This slide will be helpful if the presentation revolves around laparoscopy in gynaecological practice. Kindly like , clip and share the slide. it is free!

1. Dr. Rotimi [REGISTRAR]
Dr. Igbodike Emeka Philip {specialist
registrar OBGYN, OAUTHC]
+234 8037563976,
krh.foundation@gmail.com

2. Introduction
Historical Background
Indications / Contraindications
Anatomy / Instruments / Procedure
Advantages/ Complications
Current Trends
Challenges
Conclusion
References

3. Minimal Invasive Surgery was first
presented by John Wickham
Cuschieri in 2005, challenged the term
‘invasive’
 Invasive implied ‘total’ but
‘minimal’ gives an impression of
minor
Recommended the term Minimal
Access Surgery [ laparoscopy ,

4. Endoscopy is now the default surgical method
for most gynaecological procedure
They are advances made in the field of medical
engineering
Laparoscopy is a transperitoneal endoscopic
visualization of the abdominopelvic structures.
It can be offered on emergency or elective basis
Modifications – SILS [single incision
laparoscopic surgery], Robotic Laparoscopic
surgery.
“Key hole”, minimally invasive surgery,
minimal access surgery

5. AD 938 Abdulkasim - Reflection of light
into the cervix -
1806: Bozzini - urethral examination
using tube and candlelight (father of
endoscopy)
1901: Kelling – First diagnostic
laparoscopy on a dog
1910 : Jacobaeus – First Laparoscopy in
Humans
1912 : Nordentoeft – Developed the
trocar

6. 1920 : Ordnoff – improved on the
pyramidal point of trocar
1924: Zollikofer, Switzerland - CO2
pneumoperitoneum
1928 : Bovie introduced Diathermy
1933: First Laparoscopic adhesiolysis
1938: Janos Veress – Insufflation
needle
1966: Hopkins rod lens configuration

7. Semm 1983 – First Laparoscopic
appendectomy
1985 – Charged Couple Device [CCD]
1994 – First Robotic Arm
1996 – First live telecast of
laparoscopic surgery
2001 – Lindbergh performed the first
transatlantic surgery using ZEUS
robotic surgical system

8. It has been there in the 70s!
The FGN under President Olusegun
Obasanjo (1999–2007) instituted a
tertiary health care intervention
program of which OAUTHC was a
beneficiary.
In 2010 modern video-assisted
laparoscopy equipment were supplied
Operative laparoscopy kick started
2011.

9. Enhance recovery from by avoiding large
incisions
Cosmetically acceptable
Less tissue handling
More rapid discharge from the hospital
Quicker return to normal function
Reduced pain
Documentation of procedure(video evidence)

10. Relatively more expensive
More operating time
Loss of tactile feedback
Potential for major complications in
inexperienced hands
Difficult in complicated cases

11. Indications
• Therapeutic
• Diagnostic

12. Diagnostic Indication
• Infertility evaluation (eg, tubal patency,
ovarian biopsy)
• Evaluation of small adnexal masses
• Second look laparoscopy in ovarian cancer
treatment
• Endometriosis staging and biopsy
• Diagnosis of unruptured ectopic gestation
• Chronic pelvic pain
• Amenorrhoea especially Primary

13. Therapeutic
• Tubal sterilization:
• Adhesiolysis
• Fulguration of endometriosis
• Removal of extruded IUD
• Operations in early pregnancy e.g. -
appendectomy
• Treatment of ectopic pregnancy
• Myomectomy
• Ovarian drilling in treatment of PCOS

14. • Ova collection for IVF*
• Mini-wedge resection of ovary
• Biopsy of tumor
• Oophorectomy
• Ovarian cystectomy
• Laparoscopic hysterectomy
• Reconstructive surgery
Therapeutic

15. 15
ABSOLUTE CONTRAINDICATIONS
Surgical: Large abdominal mass
–Mechanical and paralytic ileus
/Generalized peritonitis
–Irreducible external hernia
–Shock/massive haemorrhage
Medial
–Cardiac failure / Recent myocardial
infarction
–Respiratory failure / Severe obstructive
airways disease
Advanced pregnancy

16. RELATIVE CONTRAINDICATIONS
• Previous peri-umbilical surgery
• Multiple abdominal incisions
• Abdominal wall sepsis
• Cancer involving anterior abdominal
wall
• Morbid obesity
• Ischaemic heart disease
• Blood dyscrasias and coagulopathies
• Early Pregnancy

17. RELEVANT
ANATOMY

18. Endoscopic equipment
Dr igbodike

19. Endoscopy equipment
Split into 4 categories:
• Optics or Telescopes
• Units e.g. Insufflators
• Endovision Systems
• Hand Instruments

20. The laparoscopy cart

21. Lap
cart in
oauthc

22. Ceiling

23. Imaging System
• Light source
• Light Cable
• Telescope
• Laparoscopic Camera
• Laparoscopic Video Monitor

24. LIGHT SOURCE- spectral
temperature, colour
• Halogen[150W]
3200K [mid day sun –
5600k]
yellow colour, 2000hours
• Metal halide [250-400W]
5600k [as in street lights]
• Xenon [300W]
6000K
white colour [1500hrs]
• LED

25. LIGHT CABLES
Light cable:
Fiberoptics –to keep
light beams focused
without significant loss
Do not fold
Liquid crystal gel
cable – cables filled
with a clear optical gel
[liquid crystals]-
transmits 30% more…

26.  LAPAROSCOPE – rigid or
flexible
Between 24 to 33cm in
length
Number of rod lens [6
to18], angle of view [0 to
120deg], diameter [1.5 to
15mm
•Autoclavable
•Non-autoclavable
•Disposable.
– Handling

27. Camera , video and
cables
• First medical camera – Circon
Corp 1972
• Attached to the endoscope and
converts the electronic image to
an optical image to be viewed
from the video monitor
• Single chip camera
• 3 chip camera
• HD
CCD – Charged coupling Device :
electronic memory that records the
intensity of light as variable charges
Pixels/ Resolution

28. MONITOR:
• The closer the surgeon
is to the monitor
the smaller the monitor
• Varies from 8 to 21”
• Principle of horizontal
linear scanning
• In past , no monitors,
direct eye piece
• Soulas, France first used TV for endoscopy,
1956

29. Gas insufflator:
• Electronic gas insufflator is used to
provide controlled
pneumoperitoneum.
• CO2 better choice – colourless,
odourless, non combustible, cheap,
rapidly eliminated
• The insufflator connected to the
trocar sleeve delivers gas at a
desired pressure and flow rate.

30. TROCARS and Cannula
• Act as conduits for endoscope and
other hand instruments .
• Trocar tip can be pyramidal or
conical.
• Steel, reusable, sharp tip – older
• Trocar sizes are 10-12mm, 5mm,
or 3mm to accommodate suitable
endoscopes, hand instrument or
morcellator.

31. Meta analysis
• Cochrane review 2015 by la Chapelle CF, Swank HA,
Jansen FW
• Compared visceral and vascular
complications with the use of steel trocars
and disposable types
• There was no difference in incidence
between trocar types

32. Electrosurgical generator
(ECU)

33. ENERGY SOURCES
• Electrosurgery
• Monopolar
• Bipolar
• Tripolar
• Harmonic Scapel- Ethicon Endo surgery
• Impedance controlled bipolar devices-
• Ligasure,
• Enseal,
• Plasma kinectic dissection forceps,
• Pressure & pulsed current

34. Hand Instruments : GRASPERS
Grasping and manipulating tissue, Maryland
grasper curved tip 5mm, 10mm grasper, 5
and 2 mm , scissors , clip applicator etc..

35. Laparoscopy and anaesthesia
• All patients should receive the same
attention as open surgery
• GA + ETI
• Regional
• LA + sedation

36. Physiologic changes during
Laparoscopy
• Insufflation may cause pain , respiratory
distress, or respiratory embarrassment
• Extreme Trendelenburg can worsen cardiac and
respiratory embarrassment
• Increase in intraabdominal pressure can
increase risk of aspiration
• When intra- abdominal pressure >20mmHg, IVC
is compressed – decrease in CO
• CO is unchanged at 5mmHg
• Vagus nerve may be stimulated and provoke
arrythmia

37. Open access
Close access
Expanding access
 Why intra umbilical
entry?
• Fixed peritoneum
• Thin
• Least vascular
• Cosmetic
PRIMARY PORT OF ENTRY

38. RCOG Green-top guideline
2016
• Meta analysis
• 350,000 participants
• Closed laparoscopic procedures reported
risk of bowel injuries in 0.4 per 1000
laparoscopies and 0.2 per 1000 of major
vessel injuries

39. SITE OF ENTRY
• Umbilicus
• Palmer’s [3 fingersbreath below the left costal margin in the
midline]
• Suprapubic
• Fundus of the uterus [no increased risk of ascending infection]
• Culdoscopy [avoid in endometrosis]

40. Closed Access - Veress Needle or
Direct Trocar, optical trocars,
radially expanding trocars, optical
Veress needle
• Veress needle should be held like a dart.
• Insert at 45 [90] degrees elevation angle with the
tip pointed towards the coccyx.
2 audible clicks!
Test of correct insertion:
• Saline/Irrigation test/ Aspiration test
• Hanging drop test.
• Plunger test.
• Insufflation of gas test (manometric test).

41. Comparison between
laparoscopic entry techniques
• Ahmad et al in a Cohcrane meta-analysis 2015
• 46 RCTs, total of 7389 laparoscopies
• Compared 13 different laparoscopic entry
techniques
• Compared closed technique and direct trocar
– Demonstrated no significant difference in
major complications
– Reduction in the rate of failed entry with open
versus closed
– Insufficient evidence to recommend any entry
technique, more research needed.

42. Fork and knife principle
Azimorth angle
Port wound – fulcrum for movement

43. Baseball diamond concept

44. ergonomics

45. • Set pressure 20-
25mmHg
• With Veress good entry
pressure drops at
<8mmHg
• Start at low flow
(1L/min)
• After 0.5L flow rate can
be increased
• Insufflate to pressure
20-25mmHg
• Remove Veress and
insert troca
ESTABLISHING PNEUMOPERITONEUM

46. 46
PATIENT PREPARATION
• Careful explanation of the risks and benefits
• Informed consent
• Routine blood investigations
• Shaving is rarely necessary, but if it is it should be
done immediately before the operation.
• Antibiotic prophylaxis if vagina is opened or there are
fluid instillations via the cervix.
• Thromboembolism prophylaxis if indicated.

47. INVESTIGATION
• Full blood count
• Clotting profile
• Pregnancy test
• Urinalysis
• Electrolyte, urea and creatinine
• Others :IVU,CXR, ECG, colonoscopy

48. Positioning

49. Theatre set up for laparoscopic
surgery

50. LAPAROSCOPIC PROCEDURE
• Ensure that each laparoscopic instrument is in good
working condition. Use WHO checklist !
• Anaesthesia / Positioning / Asepsis
• Entry / Lifting of Abdominal wall
• Creation of pneumoperitoneum
• Placement of trocar & cannula
• Insertion of Laparoscope with camera
• Panoramic view
• Ancillary ports if needed
• Exist / closure of port wounds

51. Complications
Dr Rotimi

52. COMPLICATIONS
ANAESTHETIC COMPLICATIONS:
• Esophageal intubation
• Gastro esophageal reflux
• Hypotension < venous return sec. to high intraperitoneal
pressure
• Narcotic overdose
• Carbon dioxide embolism
• Cardiac Arrhythmias due to hypercarbia & acidemia
• Cardiac Arrest

53. COMPLICATION
 EXTRA PERITONEAL INSUFFLATION
• Emphysema
 ELECTROSURGICAL COMPLICATIONS :
• Thermal visceral injury & current diversions
 HEMORRHAGIC COMPLICATIONS –
• Injury to vessels

54. Complications
GASTRO INTESTINAL INJURY:
• Stomach , Small Bowel, Colon, spleen
UROLOGIC INJURY:
• Bladder
• Ureter
NEUROLOGICAL INJURIES:
• Due to poor positioning , pressure or surgical
dissection
INFECTION
INCISIONAL HERNIA –port wounds
WOUND DEHISCENCE

55. Sterilization
Dr. Igbodike

56. Sterilization of laparoscopic
Instruments
• Process of free micro-organisms including spore
• Sterilization should be performed according to
manufacturers guide: can be steam or chemical
• Steam autoclaving :
– 134oC for 5 min Germany
– 134oC for 18min France
• Cleaning : recommendation is to disassemble
• After use completely immerse instruments in
water

57. Sterilization of laparoscopic Instruments
• Rinse to remove residual detergent.
Check insulation for any breech!
• Stem method is the oldest
• Not all lap instruments can withstand
heat: camera, laparoscopes, light
cables etc.
• Chemical sterilization :
– CCD is damaged by chemical
sterilization, 2% Glutarldehyde ,
Orthophthalaldehyde {OPA},
peracetic acid – biocidal oxidizer
– H2O2 , Formalin

58. 2% glutaraldehyde
• HLD
• Esp for lens instruments
• Non corrosive
• Sterilization – Immerse for 10hours at
25oC [after cleaning and drying]; then
rinse thoroughly with sterile water
• Cidex – use maximum of 15 times or 21
days after activation

59. NEW ADVANCES
• LESS – Laparo-endoscopic single site surgery
• Robotic laparoscopic surgery
– Alternative to standard ‘straight stick’
laparoscopy
– Advantages : 3D, better Ergonomics – back and shoulders,
Better dexterity and precision / Less fatigue

60. LESS – Laparo-endoscopic single site
surgery
• Single incision/ Single umbilical
port
• Laparoscope and hand
instrument in one port
• Advantages : better cosmesis,
reduced risk of hernia and
wound infection.
• Ahmad et , meta-analysis 2015
– SILS did not reduce
complication rate but
increased operation time but
less bleeding at op site

61. da Vinci surgical system
Console : control
the robot
remotely
inSite® vision -
3D image via 12
mm laparoscope
Endowrist ®
patient cart fitted
with 3 to 4
robotic arms

62. Endowrist ® patient cart fitted
with 3 to 4 robotic arms

63. Controversies
• Snowden 1984, Otubu 1990 believes that
laparoscopy complements HSG
• Okonofua 1988 believes normal laparoscopic
assessment should exclude HSG
• Giacomucci 1999, HSG was not useful compared
to hysterolaparoscopy
• Ikechebelu 2010 recommended use of
laparoscopy with dye test as first line
• Keya Vaid, 2014 recommended
hysterolaparoscopy as first and final procedure
• Agrawal 2018 believes that Hysterolaparoscopy
obviates the need for HSG

64. Local Experience
Dr Rotimi

65. LAPAROSCOPIC CASES DONE AT OAUTHC,
JANUARY 2013- DECEMBER 2017
YEAR TOTAL DIAGNOSTIC THERAPEAUTIC Conversion TO
LAPAROTOMY
2013 61 28 33 3
2014 52 18 34 2
2015 30 23 7 0
2016 15 14 1 0
2017 21 6 15 0
TOTAL 179 79 90 5

66. LAPAROSCOPIC CASES DONE AT OAUTHC,
JANUARY 2013- DECEMBER 2017
INFERTILITY ECTOPIC PREG OVARIAN PATH OTHERS
34 8 9 10
27 2 7 16
21 0 2 7
14 0 0 1
10 1 4 6
106 11 22 46
YEAR TOTAL
2013 61
2014 52
2015 30
2016 15
2017 21
TOTAL 179

67. Challenges
Dr Igbodike

68. Challenges
• Political will
• Funding
• Weak Insurance Policy
• Maintenance
• Training

69. CONCLUSION
• Women world wide love
cosmesis!
• Minimal Access surgery is
cosmetic and reduces loss of
man hours !!
• It is the default as well as
mainstay of gynaecological
surgery in most climes
• How do we combat the forces
that militate against this
welcomed development?

71. REFERENCE
1. Vaid K, Mehra S, Verma M, Jain S, Sharma A, Bhaskaran S. Pan endoscopic approach
“hysterolaparoscopy” as an initial procedure in selected infertile women. Journal of clinical and
diagnostic research: J Clin Diagn Res. 2014;8(2):95.
2. Ikechebelu J. Laparoscopic and hysteroscopy operative for West African College of Surgeons
update march 2017. 2017:1-73
3. Ikechebelu J, Eke N, Eleje G, Umeobika J. comparism of the diagnostic accuracy of Laparoscopy
with dye test and Hysterosalpingography in the evaluation of Infertile women in Nnewi, Nigeria.
Trop. J. Laparoendos. 2010;1(1):39-44
4. Etuk S. Keynote Address-Reproductive health: global infertility trend. Nigerian Journal of
Physiological Sciences. 2009;24(2).
5. Fasubaa O, Onayade A, Ajenifuja T. Experience of tubal surgery for infertility at the Obafemi
Awolowo University Teaching Hospital, Ile-Ife, Nigeria. Afr J Med Med Sci. 2004;33(4):355-360.
6. Okonofua FE, Essen U, Nimalaraj T. Hysterosalpingography versus laparoscopy in tubal infertility:
comparison based on findings at laparatomy. Obstet Gynecol Int. 1989;28(2):143-147.
7. Ikechebelu J, Mbamara S. Should laparoscopy and dye test be a first line evaluation for infertile
women in southeast Nigeria? Nigerian journal of medicine: Niger J Med. 2010;20(4):462-465.

72. References
8. Otubu J, Sagay A, Dauda S. Hysterosalpingogram, laparoscopy and hysteroscopy in
the assessment of the infertile Nigerian female. East Afr Med J. 1990;67(5):370-372.
9. Giacomucci E, Flamigni C, Rossi S, Rossi E, Vianello F, Bellavia E, et al.
Hysterosalpingography versus laparoscopy and hysteroscopy. J Am Assoc Gynecol
Laparosc. 1999;6(3):S19.
10. Hourvitz A, Lédée N, Gervaise A, Fernandez H, Frydman R, Olivennes F. Should
diagnostic hysteroscopy be a routine procedure during diagnostic laparoscopy in
women with normal hysterosalpingography? Reprod Biomed Online. 2002;4(3):256-
260.
11. Agrawal N, Fayyaz S. Can hysterolaparoscopic mediated chromopertubation obviate
the need for hysterosalpingography for proximal tubal blockage?: An experience at a
single tertiary care center. J Gynecol Obstet Hum Reprod. 2018.