Clinical Review

Laparoscopic evaluation of the pelvis: refocusing on the basics

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When a systematic approach is utilized, pelvic laparoscopy can aid clinicians in diagnosing a range of common conditions. Here, the author offers techniques for ensuring accurate findings, and reviews snapshots of various abnormalities.


 

KEY POINTS
  • Inspect the pelvis in 2 concentric circles—inner and outer—around the uterus.
  • Manipulate the ovaries for inspection of all surfaces, as endometriosis will frequently be located on the inferior surface and may result in subtle adherence of the ovary to the posterior leaf of the broad ligament.
  • Close the peritoneum and fascia—with a reliable device, under direct laparoscopic visualization—at all trocar sites greater than 5 mm in order to avoid trocar site hernias.
  • Complete the pelvic examination before performing any subsequent procedures, since blood and peritoneal trauma may make abnormal findings difficult to perceive.

Gynecologic laparoscopy offers clinicians the unique opportunity to effectively identify and treat such common conditions as endometriosis, ectopic pregnancy, ovarian cysts, and uterine fibroids. But, as with any procedure, a thorough and systematic approach is needed to ensure all pathologies are identified and all normal and abnormal findings are accurately documented. Here, for clinicians who are new to pelvic laparoscopy or those just looking to brush up on their skills, I share my recommended techniques—based on having performed approximately 1,500 laparoscopic procedures in the past 10 years. (See “7 tips for successful laparoscopy”) I have found this systematic approach to aid not only in the identification of subtle and unanticipated pathology, but also in later recall of events and findings.

7 tips for successful laparoscopy
  1. Use the same technique for evaluating every case. The time taken for the examination will decrease with each surgery.
  2. Always maintain a clean lens and well-focused laparoscope.
  3. Try to determine the optimal distance to hold the laparoscope from the target for the best view of the operative field.
  4. Do not view the target with the laparoscope partially visualizing the interior of the cannula. Instead, slightly withdraw the cannula from the abdomen to obtain a wider field.
  5. Maintain the target in the center of the field, whether taking pictures or performing operative procedures.
  6. Use the uterine manipulator and second puncture probe to enhance exposure.
  7. Review pictures or videotapes to help you recall events and findings. This may be particularly helpful if dictation of the operative report is delayed or if a report is being prepared for a third party.

Preparing the patient

Place the patient in a modified lithotomy position in Allen stirrups, with thighs parallel to the floor, knees comfortably flexed (130°), and with the weight of the lower extremities concentrated at the soles of the feet. Ensure that the buttocks are at the edge of the table. Tuck the right arm safely on the patient’s right side so that the right-handed operator on the right side of the table can have full range of motion and not be restricted by an arm board. Maintain the left arm on an arm board, but be sure to avoid hyperextension to minimize brachial plexus injury. Place the patient’s head on a sponge doughnut to minimize occipital pressure.

After standard prepping and draping, insert an appropriate uterine manipulator. For the small uterus, a disposable manipulator may be placed transcervically with the distal tip close to the fundus of the uterus. For the larger uterus—in excess of 12 weeks’ gestational size—a reusable metal manipulator may be more reliable. Place a Foley catheter to avoid distension of the urinary bladder and to facilitate better pelvic inspection.

Abdominal entry. In a low-risk patient, you may safely place a primary trocar at or near the umbilicus, then insert a 10-mm, 0° laparoscope into the channel of a 10-12 transparent, bladeless trocar. Once successful atraumatic entry is confirmed, insufflate carbon dioxide into the abdomen with the electronic insufflator set at a pressure of 15 mm Hg.

For high-risk patients, you may need to modify the preparation, including site of entry and techniques utilized. For example, in patients with a previous low abdominal scar, establish pneumoperitoneum with a Veress needle in the left upper quadrant prior to trocar placement. Landmarks are the left subcostal margin in the mid-clavicular line. Once pneumoperitoneum is established, use a 10-cc syringe containing 2 cc of saline to aspirate carbon dioxide at the intended site of trocar entry. Use a 2-inch, 22-gauge needle as the radius of a circle traced during aspiration. If free flow of carbon dioxide is not achieved, suspect adhesions and consider a separate site of entry.

With the patient supine, first inspect the upper and mid abdomen and take pictures to accurately demonstrate normal and pathologic findings. Then turn your attention to the pelvis. Under direct laparoscopic visualization, place a 5-mm trocar above the symphysis pubis at an appropriate level above the uterine fundus such that a probe inserted through a cannula at that site can easily be advanced into the posterior cul-de-sac. (A suction/irrigation cannula can serve several functions during the procedure, including manipulating and palpating organs, suctioning blood, irrigating peritoneal surfaces, and cleansing the laparoscopic lens.)

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