Reprints Available Directly from the Publisher Photocopying Permitted by License Only Laparoscopic Gynecology Procedures: Avoid the Risk

Laparoscopic approaches to gynecological surgery have been developed by an elite group of highly skilled surgeons. As these procedures become more prevalent in the general gynecological approach to disease and the general gynecologist' s approach to treatment, the complication rate for these procedures is likely to increase. In an effort to assist in avoiding these complications, guidelines for the performance of laparoscopic gynecological procedures need to be established. This article presents approaches to the most common gynecological procedures that can assist in the prevention of complications. INTRODUCTION A short review of the literature on the laparoscopic hysterectomy (1-19) revealed the following complications: bladder injuries including lacerations, punctures, vesicle-vaginal fistulas; ureteral injuries including ureterovesicle fistulas, ureteral transections, and cauterizations; bowel injuries including enterotomies, thermal injuries, and her-niations into trocar sites; nerve injuries; hemorrhage both intraoperative and postoperative, some requiring transfusion ; injuries to abdominal wall vessels and retroperi-toneal vessels; infections including pelvic abscesses requiring drainage, cellulitis, and pneumonia, with one postoperative case of pneumonia resulting in death; anesthetic problems including cardiac arrythmias and pulmonary edema; and vascular problems including deep venous thrombosis and pulmonary embolus. Of all the laparoscopic gynecological procedures, only the complication rate of the laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic hysterectomy has been studied and recorded. In one such study by Padial et al. (13) patients undergoing LAVH had a 10.6% frequency of febrile morbidity and no organ injuries or wound infections. Those having a vaginal hysterectomy during the same time frame experienced a 31% rate of febrile mor-157 bidity, with one instance each of a bladder and a bowel injury , and no wound infections. The women treated by abdominal hysterectomy experienced a 52% rate of febrile morbidity, with two instances each of bowel and bladder injury, two blood transfusions, and four wound infections. As our procedures improve and our surgical skills mature , the already low instance of complications with the laparoscopic approach to gynecological procedures can be expected to fall further. The purpose of this article is to provide the laparoscopic gynecological surgeon with techniques to minimize even further the complication rate.


plication rat
of the laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic hysterectomy has been studied and recorded.In one such study by Padial et al. (13) patients undergoing LAVH had a 10.6% frequency of febrile morbidity and no organ injuries or wound in- fections.Those having a vaginal hysterectomy during the same time frame experienced a 31% rate of febrile mor- Address for correspondence: James E. Carter, M.D., Ph.D., F.A.C.D.G., Woman's Health Center, 26732 Crown Valley #541, Mission Viejo, CA 92691.bidity, with one instance each of a bladder and a bowel in- jury, and no wound infections.The women treated by ab- dominal hysterectomy experienced a 52% rate of febrile morbidity, with two instances each of bowel and bladder injury, two blood transfusions, and four wound infections.

As our procedures improve and our surgical skills ma- ture, the already low instance of omplications with the laparoscopic approach to gynecological procedures can be expected to fall further.The purpose of this article is to provide the laparoscopic gynecological surgeon with techniques to minimize even further the complication rate.This article addresses the following areas: patient preparation; anesthesia considerations; patient position; insuf- flation and trocar placement; treatment of vascular pedicles; minimizing the risk ofbladder, bowel, and ureter injury; minimizing the risk of infection; and minimizing the risk of thromboembolic events.


PATIENT PREPARATION

Patient preparation should include careful counseling of the patients for the possibility of an open procedure as well as counseling on al of the risks of laparoscopic surgery (20)(21)(22)(23)(24)(25)(26)(27).

The patient should be instructed for all advanced la- paroscopic procedures and undergo a bowel cleansing pro- cedure with the use ofan osmotic agent such as GoLITELY (25,28).Prior to initiation of the procedure the patient J.E. CARTER should be given intravenous antibiotics such as cefotam (1 g) and metronidazole (500 mg) for infection prophylaxis.

Before using this protocol, the author experienced two vaginal cuff infections after LAVH.Since this protocol has been used, there have been no vaginal cuff infections in- 200 LAVHs.

The anesthesiologist should be instructed to

ace a na- sogastric
r orogastric tube for decompression ofthe stom- ach and should be instructed to avoid the use of nitrous oxide.A Foley catheter should be placed to empty the blad- der.In addition, the patient should not be plac d in the Trendelenberg position until the umbilical trocar has been placed (29,30).Fluid overload should be avoided as the process of operating under 15 mm Hg intra-abdominal pressure and a steep Trendelenberg position will reduce urine output, in spite of good hydration.The fluids should be warmed and the patient maintained at normal emper- ature throughout the procedure (3).The anesthesiologist should maintain vigilance for any activity that would in- dicate carbon dioxide embolism and should monitor the patient arefully for hypercapnea (32)(33)(34).

The patient should be positioned with the arms next to the sides to provide the surgeon with adequate working space and to avoid the possibility of injury from a hyperextended position at the shoulder.A nonskid pad should be placed under the patient, who should be placed on a non- electric table that can provide sufficient Trendelenberg po- sition for the surgical procedures to be performed.Regardless of the stirrup systems that will be used, great care must be exercised to ensure that no pressure is placed on nerve structures, especially the peroneal nerve.The legs should be carefully positioned so that excess stretch of nerves such as the femoral or sciatic nerves is avoided (3).Pneumatic compression boots shouldbe placed on the lower extremities and activated during the surgical pro edure.


INSUFFLATION AND TROCAR PLACEMENT Veress Needle Technique

Placement of the initial Verres needle puncture, direct tro- car puncture, or opening of the incision (if an open la- paroscopy is performed) should only occur after the surgeon has carefully cleaned the umbilical site for any remnant of contamination.This site is extremely difficult to clean and frequently must be approached with the use of a Kelly forceps to extract all material.Cellulitis can be avoided if this site is meticulously cleaned.The umbilical site is the preferred site for initial placement of either the Veress needle, direct puncture, or the open Hasson proce- dure for the first incision by most laparoscopic gynecologists (2,(36)(37)(38).

This site, however, has three major disadvantages.First, the transverse c

on will frequently lay directly under or even caudad to th
umbilical site.The second disadvantage is that the mesentery of the bowel also frequently lies di- rectly under the umbilical site.Finally, the aorta, vena cava, and especially the left common iliac vein are frequently in close proximity to, directly below, or caudad to the umbil- ical site.Therefore, when the intraumbilical incision is made (which is preferable to a subumbilical incision be- cause of the direction of the lines of Langham at the um- bilical site) the Veress needle must be inserted only millimeters through the fascia, which is elevated under ten- sion if the Veress needle is inserted in a vertical direction.If the Veress needle is inserted in a caudad direction, the skin should be elevated and the Veress needle inserted in a direction toward the uterus in the deep pelvis.This tech- nique will traverse fat, fascia, and peritoneum before entry.

If the Veress needle technique is used, the position ofthe Veress needle must be confimed by injection of 20 ml of normal saline and withdrawing the syringe.Any evidence of fluid return should be interpreted based on the color and odor of the fluid.Fluid return that is clear indicates that the Veress needle has not properly punctured the peritoneum.The Veress needle should be withdrawn and replaced.Fluid that is red in color indicates the possibility of a vascular in- jury and must be interpreted based on the color and amount of fluid.Fluid that is brown and has an odor obviously signifies puncture into the bowel, and the Veress needle in this case can be left in position and an optional trocar placement be performed so that the position of the puncture can be identified.An a ternate approach for this would be sim- ply to remove the Veress needle, appreciating the fact that frequently the bowel is very likely entered by the needle and, because of its size, is not subject to great injury as long as the needle is not moved randomly to increase the amount of the injury.This author prefers to leave the Veress nee- dle in place and evaluate the injured site if this occurs.The Veress needle can also enter the mesentery and create an emphysematous reaction in the mesentery of the bowel.The proper reaction after injection of the 20 ml of normal saline is to feel suction pressure against the syringe, indi- cating proper placement of the Veress needle.

The gas supply is then attached.It is advised to use a large bore tubing for placement of the gas as the resistance to flow of gas in a tube is inversely proportional to the fourth power of the radius of the tube.Doubling the ra- dius of the tube reduces the resistance to flow of the gas by a factor of 16.The pressure of insufflation should be monitored early in the introduction of the gas supply.If the Veress needle is properly positioned, the pressure noted on the gauge will be less than 6 mm Hg.If the pressure is >6 mm but <10 mm, it is possible that the Veress needle has found its way into the mesentery or into the bowel.If the pressure is > 10 mm, it is very possible that the Veress needle is, in fact, not in the peritoneal cavity.Flow rate at insufflation should be maint ined at liter/min flow until the anesthesiologist has advised that there is no evidence of intravascular insufflation.This author prefers to main- tain a low flow rate because of the ability of the body to recover from insufflation of CO2 into the vascular system as long as the flow rate is liter/min or less.

Direct puncture with the trocar has been evaluated and has been found to be equally as safe as Veress needle in- sufflation (37).It has the advantage of more rapid insuf- flation through a larger trocar site.When direct puncture is performed, it should not be performed in a vertical po- sition, but rather in a position toward the pelvis.Although frequently presented as a safer method of entry than di- rect puncture, the open Hasson approach has resulted in enterotomies when performed directly over adhesion areas.The open approach carries with it, however, the ad- vantage of avoiding intra-abdominal complications when adhesions do not exist such as laceration of vessels or puncture of the bowel (2).


Alternate Site for Veress Needle or Direct Puncture

The umbilical site for the initial entry should be avoided if the patient has had a p evious operation, either from a Pfannensteil incision or from a vertical incision (39,40).

The incidence of bowel adhesions in the region of the um- bilicus from these types of procedures can range from 20 to 40% (42).In addition, if a patient has had a previous umbilical hernia repair, the incidence of adhesions to this area is almost 100%.In this case the preferred site of entry is the Palmer site or equivalent right upper quadrant site.The Palmer point (left upper quadrant midclavicular line below the last rib) can be used for either direct puncture or placement of the Veress needle.It is advised by some that the placement of the needle or the trocar be in a 15 oo cephalad direction rather

han in a caudad direction (39).In either case, this
ite is preferable when lower abdomi- nal adhesions are present.By utilizing this site and be- coming familiar with it, the laparoscopic gynecological surgeon can avoid trocar in ury to bowel and laceration of vessels and adhesions and will find that the visualization, especially with the new three-chip cameras with high light sensitivity and the new 5-mm laparoscopes, is superb.tion of the inferior epigastric arteries and veins (17,24,30,43).Even in the most obese patients these ves- sels can usually be visualized because of their close prox- imity to the peritoneal surface as they cross in near proximity to the round ligament.Avoiding the inferior epigastric vessels is best accomplished for 12-mm trocars by placement of the trocars lateral to these vessels and lateral to the rectus sheath.By placing the trocars in this posi- tion, the vasculature of the rectus sheath is also avoided.The position of the circumflex artery and vein in the ab- dominal wall should also be noted.If the surgeon ap- proaches too closely to the pelvic bone, injuries to both the ileal inguinal and ileal femoral nerves as well as the superficial circumflex artery and vein are possible.A po- sition 2 cm cephalad to the anterior superior spine of ileum and at least to 2 cm lateral to the rectus sheath is usually well suited for placement of trocars.The direction ofpunc- ture initially should be straight vertically and then as the point is visualized at the peritoneal surface, the point can be reposititioned, aiming toward the deep pelvis.Smaller trocars, such as 5-mm trocars, can be placed safely me- dial to the inferior epigastric vessels through the rectus sheath.Regardless of trocar placement, lacerations of ves- sels in the abdominal wall will occur.All experienced sur- geons have encountered this difficulty and written extensively about its ramifications (17,24,30,43).These ramifications include unrecognized lacerations, which are tamponaded until the time ofpostoperative recovery when a patient becomes hypotensive; episodes wherein bleed- ing vessels cannot be controlled and laparotomy incisions are required; and episodes where bleeding vessels resulted in severe retroperitoneal hematomas.Laceration ofthe ab- dominal wall vasculature should never be ignored as these lacerations can result in morbid consequences.When they occur, the use of an emergency needle technique such as repair using the Carter-Thomason Needle-Point Suture Passer (44) or other equivalent devices such as the Semm emergency needle (31) can promptly control bleeding from these vessels.The use of bipolar energy, while at- tractive, may not be sufficient to occlude the vessel as episodes of severe hemorrhaging after the attempted con- trol by bipolar cautery of the inferior epigastric vessels may occur.

If abdominal wall vessels are lacerated, both the cau- dad and cephalad portions should be ligated to ensure com- plete control.


Sites for Accessory Trocars

The next step for the laparoscopist to avoid complications is to properly choose the sites for the accessory trocars.

All laparoscopists should now be familiar with the posi- Avoid the Use of Insulated Screw Grip Devices

The surgeon should take care to follow the "Rule of Threes" in utilizing electrosurgical instruments through the ports that have been established (45).This rule states J.E. CARTER that a conductor inside an insulator inside a conductor next to the skin is safe because the energy that is capacitively coupled is dissipated to the skin (for example, unipolar scissors inside its insulating sheath inside a metal con- ductor trocar sheath next to t e skin is safe).Screw grips should be avoided as these can result in much larger portal sizes, sometimes enlarging a 5-mm por al to almost 10 mm and a 10-mm portal to almost 15 mm in size.In ad- dition, they carry the risk ofviolation ofthe Rule ofThrees, because most screw grips are of insulated material.The surgeon should avo

placing an insulated conducting in- strument
nside a metal carrier that is in place through an insulated screw grip.Such a situation can occur if a monopolar cautery device is placed through an operating laparoscope, which is passed through a cannula separated from the skin by an insulating screw grip.It can also occur if an operating monopolar instrument is place through a metal irrigation suction cannula, which is placed also through an insulating sleeve (46,47).In these configura- tions, the possibility of capacitive coupling exists, and in- jury can occur as a result of discharge of energy from the suction cannula or the operating scope to a piece of bowel in close proximity.


PATIENT POSITION

The surgeon is prepared now to begin the operation, and the patient can be placed in the Trendelenberg position and the instruments introduced for performance of the in- tended procedure.A Foley catheter should have been place before initiation of the first incision, draining the bladder well.With all instruments now in place, to minimize com- plications one must consider the individual procedures to be performed.

hesion should be carefully visualized to ensure that in fact this is not a hernia formation with bowel being involved.

Once these steps have been taken, the adhesion should be placed on traction and treated depending on its level of vascularity and thickness.


Thin adhesions

Thin adhesions can be treated by sharp dissection with cre- ation of windows and the use of very gently appl

d bipo- lar energ
for cauterization and scissors dissection (51-53).In addition, bipolar scissors can be utilized for this type of adhesion.Bipolar cutting can be used as well for this type of adhesion.Laser energy can be utilized, but the use of laser-beamed energy such as CO2 should be carefully backstopped because of the possibility of past pointing through thin adhesions (54-56).

Thick adhesions Thicker adhesions require tra tion, the creation of win- dows, and great care to ensure that the vessels internal to the adhesion are cauterized befo e cutting.This can be dif- ficult because these adhesions can contain a great deal of fat.Because of this, the use of unipolar energy should

avoided as the
fat is not a good cartier of the thermal en- ergy required to control the vessel.The vessel should be isolated to the greatest extent possible and either treated mechanically with clips or carefully cauterized with bipo- lar cautery (57,58).If large portions of the adhesion as grasped with bipolar cautery, the surgeon must be aware that thermal energy can spread from the heat sink and the fat tissue can become very hot in the process of being cau- terized (51).Once control of the vasculature has been o - tained, the adhesion can then be cut.Great care must be exercised to place traction on the adhesion such that the traction does not pull on the bowel itself.Cutting should be away from the bowel surface.


AVOID COMPLICATIONS OF PROCEDURES


Adhesiolysis

The major dangers of adhesiolysis are 3-fold: 1) loss of control of a vascular portion of the adhesion; 2) injury to an adjacent structure near the adhesion such as bowel; and 3) injury to a structure not visualized because the adhe- sion obscures the view (28,48,49).

The first principle for adhesiolysis is to have complete visualization of the extent of the adhesion.Therefore, it is of benefit to place the visualizing laparoscope in different positions in the pelvis to obtain a complete view circum- ferentially of the adhesion (50).In this manner, the possi- bility of bowel being entrapped into the adhesion is appreciated.In addition, the point of attachment of the ad- Enterolysis If adhesions exist between loops of bowel, gynecologists should feel comfortable in

lling for general surgical as- sistance for thi
delicate type of procedure and should avoid the use of any form of electrical or thermal energy in these regions.Bowel-to-bowel adhesions are best treated by first separation and then observation and lim- ited bipolar cauterization of tendrils of vessels if neces- sary.If unipolar current is applied in bowel-to-bowel adhesions, remember that the current must pass from the instrument through one ofthe loops ofbowel and can cause thermal damage.Use short bursts of concentrated energy to avoid complications with unipolar energy (52).The blanching of bowel is indicative of deep injury that must be treated by suture control or even excision of the dam- aged bowel.In gener

, a carboniz
d appearance is indicative of a very superficial fulguration energy and may require oversewing and observation.The liberal use of clips is an appropriate approach to treatment of bowel-to- bowel adhesions to avoid risks of other energy sources.

Any site of bowel surgery should be carefully investigated and if an opening of bowel is found, a simple technique of repair is to exteriorize that section of the bowel, over- sew and repair it, and place it back into the abdominal cav- ity.Only then return to the original surgery.Liberal use of surgical consultation by gynecologists can avoid serious postoperative complications.Adhesiolysis should be car- fled out before the initiation of any of the additional procedures planned as the most critical principle of laparoscopic surgery is to maintain a clear complete field of view for the surgery to be performed (28,(59)(60)(61).

Adnexal Surgery To minimize the complications ofadnexal surgery, be aware that the most frequent complications involve hemorrhage from the vessels and damage to the ureter.In addition, spill from a possibly malignant tumor of the ovary and s ill of a caustic substance from a dermoid cyst can lead to severe complications.To minimize the risk ofthese complications, the following principles should be applied (62)(63)(64)(65)(66)(67)(68)(69)(70)(71)(72)(73).

Isolate the vascularpedicle First, the vascular pedicle of the ovary should be identi- fied and, if possible, a window created to isolate the in- fundibulopelvic ligament.Then suture ligature can be passed, and an extracorporeal knot applied.An endoloop is then inserted, the vessel is grasped and cut, and the en- doloop is placed on the vessel to control the infundibu- lopelvic ligament with two suture ligatures

40).

The second
approach to the infundibulopelvic ligament is to create a window and place the linear stapler through the window across the infundibulopelvic ligament.If this procedure is applied, great care must be taken to ensure that the vessel, when crimped within the linear stapler, does not bunch against the tissue guard, thereby present- ing a situation where the staples to be placed through the infundibulopelvic ligament are too few in number to con trol the vessel.The staple line should be carefully exam- ined after the cut has been applied to ensure that the staple line is hemostatic.Gentle application of bipolar current to the staple line can ensure that no retroperitoneal hematoma forms later.Any staple line or suture line should be ex- amined after removal of pressure and underwater to en- sure that no leak or hematoma formation is visualized (74).

A hird technique for the infundibulopelvic ligament again involves isolation of the vessel by creation of win- dows and use of bipolar energy to desiccate/coagulate the vessel.If this technique is used, it is advisable to apply 25 to 30 watts in intermittent bursts.For thicker vessels, it may be necessary to incise into the coagulated area and then reapply the coagulation until the entire vessel has been coagulated and cut.By applying the bipolar energy intermittently, we avoid the problem of carbonization and charring, which results in sticking of the bipolar tines to the tissues and initiating bleeding.

All of these techniques have been used with great suc- cess to control the infundibulopelvic ligament.With each of them there have been complications.With application of the staplers there has been the complication of retroperi- toneal hemorrhage and b eeding from the incompletely sta- pled artery.Underwater examination and care with use of bipolar energy behind the staple line in the event of a vi- sualized bleeding area is essential.With the use of bipolar cautery bleeding has occurred as well as injury to the ureter.To avoid this, ensure that the ureter has been identified and place traction on the ovary in an upward direction and somewhat toward the pelvis to ensure that the infundibu- lopelvic ligament is as far away as possible from the ureter at the point of application of the bipolar energy.In addi- tion, apply short bursts of energy and evaluate f r coagulation by visualization during the procedure.The creation of a window also was to avoid damage to the ureter.


Ovarian Cystectomies

Ovarian cystectomy can be performed safely by laparoscopic procedures.However, it is most important that the contents of the ovarian cyst not be leaked if there is evi- dence of any possibility of ovarian cancer.In addition, the contents of dermoid cysts can, if spilled, lead to chemical peritonitis and adhesion formation.The recommended procedure is to perform an excision of the cyst while the ovary is placed inside of a pouchor bag-like structure, and then to remove the cyst intact inside such a bag.While the cyst is in the bag it can be ruptured as long as the fluid is completely contained within the bag.The base of the ovary where the cyst has been removed is frequently best treated by laparoscopic fulguration using spray coagula- tion or argon beam coagulation.Superficial bipolar energy or deep monopolar energy can be used

r bleeding from the o
arian tissue.Suturing is not recommended because of adhesion formation.


Laparoscopic Burch Procedure

Complications can be avoided during a laparoscopic transperitoneal Burch procedure by ensuring that the ini- tial peritoneal incision is made at least 2 cm above the point of insertion of the bladder into the anterior abdom-J.E.CARTER inal wall and by ensuring that the bladder dissection is car- ried out to as great an extent possible by blunt dissection.Careful dissection of the paravaginal area over the operator's finger will ensure that the bladder is moved well away from the point of insertion of the sutures when they are placed.There is danger of suture placement into the sub- stance of the bladder itself, or if staples are used, they can be inadvertently placed into the bladder.It is important that cystoscopy be performed after laparoscopic bladder suspension to ensure that no evidence of bladder injury exists.Any evi

nce of blanching on the inter
or bladder mucosa requires identification of the point of injury by the energy source and long-term drainage for to 3 weeks until the bladder has repaired.In addition, oversewing of the external area ofbladder may be required to ensure com- plete healing.This can be performed laparoscopically.


Complications of LAVH

During the performance of this procedure the greatest likelihood of damage to the ureter in the ureteric canal exists.The reason for this is the close proximity of the ureter to the uterine artery at the point where the ureter crosses under the uterine artery where there are only 2 cm on average of distance.Any retroperitoneal fibrosis, en- dometriosis, or scarfing can cause traction on the ureter and bring it much closer to the uterine artery than sus- pected by the surgeon.For this reason, the application of bipolar energy, sutures, or staples in the region of the ureteric canal must be avoided.The ureter must be care- fully dissected and identified and all energy sources ap- plied to the uterine artery after careful dissection and identification of the ureter.In spite of efforts to identify the ureter, it has been stapled, cauteri

d, and sutured.The bes
way to avoid damage to the ureter is to avoid the ureter entirely, which for most surgeons may involve stop- ping their dissection above the point of the insertion of the uterine artery into the uterus commonly refered to as the ascending branch of the uterine artery.The use of ureteric stents also assists in identification of the ureter and new developments of lighted stents may make visu- alizing the ureter easier for the laparoscopic surgeon (6,7,8,9,12,15,25,27,76,78).


Treatment and Resection of Endometriosis

The most common procedure in which bowel injuries occur is the resection of endometriosis from the recto- vaginal septum in the obliterated cul-de-sac (79-81).When one suspects that surgery in this region will be performed, a bowel preparation should be provided preoper- atively for the patient.These bowel injuries can be repaired laparoscopically with standard techniques as long as the bowel is cleaned preoperatively.If it is necessary to re- move a portion of bowel in a disk excision, this can be re- moved and repaired.Excision of endometriotic tissue in the region of the uterosacral ligaments and of the recto- vaginal septum requires great care and preoperative iden- tification of the ureters.In addition, the placement of both vaginal and rectal probes can help identify planes of dis- section.If the ureter

nnot be identified and planes ofdis- sect
on cannot be identified, an open procedure may be of great benefit to both the patient and the surgeon.


Laparoscopic Tubal Surgery Including Ectopic Pregnancy

Treatment of ectopic pregnancies by laparoscopy has be- come very routine.The injection of the mesosalpinx with vasopressin solution must be performed carefully as the toxic effects of vasopressin have been documented.A very dilute solution of vasopressin should be utilized in this procedure, -1 U to 40 ml of normal saline.The most serious complication aside from hemorrhage from the tubal structure itself is retention of products of conception from the laparoscopic procedure.This usually oc- curs in the proximal section of the tube, and, therefore, careful flushing of the tube, evaluation of the proximal segments, and monitoring of the patient postoperatively with quantitative human chorionic gonadotropin are es- sential (82).


EXITING THE ABDOMEN

Once the surgical procedure has been perfo med, it is nec- essary to exit the abdomen.Exiting the abdomen is best performed by first removing all gas and evaluating the pelvis after installation of to 2 liters of normal saline or lactated Ringer's solution.Any areas of bleeding should be carefully controlled as these may result in a larger amount of bleeding postoperatively (83)(84)(85)(86)(87)(88).All tissue should be evaluated, and the areas should be cleaned care- fully.An underwater examination should be carried out in a clear field.If there is any question of potential damage to the bowel, then it should be evaluated by the placement of a sigmoidoscope and the placement ofair into the bowel lumen, and evaluation underwater to ensure that there is no gas leakage from the bowel (79).If an operation has been performed c

se to the bladder or
the ureters, the blad- der should be evaluated with cystoscopy and the bladder also be fill with 250 ml of methylene blue to evaluate for any leakage areas.If there is any suspicion of damage to the ureter, the integrity of the ureter can be checked by evaluating for the passage of indigo carmine from the ureters at the ureteric orifices while performing cystoscopy.Urological consults should be obtained if there is a question of damage to the ureters during the surgery Unrecognized damage to the bowel can be a lethal com- plication (28).In 66 cases of bowel injury, 13 cases were of large bowel damage and 53 were of small bowel dam- age.These were cases in which bowel injury occurred but was not recognized at the time of surgery.The bowel can be perforated without obvious leakage of contents.To avoid this risk, severe intra-abdominal adhesions, particularly those involving the small bowel, should only be dealt with when the patient has been adequately prepared and the surgeon has appropriate experience.

The site of any divided adhesions should be carefully inspected.After all laparoscopic surgery, the surgeon should maintain a high index of suspicion of the possibility of bowel perforation.In these 66 cases of unrecognized injury, three patients died, all of whom had a delay in di- agnosis of more than 72 hours.A y patient with increas- ing pain and malaise after laparoscopic surgery should be assumed to have a perforated viscus until proven other- wise (28).

At this point, after complete evaluation of all surgical sites has been performed, the surgeon is prepared to exit the abdomen.This author finds it helpful to place into the peritoneal cavity 20 ml of0.25% Marcain for relief ofpain and to remove all CO2 gas that has been insufflated.In ad- dition, all trocar sites are injected with 0.25% Marcain.

The pain from a bowel injury would remain af er the Marcain effect has resolved.This author has found fewer complaints ofshoulder pain and incisional pain since using this regimen and less abdominal pain.

The trocar sites of 10 mm and larger instruments should be sutured closed using techniques that allow the closure of both the fascia and the peritoneum (89)(90)(91)(92)(93)(94)(95)(96)(97)(98)(99)(100)(101)(102)(103)(104)(105)(106)(107)(108).For this purpose, the Carter-Thomason Fascial Closure Devic or an equivalent instrument should be utilized.Herniation into port sites can occur in as many as 3% of 12-mm port sites in lateral positions which are not closed and in 0.3% of those which have been closed by standard techniques that did not include closure of the peritoneum as well as the fascia (26).

All instruments should be removed under di ect vision and all sites 10 mm and larger closed under direct vision.The umbilical site can be closed by an alternative method offigure-of-eight 0 Vicryl suture using a UR-6 needle.The skin incisions should be irrigated carefully with an an- tibiotic solution and then closed in the method preferred by the surgeon.We use a 3-0 nylon which is removed 1 to 2 days after surgery, and the wound closure is reinforced with Steri-Strips.

Postoperatively, the patient's hemoglobin is evaluated in the recovery room to ensure that no vascular compro- mise has occurred.


FINAL REMARKS

Remember that the most common laparoscopic compli- cations are generally vascular.The most common cata- strophic vascular complications are those that occur at the initiation of the procedure such as placement of a trocar through the ao ta.In two cases in which this was reported, the patient survived, but only after the placement of the aortic grafts (83).

The surgeon must also remember that bowel injuries may take from 3 to 7 days to manifest themselves, and re- turn visits of the patients to the surgeon between days 3 and 6 are mandatory to ensure proper follow-up with those patients.Patients should be instructed that any increase in abdominal pain should be evaluated immediately.The pain experienced a ter laparoscopic surgery should not be as- sumed to be related to retention of CO2 gas and di- aphragmatic irritation until the

tient has been
personally evaluated by her operating surgeon (28,109,110).

In 127 advanced gynecological laparoscopic proce- dures reviewed for complications at a community hospital, significant complications were associated with oophorectomy, ovarian cystectomy, myomectomy, pelvic lysis of adhesions, and laparoscopic-assisted vaginal hysterectomy (111).In addition, 10 hysteroscopic proce- dures were also performed.Uterine perforation occurred in 8% of the hysteroscopic procedures, and there were four postoperative infections in the hysteroscopic group.The patient with the most severe case of hyponatremia had a serum sodium level of 125 mEq/1.

In this study (111), laparoscopic management ofectopic pregnancy resulted in 13% complications.Salpingectomy and paraovarian cystectomy was performed in 11 patients, and there were no complications.Translaparoscopic ad- nexal surgery, including ovarian cystectomy, oophorect my, and salpingo-oophorectomy, as performed in 30 patients, and there were complications in 5 patients 17%).The complications included problems with the stapling de- vice, unplanned hospitalization for fever and ileus, tubo- ovarian abscess, difficulty retrieving the ovary, and abdominal wall hematoma (111).

Translaparoscopic myomectomy was performed in 16 patients, (111), with 5 ofthem having complications (31%).These includes requiring a minilaparotomy to remove a fi- broid, requiring an abdominal approach to complete the pro- cedure, and having difficulty with the co potomy incision, as well as one lost fibroid.LAVH was performed on 15 pa- tients, and there were complications in 9 (60%), including excess blood loss in 8 (mean 767 ml), entering the bladder, and febrile morbidity.Pelviscopic lysis of adhesions was performed on 9 patients, and there was a 55% complication rate (5 patients).Complications included bleeding from a secondary trocar site, excess blood loss, fluid imbalance, transfusion, unplanned hospitalization, general surgical consultation, and an intraoperative intravenous pyleogram.Those who perform a large number of laparos opic procedures may be surprised at these results, but these are the types ofcomplications that can occur as more and more sur- geons begin to approach laparoscopic surgery without, per- haps, proper credentialling or training (111).

During all operative laparoscopic procedures, if lasers operated by beams are used, they should be back stopped.

If electrosurgical instruments are used, bipolar electro- surgery is safer, because the current passes only from one conductor plate to another directly in view from the oper- ator.When unipolar cautery is used, the ultimate safety in electrost/rgery can be only achieved by active shielding.All instruments should be actively shielded.The active shield leads all capacitively coupled energy back to the surgical unit and detects any energy derived from direct coupling.In the case of direct coupling, the monitor will order the electrosurgical unit to shut down (45).

Remember that the main causes of electrosurgical in- juries are inadvertent touching and grasping of tissue dur- ing current application, direct coupling between a portion of intestine and a metal probe that is touching the activated probe, insulation breaks in the electrode , direct sparking to the intestine from the active probe, and current passage to the intestine from recently coagulated, electrically iso- lated tissue (45).
 
Laparoscopically assisted vaginal hysterectomy in the university hospital: Report of 82 cases in comparison with abdominal and vaginal hysterectomy. G M Boike, Am J Obstet Gynecol. 61993

Experience with laparoscopic hysterectomy. H M Hasson, C Rotman, N Rana, J Am Assoc Gynecol Laparosc. 11993

An operative technique for laparoscopic hysterectomy using a retroperitoneal approach. N Kadar, J Am Assoc Gyeco Laparosc. 141994

Laparoscopic hysterectomy: Initial experience. A Langebrekke, O J Skar, A Urnes, Acta Obstet Gynecol Scand. 711992

Complications of total laparoscopic hysterectomy in 518 cases. C Y Liu, H Reich, Gynecol Endosc. 31994

Laparoscopic hysterectomy. A review of 72 cases. C Y Liu, J Reprod Med. 371992

Laparoscopic hysterectomy. C Y Liu, Gynaecol Endosc. 11992Report of 215 cases

Supracervical laparoscopic hys