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Laparoscopy
Laparoscopy is an operation in which the surgeon uses a laparoscope (an optical instrument) to visualize the pelvic organs and abdominal cavity, as well as instruments that can be used not only to diagnose but also to treat various diseases. Laparoscopy is an alternative to open abdominal surgery.
A shorter recovery period, minimal pain, and a better aesthetic result are the advantages that have made laparoscopy very popular among patients and surgeons. Also, some technical aspects, such as excellent image quality during surgery, a relatively low risk of complications, have led to the widespread use of laparoscopic surgery in gynecology.
A shorter recovery period, minimal pain, and a better aesthetic result are the advantages that have made laparoscopy very popular among patients and surgeons. Also, some technical aspects, such as excellent image quality during surgery, a relatively low risk of complications, have led to the widespread use of laparoscopic surgery in gynecology.
Laparoscopy diagram
At the beginning of the operation, a needle is inserted through a small puncture in the umbilical area, through which carbon dioxide is pumped into the abdominal cavity. This is necessary to create a space in which surgeons can perform the operation.
Then the surgeon makes small incisions in the skin. The first 5−10 mm long incision is usually made in the navel area due to the lowest thickness of the abdominal wall, and also due to cosmetic advantages — the incision in the navel is almost invisible. An optical trocar (port) is inserted and through it — a laparoscope, to which a camera and a light source are connected.
The place of additional incisions (usually 2−3) for instruments depends on many factors: the type of operation, the detection of a particular pathology, the presence of adhesions, the preferences of the surgeon. However, in gynecological practice, incisions 5 mm long are most often made along a line drawn between the superior anterior iliac spines, on the right, in the center and on the left.
Additional ports and instruments required for the surgeon and assistant are inserted into these incisions. The assistant holds the camera, and the surgeon manipulates two instruments. If necessary, the assistant can also work with the instrument together with the surgeon.
Then the surgeon makes small incisions in the skin. The first 5−10 mm long incision is usually made in the navel area due to the lowest thickness of the abdominal wall, and also due to cosmetic advantages — the incision in the navel is almost invisible. An optical trocar (port) is inserted and through it — a laparoscope, to which a camera and a light source are connected.
The place of additional incisions (usually 2−3) for instruments depends on many factors: the type of operation, the detection of a particular pathology, the presence of adhesions, the preferences of the surgeon. However, in gynecological practice, incisions 5 mm long are most often made along a line drawn between the superior anterior iliac spines, on the right, in the center and on the left.
Additional ports and instruments required for the surgeon and assistant are inserted into these incisions. The assistant holds the camera, and the surgeon manipulates two instruments. If necessary, the assistant can also work with the instrument together with the surgeon.
Trocar placement
After installing the optical trocar, the patient is placed in a position with the head down (15−30 degrees relative to the horizontal plane) in order to create access to the reproductive organs. After installing all the ports, the pressure in the abdominal cavity is maintained at a constant level by a special device.
At the beginning of the endoscopic operation, a panoramic examination is performed, which allows you to get a general idea of the condition of the abdominal organs and the pelvic cavity. This is another big advantage of laparoscopy — the ability to look into hard-to-reach areas that sometimes cannot be seen even with a standard open surgery. Direct and indirect signs of the disease are assessed, and already at this stage the surgeon establishes a preliminary diagnosis and determines further tactics.
At the beginning of the endoscopic operation, a panoramic examination is performed, which allows you to get a general idea of the condition of the abdominal organs and the pelvic cavity. This is another big advantage of laparoscopy — the ability to look into hard-to-reach areas that sometimes cannot be seen even with a standard open surgery. Direct and indirect signs of the disease are assessed, and already at this stage the surgeon establishes a preliminary diagnosis and determines further tactics.
Normal endoscopic view of the pelvis
Taking into account the detected pathology, the operation is performed step by step.
At the end of the operation, the incisions are sutured or sealed with special glue.
Laparoscopy is performed only under general (endotracheal) anesthesia, this is due to the fact that during laparoscopy it is necessary to relax all the muscles of the patient’s body. For these purposes, during the operation, the patient is given drugs that relax the muscles, including the respiratory muscles. In this regard, it is necessary to support breathing with an artificial lung ventilation device.
Before its implementation, the patient is consulted by an anesthesiologist to decide on the possibility of this type of anesthesia.
In preparation for surgery, patients are recommended to adhere to dietary restrictions: follow a low-fiber diet for 3 days prior to the surgery. The last meal should be no later than 23:00, and you can drink water until 6:00 on the day of surgery. Also, in the postoperative period, for 2−3 days, it is advisable to limit foods that cause intestinal bloating and the formation of dense feces. If there is a suspicion of intestinal involvement in the pathological process and the possibility of working with it during surgery (for example, with intestinal endometriosis), the doctor may ask to prepare the intestines for surgery using laxatives.
Patients are usually activated a few hours after surgery. Pain in the lower abdomen is usually bearable and does not require strong painkillers. One of the specific postoperative symptoms may be pain in the chest, shoulders, collarbone, neck, this is explained by irritation of the phrenic nerve when the diaphragm (the muscle that limits the abdominal cavity) is stretched by gas in the abdominal cavity. This symptom goes away on its own after a few days. Discharge is usually carried out on the day 1−3, but the doctor determines the discharge period individually.
In the postoperative period, it is recommended to wear compression stockings for 2−3 weeks to prevent thromboembolic complications. All patients are advised to exclude physical activity for 1−2 months, exclude intercourses for 2 to 8 weeks, depending on the type of operation. Other recommendations are prescribed by the surgeon individually.
At the end of the operation, the incisions are sutured or sealed with special glue.
Laparoscopy is performed only under general (endotracheal) anesthesia, this is due to the fact that during laparoscopy it is necessary to relax all the muscles of the patient’s body. For these purposes, during the operation, the patient is given drugs that relax the muscles, including the respiratory muscles. In this regard, it is necessary to support breathing with an artificial lung ventilation device.
Before its implementation, the patient is consulted by an anesthesiologist to decide on the possibility of this type of anesthesia.
In preparation for surgery, patients are recommended to adhere to dietary restrictions: follow a low-fiber diet for 3 days prior to the surgery. The last meal should be no later than 23:00, and you can drink water until 6:00 on the day of surgery. Also, in the postoperative period, for 2−3 days, it is advisable to limit foods that cause intestinal bloating and the formation of dense feces. If there is a suspicion of intestinal involvement in the pathological process and the possibility of working with it during surgery (for example, with intestinal endometriosis), the doctor may ask to prepare the intestines for surgery using laxatives.
Patients are usually activated a few hours after surgery. Pain in the lower abdomen is usually bearable and does not require strong painkillers. One of the specific postoperative symptoms may be pain in the chest, shoulders, collarbone, neck, this is explained by irritation of the phrenic nerve when the diaphragm (the muscle that limits the abdominal cavity) is stretched by gas in the abdominal cavity. This symptom goes away on its own after a few days. Discharge is usually carried out on the day 1−3, but the doctor determines the discharge period individually.
In the postoperative period, it is recommended to wear compression stockings for 2−3 weeks to prevent thromboembolic complications. All patients are advised to exclude physical activity for 1−2 months, exclude intercourses for 2 to 8 weeks, depending on the type of operation. Other recommendations are prescribed by the surgeon individually.
Today, about 95% of all gynecological surgeries can be performed laparoscopically: this includes diagnostics and treatment of infertility, removal of ovarian tumors, uterine fibroids, treatment of endometriosis, pelvic organ prolapse using mesh, diagnostics of the causes of chronic pelvic pain, treatment of emergency conditions (ectopic pregnancy, ovarian apoplexy). However, there is always a risk of conversion — a transition from endoscopic to open abdominal surgery. Every patient undergoing laparoscopy should understand that there is a chance that the operation may end with a large incision. The probability of such event is small — 6.3%, and this percentage depends, among other things, on the complexity of the procedure, but it is not always possible to predict the scenario in advance.
Robor-assisted laparoscopy
One of the types of laparoscopy is robot-assisted surgery. The Da Vinci robotic system was first used in gynecology in 2005 in the United States when performing a hysterectomy. Since then, robot-assisted surgeries have been widely used throughout the world. At the beginning of 2023, more than 11 million robotic surgeries have been performed worldwide with Intuitive Surgical Da Vinci robots, with over 7500 platforms installed worldwide.
The Da Vinci robotic system consists of three consoles: the surgeon’s console, at which he controls the robot using joysticks and pedals while sitting; a robotic console that transmits an image to the surgeon and repeats his movements; a rack with equipment. It is important to understand that the robot does not perform the operation on its own, but only repeats the surgeon’s movements with high accuracy.
The Da Vinci robotic system consists of three consoles: the surgeon’s console, at which he controls the robot using joysticks and pedals while sitting; a robotic console that transmits an image to the surgeon and repeats his movements; a rack with equipment. It is important to understand that the robot does not perform the operation on its own, but only repeats the surgeon’s movements with high accuracy.
DaVinci Si robot consoles
The advantages of robotic surgery are:
- 1Three-dimensional visualization systemThanks to which the surgeon receives an image with the effect of real depth.
Instruments with increased amplitude of movement which allow a surgeon to perform a very precise surgery.
Surgeon spends less energy, because of the comfortable sitting position at the console, which has a lot of settings for convenient placement of arms, legs and part for the head. - 2Reduces blood loss(Compared to laparoscopic and open access in robotic surgery).
However, the costs of robot-assisted surgery are higher compared to the above-mentioned approaches. In this regard, not all gynecological operations should be performed with a robot.
It is advisable to use it in oncogynecology, in the treatment of severe forms of endometriosis, pelvic organ prolapse, multiple uterine fibroids, especially in overweight patients.
Preparation for surgery and postoperative management are almost similar to those for conventional laparoscopy.
The points for installing trocars and inserting instruments during robot-assisted surgery differ from those during laparoscopy: the first optical trocar is usually installed above the navel (12 mm long incision), the remaining trocars (3 for robotic instruments and 1 for the assistant’s instrument) are on the right and left at the level of the navel (5−8 mm long incisions).
The points for installing trocars and inserting instruments during robot-assisted surgery differ from those during laparoscopy: the first optical trocar is usually installed above the navel (12 mm long incision), the remaining trocars (3 for robotic instruments and 1 for the assistant’s instrument) are on the right and left at the level of the navel (5−8 mm long incisions).
Comparison of robotic trocars
From 2013 to 2024, Alexey Koval performed more than 100 robot-assisted surgeries.
© 2024 Alexey Koval. All rights reserved.
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