chapter 10. endoscopy (hysteroscopy and laparoscopy)

8/12/2019 Chapter 10. Endoscopy (Hysteroscopy and Laparoscopy)

1/16

10Endoscopy: Hysteroscopy and LaparoscopyIndications, Contraindications and Complications

Gretchen M. Lentz

This chapter presents an overview of frequently used endoscopicprocedures in gynecology. Indications, contraindications, andcomplications are included for each procedure. For those unfa-miliar with the procedures, the diagnostic uses are described.Therapeutic uses and pitfalls are introduced, but complex surgi-cal procedures are covered in gynecologic surgical textbooks.

Since the 1960s, there have been significant changes in the useof endoscopy in gynecologic practice. The fiberoptic bundle andmore versatile light sources, as well as the incorporation of ad-vances in technology, have dramatically increased the diagnosticand therapeutic capabilities of the hysteroscope and laparoscope.

The tremendous advances in technology have led to the emer-gence of more office-based procedures. Many gynecologic sur-geries done by laparotomy in years past have been convertedto ambulatory, outpatient procedures. Other cases previouslycompleted by laparotomy have been converted to complex lap-aroscopic or robotic surgeries with shorter recovery time andhospital stays. This chapter serves as an introductory overviewof gynecologic endoscopy.

HYSTEROSCOPY

Hysteroscopyis the direct visualization of the endometrial cav-ity via the cervix using an endoscope and a light source. The ear-liest hysteroscope was nothing more than a hollow tube with analcohol lamp and mirror for a light source. In 1869, Pantaleonireported the successful removal of an endometrial polyp throughthe scope. Modern hysteroscopes are modifications of cysto-scopes with channels to introduce light via fiberoptics. Variousinfusion media are used for uterine cavity distention, which isnecessary for inspection. Many surgical instruments and devicesare available for diagnostic biopsy and pathology removal andtherapeutic procedures. Office and operating room hysteroscopy

requires knowledge of instrumentation, techniques, indications,contraindications, and complication management. If officehysteroscopy is used, proper office safety protocols are needed.

Inserting a hysteroscope for diagnostic purposes only is nota risky procedure. The key is predicting ahead of time whichdiagnostic procedures might be very challenging from severe cer-vical stenosis or which complex operative hysteroscopic proce-dures might be more safely accomplished in the operatingroom setting. Office hysteroscopy saves time for both the patientand physician, saves money, and is convenient. It makes sense togain experience with the simpler hysteroscopic procedures in the

office. Judgment is necessary, as a 1-cm pedunculated polyp ormyoma might be easily removed in the office; however, a 3-cmsessile polyp or 3-cm myoma with 50% of the myoma intramyo-metrial would require more expertise and might be more safelyattempted in the operating room. Once expertise has beengained from sufficient operative hysteroscopic procedural vol-ume, the more involved and challenging procedures can bemoved from the operating room to the office setting.

HYSTEROSCOPIC INDICATIONSAND CO NTRAINDICATION S

The popularity of hysteroscopy has been enhanced because it is asimple technique that can be performed in the office. Officeindications include diagnosing abnormal uterine bleeding, forboth pre- and postmenopausal women. Women with recurrentabnormal uterine bleeding, particularly if abnormal perimeno-pausal or postmenopausal bleeding recurs or persists followinga negative endometrial biopsy, are good candidates for hysteros-copy. Endometrial biopsy and dilatation and curettage (D&C)

procedures frequently miss focal lesions, particularly peduncu-lated structures. Feldman and colleagues evaluated 286 womenwith perimenopausal bleeding who had had a D&C or anendometrial biopsy. Nine of 86 (10.5%) who had negative find-ings initially, but continued to bleed, had carcinoma or complexhyperplasia on follow-up biopsy. Hysteroscopy with directedbiopsy can be useful in this setting, although controversy existsregarding the spread of endometrial cancer with hysteroscopy.Hysteroscopy is ideal for directly visualizing and removing in-trauterine foreign bodies like a partially perforated or brokenintrauterine device (IUD) or retrieving an IUD with missingstrings. Other indications include performing hysteroscopicsterilization, evaluation of recurrent miscarriage, uterine syne-chiae, abnormal hysterosalpinography (HSG), and infertility.

More involved operative procedures for correcting an abnormal-ity, which might require local, regional, or general anesthesia, in-clude resection of submucous myomas, lysis of synechiae, incisionof uterine septa, and removal of endometrial polyps or ablation ofthe endometrium.Table 10-1lists common indications.

There are few contraindications to hysteroscopy. Absolutecontraindications include acute pelvic or vaginal infections in-cluding genital herpes, because of the potential of spreadingthe disease by the media used for uterine distention. One excep-tion might be for the retrieval of an IUD if the pelvic infection isrelated to the IUD. Pregnancy is a contraindication, as is recent


2/16


3/16

(not a laparoscopic insufflator) that carefully limits flow to less

than 100 mL/min and maintains the pressure at approximately60 to 70 mm Hg. Because no fluid is involved, there is no mess.If the patient has patent fallopian tubes, the CO2gas can causediaphragmatic irritation and discomfort. The major precautionwith D5W is the monitoring of total fluid intake so as not to pro-duce water intoxication. In contrast, office hysteroscopy with thesmaller flexible scopes most commonly incorporates the use ofsaline or lactated Ringers solution because either is easier touse, causes less pain, and avoids the risk of electrolyte and osmo-lar imbalances. For operative hysteroscopy, carefully and fre-quently monitoring the intake and outflow of distentionmedia is required. Fluid management systems are available thatcalculate these values continuously. Guidelines exist for termi-nating a procedure when fluid deficits reach a set amount. For

nonelectrolyte media, the recommended cutoff is 1000 to1500 mL; and for an electrolyte media it is 2500 mL, but otherfactors should be considered such age, comorbid conditions, car-diovascular disease, and patient body mass index. For operativeprocedures with electrocautery, saline or isotonic solutions cannotbe used because they conduct electricity (except bipolar cautery).

Hysteroscopy techniques are fairly similar whether performedas an office procedure or in an operating room. A list of generalequipment needed for office hysteroscopy is given in Table 10-3.

A complete history and physical exam is needed; in particular, arelevant allergies and medication list needs to be confirmed. Ap-propriate tests might include a Papanicolaou smear, pregnancytest, hemoglobin or hematocrit testing, and gonorrhea or chla-mydia testing. Hysteroscopy can be performed at any time dur-

ing the menstrual cycle, but it is best scheduled in the early tomiddle proliferative phase. A bimanual examination is per-formed to note the size of the uterus and direction of the uterinefundus. Knowing whether the uterus is anteverted or retrovertedis important to avoid uterine perforation, and a rectovaginalexam can aid in determining position. It is helpful to explainto the patient that she will experience discomfort if cervical di-lation is needed and uterine cramping during the short time thatthe hysteroscope is inside the uterus. A single-toothed tenaculummay be used to secure the anterior cervical lip. Gentle tractionon the tenaculum straightens out the uterine axis to facilitateendocervical passage of the instruments. Techniques have beendescribed for diagnostic hysteroscopy with a small scope diam-eter than do not utilize a tenaculum and thus avoid causing that

pain. The exocervix is then cleaned of mucus and bacteria. Manyphysicians will cleanse the cervical os with an iodine solutionprior to introducing the scope. The most frequent problem inperforming hysteroscopy is cervical stenosis or spasm. When thisis encountered, the optimal method to obtain pain relief andovercome resistance is a paracervical block with 1% lidocaine(Xylocaine). Liberal use of paracervical block in difficult proce-dures allows the physician to be successful in obtaining endome-trial biopsy tissue in more than 95% of cases, so this is likely truefor hysteroscopy as well. Subsequently, the cervix can be dilatedwith tapered plastic or metal dilators, and the hysteroscopy canbe completed. Unlike with larger rigid scopes, most patients willnot require anesthesia for diagnostic procedures in the office.The infusion line should be flushed through the scope prior

to insertion, otherwise bubbles will be introduced and obscurethe view.

When inserting the hysteroscope, it is useful to wait a few sec-onds to let the distending media open the internal cervical osso the uterine cavity can be entered more easily by followingthe fluid flow. Then angle of the telescope view is opposite

Figure 10-2 Flexible hysteroscopy. Uterine distention is maintainedwith normal saline or lactated Ringers solution injected through

intravenous extension tubing. (From Goldberg JM, Falcone T: Atlasof Endoscopic Techniques in Gynecology. London, WB Saunders,

2000, p 185.)

Table 10-2 Comparison of Hysteroscopic Distention Media

Medium Advantage Disadvantage Risks

CO2 Safe

Ease of use

Rapidly

absorbed

Poor visibility in

the presence of

bleeding

Normal saline

Lactated

Ringers

Isotonic Not suitable for

monopolar

electrosurgery

Fluid overload

Glycine 1.5%

Sorbitol

Mannitol 5%

Electrolyte free

Nonconductive

Hypot onic Hypot onic

fluid overload

Hyponatremia

Hyskon

(32% dextran)

Nonconductive

Immiscible

with blood

Difficult to

deliver

Hypertonic

fluid overload

Anaphylactic

reaction

From Beiber EJ, Sanfilippo JS, Horowitz IR: Clinical Gynecology. Philadelphia,

Elsevier, 2006.

Table 10-3 Equipment for Office Hysteroscopy

Procedure table that elevates to 46 to 48 inches

Comfortable behind-the-knee padded stirrups

Open-sided speculum

Paracervical block equipment

Tenaculum

Hysteroscope with 4-mm diameter and fore-oblique 25- to

30-degree lens

Diagnostic sheath of 5 mm

Operative sheath of 7 mm

Flexible or semirigid scissors and biopsy and grasping forceps

Rigid scissors and biopsy and grasping forceps

Ring forceps

Myoma grasping forceps

Emergency kit

Foley catheter with 30-mL balloon

10 Endoscopy: Hysteroscopy and Laparoscopy


4/16

the direction of the light post. This point needs to be remem-bered in the context of viewing an anteverted versus retroverteduterus. If the light post is pointing upward, the view is down-ward. If uterine cavity vision is obscured, it may be due to insuf-ficient distention fluid, bleeding, or being up against the uterinewall or pathology. Withdraw the hysteroscope slowly whileslightly increasing the distention fluid. Never advance the hyster-oscope without good visualization because perforation can

occur. The cavity should be inspected thoroughly and systemat-ically. First, an overall view can be seen on entry looking for thegeneral cavity shape, polyps, myomas, and foreign bodies. As thehysteroscope is advanced, it is rotated clockwise and counter-clockwise to see the cornua and tubal ostia. On removal, endo-cervix is viewed. Overzealous cervical dilation can create a poorseal between the cervix and scope allowing the fluid to run out ofthe cervix and poor uterine distention. Short-term complicationsare listed in Table 10-4.

Vaginal misoprostol (prostaglandin E1), in dosages of 200 to400 micrograms, has also been used to aid in the transcervicalpassage of the hysteroscope. It is usually given the night beforethe procedure, but administration 4 to 12 hours preoperativelyhas been described for cervical softening. This can be particularly

helpful if cervical stenosis is present or suspected. Women at riskfor cervical stenosis include those with prior cervical surgery suchas cone biopsy or postmenopausal status, particularly nulliparouswomen. It acts on the extracellular matrix of the cervix, leadingto water absorption, collagenase release, and cervical softening.

Women should be warned of the side effects of misoprostol,including diarrhea, cramping, uterine bleeding, and fever.Concomitant nonsteroidal anti-inflammatory (NSAID) agentscan reduce side effects. Anxious patients may be pretreated withalprazolam, diazepam, or some other anxiolytic. Many clinicianspretreat women with NSAIDs to decrease the pain associatedwith this procedure, but studies suggest this only helps for post-operative pain, which is still an advantage. For more involvedprocedures, intravenous analgesia and conscious sedation may

be needed, and proper protocols are needed to ensure patient

safety. If extensive resections are anticipated via hysteroscopy,then the procedure is better performed on an outpatient basisin the surgical suite.

For the severely stenotic cervix, having the right instrumentsavailable is critical. Lacrimal-duct dilators (from ophthalmologicsurgery) come in sizes down to 1-mm diameter and in graduatedsizes. This can lead to cervical access when barely a dimple isseen in the external cervical os. Then, the usual tapered metal

or plastic cervical dilators can facilitate complete dilation. Also,real-time ultrasonography can help the surgeon to visualize thetip of the dilator, direct the surgeon along the right track intothe endometrial cavity, and prevent the surgeon from makinga false cervical path or uterine perforation.

OPERATIVE HYSTEROSCOPY TECHNIQUES

The variety and extent of surgery performed transcervically withthe hysteroscope have expanded significantly with technologicadvances. Endoscopic procedures have progressed from snaringsmall polyps to hysteroscopic tubal sterilization to complex myo-mectomies and ablating the entire endometrial lining. The abil-ity to detect, biopsy, or remove focal lesions is extremely useful

for abnormal bleeding workup over blind endometrial sampling.Approximately 50% of all Essure hysteroscopic tubal occlusionsperformed in the United States are done in an office setting, andthe percentage is rising. Operative hysteroscopy may be per-formed with mechanical devices such as small operating scissors,electrocautery, and modified resectoscopes and lasers. Laserhysteroscopy with carbon dioxide or neodymium:yttrium-aluminum-garnet (Nd:YAG) or argon lasers requires moreexpensive equipment and expertise. With the development ofthe second-generation technology for uterine ablation and polypand fibroid resection, the laser and resectoscope equipment issignificantly less popular and less advantageous than simplertechniques.

Women with repetitive miscarriages should have a diagnostic

hysteroscopic procedure, which often leads to an operative pro-cedure. Congenital abnormalities that interfere with the successof early pregnancies, such as septa of the uterus, may be seen andremoved (Fig. 10-3). Often endometrial polyps or submucousmyomas are discovered and may be removed with a resectoscopewire (Fig. 10-4) or a newer morcellator type device (Fig. 10-5).The uterine synechiae of a woman with Ashermans syndromecan be cut with microscissors, reestablishing the endometrial cav-ity. Because adhesions interfere with the configuration of thecavity, it can be difficult for the surgeon to identify usual land-marks. Simultaneous laparoscopy guidance is often used toavoid perforation when cutting the intrauterine adhesions. Hys-teroscopic metroplasty of intrauterine septa has replaced abdom-inal metroplasty, as it is safer and has fewer complications than

laparotomy. Simultaneous laparoscopy is often used with thisprocedure as well to gauge the end point of cutting the septum.

Hysteroscopy is superior to hysterosalpingogram (HSG) indiscovering intrauterine disease. In comparative studies, theuse of hysteroscopy revealed synechiae, polyps, or myomas in40% of patients with normal HSGs. These abnormalities wereundetected and unsuspected using radiographic techniques.The false-positive rate of HSG is 33% compared with hysteros-copy. One in three women diagnosed as having an intrauterinefilling defect by x-ray imaging will have a normal cavity directlyvisualized with the hysteroscope. Women with amenorrhea and

Table 10-4 Short-Term Complications of Hysteroscopy

Complication Rate (%)

Overall Complication Rate

Diagnostic hysteroscopy 0.95%

Operative hysteroscopy 2% to 3%

Hysteroscopic myomectomy 1% to 5%

Uterine Perforation

Operative hysteroscopy 1%

Endomet rial ablationresectoscope 2% to 2%

Endometrial ablationnonresectoscope 1%

Fluid overload 0.06% to 2%

Bleeding 0.03% to 3%

Pelvic Infection 0.01%

Deathfluid ov erload or septicemia 0.01%

Embolism; gas, air *

Cervical laceration *

Creation of false cervical passage *

Failure to complete the procedure *

Electrocautery injury *

Urinary tract or bowel injury *

Pulmonary and cerebral edema *

Dissemination of cervical or endometrial cancer *

*Rare complication or exact rate of complication unknown.

176 Part II COMPREHE NSIVE EVALUATIO N OF THE FEMALE


5/16

a history of curettage who do not respond to a hormonal chal-lenge should have an HSG or hysteroscopy. Uterine synechiaeare identified by slowly injecting a water-soluble medium onHSG or by the inability to visualize the uterine cavity on hyster-oscopy. If a woman has synechiae, tubal obstruction on HSG,and pelvic calcifications, a diagnosis of pelvic tuberculosis shouldbe strongly suspected.

Submucous myomas were initially removed with a modified

urologic resectoscope using a cutting 40-watt electric current anda 90-degree wire loop for shaving the myoma until it was flatwith the surrounding endometrial lining. The electrocauteryled to bubbles obscuring the view and the potential risk of gasor air emboli. If unsuspected perforation occurred, the risk ofthermal injury was present. Greatly improved instrumentationis available with a hysteroscopic rotary or reciprocating morcel-lator blade for removing polyps and fibroids. It does not useelectrocautery and continuously suctions out the pathology sothere are no bubbles and no pieces of shaved pathology floatingin the cavity. This problem with the resectoscope required fre-quent interruption of the procedure to remove the chips. Thedevice is simple, and the morcellator is placed against the polypor fibroid and activated. The morcellator simultaneously aspi-

rates and cuts the polyp or fibroid. Saline is used as the infusionmedia as no cautery is used, which lessens the electrolyte imbal-ance risk. The drawback without electrocautery is that morebleeding can occur. Studies have shown successful removal ofthe submucous myoma at the initial hysteroscopy being 85%to 95%. The success rate of complete resection at the initialsurgery is higher with myomas that are nearly completelysubmucous versus fibroids with a significant intramural portion.

Another surgery is needed in approximately 5% to 15% of cases,although most are another hysteroscopic surgery. Polenas 2007study of 235 patients reported a success rate of 94.6% at 1 year,which decreased to 76.3% at 5 years. The pregnancy rate is asgood as or better with hysteroscopic myomectomy than withtransabdominal myomectomy.

In women with abnormal bleeding or menorrhagia who arepoor surgical candidates, desire a minimally invasive procedure,or wish to preserve their uterus, the endometrial lining may beablated or resected through the hysteroscope. It is not indicatedif there is endometrial cancer or if the woman still desires preg-nancy. Sterilization or contraception needs should be addressed.One of the early techniques for endometrial ablation utilizeda roller ball electrode to coagulate and thus destroy the endo-metrium (Fig. 10-6) or a wire loop as described previously toresect the endometrium. Although lasers may also be used toproduce ablation of the endometrium by photovaporizing the

Figure 10-3 The loop is placed at the center of the apex of theseptum. As the current is activated, the loop is advanced toward thefundus in small increments, always staying in the center of the

septum. The septum separates, as it is divided so that no tissue needs

to be excised. (There are small endometrial fragments in the right

cornua and a small clot adherent to the left aspect of the septum.)(From Goldberg JM, Falcone T: Atlas of Endoscopic Techniques in

Gynecology. London, WB Saunders, 2000, p 194.)

A B

Figure 10-5 Intrauterine polyp before(A)and after (B) hysteroscopicmorcellation. (Images courtesy ofDr.HowardTopel and Smith & Nephew.)

Figure 10-4 A uterine polyp with the hysteroscopic resection toolbehind the polyp. (From Goldberg JM, Falcone T: Atlas of EndoscopicTechniques in Gynecology. London, WB Saunders, 2000, p 187.)



6/16

epithelium, laser photovaporization takes longer than electroderesection, and the equipment is more expensive. Hysterogramsfollowing treatment have demonstrated contraction, scarring,and dense adhesion formation. Long-term follow-up has docu-mented that endometrial carcinoma may develop in residualfoci of endometrium. The newer second-generation devicesfor endometrial ablation offer safer and simpler options. Thesenew devices are nonresectoscope types. The Food and Drug

Administration (FDA) has approved five global endometrialablation devices: thermal balloon endometrial ablation(ThermaChoice, Ethicon Inc., Menlo Park, California), radio-frequency endometrial ablation (NovaSure, Cytyc SurgicalProducts, Palo Alto, California), hydrothermal endometrialablation (HydroTermAblator, Boston Scientific, Natick, Massa-

chusetts), cryoablation (Her Option, CryoGen Inc., San Diego,California), and microwave endometrial ablation (Microsulis,Hampshire, England). The 2009 Cochrane database review con-cluded that endometrial ablation techniques offer a less invasivealternative to hysterectomies. All of the currently available non-resectoscopic endometrial ablation devices have limitationson acceptable endometrial cavity size and endometrial surface ir-regularities like myomas. No gold standard system exists yet.The second-generation devices compare favorably with the resec-toscope technique. Similar rates of intrauterine adhesions andcontracture have been found in about one third of women. Thisdoes not seem to cause problems unless obstructed bleedingoccurs (see the Complications section presented later in thechapter).

Selective salpingography is an extension of hysteroscopy toevaluate the lumen of the fallopian tubes. The tube can be can-nulized and contrast instilled for confirming proximal tubalobstruction observed on HSG.

Hysteroscopic sterilization may be accomplished with inser-tion of coils in the tubal ostia or radiofrequency and plugs. Thisis desirable, as no incision is needed as for laparoscopic steriliza-tion and it can be performed in the office. Two devices are FDAapproved in the United States: Essure in 2002 and Adiana in2009. Under hysteroscopic viewing, the Essure coil is placedin the proximal portion of the fallopian tube. Chronic

inflammation around the coil leads to tubal blockage. TheAdiana system uses hysteroscopic guidance to utilize radiofre-quency energy to disrupt the proximal tubal endothelium andthen a silicone matrix, which also causes tubal obstruction bytissue ingrowth. Neither technique works immediately, and afollow-up HSG is needed in 3 months to make sure the tubesare indeed blocked. No procedure is of yet reversible. Short-termefficacy studies suggest a rate equal to or greater than other tubal

sterilization methods.In summary, hysteroscopy is a simple technique for the diag-nosis and treatment of intrauterine pathology. The indicationsfor intrauterine surgery via the hysteroscope are expanding,and many laparotomies can be avoided. Operative hysteroscopiccosts vary depending on the time involved and the specificprocedure performed.

COMPLICATIONS

Complications following diagnostic hysteroscopy are exceed-ingly rare. The major complication is uterine perforation, andoffice hysteroscopy has an incidence of 1 or 2 cases per 1000.Infection and postprocedure hemorrhage are very rare. Some

women develop a severe vasovagal reflex from instrumentationof the uterine cavity. Symptoms include dizziness, nausea, sweat-ing, and fainting. The woman may be pale, diaphoretic, and bra-dycardic. Syncope can occur with none of the symptomsreported. This reflex can be diminished by giving the patient in-travenous atropine (0.5 to 1 mg IV), IV fluids or by performing aparacervical block. Use of the Trendelenburg position or havingthe patient lie supine with the legs raised can be beneficial in re-covery. If bleeding is excessive, electrocautery coagulation at thebleeding point may be sufficient. If not, others have reportedinjecting dilute vasopressin at the bleeding point with cautionto avoid intraarterial injection, which can result in hypertension,bradycardia, cardiovascular collapse, and even death. An inflat-able 30-cc Foley balloon can be inserted into the uterine cavity,

inflated, and left for 12 to 24 hours, facilitating hemostasis.Complications of hysteroscopy in general are noted in less

than 2% of the procedures. Jansen and coworkers, using a largedatabase of 136,000 hysteroscopies, noted the significant com-plication rate to be 0.28%. Complications include uterine per-foration (0.12%), pelvic infection (0.01%), bleeding (0.03%),fluid overload (0.06%) from absorption of distending media,and bladder or bowel injury (0.02%). Diagnostic hysteroscopyhas a significantly lower complication rate than operative hyster-oscopy (0.95%). Uterine perforation can be midline or lateral.Midline perforation rarely results in significant complicationsunless electrocautery or laser energy is used. Lateral perforationis risky in terms of bleeding complications, as the uterine arteryand vein can be punctured. Suspect uterine perforation if the op-

erative view suddenly disappears, the fluid deficit suddenly in-creases, or the hysteroscope suddenly inserts farther than thefundus. Thermal injury to surrounding organs may occur withdeep resections or perforations with the electrocautery instru-ment. If injury or perforation is suspected during hysteroscopy,then an intraperitoneal evaluation should be performed either bylaparoscopy or by laparotomy. Unrecognized uterine perforationmight result in postoperative abdominal or pelvic pain beyondwhat is normally expected; abdominal distention heavy vaginalbleeding, hypotension, nausea or vomiting or hematuria, orbowel injury, particularly thermal injuries, may present with

Figure 10-6 Endometrial cavity prior to ablation with a roller-ball.(From Goldberg JM, Falcone T: Atlas of Endoscopic Techniques inGynecology. London, WB Saunders, 2000, p 197.)



7/16

delayed onset of symptoms and often go unrecognized.Table 10-4 summarizes the complications with diagnostic andoperative hysteroscopy.

The potential complications of the distending media includeanaphylaxis to dextran, circulatory overload with D5W, pulmo-nary and cerebral edema, hyponatremia, seizure, coagulopathies,and the potential of air or gas embolism with carbon dioxide.Monitoring of the patients fluid status is important because

of problems with absorption of distending media, leading to vol-ume overload and electrolyte imbalance. Cardiac arrest has beenreported with uterine insufflation with carbon dioxide whenunmonitored amounts of gas were used.

For in-office hysteroscopy, an emergency kit is needed. Med-ication should be readily available to treat vasovagal reactions.

A Foley catheter with a 30-cc balloon is useful for persistentbleeding. The catheter is inserted via the cervix, and the balloonis filled to tamponade bleeding. The catheter acts as a drain sobleeding can be monitored.

A note is indicated about patient safety during procedures.The American College of Obstetricians and Gynecologists(ACOG) published guidelines in 2010 that contain a sectionon free-standing surgical units where many operative hysteros-

copy procedures are performed. Care must be taken to ensureadequate training of personnel, knowledge, uses, maintenanceand cleaning of equipment, and safety protocols for sedationor anesthesia complications or surgical complications. Emer-gency care and hospital transfer protocols are required in writingin many states when more than minimal sedation or localanesthetic infiltration in peripheral nerves is required.

Some long-term complications exist after endometrial abla-tion, including recurrent or persistent abnormal bleeding. The2007 ACOG Practice Bulletin states that hysterectomy rates af-ter both resectoscopic and the second-generation nonresecto-scopic ablations are at least 24%. Older women have a highersuccess rate, because menopause occurs before the recurrentbleeding problems or obstructive symptoms occur. The inability

to evaluate the endometrium if bleeding recurs and the risk of adelay in diagnosis of endometrial cancer are added concerns.Pregnancy following an endometrial ablation can occur and isoften complicated by the intrauterine scarring and contracture.This can result in abnormal placentation including placentaaccreta or percreta, uterine rupture, higher spontaneous abor-tion rates, preterm delivery, ectopic pregnancy, and fetal limbmalformations. Residual areas of endometrium that are notablated or regrown can lead to trapped bleeding within the uter-ine cavity, leading to retrograde bleeding or cornual or uterinehematometra. (Additional risks are listed in Table 10-5.)

LAPAROSCOPY

Laparoscopy has radically changed the clinical practice of gyne-cology. As an often outpatient surgical technique, laparoscopyprovides a window to directly visualize pelvic anatomy as wellas a technique for performing many operations with less morbid-ity than laparotomy (Fig. 10-7). Operative laparoscopy for com-plex surgeries is associated with an easier recovery and a shorter

hospital stay.The first human laparoscopy was first performed in 1910 in

Sweden. Two events of the early 1960s renewed interest in thissurgical technique, the first being the development of fiberopticcables for better illumination and the second the change insocietys attitude toward sterilization procedures. Patrick Steptoeis considered the father of modern laparoscopy for his work inthe mid-1960s with laparoscopic sterilization. By the mid-1970s, laparoscopy had been adopted as the method of choicefor female sterilization. Once laparoscopic cholecystectomywas embraced and new instrumentation developed, the waywas paved for laparoscopic hysterectomy.

The advantages of less postoperative pain, shorter recoverytime, and shorter hospital stays are obvious when laparoscopyis compared with laparotomy. This is particularly true in theobese woman who has increased risk of wound infection, throm-boembolic events, and other complications from laparotomy.These events are significantly less with a laparoscopic approach.Laparoscopic visualization is excellent because the video cameraand endoscope magnify the image.

LAPAROSCOPIC INDICATIONS ANDCONTRAINDICATIONS

There are multiple indications for laparoscopy, both diagnosticand therapeutic. The most common indication used to be femalesterilization but is now diagnostic laparoscopy, and this includes

the evaluation of pelvic pain. In the past decades, gynecologistshave progressed from using the laparoscope to perform such

Table 10-5 Long-Term Complications of Endometrial AblationDevices

Persistent bleeding

Central hematometra

Cornual hematometra

Postablation tubal sterilization syndrome (PATSS)

Retrograde bleeding

Inability to evaluate the endometrium if bleeding recurs

Delay in diagnosis of endometrial cancer

Pregnancy

Postablation cornual endosalpingoblastosis

Figure 10-7 Laparoscopic view of left pelvis viewing left lowerquadrant port and right atraumatic grasper holding left fallopiantube with paratubal cyst and normal ovary. (Courtesy of Dr. Seine

Chiang, University of Washington.)



8/16

simple surgical tasks as tubal ligation to more complicated sur-gery such as hysterectomy with pelvic and paraaortic lymph nodedissection for endometrial cancer. The present indications forlaparoscopy are almost identical to those for laparotomy, andthe laparoscope is utilized for numerous diagnostic and thera-peutic indications. Some indications include removal of ectopicpregnancies, resection or ablation of endometriosis, ovariancystectomy or salpingo-oophorectomy, myomectomy, hysterec-

tomy, lymph node dissections, and urogynecologic procedures.Intraperitoneal intrauterine devices are best retrieved with thelaparoscope. Laparoscopic ovarian biopsy (for karyotyping incertain endocrine disorders) is possible. Laparoscopic lysis of ad-hesions might be done for pain or to transform an abdominalhysterectomy into a vaginal hysterectomy or laparoscopicallyassisted vaginal hysterectomy. The limits and indications of sur-gical procedures via the laparoscope depend on the experienceand judgment of the gynecologist. At some point, laparotomyis the more reasonable decision. We believe that a procedureshould be performed through the laparoscope only if the gyne-cologist is prepared for the complications that might arise if thatprocedure were performed through a laparotomy.

Absolute contraindications to laparoscopy include intestinal

obstruction, hemoperitoneum that produces hemodynamicinstability, anticoagulation therapy, severe cardiovascular or pul-monary disease, and tuberculous peritonitis. Relative contrain-dications, in which each case must be individualized, includemorbid obesity, large hiatal hernia, advanced malignancy, gen-eralized peritonitis or peritonitis following previous surgery,inflammatory bowel disease, and extensive intraabdominalscarring. Even with these relative contraindications, the surgeonmay attempt laparoscopy. Failure to achieve a pneumoperito-neum should signal the potential for bowel injury. Open laparos-copy might allow safe entry or avoidance of complications, butthe surgeon and patient should be prepared to convert to alaparotomy.

LAPAROSCOPIC EQUIPMENT AND TECHNIQUES

Laparoscopy may be performed under local, regional, or generalanesthesia. For simple procedures, many prefer local anesthesiafor its safety, with the addition of conscious sedation by intrave-nous medication. Regional anesthesia is possible, but theTrendelenburg position needed for gravity to keep the bowelsin the upper abdomen can be bothersome to the patient and re-strict respiration. The risks associated with general anesthesia areone of the major hazards of laparoscopy. However, when oper-ative laparoscopy is contemplated, general anesthesia is recom-mended and ensures adequate muscle relaxation, patientcomfort, and the ability to manipulate intraabdominal organs.The standard diagnostic laparoscope is 10 mm in diameter,

but they come in sizes varying from 2 to 10 mm. The microla-paroscopes are used primarily for diagnostic evaluation. The5-mm and 10-mm forms are widely utilized. Laparoscopic tele-scopes come in 0-degree to 30-degree lens angles, but the0-degree type is most commonly used. Most laparoscopes are30 cm long and provide a field of vision of 60 to 75 degrees.The inferior margin of the umbilicus is the preferred site ofentry, as this is the thinnest area of the abdominal wall. Alterna-tive sites are detailed in Figure 10-8. The choice of gas to developthe pneumoperitoneum depends on the choice of anesthesia.Nitrous oxide is preferable with local anesthesia, but carbon di-oxide is the choice with general anesthesia. Nitrous oxide is

nonflammable but does support combustion. Carbon dioxidequickly forms carbonic acid on the moist parietal peritonealsurface, which results in considerable discomfort to a patientwithout regional or general anesthesia.

A Veress needle (Fig. 10-9; radially dilating trocar withVeress type needle) has a retractable cutting point that is usedfor entry into the abdominal cavity for the purpose of insufflat-ing the abdomen with gas for laparoscopy. A trocar is a blunt,bladed, or optical device for entering the abdominal cavity forlaparoscopy and is the cannula for holding the laparoscope orlaparoscopic instruments (Fig. 10-10). Secondary puncture tro-cars vary from 5 mm (bipolar forceps, 5-mm telescope, suction/irrigation device, vessel sealing, cutting or coagulation devices),7 or 8 mm in width (Filshie clips for sterilization), to 10 to12 mm for pouches to remove specimens, or a morcellatingdevice for removing fibroids or a uterus.

There are three techniques to access the abdomen. First,Veress needle insertion is used to create a pneumoperitoneum

followed by trocar placement. Second, direct trocar placementin a noninsufflated abdomen has been described. Third, an openorHasson techniquecan be used when adhesions are expected,particularly under the umbilicus. When using the Veress tech-nique, a skin incision is made large enough to hold the plannedtrocar, which is usually 10 mm if using the umbilical site. Theangle of the Veress needle insertion should vary according tothe body mass index of the woman from 45 degrees in a normalweight woman to 90 degrees in an obese woman. Veress intra-peritoneal pressure of 10 mm Hg is a reliable indicatorof correct intraperitoneal needle placement, and insufflation ofthe carbon dioxide gas can begin. Left upper quadrant (Palmers

2

1

45

3

Figure 10-8 Usual sites for insertion of insufflating needle inlaparoscopy: (1) infraumbilical fold, (2) supraumbilical fold, (3) left costal

margin, (4) midway between umbilicusand pubis, and (5) left McBurneyspoint.(FromCorsonSL:Operatingroompreparationandbasictechniques.

In Phillips JM (ed): Laparoscopy. Baltimore, Williams & Wilkins, 1977.#Copyright 1977 by the Williams & Wilkins Co, Baltimore.)



9/16

point) laparoscopic entry should be considered in patients withsuspected or known periumbilical adhesions, presence of an um-bilical hernia, or after three failed insufflation attempts at theumbilicus.

Once the abdomen is insufflated to 15 mm Hg, the primarytrocar can be inserted. Because it has been recognized that pri-mary trocar placement leads to the majority of vascular andbowel injuries, many surgical products are available to poten-tially lessen these injuries, but none has proved safer than an-other. A bladed, blunt, or radial dilating trocar can be passed.

A bladed cutting trocar may come with automatic blade retrac-tion or a shield for safety. These require significantly less force to

insert through the abdominal wall compared with blunt trocars.The resulting fascial defects are larger for cutting trocars than ra-dial dilating trocars. The port may not be as fixed in this case. Itis recommended that bladed port sites to 10 mm should havefascial closure at the conclusion of the surgery to avoid postop-erative hernia formation. Blunt trocars require more force forpassage into the abdomen but theoretically cause fewer vascularand bowel injuries. This has yet to be proved. Radially dilating

blunt trocars are available, and one of the touted advantages isthat even 10-mm port sites do not need fascial closure becausehernias are rare in nonbladed port sites.

Direct trocar entry has been proposed to alleviate the difficul-ties with preperitoneal or intestinal gas insufflation with theVeress needle and to reduce operative time. There are studiessupporting this technique. Disposable optical trocars are avail-able to use a cannula that allows the laparoscope to visualize pass-ing through the abdominal wall. They do not seem to reducevascular andvisceral injury, however, but do save time.

Open laparoscopy, often called the Hasson technique, may beused as an alternative to the Veress needle option. Instead ofblind entry into the peritoneal cavity, a small incision is madein the fascia and parietal peritoneum. The cone is placed in

the abdominal cavity under direct visual control. The fascia issecured to the sleeve of the cone to obtain an airtight seal. Openlaparoscopy has not been proved to reduce the rate of bowel in-

jury, but that is the theoretic benefit. Also, if the Veress needletechnique fails to result in pneumoperitoneum, open laparos-copy is oftenan option. It is the procedure of choice if the patienthas a history of multiple abdominal operations.

Once the primary trocar is in place, the telescope and cameracan be attached and the pelvis visualized. Secondary trocars canbe placed under direct visualization, which is why there are fewervascular and bowel injuries with these trocars. Third and fourthpuncture sites are often required for complex cases. Becauseeach puncture site is a potential gas leak, high-flow insufflationequipment is necessary. In addition, several video monitoring

screens are employed so that both the surgeon and assistantcan work effectively. Unlike the short time needed for diagnosticlaparoscopy, operative laparoscopy may require several hours.

Operative laparoscopy may be performed with mechanicalinstruments, including an extensive variety of scissors, scalpels,endoscopic syringes, myoma screws, suture devices, electrocau-tery instruments (both unipolar and bipolar), harmonic and ves-sel sealing devices for hemostasis and cutting, suction, irrigation,stapling devices, endoscopic clips, and laser instruments. Duringoperative laparoscopy, stabilization of the pelvic organs is essen-tial, such as traction and countertraction on the edges of an ad-hesion. This is why multiple trocar sites are needed so that theprimary surgeon and assistant can use both hands. Uterine ma-nipulators are particularly useful in laparoscopic hysterectomy.

They are designed to aid in stabilizing and manipulating theuterus and identifying the cervicovaginal junction for cervixamputation.

The FDA approved robotic-assisted laparoscopy for use ingynecology in 2005. The only currently available system inthe United States is the daVinci Surgical System. The equipmentis bulky and consists of a robot with three or four arms that holdthe camera and surgical instruments, the camera and vision sys-tem, the console where the surgeon sits away from the patientbedside, and the wristed instruments that insert through the ro-botic arms and are controlled by the surgeon at the console. Thecamera is actually two cameras and allows for three-dimensional

Figure 10-9 Radially dilating trocar with Veress type needle.(Figure 34-7 from Beiber EJ, Sanfilippo JS, Horowitz IR: Clinical

Gynecology. Philadelphia, Elsevier, 2006.)

Figure 10-10 Blunt-tip trocar for primary port. (Figure 34-8 fromBeiber EJ, Sanfilippo JS, Horowitz IR: Clinical Gynecology. Philadelphia,Elsevier, 2006.)



10/16

visualization via the computer image integrator. Other advan-tages include the added dexterity with the wristed instrumentsand ergonomic benefits for the surgeon. This can aid in surgeriesthat require a lot of suturing such as myomectomies or abdom-inal sacral colpopexy and complex gynecologic oncology or se-vere endometriosis procedures. Disadvantages include the highcost of the system and maintenance, lack of haptic feedbackfor the surgeon at the console, and increased operative time

for docking the robot and the actual procedure.

LAPAROSCOPIC PROCEDURES

Laparoscopy has made outpatient sterilization available towomen throughout the world. Cumulative 10-year pregnancyrates vary between 8/1000 and 37/1000. Sterilization is accom-plished with electrocautery, titanium, or spring-loaded clips.Because of the serious complications with unipolar cautery, mostcautery sterilization procedures are performed with bipolarcoagulation of approximately 3 cm of the isthmic portion ofthe fallopian tube without division. Use of a current meter isrecommended to indicate when complete coagulation hasoccurred, as visual inspection is not an accurate indication.

Mechanical occlusion devices commonly used in the UnitedStates include the silicone rubber band (Falope ring), thespring-loaded clip (Hulka-Clemens clip), and the titanium cliplined with silicone rubber (Filshie clip). The ring or clip shouldbe placed on the narrow isthmus so the size of the appliance con-forms to the diameter of the fallopian tube. Special equipmentis needed for each of these techniques.

There are both diagnostic and therapeutic indications forlaparoscopy in infertile women. Tubal patency and mobilitycan be directly observed via the laparoscope. Laparoscopy is amore sophisticated and accurate method of diagnosing tubalproblems during an infertility investigation than HSG. Chro-mopertubation with an innocuous dye, such as indigo carmine,demonstrates tubal patency during laparoscopy. Comparative

studies have documented that HSG discovers only 50% of theperitubal disease diagnosed by direct visualization via the laparo-scope. Laparoscopy is able to confirm or rule out intrinsic pelvicdisorders, such as endometriosis or chronic pelvic inflammatorydisease with adhesions. It is possible not only to describe andstage the extent of endometriosis or pelvic adhesions but alsoto treat them. Adhesions can be lysed, endometrioma cystscan be removed, and areas of endometriosis can be ablated byelectrocautery, laser, or completely excised, which is necessaryfor deep endometriotic implants (Fig. 10-11).

The management of pelvic pain has been dramatically chan-ged by the laparoscope. The differential diagnosis of acute painmay be defined by direct visualization of the fallopian tubes, ova-ries, and appendix. Laparoscopy may be used in the management

of acute pelvic infection, taking direct bacterial cultures of puru-lent material from the tubes, draining a tubo-ovarian abscess,or removing a tubo-ovarian abscess complex with unilateral sal-pino-oophorectomy. These direct transabdominal cultures havechanged our opinions concerning the clinical management ofpolymicrobial pelvic infections. The classic violin string adhe-sions between the liver and the abdominal wall are sometimesnoted by directing the laparoscope into the upper right quadrantin women with prior pelvic inflammatory disease (Fig. 10-12).Sometimes the enigma of chronic pelvic pain may be solved bythe findings at laparoscopy. Following the procedure, a plan for

long-term management of the pain can be discussed with thepatient.

Laparoscopic treatment of ectopic pregnancy most often in-volves salpingotomy but also may include salpingectomy(Fig. 10-13). HCG titers must be followed after conservativesurgery (salpingotomy) until the titers fall to zero (usually 3 to4 weeks) to ensure that all trophoblastic tissue has been removed.Tubal patency and subsequent pregnancy rates are comparablebetween laparoscopic techniques and laparotomy.

Laparoscopic hysterectomy is one area of considerable re-search. If vaginal hysterectomy cannot be done (which has lowercomplication rates, lower costs, and better outcomes), then lap-

aroscopic hysterectomy should be considered over abdominalhysterectomy. Many considerations need to go into this decision

Figure 10-11 Laparoscopic view of a woman with right lowerquadrant pain and an adhesion stringing between the fallopian tube

and the bowel near the cecum. Normal appearing appendix inferiorly.(Courtesy of Dr. Seine Chiang, University of Washington.)

Figure 10-12 Fitz-Hugh-Curtis syndrome in a patient withprevious pelvic inflammatory disease. (From Goldberg JM, Falcone T:Atlas of Endoscopic Techniques in Gynecology. London, WB Saunders,2000, p 71.)



11/16

such as the size of the uterus, adnexal disease with risk for ovarian

cancer, severe endometriosis, or adhesions. The Cochrane Data-base of Systematic Reviews considered 34 randomized trials ofhysterectomy route. Laparoscopic hysterectomy compared withabdominal hysterectomy was associated with faster return to nor-mal activity, shorter hospital stay, lower intraoperative bloodloss, fewer wound infections, longer operating time, and a higherrate of bladder and ureter injuries. Figure 10-14 shows thebeginning of a laparoscopic hysterectomy for uterine fibroidswith creation of the bladder flap.

Laparoscopic myomectomy has been studied in two random-ized controlled trials with comparison with myomectomy byminilaparotomy. This can be technically challenging laparos-copically because of the dissection and suturing required. Thelaparoscopic approach resulted in less blood loss, reduced length

of postoperative ileus, shorter hospital stay, reduced use ofpain medications, and more rapid return to normal activities,but a longer operative time. For unexplained infertility, bothapproaches improved reproductive outcomes similarly.

Operative laparoscopy has additionally been used for laparo-scopic assisted hysterectomy, salpingo-oophorectomy, salpingost-

omy and fimbrioplasty, tubal reanastomosis, appendectomy,uterosacral ligament transection, presacral neurectomy, retropubicbladder neck suspensions, and complex urogynecologic procedures.Laparoscopy may be used for major cancer staging, includingparaaortic and pelvic lymphadenectomy.

Newer laparoscopic equipment using robotics has increasedthe ease at which minimally invasive major pelvic surgery canoccur (Fig. 10-15). Cases that can be extremely challenging withtraditional laparoscopy are being done with increasing frequencywith robotics. Most of the published studies to date are nonrando-mized and retrospective case series comparing robotic cases withhistorical controls. There are data showing safety and feasibilityof robot-assisted surgery for numerous procedures, includingtubal reanastomosis, myomectomy, hysterectomy, adnexectomy,

pelvic, and paraaortic lymph node sampling and abdominal sa-cral colpopexy for pelvic organ prolapse. A 2010 metaanalysis of22 controlled but not-randomized studies in gynecologic roboticsurgery found robotic surgery patients had a shorter hospital stayand less blood loss than laparotomy. Compared with conven-tional laparoscopic surgery, robotic surgery achieved reducedblood loss and fewer conversions to laparotomy during the stagingof endometrial cancer. No other clinically significant differenceswere found in the gynecologic procedures published to date. Ran-domizedcontrolledtrials are ongoing that will hopefullyclarify therole this expensive technology holds for gynecology.

Advantages of operative laparoscopy over laparotomy includedecreased postoperative adhesion formation, decreased post-operative pain, shorter recovery time, and less, if any, hospital

stay. Surgical risks from cardiac, pulmonary, and thromboem-bolic disease should be treated with the same cautions as a cor-responding open procedure. These are presented in Chapter 24(Preoperative Counseling and Management).

LAPAROSCOPIC COMPLICATIONS

The major categories of complications with laparoscopy are lac-eration of blood vessels, intestinal and urinary tract injuriesincluding trocar and thermal injuries, incisional hernias, andcardiorespiratory problems arising from the pneumoperitoneum

Figure 10-13 Ectopic pregnancyin theright fallopian tube. (Courtesyof B. Beller, MD, Eugene, OR.)

Figure 10-14 The beginning of a laparoscopic hysterectomy foruterine fibroids showing the creation of the bladder flap with the

left grasper elevating the bladder peritoneum and a bipolar/cuttingdevice in the right hand. (Courtesy of Dr. Seine Chiang, Universityof Washington.)

Figure 10-15 DaVinci robot (intuitive surgical).



12/16

(Table 10-6). One complication has remained unchanged for 25years. At least 50% of the major laparoscopic complications arisebefore the planned surgery starts and occur with accessing theabdomen. Most of these injuries are with the primary trocarplacement at the umbilicus and involve major vascular injuriesor the bowel.

Several studies have evaluated the incidence of complications

withoperative laparoscopy. A large, multicenter French study of29,966 laparoscopies showed a high frequency of trocar injurieswith a total complication rate of 4.64 per thousand laparosco-pies. Complications increase with the age of the patient andthe complexity of the procedure. The overall rate of complica-tions from large series of operative laparoscopy varies from0.2% to 2%. Chandler and coworkers compiled data from a se-ries of injuries resulting from abdominal entry and laparoscopicaccess injuries reported to large insurance data banks. The seriesincluded general surgery as well as gynecology from both theUnited States and other countries. Over a 20-year period, thedata bank collected 594 reports of organ injury, 33% in gynecol-ogy patients. Importantly, 50% of bowel injuries were unrecog-nized for 24 hours or more. Sixty-five deaths were reported. Age

older than 59 years and delayed diagnosis of injury were inde-pendently associated with mortality in this series. A metaanalysisof 27 randomized controlled trials compared laparoscopy andlaparotomy for benign gynecologic procedures. The overall riskof complication was 8.9% with laparoscopy compared with 15.2with laparotomy (relative risk 0.6). The risk of major complica-tions was the same at 1.4%, so the risk of minor complicationwas higher in the laparotomy group.

Laceration of the aorta, inferior vena cava, or iliac vessels isa surgical emergency. Because abdominal wall hematomas areusually subfascial in location, care must be taken to avoid theepigastric vessels. For safety, Hurd and colleagues have recom-mended that lateral trocars be placed at least 5 cm above the sym-physis and at least 8 cm from the midline. The Veress needle or

the trocar may produce intestinal injuries. Thermal injuries maybe recognized at the time of surgery, but if they are not recog-nized intraoperatively, significant delays in recognition can leadto septicemia and death. The incidence of ureteral injuries variesfrom 1% to 4% with laparoscopic dissection of the cardinalligaments.

The risk of incisional hernia is increased for port sites of12 mm or greater and extraumbilical sites (0.17 to 0.23%).Many of these herniations occur despite fascial closure at the ini-tial surgery. Clinical symptoms include a bulge at the incisionsite, which may be painful to a bowel obstruction or infarction.

Complications directly related to the pneumoperitoneum in-clude pneumothorax, diminished venous return, gas embolism,and cardiac arrhythmias. It is important not to develop pressuresgreater than 20 mm Hg in establishing the pneumoperitoneum.High pressures impede venous return and limit excursion of thediaphragm. A rare but life-threatening complication of laparos-copy is gas embolism, which produces hypotension and the clas-sical mill wheel murmur, which can be heard over the entire

precordium. The patient with this complication should beturned on her left side and the frothy blood aspirated by a centralvenous catheter directed into the right side of the heart. Otherrare complications include incisional hernias at the site of the10- to 12-mm trocar sites. This has been estimated to occurin 1 in 5000 procedures. Metastases from ovarian malignanciesto the laparoscopic wound site are also a rare but real problem.

In summary, laparoscopy, more than any other advance, haschanged the clinical practice of gynecology since the 1970s.Todays OB/Gyn residents have a difficult time contemplatingthe practice of the specialty prior to the introduction of the sil-ver tube. Laparoscopy provides a window for the diagnosis ofinfertility, pelvic pain, ectopic pregnancy, abdominal and pelvictrauma, staging the extent of pelvic disease, and the visual diag-

nosis of abnormal anatomy. Therapeutic uses of the laparoscopevary from female sterilization to hysterectomy and node sam-pling. The role of robotics is still being established, but benefitsexist over laparotomy in nonrandomized but controlled trials,particularly in the gynecologic oncology population.

PATIENT SAFETY IN THE SURGICALENVIRONMENT

Many regulatory agencies, hospitals, medical societies and orga-nizations, physicians, and staff have been striving for improve-ments in patient safety. Wrong-site surgery, wrong-patientsurgery, wrong-side surgery, wrong-part surgery, and retained

foreign objects have all been reported. Many factors have beenassociated with wrong-site surgery, including multiple surgicalteams being involved in a case, multiple procedures being doneduring a single case, time pressures, and morbid obesity. In2003, the Joint Commission for Hospital Accreditation pub-lished a universal protocol for improving surgical safety. Theprotocol recommended a preprocedure verification process,marking the operative site and performing a time out. A timeout promotes patient safety by checking items such as confirm-ing correct patient, correct surgical site, and procedure(s). The

World Health Organization published a suggested surgicalsafety checklistto further improve care. Before induction of an-esthesia, the first checklist set is done and might include items forteam review like patient allergies, airway risks, and estimated

blood loss. Before the skin incision, another team review occurswith introductions of all personnel and roles, antibiotic prophy-laxis infused if indicated, deep vein thrombosis prophylaxis givenor in place if indicated, any equipment issues or concerns voiced,and essential imaging displayed. Before the conclusion of theprocedure, the third part of the checklist is completed and in-cludes the name of the procedure, the correct instrument, andsponge and needle counts; the checklist also ensures that speci-mens are properly labeled and key concerns for the patient recov-ery are discussed. Good communication between team membersappears to be another important factor in patient safety.

Table 10-6 Intraoperative and Delayed Laparoscopic Surgery Risks

Bleeding

Laceration of major blood vessels; epigastric, obturator, iliac, vena

cava, aorta

Surgical site bleeding

Trocar or Veress needle injury

Intestinal injury; thermal or direct instrument

Urinary tract injury; thermal or direct instrument

Anesthetic complication

Equipment malfunction

Other endoscopic instrument injury

Other thermal injury

Subcutaneous emphysema



13/16

KEY POINTS

n The most frequent problem in performing endometrialsampling is cervical stenosis or spasm; it is also a problemfor hysteroscopy, and this increases the risk of uterineperforation.

n Major indications for hysteroscopy include abnormal uterinebleeding, removal of endometrial polyps or submucous

myomas, endometrial ablations, retained IUD, desire of noincision sterilization, intrauterine adhesions diagnosis andtreatment, infertility, resection of a uterine septum, andrecurrent pregnancy loss.

n The endometrial lining may be ablated through thehysteroscope in women with abnormal bleeding ormenorrhagia who have a normal uterine cavity and arepoor surgical candidates, those who wish to retain theiruterus, and those who do not desire further childbearing.

n Older resectoscopic and second-generation nonresectoscopicendometrial ablation devices appear to be equivalent withrespect to successful reduction in menstrual flow and patientsatisfaction at 1 year.

n Vaginal misoprostol administration the night before the

hysteroscopic procedure can aid in cervical softening.

n A paracervical block with local anesthetic is the best methodof pain control for outpatient hysteroscopy compared withtopical or intracervical anesthesia.

n Complications of hysteroscopy include uterine perforationwith risk of injury to the surrounding vascular and visceralstructures, pelvic infection, bleeding, and absorption of the

distending media.n The primary laparoscopic trocar placement leads to the>50% of vascular and bowel injuries in gynecologiclaparoscopy.

n Absolute contraindications to laparoscopy include ahemoperitoneum that has produced hemodynamicinstability, bowel obstruction, anticoagulation therapy,advanced malignancy, large abdominal masses, severecardiovascular disease, and tuberculous peritonitis.

n The incidence of complications with operative laparoscopyvaries from 0.2% to 2%. Thermal bowel injuries often gounrecognized intraoperatively, and diagnostic delays can belife threatening.

REF ERENCES CAN BE F OUND ON

EXPERTCONSULT.com

SUGGESTED READINGS

Ahmad G, Duffy JMN, Phillips K, et al: Laparoscopicentry techniques,Cochrane Database Syst Rev(2),2008. Art. No. CD006583. doi:10.1002/14651858.CD006583.pub2.

American College of Obstetricians and Gynecologists:Hysteroscopy. ACOG Technology AssessmentNo. 4,Obstet Gynecol106:439442, 2005.

Azevedo JL, Azevedo OC, Miyahira SA, et al:Injuries caused by Veress needle insertion forcreation of pneumoperitoneum: A systematicliterature review, Surg Endosc 23(7):14281432,2009.

da Costa AR, Pinto-Neto AM, Amorim M, et al: Useof misoprostol prior to hysteroscopy in postmeno-pausal women: A randomized, placebo-controlled

clinical trial, J Minim Invasive Gynecol 15(1):6773, 2008.

Istre O: Managing bleeding, fluid absorption anduterine perforation at hysteroscopy, Best PractRes Clin Obstet Gynaecol23:619629, 2009.

Lethaby A, Shepperd S, Farquhar C, et al: Endometrialresection and ablation versus hysterectomy for

heavy menstrual bleeding, Cochrane Database SystRev(2), 1999. Art. No. CD000329. doi:10.1002/14651858.CD000329. Update 2009.

Nieboer TE, Johnson N, Lethaby A, et al: Surgicalapproach to hysterectomy for benign gynaecologi-cal disease,Cochrane Database Syst Rev(3), 2009.

Art. No. CD003677. doi:10.1002/14651858.CD003677.pub4.

Rahn DD, Phelan JN, Roshanravan SM, et al: Ante-rior abdominal wall nerve and vessel anatomy:Clinical implications for gynecologic surgery, Am

J Obstet Gynecol 202(3):234.e1234.e5, 2010.Vilos GA, Ternamian A, Dempster J, et al, The

Society of Obstetricians and Gynaecologists ofCanada:Laparoscopic entry:A review of techniques,

technologies, and complications,J Obstet GynaecolCan29(5):433465, 2007.

World Health Organization: Surgical safety checklist,Geneva, 2009,WHO. Availableat http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf. Retrieved November 2010.

http://www.expertconsult.com/http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://www.expertconsult.com/


14/16

BIBLIOGRAPHY

Advincula AP, Song A, Burke W, et al: Preliminary experience with robot-assistedlaparoscopic myomectomy,J Am Assoc Gynecol Laparosc11:511518, 2004.

Ahmad G, Duffy JMN, Phillips K, et al: Laparoscopic entry techniques, CochraneDatabase Syst Rev(2), 2008. Art. No. CD006583. doi:10.1002/14651858.CD006583.pub2.

Akladios CY, Dautun D, Saussine C, et al: Laparoscopic sacrocolpopexy forfemale genital organ prolapse: Establishment of a learning curve, Eur J Obstet

Gynecol Reprod Biol 149(2):218221, 2010.Albers JR, Hull SK, Wesley RM: Abnormal uterine bleeding, Am Fam Physician69:1915, 2004.

Alborzi S, Dehbashi S, Khodaee R: Sonohysterosalpingographic screening forinfertile patients,Int J Gynecol Obstet82:57, 2003.

Alessandri F, Lijoi D, Mistrangelo E, et al: Randomized study of laparoscopicversus minilaparotomic myomectomy for uterine myomas,J Minim InvasiveGynecol13:9297, 2006.

Al-Sunaidi M, Tulandi T: A randomized trial comparing local intracervical andcombined local and paracervical anesthesia in outpatient hysteroscopy,

J Minim Invasive Gynecol14(2):153155, 2007.American College of Obstetricians and and Gynecologists: Benefits and risks of

sterilization. ACOG Practice Bulletin No. 46, Obstet Gynecol102:647658,2003.

American College of Obstetricians and Gynecologists: Practice Bulletin No. 14:Management of anovulatory bleeding, ACOG Compendium434, 2004.

American College of Obstetricians and Gynecologists: Hysteroscopy. ACOGTechnology Assessment No. 4,Obstet Gynecol106:439442, 2005.

American College of Obstetricians and Gynecologists: Alternatives to hysterec-tomy in the management of leiomyomas. ACOG Practice Bulletin No. 96,Obstet Gynecol 112:201207, 2008.

American College of Obstetricians and Gynecologists: Sonohysterography.ACOG Technology Assessment No. 3, Obstet Gynecol112:14671469,2008.

American College of Obstetricians and Gynecologists: Choosing the route ofhysterectomy for benign disease. ACOG Committee Opinion No. 444,Obstet Gynecol 114:11561158, 2009.

American College of Obstetricians and Gynecologists: Robot-assistedsurgery. ACOG Technology Assessment No. 6, Obstet Gynecol114:11531155, 2009.

American College of Obstetricians and Gynecologists: The role of transvaginalultrasonography in the evaluation of postmenopausal bleeding. ACOGCommittee Opinion No. 440, Obstet Gynecol114:409411, 2009.

American College of Obstetricians and Gynecologists: Patient safety inthe surgical environment. ACOG Committee Opinion No. 464, ObstetGynecol 116:786790, 2010.

American College of Obstetricians and Gynecologists: Report of the PresidentialTask Force on Patient Safety in the Office Setting, Washington, DC, 2010,

American College of Obstetricians and Gynecologists.Ascher-Walsh C, Capes T: Robotic-assisted laparoscopic myomectomy is an

improvement over laparotomy in women with a limited number of myomas,J Minim Invasive Gynecol17:306310, 2010.

Azevedo J L, Azevedo OC, Miyahira SA, et al: Injuries caused by Veress needleinsertion for creation of pneumoperitoneum: A systematic literature review,Surg Endosc 23(7):14281432, 2009.

Baggish MS, Valle RF, Guedj H: Hysteroscopy: Visual Perspectives of Uterine Anatomy,Physiology,and Pathology,ed 3, Philadelphia,2007, Lippincott Williams, & Wilkins.

BatraN, Khunda A, ODonovanPJ: Hysteroscopic myomectomy, ObstetGynecolClin North Am31:669, 2004.

Batukan C, Ozgun MT, Ozcelik B, et al: Cervical ripening before operativehysteroscopy in premenopausal women: A randomized, double-blind,placebo-controlled comparison of vaginal and oral misoprostol, Fertil Steril89(4):966973, 2008.

Beiber EJ, Sanfilippo JS, Horowitz IR: Clinical Gynecology,Philadelphia, 2006,Elsevier.

Benson AD, Schwartz BF: Laparoscopic ports: Bladed or not? Urology TimesS4S10, 2010.

Berridge DL, Winter TC: Saline infusion sonohysterography: Technique,indications, and imaging findings, Ultrasound Med23:97, 2004.

Bettocchi S, Nappi L, Ceci O, et al: Office hysteroscopy, Obstet Gynecol ClinNorth Am31:641, 2004.

Bevan KE, Venkatasubramaniam A, Mohamed F, et al: Respect for the laparo-scopic port site: Lessons in diagnosis, management, and prevention ofport-site hernias following laparoscopic colorectal surgery, J Laparoendosc

Adv Surg Tech A 20(5):451454, 2010.

Bhoyrul S, Payne J, Steffes B, et al: A randomized prospective study of radiallyexpanding trocars in laparoscopic surgery, J Gastrointest Surg4(4):392397,2000.

Boggess JF, Gehrig PA, Cantrell L, et al: A comparative study of 3 surgicalmethods for hysterectomy with staging for endometrial cancer: Robotic assis-tance, laparoscopy, laparotomy,Am J Obstet Gynecol360:e1e9, 2008.

Breitkopf DM, Frederickson RA, Snyder RR: Detection of benign endometrial

masses by endometrial stripe measurement in premenopausal women, ObstetGynecol104:120, 2004.Campo R, Molinas CR, Rombauts L, et al: Prospective multicentre randomized

controlled trial to evaluate factors influencing the success rate of office diag-nostic hysteroscopy,Hum Reprod20:258263, 2005.

Chandler JG, Corson SL, Way LW: Three spectra of laparoscopic entry accessinjuries,J Am Coll Surg192:478, 2001.

Childers JM, Aqua KA, Surwit EA, et al: Abdominal-wall tumor implantationafter laparoscopy for malignant conditions, Obstet Gynecol84:765, 1994.

Clark TJ, Voit D, Gupta JK, et al: Accuracy of hysteroscopy in the diagnosis ofendometrial cancer and hyperplasia: A systematic quantitative review, JAMA288:1610, 2002.

Cooper JM, Brady RM: Hysteroscopy in the management of abnormal uterinebleeding,Obstet Gynecol Clin North Am26:217, 1999.

CooperJM, Carignan CS, Cher D, et al: Microinsertnonincisional hysteroscopicsterilization. Selective Tubal Occlusion Procedure 2000 Investigators Group,Obstet Gynecol102:5967, 2003.

Cooper NA, Smith P, Khan KS, et al: A systematic review of the effect of thedistension medium on pain during outpatient hysteroscopy, Fertil Steril

Jun 22, 2010 [Epub ahead of print].Cooper NA, Smith P, Khan KS, et al: Vaginoscopic approach to outpatient hys-

teroscopy: A systematic review of the effect on pain, BJOG117(5):532539,2010.

Corson SL, Brooks PG, SoderstromRM: Gynecologic endoscopic gas embolism,Fertil Steril65:529, 1996.

da Costa AR, Pinto-Neto AM, Amorim M, et al: Use of misoprostol prior tohysteroscopy in postmenopausal women: A randomized, placebo-controlledclinical trial,J Minim Invasive Gynecol15(1):6773, 2008.

DanielAG, PetersWA III: Accuracy of office andoperating room curettagein thegrading of endometrial carcinoma,Obstet Gynecol71:612, 1988.

Daniel JF, Kurtz BR, Ke RW: Hysteroscopic endometrial ablation using therollerball electrode,Obstet Gynecol80:329, 1992.

De Angelis C, Santoro G, Re ME, et al: Office hysteroscopy and compliance:Mini-hysteroscopy versus traditional hysteroscopy in a randomized trial,Hum Reprod 18(11):24412445, 2003.

De Kroon CD, de Bock GH, Dieben SEM, et al: Saline contrast hysterosono-graphy in abnormal uterine bleeding: A systematic review and meta-analysis,Br J Obstet Gynaecol110:945, 2003.

Dharia Patel SP, Steinkampf MP, Whitten SJ, et al: Robotic tubal anastomosis:Surgical technique and cost effectiveness,Fertil Steril90(4):11751179, 2008.

Di Spiezio Sardo A, Mazzon I, Bramante S, et al: Hysteroscopic myomectomy:A comprehensive review of surgical techniques, Hum Reprod Update14(2):101119, 2008.

Di Spiezio Sardo A, Bettocchi S, Spinelli M, et al: Review of new office-based hysteroscopic procedures 20032009, J Minim Invasive Gynecol17(4):436448, 2010.

Eltabbakh GH, Piver MS, Hempling RE, et al: Laparoscopic surgery in obesewomen,Obstet Gynecol94:704, 1999.

Emanuel MH, Verdel MJ, Wamsteker K, et al: A prospective comparison oftransvaginal ultrasonography and diagnostic hysteroscopy in the evaluationof patients with abnormal uterine bleeding: Clinical implications,Am J ObstetGynecol172:547, 1995.

Emanuel MH,Wamsteker K: Theintrauterine morcellator:A newhysteroscopicoperating technique to remove intrauterine polyps and myomas, J MinimInvasive Gynecol 12(1):6266, 2005.

Epstein E, Valentin L: Managing women with post-menopausal bleeding, BestPract Res Clin Obstet Gynecol18:125, 2004.

Farquhar C, Ekeroma A, Furness S, et al: A systematic review of transvaginalultrasonography, sonohysterography and hysteroscopy for the investigationof abnormal uterine bleeding in premenopausal women, Acta Obstet GynecolScand82:493, 2003.

Feldman S, Shapter A, Welch WR,et al:Two-yearfollow-up of 263patients withpost/perimenopausal vaginal bleeding and negative initial biopsy, GynecolOncol55:56, 1994.



15/16


16/16

Sagiv R, Sadan O, Boaz M, et al: A new approach to office hysteroscopy com-pared with traditional hysteroscopy: A randomized controlled trial, ObstetGynecol 108(2):387392, 2006.

Sainz de la Cuesta R, Espinosa JA, Crespo E, et al: Does fluid hysteroscopy in-crease the stage or worsen the prognosis in patients with endometrial cancer?

A randomized controlled trial, Eur J Obstet Gynecol Reprod Biol115:211215,2004.

Sarlos D, Kots L, Stevanovic N, et al: Robotic hysterectomy versus conventionallaparoscopic hysterectomy: Outcome and cost analyses of a matched case-control study,Eur J Obstet Gynecol Reprod Biol150:9296, 2010.

Sculpher M, Manca A, Abbott J, et al: Cost effectiveness analysis of laparoscopichysterectomy compared with standard hysterectomy: Results from a rando-mised trial,Br Med J328:134, 2004.

Seracchioli R, Rossi S, Govoni F, et al: Fertility and obstetric outcome after lap-aroscopic myomectomy of large myomata: A randomized comparison withabdominal myomectomy,Hum Reprod 15:26632668, 2000.

Sharma JB, Mohanraj P, Roy KK, et al: Increased complication rates associatedwith laparoscopic surgery among patients with genital tuberculosis, Int JGynaecol Obstet 109(3):242244, 2010.

Shirk GJ, Johns A, Redwine DB: Complications of laparoscopic surgery: How toavoid them and how to repair them,J Minim Invasive Gynecol13:352, 2006.

Shveiky D, Rojansky N, Revel A, et al: Complications of hysteroscopic surgery:Beyond the learning curve,J Minim Invasive Gynecol14(2):218222, 2007.

Siristatidis C, Chrelias C, Salamalekis G, et al: Office hysteroscopy: Currenttrends and potential applications: A critical review, Arch Gynecol Obstet282(4):383388, 2010.

Smith RD: Contemporary hysteroscopic methods for female sterilization, Int J

Gynaecol Obstet108(1):7984, Epub, 2010.Sultana CJ, Easley K, Collins RL: Outcome of laparoscopic versus traditional

surgery for ectopic pregnancies, Fertil Steril57:285, 1992.Summitt RL Jr, Stovall TG, Steege JF, et al: A multicenter randomized com-

parison of laparoscopically assisted vaginal hysterectomy versus abdominalhysterectomy in abdominal hysterectomy candidates, Obstet Gynecol92:321326, 1999.

Summitt RL, Lucente V, Karram MM, et al: Randomized comparison of lapa-roscopic and transabdominal Burch urethropexy for treatment of genuinestress incontinence,Obstet Gynecol95(Suppl 4):2S, 2000.

Tahir MM, Bigrigg MA, Browning JJ, et al: A randomized controlled trial com-paring transvaginal ultrasound, outpatient hysteroscopy and endometrialbiopsy with inpatient hysteroscopy and curettage, Br J Obstet Gynaecol106:1259, 1999.

Taylor GW, Jayne DG, Brown SR, et al: Adhesions and incisional hernias fol-lowing laparoscopic versusopen surgery for colorectalcancer in the CLASICCtrial,Br J Surg97(1):7078, 2010.

ThomasJA, Leyland N, DurandN, et al: The use oforal misoprostolas a cervicalripening agent in operative hysteroscopy: A double-blind, placebo-controlledtrial,Am J Obstet Gynecol 186:876879, 2002.

Timbos-Kemper TCM, Veering BT: Anaphylactic shock from intracavitary 32%dextran-70 during hysteroscopy, Fertil Steril51:1053, 1989.

Tinelli A, Malvasi A, Istre O, et al: Abdominal access in gynaecological laparos-copy: A comparison between direct optical and blind closed access by Veressneedle,Eur J Obstet Gynecol Reprod Biol 148(2):191194, 2010.

Valle RF: Office hysteroscopy, Clin Obstet Gynecol42:276, 1999.Van den Bosch T, Van Schoubroeck D, Ameye L, et al: Ultrasound assessment of

endometrial thickness and endometrial polyps in women on hormonal re-placement therapy,Am J Obstet Gynecol188:1249, 2003.

van Dongen H, Emanuel MH, Wolterbeek R, et al: Hysteroscopic morcellatorfor removal of intrauterine polyps and myomas: A randomized controlledpilot study among residents in training, J Minim Invasive Gynecol 15(4):466471, 2008.

Varma R, Gupta JK: Laparoscopic entry techniques: Clinical guideline,national survey, and medicolegal ramifications, Review, Surg Endosc22(12):26862697, 2008.

Vercellini P, Rossi R, Pagnoni B, et al: Hypervolemic pulmonary edema andsevere coagulopathy after intrauterine dextran instillation, Obstet Gynecol79:838, 1992.

Vilos GA: The ABCs of a safer laparoscopic entry, J Minim Invasive Gynecol13(3):249251, 2006.

Vilos GA, Ternamian A, Dempster J, et al, The Society of Obstetricians andGynaecologists of Canada: Laparoscopic entry: A review of techniques, tech-nologies and complications, J Obstet Gynaecol Can 29(5):433465, 2007.

Vilos GA, Vilos AG, Abu-Rafea B, et al: Three simple steps during closed lap-aroscopic entry may minimize major injuries, Surg Endosc 23(4):758764,2009.

Visco AG, Advincula AP: Robotic gynecologic surgery, Obstet Gynecol112:13691384, 2008.

Waddell G, Desindes S, Takser L, et al: Cervical ripening using vaginal misopros-tol before hysteroscopy: A double-blind randomized trial, J Minim InvasiveGynecol 15(6):739744, 2008.

Wieser F, Kurz C, Wenzl R, et al: Atraumatic cervical passage at outpatient hys-teroscopy,Fertil Steril69:549, 1998.

Witz CA, Silverberg KM, Burns WN, et al: Complications associated with theabsorption of hysteroscopic fluid media, Fertil Steril60:745, 1993.

World Health Organization: Surgical safety checklist, Geneva, 2009, WHO.Available at http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf. Retrieved November 2010.

Wortman M, Daggett A: Hysteroscopic endomyometrial resection: A new tech-nique for the treatment of menorrhagia, Obstet Gynecol83:295, 1994.

http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf

chapter 10. endoscopy (hysteroscopy and laparoscopy)

Documents