MANUAL OF GYNECOLOGICAL LAPAROSCOPIC SURGERY

untitledIInd Edition
Prof. Luca MENCAGLIA, M.D. Scientifi c Head of the “Centro Oncologico Fiorentino” (CFO),
Florence, I taly
Dr. Luca MINELLI, M.D. Head of Department of Gynecology and Obstetrics
“Sacro Cuore” General Hospital, Negrar, Italy
Prof. Arnaud WATTIEZ, M.D. Head of Department of Gynecology and Obstetrics
Faculty of Medicine, University Hospital of Strasbourg, France
Co-authors:
Elizabet ABDALLA Paulo AYROZA
Department of Gynecology and Obstetrics, Medical School of the Santa Casa University
of São Paulo, Brazil
Fabrizio BARBIERI Stefano LANDI
Department of Gynecology and Obstetrics, “Sacro Cuore” General Hospital, Negrar, Italy
Cristiana BARBOSA Sabrina CONSIGLI Emmanuel LUGO
Centro Oncologico Fiorentino, Florence, Italy
Fabio IMPERATO Mario MALZONI
Carlo TANTINI Department of Gynecology and Obstetrics,
Hospital of Cecina, Italy
Daiana TONELLOTTO Barra D’Or Hospital, Rio de Janeiro, Brazil
Beatrice VIDELA Leopoldo Carlos VIDELA Callao Surgical Institute, Buenos Aires, Argentina
Manual of Gynecological Laparoscopic Surgery4
Please note: Medical knowledge is constantly changing. As new research and clinical experience broaden our knowledge, changes in treatment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accordance with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or publisher of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, can guarantee that the information contained herein is in every respect accurate or complete, and they cannot be held responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this brochure is intended for use by doctors and other health care professionals. This material is not intended for use
Manual of Gynecological Laparoscopic Surgery IInd Edition
Prof. Luca MENCAGLIA, M.D. Scientifi c Head of „Centro Oncologico Fiorentino“, Florence, Italy
Dr. Luca MINELLI, M.D. Head of Department of Gynecology and Obstetrics, “Sacro Cuore” General Hospital, Negrar, Italy
Prof. Arnaud WATTIEZ, M.D. Head of Department of Gynecology and Obstetrics, Faculty of Medicine, University Hospital of Strasbourg, Strasbourg, France
© 2013 ®, Tuttlingen, Germany Printed in Germany, ISBN 978-3-89756-405-3 P.O. Box, D-78503 Tuttlingen, Germany Phone: +49 7461/14590 Fax: +49 7461/708-529 E-mail: [email protected]
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®, Tuttlingen, Germany, at the address given above.
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Correspondence Addresses: Prof. Dr. Luca Mencaglia Centro Oncologico Fiorentino, Via Ragionieri, 101, 50019 Sesto Fiorentino, Firenze, Italy Phone: +39/05553010 E-mail: info@centroncologicofi orentino.it Web: www.centrocologicofi orentino.it
Dr. Luca Minelli Direttore U.O. di Ginecologia e Ostetricia, Ospedale “Sacro Cuore”, Negrar – Verona Via Don A. Sempreboni, 5 37024 Negrar (VR), Italy
Prof. Dr. Arnaud Wattiez IRCAD/EITS, Hôpitaux Universitaires de Strasbourg Service de Gynécologie-Obstétrique 1, place de l‘Hôpital 67091 Strasbourg Cedex, France
All rights reserved. No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invented, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder. 01
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as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature. Some of the product names, patents, and registered designs referred to in this booklet are in fact registered trademarks or proprietary names even though specifi c reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.
Manual of Gynecological Laparoscopic Surgery 5
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Contents
I Instrumentation and Operating Room Setup Cristiana Barbosa and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
II Use of Electricity in Laparoscopy Paulo Ayroza and Elizabet Abdalla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
III Ergonomics in Laparoscopy Arnaud Wattiez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
IV Gynecologic Laparoscopic Surgical Anatomy Cristiana Barbosa, Arnaud Wattiez and Luca Mencaglia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
V Suturing Techniques in Gynecologic Laparoscopy Daiana Tonellotto, Paulo Ayroza, Arnaud Wattiez and Luca Mencaglia . . . . . . . . . . . . . . . . . . . 73
VI The Role of Diagnostic Laparoscopy and Transvaginal Endoscopy (TVE) in Infertility and Assisted Reproduction Technology (ART) Emmanuel Lugo, Carlo Tantini and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
VII Techniques of Laparoscopic Tubal Sterilization Emmanuel Lugo and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
VIII Laparoscopic Tubal Surgery Emmanuel Lugo and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
IX Laparoscopic Management of Ectopic Pregnancy Cristiana Barbosa and Luca Mencaglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
X Laparoscopic Surgery for Symptomatic Endometriosis Luca Mencaglia, Arnaud Wattiez and Sabina Consigli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
XI Laparoscopic Management of Deep Endometriosis Luca Minelli and Stefano Landi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
XII Technique of Laparoscopic Myomectomy Stefano Landi and Luca Minelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
XIII Laparoscopic Treatment of Adnexal Masses Mario Malzoni and Fabio Imperato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
XIV Laparoscopic Management of Borderline Ovarian Tumors Paulo Ayroza and Elizabet Abdalla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
XV Laparoscopic Hysterectomy Arnaud Wattiez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
XVI Laparoscopic Surgery of the Pelvic Floor Arnaud Wattiez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
XVII Laparoscopic Surgical Staging of Endometrial Carcinoma Fabrizio Barbieri and Luca Minelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
XVIII Laparoscopic Pelvic and Lumbo-aortic Lymphadenectomy Fabrizio Barbieri and Luca Minelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
XIX Complications in Laparoscopic Surgery Leopoldo Carlos Videla Rivero and Beatrice Videla Rivero . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Recommended Set for Gynecological Laparoscopic Surgery . . . . . . . . . . . . . . . . . . . . . . . 227
Manual of Gynecological Laparoscopic Surgery30
The AUTOCON® II 400 is a versatile, state-of-the-art high frequency electrosurgical unit designed for both unipolar and bipolar electrosurgical applications. The opera tional parameters of various cutting and coagulation settings can be preselected on the frontpanel display, thus providing the user with a highly accurate and reproducible method to obtain good results. Exact fi ne-tuning in 1 W-steps is enabled for procedures that require maximum precision at very low power. Up to 8 hemostatic effects for unipolar and bipolar cutting, each with up to 370 W output, permit optimal control of coagulation and the intended surgical effect. In the bipolar coagulation mode, the autostart function auto- matically activates the coagulation current as soon as the electrode has touched the tissue with both branches. The various safety circuits of the unit provide a very high level of safety for both the patient and staff. Software- supported test programs ensure easy and rapid servicing. The color touch- screen with its modern and user-friendly design allows for easy operability, maintenance and cleaning (Fig. 47).
12.0 High Frequency Electrosurgical Units
The most commonly used type of laser is the CO2 laser, which is also considered to be the most precise which causes the least thermal injury. Even though the CO2 laser is considered to be highly effi cient in terms of tissue vaporization, cutting or excision, but has only minimal coagulating properties. Lasers with a short wavelength such as Argon, Neodymium:Yttrium- Aluminum Garnet (Nd:YAG) and KTP 532 lasers (Potassium Titanyl Phosphate; KTiOPO4, KTP) have good coagulating properties but are less effi cient in terms of vaporization. The degree and extent of thermal damage produced by laser irradiation depends on the structure, water content, pigmen- tation and the state of tissue perfusion. In addition, user- determined operational parameters can have a considerable
impact on the outcome of the laser treatment, such as the inherent absorption characteristics / wavelength of the laser system specifi cally selected for the intended application, spot size, power density, mode of delivery (contact/ no contact) and exposure time (intermittent or continuous).
In summary, each of the various laser systems available on the market has a specifi c clinical application. Laser generators are much more expensive than electrosurgical systems, and there are many safety aspects, such as the potential risk of cumulative thermal effects, burns due to inappropriate expo- sure and retinal damage, that speak against the widespread use of laser technology.
13.0 Laser Systems
The use of ultrasonic energy for cutting and coagulation is an alternative to electrosurgery. Ultrasound is the unique energy form that allows both cutting and coagulation of tissues without exposing the patient to the risks associated with the application of high frequency current. The major benefi t of this alternative technique is that only a minor degree of lateral heat-induced tissue damage occurs. Ultrasonic systems that are operated at low power settings cleave water-containing tissues through cavitation sparing organized structures of low water content without coagulating vessels (frequently applied
in liver surgery). High power settings can be applied to cleave the loose surrounding tissues by frictional heat while simulta- neously coagulating the wound margins (frequently applied in colon surgery). High-power ultrasonic dissection can cause collateral damage by excessive generation of heat. However, in view of the high level of operational reliability and safety feasible with this alternative technology, the anticipated advances in the further development will certainly make it a valuable tool in the future.
14.0 Ultrasonic Dissection and Coagulation Systems
Fig. 47 The high frequency electrosurgical unit AUTOCON® II 400, (KARL STORZ Tuttlingen, Germany).
Manual of Gynecological Laparoscopic Surgery32
Advanced laparoscopic procedures can be performed safely and effectively only if the surgeon or gynecologist has gone through the initial stages of surgical training and has gained an adequate level of profi ciency in intracorporeal suturing and knot tying techniques. Laparoscopic suturing and knot tying should be practiced on a good quality endotrainer with an experienced tutor. There are two suturing methods: the intra- corporeal and the extracorporeal technique. The major steps of the intracorporeal technique are: introduction of the needle and intraabdominal suturing, placement of suture ligatures, knot tying, either extracorporeal or intracorporeal.
Intracorporeal suturing techniques involve that each knot is formed and tied inside the cavity with the aid of needle holders. There are many different types of needle holders that essentially vary in handle design and tip confi guration (Figs. 51–52). In our opinion, intracorporeal knots should be reserved to experienced surgeons, because advanced procedures require a good command of microsurgical suture techniques. Once an adequate level of profi ciency in intracor- poreal suture and ligature has been achieved, the surgeon’s conversion rate will certainly decrease.
16.0 Suture Techniques
Fig. 52a Various needle holders with curved jaws.
Fig. 52b The KOH Macro Needle Holder with curved jaws, ergonomic pistol handle and disengageable ratchet.
Fig. 51 The SZABO-BERCI Needle Holder PARROT-JAW® with straight handle and adjust able ratchet.
ba
Manual of Gynecological Laparoscopic Surgery 33
As the term denotes, extracorporeal suturing and knot tying is performed outside the body cavity. Once the tissue is sutured, the needle is removed through the trocar cannula and the suture is completed extracorporeally. In this case, a knot tier is required. Even though pre-tied loops are available in the market, surgeons-in-training should learn the basic skills of extracorporeal knot tying. For extracorporeal knotting various types of knot pushers can be used. Knot pushers are of either closed-jaw or of open-jaw type (Fig. 53). For a trainee who has strong convictions to pursue a surgic al career it is essential to make every effort to perfect his/her skills to achieve an adequate level of profi ciency in suturing techniques. The correct extracorporeal Roeder knot is very useful. For major or safety sutures, e.g., for ligature of a uterine vascular pedicle in hysterectomy, the extracorporeal Roeder knot is necessary. To push the knot, a specifi c open-jaw knot pusher is used. The endoloop is the oldest device used for laparoscopic-guided ligature; it is a loop with a pre-formed slipknot that can be positioned around the structure that needs to be removed.
In some cases, a laparoscopic clip applicator may be neces- sary. In minimally invasive surgery, surgical clips are used for tissue approximation. Most of them are made of pure titanium or of titanium alloys. Surgical clips are easy to apply and can be left inside the abdominal cavity. After a few weeks, the clip is covered by fi brous tissue. The jaw of the clip appli- cator should be located perpendicular to the wound site before deploying the clip, the surgeon should take care that both jaws are in view. Two clips are usually deployed over the structure that needs to be secured. One clip is deployed over the tissue which the surgeon wants to remove to prevent spillage of fl uid. The clips should not be applied very close to each other.
Disposable extraction bags are very important to prevent contamination of the abdominal wall during extraction of specimens from the abdominal cavity (Fig. 54). Extraction protected by an endoscopic bag is mandatory to obviate the risk of benign dissemination (e.g., in the case of endometriosis, ectopic pregnancy, and benign ovarian cysts), spillage during removal of a benign teratoma, risks of infection (pyosalpinx), and risks of malignant dissemination (suspected cysts). The extraction bag must be very strong so that it can resist the force that is exerted by the surgeon while pulling it through a small opening.
Fig. 53 Knot tier for extracorporeal knotting. The close-up views show the various types of open-end, and closed-end tip design.
Fig. 54 Disposable extraction bag.
17.0 Extraction Bag
Manual of Gynecological Laparoscopic Surgery34
An electronic or manual morcellator can be used for piecemeal removal of large specimens, such as fi broids or the uterus during laparoscopic hysterectomy, and particularly, supracervical hysterectomy (Figs. 55a, b). The fully auto clavable ROTOCUT G1 morcellator is an effi cient and time- saving alternative to previous systems. Rapid removal of large tissue segments is facilitated by the highly effi cient cutting performance of the disposable cutting blades, which can be changed intraoperatively. The blades are available in sizes of 12-mm or 15-mm. Optimal weight distribution and direct activation ensure a straight-forward and smooth operation. A specially designed trocar sleeve protects tissue from inadvertent blade contact. The powerful ROTOCUT G1 has a direct drive motor that produces a maximum speed of 1200 rpm, minimizing the amount of effort required of surgeons and reducing procedure times. The control unit that optimizes Rotocut’s performance is the UNIDRIVE®
S III, which is compatible with all previous generations of KARL STORZ morcellators.
The removal of large portions of tissue may also be accom- plished with the aid of endoscopic cold knives introduced through a minimal abdominal incision or vaginal puncture. These shielded blade carriers permit endoscopic insertion and application of cold knives in the abdominal cavity. There is a great variety of extraction devices on the market. One, that should be mentioned is the vaginal extractor. It allows intra-abdominal specimens to be retrieved via the vagina, while maintaining the integrity of the pneumoperitoneum and, therefore, endoscopic-assisted retrieval under…