The modern era of laparoscopy began in 1954, when Palmer [1] reported the results of endoscopic procedures in 250 patients without sequelae. He produced a pneumoperitoneum with CO2 at a rate of 300 to 500 mL/min and cautioned that the intraabdominal pressure should not exceed 25 mm Hg. The claimed advantages of laparoscopy over culdoscopy were a decreased chance of infection, a better view of the pelvis, improved access to the pelvic organs and cul-de-sac, and easier application of surgical techniques.

Although the basic principles of laparoscopy are the same, the instruments and the complexity of operative procedures have changed significantly since 1954. This chapter presents information for residents learning laparoscopic operations and clinicians who are updating their knowledge of operative laparoscopy.

PREOPERATIVE EVALUATION

Advanced operative laparoscopy is a major intra-abdominal procedure. Careful preoperative evaluation optimizes the operative outcome and decreases the incidence of injuries and complications. Preoperative consultations with surgeons in other disciplines (colorectal, urologic, oncologic) sometimes are necessary. The patient is informed about the possible outcome and results of the planned operation, possible complications, and the surgeon's experience in doing the particular procedure. The following preoperative work-up is suggested:

1. History and physical

2. Complete blood count (CBC) with differential

3. Serum electrolytes

4. Urinalysis

5. Papanicolaou smear

6. Thrombin time, partial thrombin time, bleeding time

7. Transvaginal sonography (TVS)

In special situations, an endometrial biopsy, cervical culture, hysterosalpingogram, barium enema, intravenous pyelogram, blood type and screen or type and crossmatch, and bowel preparation are indicated.

Adhesions are defined as connections between opposing serosal and/or nonserosal surfaces of the internal organs and the abdominal wall, at sites where there should be no connection. This connection can be a band, which is vascular or avascular, and filmy/transparent or dense/opaque, or it could be a cohesive connection of surfaces without an intervening adhesion band. Adhesion formation is an almost unavoidable consequence of abdominal surgery. Although not all patients with intra-abdominal adhesions develop symptoms, the clinical implications, such as early and late bowel obstruction, infertility, and chronic abdominal pain, remain a common problem in general surgical and gynecologic practice. In addition, adhesion formation is associated with increased socioeconomic costs.

THE RISK FACTORS AND CLINICAL SIGNIFICANCE OF ADHESIONS

The risk factors for pelvic adhesions include a history of pelvic inflammatory disease (PID), prior surgery, perforated appendix, endometriosis, and inflammatory bowel diseases. Other recognized causes of adhesions include bacterial peritonitis, radiotherapy, chemical peritonitis, foreign body reaction, long-term continuous ambulatory peritoneal dialysis, endometriosis, and pelvic inflammatory disease. However, the greatest contribution of these risk factors is a previous history of an intra-abdominal operative procedure.

Adhesion formation after abdominal and pelvic operations remains extremely common and is a source of considerable morbidity. Menzies and Ellis confirmed that after an intra-abdominal operation, most patients developed adhesions.

Despite the degree of caution used, complications occur during operative laparoscopy. Because sequelae can result from even relatively easy procedures, a surgeon must be able to recognize them promptly and carry out proper management. The risks increase with the complexity of the procedure, the relative inexperience of the surgeon, and the amount of deviation from standard technique. As laparoscopic operations become more complex, the ability to handle them endoscopically becomes important.

Diagnostic laparoscopy and laparoscopic tubal sterilization involve few risks. The rate of intraoperative and postoperative complications is less than 1% (Table 25.1). Most reports are from large practices with experienced gynecologists, surveys of American Association of Gynecologic Laparoscopists (AAGL) members, and tertiary referral clinics.

The intraoperative and postoperative complication rates in 361 women who underwent laparoscopic hysterectomy for benign pathologic conditions were evaluated. The overall complication rate for hysterectomy carried out by laparoscopy was 11.1%. Most of the complications were minor, including cystitis (1.66%), transient high fever (1.39%), abdominal wall ecchymosis (1.12%), and pneumonia and bronchitis (1.12%). There was no correlation between the type of laparoscopic hysterectomy and the complication rate. Complication rates associated with laparoscopic hysterectomy compare favorably with published complication rates for vaginal and abdominal hysterectomy.

Retropubic Burch colposuspension has been considered by many to be the “gold standard” procedure for the treatment of female stress urinary incontinence for almost 40 years. Vancaillie and Schuessler introduced the laparoscopic approach to retropubic colposuspension in 1991. Numerous reports followed in subsequent years describing laparoscopic colposuspensions and their efficacy. Analysis of the outcomes of these various laparoscopic “Burch” colposuspensions is difficult because many of the techniques are not true Burch procedures but rather other modified retropubic colposuspensions. In this section, we describe the laparoscopic Burch colposuspension, including patient selection, preoperative evaluation, operative technique, possible complications, and efficacy. We review the efficacy of the laparoscopic Burch colposuspension studies that use the Burch—Tanagho procedure and compare these techniques to other popular anti-incontinence procedures. The many modified laparoscopic retropubic procedures are not addressed.

BURCH COLPOSUSPENSION: THE EVOLUTION OF A PROCEDURE

In 1961, Burch published the description of a new female anti-incontinence procedure, based on a technique started in 1958. The technique involved entering the space of Retzius via a paramedian incision. After clearing the periurethral tissue of its overlying fat and areolar tissue, three 2-0 chromic sutures were placed at the mid-urethra and the bladder neck and then fixed to Cooper's ligament. Burch reported a subjective cure rate of 92% in 143 patients with 10 to 60 months of followup.

Successful operative laparoscopy requires the proper basic and specialized equipment to make difficult procedures technically possible and safe. Most operations can be done with two or three forceps, a suction—irrigator probe, a bipolar electrocoagulator, and a CO2 laser. With the rapid growth of operative laparoscopy, disposable, semireusable, and reusable instruments have become available. In selecting the appropriate instruments, their cost and effectiveness should be considered because too many instruments clutter the field and increase operative time.

With videolaseroscopy, the operation is observed by the surgeon and operating room staff on video monitors. The CO2 laser is used through the operative channel of the laparoscope for cutting and establishing hemostasis of small blood vessels. Electrocoagulation with a bipolar forceps is used to control bleeding from larger vessels. These instruments enable surgeons to increase the diversity of laparoscopic procedures. Some of them have multiple functions, whereas others are specialized. Most are designed to fit through trocar sleeves between 2 mm and 33 mm in diameter.

THE BASIC INSTRUMENTS

The Laparoscope

The endoscope allows one to view the abdominal and pelvic cavities and is the most important piece of equipment. It must be in optimal condition. Although the diameter of laparoscopes varies from 2 to 12 mm and the angle of view varies from 0° to 90°, the most commonly used laparoscopes are straight diagnostic (Figure 2.1A) and angled operative laparoscopes (Figure 2.1B,C).

The field of reproductive medicine is evolving rapidly. We are living in an era in which what was seemingly impossible a decade ago is being made possible, and century-old dogmas are being challenged. Thanks to new cryopreservation technologies, infertility and premature ovarian failure, especially when induced by medical treatments, are no longer unavoidable consequences. Whereas success with oocyte cryopreservation is gradually approaching acceptable levels for use in patients who face the risk of ovarian failure due to medical treatments or to create “egg banks” for oocyte donation, ovarian tissue cryopreservation and transplantation promise to be a way to reverse menopause and restore fertility. Yet, the recently proposed possibility of the presence of germ stem cells in human bone marrow is even more intriguing. Whereas bone marrow and peripheral blood transplants result in repopulation of chemotherapy-treated ovaries with primordial follicles in rodents, germ stem cell markers are already shown in human bone marrow and peripheral blood. According to this theory, the ovaries provide signals to the germ stem cells residing in the bone marrow and recruit new follicles via the bloodstream “on demand.” Although shocking and contrary to the preexisting dogma that the ovarian reserve is predetermined before birth, this hypothesis is not without supporting evidence in humans and nonhuman primates, as illustrated by the following case study.

The ability to suture laparoscopically increases a laparoscopist's versatility. Suturing is used for hemostasis and to oppose tissues during reconstructive procedures. Different types of sutures are available for endoscopic use. The Endoloop (Ethicon) suture, a preformed slipknot attached to a rigid, disposable 5-mm applicator, is available in 0-chromic gut, polyglactin, polydioxanone, and polypropylene (Figure 5.1). The loop is positioned around the pedicle by grasping the structure to be removed and pulling it through the loop. The loop is tightened against the applicator, and the suture is cut with scissors or the laser beam against a backstop.

Suture material is available with a straight or curved swaged needle specifically designed for laparoscopic use. It is available in 0-chromic catgut, 4-0 polydioxanone with a swaged ST-4 needle (PDS, Ethicon), and polyglactin. The suture is grasped with forceps several centimeters from the needle. The grasper with suture is inserted intra-abdominally through the 5-mm accessory trocar sleeve.

To place the needle intra-abdominally, the grasper or needle driver is removed along with the trocar sleeve, which remains around the grasper's shaft. The suture is grasped about 5 cm from the needle, and the grasper is reintroduced with the trocar sleeve into the suprapubic incision site.

A surgeon is required by law and bound by moral and ethical standards to explain a planned operation, its risks, and the expected outcome to the patient preoperatively. The purpose of this Appendix is to (1) provide a guide for discussing a proposed laparoscopic operation with the patient and (2) describe the informed consent as it relates to laparoscopy.

Diagnostic laparoscopy has gained widespread acceptance among gynecologic and general surgeons, but patients' expectations and the actual results from advanced operative laparoscopic procedures frequently do not coincide. For example, some patients believe that lasers are essential for a thorough operation, although most surgeons acknowledge that scissors and electrosurgical instruments are equally effective. Patients tend to consider laparoscopic procedures minor operations. This idea is reinforced by terms such as same-day surgery, Band-Aid surgery, minimal invasive surgery, and laser surgery. Patients and physicians underestimate the risks of complex operative endoscopy, which are potentially as serious as those associated with laparotomy.

The Informed Consent

Since 1914, surgeons have been required to obtain a patient's written consent before an operative procedure. This process allows the patient to participate in decisions with an understanding of the factors relevant to the proposed operation. The proper consent requires that the patient be informed of the diagnosis, the proposed treatment, the probability of success, alternative forms of therapy, and the risks of the planned operation.

This is an exciting time to be a surgeon. The field of reproductive medicine has undergone many changes over the past three decades. Gynecologic endoscopic surgery, in particular, has seen tremendous advances during this period. Breakthroughs in video technology, instrumentation, adhesion prevention, and computer-enhanced technology have certainly allowed surgeons to routinely perform a number of procedures endoscopically rather than by laparotomies. These innovations have contributed to faster recovery time, smaller scars, less adhesion formation, fewer complications, lower cost, and, most importantly, better results.

The editors deemed it necessary to update their previous edition due to popular demand and to reflect the rapid advancement in this field. With the contributions of authoritative figures in their respective areas of expertise, many new additions can be found in this book. The inclusion of hysteroscopy in the title and the dedication of a new section on hysteroscopy are meant to emphasize the importance of such surgery in the gynecologic practice today. A new section on fertility treatment and procedures reflects the rapid development in this area. As minimally invasive surgery and natural orifice surgery are becoming more and more accepted and applied in the management of gynecologic malignancy, a significant portion of the book is devoted to this topic to bring the latest information and controversies to our readers.

Sound surgical technique, whether during laparotomy or laparoscopy, is based on accurate anatomic knowledge. Laparoscopic surgeons must adapt to the altered appearance of anatomy due to the effects of pneumoperitoneum, Trendelenburg positioning, and traction from a uterine manipulator. There are inherent limitations of laparoscopy related to the fixed visual axis, loss of depth of field, and magnification. Furthermore, laparoscopes with different angles of view make orientation more challenging.

Because a three-dimensional field is projected to video monitors as a two-dimensional image, it is imperative for the endoscopic surgeon to understand that the anatomic structures appearing superior on the monitor are actually anterior and those inferior are posterior.

In this chapter, we describe some important anatomic relations that are critical during laparoscopic procedures.

SUPERFICIAL INTRAPERITONEAL ANATOMY (LANDMARKS TO RETROPERITONEAL STRUCTURES)

Superficial intraperitoneal landmarks within the pelvis alert the operator to key anatomic structures in the retroperitoneal space (Figure 6.1A—C).

The umbilicus is located at the level of L3—L4, although the location varies with the patient's weight, the presence of abdominal panniculus, and the position of the patient on the operating table (supine vs. Trendelenburg). The abdominal aorta bifurcates at L4–L5 in 80% of cases. [1]

The parietal peritoneum over the anterior abdominal wall is raised at five sites, representing the five umbilical folds.

The adnexa are in an anatomic region in the pelvis that includes the ovaries, the fallopian tubes, and the structures within the broad ligament. The differential diagnosis of an adnexal mass is complex because of the wide spectrum of disorders that involve the adnexa. Most frequently, adnexal masses involve the ovary itself because of its inherent growth properties through ovulation and thus its propensity for neoplasia. During the evaluation of an adnexal mass, the picture may be further complicated as imaging does not always clearly delineate the adnexa from other nearby organs. An estimated 5% to 10% of women in the United States will undergo a surgical procedure for a suspected ovarian neoplasm during their lifetime. Although the majority of adnexal masses are benign in nature, the primary goal of the diagnostic evaluation is the exclusion of malignancy.

ETIOLOGY

The differential diagnosis of the adnexal mass varies with age (Table 9.1.1). Age is also the most important factor in determining the potential for malignancy. In fact, the risk that an ovarian neoplasm is malignant increases 12-fold from ages 12 through 29 and 60 through 69. Although there is emerging evidence that the presence of an adnexal mass in postmenopausal women is more common than once thought, masses found in premenarchal and postmenopausal women should be considered abnormal and must be promptly evaluated.

Cystoscopy, the gold standard for diagnosis of disorders and injuries of the lower urinary tract, provides another tool for prevention and active management of urologic pathology and surgical complications by allowing the surgeon to assess the integrity and function of the urethra, bladder, and ureters. At our center, we have incidentally detected bladder endometriosis, polyps, malignant lesions, diverticula, duplicated ureter, and interstitial cystitis. One case of complete ureteral obstruction and renal necrosis due to invasive endometriosis was detected during an incidental cystoscopy. Contralateral periureteral disease was treated, resulting in successful conservation of the other kidney.

Cystoscopic technique, unfortunately, is not routinely taught during obstetrics/gynecology residency training; therefore, many gynecologists do not feel comfortable performing the procedure. This is unfortunate as gynecologists deal with urogynecologic issues daily with conditions such as urinary incontinence, pelvic organ prolapse, and severe endometriosis involving the lower urinary tract. Two large multicenter studies demonstrated that 66% to 80% of patients with chronic pelvic pain had evidence of bladder-origin pain due to bladder epithelial damage or interstitial cystitis. In the gynecologic literature, chronic pelvic pain is associated with endometriosis in 30% to 87% of cases as well. The surgical treatment of pelvic pain is the most frequent indication for operative laparoscopy, although in as many as 40% of patients, no pathology is found.

Endometriosis is classically defined as the presence of endometrial glands and stroma in ectopic locations. Affecting from 6% to 10% of reproductive-aged women, endometriosis may result in dysmenorrhea, dyspareunia, chronic pelvic pain, and/or subfertility. The prevalence of this condition in women experiencing pain, infertility, or both is as high as 50%. Endometriosis is a debilitating condition, posing quality-of-life issues for the individual patient. The disorder represents a major cause of gynecologic hospitalization in the United States, estimated to have exceeded $3 billion in inpatient health care costs in 2004 alone. The significant individual and public health concerns associated with endometriosis underscore the importance of understanding its pathogenesis. The first recorded description of pathology consistent with endometriosis was provided by Shroen in 1690. Despite the passage of time and extensive investigation, the exact pathogenesis of this enigmatic disorder remains unknown.

THEORIES REGARDING PATHOGENESIS

Numerous theories detailing the development of endometriosis have been described. For purposes of review, these theories can generally be classified into those that propose that implants arise from tissues other than the endometrium and those that propose that implants arise from uterine endometrium (Table 10.1.1).

Nonendometrial Origin

Metaplasia of coelomic epithelium represents a distinct pathogenic mechanism for the establishment of endometriotic implants.