Laparoscopy indications

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  • 1. INDICATIONS  FOR  LAPAROSCOPY   IN  GYNECOLOGY   James  Bentley   Professor  Department  of  Obstetrics  and  Gynecology     Thanks:  Katharina  Kieser   Associate  Professor   Department  of  Obstetrics  and  Gynecology  
  • 2. Speaker  disclosure:   §  I  do/do  not  have  any  direct  financial  interest  in  a  company   whose  interest  are  in  the  areas  covered  by  the  educational   material  such  as:     •  Investments  in  the  Company   •  Membership  in  the  Company’s  Advisory  Board  or  similar   committee   •  Current  or  recent  participation  in  a  clinical  trial  sponsored  by  the   Company   •  Research  sponsored  by  the  Company   •  A  paid  consultant  for  the  Company  
  • 3. Introduction   •  Surgical  approach  in  gynecology  has  changed   significantly  in  the  last  20  years   •  Laparoscopy  has  become  the  preferred  approach   •  1980’s   •  Diagnostic  Laparoscopy   •  Tubal  Ligation   •  Endometriosis  ablation   •  2010   •  Operative  laparoscopy   •  Advanced  Laparoscopy  
  • 4. Objectives   •  Review  the  role  of  laparoscopy  in  gynecology   •   To  review  indications  for  Total  Laparoscopic   Hysterectomy   •   To  review  port  placement   •   To  review  preop  &  postop  care  
  • 5. Laparoscopic  Indications   §  Ectopic  pregnancy   §  Adnexal  Mass/  Ovarian  cyst   §  Fibroid  surgery   §  Hysterectomy   §  Infertility  tubal  surgery   §  Urogynecological  surgery   §  Cancer  
  • 6. Barriers  to  laparoscopy   §  Disease   ú  Concern  with  cancer      Large  masses      Port  site  mets   ú  Large  fibroids   §  Patient  factors   ú  Patient  obesity   ú  Comorbidities   ú  Unstable  patient  i.e.  bleeding  ectopic   §  Surgical  factors   ú  Training/  skill/  experience   ú  Anaesthesia   §  Equipment   ú  Access  to  energy  sources   ú  Retrieval  bags/  uterine  manipulators  
  • 7. Is  there  a  role  for  Open   surgery?   §  Laparoscopy   ú  Advantages  of  early  discharge   ú  Lower  complications   ú  Better  cosmetic  appearance   §  The  first  approach  should  be  laparoscopic   when  surgery  is  indicated   §  BUT  the  most  minimally  invasive   hysterectomy  is  a  vaginal  hysterectomy  
  • 8. Contraindications  to   laparoscopy   §  Previous  abdominal  surgery-­‐  No   §  Bowel  obstruction-­‐Probably  OK   §  Ruptured  ectopic-­‐  OK  after  resuscitation   §  Pregnancy-­‐open  laparoscopy  OK   §  Cancer  -­‐  no  good  evidence  that  laparoscopy   causes  problems  with  spread  
  • 9. Patient  risk  factors   §  Obesity-­‐  only  a  problem  in  morbid  obesity   §  Age-­‐  No  problems   §  Previous  abdominal  surgery   §  Increased  risk  of  adhesions-­‐  but  use  open   technique,  LUQ  entry  
  • 10. Hysterectomy:  Definitions   •  Laparoscopically assisted vaginal hysterectomy (LAVH) • Vaginal hysterectomy that is assisted by laparoscopy; the laparoscopic procedures may include adnexectomy and the superior portions of the hysterectomy, but not ligation of the uterine vessels. •  Vaginally assisted laparoscopic hysterectomy (VALH) • Hysterectomy that is performed mostly laparoscopically, including ligation of the uterine vessels. The vaginal portion consists of only the vaginal incision and repair. •  Laparoscopic subtotal hysterectomy (LSH) • Hysterectomy that is performed completely by laparoscope; however, the uterine corpus is amputated from the cervix at the level of the isthmus, and the cervical stump will remain in situ. •  Total laparoscopic hysterectomy (TLH) • Abdominal hysterectomy that is performed completely by laparoscopy with no vaginal component. The vaginal cuff is closed via the laparoscope. Te Linde’s Operative Gynecology, ch 32C,p 764
  • 11. TAH  vs.  LAVH   TAH   LAVH   Operative  time  (min)   146   179   EBL  (ml)   660   568   Hospital  stay  (days)   4.1   2.1   Convalescence  (days)   38   28   Cost  (US)   $6974   $8161   Complications   32%   15%   Te Linde, ch 32, p765
  • 12. Length  of  stay   Nieboer TE. Cochrane Intervention Review. Issue 3. 2009
  • 13. Return  to  Normal  Activities  
  • 14. Intraopertative  Bowel  injury  
  • 15. Intraopertative  urological  injury  
  • 16. Intraoperative  EBL  
  • 17. Indications   •   Patient’s  physical  status,  pelvic  examination   &  pathology   •  Endometriosis   •  Fibroids   •  Menorrhagia   •  Prolapse   •  Pre-­‐malignant   •  Malignant   •  Vaginal  hysterectomy  è LAVH è VALH è TLH  
  • 18. Port  placement   •   Swording   •   Hollow  viscus  injury   •   Vessel  injury   •   Solid  organ  injury   •   Embolism   •   Hassan  entry   •   Veres  needle  entry   •   Direct  entry   Vilos G, et al. JOGC. 2007;193:433-47
  • 19. Port  placement   •   Umbilicus   •   Palmer’s  point   •   Trans  uterine   •   Trans  cul-­‐de-­‐sac   •   9th/10th  intercostal  space   ¤ ¤ ¤
  • 20. •   Umbilicus  to  aortic  bifurcation  changes   with  BMI  &  positioning   •  0.4cm  –  normal   •  2.9cm  –  BMI  >30  
  • 21. Complications  of  port  entry   §  Number  of  Veress  insertion  attempts   §  Extraperitoneal  insufflation  
  • 22. Preop  &  postop  care   §  Preop   •   CBC,  type  &  screen   •   Fleet  enema?   §  Postop   •   D/C  Foley  in  OR   •   Heavy  lifting   •   Driving   •   Intercourse  
  • 23. Summary   §  If  the  patient  needs  abdominal  surgery-­‐   §  Consider  laparoscopic  approach