 Patient Positioning

22.0 Maintenance and Sterilization

2.0 Principles of Electrosurgery

2.1 Various Forms of Electric Current

2.3 Use of the thermal effect in electrosurgery

2.4 Different Electrosurgery Modalities

Bipolar: in bipolar electrosurgery, the two tines of the forceps

3.0 Electrosurgery: General Safety Aspects

3.2 Isolated Electrosurgical Systems

3.3 Patient Return Electrodes

3.4 Direct Coupling

3.5 Insulation Failure

3.6 Capacitative Coupling during Laparoscopy

4.0 Recommendations for Avoiding Electrosurgical Complications

O Inspect all the insulation carefully O Do not activate in an open circuit

The operating column should be arranged in such a way

a 1 Trocar 10 mm, 234 Trocar 5 mm b 13 Trocar 10 mm, 24 Trocar 5 mm

3.1 Position of the Primary Trocar

3.2 Accessory Trocars

3.3 Type of Trocar and Mode of Insertion

3.4 Trocar Size

4.2 Maintenance of Instruments

5.0 Surgical Strategy

5.1 Strict Hemostasis

5.2 Do not Irrigate (Apply Only Suction) !

5.3 Correct Position of the Laparoscope

5.4 Optimal Use of Accessory Trocars

6.0 Selecting Information

7.0 Surgeons Ergonomics and Convenience

Main table Screen 2nd Screen

8.0 Quality of the Image

9.0 Staff Training

10.0 Preoperative Preparation

2.0 Anterior Abdominal Wall 2.1 Anatomical Area

2.2 Layers of the Anterior Abdominal Wall

2.3 The Umbilicus

2.4 Muscle Wall

2.5 Blood Supply of the Anterior Abdominal Wall

3.0 The Uterus

3.1 The Uterine Corpus

The tubes, the round ligaments, the utero-ovarian ligaments,

4.0 Vessels and Nerves

6.0 The Pelvic Vessels

6.1 Aorta, Inferior Vena cava and Bifurcation

6.2 The Inferior Vena cava