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Diagnostic Laparoscopy
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Diagnostic laparoscopy provides a minimally invasive surgery (MIS) option for thorough evaluation of the peritoneal cavity and pelvic organs. It is often performed to evaluate pelvic pain or causes of infertility, to diagnose endometriosis, or to ascertain the extent of adhesive disease or qualities of a pelvic mass. Importantly, systematic evaluation of the peritoneal cavity is performed during every laparoscopy, either diagnostic or operative.
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During the consenting process for diagnostic laparoscopy, a surgeon reviews procedure goals, including diagnosis and possible treatment of identified pathology. Among, others, this includes permission for lysis of adhesions, peritoneal biopsy, and excision or ablation of endometriosis. Importantly, a patient is counseled that diagnostic laparoscopy may not reveal any apparent pathology.
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Laparoscopy is typically associated with few complications. Of these, organ injuries caused by puncture or by electrosurgery tools are the most common major complications and are summarized in Chapter 41. Patients are also counseled regarding possible need to complete the diagnostic evaluation via laparotomy. Reasons for conversion during diagnostic laparoscopy include failure to gain abdominal access, organ injury during entry, or extensive adhesions. Overall, the conversion risk to laparotomy is low and approximates 5 percent.
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In general, laparoscopy is associated with lower rates of postoperative infection and venous thromboembolism (VTE) compared with laparotomy. For diagnostic laparoscopy, antibiotics are typically not required, and VTE prophylaxis is implemented for those with risk factors (Table 39-8). In addition, for most patients, bowel preparation is not administered. However, if extensive adhesiolysis is anticipated and the risk of bowel injury is thereby increased, bowel preparation can be considered.
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Several instruments are especially helpful during diagnostic laparoscopy, and most are found in a standard laparoscopy instrument set. Of these, a blunt probe and atraumatic grasper are valuable to manipulate abdominal organs. A uterine manipulator that allows for chromopertubation is also considered if performing diagnostic laparoscopy for infertility evaluation. If this is planned, indigo carmine dye or methylene blue can be diluted and used. However, current indigo carmine shortages may favor methylene blue use. Either agent is diluted into 50 to 100 mL of sterile saline for injection through the cervical cannula.
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Anesthesia and Patient Positioning
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Most laparoscopic surgery is performed in an operating room and requires general anesthesia. Much less commonly, in-office microlaparoscopy using 2- to 3-mm microlaparoscopes has been reported for second-look evaluation of cancer treatment, sterilization, and pelvic pain and infertility evaluation (Franchi, 2000; Mazdisnian, 2002; Mercorio, 2008; Palter, 1999).
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In most cases, following anesthesia induction, the patient is placed in low dorsal lithotomy position in booted support stirrups to permit manipulation of the uterus. The patient’s ...