CHAPTER 44: Minimally Invasive Surgery

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.

PREOPERATIVE

Consent

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.

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.

Patient Preparation

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.

INTRAOPERATIVE

Instruments

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.

Surgical Steps

Anesthesia and Patient Positioning

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).

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 arms are tucked at her sides. Correct patient positioning is critical to avoid nerve injury and is discussed in Chapter 41. A bimanual examination is completed to determine uterine inclination. Inclination will direct positioning of the uterine manipulator, if used. The vagina and abdomen are surgically prepared, and the bladder is drained. If a longer procedure is anticipated, a Foley catheter may be required as a full bladder can obstruct the operating view or increase the risk of bladder injury.

Uterine Manipulator Placement

Although not mandatory, a uterine manipulator may be placed to move the uterus during evaluation of the pelvis. Examples are shown in Chapter 41. For manipulator placement, a surgeon is gowned and doubly gloved. A Graves speculum or vaginal retractors are used to display the cervix. To stabilize the cervix, a single-tooth tenaculum is placed on the anterior cervical lip. A Cohen or other uterine manipulator is then inserted into the external os. Alternatively, after measurement of the uterine cavity with a uterine sound, the balloon end of an endometrial cavity manipulator may be threaded into the endometrial cavity, and the balloon inflated. The outer pair of surgical gloves is removed, and the surgeon moves to either side of the patient.

Primary Trocar Entry

Abdominal access may be attained by any of the four basic techniques described in Chapter 41. These include Veress needle insertion, direct trocar insertion, optical-access insertion, or open entry methods. For diagnostic laparoscopy, no one method is superior to the others. The umbilicus is usually chosen as the site for abdominal entry. However, if a patient’s history suggests periumbilical adhesions, then entry at Palmer point may be preferred. A 5-mm or 10-mm umbilical port will house a suitable laparoscope for diagnostic examination. Generally, starting with a 5-mm incision and laparoscope will allow for adequate visualization of the abdominopelvic cavity. Should improved optics be desired, this can be easily changed to a 10-mm size. Once safe initial entry is confirmed, the abdomen is insufflated to reach an intraabdominal pressure of 15 mm Hg or less.

Additional Port Site Selection

Often during diagnostic laparoscopy, additional operative cannulas are needed. If minimal tissue manipulation is required, a suprapubic port may suffice. However, bilateral lower quadrant ports may be desired if lysis of adhesions or greater tissue manipulation is required. These are placed under direct laparoscopic visualization as described in Chapter 41.

Upper Abdomen Evaluation

All laparoscopic procedures begin with a systematic and thorough diagnostic inspection of the entire peritoneal cavity, including the pelvis and upper abdomen. Once safe initial entry is confirmed, the area directly below the primary trocar entry site is evaluated for bleeding or other signs of entry trauma. Prior to Trendelenburg positioning, the upper abdomen is examined. Specifically, the liver surface, gallbladder, falciform ligament, stomach, omentum, and right and left hemidiaphragms are inspected. The ascending, transverse, and descending colon are also viewed. During inspection of the ascending portion, the appendix is identified. After Trendelenburg positioning, bowel and omentum fall toward the upper abdomen to expose the retroperitoneal structures. Now free of intestines, the area directly beneath the initial entry site is examined again. Previously unappreciated trauma to this area from initial abdominal entry might then be seen.

Examination of Pelvis

After examination of the upper abdomen, attention is turned to the pelvis. First, the uterus is retroflexed with the aid of the uterine manipulator to provide clear viewing of the anterior cul-de-sac. Then, the manipulator tilts the uterus up and to the right to permit left pelvic sidewall inspection. The uterus is then anteflexed to provide access to the posterior cul-de-sac. Last, the uterus is tilted to the left, and the right pelvic sidewall is viewed. Peritoneal surfaces are thereby sequentially and methodically inspected. During this, endometriotic implants, peritoneal defects or windows, adhesions, fibrosis, or studding concerning for malignancy are sought.

Next, both ureters are visualized coursing from the pelvic brim, along the pelvic sidewall, and to the cervix. Both peristalsis and caliber are assessed. Uterine size, shape, and texture are also noted. To examine both fallopian tubes and ovaries, a surgeon may place a blunt probe into the cul-de-sac and sweep the probe forward and laterally. In doing so, the tubes and ovaries are lifted from the posterior cul-de-sac or ovarian fossa for inspection.

Indicated Laparoscopic Procedures

After visual assessment of the pathology found, indicated procedures are then performed. If adhesions are encountered, they may be divided as described in Chapter 41.

Abdomen Deflation and Port Re‑moval

At laparoscopy completion, carbon dioxide (CO₂) insufflation is halted, and the gas tubing is disconnected from the primary cannula. The gas ports on all cannulas are opened to deflate the abdominal cavity. To prevent diaphragmatic irritation from retained CO₂, manual pressure is placed on the abdomen to help expel remaining gas. During this process, all secondary cannulas are removed using laparoscopic visualization. This allows exclusion of bleeding from punctured vessels that may have been tamponaded by these cannulas. Additionally, it prevents herniation of bowel or omentum up through the cannula track and into the anterior abdominal wall. Of note, pneumoperitoneum can also act as an intraoperative tamponade. Accordingly, potential bleeding sites are reinspected as the pneumoperitoneum is released. Next, the primary cannula is removed while leaving the laparoscope in the abdomen. Last, the laparoscope is slowly removed to visualize the abdomen and entry site for any evidence of bleeding and to prevent viscera from being pulled into the port site.

Incision Closure

Depending on their size, incisions may require deep fascial stitches. To prevent incisional hernia formation, fascial closure is often recommended whenever trocars measuring ≥10 mm are employed (Lajer, 1997). Nonbladed trocars may decrease this risk (Liu, 2000). For closure, interrupted or running suture line using 0-gauge delayed absorbable suture is suitable.If open entry was used, then sutures originally placed in the fascia are unthreaded from the trocar. Each of these sutures then is brought to the midline of the incision, and square knots are tied to close the fascial defect.

Skin incisions are closed with a subcuticular stitch of 4-0 gauge delayed-absorbable suture. Alternatively, the skin may be closed with cyanoacrylate tissue adhesive (Dermabond Topical Skin Adhesive) or skin tape (Steri-Strips) (Chap. 40).

After incision closure, the uterine manipulator is removed.

POSTOPERATIVE

Depending on the procedure performed, most patients can be discharged home on the same day as surgery. For most, physical activities and diet can be resumed according to patient comfort.

Approximately 650,000 tubal sterilization procedures are performed annually in the United States. Approximately half of these follow pregnancy delivery or termination, but the others are performed independent of pregnancy and are termed interval sterilization (Chan, 2010). Most interval procedures are performed laparoscopically, and most frequently they involve tubal occlusion by electrosurgical coagulation, by mechanical clips, by Silastic bands, or by suture ligation (Pati, 2000).

Current sterilization practices will likely change with recommendations now encouraging consideration of prophylactic salpingectomy at the time of sterilization, abdominal or pelvic surgery, or hysterectomy for women at average risk of ovarian cancer (American College of Obstetricians and Gynecologists, 2015). The rationale for this practice change to help decrease rates of certain epithelial ovarian cancers is described in Chapter 35.

PREOPERATIVE

Patient Evaluation

Several preventive steps can avoid sterilization procedures in women with early, undiagnosed pregnancies. Providing contraception well in advance of surgery, scheduling surgery in the follicular phase of the menstrual cycle, and preoperative serum β-human chorionic gonadotropin (β-hCG) level testing are effective methods to prevent or detect early pregnancy (American College of Obstetricians and Gynecologists, 2013a).

Patients who require treatment of advanced cervical epithelial abnormalities and who desire sterilization may choose hysterectomy rather than tubal occlusion as a means to serve both needs. For this reason, women ideally have cervical cancer screening results reviewed prior to surgery.

Consent

During the consenting process, patients are counseled regarding other reversible methods of contraception; other permanent methods, such as male sterilization; and the possibility of future regret (American College of Obstetricians and Gynecologists, 2009). Tubal sterilization is effective and should be considered a permanent procedure by the patient. Tubal sterilization is safe and associated complications are few. In general, the risks of laparoscopic sterilization mirror those of laparoscopy (Chap. 41).

Sterilizing clips and bands routinely fall from around the tube once occluded ends necrose and fibrose (Fig. 44-2.1). Most ectopic clips are incidental findings without untoward patient effects, but less commonly they can incite local foreign body reactions. Rarely, cases of clip migration to sites such as the bladder, uterine cavity, and anterior abdominal wall have been reported (Gooden, 1993; Kesby, 1997; Tan, 2004).

Contraceptive failure and pregnancy rates related to each procedure are also discussed with the patient (Chap. 5). Overall, these rates are low, and tubal sterilization is an effective method of contraception. If pregnancy does occur, however, there is a greater risk of ectopic pregnancy. Bipolar coagulation has the highest risk for this complication compared with that of clips or bands (Malacova, 2014; Peterson, 1996). Accordingly, amenorrhea following any sterilization procedure should prompt serum β-hCG testing to aid in identifying ectopic pregnancies.

Patient Preparation

For sterilization procedures, antibiotics and bowel preparation are typically not administered. VTE prophylaxis is implemented only for those at increased risk as listed in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Most laparoscopic tubal sterilization procedures are performed using general anesthesia.

To reduce postoperative pain, investigators have evaluated the adjunctive use of bupivacaine solution injected or dripped onto the tubal serosa or delivered transcervically through balloon uterine manipulators into the fallopian tube lumen. Though results have varied, one metaanalysis suggests some benefit in diminishing immediate postoperative pain with these practices (Brennan, 2004; Harrison, 2014; Schytte, 2003; Wrigley, 2000).

To begin, the patient is placed in the low dorsal lithotomy position, and patient arms are tucked at the side. A bimanual examination is completed to determine uterine size and inclination. Uterine size will affect placement of the accessory trocar, and inclination will direct positioning of the uterine manipulator, if used. The vagina and abdomen are surgically prepared, and the bladder is drained. Most sterilization procedures are brief, and a Foley catheter is seldom required. Often, a uterine manipulator or sponge stick is then placed to provide uterine anteflexion or retroflexion during evaluation of the pelvis (p. (Chap. 41).

Abdominal Entry and Accessory Ports

For all of the sterilization procedures described, the initial steps of laparoscopic abdominal entry are performed as described in Chapter 41. In most instances, one accessory port is required and is placed suprapubically in the midline to provide an equal reach to both fallopian tubes. For a normal-sized uterus, this port is placed 2 to 3 cm above the symphysis pubis. However, for a larger uterus, this position is moved cephalad as needed to access both tubes. Once ports are in place, inspection of the abdomen and pelvis is completed prior to the planned procedure.

Filshie Clip

The titanium Filshie clip is applied with the aid of a customized metal applicator that houses the clip within its single-action jaw. The applicator requires an 8-mm port for insertion into the abdominal cavity. As the jaw is closed, the shorter upper rim of the clip is forced beneath the longer lower clasp, and the clip is thereby locked into place around the fallopian tube.

Fallopian Tube Manipulation

To begin, a blunt probe or atraumatic grasping forceps is placed through the accessory port. To aid clip positioning, the surgeon stretches the fallopian tube out horizontally and laterally. Concurrently, a uterine manipulator can be used to tilt the uterus laterally and in the opposite direction. The blunt probe is then removed from the single port for insertion of the clip applicator.

Applicator Insertion

At the beginning of clip application, a Filshie clip is held within its applicator and inserted through the accessory cannula into the abdomen. A surgeon half closes the applicator’s upper jaw to insert it and the clip through the cannula. The handle of the applicator is not gripped tightly, as this may prematurely close and lock the clip (Penfield, 2000).

Once the Filshie clip emerges through the cannula, the applicator is opened slowly. The jaw of the applicator has the potential to spring open more quickly than the clip can open. This can result in the clip falling off the applicator and into the abdomen. Fallen clips are preferably retrieved, but if an open clip becomes lost and hidden by loops of bowel, laparotomy is typically not required for retrieval.

Filshie Clip Placement

After the clip is completely open, the clip and applicator are positioned with one jaw above and one below the fallopian tube at a site along the isthmic portion of the tube and 2 to 3 cm from the uterine cornu (Fig. 44-2.2). The entire width of the tube should lie across the base of the clip. The distal hooked end of the lower jaw should be visible through the mesosalpinx.

Filshie Clip Application

Once satisfied that the clip is positioned correctly, a surgeon slowly squeezes the finger bar handle to its full limit, back toward the handle backstop. With this action, the upper ridge of the clip is slowly compressed and locked under the lower hooked end of the clip (Fig. 44-2.3). This flattens the entire tube within the clip (Fig. 44-2.4). As the applicator jaws are slowly opened, the clip releases automatically from the applicator as it has locked onto the tube. These steps are repeated on the opposite fallopian tube. If there is any doubt regarding proper clip placement, a second clip is applied correctly to the same tube.

Rarely, a fallopian tube may be transected by the clip. This is usually associated with a large fallopian tube, which has been clipped too quickly. For sterilization completion, a clip is applied to both ends of the transected tube.

Bipolar Electrosurgical Coagulation

For this method, the fallopian tube is identified and grasped in the isthmic region at least 2 to 3 cm lateral to the cornu (Fig. 44-2.5). Placement here is important as pressure from retrograde menstrual flow against a coagulated stump that has been placed too close to the cornu can increase the risk of stump recanalization and fistula formation. Leaving a 2- to 3-cm segment allows ample space for absorption of intrauterine fluid without creating excess pressure against the stump.

Electrocoagulation

The coagulating paddles of the bipolar forceps should span the tube. Overextending their grasp may lead to partial coagulation of the mesosalpinx and incomplete coagulation of the entire tube width. Before current is applied, the tube is slightly elevated and pulled away from other adjacent structures to prevent thermal injury to these. As current is applied, the tube swells and fluid often bubbles and pops from the tissue. Current is delivered until the tube is completely desiccated. Failure to reach this end point has been linked with higher contraceptive failure rates (Soderstrom, 1989). Because visual inspection of the tube is typically inadequate to assess complete desiccation, an ammeter is incorporated with most bipolar generators. Water conducts current through tissues. Thus, completely desiccated tissues are unable to conduct current. For this reason, current is maintained during coagulation until zero current flow across the tube is registered by the ammeter. The tube is then released.

A second site that is lateral but contiguous with the first coagulated segment is grasped and similarly coagulated. A total of three contiguous sites are serially coagulated. This occludes a total span of 3 cm along the tube’s length (see Fig. 44-2.5). Coagulation of shorter distances along the tube can lead to recanalization and contraceptive failure (Peterson, 1999). These steps are then repeated on the opposite fallopian tube.

Occasionally following coagulation, the tube may stick to the bipolar paddles. To free the tube, the paddles are slowly opened and gently twisted to the right and then the left. Additionally, gentle fluid irrigation of the desiccated area may help release the tube.

Falope Ring (Silastic Band)

With this method, a Silastic Falope ring is applied with the aid of a custom metal applicator. To summarize the process, applicator tongs draw a portion of tube up into an inner sheath, and an outer sheath then pushes a Silastic band off the inner sheath and onto the fallopian tube loop.

Ring Loading

Prior to its insertion into the abdomen, a Falope ring is stretched around the distal tip of the inner applicator sheath by means of a special ring loader and ring guide (Fig. 44-2.6).

Ring Placement

Once inserted through the accessory port, the applicator’s tongs are opened and placed completely around the fallopian tube approximately 3 cm from the cornu. Tongs grasp the mesosalpinx directly at its attachment to the tube. This prevents excess mesosalpinx from being drawn into the inner sheath (Fig. 44-2.7).

Ring Application

A trigger on the applicator retracts the tongs and draws a loop of tube approximately 1.5 cm into the inner sheath. The total length of tube contained within the inner sheath is thus 3 cm (Fig. 44-2.8).

The outer sheath is then advanced toward the loop’s base. This outer sheath pushes the Silastic band off the inner sheath and onto the loop base (Fig. 44-2.9). The loop base will blanch from ischemia following band placement (Fig. 44-2.10). These steps are repeated on the opposite fallopian tube.

Special Circumstances

Tubal transection is uncommon, and a Falope ring can be applied to each of the divided segments. Vessels of the mesosalpinx can occasionally tear and bleed as the tongs and tube are drawn into the inner sheath. The Silastic band, once applied to the loop base, will control bleeding in most instances. Thus, electrosurgical coagulation to achieve hemostasis is infrequently needed.

Hulka Clip Application

The plastic Hulka clip is also generically known as a spring clip because of the stiff outer metal spring that locks the clip into place. Required equipment includes the clips themselves and a custom metal applicator, which holds the clip during application.

Fallopian Tube Manipulation

To be‑gin, a blunt probe or atraumatic grasping forceps is placed through the accessory port. The fallopian tube is outstretched horizontally and laterally to aid clip application. Concurrently, a uterine manipulator can be used to tilt the uterus laterally and in the opposite direction.

Clip Loading

Before the applicator and its clip are inserted through the accessory trocar, the trigger of the applicator is gently squeezed by the surgeon’s thumb. This action advances the outer rod of the applicator down and over the top of the clip. This closes the jaws of the clip to within 1 mm of each of other. This is an unlocked position yet allows the clip and applicator to be threaded down the accessory cannula.

Clip Application

Once inside the abdomen, the applicator trigger is drawn backward, the outer rod retracts, and the upper jaw of the clip reopens. Held within the applicator jaws, the open clip is positioned across the narrow isthmic portion of the fallopian tube, 2 to 3 cm from the cornu, and perpendicular to the long axis of the tube (Fig. 44-2.11). The jaws are positioned around the tube in a manner that directs the tube deeply into the crux of the clip jaws. This aids in total occlusion of the tube as it is flattened across the base of the closing clip. Additionally, the applicator tip and clip are positioned such that when closed, the clip incorporates a small portion of adjacent mesosalpinx.

Clip Closure

Once the applicator jaws are appropriately positioned, the thumb-action trigger is slowly squeezed to push forward the outer rod of the applicator and close the clip around the tube (Fig. 44-2.12). The clip application is inspected to ensure that it has completely encompassed the tube.

If placement is deemed correct, the trigger is fully depressed. This forces the center rod of the applicator forward against the butt of the clip’s stiff metal spring (Fig. 44-2.13). The spring is pushed out and around the plastic frame of the clip to compress and lock the upper and lower clip jaws in place. One clip is placed on each tube. If a clip is misapplied, a second clip can be placed lateral to the first.

Pomeroy with Endoscopic Loop

This procedure can be used as a sterilization technique but is more commonly used to excise fallopian tube ectopic pregnancies. A description and figures can be found in Section 44-3.

Wound Closure

Subsequent surgery completion steps follow those of diagnostic laparoscopy.

POSTOPERATIVE

Postoperatively, patients are given instructions similar to those following diagnostic laparoscopy. Sterilization is immediate, and intercourse may resume at the patient’s discretion.

With surgical treatment of ectopic pregnancy, goals include hemodynamic support of the patient, removal of all trophoblastic tissue, repair or excision of the damaged tube, and preservation of fertility in those who desire it. For most women, the preferred surgical approach for ectopic pregnancy management is laparoscopic. It provides a safe and effective treatment of the affected fallopian tube while offering the advantages of laparoscopy. For some, laparoscopic salpingostomy is desired to treat and retain the affected tube. However, if fertility is not a consideration or if tubal damage or bleeding does not permit fallopian tube salvage, then laparoscopic salpingectomy may be selected due to its lower risk of persistent trophoblastic tissue.

Salpingectomy may also be used to remove hydrosalpinges in women undergoing in vitro fertilization. In this case, pregnancy rates are improved if such tubes are excised (Chap. 9). Total salpingectomy can be used as a method of sterilization. This may be especially attractive if a primary sterilization technique has failed or if an ovarian cancer risk-reducing strategy is adopted. Last, in women with BRCA gene mutations, early bilateral salpingectomy followed by postmenopausal oophorectomy is one strategy to lower epithelial ovarian cancer risks yet provide extended estrogen benefits (Chap. 35).

PREOPERATIVE

Consent

The general risks of laparoscopic surgery are discussed in Chapter 41. With salpingectomy, injury to the ipsilateral ovary is possible. Thus, the potential for oophorectomy and its effects on fertility and hormone function are discussed. Prior to cases for ectopic pregnancy, a patient’s desire for future fertility is investigated. If she has completed her childbearing or has failed a prior sterilization procedure, then contralateral tubal ligation or bilateral salpingectomy may be acceptable at the time of surgery.

Following any surgical treatment of ectopic pregnancy, trophoblastic tissue can persist. The risk of this is lower with salpingectomy compared with salpingostomy and is discussed more fully on page 1013.

Patient Preparation

Baseline complete blood count (CBC), β-hCG level, and Rh status are routinely assessed. If salpingectomy is performed in the setting of an ectopic pregnancy, substantial bleeding may be encountered. Thus, the patient is typed and crossmatched for packed red blood cells and other blood products as indicated. Salpingectomy is associated with low rates of infection. Accordingly, preoperative antibiotics are usually not administered. For those undergoing laparoscopic salpingectomy for ectopic pregnancy, VTE prophylaxis is typically indicated due to the hypercoagulability associated with pregnancy (Table 39-8). For prophylaxis in those with active bleeding, intermittent pneumatic compression devices are preferred.

INTRAOPERATIVE

Instruments

Most instruments required for salpingectomy are found in a standard laparoscopy instrument set. However, a suction irrigation system is commonly needed during salpingectomy to remove blood from a ruptured ectopic pregnancy. Depending on the size of the ectopic pregnancy or hydrosalpinges, an endoscopic retrieval bag may also be needed. For salpingectomy, the fallopian tube and mesosalpinx require ligation and excision. This may be accomplished using bipolar instruments, Harmonic scalpel, or laparoscopic suture loop (Endoloop). These may not be readily available in all operating suites, and desired tools are requested prior to surgery.

Surgical Steps

Anesthesia and Patient Positioning

The patient is prepared and positioned for laparoscopic surgery (Chap. 41).

Abdominal Entry

The abdomen is entered with laparoscopic techniques, and typically two or three accessory trocar sites are added (Chap. 41). Depending on the size of the ectopic pregnancy, at least one 10-mm or larger accessory port may be needed to allow specimen removal at surgery’s end. Once ports are in place, inspection of the abdomen and pelvis is completed prior to the planned procedure.

Mesosalpingeal Incision

The affect­ed fallopian tube is lifted and held with an atraumatic grasping forceps. Kleppinger bipolar electrode forceps are placed across a proximal portion of the fallopian tube. A cutting current at 25 W should suffice (Fig. 44-3.1). When zero amperage of flow is noted, scissors can then cut the desiccated, blanched tube (Fig. 44-3.2).

The Kleppinger forceps are then advanced across the most proximal portion of mesosalpinx. Similarly, current is applied, and the desiccated tissue cut. This process serially moves from the proximal mesosalpinx to its distal extent under the tubal ampulla. As the distal mesosalpinx is cut, the tube is freed.

Other energy sources also work well. Monopolar scissors themselves may be attached to current. In this technique, vessels within the mesosalpinx are first electrosurgically coagulated and then cut. Advanced bipolar technologies (LigaSure, ENSEAL), laser energy, and Harmonic scalpel are suitable options. A surgeon’s expertise with a particular modality dictates selection. One or more of these may be preferred based on the surrounding pelvic pathology or adhesions. The major concern with any of these tools is the amount of thermal spread to surrounding tissues.

Endoscopic Loop Ligation

Alter­natively, the vascular supply to the fallopian tube within the mesosalpinx can be ligated. Figure 44-3.3 shows an endoscopic suture loop encircling a loop of fallopian tube that contains an ectopic pregnancy. Absorbable and delayed-absorbable suture loops are available, and either is suitable for ligation. Two or three suture loops are sequentially placed, and the tube distal to these ligatures is then cut free with scissors (Fig. 44-3.4).

Tissue Removal

Most tubal ectopic pregnancies are small and pliant. Thus, they can be held firmly by grasping forceps and drawn up into one of the accessory site cannulas. The cannula, grasping forceps, and ectopic tissue can then be removed together. Larger tubal ectopic pregnancies may be placed in an endoscopic sac to prevent fragmentation as they are removed through the laparoscopic port site. Alternatively, larger ectopic pregnancies can be morcellated with scissors within an enclosed bag. Tissue removal techniques are presented on page 1019 and are also illustrated in Chapter 41.

Irrigation

To remove all trophoblastic tissue, the pelvis and abdomen are irrigated and suctioned free of blood and tissue debris. Slow and systematic movement of the patient from Trendelenburg positioning to reverse Trendelenburg can also assist in dislodging stray tissue and fluid, which is then suctioned and removed from the peritoneal cavity.

Wound Closure

Subsequent surgery completion steps follow those of diagnostic laparoscopy.

POSTOPERATIVE

As with most laparoscopic surgeries, patients can resume presurgical diet and activity levels according to their comfort, typically within days. If salpingectomy is performed for ectopic pregnancy, Rh-negative patients are given a single 50- or 300-μg (1500 IU) Rh₀(D) immune globulin dose intramuscularly within 72 hours. To identify patients in whom trophoblastic tissue may persist, serial serum β-hCG levels are monitored until undetectable (Seifer, 1997). Spandorfer and associates (1997) compared serum β-hCG levels 1 day postoperatively with those drawn prior to surgery. They found a significantly lower percentage of persistent trophoblastic tissue if the β-hCG level fell more than 50 percent and noted no cases if the level declined by greater than 77 percent. Until levels are undetectable, contraception is used to avoid confusion between persistent trophoblastic tissue and a new pregnancy. Ovulation may resume as early as 2 weeks after an early pregnancy ends. Therefore, if contraception is desired, methods are initiated soon after surgery. Last, patients are counseled regarding their increased risk of future ectopic pregnancy.

For patients with ectopic pregnancy, laparoscopic linear salpingostomy offers the surgical advantages of laparoscopy and an opportunity to retain fertility by preserving the involved fallopian tube. Accordingly, suitable candidates are women with an unruptured isthmic or ampullary ectopic pregnancy and desiring future pregnancies. Success is mainly affected by the amount of bleeding, by the ability to control it, and by the degree of tubal damage.

PREOPERATIVE

Consent

Risks of laparoscopic salpingostomy mirror those for laparoscopic salpingectomy. Importantly, with salpingostomy, a patient is counseled regarding the possible need for salpingectomy if the tube is irreparably damaged or bleeding from the tube cannot be controlled. Also, rates of persistent trophoblastic disease are higher with salpingostomy compared with removal of the entire affected tubal segment.

Bleeding

Because trophoblastic tissue is vascular, disruption during ectopic pregnancy removal can lead to severe hemorrhage. The ability of tubal muscularis to contract is minimal, and thus, bleeding during salpingostomy must be controlled with external modalities such as electrosurgical coagulation. Many devices are appropriate, and the microbipolar device is effective for achieving hemostasis while creating minimal thermal spread. At times, bleeding may be extensive and persistent and necessitate salpingectomy.

To improve hemostasis, vasoconstrictive agents such as vasopressin have been evaluated. Dilutions of 20 U of vasopressin in 30 to 100 mL of saline are suitable. The mesosalpinx is then infiltrated with approximately 10 mL of solution. Because of the potential systemic vasoconstrictive effects of vasopressin, intravascular injection is avoided. Another approach is to inject the solution into the portion of the tube to be incised. This is dictated by surgeon preference. Additional complications and contraindications to vasopressin use are discussed on page 1023. Benefits to vasopressin include less frequent use of electrosurgery, shorter operating time, and lower conversion rates to laparotomy for surgery completion.

To avoid vasopressin’s cardiovascular complications, Fedele and colleagues (1998) diluted 20 U of oxytocin in 20 mL of saline and similarly injected the mesosalpinx. Oxytocin is purported to contract the smooth muscle fibers of the tube and cause vasoconstriction of mesosalpinx vessels. These researchers noted easier pregnancy enucleation, less bleeding, and less frequent use of electrosurgery.

Persistent Trophoblastic Tissue

During treatment of ectopic pregnancy, trophoblastic tissue can persist in as many as 3 to 20 percent of cases. Remnant implants typically involve the fallopian tube, but extratubal trophoblastic implants have been found on the omentum and on pelvic and abdominal peritoneal surfaces. Peritoneal implants typically measure 0.3 to 2.0 cm and appear as red-black nodules (Doss, 1998). Severe postoperative bleeding is the most serious complication of this persistent tissue (Giuliani, 1998).

The risk of persistent trophoblast tissue is highest following laparoscopic salpingostomy, especially in women in whom small, early pregnancies are removed. In these pregnancies, the cleavage plane between the invading trophoblast and tubal implantation site is poor. This may lead to a more difficult dissection and failure to completely remove all products of conception. For all cases, preventive recommendations include irrigation and complete suctioning of the abdomen, limitation of Trendelenburg position to limit blood and tissue flow to the upper abdomen, and use of endoscopic bags for removal of larger ectopic pregnancies (Ben-Arie, 2001).

INTRAOPERATIVE

Instruments

Specific tools needed for salpingostomy mirror those for salpingectomy and should be available if salpingectomy is required.

Surgical Steps

Anesthesia and Patient Positioning

The patient is prepared and positioned for laparoscopic surgery as described in Chapter 41.

Abdominal Entry

The abdomen is accessed with laparoscopic techniques, and typically two or three accessory port sites are used. Depending on the ectopic pregnancy size, at least one 10-mm or larger accessory port may be necessary to allow specimen removal at surgery’s end. Once cannulas are in place, systematic inspection of the abdomen and pelvis is completed prior to the planned procedure.

Salpingostomy

The fallopian tube is lifted and held with atraumatic grasping forceps. By means of a 22-gauge needle through one of the accessory ports or through a separate abdominal wall needle puncture, a solution of vasopressin is injected into the mesosalpinx beneath the ectopic pregnancy. If the serosal layer overlying the ectopic tissue is injected instead, then a smaller 25-gauge needle may be used.

A monopolar needle tip electrode is set at a cutting voltage and used to create a 1- to 2-cm longitudinal incision (Fig. 44-4.1). The incision is positioned opposite the mesosalpinx and on the maximally distended portion of the tube that overlies the pregnancy. Laparoscopic scissors, CO₂ laser, bipolar needle, and Harmonic scalpel have also been used.

Pregnancy Removal

For this step, atraumatic grasping forceps hold one edge of the incision while a suction-irrigation probe tip is insinuated into the tissue plane between the tubal wall and ectopic pregnancy (Fig. 44-4.2). Hydrodissection is performed on one side of the tube and then the other. A combination of high-pressure hydrodissection and gentle blunt dissection with the suction irrigator tip is used to remove the entire conceptus from the tube. Alternatively, the pregnancy or its fragments may require extraction by smooth grasping forceps.

Hemostasis

Bleeding points can be controlled with monopolar or bipolar electrosurgical coagulation (Fig. 44-4.3). The tubal incision is left open to heal by secondary intention. Tulandi and Guralnick (1991) found no differences in subsequent fertility and adhesion formation between salpingotomy with or without tubal suturing. Use of topical fibrin products for hemostasis has been evaluated in limited studies and warrants further investigation with regard to adhesion prevention and future pregnancy effects (Mosesson, 1992).

Specimen Extraction

Most ectopic pregnancies are small and pliant. Accordingly, they can be held firmly by grasping forceps and drawn up into one of the accessory cannulas. The cannula, grasping forceps, and ectopic tissue can then be removed together. Larger ectopic pregnancies may be placed in an endoscopic sac to prevent fragmentation as they are removed through the laparoscopic trocar site.

Irrigation

To prevent persistent trophoblastic tissue postoperatively, the pelvis and abdomen are irrigated and suctioned free of blood and tissue debris.

Adhesion Prevention

Adjuvants are available that can be used for the prevention of postoperative adhesion formation. However, although adhesion formation is lessened, no substantial evidence documents that their use improves fertility, decreases pain, or prevents bowel obstruction (American Society for Reproductive Medicine, 2013).

Wound Closure

Subsequent surgery completion steps follow those of diagnostic laparoscopy.

POSTOPERATIVE

As with most laparoscopic surgeries, patients can resume presurgical diet and activity levels according to their comfort, typically within days. Postoperative topics specific to ectopic pregnancy include Rh₀ [D] immune globulin administration, surveillance for persistent trophoblastic disease, provision of contraception if desired, and counseling on future ectopic pregnancy risk as described on page 1012.

Many studies have attested to the efficacy and safety of laparoscopic cystectomy for the management of ovarian cysts. Moreover, because of recovery-associated benefits, a laparoscopic technique is advocated by many as the preferred approach in women with ovarian cysts and a low risk of malignancy (Chap. 9).

PREOPERATIVE

Patient Evaluation

Sonography is the primary tool used to diagnose ovarian pathology, and the sonographic characteristics of a cyst aid in determining preoperatively the malignant potential of a given lesion (Chap. 9). In those patients with indeterminate ovarian cysts following sonography, magnetic resonance (MR) imaging may enhance discrimination.

The serum tumor marker cancer antigen 125 (CA125) is typically obtained preoperatively in postmenopausal patients and in any woman whose tumor displays other risk factors for ovarian epithelial cancer (Chap. 35). Additionally, serum alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), inhibin, and β-hCG levels may be measured to exclude germ cell or sex cord-stromal ovarian neoplasms, if these are suspected (Chap. 36).

Consent

Prior to surgery, patients are informed of the unique complications associated with laparoscopy itself (Chap. 41). Specific to ovarian cystectomy, the risks of oophorectomy due to bleeding or extreme ovarian damage are discussed. Depending on the amount of oocyte-containing ovarian stroma that is stripped away with the cyst, diminished ovarian reserve is also a risk. Obviously, because many cysts are removed due to concerns of potential malignancy, patients should be familiar with the steps involved in the surgical staging of ovarian cancer.

Patient Preparation

Rates of pelvic and wound infection following ovarian cystectomy and laparoscopy are low, and antibiotic prophylaxis is typically not required. Bowel preparation is not usually required, but may be considered if extensive adhesions are suspected. VTE prophylaxis is typically not recommended for laparoscopic cystectomy. However, those with a greater risk of malignancy, with risks for VTE, or with an increased chance for conversion to laparotomy may benefit from these measures (Table 39-8).

INTRAOPERATIVE

Instruments

Most instruments required for ovarian cystectomy are found in a standard laparoscopy instrument set. A suction irrigation system is commonly needed to remove cyst contents if rupture occurs. An endoscopic retrieval bag is also frequently used. Once contained in the sac, the cyst in some cases may be decompressed with a laparoscopic aspiration needle.

If oophorectomy is required, the infundibulopelvic ligament is ligated. This may be accomplished using bipolar instruments, Harmonic scalpel, laparoscopic suture loop, or stapler. These may not be readily available in all operating suites, and desired tools are requested prior to surgery.

Surgical Steps

Anesthesia and Patient Positioning

The patient is prepared and positioned for laparoscopic surgery (Chap. 41). A bimanual examination is completed to determine ovarian size and position and uterine inclination. Ovarian information will affect placement of the accessory ports, and uterine inclination will direct positioning of the uterine manipulator if used. A uterine manipulator may assist with moving the uterus and adnexa. In anticipation of possible hysterectomy as a part of ovarian cancer staging, the vagina and abdomen are surgically prepared, and a Foley catheter is inserted. The patient is then draped to allow sterile access to the vagina and abdomen.

Abdominal Entry

Primary and secondary trocars are placed as described in Chapter 41. For insertion of most endoscopic sacs, at least one 10-mm or larger accessory trocar may be necessary to allow specimen removal at surgery’s end. Typically, two or three accessory trocars are required for cystectomy.

Once the abdomen is entered, a diagnostic laparoscopy is performed, inspecting the pelvis and upper abdomen for signs of malignancy such as ascites and peritoneal implants or for evidence of endometriosis. Suspicious areas are biopsied, and those concerning for cancer are sent for intraoperative analysis. Prior to ovarian cystectomy, adhesions are divided to restore proper anatomic relationships.

Ovarian Incision

A blunt probe is placed under the uteroovarian ligament and posterior ovarian surface to elevate the ovary. An atraumatic grasping forceps then steadies the ovary, and the blunt probe is removed (Fig. 44-5.1). A monopolar needle tip electrode set at a cutting voltage is used to incise the ovarian capsule that overlies the cyst. Other suitable devices for incision include a monopolar scissor blade or Harmonic scalpel. This incision is ideally on the antimesenteric surface of the ovary to minimize dissection into extensive vascularity at the ovarian hilum. The incision is extended into the ovarian stroma to the level of the cyst wall but ideally does not rupture the cyst.

Cyst Dissection

A space between the ovary and cyst wall is created using blunt forceps or dissecting scissors (Fig. 44-5.2). Atraumatic grasping forceps are used to hold one edge of the incision, while a blunt probe or suction-irrigation probe tip is insinuated in the tissue plane between the ovarian capsule and cyst wall (Fig. 44-5.3).

Blunt or hydrodissection is performed on one side of the cyst and then the other. Depending on the adherence of the cyst to its surrounding ovarian tissue, cystectomy may at times require sharp dissection with scissors. During dissection, points of bleeding may be coagulated, or isolated vessels may be grasped and coagulated (Fig. 44-5.4).

Cyst Removal

Following enucleation from the ovary, the cyst is placed into an endoscopic bag (Fig. 44-5.5). The opening of the sac is closed and brought up to the anterior abdominal wall (Fig. 44-5.6). Depending on its size, the cyst and endoscopic bag may be removed in toto through one of the accessory cannulas. In this setting, the laparoscopic cannula is removed first, followed by the cyst contained within the sac.

Alternatively, with larger cysts, the cannula is removed, and the entire pursed opening of the bag is drawn up through the trocar incision and fanned out onto the skin surface. The open edges of the bag are pulled upward to lift and press the cyst up against the incision. A needle tip is then directed into the incision and pierces the cyst contained within the endoscopic bag. An attached syringe is used to aspirate contents. Alternatively, the cyst may be ruptured by a toothed Kocher clamp placed through the skin incision and into the sac (Fig. 44-5.7). Thereby, cyst fluid is retained within the endoscopic sac. The endoscopic sac and decompressed cyst wall are then removed together through the incision (Fig. 44-5.8). During removal, care is taken to ensure that the endoscopic bag is not inadvertently punctured or torn, and all measures are used to prevent spillage of cyst contents into the abdomen or port site.

Cyst Rupture

Not uncommonly during the dissection of the cyst away from the ovary, the cyst may rupture. The cyst wall is then removed using a “stripping” technique (Fig. 44-5.9). With this, both the cyst wall and cyst capsule can be grasped near the dissection plane by atraumatic forceps. Traction and countertraction can separate filmy connective tissue between these to advance the dissection plane. As a result, the grasping forceps strip the cyst wall away from the underlying ovarian stroma. To prevent damage to the underlying healthy ovary, the dissection plane between the cyst and stroma should be clearly delineated by traction on each side to prevent tearing. Injection of dilute vasopressin into this space may also help delineate the dissection plane and minimize bleeding. Histologically, Muzii and colleagues (2002) showed that this technique in nonendometriotic lesions spared ovarian tissue and did not strip away normal ovarian tissue and follicles.

Ovary Closure

Because of increased adhesion formation risk, technical difficulty, and time associated with laparoscopic suturing, in general the ovarian capsule is not sutured closed following cyst removal. Several studies show that leaving the capsule open does not lead to increased adhesion formation (Marana, 1991; Wiskind, 1990). Application of an adhesion barrier such as oxidized regenerated cellulose may be considered to prevent adhesion formation (Franklin, 1995; Wiseman, 1999). However, no substantial evidence documents that their use improves fertility, decreases pain, or prevents bowel obstruction (American Society for Reproductive Medicine, 2013).

Wound Closure

If concerning for malignancy, the specimen is submitted in most cases for immediate frozen section analysis. If benign findings are noted, then steps toward surgical closure begin. If malignancy is found, then surgical staging should ensue. Of note, if a large mass was removed and the port site was likely extended during the removal, one should consider fascial closure to prevent port-site hernias. The finishing laparoscopic steps are similar to those for diagnostic laparoscopy.

POSTOPERATIVE

Following laparoscopic ovarian cystectomy, instructions similar to those for diagnostic laparoscopy are given.

Laparoscopy can be used to safely remove many adnexa and in most cases, offers a faster recovery and less postoperative pain compared with laparotomy. As discussed in Chapter 9, indications for adnexectomy vary but may include torsion, ovarian cyst rupture, suspicion of ovarian malignancy, and symptomatic ovarian remnant. In addition, prophylactic oophorectomy is often considered in women with or at genetic risk for cancers involving the breast, ovary, and colon (Chap. 35).

Laparoscopy is a preferred approach when possible and can be safely performed in pregnancy, preferably in the early second trimester. However, for all patients, laparotomy may be preferred is certain clinical settings. These include a high suspicion of cancer, anticipation of extensive pelvic adhesions, and large ovarian size.

PREOPERATIVE

Patient Evaluation

Salpingo-oophorectomy is typically performed to remove ovarian pathology and sonography is the primary tool used for diagnosis. In cases in which anatomy may be unclear, MR imaging may add additional information. As discussed on page 1015, tumor markers may be drawn prior to surgery if malignancy is suspected.

Consent

Prior to surgery, patients are informed of the unique complications associated with laparoscopy (Chap. 41). Specific to salpingo-oophorectomy, the risk of ureteral injury is discussed. Many adnexa are removed due to concerns of potential malignancy, and patients should be familiar with the steps involved in the surgical staging of ovarian cancer.

Patient Preparation

Unless an ovarian abscess is identified, laparoscopic salpingo-oophorectomy does not require antibiotic prophylaxis (American College of Obstetricians and Gynecologists, 2014b). If hysterectomy is required during ovarian staging, antibiotics may be given intraoperatively. Bowel preparation is not usually required but may be considered if extensive adhesions are suspected. VTE prophylaxis is typically not recommended for laparoscopic cystectomy. However, those with a greater risk of malignancy, with underlying VTE risks, or with an increased chance for conversion to laparotomy may benefit from these measures (Table 39-8).

INTRAOPERATIVE

Instruments

Most instruments required for ovarian cystectomy are found in a standard laparoscopy instrument set. However, a suction irrigation system is commonly needed to remove cyst contents if rupture occurs. An endoscopic retrieval bag is also frequently used. During oophorectomy, the infundibulopelvic ligament is ligated. This may be accomplished using bipolar instruments, Harmonic scalpel, laparoscopic suture loop, or stapler. These may not be readily available in all operating suites, and desired tools are requested prior to surgery.

Surgical Steps

Anesthesia and Patient Positioning

The patient is prepared and positioned for laparoscopic surgery as described in Chapter 41. A bimanual examination is completed to determine ovarian size and position and uterine inclination. Ovarian information will affect placement of the accessory ports, and uterine inclination will direct positioning of the uterine manipulator if used. Because of possible hysterectomy as a part of ovarian cancer staging, the vagina and abdomen are surgically prepared, and a Foley catheter is inserted. A uterine manipulator may also be placed to assist with manipulation of the uterus and adnexa.

Abdominal Access

Primary and secondary trocars are placed as described in Chapter 41. Typically, two or three accessory ports are required. For insertion of most endoscopic sacs, at least one 10-mm or larger accessory port may be necessary to allow specimen removal at surgery’s end.

Pelvic Inspection and Washings

Once the abdomen is entered, a diagnostic laparoscopy is performed, inspecting the pelvis and upper abdomen for signs of malignancy such as ascites and peritoneal implants. Cellular washings from these areas are obtained and saved until frozen section analysis of the specimen has excluded malignancy. Similarly, identified peritoneal implants from these areas are biopsied and sent for intraoperative evaluation. Prior to adnexectomy, adhesions are divided to restore proper anatomic relationships.

Ureter Location

The ureter lies close to the infundibulopelvic (IP) ligament, and its course should be noted. If the location of the ureter is not clear, the peritoneum lateral to the ureter is incised, and retroperitoneal isolation of the ureter is completed (Fig. 44-6.1).

Infundibulopelvic Ligament Co­agulation

Ligation of the ovarian vessels within the IP ligament can be completed with endoscopic loop ligatures, electrosurgical coagulating devices, Harmonic scalpel, or stapler depending on surgeon preference (see Fig. 44-6.1). Once these vessels are occluded, the IP is severed distally.

Opening of the Broad Ligament

After transection of the IP, the fallopian tube and ovary are gently elevated with atraumatic forceps. Incision of the broad ligament’s posterior leaf is then extended to the round ligament (Fig. 44-6.2).

Uteroovarian Ligament Coagulation

The uteroovarian ligament and proximal fallopian tube are identified posterior to the round ligament. Similarly to the IP, these may be coagulated, stapled, or ligated (Fig. 44-6.3). Distal to this occlusion, the uteroovarian ligament and fallopian tube are transected, and the adnexum is freed.

Adnexum Removal

Various endoscopic bags are available for tissue removal (Chap. 41). The specimen is dropped into the sac, which is closed and brought up to the anterior abdominal wall. Depending on its size, the adnexum and endoscopic bag may be removed in toto through one of the accessory port sites. In this setting, the laparoscopic cannula is removed first, followed by the specimen contained within the sac.

Alternatively, with larger cystic ovaries, the cannula is removed, and the entire pursed opening of the bag is drawn up through the incision and fanned out onto the skin surface. As illustrated in Section 44-5, the open edges of the bag are pulled upward to lift and press the ovary against the incision. A needle tip is directed through the incision and into the sac. The ovary is pierced and aspiration drainage is completed by an attached syringe. Alternatively, the cyst may be ruptured by a toothed Kocher clamp placed through the skin incision and into the sac. Thereby, cyst fluid is retained in the endoscopic sac. The endoscopic sac and decompressed cyst wall are then removed together through the incision. During removal, care is taken to ensure that the endoscopic is bag is not inadvertently punctured or torn, and all measures are used to prevent spill of cyst contents into the abdomen or port site. Additionally, to prevent spill or to remove a larger solid mass, one may remove the adnexa through a minilaparotomy incision or a colpotomy incision as described on page 1031 and illustrated in Chapter 41.

Wound Closure

If malignancy is suspected, the specimen is submitted for immediate frozen section analysis. If benign findings are noted, then steps toward surgical closure begin. If malignancy is found, then surgical staging should ensue. Of note, if a large mass was removed and the port site was likely extended during the removal, one should consider fascial closure to prevent port-site herniation.

POSTOPERATIVE

Advantages to laparoscopy include a rapid return to normal diet and activities, and postoperative complication rates are low. If both adnexa are removed, then hormone replacement therapy is considered in appropriate candidates (Chap. 22).

Ovarian drilling is a technique of puncturing the ovarian capsule with a laser beam or an electrosurgical needle using a laparoscopic approach. Similar to ovarian wedge resection, this procedure’s end goal is to reduce the amount of androgen-producing tissue in women with polycystic ovarian syndrome (PCOS). However, in wedge resection, a long cortical incision is required for this degree of resection. As a result, infertility secondary to adhesions complicates many postoperative courses (Buttram, 1975; Toaff, 1976). To minimize this risk and avoid the need for laparotomy, ovarian drilling techniques using laparoscopy were developed in the early 1980s.

Compared with gonadotropin stimulation to achieve pregnancy, ovarian drilling has lower rates of ovarian hyperstimulation syndrome (OHSS) and of multifetal gestation (Farquhar, 2012). Disadvantages include the surgical risks of laparoscopy, risks of pelvic adhesion formation, and concerns regarding long-term effects on ovarian function (Donesky, 1995; Farquhar, 2012). For these reasons, ovarian drilling is viewed as a second-line therapy. It can be useful in patients who fail to ovulate with clomiphene citrate, who are at risk for OHSS, or who desire to minimize their risk for multifetal gestation.

PREOPERATIVE

Consent

There appear to be relatively few complications that arise immediately after ovarian drilling. Hemorrhage, infection, and thermal bowel injury are infrequent. Similarly, ovarian atrophy following drilling is rare but has been reported (Dabirashrafi, 1989).

Adhesion formation following this procedure, however, is common. Most of these adhesions at second-look laparoscopy have typically been graded as minimal or mild (Gürgan, 1991). Moreover, researchers have described only a minimal, if any, decline in fertility from these adhesions (Gürgan, 1992; Naether, 1993). This risk, however, is discussed with the patient prior to surgery.

INTRAOPERATIVE

Instruments

Ovarian drilling has been described using monopolar or bipolar electrosurgical energy or using various lasers, all with the goal of causing focal damage to the ovarian stroma and cortex. Currently, no studies support the superiority of one modality (Strowitzki, 2005).

Number of Ovarian Punctures

Punctures into the ovarian capsule are typically 2 to 4 mm wide and 4 to 10 mm deep. Although techniques using as few as four or as many as 40 punctures per ovary have been described, few studies have investigated the optimum number of punctures (Farquhar, 2004). For example, Malkawi and Qublan (2005) showed that five punctures per ovary compared with 10 resulted in equally improved pregnancy rates and similarly low rates of postprocedural OHSS and multifetal gestation.

Surgical Steps

Anesthesia and Patient Positioning

Patient positioning and anesthesia mirror those for other laparoscopic procedures (Chap. 41).

Abdominal Entry

Three incisions are used for this laparoscopic procedure. In addition to an umbilical incision, two bilateral lower abdominal incisions are made. These incisions serve as entry sites for the electrosurgical needle tip and grasping forceps.

Ovarian Drilling

The ovary is elevated with a blunt grasper. The electrosurgical current is set at 30 to 60 W cutting mode. A monopolar electrosurgery needle tip is used to puncture the ovary perpendicular to the cortical surface and to pierce the follicular cysts that are characteristic of PCOS. Four to five punctures are placed symmetrically on the antimesenteric surface of the ovary (Fig. 44-7.1). Drilling is avoided on the lateral surfaces of the ovaries to minimize adhesions to the pelvic sidewall and is avoided at the ovarian hilum to limit bleeding risks. The needle is inserted to a depth of 4 to 10 mm. Electrical current is applied for 3 to 4 seconds. The ovarian surface can be irrigated with saline or lactated Ringer solution to cool it (Strowitzki, 2005).

Adhesion Barriers

Because of the risk for adhesion formation, some investigators use adhesion barrier products following ovarian drilling. Greenblatt and Casper (1993), however, showed no improvement in adhesion prevention following this procedure using Interceed adhesion barrier. No other studies have addressed the efficacy of other adhesion prevention products.

Wound Closure

Subsequent surgery completion steps should follow those of diagnostic laparoscopy.

POSTOPERATIVE

Postoperatively, patients are given instructions similar to those following diagnostic laparoscopy.

Myomectomy involves surgical removal of leiomyomas from their surrounding myometrium, and accepted indications include selected cases of abnormal uterine bleeding, pelvic pain, infertility, and recurrent miscarriage. Historically, removal of serosal and intramural tumors required laparotomy. However, laparoscopic excision may be performed by those with advanced skills in operative laparoscopy and laparoscopic suturing. Robotic myomectomy has also increased in popularity for this indication (Visco, 2008).

In general, removal of subserosal and intramural leiomyomas are most appropriate for a laparoscopic approach. Submucous leiomyomas are best treated via hysteroscopic resection. The choice of abdominal or laparoscopic myomectomy is based on various factors that include tumor number, size, and location. Surgical experience and comfort with laparoscopic dissection, tissue extraction, and suturing are other requisites.

PREOPERATIVE

Patient Evaluation

Because of their impact on preoperative and intraoperative planning, leiomyoma size, number, and location are evaluated prior to surgery with sonography, MR imaging, and/or hysteroscopy, as described in Chapter 9. Specifically, leiomyomas may be small and buried within the myometrium. Therefore, accurate information as to tumor number and location ensures complete excision. Moreover, with a laparoscopic or robotic approach, the ability to palpate and appreciate smaller deep tumors may be compromised. In these cases, preoperative MR imaging may best assist with leiomyoma location and surgical planning. Last, multiple large masses or those that are located in the broad ligament, are near the cornua, or involve the cervix may increase the risk of conversion to hysterectomy, and patients are so counseled. Studies have also suggested that there is an increased risk of complications with the following: more than three leiomyomas, tumor size >5 cm, and intraligamental location (Sizzi, 2007). Accounting for these factors, a surgeon’s expertise is the most important factor in determining approach to myomectomy.

Consent

Myomectomy can cause significant bleeding that requires transfusion. Moreover, uncontrolled hemorrhage or extensive myometrial injury during tumor removal may necessitate hysterectomy. Patients are also counseled regarding the risk of conversion to an open procedure, which ranges from 2 to 8 percent (American College of Obstetricians and Gynecologists, 2014a).

Postoperatively, serosal adhesions can form and leiomyomas can recur. In some series, the risk of leiomyoma recurrence after laparoscopic myomectomy appears to be higher than in conventional myomectomy (Dubuisson, 2000; Fauconnier, 2000). As one explanation, with laparoscopic myomectomy, small, deep intramural leiomyomas may be missed because a surgeon’s tactile sensation is diminished.

The use of electrosurgical energy on the uterus and challenges of laparoscopic multilayer hysterotomy closure also heighten concerns regarding uterine rupture during a subsequent pregnancy (Hurst, 2005; Parker, 2010; Sizzi, 2007). Women undergoing myomectomy who do plan to have future pregnancies are counseled regarding the possible need for cesarean delivery based on the extent of myometrial disruption during the myomectomy.

Patient Preparation

Hematologic Status and Tumor Size

Many preparatory steps prior to myomectomy address associated patient anemia, anticipated intraoperative blood loss, and tumor size. First, many women who undergo this surgery are often anemic secondary to associated menorrhagia. Correction prior to surgery may include oral iron therapy, gonadotropin-releasing hormone (GnRH) agonist administration, or both. In anticipation of blood loss, a CBC and type and crossmatch for packed red blood cells is obtained. Autologous blood donation or cell saver devices may be considered if great blood loss is expected. In addition, uterine artery embolization may be performed the morning of surgery for large uteri to minimize blood loss. However, this is most often used prior to laparotomy for significantly sized uteri.

GnRH agonists may be considered to decrease leiomyoma size, lower intraoperative blood loss, and decreased adhesion rates. However, loss of pseudocapsule planes around the tumors and greater risk of recurrence due to missed smaller leiomyomas is the trade-off. A fuller evidence-based discussion of these same preoperative options is found in Section 43-10.

Prophylaxis

Few studies have addressed the benefits of preoperative antibiotic use. Iverson and coworkers (1996), in their analysis of 101 open myomectomy cases, found that although 54 percent of patients received prophylaxis, infectious morbidity was not lowered compared with patients in whom antibiotics were not used.

In cases of myomectomy performed for infertility, because of the potential for tubal adhesions associated with pelvic infection, antibiotic prophylaxis is commonly used. For those in whom prophylaxis is planned, 1 g of a first- or second-generation cephalosporin is appropriate (Iverson, 1996; Periti, 1988; Sawin, 2000).

The risk of bowel injury with this procedure is low, and bowel preparation is typically not required unless extensive adhesions are anticipated. Because the risk of conversion to hysterectomy is present, vaginal preparation immediately prior to surgical draping is performed. With laparoscopic gynecologic surgery, the decision to provide VTE prophylaxis factors patient- and procedure-related VTE risks (Gould, 2012). Thus, if longer operating times are anticipated or preexisting VTE risks are present, then prophylaxis as outlined in Table 39-8 is reasonable.

INTRAOPERATIVE

Instruments

Many instruments required for laparoscopic myomectomy are found in a standard laparoscopy instrument set. However, a laparoscopic injection needle may be required for vasopressin injection, and a suction irrigation system is frequently needed to remove blood following tumor enucleation. A myoma screw or tenaculum is helpful to create needed tissue tension and countertension for enucleation. After tumor excision, removal may be accomplished by several techniques described on page 1031. Thus, required endoscopic bags or morcellators are assembled preoperatively.

Surgical Steps

Anesthesia and Patient Positioning

As with most laparoscopic procedures, the patient is placed in low dorsal lithotomy position in booted support stirrups after adequate general anesthesia has been delivered. A bimanual examination is completed to determine uterine size to aid port placement. Because of the risk of hysterectomy and because colpotomy may be used for tumor removal, both the vagina and abdomen are surgically prepared. A Foley catheter is inserted. A uterine manipulator may also be placed, including one that will allow chromotubation at the procedure’s end. If planned, indigo carmine or methylene blue dye is mixed with 50 to 100 mL of sterile saline for injection through the cervical cannula.

Trocar and Laparoscope Insertion

Primary and accessory trocars are placed as described in Chapter 41. Port placement is customized to assist uterine manipulation, leiomyoma excision, and hysterotomy repair. Depending on uterine height, the primary port may need to be placed supraumbilically. In general, a distance of at least 4 cm above the level of the fundus is helpful to provide a global view of the uterus. Typically, at least three accessory ports are required. If use of an electric morcellator is planned, one of the cannulas should be at least 12 mm to accommodate the morcellator. After the abdomen is safely entered, a diagnostic laparoscopy is performed, and the serosal uterine surface should be inspected to identify leiomyomas to be removed. Correlating with preoperative imaging, the surgeon selects the optimal uterine incision to minimize myometrial disruption and to remove the maximum number of tumors thorough one incision.

Use of Vasopressin

8-Arginine vasopressin (Pitressin) is a sterile, aqueous solution of synthetic vasopressin. It is effective in limiting uterine blood loss during myomectomy because of its ability to cause vascular spasm and uterine muscle contraction. Compared with placebo, vasopressin injection has been shown to significantly decrease blood loss during myomectomy (Frederick, 1994).

Each vial of vasopressin is standardized to contain 20 pressor units/mL. Suitable doses for myomectomy include 20 U diluted in a range from 30 to 100 mL of saline (Fletcher, 1996; Iverson, 1996). Vasopressin is typically injected along the planned serosal incision(s), between the myometrium and leiomyoma capsule (Fig. 44-8.1). A laparoscopic needle placed through one of the accessory ports or a 22-gauge spinal needle placed directly through the abdominal wall is suitable for injection. Needle aspiration prior to injection is imperative to avoid intravascular injection of this potent vasoconstrictor. The anesthesiologist is informed of vasopressin injection, as a sudden increase in patient blood pressure may potentially occur following injection. Blanching at the injection site is common. The plasma half-life of this agent is 10 to 20 minutes. For this reason, injection of vasopressin is discontinued 20 minutes prior to uterine repair to allow evaluation of bleeding from myometrial incisions (Hutchins, 1996).

The main risks associated with local vasopressin injection result from inadvertent intravascular infiltration and include transient increases in blood pressure, bradycardia, atrioventricular block, and pulmonary edema (Hobo, 2009; Tulandi, 1996). For these reasons, patients with a medical history of cardiac or pulmonary disease may be poor candidates for vasopressin use.

Serosal Incision

Because of postoperative adhesion formation risks, surgeons minimize the number of serosal incisions and attempt to place incisions on the anterior uterine wall. Tulandi and colleagues (1993) found for open myomectomy that posterior wall incisions result in a 94-percent adhesion formation rate compared with a 55-percent rate for anterior incisions.

After vasopressin injection, hysterotomy may be performed using a Harmonic scalpel, monopolar electrode, or laser. For most patients, an anterior midline vertical uterine incision allows removal of the greatest number of leiomyomas through the fewest incisions. The length should accommodate the approximate diameter of the largest tumor. The incision depth should afford access to all leiomyomas (Fig. 44-8.2).

Tumor Enucleation

Once the hysterotomy is created, the myometrium will generally retract, and the first leiomyoma may be grasped with a laparoscopic single-toothed tenaculum. Alternatively, a leiomyoma screw can also retract tissue to create tension between the myometrium and mass (Fig. 44-8.3). Using a blunt tool or suction-irrigator tip, blunt dissection of the pseudocapsule surrounding the leiomyoma frees the tumor from the adjacent myometrium. Areas requiring sharp dissection from the myometrium may be freed with any of the electrosurgical instruments that were used for the uterine incision.

Bleeding

Hemorrhage during myomectomy primarily develops during tumor enucleation and positively correlates with preoperative uterine size, total weight of leiomyomas removed, and operating time (Ginsburg, 1993). Approximately two to four main arteries feed each leiomyoma and enter the tumor at unpredictable sites. For this reason, surgeons must watch for these vessels, coagulate them prior to transection when possible, and be ready to immediately fulgurate remaining bleeding vessels (Fig. 44-8.4). To avoid myometrial damage, the surgeon applies electrosurgical energy only when necessary.

Myometrial Closure

Following removal of all tumors, redundant serosa may be excised. Laparoscopic suturing techniques described in Chapter 41 are used during incision reapproximation. The same general principles of myometrial closure for abdominal myomectomy are employed during laparoscopic myomectomy. In one method, for deep myometrial closure, a needle driver can be used with 0-gauge delayed-absorbable suture on a CT-2 needle in a continuous running fashion. Smaller internal myometrial incisions are closed first. The primary incision(s) is then closed in layers to improve hemostasis and prevent hematoma formation (Fig. 44-8.5). A gauge of sufficient strength to prevent breakage during muscle approximation is selected, typically 0 to 2-0 gauge. Alternatively, barbed sutures can close myometrial defects during laparoscopic myomectomy. These obviate the need for knot tying and yield consistent wound opposition (Einarsson, 2010; Greenberg, 2008).

Serosal Closure

Closure of the serosal incision using a running suture line with 4-0 or 5-0 gauge monofilament delayed-absorbable suture may help to limit adhesion formation (Fig. 44-8.6). Moreover, absorbable adhesion barriers have been shown to reduce the incidence of adhesion formation following myomectomy and may be introduced through laparoscopic ports (Ahmad, 2008). However, no substantial evidence documents that adhesion barrier use improves fertility, decreases pain, or prevents bowel obstruction (American Society for Reproductive Medicine, 2013).

Tissue Extraction

Once amputated, the myomas must be removed, and options include minilaparotomy, colpotomy, and tissue morcellation. These are fully described in Section 44-10 and illustrated in Chapter 41.

Laparoscopically Assisted Myome­ctomy (LAM)

Another MIS technique that may allow for safe and efficient myomectomy is LAM. The procedure is initiated as described above, and abdominal cavity assessment, uterine inspection, and incision of the serosa and myometrium are performed laparoscopically. To aid in the laparoscopically challenging steps of myomectomy, LAM offers a hybrid approach. Specifically, tumor enucleation and uterine closure are completed through a 2- to 4-cm minilaparotomy incision placed suprapubically. With this, the pneumoperitoneum and visualization through the laparoscope are lost. Instead, application of a wound retraction system such as the Alexis or Mobius retractor provides visual access to the operative field. The uterus and leiomyoma are brought to the surface of the anterior abdominal wall and through the laparotomy incision. The tumors are then enucleated and divided through this incision (Fig. 44-8.7). This open incision also allows for conventional suturing techniques and aids suturing of large defects that require a multilayer closure (Fig. 44-8.8). Advantages include decreased operative time, technical simplicity, improved tactile sensation to detect deep intramural leiomyomas, and easier removal of very large tumors (Prapas, 2009; Wen, 2010). Disadvantages stem mainly from the larger abdominal wall incision.

POSTOPERATIVE

Following abdominal myomectomy, postoperative care follows that for any major laparoscopic surgery. Hospitalization typically varies from 0 to 1 days, and febrile morbidity and return of normal bowel function usually dictate this course (Barakat, 2011). Postoperative activity in general can be individualized, although vigorous exercise is usually delayed until 4 weeks after surgery.

Fever

Febrile morbidity of greater than 38.0°C is common following myomectomy (Iverson, 1996; LaMorte, 1993; Rybak, 2008). Purported causes include atelectasis, myometrial incisional hematomas, and factors released with myometrial destruction. Although fever is common following myomectomy, pelvic infection is not. LaMorte and colleagues (1993) noted only a 2-percent rate of pelvic infection in their analysis of 128 open myomectomy cases.

Subsequent Pregnancy

There are no clear guidelines as to the timing of pregnancy attempts following myomectomy. Darwish and colleagues (2005) performed sonographic examinations on 169 patients following open myomectomy. Following myometrial indicators, they concluded that wound healing is usually completed within 3 months. There are no clinical trials that address the issue of uterine rupture and therefore route of delivery of pregnancies occurring after myomectomy (American College of Obstetricians and Gynecologists, 2014a). Management of these cases requires sound clinical judgment and individualization of care. In general, large incisions or those entering the endometrial cavity favor cesarean delivery.

Several laparoscopic techniques have been developed for hysterectomy and vary depending on the degree of laparoscopic dissection versus vaginal surgery required to remove the uterus (Garry, 1994). These include:

• Diagnostic laparoscopy prior to vaginal hysterectomy (VH)

• Vaginal hysterectomy assisted by laparoscopy, that is, lysis of adhesions and/or excision of endometriosis prior to VH

• Laparoscopically assisted vaginal hysterectomy (LAVH): laparoscopic dissection down to, but not including, uterine artery transection

• Laparoscopic hysterectomy (LH): laparoscopic dissection, including uterine artery transection, but completion of hysterectomy vaginally

• Total laparoscopic hysterectomy (TLH): complete laparoscopic excision of the uterus.

The laparoscopic approach offers advantages over traditional total abdominal hysterectomy (TAH). These include significant lower analgesia requirements, shorter hospital stays, rapid recovery, greater patient satisfaction, and lower rates of wound infection and hematoma formation (Kluivers, 2007; Schindlbeck, 2008). Disadvantageously, sur­gical time is lengthened, although the learning curve may be a factor. TLH offers fewer advantages compare with VH. Thus, in most cases, TLH should be an alternative to TAH (American College of Obstetricians and Gynecologists, 2011; Marana, 1999; Nieboer, 2009).

For all the hysterectomy types described in the following sections, plans for concurrent bilateral salpingo-oophorectomy (BSO) or for prophylactic salpingectomy are individualized. A detailed discussion of the surgical BSO is found in Chapter 43, whereas the advantages of risk-reducing salpingectomy are outlined in Chapter 35.

PREOPERATIVE

Patient Evaluation

A thorough pelvic examination and history reveal factors that help determine the optimal surgical route. Poor candidates for a vaginal approach include patients with minimal uterine descent, extensive abdominal or pelvic adhesions, a large uterus not amenable to tissue extraction methods, adnexal pathology, and a restricted vaginal vault or contracted pelvis. Patients with these findings are generally considered for TAH and also for TLH (Schindlbeck, 2008).

Of factors, uterine size and mobility are important. There is no agreed-upon size that precludes LH. However, a wide bulky uterus with minimal mobility may make it difficult to visualize vital structures, to manipulate the uterus during surgery, and to remove it vaginally. Once a patient has been deemed eligible for a laparoscopic approach, the same preoperative evaluation as for abdominal hysterectomy applies (Section 43-12).

Consent

Similar to an open approach, possible risks of hysterectomy include increased blood loss and need for transfusion, unplanned adnexectomy, and injury to other pelvic organs, especially bladder, ureter, and bowel. The ureters are also at greater risk during LH compared with other hysterectomy approaches (Harkki-Siren, 1997, 1998). Kuno and colleagues (1998) evaluated ureteral catheterization to prevent such injury but found no benefit. Complications related specifically to laparoscopy include injury to the major vessels, bladder, and bowel during trocar placement (Chap. 41).

The risk of conversion to an open procedure is also discussed. In general, conversion to laparotomy may be necessary if exposure and organ manipulation is limited or if bleeding is encountered that cannot be controlled laparoscopically.

Concurrent salpingectomy during hysterectomy may be considered to lower future rates of some epithelial ovarian cancers. For this, complete rather than partial salpingectomy is preferred. Operating time is minimally lengthened, but complication rates are not increased. Notably, the American College of Obstetricians and Gynecologists (2015) has emphasized that the planned route of hysterectomy should not be changed to complete prophylactic salpingectomy.

Patient Preparation

A blood sample is typed and crossmatched for potential transfusion. If considered, bowel preparation prior to laparoscopy may assist with colon manipulation and pelvic anatomy visualization by evacuating the rectosigmoid. Alternatively, enemas prior to surgery may be as effective for this goal. Antibiotic prophylaxis is administered within the hour prior to skin incision, and appropriate antibiotic options are listed in Table 39-6. Overall, the likelihood of VTE during laparoscopic hysterectomy is significantly reduced when compared to abdominal hysterectomy (Barber, 2015). Thus, the decision to provide VTE prophylaxis should factor patient- and procedure-related VTE risks (Gould, 2012). If longer operating times are anticipated, conversion to laparotomy is a concern, or preexisting VTE risks are present, then prophylaxis as outlined in Table 39-8 is reasonable.

INTRAOPERATIVE

Instruments

Vessel occlusion is an important component of any hysterectomy. For this, suitable instruments include monopolar or bipolar instruments, Harmonic scalpel, stapling devices, traditional sutures, and suturing devices. Several of these can be used for dissection and hemostasis. The Harmonic scalpel is frequently used for its ability to cut with minimal smoke plume and little surrounding thermal tissue damage, although it should only be used to seal vessels up to 5 mm. Several advanced bipolar devices also offer improved vessel sealing. With various instruments, vessels measuring up to 5 mm (LigaSure, Gyrus Plasma Kinetic) and up to 7 mm (ENSEAL) can be coagulated with minimal thermal spread (Lamberton, 2008; Landman, 2003; Smaldone, 2008).

Surgical Steps

Anesthesia and Patient Positioning

For most women, these procedures are performed in an inpatient setting under general anesthesia. The patient is placed in a low dorsal lithotomy position in booted support stirrups. A bimanual examination is completed to determine uterine size and shape to aid port placement. The abdomen and vagina are surgically prepared, a Foley catheter is inserted, and orogastric or nasogastric tube is placed. Uterine manipulators can assist with visualization. These are considered in cases in which anatomic distortion is anticipated or in those with large uteri.

Initial Steps

The introductory steps for LH mirror that for other laparoscopic procedures (Chap. 41). The number of ports and their caliber may vary, but in general, LH requires a 5- to 12-mm optical port placed at the level of the umbilicus or higher for larger uteri. Left upper quadrant entry is considered in cases of suspected periumbilical adhesions. For larger uteri, if the uterine fundus is close to or above the level of the umbilicus, the optical port is placed approximately 3 to 4 cm above the fundus for optimal viewing. Two or three accessory ports are also placed through the lower abdominal wall. Specifically, two ports are positioned beyond the lateral borders of the rectus abdominis muscle, whereas a third may be positioned centrally and cephalad to the uterine fundus.

Pelvic Evaluation

With the ports and laparoscope inserted and the patient in Trendelenburg position, a blunt laparoscopic probe can aid organ manipulation. The pelvis and abdomen are visually explored. At this point, the decision is made whether to continue with LH or convert to laparotomy. If needed, adhesions are lysed to restore normal anatomy. The bowel is displaced from the pelvis into the abdomen to expand available operating space and viewing.

Ureter Identification

Irrigating fluids and CO₂ used for insufflation can, with time, create edema of the peritoneum and hinder viewing of retroperitoneal structures. For this reason, the ureters are identified early. The ureters can often be seen easily beneath the pelvic peritoneum, or the peritoneum may be open to identify these. In such situations, the peritoneum medial to the infundibulopelvic (IP) ligament is grasped and tented using atraumatic forceps and incised with scissors. Hydrodissection techniques may be employed. The opening in the peritoneum then is extended caudally and cephalad along the length of the ureter. Through this peritoneal window, the ureter is identified, and peristalsis should be noted (Fig. 44-9.1) (Parker, 2004).

Round Ligament Transection

The proximal round ligament is grasped and divided.

Ovarian Conservation

If ovarian pre­servation is planned, proximal portions of the fallopian tube and uteroovarian ligament are also desiccated and transected (Figs. 44-9.1 and 44-9.2). With this, the tube and ovary are freed from the uterus and can be placed in the ovarian fossa.

Oophorectomy

If removal of the ovaries is desired, the IP ligament is grasped and pulled up and away from retroperitoneal structures. The presence and path of the ureter is identified. The IP ligament is isolated and dissected away from the ureteral course. The pedicle is coagulated, desiccated, or stapled, and then divided (Fig. 44-9.3).

Broad Ligament Incision

Following transection of the round ligament, the leaves of the broad ligament fall open and loose gauzy connective tissue is found between these leaves. The anterior leaf is incised sharply (Fig. 44-9.4). This incision is directed caudally and centrally to the midline above the vesicouterine fold. The posterior leaf requires incision caudally to the level of the uterosacral ligament. The loose areolar tissue separating the anterior and posterior leaves is dissected as well. Ultimately, opening the broad ligament provides access to lateral uterine anatomy, which is important for subsequent uterine artery ligation.

Bladder Flap Development

After broad ligament incision bilaterally, the vesicouterine fold is grasped with atraumatic forceps, elevated away from the underlying bladder, and incised (Fig. 44-9.5). This exposes connective tissue between the bladder and underlying uterus in the vesicouterine space. Loosely attached connections can be bluntly divided by gently pushing against the cervix and caudally to move the bladder caudad (Fig. 44-9.6). Denser tissue in the vesicouterine space is better divided sharply. With this, the tissue is elevated, and the scissors are kept close to the surface of the cervix to minimize inadvertent cystotomy risk. As this tissue is dissected, the vesicouterine space is opened. Electrosurgery may be needed to coagulate small bleeding vessels. Creating cephalad traction on the uterus with the uterine manipulator may also help with this dissection. Development of this space allows the bladder to be moved caudally and off the lower uterus and upper vagina. This mobilization of the bladder is necessary for final colpotomy and uterus removal. Of the hysterectomy types, MIS approaches have the highest risk of bladder injury, and injury occurs most frequently to the dome during this sharp or blunt dissection (Harkki, 2001). This risk is increased if prior cesarean delivery or endometriosis has left scarring.

Uterine Artery Transection

After the uterine arteries are identified, the areolar connective tissue surrounding them is grasped, placed on tension, and incised. This skeletonizing of the vessels leads to superior occlusion of the uterine artery and vein. The arteries then are then coagulated and transected (Fig. 44-9.7). Alternatively, surgeons may elect to terminate the laparoscopic portion prior to uterine artery transection and complete artery ligation from a vaginal approach (LAVH).

Vaginal Hysterectomy

With LH, after the uterine arteries are transected, the surgical approach is converted to that for vaginal hysterectomy and is completed as outlined in Section 43-13. In this transition, the patient is repositioned from low dorsal lithotomy to standard lithotomy position.

Abdominal Inspection

After vaginal completion of the hysterectomy, attention is redirected to laparoscopic inspection of the pelvis for signs of bleeding. Before returning to the abdomen, surgeons will replace their surgical gloves. Copious irrigation of the abdominopelvic cavity and confirmation of hemostasis is performed. During this inspection, intraabdominal pressures are lowered to better identify sources of bleeding. The laparoscopic procedure is terminated as outlined in Section 44-1.

POSTOPERATIVE

Following LH, patient recovery mirrors that for vaginal hysterectomy. In general, compared with those undergoing abdominal hysterectomy, LH patients have faster return of normal bowel function, easier ambulation, and decreased analgesia requirements. A clear liquid diet can be initiated the day of surgery and advanced quickly as tolerated. Postoperative complications in general mirror those for abdominal hysterectomy with the exception that superficial surgical site infection rates are lower.

Laparoscopic supracervical hysterectomy (LSH) differs from total laparoscopic hysterectomy (TLH) in that the uterine corpus is amputated, but the cervix remains. Once freed, the corpus either is delivered through a posterior colpotomy or minilaparotomy incision or undergoes enclosed morcellation. Advantageously, the uterosacral and cardinal ligaments, which are important to pelvic support, are retained. It is also an excellent alternative for cases complicated by extensive scarring. Specifically, adhesions between the bladder and the lower uterine segment in the vesicouterine space or those in the cul-de-sac may make removal of the cervix difficult. Related to this, ureteral and bladder injury rates are decreased by avoiding difficult dissection.

Certain contraindications to preserving the cervix are excluded prior to selecting supracervical hysterectomy. Examples include Pap test findings of high-grade cervical dysplasia; endometrial hyperplasia with atypia or endometrial cancer; or a patient at risk for noncompliance with routine cervical cancer screening.

PREOPERATIVE

Patient Evaluation

A thorough pelvic examination and history reveal factors that help determine the optimal surgical route. Uterine size and mobility are important, although there is no agreed-upon size that precludes LSH. That said, a large bulky uterus with minimal mobility may be difficult to adequately manipulate, may limit exposure during surgery, and may be challenging to extract. Once a patient has been deemed eligible for a laparoscopic approach, the same preoperative evaluation as for an abdominal hysterectomy applies (Section 43-12).

Consent

Similar to an open approach, possible risks of LSH include blood loss and need for transfusion, unplanned adnexectomy, and injury to other pelvic organs, especially bladder, ureter, and bowel. Complications related specifically to laparoscopy include injury to the major vessels, bladder, and bowel during trocar placement (Chap. 41, 877).

Postoperatively, endometrium within the lower uterine segment may be retained with LSH. As a result, the risk of cyclic long-term bleeding is a potential consequence. Rates quoted in early studies are as high as 24 percent but are lower in more recent investigations and range from 5 to 10 percent (Okaro, 2001; Sarmini, 2005; Schmidt, 2011; van der Stege, 1999). Techniques that resect more of the lower uterine and proximal endocervical tissue appear to decrease these long-term bleeding risks (Schmidt, 2011; Wenger, 2005).

In some case, secondary excision of the cervical stump may later be required. Termed trachelectomy, this excision may be indicated if refractory long-term bleeding or significant subsequent cervical neoplasia develops postoperatively. Trachelectomy has the additional indication for residual persistent infection, although this is more anecdotal and not quoted with a consistent incidence. Overall rates of trachelectomy appear to mimic the bleeding rates above and are on a downward trend.

The risk of conversion to an open procedure is also discussed. In general, conversion to laparotomy may be necessary if exposure and organ manipulation are limited or if bleeding is encountered that cannot be controlled with laparoscopic tools and techniques.

Patient Preparation

A blood sample is typed and crossmatched for potential transfusion. If considered, bowel preparation prior to laparoscopy may assist with colon manipulation and pelvic anatomy visualization by evacuating the rectosigmoid. Enemas prior to surgery may be as effective for this goal. Antibiotic prophylaxis is administered within the hour prior to skin incision, and appropriate antibiotic options are listed in Table 39-6. With laparoscopic gynecologic surgery, the decision to provide VTE prophylaxis factors patient- and procedure-related VTE risks (Gould, 2012). Thus, if longer operating times are anticipated, conversion to laparotomy is a concern, or preexisting VTE risks are present, then prophylaxis as outlined in Table 39-8 is reasonable.

INTRAOPERATIVE

Instruments

During cervical amputation, blunt scissors, Harmonic scalpel, laser, or monopolar needle or scissors may be used to excise the corpus. Vessel occlusion is an important component of any hysterectomy. For this, suitable instruments include monopolar or bipolar instruments, Harmonic scalpel, stapling devices, traditional sutures, and suturing devices. Many of these instruments may not be readily available in all operating suites, and desired tools should be requested prior to surgery. After tumor excision, removal may be accomplished by several techniques described in Steps 3, 4, and 5. Thus, required endoscopic bags or morcellators are assembled preoperatively.

Surgical Steps

Initial Steps

The initial surgical steps for LSH mirror those for LH, including coagulation of the uterine vessels as described in Section 44-9, Steps 1 through 10.

Uterine Amputation

The corpus is amputated from the cervix at a point just below the internal cervical os and superior to the uterosacral ligaments (Fig. 44-10.1). To limit the possibility of residual endometrium, the incision is conical and extends down into the cervix (Figs. 44-10.2 through 44-10.4). Following amputation, adjunctive coring or ablation of the endocervical canal also may be performed to decrease the risk of postoperative cyclic bleeding (Fig. 44-10.5).

Tissue Extraction

Once amputated, the uterine corpus must be removed, and options include minilaparotomy, colpotomy, and enclosed morcellation. Although described here for the uterine corpus, these methods translate to surgical removal of other specimens.

First, for smaller specimens, a minilaparotomy incision ranging from 1 to 4 cm can be made to extract the corpus. Typically, a small Pfannenstiel incision is made, although a small midline vertical incision is also suitable. Both incisions are illustrated in Chapter 43.

For larger uteri, the addition of a tissue retrieval bag and self-retaining retractor can create a closed environment for manual morcellation. For this, a retrieval bag is initially placed into the abdomen. The bag containing the excised specimen is then brought to the surface and is fanned open outside and around the minilaparotomy incision. A self-retaining circular retractor is placed into the bag’s interior and simultaneously opened within the incision (see Fig. 44-8.7). This creates a closed environment where the specimen can be sharply divided manually with scissors or knife. Long-term data on safety and efficacy are not currently available.

Colpotomy

As another option, a posterior colpotomy can be created similar to that for vaginal hysterectomy and shown in Figure 41-27. To enter the posterior cul-de-sac, attention is turned to the vagina, and handheld retractors are placed to expose the cervix and posterior fornix. The uterine manipulator is used to anteflex the uterus, and an Allis clamp is placed on the posterior vaginal wall 2 to 3 cm from the posterior cervicovaginal junction. The Allis clamp is pulled downward to create tension across the posterior vaginal wall. The posterior vaginal vault is then cut with curved Mayo scissors, and the cul-de-sac of Douglas is entered.

Alternatively, a colpotomy may be created laparoscopically by incising the posterior cul-de-sac with a monopolar instrument, a harmonic scalpel, or Endo Shears near the cervicovaginal junction. A uterine manipulator is used to reflect the uterus anteriorly to create space for the colpotomy, and a sponge stick may be used vaginally to help delineate the space. As Figure 41-28 illustrates, care is taken to avoid damage to the rectosigmoid and to the ureters, which lie lateral to the planned colpotomy.

With colpotomy, pneumoperitoneum is lost immediately. If a laparoscopic instrument is already holding the specimen, this can be passed through the colpotomy and removed vaginally. For larger uteri, the addition of a tissue retrieval bag during tissue extraction can create a closed environment for scissor morcellation (Fig. 41-29). This reduces the risk of inadvertent tissue dissemination during fragmentation, although long-term safety data are needed (Cohen, 2014; Einarsson, 2014).

Following extraction, the vaginal incision is closed with interrupted stitches or a running suture line using 0-gauge delayed-absorbable suture. If colpotomy is used for specimen removal, a single prophylactic dose of antibiotics is administered. Suitable agents are listed in Table 39-6.

Morcellation

A third method, enclosed power morcellation, is still being studied. For this, a large containment bag that can house the insufflation gas, can conform to the abdominal cavity, and can flatten against the intraperitoneal organs is introduced into the abdomen. Once in the abdomen, it is unfolded to allow the specimen and gas to be contained. Depending on the pathology, the bag may be exteriorized through one abdominal port or incision or may function simply as a liner that catches any disseminated tissue during power or manual morcellation (Einarsson, 2014).

During power morcellation, the corpus specimen is grasped securely with a toothed instrument such as a tenaculum and brought to the anterior abdominal wall. Because of the potential for surrounding organ injury, morcellators should not be moved toward the grasped tissue, but rather, those tissues should be brought to it (Fig. 44-10.6) (Milad, 2003). Importantly, the morcellator tip is always kept in laparoscopic view. A peeling rather than coring technique is used to pare down the mass. During this, the tenaculum holding the corpus is drawn up into the morcellator cylinder and well past the edge of the morcellating blade. This avoids metal-to-metal contact, which dulls the blade. In cases of prolonged morcellation, such as with large uteri, the blade may dull. For this, the generator allows a reverse in the blade’s rotary direction. Improved cutting is usually restored with this step and generally offers enough blade life to complete the procedure.

Following morcellation, the gas is released, and bag and tissue fragments are removed. Limitations of currently available retrieval bags involve pouch size, working aperture diameter, tensile strength of the bag, and bag permeability.

Hemostasis

Points of bleeding are coagulated, and the surgeon may elect to reapproximate the anterior vesical and posterior cul-de-sac peritoneum to cover the cervical stump using 2-0 or 0-gauge delayed-absorbable suture. Alternatively, absorbable adhesion barriers (Interceed, Seprafilm) can be placed at the hemostatic surgical stump.

Laparoscopy Final Steps

Completion of the procedure follows that for general laparoscopic procedures.

POSTOPERATIVE

Advantages of laparoscopy include a rapid return to normal diet and activities. With supracervical hysterectomy, there is no vaginal cuff that requires extended healing. Sexual intercourse, however, is delayed for 2 weeks following surgery to allow adequate internal healing.

Total laparoscopic hysterectomy (TLH) is similar to LAVH, LSH, and LH with the exception that the procedure is completed entirely from a laparoscopic approach. After detachment, the specimen is removed vaginally or by tissue extraction techniques described on page 1031.

If all factors are equal, vaginal hysterectomy is considered for women undergoing hysterectomy. Ideal candidates for TLH are those not suitable for vaginal hysterectomy (American College of Obstetricians and Gynecologists, 2011). As such, TLH is viewed as a less invasive alternative to TAH. Compared with TAH, TLH benefits include rapid recovery, shorter hospitalizations, fewer minor complications of the wound or abdominal wall, and less blood loss (Nieboer, 2009; Walsh, 2009). These benefits are dependent on a learning curve and may not be readily apparent (Schindlbeck, 2008). Moreover, longer operative times and higher rates of urinary tract injuries are negative balancing factors.

PREOPERATIVE

Patient Evaluation

A thorough pelvic examination and history reveal factors that help determine the optimal surgical route. Uterine size and mobility are important, although there is no agreed-upon size that precludes TLH. That said, a wide bulky uterus with minimal mobility may be difficult to adequately manipulate, may limit exposure during surgery, and may be challenging to extract. Once a patient has been deemed eligible for a laparoscopic approach, the same preoperative evaluation as for an abdominal hysterectomy applies (Section 43-12).

Consent

Similar to an open approach, possible risks of this procedure include increased blood loss and need for transfusion, unplanned adnexectomy, and injury to other pelvic organs, especially bladder, ureter, and bowel. Complications related to laparoscopy include entry injury to the major vessels, bladder, and bowel (Chap. 41). The ureters are also at greater risk during laparoscopic hysterectomies compared with other hysterectomy approaches (Harkki-Siren, 1998). Kuno and colleagues (1998) evaluated the use of ureteral catheterization to prevent such injury but found no benefit.

The risk of conversion to an open procedure is also discussed. In general, conversion to laparotomy may be necessary if exposure and organ manipulation is limited or if bleeding is encountered that cannot be controlled with laparoscopic tools and techniques.

Patient Preparation

A blood sample is typed and crossmatched for potential transfusion. If considered, bowel preparation prior to laparoscopy may assist with colon manipulation and pelvic anatomy visualization by evacuating the rectosigmoid. Alternatively, enemas prior to surgery may be as effective for this goal. Antibiotic prophylaxis is administered within the hour prior to skin incision, and appropriate antibiotic options are listed in Table 39-6. With laparoscopic gynecologic surgery, the decision to provide VTE prophylaxis factors patient and procedure-related VTE risks (Gould, 2012). Thus, if longer operating times are anticipated, conversion to laparotomy is a concern, or preexisting VTE risks are present, then prophylaxis as outlined in Table 39-8 is indicated.

PREOPERATIVE

Instruments

The same instruments that are used for the LH or LSH can be used for this procedure. In addition, a uterine manipulator that has a cupping device for delineating the cervicovaginal junction is helpful for colpotomy and also for final tissue extraction. If these are not available, a low-cost alternative is a right-angle retractor to delineate the anterior and posterior fornices for colpotomy.

Surgical Steps

Anesthesia and Patient Positioning

For most women, TLH is performed as an inpatient procedure under general anesthesia. The patient is placed in low dorsal lithotomy position in booted support stirrups. A bimanual examination is completed to determine uterine size and shape to aid port placement. The abdomen and vagina are surgically prepared, a Foley catheter is inserted, and an orogastric or nasogastric tube is placed.

Uterine Manipulator

A uterine manip­ulator with its attached cervical cup (VCare or KOH Cup with RUMI manipulator) is placed vaginally to assist uterine manipulation and delineate the cervicovaginal junction for colpotomy. To accomplish placement, the cervical diameter and thickness are assessed. From this information, the manipulator-cup size, which is small, medium, or large, is selected. To permit manipulator insertion, the cervical os is dilated to accept a no. 8 cervical dilator. The uterus is also sounded to determine cavity depth for correct manipulator placement. The surgeon tests the balloon at the manipulator’s end for patency by filling it with air via a port at the opposite end. Once again deflated, it is passed through the cervical os to the fundus and then reinflated to hold the manipulator in place (Fig. 44-11.1A). Two stay sutures of 0-gauge delayed-absorbable suture are placed at 6 and 12 o’clock or at 3 and 9 o’clock, depending on surgeon preference. To securely anchor the cup and cervix, stitches enter the ectocervix and exit just lateral to the endocervix. Each suture end is then passed through openings in the cup base (Fig. 44-11.1B). They are then tied firmly to the cervix on the outside face of the cup (Fig. 44-11.1C). Once in position, the proximal rim of the cup will delineate the cervicovaginal junction. With the VCare, the blue vaginal cup is then advanced to join the interior cup and is locked in place by a locking knob at the manipulator’s distal end (Fig. 44-11.1D). If the KOH Cup is used, then a pneumo-occluding balloon is positioned behind the colpotomy cup.

Initial Laparoscopic Steps

The intro­ductory steps for LH mirror those for other laparoscopic procedures (Chap. 41). The number of trocars and their caliber may vary, but in general, TLH requires a 5- to 12-mm optical port, usually at the umbilicus, and two or three accessory ports placed through the lower abdominal wall. Specifically, two trocars are placed beyond the lateral borders of the rectus abdominis muscle, whereas a third may be positioned centrally and cephalad to the uterine fundus. Left upper quadrant entry is considered for initial entry in cases with suspected periumbilical adhesions.

Pelvic Evaluation

With the cannulas and laparoscope inserted and the patient in Trendelenburg position, a blunt laparoscopic probe aids bowel displacement. The pelvis and abdomen are thoroughly explored. At this point, the decision to continue with TLH or convert to laparotomy is made. If necessary, adhesions are lysed to restore normal anatomy.

Ureter Identification

Irrigating fluids and CO₂ used for insufflation can with time create edema of the peritoneum and hinder visualization of structures beneath it. For this reason, the ureters are identified early. The ureters are often easily seen retroperitoneally, or the peritoneum may be opened to locate them. In such situations, the peritoneum medial to the infundibulopelvic (IP) ligament is grasped and tented using atraumatic forceps and incised with scissors. An irrigating probe is used to force water beneath and elevate the peritoneum for easier incision. The opening in the peritoneum then is extended a short distance caudally and cephalad over the suspected path of the ureter. Through this peritoneal window, the ureter is identified (see Fig. 44-9.1) (Parker, 2004).

Round Ligament, Adnexa, and Uterine Artery

The initial steps for TLH mirror those for LH, described in Section 44-9, Steps 5 through 10. These steps include transection of the round ligament, conservation or excision of the adnexa, caudad displacement of the bladder, and coagulation of the uterine vessels.

Cardinal Ligament Transection

Following uterine artery coagulation, the cardinal ligaments are transected on each side to reach the level of the uterosacral attachments (Fig. 44-11.2).

Colpotomy

Incision at the cervicovaginal junction may be performed with Harmonic scalpel, monopolar scissors, monopolar hook, or plasma kinetic needle point. Prior to incision, the uterine manipulator is pushed cephalad to allow the cervical cupping device to displace the ureters laterally and expose the optimal location for colpotomy. Additionally, dissection within the vesicouterine space should be sufficient to mobilize the bladder caudad and away from the planned colpotomy site.

With these preparatory steps completed, colpotomy is begun by placing the incising tool at the posterior cervicovaginal junction, which is delineated by the cervical cup. If a colpotomy cup is not used, a simple tool such as a right-angle retractor or sponge on a stick placed vaginally in the posterior fornix can also assist with delineating the cervicovaginal junction. The posterior vaginal wall is opened first (Fig. 44-11.3). By extending this incision, the uterosacral ligament is next transected (Fig. 44-11.4). The opposite uterosacral ligament is then divided close to the cervix. Last, the anterior colpotomy incision is created (Fig. 44-11.5). To minimize twisting and specimen disorientation, the lateral vaginal cuff points are transected last (Fig. 44-11.6). Hemostasis is generally maintained using this technique. To prevent vaginal tissue thermal damage and subsequent cuff dehiscence, surgeons use the minimum necessary amount of electrosurgery on the vaginal cuff.

Removal of Uterus

The uterus is removed intact through the vaginal vault using the manipulator, unless uterine size limits this (Fig. 44-11.7). In the case of large uteri, the uterus is removed using tissue extraction techniques described on page 1031.

Repair of the Vaginal Cuff

The cuff is closed laparoscopically with a running closure of absorbable suture, with interrupted figure-of-eight sutures, or with a suturing device. For this, delayed-absorbable material is preferred, and the uterosacral ligament is incorporated into the closure for vaginal cuff support (Fig. 44-11.8). If traditional suture is used, one must maintain tension to sufficiently close the cuff. If using barbed suture, the procedure is modified by manufacturer’s recommendations to loosen stitch tension between the approximated cuff tissues. Moreover, if barbed suture is used, it is recommended to throw at least two bites in the opposite direction to the original direction of suture line closure to maintain tissue tension. For example, if closure is performed from right to left, the surgeon will reach the far left end and then will place two additional stitches in the left-to-right direction prior to final suture cutting. It is advisable to cut the suture flush with the tissue to decrease bowel damage risk from the barbed end. Confirmation of full-thickness closure is necessary to prevent later cuff dehiscence. Alternatively, for those less proficient with laparoscopic suturing, the cuff may be closed vaginally after removal of the uterus as described in Section 43-13.

After cuff closure, irrigation and confirmation of hemostasis is performed. Intra­abdominal pressures are lowered during this inspection to better identify sources of bleeding.

Laparoscopy Final Steps

Completion of this operation follows that for diagnostic laparoscopy.

POSTOPERATIVE

The advantages of a laparoscopic approach include a rapid return to normal diet and activities. Generally, the evening of the surgery, the Foley catheter is removed, diet is advanced, and the patient is allowed to ambulate. Oral analgesics are quickly adopted in place of parenteral options. The usual precautions for abdominal hysterectomy in regard to limitation of stress on the abdominal cavity by heavy lifting are followed. Delay of sexual activity mirrors that for abdominal hysterectomy, which is typically 6 weeks.

Vaginal cuff dehiscence is a serious postoperative complication that more frequently follows laparoscopic hysterectomy approaches compared with VH or TAH (Agdi, 2009; Walsh, 2007). In most cases, the precipitating event is sexual activity in premenopausal women and increased intraabdominal pressure coupled with a weak, atrophic vagina in postmenopausal women (Lee, 2009). Patients present with vaginal bleeding or evisceration. Typical treatment includes debridement of vaginal cuff edges, reapproximation with delayed-absorbable suture, and administration of antibiotic prophylaxis. However, compromised bowel may require more extensive surgeries to repair.

Preventatively, sound initial surgical technique strives to minimize electrosurgical damage during colpotomy creation and limit undue desiccation of the vaginal cuff. Approximation of all tissue planes, particularly full-thickness closure of the vaginal wall, should also be ensured. Reapproximation includes an adequate amount of viable tissue that is free of thermal effect. In addition, a two-layer closure may have an advantage over a single-layer figure-of-eight closure (Jeung, 2010).

Hysteroscopy allows an endoscopic view of the endometrial cavity and tubal ostia. Indications are varied and include evaluation of abnormal uterine bleeding, infertility, or a sonographically identified uterine cavity mass Contraindications to surgery include pregnancy and current reproductive tract infection.

PREOPERATIVE

Consent

Risks with diagnostic hysteroscopy are infrequent. Those described in Chapter 41 include uterine perforation and volume overload. Gas embolism is rare.

Patient Preparation

Infectious and VTE complications following hysteroscopic surgery are also rare. Accordingly, prophylaxis is typically not required (American College of Obstetricians and Gynecologists, 2013c, 2014b).

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Diagnostic hysteroscopy can be performed in an outpatient setting under local anesthesia with or without intravenous sedation. Alternatively, a day-surgery setting and general anesthesia may be selected.

The patient is placed in standard lithotomy position, the vagina is surgically prepared, and the bladder is drained. Because diagnostic hysteroscopy is a short procedure with little if any blood loss, CO₂ or saline is typically selected for uterine distention. Trendelenburg positioning should be avoided to prevent the risk of gas embolism.

Hysteroscope Assembly

For assembly, the hysteroscope is placed within its outer sheath and locked into place. The light source is then attached to the endoscope. By convention, during hysteroscope insertion, the light source is kept pointing toward the floor. The distention media tubing port is attached to a port that typically lies 180 degrees away from the light source connection.

Hysteroscope Introduction

For most diagnostic hysteroscopic procedures, cervical dilatation is not required to admit the 4- to 5-mm hysteroscope. Uterine sounding is not recommended by many because information regarding uterine depth and cavity inclination is provided by direct visualization during hysteroscope insertion. Moreover, the sound may disrupt the endometrium. This may alter endometrial anatomy prior to inspection and may cause obscuring bleeding.

For diagnostic purposes, a hysteroscope equipped with a 0-, 12-, or 30-degree forward oblique-view lens is suitable. A single-toothed tenaculum is placed on the anterior cervical lip, the flow of distention medium is begun, and the hysteroscope is introduced into the endocervical canal. Pressure exerted by the medium opens the endocervical canal and allows entry of the hysteroscope.

If using an angled lens, the surgeon should keep in mind that a panoramic image with a dark hole directly in the middle of the view is incorrect. The desired image would have the cervical canal at the bottom of the monitor if the light cord is directed downward, thus implying that the hysteroscope is in fact in the center of the cervical canal (Fig. 41-37).

Hysteroscopic Evaluation

As the hysteroscope is inserted, the endocervical canal is examined for abnormalities. Upon entering the cavity, the hysteroscope is held at the distal portion of the cavity to allow a panoramic evaluation. Systematically, the hysteroscope is moved to the fundus and then to the left and right to permit inspection of the tubal ostia (Fig. 44-12.1). If an angled lens is employed, the hysteroscope may remain just beyond the internal cervical os and the light cord moved in a 180-degree rotational arc to obtain a global assessment of the endometrial cavity. Some surgeons also advocate keeping the hysteroscope in the cavity, evacuating it of distention medium, and evaluating the cavity in this decompressed stage. This helps identify lesions that may have been obliterated or flattened by the increased pressure of the distention medium.

Specific Procedures

Following complete cavity inspection, if specific lesions are identified, they are typically biopsied under direct visualization with hysteroscopic forceps. If intrauterine device (IUD) removal is planned, most are grasped by the string or stem with hysteroscopic grasping forceps and are easily extracted as the entire hysteroscope is removed. However, embedded or fragmented devices may require removal in pieces. In these instances, a sturdy portion of the IUD is firmly grasped and traction on the forceps is exerted toward the vagina. For cases in which the IUD is deeply embedded, laparoscopy can assist in identifying uterine perforation and in determining whether the device is best removed hysteroscopically or laparoscopically.

Procedure Completion

At the end of the procedure, the flow of distending medium is stopped, and the hysteroscope and then tenaculum are removed. A critical step at this point, and throughout the procedure, is to note the amount of distention fluid used and the amount retrieved. These values are used to calculate the fluid deficit, which is included in the operative report.

POSTOPERATIVE

Patient recovery is typically rapid and without complication and mirrors that following dilatation and curettage. Diet and activities may be resumed as desired by the patient. Spotting or light bleeding is not uncommon and typically stops within days.

Indications for endometrial polyp removal include abnormal uterine bleeding, infertility, and risk of malignant transformation (Chap. 8). Hysteroscopic excision of these growths may be completed by incision of the polyp base with hysteroscopic scissors or resectoscope loop, avulsion of the polyp with hysteroscopic forceps, or retrieval using suction and morcellation. Of these, the resectoscope and morcellator offer the most versatility in managing lesions, both large and small.

PREOPERATIVE

Patient Evaluation

In many women undergoing polypectomy, preoperative transvaginal sonography or saline infusion sonography examinations have been completed. Information regarding the size, number, and location of polyps is reviewed prior to surgery. Rarely, MR imaging may be indicated to fully distinguish a presumed polyp from a submucous leiomyoma. This often helps determine if myomectomy is instead required.

Consent

The complication rates for this procedure are low and mirror that for hysteroscopy in general (Chap. 41). Thus, bleeding, infection, and uterine perforation, and rare fluid overload and gas embolism are described.

Patient Preparation

As with most hysteroscopic procedures, polypectomy is ideally performed during the follicular phase of the menstrual cycle, when the endometrial lining is thinnest and polyps would be most easily identified. Preoperative endometrial biopsy is optional but is generally considered part of abnormal uterine bleeding evaluation for those with endometrial cancer risks (Chap. 8). Preoperative antibiotics or VTE prophylaxis is typically not required (American College of Obstetricians and Gynecologists, 2013c, 2014b).

INTRAOPERATIVE

Instruments

A resectoscope with a 90-degree loop electrode is ideal for polyp excision. Alternatively, an intrauterine morcellator has a hollow cannula that is attached to suction and can quickly excise small to large growths. For smaller polyps, polyp forceps may also be used through the 5F channel of the operative port.

Surgical Steps

Anesthesia and Patient Positioning

Although simple polypectomy procedures under local analgesia in an office setting have been described, most cases are outpatient procedures performed under general or regional anesthesia. The complexity of fluid management, particularly with the use of hypotonic fluids, warrants a degree of safety that can be best provided in the operating suite. Following adequate anesthesia administration, the patient is placed in standard lithotomy position, the vagina is surgically prepared, and a Foley catheter is inserted.

Media Selection

Hysteroscopic morcellation may be performed with a physiologic saline solution. However, if a monopolar resectoscope is used, then a nonelectrolyte solution is required. Because of the risks for hyponatremia with sorbitol and glycine, many prefer 5-percent mannitol. Alternatively, selection of a bipolar resecting system (Versapoint) allows performance within an isotonic electrolyte medium. The basics of medium selection are further described in Chapter 41. As with any hysteroscopic procedure, fluid volume deficits are calculated and noted regularly during surgery.

Cervical Dilatation

The larger diameter of an 8- or 10-mm resectoscope or morcellator typically requires dilatation up to 9 mm with Pratt or similar dilators (Chap. 43).

Resection

Medium flow is begun, and the resectoscope is inserted into the endocervical canal under hysteroscopic visualization. Upon entering the cavity, a panoramic inspection is completed to identify the location and number of polyps. The resectoscope loop is then extended to reach behind the polyp. Electrosurgical current is applied as the loop is retracted toward the cervix to cut the polyp base. During resection, the loop should remain in view. The freed polyp is then grasped and delivered through the cervical os. This is similar to myoma excision, shown on page 1041.

In cases in which the polyp is large, several passes with the loop electrode may be required for complete excision. Passes begin at the polyp tip and progress until the base is reached. The uterus is not emptied after each pass. This practice maintains visualization of the polyp and minimizes the gas embolism and perforation risks associated with multiple introductions and reintroductions of instruments into the cavity. Instead, resected segments are allowed to float within the cavity as resection continues. Once the entire polyp is excised, then the fragments are collected on a Telfa sheet as they flow out of the cavity along with the distending medium. For larger polyps, the number of floating fragments will accrue. Thus, the cavity may need to be emptied prior to complete resection to permit an unobstructed view during resection.

Morcellation

As with loop resection, distention medium flow is begun, and the morcellation unit is inserted. During morcellation, it is important to work from the polyp tip toward the base (Fig. 44-13.1). Moreover, the mass is kept between the morcellator opening and the optics of the camera.

The morcellator also has suction action. This can be used to clear blood, tissue debris, and clots during resection of large growths. Better visual acuity and the continuous retrieval of the tissue are two of the advantages to this approach.

Control of Bleeding

Bleeding sites may be coagulated with the same resection loop using a coagulating current. Alternatively, for heavy bleeding, a Foley catheter balloon may be inflated to tamponade vessels. This can be left in for several hours depending on bleeding severity. This is later removed, and vaginal bleeding is reassessed.

Instrument Removal

The resectoscope or morcellator is removed, and the surgical specimen is sent for pathologic evaluation. At the end of the procedure, the flow of distending medium is stopped, and the hysteroscope and then tenaculum are removed. A critical step at this point, and throughout the procedure, is to note the amount of distention fluid used and retrieved to calculate the fluid deficit.

POSTOPERATIVE

Recovery following polypectomy is rapid, is typically without complication, and follows that for other hysteroscopic procedures.

For symptomatic women with submucous leiomyomas, hysteroscopic resection of these tumors may provide relief of symptoms in most cases. Candidates may include those with abnormal uterine bleeding, with dysmenorrhea, or with infertility in which leiomyomas are suspected to be contributory. Tumors selected for resection should be either submucous or intramural with a prominent submucous component. During surgery, pedunculated submucous leiomyomas may be excised similarly to polyps. However, tumors with an intramural component require resection with a resectoscope, morcellator, or laser.

PREOPERATIVE

Patient Evaluation

Hysteroscopic myomectomy is a safe and effective option for most women. Contraindications to surgery, however, include pregnancy, potential endometrial cancer, current reproductive tract infection, and medical conditions sensitive to fluid volume overload.

Specific leiomyoma characteristics such as great size, large number, and greater degree of intramural penetration can increase the technical difficulty, complication rate, and clinical failure rate of this procedure (Di Spiezio Sardo, 2008). Thus, prior to resection, women typically undergo transvaginal sonography, saline infusion sonography (SIS), or hysteroscopy to evaluate leiomyoma characteristics. Alternatively, MR imaging can also accurately document uterine anatomy, but its expense and availability may limit its routine use.

During the evaluation by SIS or hysteroscopy, leiomyomas may be grouped according to criteria developed by Wamsteker and associates (1993) and adopted by the European Society for Gynaecological Endoscopy (ESGE).

• Class 0: complete submucosal location

• Class I: greater than 50-percent submucosal component

• Class II: some submucosal involvement but greater than

  • 50-percent myometrial component.

These criteria help predict which leiomyomas are suitable for hysteroscopic resection. A more recent classification has also been proposed by Lasmar and coworkers (2005, 2011). Similar to the ESGE system, their evaluation grades the degree of tumor penetration into the myometrium. But, in addition, larger tumor size, wider tumor base, tumors in the upper portion of the cavity, or those found along the lateral wall receive higher scores. For higher scores, a nonhysteroscopic technique may be the safest and most successful.

Large or predominantly intramural tumors decrease clinical success rates, increase surgical risks, and increase the need for more than one surgical session to complete resection. For these reasons, many choose to resect only type 0 and I tumors and those measuring less than 3 cm (Vercellini, 1999; Wamsteker, 1993). More recent studies have reported resection of larger leiomyomas, although many need a two-step procedure and require a longer recovery (Camanni, 2010).

Consent

Complications of this procedure mirror that for hysteroscopy in general, and rates of 2 to 3 percent have been reported. Hysteroscopic myomectomy is associated with a greater risk of uterine perforation. This complication may follow cervical dilatation, but more frequently results during aggressive resection into the myometrium. Because of this risk, women are also consented for laparoscopy to assess and treat uterine or abdominal organ damage if perforation occurs.

Additionally, patients planning to seek pregnancy should be aware of possible intrauterine adhesion formation following resection and of rare uterine rupture during subsequent pregnancies (Batra, 2004; Howe, 1993).

During hysteroscopic myomectomy, distending medium is absorbed through venules that are opened during myometrial resection. Media is also absorbed across the peritoneum as the fluid flows in a retrograde direction through the fallopian tubes. Thus, resection of type I or II tumors or removal of large leiomyomas may be halted due to advancing fluid volume deficits. Patients are counseled that a second surgery may be required to finish resections in these cases. Fortunately, because of newer hysteroscopic morcellating tools, operating times and thus fluid deficits are decreased, even with large tumors.

Last, myomectomy is effective treatment, but 15 to 20 percent of patients will eventually require reoperation. This may be hysterectomy or repeat hysteroscopic resection at a later time for either persistent or recurrent symptoms (Derman, 1991; Hart, 1999).

Patient Preparation

GnRH agonists can preoperatively shrink leiomyomas to enable resection of large tumors or allow patients to rebuild their red cell mass before surgery (Chap. 9). However, disadvantages include preoperative hot flashes, difficulty in cervical dilatation, increased risk of laceration or perforations, and reduced intracavitary volume, which limits instrument mobility. Thus, GnRH agonist use is individualized.

To allow easier cervical dilatation and resectoscope insertion, misoprostol (Cytotec) can aid cervical softening. This practice is supported in some but not all studies, and postmenopausal women may benefit less from this pretreatment (Ngai, 1997, 2001; Oppegaard, 2008; Preutthipan, 2000). Commonly used dosing options include 200 or 400 μg vaginally or 400 μg orally once 12 to 24 hours prior to surgery. Common side effects include cramping, uterine bleeding, or nausea. Another alternative for cervical preparation prior to dilation is the use of dilute vasopressin (0.05 units/mL). Twenty milliliters of diluted vasopressin can be injected in divided doses intracervically at 4 and 8 o’clock. This method has the advantage of working rapidly at the time of surgery if the need for preoperative preparation was not anticipated (Phillips, 1997). Precautions with this potent vasocontrictor are outlined in Step 3 on page 1023.

Although the risk of postoperative infection is low, because pelvic infections can have devastating effect on future fertility, most recommend antibiotic prophylaxis prior to extensive hysteroscopic resections, as with myomectomy. Suitable agents are found in Table 39-6.

Concurrent Ablation

In those women with menorrhagia and with no desire for future fertility, endometrial ablation may be concurrently performed (Loffer, 2005). However, because leiomyoma resection alone resolves abnormal bleeding in most women, we do not routinely perform concomitant endometrial ablation unless the patient desires hypomenorrhea.

INTRAOPERATIVE

Instruments

Hysteroscopic myomectomy can be performed using a resectoscope or hysteroscopic morcellator. Both procedures are described.

Surgical Steps

Anesthesia and Patient Positioning

For most cases, hysteroscopic myomectomy is an outpatient procedure performed under general anesthesia. The patient is placed in standard lithotomy position, the vagina is surgically prepared, and a Foley catheter is inserted.

Medium Selection

The choice of distending medium is dictated by the resecting tool used. Resection using a morcellator, bipolar electrosurgical loop, or laser can be performed in saline solution. Alternatively, cases using a monopolar electrosurgical loop require an electrolyte-free solution. Solution differences are discussed in Chapter 41.

Cervical Dilatation

Using Pratt or other suitable dilators, the surgeon dilates the cervix as shown in Chapter 43.

Instrument Insertion

The distending medium flow is begun, and the resectoscope or morcellator is inserted into the endocervical canal under direct visualization. Upon entering the endometrial cavity, a panoramic inspection is first performed to identify and assess leiomyomas.

Resection

The electrosurgical unit is set to a continuous-wave mode (cutting). The resectoscope loop is advanced to lie behind the leiomyoma, and electric current is applied before the loop contacts the tissue. To minimize thermal injury and perforation, current is applied only as the loop is retracted and not when it is being extended. During resection, the loop should remain in view. Upon contact, the loop electrode is retracted toward the resectoscope (Fig. 44-14.1). To ensure a clean cut and complete excision of the shaved strip, current is not stopped until the entire loop is retracted. The shaved strip of smooth muscle floats within the endometrial cavity.

This shaving process is repeated serially toward the myoma’s base until the tumor is removed. Although strips can be removed from the cavity after each pass, this results in a repetitive loss of uterine distention. Repeated removal and reinsertion of a resectoscope increases the risk of perforation, gas embolism, and fluid intravasation. Thus in most cases, pushing removed strips to the fundus will help to adequately clear the operative field. However, if the view becomes obstructed, a pause in resection may be required to remove these strips.

Morcellation

Morcellators currently available include Hologic’s MyoSure, Smith & Nephew’s TruClear system, and Boston Scientific’s Symphion system. In general, sharp moving blades are contained within a hollow, rigid tube. By means of a vacuum source connected to the hollow tube, tissue is suctioned into the window opening at the device tip and is shaved off by the moving blade (Fig 44-14.2). Suction also removes morcellated tissue fragments through the device cylinder and allows collection for pathologic analysis.

In retrospective comparisons, hysteroscopic morcellation is faster than resectoscopy and appears easier to perform. It is associated with fewer fluid-related complications and has a shorter learning curve compared with conventional resectoscopy (Emanuel, 2005).

Intramural Leiomyomas

During removal of leiomyomas with an intramural component, uterine perforation risks are increased if resection extends below the level of the normal myometrium. Therefore, when resection reaches this level, the surgeon should pause and wait for the surrounding myometrium to contract around the now smaller tumor. This delivers deeper portions of the leiomyoma into the uterine cavity. Diminishing the intrauterine pressure, by decreasing the fluid inflow pressure, can also help to deliver the myoma.

Fluid Volume Deficit

Because of the hypervolemia risk during hysteroscopic myomectomy, fluid volume deficits are carefully monitored throughout the procedure. The final fluid deficit is noted in the operative report.

Hemostasis

Bleeding is common during myomectomy and will often cease as the myometrium fibers contract due to the reduction in intracavitary volume. Vessels that are more actively bleeding may be coagulated with the edge of the resecting loop, and the electrosurgical unit set to a modulating (coagulating) current. At times, a ball electrode may be required to increase the surface area over which current is delivered. Global endometrial ablation offers a similar treatment in the case of multiple bleeding sites but is not suitable for patients desiring fertility. Rarely, bleeding may be poorly controlled with electrosurgical tools. In such cases, mechanical pressure applied to bleeding vessels by a Foley balloon inflated with 5 to 10 mL of saline may be required. This can be left in for several hours depending on bleeding severity. The catheter is later removed, and vaginal bleeding is reassessed.

POSTOPERATIVE

Recovery following myomectomy is quick and typically without complication. Patients may resume diet and activities as tolerated. Spotting or light bleeding may follow surgery for 1 to 2 weeks.

For patients desiring pregnancy, conception may be attempted in the menstrual cycle after the resection, unless the leiomyoma was broad-based or had a significant intramural component. In these patients, barrier contraception is advised for three cycles. For women who fail to conceive or continue to have abnormal bleeding following resection, postoperative hysterosalpingography or hysteroscopy is recommended to evaluate for intrauterine synechiae.

Endometrial ablation broadly describes a group of hysteroscopic procedures that destroys or resects the endometrium and leads to eumenorrhea. For many women, ablation serves as a minimally invasive and effective treatment of abnormal uterine bleeding. Within the ablation group, techniques are defined as first- or second-generation depending on their temporal introduction into use and the need for hysteroscopic skills. First-generation tools require advanced hysteroscopic skills and longer operating times and can be associated with distention medium complications, such as volume overload. These techniques include endometrial vaporization with the neodymium:yttrium-aluminum-garnet (Nd-YAG) laser, rollerball electrosurgical desiccation, and endometrial resection by resectoscope.

Comparing first-generation methods, it appears that all three produce similar outcomes in terms of bleeding and patient satisfaction. However, resection methods have been associated with more surgical complications, and thus desiccation methods may be preferred for women without intracavitary lesions (Lethaby, 2002; Overton, 1997).

To reduce risks and required specialized training of these early ablative tools, second-generation nonresectoscopic methods have been introduced during the past 10 years. These tools use various modalities to destroy the endometrium but do not require direct hysteroscopic guidance. Modalities include thermal energy, cryosurgery, electrosurgery, and microwave energy.

PREOPERATIVE

Patient Evaluation

Prior to ablation, complete evaluation of abnormal uterine bleeding should be completed. Accordingly, the possibility of pregnancy, endometrial hyperplasia or endometrial cancer, and active pelvic infection is excluded. During evaluation of bleeding, transvaginal sonography (TVS), saline infusion sonography (SIS), and hysteroscopy may be used solely or in combination (Chap. 8). However, many second-generation ablation techniques require a normal endometrial cavity, and endometrial pathology, if identified, can be treated concurrently by several of these ablative methods. Thus, SIS and hysteroscopy are more sensitive than TVS for focal lesions, and either is preferred for preoperative evaluation. In addition, several second-generation techniques are not appropriate for large endometrial cavities. Thus, uterine depth is also assessed preoperatively by uterine sounding or sonography.

Myometrial thinning from prior uterine surgery may increase the risk of damage to surrounding viscera during ablation. Therefore, women with prior transmural uterine surgery are evaluated for type and location of uterine scar. A history of prior classical cesarean delivery or of abdominal or laparoscopic myomectomy may be considered a relative contraindication to ablation. Some experts advocate the sonographic evaluation of myometrial thickness to determine whether a patient is a candidate for ablation, although no specific thickness has been established (American College of Obstetricians and Gynecologists, 2013b).

Consent

Patients selecting ablation should be aware of success rates relative to other treatment options for abnormal bleeding (Chap. 8). In general, rates of decreased menstrual flow range from 70 to 80 percent and of amenorrhea, from 15 to 35 percent (Sharp, 2006). Eumenorrhea, rather than amenorrhea, is considered the treatment goal. Therefore, a patient should not undergo ablation if guaranteed amenorrhea is desired. In addition, endometrial ablation effectively destroys the endometrium and is contraindicated in those who desire future fertility.

Endometrial tissue has tremendous regenerative capabilities. Therefore, premenopausal women are counseled before surgery regarding the need for adequate postoperative contraception. If pregnancy does occur, complications after ablation include prematurity, abnormal placentation, and perinatal morbidity. For this reason, many providers recommend concomitant tubal sterilization at the time of endometrial ablation (American College of Obstetricians and Gynecologists, 2013b).

However, in women with tubal sterilization, cornual hematometra or postablation tubal sterilization syndrome (PATSS) can develop from bleeding from regenerated or remnant endometrium. With cornual hematometra, blood is trapped between the postoperative cornual synechiae. With PATSS, blood collects between the occluded proximal tubal stump and synechiae to cause proximal hematosalpinx. Both conditions cause associated cyclic pain. Hysterectomy is commonly required for resolution (McCausland, 2002).

Following ablation, later evaluation of the endometrium for recurrent abnormal bleeding can be challenging. Namely, a Pipelle may not reach remnant endometrium, and endometrial stripe measurements may be less accurate. The American Society for Reproductive Medicine (2008) advises against endometrial ablation in postmenopausal women because excluding malignancy in these women can be more difficult. Women with risks for endometrial cancer pose similar sampling challenges.

Complications associated with ablation mirror those with operative hysteroscopy, although the risk of fluid volume overload is avoided with second-generation tools.

Patient Preparation

During hysteroscopic surgeries, bacteria in the vagina may gain access to the upper reproductive tract and peritoneal cavity. However, postablation infection is rare, and preoperative prophylactic antibiotics are generally not indicated. Because the endometrium can thicken from only a few millimeters in the early proliferative phase to deeper than 10 mm in the secretory phase, all first-generation techniques and some of the second-generation ones are ideally performed in the early proliferative phase. Otherwise, drugs that induce endometrial atrophy such as GnRH agonists, combination oral contraceptives, or progestins may be used for 1 to 2 months prior to surgery. Alternatively, curettage may be performed immediately prior to ablation.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Endometrial ablation is typically a day-surgery procedure, performed under general anesthesia. Some studies state that second-generation techniques may be satisfactorily completed in an outpatient setting with intravenous sedation, local anesthetic blockade, or both (Sambrook, 2010; Varma, 2010). The patient is placed in dorsal lithotomy position, and the perineum and vagina are surgically prepared.

Selection of Distending Medium

With first-generation procedures, distending medium is required and selected based on the destructive energy used as described in Chapter 41. In general, saline may be used for laser and bipolar electrical current, whereas monopolar tools require nonelectrolyte solutions.

Neodymium: Yttrium-Aluminum-Gar­net Laser

Introduced in the 1980s, the Nd-YAG laser was the first ablative tool. Under direct hysteroscopic observation and uterine distention with saline, a Nd-YAG laser fiber touches the endometrium and is dragged across the endometrial surface. This creates furrows of photocoagulated tissue that are 5 to 6 mm deep (Garry, 1995; Goldrath, 1981).

Transcervical Resection of the Endometrium (TCRE)

In addition to less expense, because of the larger loop diameter, TCRE can be completed more quickly than laser fiber ablation. The shorter procedure duration can reduce the risk of excess media absorption.

This method uses a resectoscope with monopolar or bipolar electrical current to excise strips of endometrium. The resection technique is similar to that described for hysteroscopic myomectomy. The excised tissue strips are sent for pathologic evaluation. In cases with concurrent intrauterine pathology such as endometrial polyps or submucous leiomyomas, TCRE can excise these lesions in addition to the endometrium.

However, TCRE has been associated with higher rates of perforation, especially at the cornua, where the myometrium is thinner. For this reason, many use a rollerball electrosurgical electrode in combination with TCRE, with the rollerball used in the cornua (Oehler, 2003).

Rollerball

A 2- to 4-mm ball-shaped or barrel-shaped electrosurgical electrode can be rolled across the endometrium as an effective means of vaporizing the tissue (Vancaillie, 1989). Advantages to rollerball ablation compared with TCRE include shorter operating time, less fluid absorption, and lower perforation rates. Unfortunately, it is not effective in the treatment of intracavitary lesions, and pathology specimens are not obtained.

Thermal Balloon Ablation

Several thermal balloon ablation systems are now currently used worldwide (Fig. 44-15.1). Of these, only the ThermaChoice III Uterine Balloon Therapy System is approved for use in the United States. Other balloon systems available in other countries include the Cavaterm Plus system or the Thermablate Endometrial Ablation System.

The ThermaChoice III Uterine Balloon Therapy System is a software-controlled device designed to destroy endometrial tissue using thermal energy. After cervical dilation to 5.5 mm, the Thermachoice device is inserted into the uterine cavity. Once inside the cavity, a 5-percent dextrose and water solution is instilled into a disposable silicone balloon at the tip and heated to coagulate the endometrium. During the treatment, the contained fluid within the balloon is circulated to maintain a temperature of 87°C (186°F) for 8 minutes. The balloon can be introduced without hysteroscopic assistance into the uterine cavity, and when inflated, it conforms to the cavity contour.

All hot-liquid balloon devices require no advanced hysteroscopic skills, and complication rates are low (Gurtcheff, 2003; Vilos, 2004). One disadvantage is the requirement for an anatomically normal uterine cavity. Some studies, however, have demonstrated successful use in patients with submucosal leiomyomas (Soysal, 2001). Another limitation is the required pharmacologic thinning prior to thermal ablation. Alternatively, mechanical thinning can be accomplished with dilatation and curettage prior to ablation.

Hysteroscopic Thermal Ablation

Several second-generation ablation procedures require a normal uterine cavity. However, the HydroThermAblator (HTA) system allows treatment of the endometrium concurrent with submucous leiomyomas, polyps, or abnormal uterine anatomy. Another advantage of this system is that it is performed under direct hysteroscopic visualization, allowing the surgeon to observe the endometrium being destroyed. However, the risk of external burns from circulating hot water appears to be higher using this method compared other second-generation methods (Della Badia, 2007).

This tool is designed to ablate the endometrial lining of the uterus by heating an uncontained saline solution to a temperature of 90°C and recirculating it through the uterus for 10 minutes (Fig. 44-15.2). Spill through the fallopian tubes is avoided because hydrostatic pressure during the procedure remains below 55 mm Hg, which is well below pressures needed to open the tubes to the peritoneal cavity. Similarly, the water seal created between the hysteroscope and internal cervical os prevents leakage of fluid into the vagina. For this reason, care is taken not to dilate the cervix to a diameter greater than 8 mm.

Initially, a hysteroscope is inserted into the 7.8-mm diameter disposable HTA sheath. This combination is introduced into the endometrial cavity to enable viewing while room-temperature saline is instilled into the uterine cavity. The fluid flow is then gradually heated and circulated to treat the endometrium. At the completion of the treatment phase, cool saline replaces the heated fluid, and the instrument is then removed (Glasser, 2003).

Impedance-controlled Electrocoagu­la­tion

The NovaSure endo­metrial ablation system consists of a high-frequency (radiofrequency) bipolar electrosurgical generator and a single-use, fan-shaped device constructed of metal mesh. The mesh fan is designed to contour to the shape of the endometrial cavity. During treatment, an attachment provides suction to draw the endometrium and myometrium up against the mesh electrode for improved contact and to remove generated vapor (Fig. 44-15.3). The treatment time of 2 minutes results in desiccation of the endometrium. An advantage of this system is that it does not require preoperative endometrial preparation. Although Food and Drug Administration (FDA) approval studies evaluated the system in normal ­uterine ­cavities, it has been used successfully in patients with small submucosal leiomyomas and polyps (Sabbah, 2006).

Cryoablation

In addition to thermal damage, endometrial ablation can be achieved with extreme cold using the Her Option cryoablation system. Similar to the physics of cervical cryotherapy, gases compressed under pressure with this unit can generate temperatures of –100° to –120°C at the cryoprobe tip to produce an iceball. As an iceball grows, its leading edge advances through tissue, and cryonecrosis develops in those tissues reaching temperatures below –20°C (Chap. 43).

The Her Option cryoablation system contains a metal probe, which is covered by a 5.5-mm disposable cryoprobe. After dilatation of the cervix, the cryoprobe’s 1.4-inch cryotip is placed against one side of the endometrial cavity and advanced to one uterine cornu (Fig. 44-15.4). Concurrent transabdominal sonography is required to ensure accurate cryotip placement and surveillance of the increasing iceball diameter, which is seen as an enlarging hypoechoic area. The first freeze is terminated after 4 minutes or sooner, if the advancing iceball reaches to within 3 mm of the uterine serosa. The cryotip is allowed to warm, is moved from the cornu, and is redirected into the contralateral cornu. A second freeze is performed for 6 minutes or less based on iceball advancement.

Microwave Ablation

The microwave endometrial ablation (MEA) technique uses microwave energy to destroy the endometrium. During the procedure, a microwave probe is inserted until the tip reaches the uterine fundus. Once placed, the probe tip is maintained at 75° to 80°C and moved slowly from side to side. Microwave energy is spread with a maximum penetration of 6 mm over the entire uterine cavity surface. Speed is an advantage, with the entire treatment completed in 2 to 3 minutes (Cooper, 1999). Due to complications of bowel burns in patients without evidence of uterine perforation, to obtain FDA approval, the manufacturers of the MEA system recommend preoperative myometrial thickness assessment to document at least a 10-mm thickness throughout the uterus (Glasser, 2009; Iliodromiti, 2011). MEA was FDA-approved in 2003, but Microsulis discontinued worldwide sales of the MEA device in 2011.

POSTOPERATIVE

Advantages to endometrial ablation include rapid patient recovery and low incidence of complications. Patients may resume normal diet and activities as tolerated. Patients may expect light bleeding or spotting during the first postoperative days as necrotic endometrial tissue is shed. A serosanguinous discharge follows for 1 week and is replaced by a profuse and watery discharge for another 1 to 2 weeks.

Hysteroscopic sterilization is a minimally invasive, transcervical method to perform surgical sterilization. Currently, only two forms of transcervical sterilization are approved by the FDA. These are the Essure Permanent Birth Control system and Adiana Permanent Contraception system (Chap. 5). However, the Adiana System is no longer manufactured, although not because of safety or efficacy concerns.

Essure employs a coil device, termed a microinsert, which is inserted into the proximal section of each fallopian tube. Once in place and released from its delivery catheter, the microinsert expands to anchor itself within the fallopian tube (Fig. 44-16.1). Over time, synthetic fibers within the microinsert incite a chronic inflammatory response and a local tissue ingrowth from the surrounding tube. This ingrowth leads to complete tubal lumen occlusion, which is documented by hysterosalpingography (HSG) at 3 months following surgery.

As with any permanent birth control method, candidates should be confident in their decision for sterilization. Contraindications include pregnancy or pregnancy termination within the prior 6 weeks, recent pelvic infection, known tubal occlusion, and for Essure, allergy to radiographic contrast medium or nickel.

PREOPERATIVE

Patient Evaluation

Pregnancy is excluded prior to sterilization using a serum or urine β-hCG test.

Consent

For many women, hysteroscopic sterilization is a safe and effective method of birth control. Efficacy rates are comparable with current laparoscopic sterilization rates, although long-term data are limited (Magos, 2004). With proper placement, Essure appears to have similar or superior contraceptive efficacy compared with other methods of sterilization (Levy, 2007).

Effective bilateral tubal occlusion or insert placement may not be possible in all patients due to tubal ostium stenosis or spasm or an inability to visualize the ostia (Cooper, 2003). Rates of successful placement average 88 to 95 percent (Kerin, 2003; Ubeda, 2004).

In general, complications of transcervical sterilization are similar to those of hysteroscopy. However, rates of fluid volume overload are low because in most cases procedure lengths are short (15 to 30 minutes) and opening of endometrial vascular channels is minimal. Uterine or tubal perforation has been noted. Rates approximate 1 to 2 percent, and in most cases, these are clinically insignificant (Cooper, 2003; Kerin, 2003). A perforated Essure insert may need to be removed from the peritoneal cavity to prevent complications. Chronic pelvic pain and insert erosion or migration can also occur.

Patient Preparation

Because menstrual bleeding and a thick endometrium can impair identification of tubal ostia, this procedure is typically performed during the early proliferative phase of the menstrual cycle. This also decreases the chance of an unidentified luteal-phase pregnancy. Preoperative analgesia may be considered and typically consists of a nonsteroidal antiinflammatory drug given 30 to 60 minutes before the procedure. Prophylactic antibiotics are not required.

INTRAOPERATIVE

Instruments

The Essure system is disposable and comes individually wrapped. It contains a handle, delivery catheter, release catheter, delivery wire, and microinserts. Each microinsert is attached to the end of a delivery wire, which is housed within a release catheter. In turn, the release catheter is surrounded by a delivery catheter.

Surgical Steps

Anesthesia and Patient Positioning

Transcervical sterilization can be performed in an outpatient setting under local anesthesia with or without intravenous sedation. Alternatively, a day-surgery setting using general anesthesia may be selected. The patient is placed in the standard lithotomy position, and the vagina is surgically prepared.

Media Selection

For the Essure system, electrosurgery is not required, and therefore, 0.9-percent saline is commonly used to avoid the increased expense and risk of hyponatremia associated with nonelectrolyte solutions. As with any hysteroscopic procedure, accurate calculation of fluid volume deficits during the procedure is essential. The final deficit is recorded within the operative note.

Hysteroscope Insertion

Vaginal retrac­tors or speculum provides access to the cervix, and a tenaculum may be used for adequate cervical traction to insert the hysteroscope. Depending on the diameter of the operative hysteroscope, standard cervical dilatation may or may not be required. A 12- to 30-degree hysteroscope is preferred to provide easy visualization of the cornua, and a 5F operating channel is needed.

Essure Microinsert Delivery

Requisite for completion of the procedure, both tubal ostia must be visualized. To begin delivery, the outermost catheter of the system, the delivery catheter, is threaded through the operating channel of the hysteroscope. Its tip is inserted into one tubal ostium. This delivers the tightly coiled, collapsed insert into the ostium. The delivery catheter is then retracted into the Essure device handle, and an inner cannula, which is the release catheter, is now seen. As the release catheter is retracted, the microinsert begins to uncoil. Ideally, if correctly placed, three to eight coils of the microinsert trail into the endometrial cavity (Fig. 44-16.2). As a final step, a guide wire that is attached to the distal end of the microinsert is detached and retracted. These steps are repeated at the opposite ostium.

POSTOPERATIVE

Patients typically resume normal diet and activity within the first 24 hours following surgery. Cramping is common within the first few days, and light spotting or bleeding may be noted during the week following surgery.

To document complete tubal occlusion, HSG is performed at 3 months following insertion (Fig. 44-16.3). Until this time, an alternative method of contraception should be used. Rarely, in those with correct placement, tubal occlusion may not be complete at 3 months, and a second HSG at 6 months may be required to document sterilization. Of note, although Essure microinserts are radiopaque with fluoroscopy, the Adiana silicone implant is not visible. Microinserts can be expelled. Thus, if no Essure device is identified during HSG or if 18 or more of its coils are seen trailing into the uterine cavity, then the microinsert should be replaced or an alternative method of contraception used (Magos, 2004).

Essure microinserts conduct thermal energy, and this is factored into future surgery across the proximal fallopian tube. Also, synechiae after endometrial ablation can obscure Essure HSG. Thus, ablation and Essure insertion are not performed concurrently. However, following HSG confirmation, Novasure, HTA, and Thermachoice III are thermal methods that can be performed with Essure inserts in place (Aldape, 2013). Last, MR imaging can safely be completed in those with Essure inserts.

Most uterine septa form from incomplete regression of the medial portion of the müllerian ducts during their fusion (Fig. 44-17.1) (Chap. 18). These septa rarely result in infertility. However, they have been associated with malpresentation and increased rates of first- and second-trimester spontaneous abortion. This serves as the main indication for septoplasty.

Before the popularity of operative hysteroscopy, septoplasty was performed abdominally and with a hysterotomy incision. Fortunately, hysteroscopic septoplasty affords MIS with decreased morbidity to the patient and uterus. Septoplasty refers to central division of the septum in a caudad-to-cephalad direction, generally with the use of hysteroscopic scissors. Bleeding is minimal due to the relative avascularity of the septum’s fibroelastic tissue, which retracts upon incision. Septum resection is performed for broader, larger septa that have wider bases. A loop resectoscope or morcellator may be preferred for this.

PREOPERATIVE

Patient Evaluation

Diagnosis of a septate uterus follows guidelines outlined in Chapter 18 and includes HSG, SIS, and transvaginal sonography. Because of the frequent association between renal and müllerian anomalies, intravenous pyelography is also performed. Finally, although a septate uterus is associated with infertility and pregnancy loss, evaluation for other causes of these two conditions is completed prior to septum excision. Contraindications to septoplasty include pregnancy and active pelvic infection, and these should be excluded.

Consent

Hysteroscopic septoplasty is a safe and effective treatment for recurrent pregnancy loss, and postoperative live birth rates approximate 85 percent (Fayez, 1987). In general, complications mirror those for operative hysteroscopy, although the risk of uterine perforation appears increased. For this reason, concurrent laparoscopy in some cases is recommended to help inform a surgeon as to the proximity of the uterine serosa. As the hysteroscope nears the fundal serosa, transillumination of the hysteroscopic light indicates the potential for uterine perforation. Accordingly, a patient may also be consented for concurrent diagnostic laparoscopy as outlined on page 1003.

Patient Preparation

Infectious and VTE complications following hysteroscopic surgery are rare. Accordingly, preoperative antibiotics or VTE prophylaxis is typically not required (American College of Obstetricians and Gynecologists, 2013c, 2014b). Misoprostol may be used preoperatively to ease cervical dilatation.

INTRAOPERATIVE

Instruments

Septum incision or resection can be completed using hysteroscopic scissors, resectoscope loop, Nd-YAG laser, or mechanical morcellators. Selection is according to septum dimensions and surgeon preference.

Surgical Steps

Anesthesia and Patient Positioning

Hysteroscopic septoplasty is typically a day-surgery procedure performed under general anesthesia. A woman is placed in standard lithotomy position, the vagina is surgically prepared, and a Foley catheter inserted. If surveillance laparoscopy is planned, then the abdomen is also prepared.

Medium Selection

The choice of distending medium is dictated by the incising tool used. Sharp incision with scissors, Nd:YAG laser, or bipolar instrument is commonly selected and can be performed in any liquid medium. Monopolar technology will require a hypotonic nonconductive medium.

Concurrent Laparoscopy

If planned concurrently, placement of the laparoscope follows the steps described in Chapter 41.

Cervical Dilatation

A tenaculum is placed on the anterior cervical lip. Using a Pratt or other suitable dilator, the surgeon serially dilates the cervix.

Instrument Insertion

The distending medium flow is begun, and the operative hysteroscope is inserted into the endocervical canal under direct visualization. Upon entering the endometrial cavity, a panoramic inspection is first performed to identify the septum.

Septum Incision

If scissors are used, a surgeon attempts to keep the line of incision in the anteroposterior midline. Transection begins caudally, at the septum apex, and continues cephalad toward the fundus. Bites with the scissors are taken bilaterally and are directed toward the horizontal midline (Fig. 44-17.2). During incision of the septum, drifting from the vertical midline is common. Incisions typically drift posteriorly in an anteverted uterus and anteriorly in a retroverted one. Thus, a surgeon may pause and reorient periodically.

During septoplasty, incision rather than complete resection of the septum is sufficient. Septal stumps are retracted into the myometrium as the septum is transected. In most cases, the septum is relatively avascular, and cutting at its midpoint causes little bleeding. Signs that transection is complete include increasing tissue vascularity, serosal transillumination of the hysteroscope at the uterine fundus, and reaching a level in line with the tubal ostia.

Septum Resection

In some cases, the septum is broad, wide, and difficult to simply incise. Thus, to achieve the desired uterine cavity, a surgeon must completely excise or resect the septum. In general, scissors may be used, but in some instances, vaporizing electrodes, loop electrodes, or morcellators are more useful. Instruments are selected according to surgeon skill and preference.

Procedure Completion

After incision completion, the hysteroscope and tenaculum are removed. The final fluid deficit is noted in the operative report. Final steps of laparoscopy, if performed, follows those outlined in Chapter 41.

POSTOPERATIVE

Recovery following septoplasty is rapid and typically without complication. Light bleeding or spotting may last 1 week or more. Patients may resume normal diet and activities as desired. Following resection, symptoms such as dysmenorrhea ultimately are greatly decreased.

To stimulate endometrial proliferation and prevent adhesion reformation, oral estrogen administration has proved effective. Although several regimens can be used, we prescribe 2 mg of estradiol, orally for 30 days.

Attempts at conception are delayed for 2 to 3 months following surgery. If septum resection appeared incomplete at the time of surgery or if recurrent miscarriage or amenorrhea develops, then postoperative HSG or a second hysteroscopy may be performed. Complete removal of the septum or adhesiolysis may be required. With subsequent pregnancy, if the myometrium was not entered, cesarean delivery is required only for obstetric indications.

Proximal fallopian obstruction may results from pelvic inflammatory disease, intratubal debris, congenital malformations, tubal spasm, endometriosis, tubal polyps, and salpingitis isthmica nodosa. It is generally diagnosed during evaluation of infertility when documentation of tubal patency is sought. Therapeutic options have the goal of a successful pregnancy. Therefore, approaches to occlusion in this portion of the tube include tubal cannulation, surgical tubocornual anastomosis, and in vitro fertilization (IVF) (Kodaman, 2004). During cannulation, attempts are made to flush debris from within the tubes and perform chromotubation.

Proximal fallopian tube cannulation may be used to treat up to 85 percent of proximal tubal obstructions, but the occlusion may recur following the surgery. It may be performed as an outpatient radiologic procedure using fluoroscopy (Papaioannou, 2003). Alternatively, cannula placement may be completed with hysteroscopic guidance (Confino, 2003). If a hysteroscopic approach is selected, laparoscopy is typically used concurrently. This allows evaluation and treatment of both proximal and distal tubal disease and provides identification of tubal perforation by the cannulating guide wire if this occurs.

PREOPERATIVE

Patient Evaluation

Proximal tubal occlusion is typically identified with HSG during evaluation of female infertility. To avoid disrupting an early pregnancy, preoperative β-hCG testing is warranted in most patients. Although this procedure may be performed at any time during the menstrual cycle, the early proliferative phase offers the advantage of a thinner endometrium to allow easy identification of tubal ostia and avoids disruption of an early luteal-phase pregnancy.

Consent

In addition to general complications associated with hysteroscopy and laparoscopy, patients undergoing proximal tubal cannulation are informed of the small risk of tubal perforation. Fortunately, because the guide wire measures only 0.5 mm in diameter, tubal damage is rarely significant and can be assessed by concurrent laparoscopic examination of the perforated tube.

In most cases, patients with combined proximal and distal tubal disease are best managed with IVF. As discussed in Chapter 9, hydrosalpinges, when present, can lower IVF success rates and are typically removed. Thus, consideration of and consent for salpingectomy should accompany plans for proximal tubal cannulation.

Patient Preparation

The risk of pelvic infection is low. However, because adhesions following such infection can have damaging effects on fallopian tube health, patients are given either a first- or second-generation cephalosporin prior to surgery. In addition, misoprostol may be used preoperatively to aid cervical softening and hysteroscope insertion.

INTRAOPERATIVE

Instruments

Fallopian tubes may be cannulated with a catheter system displayed in Figure 44-18.1. This system contains an outer cannula, inner cannula, and inner guide wire. The preset bend of the outer cannula aids placement of both the inner cannula and guide wire into the tubal ostium. Once the inner cannula has been threaded into the proximal fallopian tube, the guide wire is removed. The inner cannula, now emptied of the guide wire, can be used to flush debris from the fallopian tube and allow chromotubation, which is visualized laparoscopically (Fig. 19-9).

Surgical Steps

Anesthesia and Patient Positioning

Hysteroscopic tubal cannulation with concurrent laparoscopy is typically an outpatient procedure performed under general anesthesia. The patient is placed in standard lithotomy position, the abdomen and vagina are surgically prepared, and a Foley catheter is inserted.

Medium Selection

No electrosurgery is required for tubal cannulation, thus saline is the preferred medium.

Laparoscopy

The laparoscope is inserted as described in Chapter 41.