Atlas of Lift-Laparoscopy: The New Concept of Gasless Laparoscopy

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ATLAS OF LIFT-LAPAROSCOPY

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ATLAS OF LIFT-LAPAROSCOPY THE NEW CONCEPT OF GASLESS LAPAROSCOPY

DANIEL KRUSCHINSKI MD EndoGyn® Ltd Endoscopic Gynecology Centers Germany www.EndoGyn.com

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© 2007 Informa UK Ltd First published in the United Kingdom in 2007 by Informa Healthcare, 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN. Informa Healthcare is a trading division of Informa UK Ltd. Registered office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales number 1072954. Tel: Fax: Email: Website:

+44 (0)20 7017 6000 +44 (0)20 7017 6336 [email protected] www.informahealthcare.com

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. Although every effort has been made to ensure that drug doses and other information are presented accurately in this publication, the ultimate responsibility rests with the prescribing physician. Neither the publishers nor the authors can be held responsible for errors or for any consequences arising from the use of information contained herein. For detailed prescribing information or instructions on the use of any product or procedure discussed herein, please consult the prescribing information or instructional material issued by the manufacturer. A CIP record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Data available on application ISBN-10: 1 84214 118 X ISBN-13: 978 1 84214 118 2 Distributed in North and South America by Taylor & Francis 6000 Broken Sound Parkway, NW, (Suite 300) Boca Raton, FL 33487, USA Within Continental USA Tel: 1 (800) 272 7737; Fax: 1 (800) 374 3401 Outside Continental USA Tel: (561) 994 0555; Fax: (561) 361 6018 Email: [email protected] Distributed in the rest of the world by Thomson Publishing Services Cheriton House North Way Andover, Hampshire SP10 5BE, UK Tel: +44 (0)1264 332424 Email: [email protected]

Composition by Cepha Imaging Pvt. Ltd., Bangalore, India. Printed and bound in India by Replika Pvt Ltd.

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CONTENTS

Preface

vii

Acknowledgments

ix

1 2 3 4 5 6 7 8 9 10 11

What makes gasless laparoscopy superior to pneumoperitoneum

1

Complications and problems due to carbon dioxide and pneumoperitoneum: pathophysiologic effects of carbon dioxide insufflation

7

General technical abilities and advantages of lift (gasless)-laparoscopy

11

Setting up the operating theater, devices, and instruments

35

Patient positioning and anesthesia

45

Creation of abdominal wall elevation

49

Termination of the lift (gasless)-laparoscopic procedure

71

Enucleation of ovarian cyst without rupture using endobag

77

Myomectomy

95

Laparoscopic hysterectomy

107

Adhesiolysis

125

Index

143

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PREFACE

Lift-laparoscopy is a new concept of gasless laparoscopy with a reusable abdominal wall lifting system, which provides the surgeon with the necessary space and vision comparable to that of pneumoperitoneum laparoscopy. This concept avoids several typical intraoperative problems of pneumoperitoneum laparoscopy. By utilizing flexible and valveless trocars, conventional instruments, and standard surgical techniques and moreover avoiding disposables, lift-laparoscopy is a cost effective procedure with benefits for patients, surgeons, hospitals, and the health system. Lift laparoscopy, on the one hand, is a simple, effective, and economical introduction to operative laparoscopy and, on the other hand, extends the indications of minimal invasive surgery. Conventional instruments, which have been developed and modified over a very long period, allow the surgeon, in contrast to laparoscopic instruments, to use tactile sense and palpation. Complications during the blind Veress needle or trocar insertion such as vascular lesions or intestinal injury are virtually excluded by this technique. Problems and complications of the iatrogenic insufflation of carbon dioxide (pneumothorax, pneumomediastinum, pneumopericardium, air embolism, massive subcutaneous emphysema) are completely excluded. Physiologically, gasless laparoscopy is less invasive than pneuomoperitoneum insufflation and allows the performance of laparoscopic surgery in at-risk patients, e.g. those with heart insufficiency or lung obstruction, as well as in pregnancy. The ability to utilize operative laparoscopy under regional anesthesia has become a new challenge. Lift-laparoscopy continues to pursue the concept of laparoscopy as minimal invasive surgery; however, it offers simplification and cost-effectiveness and extends the range of application. This atlas represents a procedural guide, and not a textbook, as endoscopy is a visual topic. It offers the experienced laparoscopic and laparotomic surgeon an excellent guide to starting lift-laparoscopic procedures and, based on this description, to developing personal skills in a reasonable learning time. Daniel Kruschinski

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ACKNOWLEDGMENTS

Abdo-Lift™ is a trademark of EndoSurgery Ltd, Germany. The author expresses his thanks to Michaela Katzer from EndoGyn® Ltd for her continuous assistance during surgeries in the operating theater since July 2002. The author also expresses his gratitude to Dr Swapnil Langde and Dr Ameya Purandare (both from India) and Dr Mohammed Sedkey (Egypt) for assisting in many hours of surgery and Dr Ameya Purandare for his proofreading of the draft version of this atlas. Please also refer to www.Lift-Laparoscopy.com

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In modern surgical practice, the surgical procedure known as keyhole surgery or minimally invasive surgery permits operations to be performed which formerly would have necessitated the use of large incisions and instruments. Keeping the surgical wound as small as possible was for a long time the aim of surgeons. Therefore, surgical techniques were continually being refined in order to gain access, with the minimum of adverse effects, to the site of disease. In gynecology, endoscopic investigations of the abdominal sex organs, such as the uterus, fallopian tubes, and ovaries, have a long history. Operations using the endoscope were a routine procedure in the diagnosis of various gynecologic conditions. In the 1970s laparoscopy was performed mainly for diagnosis or for tubal ligation. Thanks to the pioneer Professor Kurt Semm, from Kiel, more and more indications were established in Germany and worldwide. Today, laparoscopic procedures to treat benign manifestations in the ovaries and fallopian tubes (extrauterine pregnancy, ovarian cysts) as well as in the uterus (myomas) are standard procedures carried out as a routine measure in endoscopic centers. The advantages of endoscopic operations for malignant cases cannot yet be definitively elucidated, which is why such operations are being conducted on an experimental basis in very few hospitals.

ADVANTAGES OF ENDOSCOPY Large surgical wounds are avoided using endoscopy. Therefore, there is markedly less wound pain after surgery. The patient recovers and becomes mobile more quickly; hence, the hospital stay is considerably shortened and indeed procedures can even be carried out in many cases on an outpatient basis. The cosmetic result is considerably better since only small scars remain. Wound healing disorders are seen less often after endoscopic operations than after open abdominal surgery, and there are fewer problems due to adhesions and scars.

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RISKS AND DISADVANTAGES OF ENDOSCOPIC OPERATIONS However, like all operations, endoscopic procedures also pose certain risks such as, for example, hemorrhage, organ injury, or infection. Moreover, it can come to light in the course of an endoscopic procedure that conventional surgery is warranted. Endoscopic procedures necessitate insufflation of the abdominal cavity with carbon dioxide in order to obtain a sufficient view of the surgical field and grant the surgeon enough space to work. This causes a considerable build-up of pressure in the abdominal cavity and reduces the body temperature due to the cold gas, which in turn causes pain that in some cases can persist for several days, radiating to the shoulder and neck regions; these manifestations can prolong and complicate the recovery period. Moreover, the gas is held responsible for further side effects whose implications have not yet been adequately clarified. For example, there are increasingly more reports in the literature about incidences relating to carbon dioxide, which is converted in the body to carbonic acid. Long operations using carbon dioxide may lead, above all in older and less healthy patients, to a decrease in the pumping action of the heart or to overloading the organism with carbonic acid, and this in turn can cause acidosis of all organ systems. Insufflated gas can in very rare cases lead to gas accumulation in the vascular systems of the lungs (gas embolism), heart (decrease in coronary blood supply), and the kidneys (poorer perfusion), or to the accumulation of carbon dioxide in the subcutaneous tissue of the skin (emphysema). While such side effects of carbon dioxide are extremely rare, they can prove fatal (kidney failure, heart attack, pulmonary embolism). Typical complications of an endoscopic procedure can occur while inserting the Veress needle – for gas insufflation – or the secondary trocars. This ‘insufflation needle’ is pierced ‘blindly’, i.e. without visual control, into the abdominal cavity. After the abdominal cavity has been filled with gas, the first trocar for the optic is inserted (also without visual control). Both can in rare cases cause injury to vessels or organs (for example the bladder, intestines, stomach, and others), and this in turn can trigger emergency situations (e.g. bleeding) warranting immediate action. An undetected bowel injury following coagulation often results some time later in acute ileus and massive infection. Endoscopic operations are clearly more difficult, and are therefore performed by only a few centers. By working with overly long, specially modified instruments, the surgeon loses tactile perception. The instruments are unfamiliar; they have the most diverse gripping systems and small graspers. All this detracts from precision during surgery. Only a very few surgeons develop the ability to operate in the abdominal cavity with only indirect visual contact, i.e. looking at the monitor. Therefore, the learning curve associated with endoscopic surgical techniques is very long. The complication rate for 2

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endoscopic procedures is also higher than in open surgery, especially in the case of surgeons who are not yet optimally trained. This is also one of the reasons why, following the initial euphoria, stagnation can be noted in the spread of endoscopy. In order to avoid gas loss via the instruments, special trocars with valves were developed. The instruments themselves consist of multiple tubular and shaft systems which mimic the rotary and angled movements of the hand. To avoid gas loss while changing the instruments (for example between scissors and graspers), multi-functional instruments were developed. Industry has to make massive investments to manufacture these instruments, which is why the costs incurred for such instruments are much higher than in the case of conventional instruments. Endoscopic instruments are more laborious when it comes to maintenance and processing. Due to the myriad tubular systems, special washer-disinfectors must be purchased to clean these instruments and eliminate contaminants based on body secretions and blood, which could cause infection. For the past 75 years (since the introduction of laparoscopy with carbon dioxide) industry has been trying, in close cooperation with endoscopic surgeons, to overcome the problems emanating from endoscopic procedures using gas. In the meantime, a very important market segment has therefore developed which, by continually developing newer instruments and equipment, makes endoscopic procedures using gas safer but also more expensive. The costs are spiraling due to, among other things, the use of special thread and suture materials, the widespread use of disposables, such as titanium clip systems, and the use of suturing devices and angled instruments; all this calls into question the benefits of endoscopic procedures. Professor Axel Perneczky, a neurosurgeon from Mainz, made the following statement regarding endoscopic surgery: ‘Keyhole surgery can be likened to a situation where we try to sew on a button on the bed linen in the bedroom with a tweezers through the keyhole of the front door; moreover, the rooms are full of furniture, around which we have to maneuver the tweezers …’ This is a corresponding quotation by the present author on the development and introduction of gasless laparoscopy: ‘Keyhole surgery can also be likened to a situation where we use a ladder to try to come in through a closed window of a bedroom on the first floor, although the front door is wide open …’

ADVANTAGES OF GASLESS ENDOSCOPY Gasless laparoscopy continues to pursue the concept of a minimally invasive operating method, however offering the principle of simplification, cost-effectiveness, and a wide range of application. This technique is based on the principles of minimally invasive operating methods, combined with the conventional technique used in ‘open’ abdominal surgery. The gasless technique reduces all of the aforementioned disadvantages, risks, and

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complications of gaseous endoscopic surgery to a minimum, but retains, however, all the advantages of laparoscopy such as small scars, better appearance, less pain, quicker recovery, shorter hospital stay, etc. The method thus offers progress (the combination of the latest techniques of endoscopic surgery) by taking a step back (proven and established, conventional abdominal surgery techniques).

Advantages for the Patient By dispensing with insufflation using carbon dioxide, there is considerably less pain after surgery. Essentially, the shoulder pain observed after endoscopic procedures is avoided or greatly reduced. The patient needs fewer painkillers compared to laparoscopy with gas. The recovery period is shorter, with the patient returning to normal activity faster than after laparoscopy with gas; for instance, the recovery period after a hysterectomy is only approximately 2 weeks. The operation is safer and more precise because one can dispense completely with the long and unfamiliar instruments. The risk of infection posed by inadequately cleaned endoscopic instruments and by different tubular and pumping systems is eliminated. The serious complications associated with ‘blind’ insertion of the Veress needle or trocars into the abdominal cavity are avoided, because in gasless laparoscopy the abdominal cavity is accessed under visual control. Complications relating to clips, suturing systems, or electrical coagulation, e.g. injuries to the ureter during an endoscopic hysterectomy, are avoided. The not yet foreseeable late complications caused by titanium clips remaining in the body, which must still be investigated, can be avoided. All aforementioned side effects, risks, and complications caused by carbon dioxide are circumvented, so that in addition to young and healthy patients, older or at-risk patients can also be operated on using the gasless method. This technique also makes it possible to perform endoscopic procedures under regional anesthesia, something that was not hitherto possible because of the massive pressure from the pneumoperitoneum in the abdominal cavity, which causes pain and organ compression (diaphragm, lung). Operations can also be conducted in pregnant women using gasless laparoscopy, as there is no pressure build-up, caused by gas, on the growing uterus (miscarriage, decreased perfusion of the placenta and of the baby). Gasless laparoscopy carried out in pregnancy avoids acidity of the blood of the fetus so that organ damage can be prevented, and, moreover, the operation can be performed without general anesthesia. Domenico D’Ugo, an anesthesiologist from Rome, stated in 1997 at the International Symposium on Gasless Laparoscopy in Gynecology: ‘The use of carbon dioxide is almost the only reason for exclusion of risk patients from laparoscopy, who in truth would be the only ones to benefit from the minimally invasive procedure …’ 4

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Advantages for the Surgeon The dangerous complications which are typical of endoscopic surgery, resulting from ‘blind’ insertion of the Veress needle for gas insufflation or of the first trocar, are avoided. In addition to special instruments, the surgeon can also use traditional surgical instruments. Accordingly, sutures can be applied using the tried and tested needle and thread method instead of clip and suture apparatus or electrical coagulation, which are expensive or can cause complications and whose benefits have not yet been clarified. Inadequate suture techniques that often occur during endoscopic treatment also do not represent a problem for the gasless method, as conventional suture techniques with needle and thread are used without a problem. It is often seen that, when closing up the myometrium after the enucleation of an intramural myoma, endoscopic suture techniques can fail. As a result, the inadequate adaptation of the myometrium has been stated as a cause for possible rupture of the uterus during pregnancy and childbirth. Tried and tested surgical techniques which have proved themselves over decades can also be used, thus enhancing precision and safety and shortening the operating time. Unlike when using the long endoscopic instruments, the surgeon preserves tactile manual perception and can thus feel what he is cutting, holding, or compressing. With the magnification conferred by the endoscope, the operation evolves more precisely and more safely. Gasless laparoscopy also simplifies the removal of samples and tissue from the abdominal cavity, as these can be morcellated with a scalpel or scissors. As the organ or part of an organ is immediately removed, the loss of features associated with the organ, such as myomas, is counteracted. During a gas laparoscopic operation, the organ is in most cases removed at the end of the operation to prevent any gas loss through the extended opening during the removal procedure. Also, the learning curve associated with the gasless technique for the surgeon is markedly shorter, because he needs only to learn how to interact with the monitor, since the surgical technique remains the same as that practiced in open abdominal surgery, and is therefore easier.

Advantages for the Healthcare System Minimally invasive operations using laparoscopy with carbon dioxide are about seven times more expensive than laparotomy. Minimally invasive operations using gasless laparoscopy are more cost-effective as they dispense with systems that render laparoscopy with gas expensive. Instruments can be cleaned in the same way as hitherto; no special washerdisinfectors are required.

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Conventional instruments last considerably longer: they do not break as often as those instruments used for the gas method, and need not be repaired or replaced so often. Neither is it necessary to continue using every novel instrument and technique that comes on the market so that the safety and maneuverability of gas laparoscopy can be improved. With the gasless method no disposables are used, such as titanium clips and special threads, which are enormously expensive. By combining the minimally invasive technique (short hospital stay and recovery period) with the cost-effectiveness of the gasless method, this method of surgery is overall markedly more favorable than laparoscopy with gas. This technique is simple and easy to learn, and hence more surgeons, who have so far not performed endoscopic surgery due to its inherent difficulties, can employ the technique, and therefore more patients will benefit from the minimally invasive surgical method. Especially in the developing countries of our world where, because of the lack of appropriate equipment and the high costs of devices and instruments, endoscopic surgical techniques were scarcely encountered or introduced, patients can be operated on with laparoscopy using the lifting technique.

CONCLUSION Gasless laparoscopy using the Abdo-Lift™ abdominal wall retractor system combines the advantages of minimal invasive surgery with the advantages of laparotomy, eliminating at the same time the disadvantages of both methods. The method thus fulfills the target criteria, as defined by Scheidel, for checking innovative treatment concepts. As patients experience less postoperative pain after the same operation, the therapy is more successful (cost-effective). Also, a therapy result which is at least equally as good is achieved at a lower cost (cost-utility) and the benefit of the therapy for the patient is increased, as both the costs and the complications are reduced (cost-benefit).

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COMPLICATIONS AND PROBLEMS DUE TO CARBON DIOXIDE AND PNEUMOPERITONEUM: PATHOPHYSIOLOGIC EFFECTS OF CARBON DIOXIDE INSUFFLATION

PATHOPHYSIOLOGIC EFFECTS OF CARBON DIOXIDE INSUFFLATION Whilst instruments and devices have become more advanced, the principle of the CO2 pneumoperitoneum has not changed for decades, and it is precisely the carbon dioxide which limits the scope of this operative technique. The occurrence of possible side effects and complications is more significant in the cases of older and higher-risk patients and longer operations. Problems relating to CO2 laparoscopy such as hypothermia with increased postoperative pain, but also hemodynamic and metabolic effects such as CO2 absorption and CO2 intravasation coupled with an increase in pCO2, have been described by Chernlack et al. and Alexander and Brown.1,2 The CO2 is known to produce metabolic acidosis and hypercapnia as well as hypoxemia in the tissues, as described by Wolfe et al., Taura et al., Wittgen et al., and McLaughlin et al. in their cases of endoscopic cholecystectomy.3–6 The pneumoperitoneum itself leads to an increase of the intraabdominal pressure, which causes an elevation of the diaphragm and can result in hyperventilation. The pneumoperitoneum may lead to compression of the vena cava, causing the cardiac output and volume to be reduced and the central venous pressure to be increased, resulting in increased vascular resistance in the arterial circulation, as noted by Brown et al., ben-David et al., and Sharma et al.7–9 With the increased popularity and usage of operative laparoscopy, an increase in indications along with prolonged operating times and operations on older patients or high-risk patients occurred. Unfortunately, this was followed by more reports of acute organ failure8 or fatal complications caused by CO2 insufflation,9–11 as described by several anesthetic and intensive care departments.

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If one, however, looks at experimental studies, these show that gasless laparoscopy offers clear advantages compared to pneumoperitoneum laparoscopy. A randomized study of renal excretion and the electrolyte metabolism during gasless interventions and gas laparoscopy carried out in pigs12 showed that a significant reduction of creatinine clearance and urinary excretion occurred during and after CO2 laparoscopy. Also, a significant increase in the serum aldosterone occurred, an indication of a disorder of the renin–angiotensin system due to underperfusion of the kidneys, causing a reduction of the sodium and potassium level in the urine. Apart from other physiologic advantages of gasless laparoscopy discussed in this study, the authors concluded that gasless laparoscopy clearly offered better results than gaseous laparoscopy with regard to renal hemostasis. To increase the safety of laparoscopic surgery, the authors even recommended monitoring the urine electrolytes and the urine volume during a gas laparoscopy process and, in particular, in the case of longer operations. Another experimental study by Woolley et al.,13 carried out in pigs, clearly showed that gasless laparoscopic surgery also achieved significantly better pulmonary and systemic hemodynamics compared to a CO2 pneumoperitoneum. During endoscopic surgery, lasting several hours, more than 100 liters of cold CO2 may circulate through the abdominal cavity, causing hypothermia; the body temperature can sink by 3°C during this process. A further problem of CO2 laparoscopy is possible contamination of the CO2 with viruses, bacteria, rust, metal dust, or Teflon™14 in the insufflation device or the hose system. This problem occurs, in particular, in countries in which it is not usual to produce medical CO2. Recent studies by Koninckx in Leuven15,16 showed in animal trials that, depending on the duration of the operation, CO2 stimulates the formation of adhesions. Finally, to complete the list, one should also mention the studies by various work groups carried out in animals to solve the problem of the spread of malignant cells, apparently caused by modulation (acidosis) of the peritoneum by the CO2 gas.17 This in turn led to statements such as that minimally invasive surgery is maximally invasive from a physiologic point of view, and that consequently patients subjected to endoscopy should be carefully selected to minimize such complications.8–11

OTHER COMPLICATIONS DURING PNEUMOPERITONEUM LAPAROSCOPY Apart from possible complications caused by the CO2 gas, problems with the pneumoperitoneum in laparoscopic surgery should also be mentioned. Complications arising from blind insertion, such as vascular lesions or intestinal injury, occur relatively seldom, but can, however, be serious. 8

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Also, a pneumothorax, a pneumomediastinum, a pneumopericardium, an air embolism, or a massive subcutaneous emphysema could result.18,19 Absolute contraindications to laparoscopy using a pneumoperitoneum are cardiac insufficiency and lung obstruction, whilst relative counterindications are pregnancy, diaphragmatic hernia, and obesity. Every surgeon knows about the dangers of a collapsing pneumoperitoneum at the moment a hemorrhage occurs. In most cases, the suction irrigation system also fails, making it impossible to see the area, whilst the surgeon tries to pinpoint the hemorrhage using suction and irrigation. As a result of the escaping pneumoperitoneum, the space in the upper abdomen is lost (reservoir for intestinal loops), causing the intestines to move back from the upper abdomen into the pelvis, and the precisely located site of hemorrhage once again disappears from view. If the bleeding from the vessel covers the lens system, which, anyway, is constantly misted up (temperature difference between that of the irrigation solution and body temperature), the surgeon will experience hampered vision and this will lead to confusion. It is also nearly impossible to grasp the bleeding vessel with the tiny ends of a laparoscopic forceps or even ligate the vessel, so that conversion to open surgery can hardly be avoided. None of these problems is encountered in gasless laparoscopic surgery, and hence we must strongly consider that gasless laparoscopy is indeed much safer, more physiologic, and more effective than pneumoperitoneum laparoscopy.

REFERENCES 1. Chernlack NS, Longobardo GS, Staw I, Heymann M. Dynamics of carbon dioxide stores changes following an alteration in ventilation. J Appl Physiol 1966; 21:785–93. 2. Alexander GD, Brown EM. Physiological alterations during pelvic laparoscopy. Am J Obstet Gynecol 1969; 105:1078–81. 3. Wolfe BM, Gardiner BN, Leary BF, Frey CF. Endoscopic cholecystectomy: an analysis of complications. Arch Surg 1991; 126:1192–5. 4. Taura P, Lopez A, Lacy AM et al. Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis. Surg Endosc 1998; 12:198–201. 5. Wittgen CM, Andrus CH, Fitzgerald SD et al. Analysis of hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 1991; 126:97–101. 6. McLaughlin JG, Bonnel BW, Scheeres DE, Dean RJ. The adverse hemodynamic effects related to laparoscopic cholecystectomy. Anesthesiology 1992; 77:70–7. 7. Brown DR, Fishburne JI, Roberson VO, Hulka JF. Ventilatory and blood gas changes during laparoscopy with local anesthesia. Am J Obstet Gynecol 1976; 124:741–5. 8. ben-David B, Croitoru M, Gaitinin L. Acute renal failure following laparoscopic cholecystectomy: a case report. J Clin Anesth 1999; 11:486–9. 9. Sharma KC, Kabinoff G, Ducheine Y, Tierney J, Brandstetter RD. Laparoscopic surgery and its potential for medical complications. Heart Lung 1997; 26:52–64; quiz 65–7. 10. Koivusalo AM, Kellokumpu I, Ristkari S, Lindgren L. Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: a comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method. Anesth Analg 1997; 85:886–91.

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11. Naude GP, Ryan MK, Planim NA et al. Comparative stress hormone changes during helium versus carbon dioxide laparoscopic cholecystectomy. J Laparoendosc Surg 1996; 6:93–8. 12. Chiu AW, Chang IS, Birkett DH, Babayan RK. Changes in urinary output and electrolytes during gaseous and gasless laparoscopy. Urol Res 1996; 24:361–6. 13. Woolley DS, Puglisi RN, Bilgrami SB, Quinn JV, Dlotman GJ. Comparison of the hemodynamic effects of gasless abdominal distension and CO2 pneumoperitoneum during incremental positive end-expiratory pressure. J Surg Res 1995; 58:75–80. 14. Ott DE. Contamination via gynaecologic endoscopy insufflation. J Gynecol Surg 1989; 5:205–8. 15. Molinas CR, Tjwa M, Vanacker B, Binda MM, Elkelani O, Koninckx PR. Role of CO2 pneumoperitoneum-induced acidosis in CO2 pneumoperitoneum-enhanced adhesion formation in mice. Fertil Sterile 2004; 81:708–11. 16. Molinas CR, Binda MM, Carmeliet P, Koninckx PR. Role of vascular endothelial growth factor receptor 1 in basal adhesion formation and in carbon dioxide pneumoperitoneum-enhanced adhesion formation after laparoscopic surgery in mice. Fertil Steril 2004; 82 suppl 3:1149–53. 17. Volz J, Köster S, Weiss M et al. Pathophysiologic features of a pneumoperitoneum at laparoscopy: a swine model. Am J Obstet Gynecol 1996; 174:132–40.

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Figure 3.1 Using conventional instruments allows more flexibility and security during laparoscopic procedures as the surgeon has the ability of tactile sense and palpation, because conventional instruments are short and contain only one joint

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Figure 3.2 The grasping part or the cutting edge of a conventional instrument is ergonomic, with the ability to grasp or to cut tissue very precisely

Figure 3.3 Bipolar scissors (Bissinger, Germany) can be used, which help in precise cutting as well as simultaneous coagulation of tissues

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Figure 3.4 As conventional instruments are short and contain only one joint, more flexibility and better security during laparoscopic procedures are obtained

Figure 3.5 Using diathermic bipolar scissors, coagulation and cutting can be securely performed in one step without carbonization and with less of a coagulation edge. With one-step coagulation and cutting, the laparoscopic procedure becomes very fast as there is no change of instruments

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Figure 3.6 Coagulation with bipolar forceps or other energy sources is, of course, also possible in gasless laparoscopy. An additional positive effect is that the permanent exsufflation, working in gasless laparoscopy, removes smoke and avoids foggy effects on the optic

Figure 3.7

14

It is also very easy to control bleeding by suction with a conventional plastic tube

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Figure 3.8 The suction irrigation device is also used to identify the bleeding vessels so that they can be coagulated

Figure 3.9

Sponges can also be used very efficiently to localize and tackle the bleeding

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Figure 3.10 With sponges for blunt dissection the procedures become easy and rapid. Where necessary, one can introduce a finger for palpation or dissection

Figure 3.11 Utilizing a conventional needle driver with a double joint allows suturing in deeper pelvic regions

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Figure 3.12 In contrast to gas laparoscopy, conventional needle drivers can be used to manipulate suture material with a round needle for an adequate closure

Figure 3.13 The suturing can be performed very easily and quickly using conventional suture material with round needles as in open surgery

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Figure 3.14 Use of the lift-laparoscopy suturing technique for closure of the myometrium after removing an intramural fibroid is shown. Especially in the case of intramural fibroids, optimal closure of the myometrium is essential

Figure 3.15 is then tied

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The needle is brought out of the trocar, the suture is cut and an extracorporeal knot

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Figure 3.16

Tying the thread extracorporeally makes suturing as fast and easy as in open surgery

Figure 3.17 After the extracorporeal knot is tied it is placed with a knot pusher and guided under laparoscopic vision. Several knots are placed similarly to enhance suture strength

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Figure 3.18 In myomectomy, closure of all layers is performed with as few stitches as necessary to achieve an adequate and functional closure of the myometrial wound. With this technique, we avoid wound healing problems due to infections and necrosis that may occur with numerous stitches

Figure 3.19 As no gas leakage occurs, lift-laparoscopy allows extraction and removal of tissue from the abdominal cavity in a less problematic manner than with gas laparoscopy

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Figure 3.20 Small myomas can be morcellated without difficulty with a scalpel or scissors and can be extracted directly through the flexible trocar

Figure 3.21 Multiple or very large myomas can be morcellated using an electrical morcellator, easily and completely

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Figure 3.22

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These are the morcellated strips of myomatous tissue at the end of the procedure

Figure 3.23 Recent applications show that it is possible to perform surgery even with one incision, where two instruments can be introduced at the same time. This incision can be widened as required and a laparoscopic assisted mini-laparotomy (LaMiLa) can be performed, which allows an extension of possibilities and principles from open surgery, such as palpation and grasping of tissue or applying a ligature knotting with two fingers

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Figure 3.24 When the procedure is completed, the entire abdominal cavity is checked for hemostasis. Lowering the position of the Abdo-Lift™ can be performed by the height adjusting wheel. Then, the ancillary trocars should be withdrawn under visual control. The Abdo-Lift is subsequently removed piece by piece from the operating table and prepared for cleaning and sterilization

Figure 3.25 Afterwards, the retractor can be removed from the abdominal cavity by turning it counter-clockwise

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Figure 3.26 The abdominal cavity can then be elevated using one hand while the other hand is holding the endoscope. The trocar sheath is removed from the incision while the optic remains in the abdomen. Withdrawing the endoscope slowly from the abdominal cavity ensures that no bowel or omentum is pinched in the incision

Figure 3.27 To prevent hernia formation, the fascia of the umbilical and ancillary ports should be closed. Closure of ancillary ports should be performed under endoscopic visualization. The fascia is sutured, and, after approximating subcutaneous tissue, the skin is adapted using sutures

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Figure 3.28 As the ancillary ports can be introduced in the suprapubic region very close to each other and about 1 cm under the pubic hairline, the cosmetic results obtained by lift-laparoscopy are better than in pneumoperitoneum laparoscopy. After a few weeks the pubic hair covers the incisions so that any scar structures cannot even be recognized

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Figures 3.29 and 3.30 Some technical remarks: the fulcrum is far from the object, and thus the movements of the hands are long, which results in low precision

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Figures 3.31 and 3.32 The fulcrum is close to the object, and thus the movements of the hands are short, which results in high precision

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Figure 3.33 In gas laparoscopy the incisions have to be made relatively higher to be able to reach the pouch of Douglas

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Figures 3.34 and 3.35 The instruments for lift-laparoscopy are curved, and therefore it is possible to place the incisions closer to the pubic bone. We perform the incisions as close to each other as possible, so they can be connected to a mini-laparotomy if needed (see Figure 3.23)

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Figure 3.36 The trocars are made from silicon and are flexible. There is a sharp and a blunt obturator to insert the trocars

Figure 3.37 The trocars from the abdominal view: via the open trocars all instruments can be introduced, both laparoscopic and instruments from open surgery

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Figure 3.38

This shows the variety of instruments that can be used in lift-laparoscopy

Figure 3.39 Lift-laparoscopy usually allows working with only two ancillary ports, instead of mulitple ones needed in gas laparoscopy

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Figure 3.40 New bipolar instruments for use in lift-laparoscopy (Bissinger, Germany) are in the process of design and manufacture. Utilizing a double joint technology allows coagulation and grasping in deeper pelvic/abdominal regions

Figure 3.41 A bipolar clamp enables grasping and coagulation with the same instrument. The tip is designed to allow its use for point as well as plain coagulation

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Figure 3.42

Bipolar scissors allow bipolar cutting and coagulation with the same instrument

Figure 3.43 With the bipolar clamp, tissue can be grasped while coagulation and cutting are performed by the bipolar scissors. Alternatively, coagulation can be carried out with the grasper and cutting with the scissors

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Figure 4.1 For gynecologic procedures the Abdo-Lift™ is located on the right side of the patient at shoulder height and is mounted on the rail of the operating table. Shoulder braces allow a deep Trendelenburg position and prevent sliding of the patient. Components for laparoscopy, imaging and multimedia systems are very important in laparoscopic surgery

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Figure 4.2 For any procedure some conventional instruments are needed. The Abdo-Lift™ is at the top of the figure

Figure 4.3 Besides the optic some laparoscopic instruments such as bipolar forceps, or grasping forceps, can be used

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Figures 4.4 and 4.5

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The Abdo-Lift™. The black support system is mounted on the rail of the operating table

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Figures 4.6 and 4.7 Silicon trocars in two lengths are available. The trocars are flexible and can be inserted with a sharp and a blunt tip. The trocars are valveless, and thus allow insertion of all kinds of instruments, laparoscopic ones and also instruments from open surgery

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Figure 4.8

This shows the longer version of the trocar with a blunt tip

Figures 4.9 and 4.10 These images show the sharp and blunt obturators in the trocar sheath, which allows insertion and afterwards manipulation without the possibility of organ injuries

Figure 4.11 Here it is shown how the double joint instruments open in the trocars and thus allow deeper areas in the abdominal cavity to be reached

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Figure 4.12 The conventional needle holder from open surgery is modified to a double jointed needle holder. It permits the mastering of all conventional needles and suture materials from open surgery

Figure 4.13 A Bozeman clamp: this instrument can be used for grasping and suture holding, and as a Deschamps for ligating vessels and tissue with suture material without a needle

Figure 4.14

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A blunt, straight bowel clamp

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Figure 4.15

A blunt, curved bowel clamp

Figure 4.16

A double-toothed tenaculum: allows grasping of tissue

Figure 4.17

A tenaculum: allows grasping of tissue such as a myoma

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Figure 4.18

A myoma screw

Figure 4.19

A grasper for small sponges, with sharp teeth

Figure 4.20 Conventional scissors can be utilized for anatomic preparation (Metzenbaum) or for cutting tissue or thread

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Figure 4.21

A simple knot pusher permits the performance of extracorporeal knots and suturing

Figure 4.22

The knot pusher has an open area to catch the thread

Figure 4.23 The specially designed S-hook allows one to approach the abdominal cavity layer by layer under visual control and using an open technique. In general its use avoids complications such as injury to the bowel or vessels

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PATIENT POSITIONING The patient is placed in a lithotomy position with the buttocks extended over the end of the table. The thighs should be flexed to allow good instrument manipulation. Attention should be given to proper positioning of the patient’s legs to avoid peroneal nerve injury during lengthy procedures. Shoulder braces must be used to make the steep Trendelenburg position possible during surgery. If shoulder braces are used they should be placed over the acromion to avoid possible brachial plexus injury. It is advisable that both arms should be tucked along the patient’s body to prevent brachial plexus injury and provide more space for the surgeon. If monopolar electrosurgery is to be used during the procedure, a ground electrode for the unipolar instruments must be properly placed over the patient’s thigh, and full surface contact of the electrode must be assured. It is recommended that the patient be covered with a sterile drape before any other procedure to ensure mounting the Abdo-Lift™ system in sterile conditions. The patient is draped with leggings and a laparoscopy sheet. On the right side of the operating table only one layer of covering material may be used. Straight bladder catheterization is performed for short laparoscopic procedures, or a Foley catheter is placed in the bladder if prolonged surgery is anticipated. The bladder has to be emptied to minimize any potential injury during ancillary trocar placement. After placement of a cervical tenaculum, a uterine manipulator is inserted into the cervix and uterine cavity to enable manipulation of the uterus during the procedure. A rectal probe can also be introduced for manipulation and better visualization of the rectum, and identification of the recto-vaginal septum during extensive laparoscopic resection. For gasless laparoscopy it is recommended that the bowel be prepared as for laparotomy, in the case that not only a diagnostic procedure but also operative surgery is to be performed. If extensive surgery is likely to be carried out, and bowel manipulation or injury anticipated, as in the case of extensive adhesions or endometriosis, it is advisable to administer a mechanical bowel preparation prior to surgery. The use of a nasogastric tube is not strictly mandatory, as no blind puncture to insert a trocar is to be performed.

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ANESTHESIA If general anesthesia is chosen and the operating time is scheduled to be more than 90 minutes, the anesthetist should perform a TIVA (total intravenous anesthesia) without the use of N2O, as nitrous oxide begins to inflate the bowel after 90–120 minutes, with the consequence that the distended bowel is placed in the pouch of Douglas and might disturb parts of the operation. If there is no possibility to perform a TIVA, a bladder catheter can be inserted into the rectum during the procedure to evacuate air from the bowel. In cases of spinal, epidural, or combined spinal/epidural anesthesia it is recommended to leave the patient with both hands free, since psychological stress is high and the patient is unable to move any other part of the body. To help the patient relax a CD player or DVD player is very useful. To prevent intraoperative pain or nausea, especially in anxious patients, sedative drugs can be administered.

Figure 5.1 For gynecologic procedures the Abdo-Lift™ is located on the right side of the patient at shoulder height and is mounted on the rail of the operating table. Shoulder braces allow a deep Trendelenburg position and prevent sliding of the patient

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Figure 5.2 To avoid asymmetric secondary incisions a line is marked about 2 cm above the suprapubic bone in the pubic hair region

Figure 5.3

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For patient relaxation a CD player or a DVD player is very helpful

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Figure 5.4 In the case of regional anesthesia, important intraoperative findings can be demonstrated to the patient

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The technique is similar to the Hasson open procedure; however, the skin incision in the lower umbilical fold is only 12–15 mm. By the use of specially developed S-hooks the abdominal cavity can be reached without the difficulties encountered during the Hasson technique. All steps are performed under visual control, including the first incision. To a greater extent than in pneumoperitoneum laparoscopy, lift (gasless)laparoscopy becomes difficult when severe adhesions are present around the periumbilical area. If adhesions are found in the lower abdominal quadrant, the retractor can be inserted first in the direction of the upper abdominal cavity or in a direction where no adhesions are present. After inspecting the abdominal cavity with the endoscope, an area free from adhesions must be located where a trocar can be introduced enabling an initial adhesiolysis to be performed. Sometimes a low-pressure (8–10 mmHg) pneumoperitoneum is necessary to perform adhesiolysis, prior to insertion of the abdominal wall retractor. In some corpulent patients, it might be necessary to change the position of the retractor to the upper abdomen for visualization of the organs from the upper abdominal quadrant. A steep Trendelenburg position (up to 30°) allows the bowel to slide to the upper abdominal quadrant that serves as a ‘reservoir’ for the intestine. Routinely, two ancillary ports can be introduced in the suprapubic region. In contrast to gas laparoscopy, these ports might be placed very close to each other (both trocars are medial from the epigastric vessels!) and about 1 cm under the pubic hairline, since using conventional curved instruments makes it possible to reach all pelvic organs and structures. After a few weeks the pubic hair covers the incisions and the cosmetic results obtained by this technique are better than in pneumoperitoneum laparoscopy.

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Figure 6.1 The patient is draped with leggings and a laparoscopy sheet. To avoid asymmetric secondary incisions a line is marked about 2 cm above the suprapubic bone in the pubic hair region

Figure 6.2 The patient is put in the lithotomy position and covered with sterile drapes. The fixing stand has to be attached to the right rail of the operating table by a fixation device, usually at the height of the patient’s shoulder

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Figure 6.3

The vertical arm of the Abdo-Lift™ is attached on top of the fixing stand

Figure 6.4 The spring balance and the retractor can be inserted and the system can be adjusted to the anatomic position of the patient by using all joints to correct the positions of the components

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Figure 6.5 The retractor is placed in the spring balance to achieve an idea of which position will be attained after inserting it into the abdominal cavity

Figure 6.6 While approaching the abdominal cavity the technique is similar to the Hasson open procedure; however, the skin incision in the lower umbilical fold is only 12–15 mm

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Figure 6.7 With two Backhaus clamps on each side of the umbilical fold, one elevates the abdominal wall and the skin incision can be performed

Figure 6.8

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Specially designed S-shaped hooks can be used to reach the abdominal cavity

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Figure 6.9 With the help of the S-shaped hooks, the size of the incision is only 12 mm long. One can reach the fascia layer by layer, displacing the subcutaneous and fatty tissue by blunt dissection. After reaching the fascia a small incision (2–3 mm) is made with a number 11 scalpel followed by insertion of blunt scissors and opening the fascia up to 15 mm

Figure 6.10 By means of the S-hooks the rectus muscle is pushed aside and the peritoneum can be visualized. By transillumination with the light of the endoscope, the abdominal cavity can be visualized and adhesions can be detected

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Figure 6.11 At an adhesion-free area, incision of the superficial layer of the peritoneum can be performed using a number 11 scalpel

Figure 6.12 The incision of the peritoneum is then widened with a scalpel or by spreading the scissor arms

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Figure 6.13 After reaching the abdominal cavity, the left and the right S-hooks are inserted into the abdomen under visual control and the abdominal wall is elevated. Upon introducing the endoscope, the entire periumbilical area can be visualized to detect adhesions that would prevent insertion of the retractor

Figure 6.14 The abdominal wall is elevated with the S-hooks by the assistant, and the retractor is then inserted under visual control, rotating it into the abdominal cavity

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Figure 6.15 The retractor must be moved into the abdominal cavity completely freely and without any force to avoid squeezing the bowel or omentum

Figure 6.16 By lifting the abdominal wall with the hand, the left hook is moved proximal and the right S-hook is removed

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Figure 6.17 Behind the retractor the endoscope, armed with a trocar, is introduced, and the lower abdominal quadrant can be visualized mainly to examine whether the omentum or bowel has become pinched between the retractor and the abdominal wall. If this is the case, it is necessary to remove the retractor and to start the procedure again for repositioning of the retractor

Figure 6.18 Turning the trocar clockwise towards the abdominal wall, the trocar sleeve can be introduced into the abdominal cavity

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Figure 6.19 checked

The retractor arm is introduced into the spring balance and its appropriate position is

Figure 6.20 After introducing the retractor arm into the spring balance and checking the appropriate position of the retractor, the abdominal wall can be elevated by the height adjusting wheel

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Figure 6.21

Thus, the abdominal wall is elevated

Figure 6.22 The abdominal wall can be elevated by the height adjusting wheel to the mark ‘max’ on the spring balance which gives a level of approximately 1.5 kilopounds. This mark can be higher or lower according to the weight of the abdominal wall and the corpulence of the patient

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Figure 6.23 After the abdominal wall is elevated one can realize the same dome-shaped extension of the abdominal wall as with pneumoperitoneum

Figure 6.24 A view of the retractor inside the abdominal cavity. The design of the retractor allows smooth elevation of the abdominal wall

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Figures 6.25 and 6.26 Visualization of the upper abdominal quadrant with the endoscope is carried out in the same manner as in laparoscopy with a pneumoperitoneum, as the intraabdominal visualization is similar

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Figure 6.27 Returning to the pelvis, the patient has to be put in a steep Trendelenburg position (up to 30°) which allows the bowel to slide to the upper abdominal quadrant that is serving as a ‘reservoir’ for the intestine

Figure 6.28 The pelvis and the pouch of Douglas can be examined. All the pelvic organs and structures are visible as in laparoscopy with a pneumoperitoneum

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Figure 6.29

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Two ancillary ports can be routinely introduced in the suprapubic region

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Figure 6.30 In contrast to gas laparoscopy these ports might be placed very close to each other (both trocars are medial from the epigastric vessels!) and about 1 cm under the pubic hairline. After a few weeks the pubic hair covers the incisions and the cosmetic results obtained by this technique are better than in pneumoperitoneum laparoscopy, where the incisions have to be put above the hairline, as marked in the figure, in order to reach the area behind the uterus with the long and straight laparoscopic instruments

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Figure 6.31

Using conventional curved instruments it is possible to reach all pelvic organs and structures

Figure 6.32

To introduce the ports one can use the same technique as in gas laparoscopy

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Figure 6.33 Through a skin incision of 12 mm a round, sharp obturator with a rubber sheath, which has an external thread, can be introduced with little force by turning it clockwise through the abdominal wall

Figure 6.34 The abdominal wall may be transilluminated by the endoscope in order to avoid lesions to epigastric vessels

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Figure 6.35

The obturator is removed after being inserted, leaving the trocar sheath in place

Figure 6.36

The two flexible silicon accessory trocars inserted into the peritoneal cavity are seen

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Figure 6.37 The concept of gasless laparoscopy allows identical exposure and visualization to those in pneumoperitoneum laparoscopy. However, the operative procedure is technically less difficult to perform. By means of lift-laparoscopy it is possible not only to manage all operative procedures performed under gas laparoscopy, but also to extend the range of application to more complex procedures and advanced surgery

Figure 6.38 Examination of the pelvic organs can take place in exactly the same manner as in pneumoperitoneum laparoscopy and the operative procedure can start

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When the procedure is completed, the entire abdominal cavity is checked for hemostasis. Then, the ancillary trocars should be withdrawn under visual control. To prevent hernia formation, the fascia of the umbilical and the ancillary ports should be closed. Closure of the ancillary ports should be performed under endoscopic visualization. Afterwards, the retractor can be removed from the abdominal cavity by turning it counter-clockwise. The abdominal cavity can then be elevated by one hand while the other hand is holding the endoscope. The trocar sheath is removed from the incision while the optic remains in the abdomen. Withdrawing the endoscope slowly out of the abdominal cavity ensures that no bowel or omentum is pinched in the incision. The fascia is sutured, and, after approximating subcutaneous tissue, the skin is adapted by sutures. The AbdoLift™ is then removed piece by piece from the operating table and prepared for cleaning and sterilization.

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Figure 7.1 Lowering the position of the Abdo-Lift ™ can be performed by the height adjusting wheel. Then, the ancillary trocars should be withdrawn under visual control. The Abdo-Lift is then removed piece by piece from the operating table and prepared for cleaning and sterilization

Figure 7.2 clockwise

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Afterwards, the retractor can be removed from the abdominal cavity by turning it counter-

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Figure 7.3 The abdominal cavity can then be elevated by one hand while the other hand is holding the endoscope. The trocar sheath is removed from the incision while the optic remains in the abdomen. Withdrawing the endoscope slowly from the abdominal cavity ensures that no bowel or omentum is pinched in the incision

Figure 7.4 To prevent hernia formation, the fascia of the umbilical and the ancillary ports should be closed. Closure of the ancillary ports should be performed under endoscopic visualization. The fascia is sutured, and, after approximating subcutaneous tissue, the skin is adapted by sutures

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Figure 7.5

The Abdo-Lift ™ can be cleaned and separated into three pieces after opening the joints

Figure 7.6

After cleaning, the Abdo-Lift ™ can be stored in a usual sterilization box

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Figures 7.7 and 7.8 sterilization box

As well as the Abdo-Lift ™, all components can be stored in the same

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ENUCLEATION OF OVARIAN CYST WITHOUT RUPTURE USING ENDOBAG

In the case of enucleation of an ovarian cyst, it is very important to remove the cyst or the ovary without rupture and spillage of the cystic contents, especially in the case of suspicious findings. Conventional surgical methods, which are very easy to apply using lift (gasless)-laparoscopy, avoid spillage. Blunt dissection with a sponge and countertraction with a conventional forceps allow a surgical technique that makes it possible to avoid spillage in most ovarian tumors. Even if there is a microrupture, it is easy to continue surgery as one is able to grasp the rupture site with a long forceps longitudinally and continue the procedure of enucleation, or apply a ligature over the ruptured cyst capsule. In liftlaparoscopy the removal of tissue specimens is less problematic as there is no interaction with gas leakage, and the endobag can be grasped and opened with conventional curved instruments, allowing the bag to be held open around the instruments. Closure of the ovarian capsule is performed with conventional suture material and a curved needle and conventional needle driver.

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Figure 8.1

Ovarian cyst seen in the right ovary

Figure 8.2 Using a scalpel, an incision is made in the ovarian capsule. The ovary is held steady with a Bozeman forceps

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Figure 8.3 The incision is deepened and extended using bipolar scissors, making sure that the plane of the cyst is maintained

Figure 8.4

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The ovarian capsular incision is adequately made

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Figure 8.5

Now the capsule of the cyst is identified below the capsule of the ovary

Figure 8.6 Using the principle of traction and countertraction the cyst wall is separated delicately from the ovarian capsule by using two graspers

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Figure 8.7

Thus the cyst wall is further exposed

Figure 8.8

Using bipolar scissors, the incision in the ovarian capsule is further extended

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Figure 8.9 Using a sponge, the cyst wall is mobilized further. It is essential to be in the correct plane and also not to exert excess force during this step or else it will cause the cyst to rupture

Figure 8.10 The intact cyst is now separated using a sponge, and the plane of separation between the thin cyst wall and the thick ovarian capsule can be well appreciated

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Figure 8.11

This process is thus carried out all around the cyst wall

Figure 8.12 Using a combination of blunt and sharp dissection with bipolar scissors, adequate coagulation and separation of tissues is achieved

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Figure 8.13

Thus the cyst with an intact cyst wall is completely separated from the ovary

Figure 8.14 bleeding

The ovary is inpected for bleeding. Using the correct technique should not result in any

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Figure 8.15 At the lower portion of the ovarian tumor another cyst appears, and thus a multicystic process requires a rupture-free enucleation

Figure 8.16 Douglas

The cyst is then placed (“parked”) either anterior or posterior to the uterus in the pouch of

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Figure 8.17

An endobag is then introduced into the peritoneal cavity via a flexible plastic trocar

Figure 8.18 The opening or mouth of the endobag has a purse-string suture which is tightened once the cyst is placed inside the endobag. Using tissue graspers the mouth of the endobag is adequately opened and kept ready for placement of the cyst inside it

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Figure 8.19

The intact unruptured ovarian cyst is then placed in the endobag

Figure 8.20

The endobag is then held with tissue graspers so that the cyst falls completely into it

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Figure 8.21 endobag

Now the purse-string around the endobag is tightened and the cyst lies completely in the

Figure 8.22

The endobag with the cyst inside is now retrieved via the accessory port

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Figure 8.23

This process requires an incision of the cyst capsule

Figure 8.24 The fluid is removed with an additional suction device which can be thrown away after the procedure to avoid contamination of the abdominal cavity

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Figure 8.25

The endobag is now almost completely outside the peritoneal cavity

Figure 8.26 Thus the cyst is removed using the endobag making sure that there is no rupture of the cyst in the peritoneal cavity and hence no contamination of the peritoneal cavity by the cyst contents

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Figure 8.27

This is the specimen of the ovarian cyst

Figure 8.28 A needle holder loaded with polydioxanone (PDS) 3-0 is now introduced into the peritoneal cavity for reconstruction of the ovarian surface

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Figure 8.29 enucleation

The ovarian surfaces are sutured together to close the defect caused as a result of the cyst

Figure 8.30

The sutures are thus placed to approximate the ovarian serosal surfaces

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Figure 8.31

Sutures are tied extracorporeally and placed using a knot pusher and then tightened

Figure 8.32

The thread is then cut using scissors

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Figure 8.33 Reconstruction of the ovary completely restores the ovary to its normal anatomic position. Closure of the ovarian capsule will prevent adhesions postoperatively

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MYOMECTOMY

Fibroids that are located intramurally are sometimes difficult to enucleate. After an incision is made through the myometrium with bipolar scissors, the enucleation of the myoma can be performed using bipolar forceps or bipolar scissors and a regular grasping forceps. In the case of bleeding, conventional plastic suction tubes from open surgery can be used to evacuate blood clots, and rinse out water and smoke. Additionally a forceps with a sponge can control the bleeding. After removing the fibroid, the myometrium must be sutured. In the case of intramural fibroids, adequate closure of the myometrium is necessary. In contrast to gas laparoscopy, conventional needle drivers can be used to manipulate suture material with a curved needle for adequate closure of the myometrial tissue. We perform closure of all layers with as few stitches as necessary to achieve an adequate and functional closure of the myometrial wound. With this technique, we avoid wound healing problems due to infections and necrosis that may occur with numerous stitches. Using this technique there is not much coagulation needed, which particularly causes necrosis and healing problems and, hypothetically, ruptures. More than 500 fibroid enucleations have been performed with the described technique and there have been no uterine ruptures during pregnancy or during delivery. Lift-laparoscopy extends organ-preserving operations for fibroid removal of any size according to the skill of the surgeon. Even myomatous uteri with a size of about 1.5 kg can be managed. For morcellation of such huge fibroids, an electrical morcellator should be used; however, small myomas can be morcellated without difficulty with a scalpel or scissors.

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Figure 9.1 An incision is made in the uterine serosa just over the bulge of the fibroid using bipolar scissors. Diluted intramyometrial vasopressin is injected to reduce blood loss

Figure 9.2

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Using bipolar scissors the incision is deepened to reach the myoma

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Figure 9.3

Simultaneous bipolar coagulation is done if any bleeding vessels are encountered

Figure 9.4 The intramural myoma is thus reached and its pseudocapsule identified. This will be the plane of enucleation

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Figure 9.5 The substance of the myoma is then grasped and the myoma is enucleated following the plane mentioned in Figure 9.4 legend. This is done using bipolar scissors and hence blood loss is minimal

Figure 9.6

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The myoma is thus completely enucleated using sharp and blunt dissection

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MYOMECTOMY

Figure 9.7

The enucleated myoma is then grasped with a grasper and placed in the pouch of Douglas

Figure 9.8 The myoma is thus seen in the pouch of Douglas and the bed of the myoma is mopped with a sponge to check for hemostasis

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Figure 9.9 This shows the myoma bed, which must be sutured using the correct technique so that the risk of subsequent uterine rupture is minimized. This is an advantage of suturing in gasless laparoscopy as the proximity of the tissues and instruments to the surgeon help him to place sutures precisely and with adequate strength

Figure 9.10 The myoma bed is closed using a conventional needle holder. As it is a conventional instrument the mechanics help in precise and easy surgical movement

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Figure 9.11 The suture is guided through the opposite wall of the myoma bed. It is important to note that the suture should incorporate adequate myometrial depth in order to achieve optimal and secure closure

Figure 9.12 The needle is seen coming out of the serosal surface. A grasper forceps is used to help in guiding the needle precisely by holding the myometrial wall

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Figure 9.13 The needle is then grasped with a tissue grasper and brought out through the same accessory portal where it was introduced

Figure 9.14 An extracorporeal knot is tied and is placed under laparoscopic visual control with a knot pusher so that adequate strength is applied during approximation of the two myometrial surfaces

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Figure 9.15

The suture is thus placed and the remaining thread is cut off

Figure 9.16 myoma bed

Similar sutures are applied at equal distances using the same technique to close the

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Figure 9.17 At all times during closure, importance should be given to proper suture placement, knotting, and hemostasis. The uterus is manipulated with a uterine manipulator inserted within to aid the surgeon’s view during suturing

Figure 9.18

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Thus the myoma bed is entirely closed. Hemostasis is checked

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Figure 9.19 tenaculum

The enucleated myoma which was placed in the pouch of Douglas is grasped with a

Figure 9.20 Using a scalpel the myoma is removed piecemeal. This step is done under visual control and in stages in order to prevent any injury to the various peritoneal structures

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Figure 9.21 Using the scalpel the myoma is debulked into small strips and retrieved from the peritoneal cavity

Figure 9.22

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SprayGel ™ (blue) is then applied over the suture line for prevention of adhesion formation

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LAPAROSCOPIC HYSTERECTOMY

The most difficult problem in hysterectomy is how to divide vessels, especially the uterine artery. Many surgeons therefore perform a laparoscopic assisted vaginal hysterectomy (LAVH) to avoid the risk of hemorrhage from the uterine vessels. Gasless laparoscopy allows plenty of variation for the ligation of vessels. One can apply ligatures around the uterine vessel, and after applying a ligature contralaterally the uterine vessels can be divided. Coagulation using bipolar forceps or other energy sources is also possible in lift (gasless)-laparoscopy. An additional positive effect is that the open trocars allow the evacuation of smoke by simple exsufflation via the insufflation channel of the optic trocar, thus avoiding additionally fogging of the laparoscope. Using the bipolar scissors, coagulation and cutting can be securely performed in one step without carbonization and with less coagulation necrosis. With one-step coagulation and cutting, the laparoscopic procedure becomes very fast as there is no change of instruments. To open the vaginal cuff, one can use a scalpel or bipolar scissors. No special tools need to be inserted to avoid gas leakage after opening the vagina.

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Figure 10.1

The uterus is manipulated using a uterine manipulator which is inserted into the uterus

Figure 10.2

The round ligament on the right side is identified and grasped with a grasper and stretched

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Figure 10.3

Using bipolar scissors the round ligament is coagulated and divided simultaneously

Figure 10.4 Thus the round ligament is divided until the two leaves of the broad ligament are seen anteriorly and posteriorly

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Figure 10.5

The anterior leaf is incised and the utero-vesical fold of the peritoneum is incised

Figure 10.6 The cornual end of the fallopian tube and the tuboovarian ligament are coagulated and then divided to detach the adnexa from the uterus

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Figure 10.7

Thus the ovary and the tube are pushed away, now exposing the uterine vessels

Figure 10.8 Similar procedure is performed on the other side. Here the fallopian tube is being coagulated and divided using bipolar scissors

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Figure 10.9 After coagulation the bipolar scissors are used to divide the tube and detach it from the uterus

Figure 10.10 junction

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The uterine vessels are seen here skeletonized and lying lateral to the isthmico-uterine

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Figure 10.11

The uterine vessels are coagulated and then divided using bipolar scissors

Figure 10.12

Adequate hemostasis is achieved and confirmed while coagulating the uterine vessels

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Figure 10.13

The cervico-vesical fascia is cut in order to push the bladder away

Figure 10.14

This dissection is continued along the entire surface of the cervix anteriorly

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Figure 10.15

The uterine vessels are coagulated and divided similarly on the opposite side

Figure 10.16 By moving the uterine manipulator, the limit of the vagina can be noted. The cervicovesicovaginal fascia is dissected away to reach the anterior vaginal fornix using bipolar scissors

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Figure 10.17 The vagina is incised anteriorly over the vaginal tube of the uterine manipulator in a circumferential manner using bipolar scissors

Figure 10.18 The vagina is then incised laterally and posteriorly. Thus the uterus is detached from the vagina

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Figure 10.19

The opened vagina is thus seen

Figure 10.20 The cervix is grasped with a tenaculum inserted through the vagina under laparoscopic visualization

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Figure 10.21 The uterus is then pulled out through the vagina. In the case of a large uterus it can be debulked using a scalpel. In this case the uterus is enlarged because of the myoma

Figure 10.22

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The myoma is bisected to faciltate removal of the uterus from the vagina

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Figure 10.23

Thus even large uteri can be removed vaginally by this simple method

Figure 10.24

Now the anterior and posterior walls of the vagina are sutured on the right side

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Figure 10.25 A knot is tied extracorporeally and is placed with a knot pusher. The ends of the thread are held

Figure 10.26

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A similar suturing technique is repeated on the oppsite side to close the vagina

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Figure 10.27

Thus both lateral fornices of the vagina are closed

Figure 10.28

A suture is placed in the central portion of the vagina wall anteriorly

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Figure 10.29 This suture is then brought out posteriorly such that both sacro-uterine ligaments are plicated. This step helps in vaginal vault suspension and prevents subsequent vault prolapse. Care must be taken to avoid the injury of the ureters during this step

Figure 10.30 The suture is then brought out anteriorly and tied extracorporeally and placed with a knot pusher. The two lateral threads are cut

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Figure 10.31 reconfirmed

The vaginal vault is then inspected for hemostasis. Lavage is applied. Hemostasis is

Figure 10.32 A drain is then inserted via one of the accessory ports into the peritoneal cavity and placed in the pouch of Douglas

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ADHESIOLYSIS

Adhesions are an inevitable consequence of surgery and their optimal management and prevention remain unanswered. The magnitude of this problem has been overlooked due to a lack of awareness of their clinical significance. Adhesions cause serious short-term and long-term complications related to bowel obstruction, infertility, and pelvic pain, worsening the quality of life of the patients. This further increases the burden on patients and doctors, and drains the economic resources of the healthcare system. Despite advances in the surgical technique (laparoscopy) and instrumentation (microsurgical instruments), the frequency of adhesion-related complications or disorders (ARD) still remains relatively unchanged. Clinical studies and research clearly reveal that the burden of adhesion-related problems (i.e. de-novo adhesion formation, recurrence, complications, and readmission and re-surgery rates) following laparoscopic gynecologic surgery is unfortunately similar to that found after open surgery. Adhesion surgery has to be based on two most important issues: ● ●

surgical tools and techniques adhesion prevention.

Avoiding carbon dioxide (CO2) insufflation is very important to avoid hypoxemia, dessication of the peritoneal tissue, and acidosis. Already after 5 minutes of ischemia there is a significant production of free radicals that have not enough oxygen to react with. Therefore, free radicals will initiate adhesion formation, starting with cytolysis of these cells and peroxidation of lipids in the cell membrane that lead to an increase in vascular permeability which causes, among other things, also an imbalance in fibrin deposition and fibrin dissolution, producing fibrinous adhesions. Using carbon dioxide gas induces adhesion formation by lowering the level of special molecules that are needed for the healing process, and so carbon dioxide is (for the surgeon) an invisible instrument that causes injury to the peritoneum with the result of adhesion formation. Thus, lift (gasless)-laparoscopy is the ideal tool for laparoscopic adhesiolysis. In addition to special and new bipolar instruments, lift-laparoscopy allows control of hemostasis, which is a condition sine qua non in adhesiolysis surgery to avoid adhesion reformation. Several adhesion-reducing agents (barriers) have been experimented with, but their widespread use is limited by efficacy, cost-effectiveness, safety, and

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technical issues. In spite of extensive research involving enormous financial expenditure aimed at the prevention and treatment of adhesions, an ultimate solution has still not been forthcoming to conquer this challenging problem. Clearly, to enhance good and safe medical practice, optimal strategies for management and prevention are needed. SprayGel™ is a new product (Confluent Surgical, Waltham, MA) based on two liquids, which are polyethylene glycol (PEG) and hydrogel. When these two liquids are applied while mixing them in situ, they polymerize within seconds to form a visible, adherent, and conforming hydrogel barrier on the target tissues. The gel remains intact for the next 5–7 days before breakdown by hydrolysis, and eventual clearance through the kidneys. Our long-term utilization of SprayGel™ along with lift-laparoscopy in patients undergoing adhesiolysis in combination with second-look laparoscopy shows excellent results, with a high decrease of adhesion reformation in the second look as well as in long-term follow-up.

Figure 11.1

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Dense adhesions between the anterior abdominal wall and bowel are noted

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Figure 11.2

Separation of adhesions using fine scissors is started by dissecting the parietal peritoneum

Figure 11.3

Excision of fibrous bands is carried out using scissors

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Figure 11.4 A sponge is used to carry out blunt dissection closer to the bowel to prevent bowel injury. Separation of the adhesions can be appreciated

Figure 11.5 Separation of the adhesions from the anterior abdominal wall is continued by gentle blunt dissection using a sponge

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Figure 11.6

Here the plane of separation is well noted. The parietal peritoneum is excised as well

Figure 11.7 By applying traction on the peritoneum it is seen to stretch and is easily dissected. The instrument or a sponge can be used for traction

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Figure 11.8 Once the adhesion has been freed from the anterior abdominal wall a site for an accessory trocar entry is selected

Figure 11.9 An accessory trocar is introduced and a sponge holder inserted via it to push the adhesion away

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Figure 11.10 Using scissors the flimsy adhesions are cut. Care must be taken to remain away from the edge of the bowel wall

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Figures 11.11 and 11.12 By placing the adhered bowel loops at a stretch with a sponge these adhesions can be easily and safely cut

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Figure 11.13 A sponge is used to gently push down the flimsy adhesions from the anterior abdominal wall

Figure 11.14 By placing the adhered bowel loops at a stretch with a sponge these adhesions can be easily and safely cut

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Figure 11.15 For more dense adhesions, scissors are used to cut. The loops of bowel seen adherent to the anterior abdominal wall are separated carefully

Figure 11.16 The distal end of the adhesions are excised under coagulation using bipolar scissors. This step has to be performed with extreme care as the bowel loops are very close to the scissors

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Figure 11.17 Here the use of traction by the sponge holder can be well appreciated. The sponge keeps the tissues at a stretch so that the scissors can cut in the correct plane. Bipolar scissors free the adhesions from the anterior abdominal wall

Figure 11.18 The edge of the bowel loop is held with non-traumatic grasper forceps and a suction irrigation cannula is used for separation of the adhesions from the anterior abdominal wall

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Figure 11.19

While the suction cannula applying traction, bipolar scissors are used to cut the adhesions

Figure 11.20

The bowel is inspected for any interluminal adhesions

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Figure 11.21

Running the bowel by non-traumatic grasper forceps to detect interluminal adhesions

Figure 11.22 The raw surface over the bowel is inspected after separation of adhesions for any injury or bleeding

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Figure 11.23 Adequate irrigation is always done with a suction irrigation device to keep the tissue surfaces moist and to look for any bleeding. Using the suction device, any collected blood, blood clots, or tissue debris is removed, as these can be a nidus for adhesion reformation. An intraperitoneal drain is placed and removed after 24 hours

Figure 11.24 Bleeding vessels, if any, are identified and coagulated, and also the bowel surfaces are inspected for any trauma

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Figure 11.25 SprayGel ™ is used as an adhesion-prevention barrier agent. The SprayGel ™ apparatus is assembled and connected to the air pump. The SprayGel ™ applicator is inserted into the peritoneal cavity and its tip is inclined slightly for proper application of the SprayGel ™. SprayGel ™ is then sprayed (applied) over the separated raw surfaces to prevent adhesion formation with the help of a sprayer attached to the air pump

Figure 11.26

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SprayGel ™ is applied over the raw peritoneal surfaces using the angulated tip

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Figure 11.27 Now SprayGel ™ is applied on the bowel surfaces as well. It takes around 1 or 2 minutes for the gel to set over the tissue surfaces

Figure 11.28 Once the gel is set, intraperitoneal lavage is applied. The bowel is then finally inspected for hemostasis and trauma with the blunt tip of the suction irrigation device. One can see the SprayGel ™ ‘treated and untreated’ bowel loops

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Figure 11.29 appreciated

Here the adhesion-free peritoneal surfaces at second-look laparoscopy can be well

Figure 11.30 The external surface of the peritoneum at the abdominal wall is adhesion free and undergoing the healing process

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Figure 11.31 The serosa of the bowel is seen at second-look laparoscopy. Adequate vascularity and rugosity can also be noted

Figure 11.32 At second-look laparoscopy no scar or fibrotic tissue is noted on the bowel serosa at the site of adhesiolysis. One can note neovascularization in the new peritoneum that has built up under the surface of the SprayGel ™. At the bowel loops the peritoneal healing process is nearly finished

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N.B. Numbers in italic refer to figure legends. Abdo-Lift 23, 36, 37 adjustment 51, 60 assembly/disassembly 51, 60, 74 cleaning 74 components 75 port suturing 24 positioning 50 for gynecology 35, 46 on procedure termination 72 removal 23–4, 71, 72 storage 74–5 support system 37, 50 abdominal examination 61, 62 abdominal wall elevation 49, 50–69, 60 adjustment 60 incisions 55, 64, 65 view inside abdominal cavity 61 visualization of pelvic area 63 see also patients, positioning abdominal wall retractors assembly on Abdo-Lift 52, 59 in corpulent patients 49 insertion 56–7 positioning 59 view inside abdominal cavity 61 withdrawal 71, 72 acidosis with CO2 insufflation 7, 8 adhesiolysis 49, 125–6, 126–42 abdominal wall, separation from 128, 133, 134, 135 accessory trocars blunt dissection through 130 site selection 130 bowel, dissection around 128, 131, 132, 133 with coagulation 134 debris removal 138 dense adhesions 134 fibrous band excision 127 with grasper/suction irrigation cannula 135–6 interluminal adhesions, checking for 136, 137 lavage 140

adhesiolysis—cont’d neovascularization after 142 peritoneum dissection 129 parietal 127, 129 with scissors 131, 134 bipolar 134, 135, 136 second-look laparoscopy 142 second-look laparoscopy after 141–2 traction, application of 129, 132, 133, 135 trauma, checking for 137, 138 adhesion-free areas 55 after adhesiolysis 141–2 adhesion-reducing agents (barriers) 125–6, 139–40 adhesion surgery 125 adhesions 1, 125 with CO2 insufflation 8 complications 125 deep, abdominal wall/bowel 126 detection 54 in gasless endoscopy 49 prevention 94, 106 interluminal, checking for 136, 137 laparoscopy vs open surgery 125 mechanism 125 prevention see adhesion-reducing agents (barriers) ancillary ports 49, 64, 65 closure 71, 73 introduction into abdominal cavity 66–8 anesthesia 46 general 46 regional 4, 48 Backhaus clamps 53 barriers see adhesion-reducing agents (barriers) bipolar instruments 32 clamps 32, 33 forceps 14 scissors 12, 13, 32, 33

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bladder 1 catheterization 45 bleeding control see hemostasis (bleeding control) bowel clamps 40, 41 bowel preparation 45 Bozeman clamps 40, 78 carbon dioxide contamination of 8 and patient exclusion 4 side effects of insufflation 2, 7–8, 125 see also insufflation; pneumoperitoneum carbonic acid 2 cd players 46, 47 coagulation 14, 15, 107 avoidance 95 one-step, with cutting 13, 33, 107, 109 communication with patient 48 cosmetic results 49, 65 cost implications adhesions 125 endoscopic instruments 3 gasless endoscopy 5–6 dissection blunt in adhesiolysis 128, 129, 130 entering abdominal cavity 54 in fibroid removal 98 in hysterectomy 114, 115 in lift-laparoscopy 16 in ovarian cyst enucleation 77, 81–3 sharp in adhesiolysis 127, 131–6 in fibroid removal 98 in ovarian cyst enucleation 83 dvd players 46, 47 efficiency of endoscopy 3 gasless 4 electrosurgery precautions 45 emphysema 2, 8 endobag 77 cyst collection 87–8 insertion 86 opening/closing 86, 88 retrieval 88–90 endoscope introduction into abdominal cavity 58 transillumination with 54, 67 withdrawal 71 endoscopic instruments costs 3 disadvantages 3 removing need for 5 endoscopy advantages 1

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endoscopy—cont’d complication rate 2–3 gasless see gasless endoscopy; lift-laparoscopy learning curve 2 risks/disadvantages 2–3 fibroids, intramural morcellation 95, 105–6 myoma bed treatment/closure 100–4 suture placement 102, 103, 104 tying off, extracorporeal 102, 104 myometrium closure 95 removal 18, 95 advantages of lift laparoscopy 95 coagulation 97 difficulties 95 incisions 96 myoma enucleation 97–9 gas embolism 2, 8 gasless endoscopy advantages 3–4 for healthcare system 5–6 for patient 4 physiologic 8 for surgeon 5 complications 4 see also lift-laparoscopy gasless laparoscopy see gasless endoscopy grasper 42 Hasson open procedure 49, 52 hemostasis (bleeding control) 14, 15 in adhesiolysis 137, 138 in fibroid removal 96, 104 in hysterectomy 113, 123 in lift-laparoscopy 125 in ovarian cyst enucleation 84 on termination of procedure 71 hospital stay duration 1 hypercapnia 7 hypothermia 2, 7, 8 hysterectomy, laparoscopic 107, 108–23 bladder, displacement of 114 cervico-vesical fascia dissection 114, 115 drain placement 123 fallopian tube division 110, 111–12 hemostasis (bleeding control) 113, 123 ligament division broad ligament 109–10 round ligament 108–9 tubo-ovarian ligament 110 uterine vessels coagulation 113, 114, 115 division 107, 113, 114, 115 visualization 111, 112

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lift-laparoscopy—cont’d procedure termination 71, 72–5 suturing technique 18 see also gasless endoscopy

hysterectomy, laparoscopic—cont’d uterus debulking 118–19 detachment 117 manipulation 108 removal 117–19 vagina incision 116 suturing 119–22 visualization 117 incisions 22 in abdominal wall elevation 53, 55, 64, 65 intramural fibroid removal 96 numbers required 31 pneumoperitoneum laparoscopy 28 positioning 25, 29 ancillary ports 49, 64, 65 marking 47, 50 and precision 26–7 size 52, 54 instruments curvature 29, 66 double-jointed 16, 32, 40 open in trocar 39 gasless endoscopy 8, 11–22 advantages 5, 11, 13 conventional 36 laparoscopic 36 range 31 see also specific instruments for use with insufflation 3 insufflation 2 disadvantages 2 side effects 2, 7–8, 125 see also carbon dioxide; pneumoperitoneum insufflation needle insertion, ‘blind’ 2, 8 intramural fibroids see fibroids, intramural irrigation 15, 138 keyhole surgery 1, 3 knot pushers 19, 43 laparoscopic assisted mini-laparotomy (LaMiLa) 22 laparoscopic assisted vaginal hysterectomy (LAVH) 107 laparoscopy 1 gasless see gasless endoscopy learning curve 5 lift-laparoscopy advantages 68 in hysterectomy 107 cosmetic results 25 equipment see also Abdo-Lift; instruments; specific equipment hemostasis (bleeding control) 125

malignancy, spread of 8 mini-laparotomy connection to gasless endoscopy 29 laparoscopic assisted mini-laparotomy (LaMiLa) 22 morcellation fibroids, intramural 95, 105–6 myomas 21–2 morcellator 105–6 myoma screw 42 myomas enucleation 98 advantages of gasless endoscopy 5 closure 100–4 myoma bed treatment 99–100 pseudocapsule location 97 removal of enucleated tissue 99, 105–6 morcellation 21–2 removal in hysterectomy 118 myomectomy 95, 96–106 closure 20 needle driver 16 needle holder 91 double-jointed 40 nitrous oxide, contraindication of 46 obturators 30, 39 introduction into abdominal cavity 67 removal 68 operating theater set-up 35, 46 ovarian cysts 78 ovarian cyst enucleation 77, 78–94 bleeding, inspection for 84 closure 77 cyst capsule identification 80 removal 87–90 separation, intact 84, 85 specimen 91 wall separation/exposure 80, 81–4 endobag cyst collection 87–8 insertion 86 opening/closing 86, 88 retrieval 88–90 microrupture 77 multicystic process 85 ovarian capsule incision 78 extension 79, 81 ovary position restoration 94 surface reconstruction 91–4

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pain, postoperative CO2 insufflation 2, 7 gasless endoscopy 4 patients positioning 35, 45, 46, 49, 50, 63 preparation 45 relaxation 46, 47 pelvic examination 63, 68 pneumomediastinum 8 pneumopericardium 8 pneumoperitoneum complications 7, 8–9 contraindications 8 in gasless endoscopy 49 see also carbon dioxide; insufflation pneumothorax 8 ports see ancillary ports; umbilical ports precision 26–7 pregnancy, risk reduction in 4 recovery time 1 rectal probes/manipulators 45 retractors see abdominal wall retractors S-hooks 43, 53, 54 abdominal wall elevation 56 adjustment 57 safety of gasless endoscopy 4 scarring 1 lift vs pneumoperitoneum laparoscopy 25 scissors bipolar see under bipolar instruments conventional 42 second-look laparoscopy 141–2 sedation 46 shoulder braces 35, 46 SprayGel 106, 126 application 139–40 sterile conditions, ensuring 45 suction 14, 15 suction irrigation cannula 135–6 suturing advantages, in 5 in deeper pelvic regions 16

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suturing—cont’d fascia/skin 71, 73 hemostasis (bleeding control) 104 in hysterectomy 119–22 tying off, extracorporeal 120, 122 myometrium closure 18, 20, 95, 100–4 suture placement 103, 104 tying off, extracorporeal 102, 104 ovarian surface reconstruction 91–3 on procedure termination 71 round needle 17 sacro-uterine ligament plication 122 tying off, extracorporeal 18, 19, 102, 104, 120, 122 tenacula 41 tissue sampling/removal 20–2 advantages of gasless endoscopy 5 titanium clips, long-term risks of 4 total intravenous anesthesia (TIVA) 46 transillumination 54, 67 trocars 30, 38–9 introduction into abdominal cavity 58, 68 withdrawal 71, 72, 73 umbilical ports closure 24, 71, 73 opening 43 uterine manipulators 45 in hysterectomy 108, 115, 116 uterine vessels coagulation 113, 114, 115 division 107, 113, 114, 115 visualization 111, 112 Veress needle insertion ‘blind’ 2, 5 risk reduction 4 visualization of abdominal cavity 54 upper quadrant 62 visualization of pelvic area 68 wound healing disorders 1 avoidance 95 wound size 1, 52, 54

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