The modern era of laparoscopy began in 1954, when Palmer [1] reported the results of endoscopic procedures in 250 patients without sequelae. He produced a pneumoperitoneum with CO2 at a rate of 300 to 500 mL/min and cautioned that the intraabdominal pressure should not exceed 25 mm Hg. The claimed advantages of laparoscopy over culdoscopy were a decreased chance of infection, a better view of the pelvis, improved access to the pelvic organs and cul-de-sac, and easier application of surgical techniques.

Although the basic principles of laparoscopy are the same, the instruments and the complexity of operative procedures have changed significantly since 1954. This chapter presents information for residents learning laparoscopic operations and clinicians who are updating their knowledge of operative laparoscopy.

PREOPERATIVE EVALUATION

Advanced operative laparoscopy is a major intra-abdominal procedure. Careful preoperative evaluation optimizes the operative outcome and decreases the incidence of injuries and complications. Preoperative consultations with surgeons in other disciplines (colorectal, urologic, oncologic) sometimes are necessary. The patient is informed about the possible outcome and results of the planned operation, possible complications, and the surgeon's experience in doing the particular procedure. The following preoperative work-up is suggested:

1. History and physical

2. Complete blood count (CBC) with differential

3. Serum electrolytes

4. Urinalysis

5. Papanicolaou smear

6. Thrombin time, partial thrombin time, bleeding time

7. Transvaginal sonography (TVS)

In special situations, an endometrial biopsy, cervical culture, hysterosalpingogram, barium enema, intravenous pyelogram, blood type and screen or type and crossmatch, and bowel preparation are indicated.

Adhesions are defined as connections between opposing serosal and/or nonserosal surfaces of the internal organs and the abdominal wall, at sites where there should be no connection. This connection can be a band, which is vascular or avascular, and filmy/transparent or dense/opaque, or it could be a cohesive connection of surfaces without an intervening adhesion band. Adhesion formation is an almost unavoidable consequence of abdominal surgery. Although not all patients with intra-abdominal adhesions develop symptoms, the clinical implications, such as early and late bowel obstruction, infertility, and chronic abdominal pain, remain a common problem in general surgical and gynecologic practice. In addition, adhesion formation is associated with increased socioeconomic costs.

THE RISK FACTORS AND CLINICAL SIGNIFICANCE OF ADHESIONS

The risk factors for pelvic adhesions include a history of pelvic inflammatory disease (PID), prior surgery, perforated appendix, endometriosis, and inflammatory bowel diseases. Other recognized causes of adhesions include bacterial peritonitis, radiotherapy, chemical peritonitis, foreign body reaction, long-term continuous ambulatory peritoneal dialysis, endometriosis, and pelvic inflammatory disease. However, the greatest contribution of these risk factors is a previous history of an intra-abdominal operative procedure.

Adhesion formation after abdominal and pelvic operations remains extremely common and is a source of considerable morbidity. Menzies and Ellis confirmed that after an intra-abdominal operation, most patients developed adhesions.

Despite the degree of caution used, complications occur during operative laparoscopy. Because sequelae can result from even relatively easy procedures, a surgeon must be able to recognize them promptly and carry out proper management. The risks increase with the complexity of the procedure, the relative inexperience of the surgeon, and the amount of deviation from standard technique. As laparoscopic operations become more complex, the ability to handle them endoscopically becomes important.

Diagnostic laparoscopy and laparoscopic tubal sterilization involve few risks. The rate of intraoperative and postoperative complications is less than 1% (Table 25.1). Most reports are from large practices with experienced gynecologists, surveys of American Association of Gynecologic Laparoscopists (AAGL) members, and tertiary referral clinics.

The intraoperative and postoperative complication rates in 361 women who underwent laparoscopic hysterectomy for benign pathologic conditions were evaluated. The overall complication rate for hysterectomy carried out by laparoscopy was 11.1%. Most of the complications were minor, including cystitis (1.66%), transient high fever (1.39%), abdominal wall ecchymosis (1.12%), and pneumonia and bronchitis (1.12%). There was no correlation between the type of laparoscopic hysterectomy and the complication rate. Complication rates associated with laparoscopic hysterectomy compare favorably with published complication rates for vaginal and abdominal hysterectomy.

Retropubic Burch colposuspension has been considered by many to be the “gold standard” procedure for the treatment of female stress urinary incontinence for almost 40 years. Vancaillie and Schuessler introduced the laparoscopic approach to retropubic colposuspension in 1991. Numerous reports followed in subsequent years describing laparoscopic colposuspensions and their efficacy. Analysis of the outcomes of these various laparoscopic “Burch” colposuspensions is difficult because many of the techniques are not true Burch procedures but rather other modified retropubic colposuspensions. In this section, we describe the laparoscopic Burch colposuspension, including patient selection, preoperative evaluation, operative technique, possible complications, and efficacy. We review the efficacy of the laparoscopic Burch colposuspension studies that use the Burch—Tanagho procedure and compare these techniques to other popular anti-incontinence procedures. The many modified laparoscopic retropubic procedures are not addressed.

BURCH COLPOSUSPENSION: THE EVOLUTION OF A PROCEDURE

In 1961, Burch published the description of a new female anti-incontinence procedure, based on a technique started in 1958. The technique involved entering the space of Retzius via a paramedian incision. After clearing the periurethral tissue of its overlying fat and areolar tissue, three 2-0 chromic sutures were placed at the mid-urethra and the bladder neck and then fixed to Cooper's ligament. Burch reported a subjective cure rate of 92% in 143 patients with 10 to 60 months of followup.

Successful operative laparoscopy requires the proper basic and specialized equipment to make difficult procedures technically possible and safe. Most operations can be done with two or three forceps, a suction—irrigator probe, a bipolar electrocoagulator, and a CO2 laser. With the rapid growth of operative laparoscopy, disposable, semireusable, and reusable instruments have become available. In selecting the appropriate instruments, their cost and effectiveness should be considered because too many instruments clutter the field and increase operative time.

With videolaseroscopy, the operation is observed by the surgeon and operating room staff on video monitors. The CO2 laser is used through the operative channel of the laparoscope for cutting and establishing hemostasis of small blood vessels. Electrocoagulation with a bipolar forceps is used to control bleeding from larger vessels. These instruments enable surgeons to increase the diversity of laparoscopic procedures. Some of them have multiple functions, whereas others are specialized. Most are designed to fit through trocar sleeves between 2 mm and 33 mm in diameter.

THE BASIC INSTRUMENTS

The Laparoscope

The endoscope allows one to view the abdominal and pelvic cavities and is the most important piece of equipment. It must be in optimal condition. Although the diameter of laparoscopes varies from 2 to 12 mm and the angle of view varies from 0° to 90°, the most commonly used laparoscopes are straight diagnostic (Figure 2.1A) and angled operative laparoscopes (Figure 2.1B,C).

The ability to suture laparoscopically increases a laparoscopist's versatility. Suturing is used for hemostasis and to oppose tissues during reconstructive procedures. Different types of sutures are available for endoscopic use. The Endoloop (Ethicon) suture, a preformed slipknot attached to a rigid, disposable 5-mm applicator, is available in 0-chromic gut, polyglactin, polydioxanone, and polypropylene (Figure 5.1). The loop is positioned around the pedicle by grasping the structure to be removed and pulling it through the loop. The loop is tightened against the applicator, and the suture is cut with scissors or the laser beam against a backstop.

Suture material is available with a straight or curved swaged needle specifically designed for laparoscopic use. It is available in 0-chromic catgut, 4-0 polydioxanone with a swaged ST-4 needle (PDS, Ethicon), and polyglactin. The suture is grasped with forceps several centimeters from the needle. The grasper with suture is inserted intra-abdominally through the 5-mm accessory trocar sleeve.

To place the needle intra-abdominally, the grasper or needle driver is removed along with the trocar sleeve, which remains around the grasper's shaft. The suture is grasped about 5 cm from the needle, and the grasper is reintroduced with the trocar sleeve into the suprapubic incision site.

A surgeon is required by law and bound by moral and ethical standards to explain a planned operation, its risks, and the expected outcome to the patient preoperatively. The purpose of this Appendix is to (1) provide a guide for discussing a proposed laparoscopic operation with the patient and (2) describe the informed consent as it relates to laparoscopy.

Diagnostic laparoscopy has gained widespread acceptance among gynecologic and general surgeons, but patients' expectations and the actual results from advanced operative laparoscopic procedures frequently do not coincide. For example, some patients believe that lasers are essential for a thorough operation, although most surgeons acknowledge that scissors and electrosurgical instruments are equally effective. Patients tend to consider laparoscopic procedures minor operations. This idea is reinforced by terms such as same-day surgery, Band-Aid surgery, minimal invasive surgery, and laser surgery. Patients and physicians underestimate the risks of complex operative endoscopy, which are potentially as serious as those associated with laparotomy.

The Informed Consent

Since 1914, surgeons have been required to obtain a patient's written consent before an operative procedure. This process allows the patient to participate in decisions with an understanding of the factors relevant to the proposed operation. The proper consent requires that the patient be informed of the diagnosis, the proposed treatment, the probability of success, alternative forms of therapy, and the risks of the planned operation.