Introduction

Nowadays, laparoscopic surgery is highly acclaimed surgical modality among each patients as well as doctors. It would appear that laparoscopic surgery is applicable in almost every clinical situation. A general surgeon ought to be familiar with the uterine as well as adnexal diseases and that he or she will be able to tackle these situations in a scientific manner. A general surgeon may have to tackle the incidental adnexal pathologies whilst doing routine laparoscopic general surgery which gynaecological situations may include adnexal masses like ovarian cyst, ectopic pregnancy, benign and malignant ovarian tumours, tuboovarian abscess, ovarian torsion, endometriosis resulting in to development of endometriomas etc. Becoming gynaecologist, within this chapter we wish to highlight these types of typical gynaecological treatments which can be done by an over-all surgeon in a simple and scientific way.

Pelvic Anatomy

Sound surgical technique is based on accurate anatomic knowledge. Wish to consider describe several important anatomic relations which are critical during laparoscopic methods.

Anterior abdominal wall

An umbilicus is located at the degree of L3-L4. The parietal peritoneum over the anterior abdominal walls is elevated with 5 sites, representing the five umbilical folds. The median umbilical fold, operating in the dome from the bladder to the umbilicus, covers the obliterated urachus. Lateral to the urachus, on each side, would be the medial umbilical folds, overlying the obliterated umbilical arteries. Just lateral to every medial umbilical fold may be the lateral umbilical ligament (fold), formed through the peritoneum overlying the inferior epigastric vessels. Generally, their location might be visually confirmed with the peritoneum with the laparoscope, staying away from injury to them throughout the placement of accessory trocars.

Pelvic vessels

The interior iliac artery travels parallel and just posterior towards the ureter. The external iliac artery is numerous cm anterior into it about the psoas muscle and can be seen pulsating with the peritoneum. The external and inner iliac arteries may then be followed superiorly to find the bifurcation of the common iliac artery at the pelvic brim overlying the sacroiliac joint. The best common iliac artery will then be followed superiorly to obtain the bifurcation from the aorta, above the “presacral” space at approximately your fourth lumbar vertebra.

Pelvic brim symbolizes the entry of multiple important structures to the pelvic cavity and also should be appreciated layer by layer. From the peritoneal surface for the sacroiliac joint, the following structures are simply crisscrossing each other, and can be recognized laparoscopically because superficial peritoneal landmarks; the peritoneum, the ovarian vessels within the infundibulopelvic ligament, the ureter, the bifurcation from the typical iliac artery and the common iliac vein. Dissecting in a deeper layer, the medial fringe of the psoas muscles, the obturator nerve and also the parietal fascia overlying the capsule of the sacroiliac joint is going to be exposed.

Pelvic side-wall

The pelvic side-wall is usually entered by opening the peritoneal reflection between your round ligament anteriorly, the infundibulopelvic ligament medially and the external iliac artery laterally.

Pelvic lymphnode

The external pelvic nodes are found across the external iliac artery and vein in the bifurcation of the common iliac vessels in order to deep circumflex veins caudally. The obturator nodes are simply within the obturator fossa, which is bordered medially through the hypogastric artery, laterally by the external iliac vein, the obturator internus muscle and its fascia, along with anteriorly by the obturator nerve and vessels.

Broad ligament

The bottoms of the broad ligaments would be the cardinal ligaments also known as the ligaments of Mackenrodt. Dissection of the pelvic sidewall will lead within this region. You should comprehend how the inner iliac artery continues into superior vesical artery and then to the obliterated umbilical artery. Traction on the medial umbilical fold can help identify the internal iliac artery, and also the medial offshoot passing better than the ureter will then be recognized as the uterine artery. Top of the part of the cardinal ligament is penetrated by the ureter since it travels into the ureteric “tunnel” just beneath the uterine artery, 1 to 2 cm lateral towards the isthmus of the uterus using the uterosacral ligament being just medial.

Ureter

The actual lumbar ureter lies on the psoas muscle medial to the ovarian vessels. It enters the pelvic cavity simply superficial towards the bifurcation of the common iliac artery and just deep towards the ovarian vessels, which lie within the infundibulopelvic ligament at the pelvic brim. This is based on the medial leaf of the broad ligament since it courses for the bladder and can end up being identified by its characteristic peristaltic motion. The particular ureter then passes just lateral to the uterosacral ligament, approximately 2 cm inside to the ischial spine with the upper the main cardinal ligament in the lower broad ligament. Here it lies underneath the uterine artery, approximately 1.5 to two.0 cm lateral aside of the cervix. The ureter forms a “knee” turn at this time and travels medially and anteriorly to pass through on the anterolateral facet of top of the third from the vagina for the bladder.

Total laparoscopic hysterectomy (TLH)

Hysterectomy is a type of surgery in women. The laparoscopic route has lesser morbidity than an abdominal approach, avoiding the requirement for a sizable abdominal scar, less disfiguring and allows early postoperative recovery. However, recent studies have now made it evident how the laparoscopic route doesn't have advantages over a vaginal hysterectomy. The indications for choosing to do a laparoscopic hysterectomy would hence be contraindications for vaginal hysterectomy or any suggestion of abdominal hysterectomy. Including severe endometriosis, pelvic adhesions, large fibroids, associated adnexal pathology, requirement for oophorectomy.

The technique of total laparoscopic hysterectomy

The entire laparoscopic hysterectomy is done under general anesthesia with the patient in low lithotomy position. Prophylactic antibiotic is administered 30 minutes before the procedure. The bladder is catheterized. The laparoscope is introduced through the 10 mm port within the infraumbilical region. A couple of ancillary 5mm ports are made. These can be situated in the best and left lower quadrants.

1. The round ligaments are divided with bipolar coagulation and scissors.
2. The infundibulopelvic ligament is dessicated with bipolar cautery and incised. The ovaries ought to be pulled inward and cauterization is performed close to the ovary to avoid harm to the ureter. When the ovaries have to be conserved then coagulate and cut the uteroovarian ligament.
3. A vesicouterine fold of peritoneum is incised. The bladder can then be dissected free from the uterus and pushed down.
4. The broad ligament is cauterized and cut and then uterine artery is skeletonised. Uterine artery could be either coagulated with bipolar cautery, or even the ligasure or could be ligated by endosutures with 1-0 vicryl.
5. After securing the uterine vessels, the cardinal and uterosacral ligaments are divided. This is then circumferential culdotomy with division of cervicovagnial attachments. In the end the attachments from the uterus are severed, the uterus is pulled into the vagina also it can be placed there like a plug to prevent lack of pneumoperitoneum. When the uterus is extremely big in size as with case of fibroid uterus then your uterus could be morcellated by electronically operated morcellator.
6. The vaginal vault is closed with three sutures: one attaching the uterosacrals using the vaginal vault and another in the midline.

Uterine manipulator

There are various manipulators available for sale for uterine manipulation during total laparoscopic hysterectomy. The most prominent the first is “Clermont Ferrand manipulator”. It's all reusable components and it has a half-cup that is rotatable. There are three rings, that squeeze into the vagina and control loss of pneumoperitoneum. However, the silicon, curved tube that matches onto the particular cervix, thereby presenting the fornices may also be used for manipulation of uterus. This kind of tube should be shut from another end with wet gauge or a cap to prevent lack of pneumoperitoneum.

Oophorectomy

The particular incidence of ovarian malignancy beneath the age of 45 years is extremely reduced, so the normal looking ovaries should not be removed whilst doing total laparoscopic hysterectomy. However, if the patient age is much more compared to 45 years then its the routine exercise to remove ovaries during the time of surgery. In all cases of postmenopausal women we prefer to remove the ovaries.

Laparoscopic management of adnexal masses

Adnexal masses are often present in both symptomatic and asymptomatic women. Within premenopausal ladies, physiologic follicular cysts along with corpus luteum cysts are the most common adnexal masses, but the chance of ectopic pregnancy should always be looked at. Other masses on this age bracket include endometriomas, polycystic ovaries, tubo-ovarian abscesses as well as benign neoplasms. Malignant neoplasms tend to be uncommon within young women however become more regular with growing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms should be considered, along with leiomyomas, ovarian fibromas. Information in the history, physical examination, ultrasound evaluation and selected laboratory tests will enable problems to obtain the probably cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or positioned on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts under 3 cm within diameter can also be followed, provided the serum CA-125 level is not elevated and also the patient has no indicators suggestive of malignancy.

Ovarian cysts

Broadly ovarian cysts can be classified into three categories:

• Functional cyst: follicular cyst, corpus luteum cyst, theca lutein cyst
• Inflammatory: tubo-ovarian abscess
• Neoplastic: germ cell tumor, benign cystic teratoma, epithelial tumors, serous cystadenoma, mucinous cystadenoma etc.

Functional ovarian cysts

All are benign in most cases don't cause symptoms or require surgical management. The most typical functional cyst is the follicular cyst, that is rarely larger than 8cm. These cysts are usually found incidental to pelvic examination, whilst they may rupture spontaneously, causing pain and peritoneal signs. These usually resolve in 4-8 weeks. Corpus luteum cysts are less common than follicular cysts. A corpus luteum is called a cyst when its diameter is greater than 3 cm. Corpus luteum cysts may rupture leading to hemoperitoneum and requiring surgical management.

Theca lutein cysts: are the least typical of the functional ovarian cysts. They're usually bilateral along with occur with pregnancy as well as in molar pregnancies. They might be also related to clomiphene citrate, hMG/hCG ovulation induction and the use of GnRh analogues. Sometimes, theca lutein cysts may acquire very large size (upto 30cm) and become multicystic and regress spontaneously. Functional cysts often gradually regress or resolve either spontaneously or with hormonal suppressive therapy within 8 weeks. You don't have to get rid of ovaries in the event of functional ovarian cyst.

Laparoscopic management of ovarian cyst

Management of benign appearing adnexal masses are required to follow a protocol which includes obtaining cytology of pelvic and cyst fluid, possible frozen portion of a biopsy specimen, and removing the mass for histologic examination. Aspirating a cyst and vaporizing or coagulating the capsule are acceptable alternatives.

Laparoscopic management of adnexal masses depends on the actual patient’s age, pelvic examination, sonographic images and serum markers. A large solid, fixed or irregular adnexal mass associated with ascites is concered about malignancy. Cul de sac nodularity, ascites, cystic adnexal structures, and fixed adnexae occur with endometriosis and ovarian malignancy.

Laparoscopic ovarian cystectomy

Laparoscopic ovarian cystectomy should be done in such a way that the cyst doesn't rupture and with minimal trauma towards the residual ovarian tissue. When the ovarian cysts is very large, the cyst fluid can be aspirated with laparoscopic aspiration needle to minimize spillage and facilitate its removal. The suction irrigator system cuts down on the spillage by inserting the suction irrigator probe to the cyst.

However, many cysts rupture during manipulation. The aspirate is sent for cytologic examination. The ovary is then freed from the adhesions to the lateral pelvic wall, uterus or bowel. The cyst and pelvis are usually irrigated continuously. Probably the most dependent portion of the cyst wall is opened with the help of bipolar forceps and scissors and also the internal surface is inspected. If excrescence or papillae are simply, the specimen is sent for frozen section. The capsule is stripped from the ovarian stroma using two claw forceps. Bipolar forceps is used to control. Oophorectomy should be done in the event of large ovarian cyst where no identifiable ovarian cortex is seen.

Ectopic pregnancy

The incidence of ectopic pregnancy is increasing now-adays. It's been attributed to several factors such as increases in sexually transmitted diseases, increase in reversal of tubal sterilization and assisted reproductive technology. Laparoscopy has replaced the laparotomy for the surgical management of ectopic pregnancy, because this is assigned to less trauma, faster recovery, fewer adhesions and better results.

Salpingotomy

In a case of ectopic pregnancy if the fallopian tube is unruptured, then salpingotomy ought to be done and fallopian tube ought to be preserved. Sometimes ectopic pregnancy can be seen laparoscopically along the way of abortion with the fimbrial end with homoperitoneum. In such cases the blood from the peritoneum ought to be removed with a good suction canula and the products can be taken off from the tubal end with the help of hydrodissection and sometimes by grasping the products with grasper. In such instances also tube should not be removed.

Standard operative laparoscopy is performed with two standard 5mm ipsilateral ports on surgeon’s side, one 5mm port about the right side and infraumbilical port for the laparoscope. Along side it, size ectopic pregnancy and the tubal status are assessed thoroughly. We prefer to instill dilute vasopressin (1 amp in 100ml saline) within the mesosalpinx and also the antimesentric border of the unruptured ectopic pregnancy. Uterus is anteverted with manipulator. The proximal part of the tube near to the ectopic pregnancy is held by ureteric grasper within the left lower port with a monopolar point electrode at 40-60 watts of pure cutting current, an optimum incision is created about the tubal seromuscular area. A suction irrigation is positioned within the plane between your tubal mucosa and ectopic pregnancy sac first irrigation at ruthless separates the ectopic pregnancy from surrounding tubal mucosal attachment and then immediately suction is put on the ectopic pregnancy sac which usually comes out effortlessly. Occasionally one has to grasp products of conception when they are stuck towards the tube and gently remove out of the tube. Bleeding from incised area is coagulated with bipolar Kleppinger at 25-30 watts. We avoid closing the opening within the tube with suture or bipolar glueing both margins.

Laparoscopy salpingectomy

If salpingectomy is required, as with case of ruptured ectopic tube or when future fertility is not a matter of concern proximal area of fallopian tube is coagulated and cut. We would rather use Kleppinger bipolar forceps at 25-30 watts and scissors to cut tube and mesosalpinx. One should remember that the tube ought to be coagulated carefully, flushed to the tube, to prevent the damage to the ovarian blood supply. The particular excised tube is then sent for histopathology, using the products of conception. A thorough peritoneal wash is given with saline to remove the residual thrombus and the scattered products of conception. The ovary shouldn't be removed.

Tubo-ovarian abscess

The entire abdominal cavity is thoroughly rinsed with irrigating fluid to get rid of blood, pus and debris. Using a blunt dissection probe, omentum, small bowel and large bowel are carefully dissected in the pelvic structures. Irrigating fluid helps you to develop dissection planes between bowel and pelvic structures. When the abscess cavity is entered, immediately the entire cavity is rinsed to prevent contamination. The adnexal structures are then dissected free. As these adhesions are filmy and avascular, scissors dissection is rarely necessary. After separating all the adhesions, the abscess cavity is taken away having a tissue grasping forceps and claw forceps. 1-2 liters of fluid is left inside the abdomen to reduce the postoperative adhesive disease.

Torsion of ovarian cysts

Adnexal torsion is a surgical emergency. If detected early, the torsion could be untwisted. When the diagnosis is delayed, the cyst becomes haemorrhagic, necrotic and ischaemic. If the affected structures regain colour after untwisting indicating viability of the organ then you don't have to remove adnexa and the cyst should be aspirated in the event of functional ovarian cyst and cystectomy ought to be performed in other cases of ovarian cyst. The uteroovarian ligament should be shortened by continuous suture using vicryl 1-0 to avoid further torsion from the ovary. Too much delay causes gangrenous changes in the cyst which are irreversible along with a salpingooophorectomy is advocated. What causes ovarian or adnexal torsion include paraovarian cysts, functional and pathologic ovarian cysts, ovarian hyperstimulation, ectopic pregnancy and adhesions.

Endometriosis

Endometriosis is commonly defined as presence of endometrium at places other than the standard uterine cavity. This article will evaluate the surgical choices for treating endometriosis having a specific reason for enhancing fertility and relieving pain. Endometriosis is really a progressive often debilitating disease affecting 10 to 15% of women during reproductive years. Management of this disease is determined by age, extent from the disease, severity of symptoms and also the desire to have fertility. Intervention is generally indicated for pain, infertility or impaired function of bladder, ureter or intestine. The disease is generally restricted to pelvis and lower abdominal organs. Susceptible tissues and organs are ovaries, uterosacral ligaments, broad ligaments, cardinal ligaments, peritoneum from the lower anterior abdominal wall, urinary bladder, round ligaments, rectovaginal pouch, rectum, sigmoid colon and ureters

The classical triad of dysmenorrhoea, dyspareunia andinfertility is the characteristic of the disease. Bimanual pelvic examination may reveal tender uterosacral ligaments, cul-de-sac nodularity, induration from the rectovaginal septum, fixed retroversion from the uterus, adnexal masses and pelvic tenderness. The classical lesions of endometriosis are pigmented lesions and can be viewed as red, purple, raspberries, blue berries, blebs and peritoneal pockets. The nonpigmented type of endometriosis appears as clear vesicles, pink vascular patterns, white scarred lesions, yellowish brown patches and peritoneal windows. Early lesions result from proliferation of retrograde menstrual tissue and forms superficial implants and sometimes they become inactive or penetrate deeper and be deep implants. Endometrioma (chocolate cyst) can also be seen as large ovarian cysts.

Diagnosis

CA125 is found to become elevated on this condition and ultrasound may diagnose chocolate cyst of ovary as enlarged cysts with uniform granular hypoechoic fluid collection. Colour Doppler may demonstrate flow around although not inside the endometriotic cyst.

Operative laparoscopy

It commences by lysing adhesions in between bowel and pelvic organs. The primary step of surgery for endometrioma is how the ovaries are dissected from culdesac or pelvic side wall very cautiously attempting to avoid spillage from the chocolate material whenever possible. The tubes are free of adhesions. Endometrial implants and endometriotic cyst lining are resected or vaporized with bipolar coagulation of 30-40 Watts. In patients with significant pelvic pain, laser uterosacral nerve ablation (LUNA) or presacral neurectomy is conducted together with treatment of the main disease from time to time if pain is significant. Lesion could be excised in the peritoneum and draining the chocolate material. Subsequently the peritoneum could be shaved off and fulguration is performed. Hydrodissection is advantageous to recognize and develop dissection plane. Peritoneal implants ought to be destroyed within the most effective and least traumatic manner to minimize postoperative adhesions. The incidence of genitourinary endometriosis is reported in 1-11% of ladies diagnosed with endometriosis. Bladder lesions are excised just as as peritoneal disease then cystoscopy to rule out mucosal involvement. All the peritoneum over bladder is totally removed, peritonealisation happens in up to fourteen days.

Malignancy

From time to time, severe atypia is reported in females with ovarian endometriosis. Adenocarcinoma, adenocanthoma, clear cell carcinoma, and endometrioid carcinoma would be the most common malignancies related to atypical ovarian endometriosis. The cyst wall should be sent for histopathological examination and pathologists should emphasize foci of atypical endometriotic epithelium in their reports.

Radical surgery

Hysterectomies with bilateral salpingo-oophorectomy are pointed out for patients with severe symptoms who have not taken care of immediately any other type of treatment and are not thinking about pregnancy. Bilateral oophorectomy must be performed to get rid of the estrogen that sustains and energizes the ectopic endometrium. These days the laparoscopic surgery has substituted the traditional surgery, as laparoscopic surgery provides all of the benefits of minimally access surgery. An over-all surgeon should be familiar with common gynaecological surgical procedures which may be done laparoscopically to provide all of the possible benefits of laparoscopic surgery to the affected person.