This document provides an overview of basics of laparoscopy in gynecology. It describes the components and process of laparoscopy including pneumoperitoneum creation using Veress needle or open technique, imaging systems, trocar placement, operative instruments, and energy sources. Advantages of laparoscopy include reduced pain, scarring and recovery time compared to open surgery. Potential complications include injuries to abdominal organs or blood vessels that may require conversion to open surgery.

1. BASICS OF
LAPAROSCOPY IN
GYNECOLOGY
PRESENTED BY- DR NEHA SHAEMA
RESIDENT IN OBS/GYN
SNMC,AGRA

2. Laparoscopy literally means, "to look
inside the abdomen.
The Angle of View with Telescopes

4. WHY LAPAROSCOPY?
ADVANTAGES OF LAPAROSCOPIC SURGERY
VERSUS OPEN SURGERY.
 Less post-operative scarring
 Reduced pain , Shorter recovery time
 Less time spent in hospital to recover
 Reduced hemorrhage
 Reduced risk of exposing internal organs to external
contaminants
 Quicker return to normal activities
 Reduced wound complications

6. INTRODUCTION
 LAPAROSCOPIC SURGERY- A key hole surgery in
which small incision(0.5-1.5cm) are made in the
abdominal wall through which a laparoscope and
other instruments can be placed to permit structures
within the abdomen and pelvis to be seen.
 THREE COMPONENTS-1.Image production
2.Pneumoperitoneum
3.laparoscopic instruments

8. IMAGING SYSTEMS
The imaging system is a chain of following equipments
that are link together to produce an excellent
laparoscopic image-
• Light source
• Light cable
• Telescope
• Laparoscopic camera
• Laparoscopic video monitor.

9. MONITOR &
RECORDING
SYSTEM
CAMERA 3D
TRIPLE CHIP CAMERA (HD)
Xenon (300 watt)
500 hrs (Best illumination by powerful
sources)
Minimum heat conduction to the
telescope body- “cold light”
LIGHT CORD(fibre-optic

10. LIGHT SOURCE
 High-intensity light is created with bulbs of halogen
gas, xenon gas or mercury vapor.
 Light is absorbed by blood, any procedure in which
bleeding is encountered may require more light.
 Availability of light is a challenge in many bariatric
procedures where the abdominal cavity is large.

11.  A good laparoscopic light source should emit light
as much as possible near the wavelength of
natural sun light.
 Three types of light source are in use today:
1. Halogen light source
2. Xenon light source
3. Metal halide light source
 The output from the light sources is conducted to the
telescope by light cables that contain either glass fiber
bundles or special fluid.

12.  Quality of the image obtained very much depends
on the quantity of light available at each step of
optical and electronic system.
 A typical light source consists of:
• A lamp (bulb)
• A heat filter
• A condensing lens
• Manual or automatic intensity control circuit
(shutter).

13.  The quality of light depends on the lamp used. Several
modern types of light sources are currently available
These light sources mainly depend on the type of bulb
used.
 Three types of lamp/bulb are used more recently:
1. Quartz halogen Incandescent lamp
2. Xenon lamp
3. Metal halide vapor arc lamp.

15.  The two most frequently used types of lamps are
halogen and xenon. The main difference between
them is in the colors obtained.
Condensing Lens
The purpose of condensing lens is to converge the
light emitted by lamp to the area of light cable input.

16. LIGHT CABLE
 The principle of fiber optic cable is based on the total
internal reflection of light due to this light conducts
along a curved glass rod.
 Nowadays, there are two types of light cable available:
1. Fiber optic cable
2. Liquid crystal gel cable.

18. 1. FiberopticCable
 Fiber optics cable transmits light through very fine,
flexible glass or plastic fibers.
 The fiber size used is usually 20 to 150 micron in
diameter. A good fiber optic cable will transmit all the
spectrum of light without loss.
 Due to their flexibility makes them much easier to
maintain.
2 LIQUIDCRYSTALGEL CABLE- These made up of clear optical
fiber are capable of transmitting up to 30 percent more
light than optic fibers.

20. laparoscope
 There are two type of laparoscope-1.Rigid
2.Flexible.
The standard laparoscope consists of a metal shaft
between 24 to 33 cm in length. There are three
important structural differences in laparoscope
available in the market:
• No. of the rod lens: From 6 to 18 rod lens system
laparoscopes
• The Angle of view: Between 0 degree to 120°
laparoscopes
• The Diameter: 1.5 to 15 mm of laparoscopes.

21. The Angle of View with
Laparoscopes
 Straight/forward view with - 0 degree
 Angled at -25 to 30 or 45 to 50 degrees.
 The 30° forward oblique angle -permits far greater
latitude for viewing underlying areas under difficult
anatomical conditions e g: study of adhesions, ovarian
surfaces.

23. DIAMETERS OF LAPaROSCOPE
1. 10mm-Most commonly used for operative as
well as Diagnostic purpose.
2. 5mm- Mainly used for diagnostic purpose ,
can be used for operative purpose.
3. < 5mm- Very delicate MINIlaparoscopy
mainly used in children (1.1mm) Diagnostic
purpose also in operative purpose.

24. The Lens System
There are two lens system designs used with the
laparoscopy.
1. The conventional thin lens system
2. The Hopkins rod lens system design -which is most
commonly used .

26. Laparoscopic Camera
 First medical camera was introduced by Circon
Corporation in 1972.
 The camera system has two components:
1. The head of the camera-
which is attached to the ocular
of the laparoscope
2. The controller-
which is usually located on the
trolley along with the monitor.

27. Laparoscopic Video Monitor
 The size of the screen varies from 8 to 21 inches.
 The basic principle of image is horizontal beam
scanning on the face of the picture tube.

28. PNEUMOPERITONEUM
FIRST STEP IN LAPROSCOPY
 Open technique-
-Hasson Cannula
 Closed technique-
-Veress neddle
-Trocar sheath

30. PNEUMOPERITONEUM IN
CLOSED TECHNIQUE
 Pneumoperitoneum created by insufflation
of gas in peritoneal cavity to provide
sufficient space to ensure adequate
visualization and manipulation.
 Insufflators are designed to deliver gas at
low rates 8-10lts/min during initial Veress
needle insertion and monitor
intraabdominal pressure usually 12-
15mmHg.

31. VERESS NEEDLE
 Spring loaded
 Blunt tip retractable into sharp sheath
 Small caliber penetrates tissue by separating rather
than cutting
 Disposable or reusable
 Diameter 2mm and length 12-15mm
 Insufflation upto 2.5L/min

32. VERESS NEEDLE INSERTION

33. Test to identify correct position
 Hanging drop method-a small amount of sterile saline is
placed on the top of veress needle. The saline drops in the
peritoneal cavity shows negative intraperitoneal pressure.
 Aspiration test-A 10ml syringe with NS is attached to the
veress needle. Aspiration is done to rule out blood or bowel
contents. The saline is then pushed down and aspiration is
again done. If the needle placement is correct ,the fluid
cannot be withdrawn as it goes it he peritoneal cavity.
 Double click test-First needle hold perpendicularly(90⁰)-
resistance followed by a give felt(1st click), as passes
through sheath then at 45°- click is felt as passes through
peritoneum.

36. INSUFFLATOR
Cylinder
Pressure
Abdominal
Pressure
Flow
Rate
Total
Volume of
Gas

37.  During insufflation Initially flow rate is low flow &
then increased, preferably to 3-6 L/ min.
 Throughout insufflation, vitals are closely monitored.
 Pressure 12-15mmHg
 Pressure gauge automatically stops gas flow on
reaching pre-selected pressure
 Rapid insufflation causes- dysarhythmias & post-
operative pain

38. INSUFFILATION
 GASES USED FOR INSUFFLATION:
-Filter room air
-Carbon dioxide- commonly used , has
advantages of being rapidly absorbed by blood,
nontoxic, cost effective and can be used with cautery.
-Nitrous oxide
-Helium

39. SIDE EFFECT OF PNEUMOPERITONEUM
 Gas effects
 With CO2 respiratory acidosis,
 Hypercarbia- Tachycardia, increased in vascular
resistance, increased BP & myocardial O2 demand.
 Cardiac arrhythmias- Bradycardia(mc)
 Gas embolism-sudden hypertension ,Mill wheel
murmur, increased end tidal CO2

40. PRESSURE EFFECTS
 Vasovagal effect-due to stretching of peritoneum
 CVS-decreased VR,CO-due to pressure on IVC
-Venous engorgement with endothelial damage of lower
limb veins
 DVT
 RS-decrease lung compliance, increased risk of
barotrauma ,mild V/O mismatch
 Renal system-decrease RBF,GFR & urine output.

41. Gasless Laparoscopy
 It can be performed with the use of a mechanical
lifting arm that attaches to a fanlike retractor along the
peritoneal surface of the abdominal wall. This
approach favored in patients with cardiopulmonary
risk factors.

42. PLACEMENT OF TROCAR

43. BASE BALL DIAMOND CONCEPT

45. ERGONOMICS

52. Operative Instruments
 Graspers: Retraction may be achieved by using large
grasping instruments.
 Bullet Nose Grasper with either straight or
diamond-cut serrations, has a blunt bullet nose tip
design with an atraumatic grasping jaw. These graspers
are ideal for dissecting or grasping delicate anatomy.
 Dorsey Intestinal Fenestrated Grasper has
atraumatic horizontal serrations.

56. Dissectors- These are used for separation of
tissue with hemostasis.

57. Scissors-In minimal access surgery scissors require greater skill
because in inexperienced hand it may cause unnecessary bleeding
and damage to important structures.

59. Ligasure Vessel Sealing System (LVSS)
The Ligasure System-
• It is a bipolar electrosurgical
device used to cut, vaporize,
coagulate and seal blood vessels.
• It delivers higher current and
lower voltage (180 V) and melt
vessel collagen and elastin to
form a translucent seal
• It seals vessels upto 7 mm in
diameter.

60. Ultrasonic Energy Source
Harmonic scalpel-
•It is a ultrasound
energy source to break
hydrogen bonds in
tissue.
•It uses vibration at the
rate of 55,000 cycles per
seconds.
•It is effective in sealing
upto 4mm diameter of
vessels.

61. ENERGY SOURCES
MONOPOLAR
 Hand piece (Active electrode) is at the surgical site
 Ground pad (Return electrode)
is elsewhere on body
 Current passes through large
amount of tissue
DISADVANTAGES
 Large volumes of tissues are
injured
 Distant burns can occur

62. BIPOLAR
 Active & return electrode are
located in same instrument
 More limited area of thermal spread
 Very effective in hemostasis.
 Damage to tissue is more precise.
 e.g. Robi, Bipolar grasping
forceps (Kleppinger)

63. Advantage s of LAPAROSCOPY
 Reduced postoperative morbidity - pain, chest &
wound complication
 Accelerated recovery
 Lesser adhesion formation
 Better cosmesis
 Reduced contact with body fluids & disease
 transmission
 Reduced incidence of ventral hernia.
(11% in midline vs 4.7% in transverse scar vs 0.7% after
laparoscopy.)

64. DISADVANTAGES
 Longer duration of surgery
 Loss of 3D view, impaired touch sensation.
 Long learning curve for surgeons.
 Diathermy burns
 Hemostasis more difficult
 Trocar related injuries to vessels and viscera
 Insufflation related postoperative pain

65. INDICATIONS OF LAPAROSCOPY
DIAGNOSTIC-
1.Infertility work up-Ovulation study
 Tubal patency
 Endometriosis
 Pelvic adhesions
2.Acute pelvic lesion-Acute ectopic
 Acute Appendicitis
 Acute Salpingitis

66. 3.Pelvic mass-
Fibroid
Ovarian Cyst
4.Follow up of pelvic surgery
 Tuboplasty
 Ovarianmalignancy
 Evaluation of endometriosis Rx
5.Suspected Mullerian abnormalitis
6.Suspected Uterine perforation.

67. Therapeutic Laparoscopy
 Adhesiolysis
 Aspiration of ovarian cyst
 Ovarian drilling
 Ovarian cystectomy
 Ectopic pregnancy
 Tubal sterilization
 Endometriosis(Laser or thermal ablation)
 Myomectomy
 LAVH

68. Contraindications
• Severe cardiopulmonary diseases
• Generalised peritonitis
• Intestinal obstruction
• Significant hemoperitoneum
• Extensive peritoneal adhesions
• Large pelvic tumour
• Obesity

69. COMPLICATIONS OF
LAPAROSCOPICSURGERIES
 1. Anaesthetic Complications
 2. Complications due to pneumoperitonium
 3. Surgical complications
 4. Diathermy related injuries
 5. Patients factors related complications
 6. Post operative complications

70. SURGICAL COMPLICATIONS
Injury to Viscus
• Stomach -Hyperventilation by Mask
-Injured with trochar or needle.

71. Management of stomach
INJURY
• Extend trocar incision into a minilap. for a two layer
closure.
• Laparosocpically
- Purse string suture or a figure of 8 suture
in the seromuscular layer surround the
defect.
- Nasogastric tube drainage for two days.

72.  Bowel - May be injured due to trocar or veress
needle.
 Diagnosis -
Foul smelling gas through pneumoperitoneum-
peritoneal needle is a helpful diagnostic sign.
• There may be GI contents at the tip of needle.

73. Management
• If due to verres’ needle it is managed
conservatively.
•Convert it to Minilaprotomy and repair of perforation.
• It may be sutured of laparoscopic stapler (ENDO-GIA)
can be used.
• Colostomy to be done.

74. • Small Bowel Perforation - Most often
during insertion of umbilical or lower
quadrant trocars .
• Usually recognized later in the procedure
• If adhesions are not freed from anterior
abdominal wall perforation may not be
recognized

75. Management
• One should consider higher primary site if
adhesions are found through umblical port.
• Perforation repaired transversally
• If injury is free of adhesions bowel can be
withdrawn through 10 mm trocar tract and
repaired

76. Injury to Viscus
• Bladder - Injury caused by second puncture of trocar
usually .
• Diagnosis : Appearance of gas and blood in Foley’s
catheter bag.
• Management –
• Early detection is important.
• Place an indwelling catheter for 7-10 days and
prophylactic antibiotics - If defect is larger.
• Repaired by a figure of 8 suture through muscularis of
bladder & second suture to close peritoneum.

77.  Ureter - May be injured in adenexal surgeries.
• Thermal injury will result in ureteral narrowing and
hydroureter.
 Management –
• Placement of ureteric stent for 3 – 6 weeks

78. Vessel Injury
• Larger vessels may be injured by trocar or verres’needle.
• CO2 peritoneum may tamponade a large vessel injury.
When pressure normalizes it starts bleeding.
• Management –
• Examine the course of large vessels.
• Overlying peritoneum is opened with laproscopic
scissors or a CO2 laser.
• Hematoma evacuated by alternate suction and
irrigation.
• Laprotomy is required if hematoma is expanding or
persistent bleeding

79. Epigastric Vessels
• Deep epigastric vessels most frequently injured in
laproscopic hysterectomy.
• Management –
• By Tamponade
• By Foley’s catheter
• Bipolar cautery
• Needle suturing
• Small haemostate (Mosquito clamp)

80.  Ovarian or uterine vessels –
• Injured during laproscopic hysterectomy
• Management –
• Bipolar desiccation
• Ureter must be identified before desiccation

81. DIATHERMY RELATED INJURIES
Due to –
• Inadvertent activation of the diathermy pedal.
• Faulty insulation
Injuries –
• Thermal necrosis of organs.
• Inadvertent organ ligation.
• Unrecognized haemorrhage.

83.  PATIENT’S FACTORS RELATED COMPLICATIONS
• Obesity
• Ascites
• Organomegaly – organ damage
• Coagulation disorder – haemorrhage

84.  POST OPERATIVE COMPLICATIONS
• Concealed injury to organs
• Delayed fecal fistula
• Port site metastasis
• Residual air (Referred chest or shoulder pain)

85. STERILISATION OF INSTRUMENTS
 CDC recommends Sterilisation or High Level Disinfection
 Steps involved-
1. Dismantling- To remove debris from crevices
2. Decontamination- visible blood & tissue is wiped off, then
soaked in 0.5% chlorine for 10 minutes
3. Pre-cleaning- with an enzymatic product viz. protease
recommended
4. Cleaning- with soft brush, detergent & water
5. Rinsing- under running water
6. Drying

86. a) Steam Sterilisation-
 Autoclaving at 134° for 30 minutes
 All insulated instruments, tubings, cords should be
doubly wrapped in cloth
b) Ethylene Oxide Gas Sterilisation-
 Non-corrosive to optics
 Permeates porous material
c) Low Temperature Plasma Sterilizer
 heat & moisture sensitive equipment
 25-50min cycle
 Keep the instrument in it after plastic covering

87.  High Level Disinfection with 2% Glutaraldehyde
(Cidex Plus) for 20-30 minutes
 Good alternative to sterilisation in case of
telescopes, and fibreoptic light cords; as easily
damaged
 The length of time that commercially available
glutaraldehyde solutions may be used varies,
usually from 14-30 days. It ought to be tested daily
with the manufacturer’s test strip
 Solutions should be replaced any time they become
cloudy
 Use of sterile drapes over camera and cord is
another alternative .

88. THANK YOU