Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
2-35
Section III. ABDOMINAL GYNECOLOGICAL AND OBSTETRICAL SURGERY
2-35. LAPAROSCOPY (PERITONEOSCOPY, CELIOSCOPY)
a. General. This procedure involves the endoscopic visualization of the peritoneal cavity through the anterior abdominal wall after the establishment of a pneumoperitoneum. It provides the gynecologist the same anatomical view of the pelvic organs as is seen at the diagnostic laparotomy. The pathological condition can be seen, the ancillary procedures such as aspiration of cysts, tubal plastics, and tissue biopsies can be performed. Hemostasis can readily be obtained by using the active electrode probe. This procedure may enable the surgeon to avoid unnecessary pelvic surgery.
b. Preparation of Patient. The patient is placed in the supine position, given general anesthetic, and skin prepped as for a laparotomy. A Foley catheter is inserted, and the table is placed in extreme Trendelenburg position with shoulder braces correctly placed.
c. Operative Procedure.
(1) A 1-cm incision is placed below or to the left of the umbilicus.
(2) The skin is elevated with hooks. The trocar and valve sleeve are inserted first subcutaneously, then thrust boldly through the remaining layers of the abdominal wall into the peritoneal cavity. The angle taken by the trocar is approximately 45º toward the concavity of the pelvis.
(3) The trocar is removed, the valve sleeve closed, the rubber tubing from the gas source attached, and a pneumoperitoneum produced. Care must be taken to prevent overdistention of the abdomen.
(4) After the patient is placed in the Trendelenburg position, the laparoscope is introduced and inspection begun. Should the biopsy or cautery forceps be needed, they are introduced by trocar through a separate small incision in the abdomen.
(5) The scopes are withdrawn; gas is allowed to escape from the sleeve before it is withdrawn. Subcuticular closure of the skin is followed by the application of a small dressing.
