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