Gynecologic laparoscopy is used for both diagnostic and therapeutic purposes.
Indications for laparoscopy are listed in Table
109-2. Laparoscopy is almost always an ambulatory surgical
procedure and is performed under general anesthesia with endotracheal
Table 109-2 Common Indications
for Laparoscopy |Favorite Table|Download (.pdf)
Table 109-2 Common Indications
|Lysis of adhesions|
|co2 laser ablation of endometriosis|
|Uterine surgery (including myomectomy)|
|Tubal surgeries (including salpingectomy)|
|Ovarian surgery (including oophorectomy and oophorocystectomy)|
|Paraovarian cyst excision|
|Laparoscopic vaginal hysterectomy retropubic urethropexy|
The most common surgical procedure in the U.S. is female sterilization. More
than 60% of these procedures are performed laparoscopically, and the
complication rate is 1.6 per 100 procedures.3 The
incidence of major complications in the U.S. for laparoscopy overall
may be as low as 0.22%.4–7 Data
suggest that an overall complication rate for operative gynecologic laparoscopy
my be <1% and is improved by surgical experience.8
Both diagnostic and therapeutic gynecologic laparoscopy are accomplished
by passing a rigid endoscope through a trocar that is inserted bluntly
through a small infraumbilical incision into the abdominal cavity after
a Veress needle has been used to insufflate the abdomen with CO2. The
pneumoperitoneum must be sufficient to displace the bowel and is maintained
throughout the surgery. Additional trocars can be placed so that
other accessories can be used during the surgery.
All laparoscopic procedures entail the same potential complications,
but more complex surgeries carry considerably more risk. Approximately half
of all complications are related to the installation of laparoscopy, though
some studies show that open laparoscopy may be safer.7,9 The overall
incidence of complications in major operative laparoscopy is significantly
less than that of major gynecologic surgery performed through abdominal
incisions, although data related to the two approaches are not directly
comparable because of other factors that may mandate a traditional
The major complications associated with laparoscopy are listed
in Table 109-3.
Table 109-3 Major Complications
Associated with Laparoscopy |Favorite Table|Download (.pdf)
Table 109-3 Major Complications
Associated with Laparoscopy
|Thermal injury of the bowel|
|Perforation of viscus|
|Ureteral or bladder injuries|
Although many significant complications of laparoscopy are recognized in
the operating room under direct visualization, patients with thermal injury may
not develop symptoms for several days and up to several weeks postoperatively.
The incidence of electrothermal injuries is in the range of 0.5
to 3.2 per 1000 cases.5–7 Patient presentations
include bilateral lower quadrant pain and tenderness, fever, elevated
white blood cell count, and peritonitis. Plain radiographs may show
an ileus or free air under the diaphragm. Patients with greater
than expected pain after laparoscopy should be considered to have
a bowel injury until proven otherwise. Early gynecologic
consult is critical if a thermal injury is suspected.
Traumatic injury to the bowel is usually less serious than thermal
injury. The small diameter Veress needle is usually the cause of
a bowel perforation, which is recognized on withdrawal of the needle.
A sharp trocar may cause more damage, though most operations are
now performed with a blunt trocar. Gastric perforation can occur,
usually due to stomach distention from aerophagia or as a result
of a difficult intubation. The large or small bowel can also be
perforated. These injuries are usually noted during the operation.
On rare occasions, perforation occurs through a single loop of bowel
adherent to the anterior abdominal wall. Complications include peritonitis,
abscess, enterocutaneous fistula, and septic shock.
Vascular injury occurs at a rate of 0.1 to 6.4 per 1000 cases.5–7 Although such
injuries can be immediately life-threatening, they are almost universally
recognized during the operation. Patients may later present with a
postoperative hematoma. Local compression, if feasible, is the initial treatment.
If the mass enlarges or signs of hypovolemia occur, the wound must
be explored by the gynecologist.
Bladder and ureteral injuries can occur from either mechanical
or thermal trauma. Trocar or dissection injuries to the bladder
are typically recognized intraoperatively. Thermal injuries, however,
may not be initially apparent and may present with peritonitis or fistula.
The diagnosis of a ureteral injury is usually delayed. Thermal injury
may present up to 14 days postoperatively with abdominal or flank
pain, fever, and peritonitis. White blood cell count may be elevated.
An IV pyelogram (IVP) or CT scan shows extravasation of urine or
a urinoma. Mechanical obstruction of the ureter from sutures or
staples may be recognized intraoperatively by direct visualization,
but may present up to 1 week postoperatively with fever and flank
pain. An IVP or a CT scan of the abdomen and pelvis helps define
the site and degree of obstruction.
Incisional hernias and dehiscence are rare complications after
laparoscopy. Incisional hernias are more common when defects >10
mm are made and can develop within the first postoperative week.
Patients may be asymptomatic or they may note pain, fever, mass,
evisceration, or signs and symptoms of a mechanical bowel obstruction.
Fever may present if the bowel is incarcerated, and peritonitis
may develop after bowel perforation.
Dehiscence usually involves protrusion of the omentum, and, in
rare cases, the small bowel. Immediate incisional repair by a gynecologist
is usually sufficient; however, a laparotomy may be necessary if
the bowel is incarcerated or perforation is a risk.
Wound infection after laparoscopy is uncommon and, often, not
a serious complication. Most are minor skin infections that can
be managed with oral antibiotics or with drainage. The risk of infection
after laparoscopy is much lower than after abdominal or vaginal
surgery. Excluding minor skin infections, pelvic infection is reported
in <1 in 1000 cases. Pelvic cellulitis and abscess can occur,
and severe necrotizing fasciitis, while rare, has been reported.
Most infections are probably secondary to a subacute coexisting
infection present before the procedure or secondary to skin contamination.
Broad-spectrum antibiotics typically provide a rapid response.
Hysteroscopy is the direct visualization of the uterine cavity
using a rigid or flexible fiberoptic instrument. Hysteroscopy can
be done as an office procedure under IV sedation or in an operating
room under general anesthesia, spinal or epidural anesthesia, or
IV sedation. Hysteroscopy is done for both diagnostic and therapeutic
purposes. Complications occur more frequently as a result of operative
hysteroscopy than diagnostic hysteroscopy.
The most common indication for hysteroscopy is abnormal vaginal bleeding.
Other indications include uterine leiomyomata, intrauterine adhesions,
proximal tubal obstruction, removal of intrauterine devices, müllerian
anomalies, and infertility evaluation. Therapeutic applications include
directed biopsies, removal of small myomata or polyps, and endometrial
ablation for menorrhagia.
Complications of hysteroscopy occur in <1% of cases11 (Table 109-4). Fluid overload is rare but
can occur from absorption of electrolyte and nonelectrolyte solutions
injected into the uterus during lengthy procedures. The entry of
dextran into the circulation can lead to pulmonary edema and disseminated
intravascular coagulation. For this reason, no more than 500 mL
of dextran should be used during a procedure.11 A lack
of recovery of distention medium in excess of 1000 mL also places the
patient at risk for fluid overload. If fluid overload is suspected,
hyponatremia is likely. Therapy to decrease the serum sodium level
may prevent generalized cerebral edema, seizures, and death (see Chapter 21, Fluids and Electrolytes).
Table 109-4 Complications
Associated with Hysteroscopy |Favorite Table|Download (.pdf)
Table 109-4 Complications
Associated with Hysteroscopy
|Toxic shock syndrome|
Uterine perforation occurs in 0.7% to 0.8% of
cases.11 Midline uterine perforation generally
does not have significant sequelae. Lateral perforation can lacerate
uterine vessels and cause substantial bleeding. Most often, the
perforation is noted at the time of surgery, and a laparoscopy is done
to investigate for bleeding and/or damage to bowel or bladder.
If the complication is not noted at the time of surgery, the patient
may present with peritoneal signs.
Infection is very rare and most commonly occurs in patients with
concurrent genital tract infections. Endometritis or even toxic shock can
Postoperative bleeding can be uterine or cervical in origin.
Cervical lacerations are caused by forceful dilation or tears from
the tenaculum. Uterine bleeding can result from resection procedures.
After hemodynamic stabilization of the patient, the gynecologist
may choose to tamponade the bleeding by placing a Foley or balloon
catheter into the uterine cavity. The catheter is then filled with
approximately 10 to 15 mL of water or saline solution. One half
of the fluid is removed from the balloon after 1 hour and the other
half after 2 hours. If bleeding remains stopped, the patient can
usually be discharged. If bleeding persists, the patient should
be admitted. In this case, the catheter is reinflated and left overnight.
Occasionally reexploration is required. Vasopressin and misoprostol are
alternative treatments. As a last resort, embolization of the uterine
artery or hysterectomy is performed.
Embolism is the most feared complication of using co2 gas
as a distention medium for laparoscopy. The risk of occurrence is
low when the principles of low flow and low pressure are followed.
This complication is likely to occur during the procedure. Treatment
includes positioning in the Trendelenburg position or left lateral
decubitus and resuscitative measures. Aspiration of gas and treatment
in a hyperbaric chamber has been described.12 Patients
with gas or air embolism require admission to an intensive care