Minilaparoscopy: The Best of Both Worlds
Our Experience
With minilaparoscopy, we can maintain triangulation and employ the fundamental principles of conventional laparoscopy with greater technical ease. The approach also has the potential to reduce the risk of incision-site hernias and the incidence of wound complications.
The following drawbacks to minilaparoscopy have been cited:
• A smaller view of the operative field.
• Less tensile strength of the instruments.
• Electrosurgery instruments that are limited to small vessels/pathology.
• Difficulty with large-tissue extraction.
There are solutions to each of these challenges, many of which involve hybrid approaches that incorporate single-incision or conventional laparoscopic ports at the umbilicus to facilitate electrosurgery, tissue extraction, and visualization while maintaining cosmesis. The solutions include the following:
• Better optics. Significant strides have been made in the area of optics, and newer minilaparoscopes (Figure 1) have better resolution and optical clarity than does the previous generation of miniature scopes. We have found that we can zoom the image and reduce light to improve visualization and maximize the operative field.
• Improved instrument strength. As with miniaturized laparoscopes, a wide array of durable instrumentation (Figures 2 and 3) is now available. We employ instruments that are 2.3-3.3 mm in diameter and up to 36 cm in length, ports that are 3.5 mm in diameter and 10-15 cm in length, and scopes that are 2.9-3.3 mm in diameter and up to 25 cm in length.
For skin incisions, a 14-gauge needle is used instead of a scalpel to avoid an incision that is too large and would allow easy slippage of the port. On the 2.3-mm disposable instruments, the tip itself is a 13-gauge needle that is utilized to incise the skin and enter the abdominal cavity. (See Figure 4.) Wounds are not sutured closed, but are merely reapproximated with Steri-Strips at the end of the procedure.
• More versatile electrosurgery instruments. We utilize reusable and disposable bipolar coagulating forceps, as well as reusable instruments with monopolar electrosurgical capability, including dissecting and grasping forceps, scissors, hook, and spatula. For example, when we excise endometriosis, we will utilize a sharp grasping instrument to elevate the lesion away from vital structures, as well as monopolar scissors to excise the disease. Needle holders and knot pushers are sturdy for suturing, and a suction tip is also available in miniaturized form.
In procedures in which the vessel-sealing capacity of a 3-mm energy source is not sufficient, a 5-mm port can be placed at the umbilicus so that a standard 5-mm energy source can be utilized to improve or maintain hemostasis.
• Extraction of large tissues. For tissue extraction requiring an incision larger than 5 mm, a 10- to 12-mm trocar can be placed at the umbilicus for the possible use of an endoscopic specimen bag. We dilate the umbilicus with Hegar dilators to a size 16 to ease the extraction of tissue, if necessary, or for the placement of a laparoscopic morcellator.
Recently, however, we have been able to perform minilaparoscopic hysterectomies with the use of three 3-mm ports, a minilaparoscope, and other miniaturized instrumentation. Specifically, we utilize the 3-mm PKS MoLly forceps by Olympus Gyrus (Figure 5) to coagulate and monopolar scissors to transect the pedicles. A colpotomy is completed with the scissors, and the specimen is delivered through the colpotomy incision. The colpotomy incision is reapproximated with 0-PDS suture on CT-1–sized needles. The suture is backloaded through the miniport and is introduced into the abdomen without difficulty. The incision is sutured; the needle is parked in the upper abdominal wall, and is then cut free. The suture is then pulled through the port for extracorporeal knot tying. The needle is retrieved and pulled through the incision with the removal of the port, and is now ready for loading another suture.
A minilaparoscopic supracervical hysterectomy can be performed in a similar fashion. For tissue extraction, we perform transcervical morcellation. We have found that the morcellators with extra-long shafts (such as the Storz 12-mm extra-long Rotocut or Gynecare Morcellex) work best for transcervical morcellation. Once uterine amputation is completed, the cervical stump is dilated with cervical dilators to allow for the morcellator tip to advance through the cervix and into the pelvic cavity transvaginally. Under direct visualization and with the assistance of a laparoscopic grasper, the specimen is morcellated. Similarly, an endoscopic specimen bag can also be placed transcervically to retrieve specimens that are not to undergo morcellation.
Minilaparoscopy now has multiple applications in our practice. Diagnostically, we employ the use of minilaparoscopic instrumentation in conjunction with hysteroscopic metroplasty, adhesiolysis, or tubal cannulation. Operatively, we have utilized minilaparoscopic instrumentation for excision of endometriosis, ovarian cystectomy, adhesiolysis, enterolysis, tuboplasty, and supracervical and total hysterectomy with or without bilateral salpingo-oophorectomy.
Dr. Cholkeri-Singh is associate director of minimally invasive gynecologic surgery, director of gynecologic surgical education, and codirector of the AAGL/SRS (Society of Reproductive Surgeons) fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. In addition, she is a board member of the AAGL/SRS fellowship in minimally invasive gynecology and is chair of a postgraduate course at this year’s AAGL Global Congress on Minimally Invasive Gynecology. Dr. Cholkeri-Singh disclosed that she is a speaker for Conceptus Inc., Olympus Gyrus ACMI, and Ethicon Endo Surgery.
