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complications, the open techniques reduced the incidence of
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failed procedures, inappropriate gas insufflation, gas embolism,
bladder and pelvic kidney punctures, major vessel injuries, and
postoperative herniations.[26]
In a survey conducted by Penfield [27], intestinal laceration
was the most serious complication of open laparoscopy, and
most of those lacerations occurred during the early use of this
technique. In 10,840 open laparoscopies attempted by 18 boardcertified obstetrician/gynecologists, six bowel lacerations were
reported, four were recognized and repaired, and two were not
suspected until several days postoperatively.
To reduce the risk of bowel laceration, the surgeon should
use a focus spotlight, work with an experienced assistant, make
a vertical incision to facilitate exposure, grasp and elevate the
fascia with small Kocher clamps, and cut between the clamps.
A gynecologist who attempts open laparoscopy only in special
situations will find that the procedure is slow and cumbersome
because of difficulty in exposing and identifying each layer of the
abdominal wall.
ACCESSORY TROCARS
Additional cannulas are needed through which various instruments are inserted into the abdomen for manipulation andoperative procedures. Placement sites dependon the patient’s anatomy,
the contemplated procedure, and the surgeon’s preference. For
diagnostic purposes, an incision generally is made 4 to 5 cm
above the symphysis pubis in the midline. This area, delineated
by the two umbilical ligaments and the bladder dome, is safe and
usually avascular.
For operative laparoscopy, two accessory trocars (5 mm) are
placed 4 to 5 cm above the symphysis pubis at the outer border of
the rectus muscle, 3 to 4 cm below the iliac crest, 2 to 3 cm lateral
to the deep inferior epigastric vessels. These trocars are inserted
under direct vision to lessen the risk of intra-abdominal visceral,
uterine, and vascular injury and to provide freeaccesstotheposterior cul-de-sac.Vascularization of the lower abdomenis provided
by two vessels: the deep inferior epigastric originating from the
external iliac artery and the superficial epigastric, a branch of the
femoral artery. Transillumination helps identify the superficial
vessels, but they are difficult to see in obese patients. The deep
inferior epigastric vessels run lateral to the umbilical ligaments
(Figure 4.1.10) and are seen intraperitoneally and identified easily.These vessels pass the roundligament, proceed tothe anterior
abdominal wall, and are seen above the peritoneum. To avoid
injuring these vessels, the trocar is inserted medial or lateral to
the umbilicalligaments by viewing the undersideof the abdomen
wall laparoscopically (Figure 4.1.11). Despite these precautions,
aberrant vascular branches occasionally are traumatized, and the
operator must be able to manage this type of injury.
To reduce the chance of trauma to the abdominal structures,
the proposed site for the secondary punctureisindentedbyapplying abdominal pressure with the index finger and observing the
peritoneal surface with the laparoscope. Next, mapping of the
potential sites for accessory trocar placement is done by advancing the tip of an 18-gauge needle attached to a syringe transabdominally through the peritoneum, revealing the exact course
and placement of the accessory trocar. This allows optimal placement. These maneuvers are important, particularly in a patient
Principles of Laparoscopy — 47
Urachus
Left umbilical
ligament
Figure 4.1.10. Deep inferior epigastric vessels run lateral to the umbilical ligaments.
Bladder
Uterus
Right inferior
epigastric vessels
with evidence of abdominal wall adhesions, and help ensure safe
access.
The trocar, held with the index finger extended on the sheath
to control the depth of penetration, is inserted through the skin,
fat, andfascia. Further advancement iscontrolledunder a laparoscopic view (Figure 4.1.11). Thetrocar is aimed toward the center
of the abdomen and hollow of the sacrum. If it is aimed laterally,
it can slide down the pelvic side wall without being seen through
the laparoscope, resulting in injury to the iliac vessels. The accessory trocars are never inserted without laparoscopic observation
of their indentation on the abdominal wall or before mapping
the abdomen. When insertion of the trocars is viewed directly
from the monitor, the surgeon should be sure the camera has
not been rotated so that it shows the wrong view of the pelvis.
Most laparoscopic procedures do not require more than two or
three accessory trocars. Other sites of entry include the midpoint
between the symphysis pubis and the umbilicus and McBurney’s
point.
Some accessory trocar sleeves are too long to allow free access
to the pelvic structures and tend to slip out of the peritoneal cavity.The presence of trapvalves may interfere withefficient instrument exchange, prevent the introduction and removal of suture
material, and prevent the removal of tissue. Several accessory
trocar sleeves either screw in or have an umbrella to secure them
to the abdominal wall. Radially expanding trocars may reduce
laparoscopic complications, lessen a surgeon’s exposure to liability, and improve patient outcomes.[28] Two hundred twelve
women underwent various laparoscopicproceduresinvolving the
placement of 541 radially expanding access cannulas, and no
major complications occurred. One patient developed a postoperative mesenteric hematoma that was assumed to be secondary
to a venous injury from the Veress needle. Despite the absence of
fascial anchoring devices, only six cannulas (1%) slipped.
Accessory Sites
Examples of single accessory site procedures include tubal sterilization, aspiration of an ovarian cyst, and mild peritubal and
48 — Camran Nezhat, Ceana Nezhat, Farr Nezhat, and Roger Ferland
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Sympyhsis pubis
Uterus
Bladder
4 cm
Left umbilical
ligament
Umbilicus
Figure 4.1.11. Accessory trocars are placed under direct vision to avoid injury to the inferior epigastric vessels
and anyorgans thatmay be adherent to the pelvic side wall or the anterior abdominal wall. The trocar is inserted
lateral to the left umbilical ligament, avoiding inferior epigastric vessels that are invariably lateral to umbilical
ligaments.
peri-ovarian adhesiolysis. The suction–irrigator probe is placed
through a suprapubic trocar site. Twoaccessory sites are suggested
for lysing peritubal and peri-ovarian adhesions, doing a salpingectomy, removing an ectopic pregnancy, or excising moderate
pelvic endometriosis. The suction–irrigator and one additional
instrument are needed. Traction is required for these procedures.
The suction–irrigator is used for manipulation and smoke evacuation. Bipolar forceps replace the grasping instruments if necessary to achieve hemostasis. For procedures requiring traction,
hemostasis, and suturing almost simultaneously, three sites are
necessary. Examples are salpingo-oophorectomy, hysterectomy,
repair of an ovarian or uterine incisional defect, lysis of extensive abdominal or pelvic adhesions, myomectomy, and cystectomy. During oophorectomy, the infundibulopelvic ligament is
grasped withforcepsfortraction. The assistantholdsthe grasping
forceps,and the surgeon uses the bipolar electrocoagulatortodesiccate the infundibulopelvic ligament. The forceps are removed
and held by an assistant. The surgeon uses the suction–irrigator
probe, and while the plume is suctioned, the CO
laser is used
2
for excision. During reconstructive procedures, the operator can
give the videolaparoscope to the assistant, freeing the operator’s
hands for applying traction and suturing. An assistant maintains
traction with the grasping forceps as the surgeon uses the needle
driver. As with other techniques, surgeons modify procedures as
they gain experience.
Operative laparoscopy enables a physician to do complex,
delicate procedures through small incisions, thus decreasing
the patient’s discomfort, morbidity, expense, and duration of
convalescence.[29] Laparoscopy is a technique for accessing the
patient’s diseased organs and gives the surgeon an opportunity
to remove abnormal tissue and reconstruct damaged organs.
Right inferior
epigastric vessels
Laser-laparoscope
HIGH-RISK PATIENTS
Body Habitus
Special considerations are required for obese patients becausethe
trocarisinsertedalmostvertically. The distancebetweenthesacral
promontory and the trocar tip isrelatively small, and there is a risk
to the major vessels. In thin patients, it is safer to overdistend the
abdomen with CO
before trocar insertion. The force required
2
to introduce the trocar is less than anticipated because the fascia
is thin and offers little resistance.
Bowel Distention
Boweldistentionsecondarytoobstructionisarelativecontraindication to laparoscopy. This condition may be iatrogenic, resulting from the placement of the Veress needle within the bowel
lumen. The filling pressure of the small bowel is the same as that
of the abdominal cavity because of the intestine’s large capacity.
The operator, unaware of the possibility of an “apparent” pneumoperitoneum, might lacerate the distended bowel during the
insertion of the trocar.
Previous Laparotomy
In women who have had previous laparotomies, the underlying intra-abdominal anatomy may be altered. Inflexible adhesive
bridging between the intestine and the abdominal wall can nullify any protection from trocar injury afforded by elevating the
abdominal wall, creating a pneumoperitoneum, using the Trendelenburg position, and maintaining intestinal mobility. In some
patients, injury will occur to adherent omental vessels or directly
Principles of Laparoscopy — 49
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Table 4.1.6: Patients by Type and Number of Incisions
No. Incisions
Incision Type 1 23456
Pfannenstiel 180 51 19 4 4 0 258
Midline below
umbilicus
Midline above
umbilicus
55 18 9 4 0 1 87
1021200 15
Total
Patients
Table 4.1.7: Incidence of Adhesions after Previous
Laparotomy
Type of Incision No. Percent Omental,% Bowel,%
Pfannenstiel 258 72 23 4
Midline below
umbilicus
Midline above
umbilicus
Total 360 100
87 24 46 9
15 4 40 27
to the bowel wall. The patients at the highest risk are those who
have undergone major abdominal surgery, such as bowel resection, or an exploratory laparotomy for abdominal trauma or
ovarian carcinoma.[5] Women who have had an uncomplicated
abdominal operation are not at increased risk.
The association between intestinal and omental adhesions
and injury to those structures during operative laparoscopy was
evaluated in 360patients who previously had undergone avariety
of abdominal operations (Tables 4.1.6 through 4.1.8).[30]
The following approach is recommended:
1. Patients with prior midline incisions have more adhesions
than do those with prior Pfannenstiel incisions.
2. Patientswith multiple priorincisions do nothavemore adhe-
sions than do those with a single prior incision.
3. The presence of adhesions does not have a linear correlation
with increasing numbers of prior incisions.
4. Women withpriormidline or Pfannenstiel incisions forgyne-
cologic operations have more adhesions than do those who
have undergone obstetric operations.
5. Patients with prior midline incisions for obstetric operations
do not have more adhesions than do those with a prior Pfan-
nenstiel incision for obstetric operations.
Table 4.1.8: Patients by Clinical Indication and IncisionType
Incision Type Gynecologic Obstetric
Pfannenstiel 186 43
Midline above or below umbilicus 73 12
Total 259 55
During insertion of the primary trocar and entry into the
abdominal cavity,intestinalinjuriesoccurredin21instances(6%;
Table 4.1.9). Of these injuries, six were to the small bowel. Only
one patient had a single incision; the remaining five had multiple incisions and complicated surgical histories. Two small bowel
injuries occurred during open laparoscopy. In these two patients,
the small bowel was attached to the anterior abdominal wall,
directly under the umbilicus. It was entered during incision of
the fascia that was attached to the intestine. With the exception
of 32 patients in whom open laparoscopy was done, the closed
technique with prior establishment of pneumoperitoneum was
used. Theuse ofopen laparoscopy wasbased on the patients’ surgical history (bowel resection, bowel obstruction, ovarian cancer
surgery) and the surgeons’ preoperative judgment.
The attachmentof thebowel and omentum to the abdominal
wall is primarily distal to the umbilicus (Figure 4.1.12A). If the
insertion of the trocar is more vertical than oblique,thepossibility
of bowel injury is low if a disposabletrocarwith a shieldis used. In
patients who have had complicatedabdominaloperations (bowel
resection, bowel obstruction, etc.), the bowel may be attached
under, very close to, or occasionally above the umbilicus (Figure
4.1.12B).
In a subsequent study, the safety of direct trocar insertion
was evaluated in 246 consecutive women with previous uncomplicated Pfannenstiel ormidline incisions. Allof them underwent
bowel preparation and understood that laparotomy was possible.
Trocar insertion was almost at a 90
◦
angle while the operator and
the assistant elevated the abdominal wall, lateral to theumbilicus.
Fifty patients had omental adhesions, and 34 had bowel adhesions to the anterior abdominal wall. There were no small bowel
injuries. There were five omental injuries; in one, the injury was
associated with bleeding and was managed laparoscopically.
On the basis of these findings, it can be concluded that the
incidence of subumbilical bowel adhesions andsubsequentbowel
injury is related to the indication for previous laparotomy rather
than to the type or number of previous laparotomies. The incidence of bowel injuries during insertion of the primary trocar is
low. The closed technique with or without prior establishment of
a pneumoperitoneum is used in most instances without increasing the chance of bowel injury.
The following conditions were associated with severe
adhesions:
1. Generalized peritonitis
2. Bowel resection after intestinal obstruction
3. Oncologic procedure with omentectomy
4. Previous radiation and intraperitoneal chemotherapy
5. Previous adhesions
Special Techniques
Several procedures have been described to assess the anterior
abdominal wall for intestinal adhesions. DeCherney [31] advocates using asmall-gauge needle laparoscope2 to 3 mmin diameter. The needlescopeis inserted insteadofthe Veress needleunder
direct vision through the umbilical, preperitoneal, and subperitonealstructures.TheVeress needle is inserted intra-abdominally,
and insufflation proceeds under direct observation.
50 — Camran Nezhat, Ceana Nezhat, Farr Nezhat, and Roger Ferland
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Table 4.1.9: Incidence of Injury – 21/360 (6%)
Omental Hematoma Omental Bleeding Small Bowel Injury
(Closed Technique) (Closed Technique) (Closed, 6; Open, 2)
Type of Injury Single Multiple Single Multiple Single Multiple
Number 157215
Percent 0.3 1.4 1.9 0.6 0.3 1.4
Exploring the periumbilical area with an 18-gauge needle
attached to a syringe after establishing the pneumoperitoneum
(Figure 4.1.13) also is possible. If adhesions are detected by these
techniques, theoptions includeopen laparoscopy and alternative
sites of abdominal entry. The primary trocar is inserted in the
midline between the xiphoid and the pubic symphysis provided
that care is taken to remain at least 5 cm below the xiphoid and
5 cm above the pubic symphysis (Figure 4.1.8).[16] Although
these techniques help detectperiumbilical adhesions, they arenot
definitive and are time consuming. Based on these observations,
the following approach is recommended:
1. Patients who have had a previous laparotomy are allocated to
noncomplicated and complicated groups.
2. One-day or 3-day bowel preparation is administered, based
on the patient’s history. All patients must understand that
bowel injury is possible and must consent to a possible con-
version of the procedure to laparotomy.
3. In the noncomplicated group, open or closed techniques are
used. If the closed technique is used, a disposable trocar with
a bullet shieldis preferable. Trocar entry is controlled, and the
Adhesions between the small bowel
and the anterior abdominal wall
directly beneath the umbilicus
placementangleisverticalratherthanoblique(Figure4.1.14).
Either previous establishment of a pneumoperitoneum by a
Veress needle or direct trocar insertion is used. If the Veress
needle is used, the subumbilical area is searched for bowel
adhesions before trocar insertion. If adhesions are suspected,
other locations are explored until a safe area is detected and
the trocar is inserted. In patients at risk for significant adhesions, a pneumoperitoneum is created byinserting the Veress
needle transumbilically or in the left subcostal area in the
midclavicular line after aspirating with a syringe to rule out
bowel entry. The abdomen is insufflated with CO
. The area
2
is explored with a 20-gauge needle to inject saline (Figure
4.1.13). If no fluid is aspirated (the conditions are favorable),
a 5-mm trocar is inserted and a 4-mm laparoscope is placed
to observe the peritoneal cavity (Figure 4.1.14). If there is
no intestinal injury, the 5-mm trocar is replaced with the 10mm trocar.Ifintestinalentry occurs,the5-mmtrocar is left in
place and a safe area is found to insert the 10-mm trocar and
laparoscope. The loops of injured bowel are mobilized and
repaired laparoscopically or through a minilaparotomy.[2]
Since this approach was adopted, no bowel injuries have
A
Figure 4.1.12. The bowel is attached to the anterior abdominal wall. (A) The bowel is attached directly under the umbilicus. (B) The attachment
is below and distal to the umbilicus.
Trocar injury of
the small bowel
Adhesions between the small bowel
and the anterior abdominal wall
caudal to the umbilicus
Trocar injury of
the small bowel
B
Principles of Laparoscopy — 51
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A
C
C
Blood and
bowel contents
B
A
B
Figure 4.1.13. The abdomen is “mapped” by using an 18-gauge spinal needle around the Veress needle. A
20-gauge needle is inserted under negative pressure at several cardinal points of a 20-mm circle around the
umbilicus. If blood or bowel content is aspirated instead of CO
trocar insertion should be chosen.
Adhesions between the
omentum and small bowel
to the anterior abdominal wall
Figure 4.1.14. This patient had bowel adhesions from a previous
laparotomy.
gas at any of these points, alternative sites for
2
been observed resulting from trocar insertion in more than
700 patients with different types of laparotomiesfor different
indications. Another instrument that may be helpful is the 2mm microlaparoscopeforinitialintra-abdominal evaluation.
If the patient has undergone an adequate bowel preparation,
an incidental bowel perforation can be managed conservatively after thorough and extensive irrigation of the abdominal cavity, unlike similar injuries caused by the 4-mm laparoscope.
4. For patients in the complicated group, a mapping technique
is used to lessen the chance of sequelae. After insertion of
the laparoscope, the abdominal wall with adherent bowel or
omentum isexplored. If the adhesions aresevere and no clear
spaceforaccessorytrocarinsertion is seen,theabdominalwall
is observed through the laparoscope and gentleexternal compression is done, marking areas that seem free of adhesions.
52 — Camran Nezhat, Ceana Nezhat, Farr Nezhat, and Roger Ferland
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Ovary
Fallopian
tube
Ureter
Uterosacral
ligament
Sigmoid
Anatomy of pelvis
Bladder
Uterus
Rectum
Obliterated
hypogastric
artery
Round
ligament
Uterine
artery
External
iliac artery
and vein
Hypogastric
artery
Sacral
promontory
Ureter
Figure 4.1.15. Panoramic view of the lower abdomen and pelvis.
Before inserting the trocar, the surgeon should simulate its
track with a 21-gauge spinal needle. If this identifies a clear
path, the trocar is introduced next to the needle, or the needle is removed and the trocar is introduced. An advantage
of first inserting the 21-gauge needle is its small diameter,
because the injury incurred does not require repair. As the
needle’s placement is seen, there is little risk of missing a visceral injury. The insertion of the needle through the skin of
the abdominal wall is easy, so the surgeon can control the
needle precisely and prevent any deviation from the present
course.
PELVIC EXPLORATION
The initial phase of laparoscopy is done to assess the extent of
disease, document it with photographs or video recordings, and
identify anatomic landmarks. The characteristics of the bladder,
ureters, colon, rectum, uterosacral ligaments, and major blood
vessels are noted (Figure 4.1.15). The appendix is inspected for
endometriosis. The upper abdomen, including the abdominal
walls, liver, gallbladder, and diaphragm, is examined for any
abnormality that could contribute to the patient’s symptoms.
As the laparoscope is turned toward the left, the intestine is evaluated, and then the laparoscope is returned to view the pelvic
cavity. The omentum and intestines are examined to confirm
AO IVC
that they were not injured during insertion of the Veress needle
and trocar.
After the posterior cul-de-sacisfilled with irrigationfluid, the
right adnexa are assessed. The fimbriae are lifted, and the posterior aspect of the ovary and the ovarian fossa are evaluated. The
ureterisseen,and its directionis traced fromthe pelvic brim to the
bladder. The uterus is anteverted, and the uterosacral ligaments,
posterior cul-de-sac, and rectum are examined. The patient is
placed in a 30
◦
Trendelenburg position to allow the surgeon to
push the small bowel into the upper abdomen to aid in viewing
the posterior cul-de-sac (Figure 4.1.16). The rectosigmoid colon
and its folds are evaluated, and after the rectosigmoid colon is
pushed laterally, the left and right pararectal areas are examined.
The leftovary andtube are evaluated.In the presenceof extensive
adhesions, this technique is modified. Thegynecologistascertains
the approximate location of the normal structures, assesses the
type of adhesion, plans the procedure, and decides whether the
procedure is to be done by laparoscopy or laparotomy. This decision depends on the abnormalities, the time needed to correct
them, and the surgeon’s experience.
END OF THE OPERATION
Chromopertubation is done in all infertility patients intraoperatively. The patient’s position is changed from Trendelenburg
Principles of Laparoscopy — 53
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Figure 4.1.16. The patient is placed in a Trendelenburg position. Inset shows the elevation of the pelvis.
to horizontal to allow fluid from the upper abdomen to collect in the pelvic cavity. The entire peritoneal cavity is irrigated copiously with isotonic fluid, usually lactated Ringer’s
solution, and inspected for blood clots, pieces of adhesions,
cyst wall, endometriosis implants, and bleeding. Bleeding points
are identified and coagulated with bipolar forceps. Because the
intra-abdominal pressure created by the pneumoperitoneum can
tamponade bleeding from smallvessels, the gas is evacuated temporarily and the operative sites are inspected for bleeding before
the abdominal cavity is reinsufflated. The presence of clear irrigating fluidconfirms adequate hemostasis. The procedure is concluded by evacuating the CO
from the abdomen.
2
Release of Pneumoperitoneum
The CO2used to distend the abdomen is evacuated to reduce
postoperative shoulder pain caused by gas trapped under the
diaphragm. The patient is put in a straight, supine position as the
gas escapes from the umbilical and suprapubic trocars. Suprapu-
bic trocars are removed under low pneumoperitoneal pressure to
search for possible inferior epigastric vessel injury. The umbilical
trocar is removed, and the skin incisions are inspected for bleeding. Except for patients in whom Interceed (Ethicon) is applied,
300 to 400 mL of lactated Ringer’s solution is left in the abdominal cavity to aid in displacing the gas and possibly to decrease
postoperative adhesions.[32] Sincethis procedure wasinstituted,
the prevalence of postoperative shoulder pain has decreased.
Closure of Incisions
The trocar incisions are closed using Steri-Strips or inverted subcutaneous 4–0 polyglactin (Ethicon) sutures. Incisions made for
trocars larger than 5 mmare closed in layers,especially in olderor
thin women, because failuretoclosethe fascia hasbeenassociated
with small bowel strangulation and hernia. Several instruments,
including the J-needle and the Carter–Thomason needle (Figure
4.1.17), have been developed to allow for fascial and peritoneal
closure of the trocar site incisions under direct observation.
54 — Camran Nezhat, Ceana Nezhat, Farr Nezhat, and Roger Ferland
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A
B
Figure 4.1.17. The Carter–Thomason needle. The system allows the passage of suture through soft tissue and then retrieval from a separate entry
with the same device. (A) The CloseSure Procedure Kit (Inlet Medical Inc.) contains the Carter–Thomason suture passer and the Pilot suturing
guides. (B) A stepdown from the distal to proximal segment of the jaws allows the distal tip to close completely with the suture in the proximal
stepdown segment. (Continued )
Skin
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Principles of Laparoscopy — 55
Fascia
Muscle
Peritoneum
C
E
Figure 4.1.17. (continued) (C) A suture passer is used to push suture material through the Pilot guide, fascia, muscle, and peritoneum and into
the abdomen. The suture is dropped, and the suture passer is removed. (D) The suture passer is pushed through opposite side of the Pilot guide
and used to pick up the suture. (E) The suture passer is removed, pulling the suture through the peritoneum, muscle, fascia, and guide. (F)The
guide is removed, and the suture is tied to complete the closure.
D
F
POSTOPERATIVE CARE
Patients are provided with postoperative instructions before the
operation to prepare them for the postoperative experience. The
gynecologist sees the patient in the outpatient extended recovery
room to explain the operative findings and the expected postoperative course. Before discharge, patients are given prescriptionsfor
pain medications (usually Tylenol with codeine) as needed and
routine postoperative instructions. Outpatient nurses or office
nurses contact the patient 1 or 2 days postoperatively to answer
additional questions and monitor her recovery. If a patient complains of pain, fever, or bowel or bladder symptoms, she is examined promptly. Patients routinely are seen 1 to 6 weeks postoperatively. Most women return to normal activity within 1 week.
The time required for full recovery is between 1 and 3 weeks,
depending on the extent of the operation.
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Common Postoperative Complaints
Nausea and vomiting most likely are related to intra-abdominal
and the narcotics frequently used perioperatively. Usually
CO
2
these symptoms respond to parenteral antiemetic medication,
but patients occasionally are admitted overnight for continued
care. Shoulder pain referred from the collection of CO
under the
2
diaphragm is the most common complaint and generally resolves
within 48 hours. Resting on the abdomen with pillows under it
is helpful. Elevating the lower pelvis also will alleviate this pain.
Occasionally a patient develops hypotension unrelated to
blood loss. These patients are cured promptly after a bolus of
intravenous fluid is given.
Postoperative incisional pain is usually mild and is managed
by using a heating pad and analgesics. A randomized, doubleblinded trialof preemptive analgesiain laparoscopy patients concluded that theadministration of bupivacainebefore laparoscopy
results in decreased postoperative pain compared with the popular practice of infiltrating bupivacaine at the time of incision
closure.[33] Patients who undergo extensive intra-abdominal
procedures may have severe visceral pain. Narcotic or nonsteroidal anti-inflammatory agents are needed in addition to a
heating pad. Persistentpainformorethana few hours after release
from the hospital requires that the patient be examined.
When large amounts of isotonic fluidare left inthe abdomen,
the patient tends to drain pinkish fluid through the abdominal
puncture wounds. This ceases within24 to 48 hours. Reassurance
allays the patient’s concern.
To become proficient with operative laparoscopy, a gynecologist must understand the learning curve and begin with simple procedures before gradually advancing to more complicated
ones. Complications may occur during the simplest procedures.
The primary steps are exposure (by identifying the anatomy and
pathology), traction,and action (cutting,vaporization, hemostasis, or suturing). The gynecologist holds the video-laproscope
with the dominant hand. Most procedures require only one or
two accessory instruments.
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