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^ ANAESTHESIA OF GYNECOLOGICAL OPERATIONS

For anesthetizing of great gynecological operations most frequently combined endotracheal anesthesia in combination with neuromuscular relaxant and with artificial pulmonary ventilation (APV) is used. This method allows to maintain sufficient passability of respiratory tract in any patient's position, pro­vides maximum muscles relaxing and absence of pain sensitiveness with minimum amounts of anesthetic, and also they use epidural anesthesia.

Such stages in realization of general anesthesia are carried out:

  • premedication

  • initial narcosis (intravenous introduction of Thiopental sodium or Hexenal in dose 6-8 mg/kg; in case of blood loss, allergy, bronchial asthma — Ketamine in dose 2 mg/kg)

  • introduction of depolarizing muscle relaxant (Dithylinum, Lystenon — 2 mg/kg)

  • mask APV and intubation of trachea

  • supporting of basic narcosis (APV with Nitrous oxide and Oxygen; intra­venous introduction of narcotic analgesics, neuroleptics and tranquilizers; total muscle relaxation; supporting of adequate gaseous exchange and hemo­dynamics, blood volume correction)

  • withdrawing of narcosis (canceling of inhalative anesthetics introduction, inhalation of Oxygen; introduction of antidotes for neuromuscular relaxants control for renewing of consciousness, appearing of protective reflexes)

  • extubation

  • supporting of stable breathing and blood circulation

Anesthetist has to be prepaired for anesthetizing in advance: to check out the readiness of narcosis apparatus, presence of necessary medications and oxygen in oxygen cylinder. On the sterile table there must be all the necessary instruments: laryngoscope, intubation tubes, sterile single-use syringes, mask, medicines. It is necessary to keep an eye on the patient's state permanently and fill in the narcosis card.

Small in volume and short-term gynecological interventions also need ade­quate anesthetizing because of great pain intensity, which appear in the result of irritation of high-sensitive uterine reflexogenic zones. With aim of anesthesia intravenous anaesthetizing by Thiopental sodium, Ketamine or Ketanest, neurole­ptanalgesia, ataralgesia are used.

Local anesthesia is used only in case of presence of contra-indications concerning the general one: acute inflammatory processes in upper respiratory tracts, full stomach, and also in case of absence of conditions for performing narcosis or patient’s refusal from general anaesthesia. The basic method of

local anaesthetizing at uterine curniage, punctures is patacervical anaesthes that is reached by introduction of anesthetic (Lidoeaine 0,25-0,5%) into pin metrial cellular tissue, where nervous plexes arc situated. For paraeervu anaesthesia it is necessary to prepare a Novocaine or other anesthetic, syringe 20 ml capacity and a long needle.


^ PREPARATION OF PERSONNEL FOR OPERATION

Personnel hands scrubbing

Method of scrubbing with "Pervomur". Surgical team wash hands w soap under running water during 3-5 min, then they immerse them into hi with solution, made from 10 1 of distilled water, 17 ml of perhydrol and 6°- nil formic acid, and during 3 min they process the hands with help of sterile servie

^ Method of scrubbing with Degmicide. Hands are washed with brush ; soap under running water during 5 min, dry and process them with two stei serviettes, moistened by 1% solution of Degmicide, during 3 min with e<

serviette.

Method of scrubbing with Chlorhexidine. Hands are washed with sc under running water, then they are dried with 0,5% solution of Chlorhexidim 70% Ethyl alcohol in amount of 5-8 ml and during 2 min rub it into skin.

Any of the methods does not guarantee absolute sterility of hands, thi why all the operations are performed in sterile surgical gloves.

^ Dressing of sterile surgical coat

After scrubbing medical nurse is the first to enter the operating-room : with other nurses' help she proceeds to dressing of sterile surgical coat. ' nurse opens the sterilizer box with sterilized operating coats. The operating m checks out appropriateness of operating coats for use by means of stcri indicator, then she takes one out unfolds it and dresses. A practical nursi another nurse tie behind the strings and belt of the coat.

Surgeons dress themselves independently. An operating nurse gives tr unfolded surgical coats, the nurse ties the belt. If there is need, operating m can help surgeons to tie up string on sleeves.


^ Dressing of sterile surgical gloves

The practical nurse opens sterilizer box with gloves, checks out their steri by means of indicator. An operating nurse pulls on gloves herself, and gives into the glove as deeply as possible. Dressed gloves are wiped by 96% alcohol to remove the talc remains. On external gloves surface there must be no talc, because, getting on peritoneum, it causes aseptic inflammation giving rise to forming of abdominal adhesions. If during operation glove puncture has happened acciden­tally, it should be replaced immediately.


LAPAROSCOPY

PATIENT EVALUATION Initial patient evaluation considers the indications and contraindications of laparoscopic surgery. There are no hard and fast rules and even the term “absolute contraindication” must be considered as a guideline, rather than a final decree.


^ ABSOLUTE CONTRAINDICATIONS

There are very few absolute contraindications as previously noted. With increased anesthesia ability, even some of these may not be considered absolute.

• Severe cardiac disease: (Class IV) these patients may not tolerate the deep Trendelenburg positions necessary during most operative laparoscopy to maintain an adequate pneumoperitoneum that is frequently required for satisfactory vision and instrument movement.

• A hemodynamically unstable patient with the need for control of bleeding probably should be approached by laparotomy. However, many surgeons believe that they can rapidly enter an abdomen safely laparoscopically, even in the face of a ruptured ectopic, for example.

• Intestinal obstruction with distended bowel is best approached by laparotomy, however, with some of the open laparoscopy techniques, it may be possible to utilize laparoscopy even in these conditions.


^ RELATIVE CONTRAINDICATIONS

• Multiple previous major surgeries must be considered a possible contraindication, depending upon both the entry technique and the skill of the operating surgeon. However, utilization of left upper quadrant insufflation techniques or open laparoscopy may afford safe entry even in the event of multiple previous surgeries.

• Morbid obesity may be daunting to the inexperienced laparoscopist, patients as heavy as 120+kg often may be candidates for laparoscopy.

• Pregnancy beyond five months gestation must be approached with a great deal of caution as the pelvis is almost completely filled with the enlarged uterus. Some surgeons have used gasless laparoscopy in more advanced pregnancies. However, some studies have shown that the CO2 gas of the pneumoperitoneum does not harm the fetus.

• Severe, chronically ill patients may present anesthesia problems, but may still be approached cautiously with laparoscopic surgery. It is important not to compromise the respirations with a pneumoperitoneum that is too large.

• The patient should not be compromised by laparoscopic surgery if malignancy is a possibility. If a mass is known to be malignant and the surgeon does not have the skills necessary for complete removal without rupture of the mass, then laparoscopy is not the operation of choice. Some gynecologic oncologists have the skills not only to remove a mass, but also to perform lymph node dissections. In the hands of such surgeons, laparoscopy is acceptable.


^ INFORMED CONSENT

Good informed consent actually provides much more than merely a legal requirement. The patient who has a full understanding of the surgical procedure is much less anxious than one who is fearful because of lack of knowledge. We highly recommend the use of videotapes or movies to explain the surgery. Plastic models or pictures may also be used so that the patient has a full comprehension of her pathology and of the proposed operation. The patient should be given time to ask any questions that may be of concern to her. It is always best, if possible, to have a member of the family or a close friend present during these discussions. Because of nervousness and apprehension, patients frequently forget the information that has been explained to them and the support person may be able to fill in the blanks. The patient should be honestly informed of the alternative procedures. She should be told that general anesthesia is usually required and this will necessitate the use of a tube being placed into her throat. This may give her a slight sore throat. She should be seen preoperatively by the anesthesiologist who will explain the procedure and risks to her. She should be told how she will be positioned during surgery and of the method used to create a pneumoperitoneum. She should also understand about the placement of trocars and the possibility of injury to bowel or urinary tract. She must be apprised of the risks of injury up to and including death. It is advisable to design an informed consent sheet that is specific for laparoscopy. This should be written in layman’s language. Never promise that the surgery will be accomplished by laparoscopy. It is best to say that if surgery can be performed by laparoscopy, then the patient will usually have certain advantages: quicker recovery time, less pain and less scarring. The patient should be informed at this time regarding her expected postoperative course. She should be advised of the degree of pain that may or may not be expected. She should be encouraged to call regarding any pain that is present for more than 48 hours postoperatively.


^ PREOPERATIVE ROUTINE

The patient should be seen within 1-2 weeks of the surgery at which time a review of the history and a physical exam should be conducted that at least covers the following:

1. Weight; 2. Blood pressure and pulse; 3. Auscultation of the lungs and heart; 4. Palpation of the abdomen for organomegaly and hernias. 5. Complete bimanual pelvic examination including PAP smear if indicated. Many hospitals require laboratory tests within one or two weeks of the surgical procedure. Most laparoscopy requires a minimum of laboratory tests usually consisting of only hemoglobin and hematocrit and urinalysis. A coagulation profile may be needed for any patient with a history of bleeding problems.


^ PATIENT PREPARATION

The medical problems may also need further evaluation by their general medical doctor who may require other laboratory testing such as a multi-panel test. Patients who are over 40 years old often benefit from a chest X-ray if one has not been obtained within the last 2 years. It is important to review her medicines and to inquire about the use of aspirin. Many patients do not consider aspirin a drug and neglect to inform the doctor of its chronic use. If the patient has been taking aspirin it should be discontinued for 3 or 4 days prior to surgery. We recommend that all patients eat lightly for 24 hours and be NPO at least 12 hours prior to surgery. An empty bowel permits better visualization during surgery, and in the event of a bowel injury, decreases the possibility of complications.


^ DAY OF SURGERY

Since most laparoscopic surgery is performed on an outpatient basis, it is recommended that surgery be started in the morning if possible. The patient is instructed to arrive at least 1.5 hours prior to surgery to allow adequate time for the anesthesiologist to see the patient, and for all laboratory results to be checked. Before the patient receives any medication for anesthesia, review the anticipated surgery with her and again allow opportunity for any questions. When the surgery is completed and the patient is awake, she is given written instructions regarding follow-up visits and how to take care of herself. The instructions should cover when she should bath (anytime), begin to drive (after 24 hours), perform household duties, and when she may return to work. It should be carefully worded to explain expected postoperative discomfort and to differentiate it from severe pain that requires her to contact either the surgeon or a designated contact person with a telephone number that is answered 24 hours a day. Patients should be discharged with all the appropriate instructions and medication or a prescription for pain relief.


Instrumentation and equipment

^ GENERAL ROOM SETUP

The setup should be designed to optimize efficiency using the team concept. The team usually consists of the surgeon, a first assistant, a scrub nurse and a circulating nurse. The most recent addition to the traditional team is the biomedical technician. He/she may not be required for the entire case, but it is helpful if they are in attendance at the start, as well as intermittently, and at the end of the

case. The technician should be trained and skilled in the use of all electronic equipment, the video camera, laser equipment, and other electronic supplies and be able to possess on-site trouble shooting skills. Since operative endoscopy is completely dependent on high tech equipment, all should be thoroughly checked prior to the start of each case. The circulating nurse is the main coordinator of the team and he/she will be responsible during the procedure for running the video, checking suction and irrigation equipment, and generally providing support and maintaining the steady rhythm of the operating team. The operating room set-up requires an operating table that can be placed in deep Trendelenburg position. It must have rails that will accommodate the stirrups, shoulder braces, and other possible equipment. Most gynecologic surgeons perform laparoscopy from the left side; however, this is an individual idiosyncrasy that started when laparoscopy was performed without a camera and therefore required holding the scope with one hand while leaving the right to manipulate instruments. Generally, if the surgeon is right handed then he/she should stand on the patient’s left side in order to introduce the Veress needle and trocars with the dominant hand. In the ideal OR, to decrease the floor clutter and to allow more room for lasers, fluid monitors and other large equipment, monitors, and most electronic equipment may be suspended from the ceiling along with all gas lines and electric outlets. Many of the commands in the modern futuristic operating rooms can be voice operated and controlled by the surgeon's voice with the help of the HERMES™ system (Stryker Endoscopy, Santa Clara, CA) or OR1™ (Karl Storz Endoscopy, Tuttlingen Germany). This technology uses the latest in electronic control systems to seamlessly integrate devices and environmental components of the operating room, including overhead mounting systems, lighting, operating room tables, endoscopic equipment, cameras, image capture systems and information networks. It brings all of these technologies under the direct control of the surgical team. Always check the instruments and the equipment before each procedure.


The operating room set-up. Ideally, two monitors would be available with one to each side of the legs; however, if only one monitor is available it should be between the legs. The back table should hold all of the hand-held instruments that may be needed during the case. They should be grouped in an orderly manner just as the back table is arranged during open surgery. A Mayo stand can either be placed between the legs or adjacent to a leg with the equipment that will be frequently exchanged during the procedure, i.e. suction irrigator, scissors and several different types of graspers. After the patient is positioned on the table, anesthetized, prepped, and draped she is then catheterized. The multiple instruments that may be utilized for safe and efficient endoscopic surgery are now described.


^ VIDEO IMAGING AND CAPTURING

Modern video cameras are based on the solid-state microprocessor chip. There are one or three-chip cameras with a head that attaches to the eyepiece of the laparoscope and connects to the camera controller by a cable. The signal is then fed into the monitor to display the image. Another type of camera is a combination of scope and camera built together with the camera chip integrated at the distal end of the scope so that there are no optical lenses. With this type of system there is direct digital image transmission from the distal tip. The quality of the video display has advanced along with technology. It is important to realize that the image as seen on the monitor is related to the resolution of the camera and the monitor. If one has a resolution capability of 750 lines and the other 500 lines, you will only be able to visualize at the lower level. High definition endoscopic cam- eras are also available. The HDTV camera and monitor have more than twice the number of scanning lines than the frame of the conventional videos, making the images more clear. These high-definition systems may prove quite useful in diagnosing endometriosis and early metastatic spread. No perusal of instrumentation would be complete without a look at what is development for the future. There are some limitations to using the two-dimensional view of the surgical field. Depth perception allows surgeons to acquire laparoscopic skills quickly. Although there have been some attempts at using 3-D imaging it has not been well accepted. This is due primarily to the fact that current technology has been limited by the projection systems used to bring the image of the surgical field to the surgeon. New instruments such as the EndoSite Digital Camera™ utilize a personal monitor attached to a headband in front of the user’s eye so the end result is similar to that used by surgeons who wear magnifying binoculars during surgery. The special scopes that are needed come in 0° and 30° 10 mm size.

Video capturing has also become an important part of supplying documentation for record keeping. A high definition capture system such as the Stryker SDC HD™ is designed to capture and route the high definition images without the loss of quality. This equipment allows the surgeon to document their cases on several types of media such as CD or DVD as well as routing pictures directly to a printer.


^ UTERINE MOBILIZATION

Most laparoscopic surgery is expedited by the use of a good uterine manipulator. This device should be capable of anteverting and positioning the uterus as needed depending upon the procedure. If a standard uterine manipulator is not available, one may insert a uterine sound high into the fundus and attach it with tape or rubber bands to a tenaculum previously placed on the anterior lip of the cervix. There are many types of commercial manipulators.

Ideally, the manipulator should also have the ability to chromopertubate. The tip of the manipulator is usually held in place by a small balloon that may be inflated with a few milliliters of sterile water.




^ INSUFFLATION INSTRUMENTS

Most techniques of insufflations utilize Veress needle. These springloaded needles are available as reusable instruments, partially disposable, or completely disposable. It is a delicate instrument that has a sharp outer sleeve and contains an inner sleeve with a dull tip on a spring mechanism that retracts back when a resistance is encountered.

Without resistance, the dull tip springs forward to protect intraabdominal structures from the sharp tip. If the reusable needle is sharpened frequently it is as functional as, and certainly less expensive than, the disposable type. The disposable Veress needle has an advantage in always being sharp which enhances its use. The spring mechanism should be checked prior to insertion, even with the disposable instruments.


INSUFFLATORS

There are multiple insufflators on the market. The ideal insufflator can deliver rapid, accurate flow rates of CO2 gas up to 15 L/min. However, it is obvious that the gas flow supplied at the outlet of the machine is not what is delivered intraabdominally owing to the diameter and the distance of the connecting tube. In actual measurements, the true amount delivered at the end of the tube may be only 60%-70% of the capable flow rate of the insufflator. Some insufflators such as Thermoflator® (Karl Storz Endoscopy, Tuttlingen, Germany and Turbo Flow 8000™ Insufflator, Gyrus ACMI, Maple Grove, MN) have heating capability to warm the gas, thus decreasing the intraabdominal hypothermic effect of cold CO2 gas and decreasing fogging of the distal lens of the laparoscope. The Insuflow® device (Lexion Medical, St. Paul, MN) is relatively inexpensive equipment that can be attached to the insufflator that will both hydrate and warm the gas.


^ ABDOMINAL ACCESS INSTRUMENTS

An entire chapter could be used to address this highly debated issue. There are several categories in which all of the instruments may be grouped.

The basic information that should be supplied by the readout of the insufflator is:

1. Insufflation pressure

2. Intraabdominal pressure

3. Insufflation volume per minute

4. Total amount of gas used (the least important)

5. Disposable or reusable

6. Open or closed technique

7. Mini-entry techniques or direct view.

The argument of disposable versus reusable equipment may be focused on trocars and sheaths. The traditional disposable trocars have become popular mainly because the tips are always sharp, thus requiring a much smaller force to achieve penetration than the reusable instruments. The shield that springs out over the tip after entry into the abdominal cavity plays little, if any, role in safety. There has been a continuing area of contention regarding the style of the trocar tip in reusable instruments. Some surgeons favor the pyramidal tip while others extol the virtues of the conical tip. Most trocars today use the pyramidal style tip. There are advantages to each, but sharpness is of most importance in the closed technique. Reusable trocars and sheaths have a distinct economic advantage; however, the necessity of frequent sharpening and cleaning may offset the savings. Trocars are available in many sizes, from 3 mm up to 12 mm and greater. Most standard laparoscopy is performed using a 10 or 12 mm umbilical port for the laparoscope and 5 mm lower abdominal ports for the secondary instruments. There are even smaller trocars that may be used for 3 mm instruments. Most closed technique instruments have sharp tips, which may potentially injure bowel or large blood vessels. This instrument requires opening into the peritoneal cavity prior to the insertion of the sheath and does not develop a pneumoperitoneum prior to its use. The use of vision directed trocars such as the Endopath™ bladeless trocar, a disposable instrument produced by Ethicon Endosurgery, (Cincinnati, OH) is a hybrid that combines a bit of each technique. Another innovation using visual access is the ENDOTIP™ device which is a reusable threaded port that dilates the tissue as it is threaded in (Karl Storz Endoscopy, Culver City, CA). With each of these methods, a 10 mm 0° laparoscope is inserted into the trocar and as the trocar is advanced through the abdominal wall layers, the passage into the abdomen is constantly monitored and, thus, damage to bowel or blood vessels may be avoided. Expandable sheath technology, Step™ (InnerDyne Medical, Sunnyvale, CA) permits the passage of a Veress needle type instrument that has a sheath, which can then be expanded allowing passage of larger sheaths without potential damage, particularly to major vessels. Another dilating trocar uses an asymmetric tip that divides the tissues by dilating through the layers rather than cutting them. One model has a balloon that can be inflated with 10 mL of saline to secure it in place.


^ LIGHT SOURCE

An adequate light source is absolutely essential for performing laparoscopic surgery, as it is important to have good illumination in order to obtain image clarity and true colors. A 250 W halogen or xenon light source provides excellent light intensity. The temperature of 6000°K obtained from xenon provides true white light that enhances visualization to permit recognition of pathological changes. A fluid light cable that connects the light source with the laparoscope may provide optimal light transmission. The fiberoptic light cord should be handled with care, since the fibers within the housing may be broken if the cord is kinked or dropped. If there is a decreased light transmission, one end of the light cord can be held up to a room light and by looking at the other end it is possible to assess whether a significant number of fibers are broken. Due to the concentrated light intensity at the end of the light cable, a significant amount of heat is produced. Therefore, the end of the light cable should not be placed on drapes nor allowed contact with the skin of the patient in order to prevent possible burns.


^ OPTICS (LAPAROSCOPES)

It is important to obtain as panoramic a view as possible, allowing the operator to coordinate proper placement of the instruments. Often the surgeons do not realize the magnification afforded by laparoscopy. Indeed, the magnification is one of the many advantages of this technique. The lenses in the scope enable magnification up to 6 times depending upon the distance between the end of the scope and the object. At 3 cm from the tip to the object, the magnification is 4x and at 4 cm it is 6x. There are several categories of laparoscopes depending on: function, size and angle of view. Function: Scopes may be either diagnostic only or they may be operative. Although most laparoscopic procedures may begin with a 10 mm 0° diagnostic scope, many surgeons prefer operating laparoscopes to be used during the entire case. Most operative scopes have a channel that will allow at least the passage of a 5 mm diameter, 44 cm long instrument. Some scopes have a channel that will allow the passage of 8 mm diameter instruments that can be used in sterilization procedures. These are large diameter scopes that require a 12 mm trocar sheath. The larger diameter scopes may also be utilized for either connecting to a CO2 laser or permitting the passage of a fiber for a YAG laser. Size: The optimal diagnostic scope is a 10 mm diameter instrument. However, as fiber optics have improved through the years, the ability to decrease the size of scopes while enhancing the objective view has increased. Frequently a 5 mm scope is utilized for diagnostics as well as directing the use of 5 mm instruments Angle of view: When using a 10 mm scope as the viewing instrument during operative procedures, it is optimal to have 0° vision (i.e. looking straight ahead). If a scope is used just for diagnostics, it may be advantageous to have an increased angle of vision to observe a more panoramic view of the pelvis. Operative laparoscopes may have a 6° viewing angle. Other scopes may have viewing angles up to 50°. It is important to mention that on every scope there is the engraved number by the eyepiece that specifies the angle of view. If the scope has an angled view, the direction of vision is always pointing away from the light source attachment.


^ ELECTROSURGICAL GENERATORS

Electrosurgical generators are designed to produce a high frequency electric energy in either a monopolar or bipolar format. Generators have the ability to deliver the energy in either a coagulation (modulated/interrupted) or cutting (non modulated/continuous) waveform. Many generators have some style of ammeter to permit either visually, or by sound, the monitoring of the current flow. This is important because it informs the surgeon when complete desiccation of the tissue, either when coagulating a blood vessel or when sealing a Fallopian tube during sterilization, has occurred. Some instruments have built-in circuitry to detect insulation failure or capacitative coupling. The generator may be connected to various instruments including scissors, graspers, needles and bipolar forceps.


^ OPERATIVE INSTRUMENTS

The instruments used during operative laparoscopy may be divided into the following groups.

1. Graspers – traumatic or atraumatic;

2. Cutting instruments;

3. Coagulating instruments (bleeding control)

(Staplers, bipolar graspers, harmonic energy instruments, vessel sealing instruments, ligation and suturing equipment);

4. Morcellating and retrieval instruments;

5. Irrigation suction instruments;

6. Lasers;

7. Specialty instruments (sterilization and mini-instruments).

A complete book would be needed to describe all of the various instruments produced by a myriad number of companies.


Therefore, only examples of instruments will be described.


1. All graspers, whether atraumatic or traumatic may be found in a variety of diameters and lengths. They usually range from 3 mm to 11 mm, however, the most commonly used graspers are 5 mm in diameter and 33 cm long. Longer instruments (44 cm) are designed to pass down the channel of operating scopes. Handles are generally of two basic types – those that will lock (box lock type) and handles that are not locked. The non-locking handles are best used on dissecting type instruments. The tips vary in design depending upon their use. Some have very rounded tips that are extremely dull and the inside of the jaws are also blunt with rounded ridges. This style of instrument is best used for mobilization of bowel and the Fallopian tubes and may be referred to as atraumatic. The authors prefer the atraumatic grasper with locking handle and long jaws by Aesculap (Tuttlingen, Germany) or Snap-In Snap-Out® II or Optima III Laparascopic hand instruments, (Gyrus ACMI, Maple Grove, MN). The best way to determine whether an instrument is atraumatic is to grasp the web space between the thumb and forefinger. If absolutely pain free it may be considered atraumatic. The more pronounced and sharp the ridges in the jaw, the more traumatic the instrument. This type of instrument should only be used on tissue that will be removed or on tissue not expected to bleed. It does afford a stronger hold on tissue than the atraumatic type.


2. Cutting instruments are usually scissors; however, lasers, harmonic energy, and electrical energy may also be used to incise tissue. Scissors may be found in a multitude of forms: straight or curved or hooked and may be reusable or disposable. Some are designed with semi-disposable tips that may be replaced after a number of uses or if they become dull. No matter which scissor is used, the most important aspect is having a sharp instrument. Monopolar electrical energy may be used with the scissor for simultaneous coagulation and tissue cutting. Harmonic energy may be used either in the form of a cutting instrument alone, or in the form of a combination grasper/cutting instrument that not only cuts the tissue, but also coagulates.


3. The control of bleeding is the most crucial element in all surgery. For hemostasis, the most commonly used instrument in laparoscopy is the bipolar forceps. Dr. Richard Kleppinger invented this type of forceps and most surgeons refer to this type of instrument as Kleppingers, even though they may not be in the classic form. The use of bipolar, high frequency electrical energy is a safe, inexpensive and reliable type of laparoscopic control of bleeding.

Technical improvements in the delivery of radio frequency (RF) energy have resulted in the development of new instruments that not only control bleeding, but also have the ability to cut. These instruments use low voltage and high amperage. The Ligasure™ (Valleylab, Boulder, CO) is an electrothermal bipolar vessel sealer that applies high current and low voltage, and pressure from the jaws of the instrument to seal vessels up to 7 mm in diameter. This differs from the energy in standard monopolar and bipolar cautery instruments that use high voltage and low current. Technology offers ultra low voltage combined with very high impact sustainable power to permit predictable next generation RF energy to cut, vaporize, coagulate, and seal over a wide range of tissue conditions while minimizing thermal spread and virtually eliminating sticking.

They may now be found in a variety of styles and are extremely useful for rapid cutting of tissue while simultaneously firing a double row of titanium staples for the control of bleeding. The stapler fits through a 12 mm trocar sleeve. The staplers are disposable and use disposable cartridges that have either 48 or 54 titanium staples depending upon which company manufactured the stapler. The staple line is approximately 37 mm with a cut line of 33 mm.


4. The “Holy Grail” of laparoscopy is the most effective method for removing tissue from the body. Presently the two methods of tissue removal are either through morcellation or by use of a sack or some combination of both. The ideal method has to be safe, efficient, and prevent spillage within the abdomen. A retrieval system plays a vital role in laparoscopic surgery. To supply this system it may be necessary to use some type of extraction sack. The specimen bag must be used in the removal of ovarian tissue that has a possibility of neoplasia in order to obviate the dissemination of possible malignant cells and prevent spillage during removal of a benign teratoma. It is necessary that a removal bag be very strong so that it may resist breakage in the face of a large force in pulling it through a small opening. The sack also should be easily deployed within the abdomen and be capable of holding a mass larger than 7 cm such as a Cook sac.


5. Irrigation and aspiration are necessary for operative laparoscopy because without a clear surgical field the surgeon is blind. Irrigation is used to clear away debris, blood, blood clots, and char that may be produced by electrosurgery or laser treatment. The ideal irrigator must produce enough hydraulic pressure to disrupt clots and assist in aqua dissection. The hand-controlled valve should easily operate both the suction and irrigation. It is important that it be usable with a large enough channel so that large clots may be removed rapidly without clogging the instrument. If the probe tip is to be used for suctioning near bowel, small holes near the tip are useful to avoid pulling bowel into the probe. There are several different types of instruments with varied pumps to deliver the fluid for irrigation such as Endomat™ (Karl Storz Endoscopy, Tuttlingen, Germany).


6. The major types of lasers that are currently used for gynecologic surgery are the CO2, argon, KTP-532 and the Nd- YAG (neodymium-yttrium, aluminum, garnet). Each of these has various indications that are not within the purview of this chapter. The basic instruments that supply these different energy sources are fairly large, expensive, and require specific training in their use.


^ THE MOST COMMON LAPAROSCOPIC OPERATIONS

1   2   3   4   5

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