Surgical technology has advanced to the point that complex surgeries can be performed through small openings. These minimally invasive approaches usually result in a shorter hospital stay and a quicker recovery time. They have become the standard of care for select procedures and have provided patients with more treatment alternatives. Laparoscopy is the term that refers to minimally invasive surgery of the abdomen and pelvis and this article will review the details of this procedure when used in gynecology.
Laparoscopy is done under general anesthesia and the patient is placed supine with their feet in boot-shaped holder so the legs can be spread laterally but the thighs remain parallel to the abdomen. This position is called dorsal lithotomy. This allows access to the birth canal so a uterine manipulator can be placed. After anesthesia is completed the abdomen, perineum and genital area are thoroughly cleaned and draped.
Initial entry can be done via a variety of techniques through a 10-12 mm opening. Using the Hasson technique, an incision is made in the umbilicus, which allows the placement of a port through which a camera is placed. A smaller side opening in the port is used to instill the gas, carbon dioxide, to distend the abdomen. Another classical route starts with the insertion of a Veress needle in the umbilicus through which gas is instilled. Once the abdomen is adequately distended, the Veress needle is removed, and then a sharp trocar with a covering sheath is then placed blindly using standardized and specific maneuvers to avoid injury to internal structures. The trocar is then removed, the camera is inserted and visualization confirms correct placement.
Once the abdomen is full distended the internal structures of the pelvis are visible. Additional trocars can then be inserted in the lower abdomen and this is done under direct visualization. The position and size of these trocars are dependent on the type of procedure planned. Two 5 mm trocars placed in the right lower quadrant, left lower quadrant and/or suprapubic location are the most common sites for the majority of simple laparoscopic cases. This includes procedures such as removal of an ovarian cyst or fallopian tube, diagnostic procedures, ectopic surgery procedures and tubal ligation. More complex procedures may require larger trocars or placement of these trocars in higher locations.
The surgical time is dependent on the procedure and other factors but can be between 1-2 hours. Once the procedure is completed, the trocars are removed and the gas is allowed to escape. The incisions is closed in 2 layers at the larger trocar sites while only the skin needs to be closed at the 5 mm sites. The uterine manipulator is removed and if used, the bladder catheter can be removed. After a standard recovery time of 2-4 hours, most women can be discharged to home.
Laparoscopy is a widely available option for performing many gynecologic procedures and should be offered as an alternative to laparotomy. The procedure is safe, effective and the recovery time is much faster than open surgery. If you are considering surgery, know your options and find a provider who can provide you with modern therapies that are considered standard of care.
I hope this article has provided you with information that will help you make wise choices, so you may:
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