Laparoscopic Gynecology Procedures: Avoid the Risk

Abstract

Laparoscopic approaches to gynecological surgery have been developed by an elite group of highly skilled surgeons. As these procedures become more prevalent in the general gynecological approach to disease and the general gynecologist' s approach to treatment, the complication rate for these procedures is likely to increase. In an effort to assist in avoiding these complications, guidelines for the performance of laparoscopic gynecological procedures need to be established. This article presents approaches to the most common gynecological procedures that can assist in the prevention of complications.KEY WORDS: Laparoscopy, complications, bowel injury, Richter's hernia INTRODUCTION A short review of the literature on the laparoscopic hysterectomy (1-19) revealed the following complications: bladder injuries including lacerations, punctures, vesiclevaginal fistulas; ureteral injuries including ureterovesicle fistulas, ureteral transections, and cauterizations; bowel injuries including enterotomies, thermal injuries, and herniations into trocar sites; nerve injuries; hemorrhage both intraoperative and postoperative, some requiring transfusion; injuries to abdominal wall vessels and retroperitoneal vessels; infections including pelvic abscesses requiring drainage, cellulitis, and pneumonia, with one postoperative case of pneumonia resulting in death; anesthetic problems including cardiac arrythmias and pulmonary edema; and vascular problems including deep venous thrombosis and pulmonary embolus.Of all the laparoscopic gynecological procedures, only the complication rate of the laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic hysterectomy has been studied and recorded. In one such study by Padial et al. (13) surgery (20-27).The patient should be instructed for all advanced laparoscopic procedures and undergo a bowel cleansing procedure with the use ofan osmotic agent such as GoLITELY (25,28 (2,(36)(37)(38).This site, however, has three major disadvantages. First, the transverse colon will frequently lay directly under or even caudad to the umbilical site. The second disadvantage is that the mesentery of the bowel also frequently lies directly under the umbilical site. Finally, the aorta, vena cava, and especially the left common iliac vein are frequently in close proximity to, directly below, or caudad to the umbilical site. Therefore, when the intraumbilical incision is made (which is preferable to a subumbilical incision because of the direction of the lines of Langham at the umbilical site) the Veress needle must be inserted only millimeters through the fascia, which is elevated under tension if the Veress needle is inserted in a vertical direction. If the Veress needle is inserted in a caudad direction, the skin should be elevated and the Veress needle inserted in a direction toward the uterus in the deep pelvis. This technique will traverse fat, fascia, and peritoneum before entry.If the Veress needle technique is used, the position ofthe Veress needle must be confimed by injection of 20 ml ...