Laparoscopic evaluation of the pelvis: refocusing on the basics

Proceed by placing the patient in a Trendelenburg position, steep enough so that you will later be able to retract the small bowel from the posterior cul-de-sac, and keep it in the lower abdomen near the bifurcation of the aorta. Alert the anesthesiologist at this point to observe cardiorespiratory function, especially in the at-risk patient. Decrease the angle of the Trendelenburg position when necessary. Use the uterine manipulator to displace the uterus in all directions to confirm that the instrument is properly located. Identify any obvious pelvic pathology prior to the detailed examination.

Technique

The key to conducting a successful examination of the pelvis is to utilize a technique that enhances meticulous and complete evaluation. To achieve this, inspect the pelvis in 2 concentric circles—inner and outer—around the uterus. Be sure to maintain the laparoscope at an optimal distance from the target at all times, and keep the lens clean and the instrument well focused to ensure as clear a view as possible.

Pelvic inspection should include the lower anterior and lateral abdominal walls, anterior cul-de-sac, uterus and supporting ligaments, adnexae, pelvic sidewalls, posterior cul-de-sac, rectosigmoid, and posterior abdominal wall up to the bifurcation of the aorta.

Inner concentric circle. First, inspect the uterus, noting the size, contour, and consistency, as well as the presence of any abnormalities. Then examine the left round ligament (FIGURE 1A). Proceed in a clockwise fashion through the anterior cul-de-sac to the right round ligament. Zoom in and pan out with the laparoscope, performing suction and irrigation as needed for better inspection of all peritoneal surfaces.

Mobilize the right adnexa with the suprapubic probe and examine the fallopian tube and ovary completely (FIGURE 1B). Manipulate the adnexa out of the true pelvis and assess the right lateral pelvic sidewall.

Continue to the fossa ovarica, checking for endometriosis. Also, identify retroperitoneal structures. (Of note, the ureter may run an aberrant course, especially when midpelvic endometriosis is present.) The uterosacral ligament, hypogastric artery, ureter, and infundibulo-pelvic ligament should be noted from medial to lateral just beyond the pelvic inlet.

With the patient in a steep Trendelenburg position and the small bowel displaced into the lumbar area, evaluate the posterior cul-de-sac including the rectum and pararectal areas (FIGURE 1C). Suction excess fluid as needed for better visualization. Palpate and examine the uterosacral ligaments from the uterus to the sacral attachment. By manipulating the sigmoid colon and adnexae, you will better expose the ovarian fossa and pararectal areas.

Displace the sigmoid colon to the right and appraise the left pelvic sidewall (FIGURE 1D). A good initial reference point in identifying the midpelvic ureter is the hypogastric artery, readily identified in pulsation just beyond the pelvic inlet. You may note the ureter in peristalsis superior and lateral to the vessel. Trace the ureter distally by manipulating the left adnexa. The external iliac vessels are now superior and lateral to the ureter, and the uterosacral ligament is inferior and medial.

Complete the inner concentric circle evaluation by checking the left adnexa and anterior leaf of the broad ligament up to the round ligament. Manipulate the left ovary 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.

Outer concentric circle. Begin with the left medial umbilical ligament and continue clockwise through the low anterior abdominal wall to the right medial umbilical ligament (FIGURE 2A). Identify both inferior epigastric vessels prior to inserting low lateral trocars. Low-abdominal trocars may be placed during inspection, especially if pathology is identified preoperatively. However, trocar size, location, and number is dependent on the location and nature of the pathology encountered.

Advance toward the right ilio-psoas muscle and note the genitofemoral nerve through the transparent peritoneum running longitudinally along the middle of the muscle (FIGURE 2B). Trace the right common iliac artery proximally to the bifurcation of the aorta (FIGURE 2C). Progress to the left common iliac. Identify the inferior mesenteric vessels and ureter lateral to the common iliac artery by manipulating and inspecting the sigmoid colon and mesentery. Finally, examine the left psoas muscle and adjoining structures.

Completing the pelvic evaluation. At the end of every laparoscopic procedure, 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 (FIGURE 3). Then remove all instruments and cannulas and expel carbon dioxide under laparoscopic observation. Lastly, withdraw the laparoscope slowly while viewing the tract of the trocar.