Laparoscopic Adnexal Surgery

Fig. 3.1

The first surgeon stands to the left of the patient, raised above a platform for proper ergonomics in order to reduce arm muscle fatigue

3.3 Placement of the Trocars

Usually, the first trocar is placed through the umbilicus, but other positions may be explored according to the largest diameter of the adnexa or previous interventions. Different techniques may also be adopted for the insertion of the first trocar, such as the Verress needle, optic trocars, direct trocar, or open access. The diameter of the first trocar may vary between 5 and 10 mm; this is related both to the diameter of the optic and the need to use an endobag large enough to remove the adnexal cyst or adnexa.

Regarding ancillary trocars, we prefer to use three 5-mm trocars because the main instruments for all laparoscopic procedures are frequently 5 mm. Whatever the caliber, in each case the positioning of these trocars at the lateral side of the pelvis and the suprapubic position must always be controlled. At the time of accessory trocar placement, injury of the inferior epigastric vessels can cause bleeding that can be difficult to control. These deep vessels of large diameter cannot be viewed through the transillumination of the wall, which shows only the superficial epigastric vessels. Only palpation of the wall exposing the edge of the rectus abdominis muscle and laparoscopic visualization of this area allow the surgeon to choose the exact point for good trocar placement. The trocar should be introduced perpendicularly to the wall under visual control. The third trocar is introduced at the midline height of the two lateral trocar instruments.

3.4 Placement of Laparoscopic Instruments

There is a wide range of existing instruments for laparoscopic adnexal surgery. It is our opinion that only a few tools are reliable and therefore necessary. It is preferable to use an instrument with a handle and no clamping system in order to make the most dynamic movements. In our opinion, the essential instruments to perform laparoscopic adnexal surgery include

Grippers: there are different types of grippers; those with a strong hold on the tip are preferable in the event of enucleation (stripping) of the cyst.
Bipolar forceps: the development and constant search by medical engineering make currently available bipolar forceps completely different than those of the past. The latest generation of bipolar forceps, in fact, allows not only the ability to apply energy to the tissues for hemostatic purpose, but also allows the surgeon to exercise adequate traction. The ideal grasp is one that can be used for the duration of the intervention without the need for replacement and can also be useful to coagulate the ovarian vessels and bed of the cyst.
Forceps: any type of scissors can be used if they ensure continued reliable cutting.
Suction/irrigation system: any model can be used that provides adequate visualization of the surgical field and hydrodissection.

Many other new generation instruments are available for both coagulating, cutting, and handling. The choice depends on the surgeon, the type of surgery, and financial capabilities.

3.5 Surgical Technique

The first steps in laparoscopy involve the creation of the pneumoperitoneum and placement of trocars. When done properly, this greatly facilitates the smooth running of the surgery. After trocars are placed, an assessment of the pelvis, abdomen, and external surface of the cyst is performed for possible evidence of malignancy. Peritoneal fluid or washing is collected for cytologic examination. If necessary, lysis of adhesions is performed to free the adnexa. Once surgery and control of bleeding have been completed, the abdomen is deflated, the ports can be removed, and the incisions closed.

3.5.1 Fallopian Tube Surgery

3.5.1.1 Anatomy

The fallopian tubes are paired and symmetric tubular organs, connecting the body of the uterus with the adnexal region and providing a wide area for ovum catch. They can measure from 7 to 12 cm in length and up to 3 mm in thickness. These organs are covered by two layers of peritoneum, forming the mesosalpinx. Each tube can be divided into four portions going from the body of the uterus to the peritoneal cavity: the interstitial, the isthmic, the ampullary, and the fimbriated portions. The tubal branches of the uterine and ovarian arteries anastomose in the round ligament, providing branches for the different portions of the tubes passing through the mesosalpinx. The venous and lymphatic drainage follows the uterine and ovarian vessels. Laparoscopy, or in select cases robotic surgery, is currently the gold standard for tubal surgery.

3.5.1.2 Laparoscopic Salpingectomy

Indications

Monolateral salpingectomy is generally indicated in ectopic pregnancy and for salpingo-ovarian abscess. Bilateral salpingectomy is usually indicated in sterilization and in the prevention of ovarian cancer in high-risk patients.

Surgical Procedure

Once the tube has been isolated, it must be lifted and gently held with atraumatic graspers, without injuring adjacent structures. In order to minimize blood loss, all vessels in the mesosalpinx need to be coagulated. Using a bipolar grasp, it is possible to coagulate the proximal portion until no bleeding is noted. Scissors can be used to cut the coagulated portion. This process needs to be repeated serially in order to move from the proximal to the distal portion of the mesosalpinx. In the case of ectopic pregnancy, an endoscopic loop ligation can be performed, followed by cutting the distal tube to the looped portion. Once the distal portion is cut, the tube is freed and can be removed. Instead, it is also possible to use only monopolar scissors electrosurgically, thus coagulating the tube and then cutting it. If available, multifunctional devices can be used to reduce operative time. Irrigation and suctioning of free blood may help check the bleeding control before closing up the incision..

3.5.1.3 Laparoscopic Salpingostomy

Indications

Monolateral salpingostomy is mainly employed in the surgical conservative management of ectopic pregnancy. Patients need to be informed of the approximate 8 % risk of persistent trophoblastic tissue after the procedure and of possible permanent damage to the Fallopian tube. Chances of these adverse outcomes are increased in cases of high levels of beta-human chorionic gonadotropin (usually more than 6,000 IU/L) or large masses (>3.5–4 cm). Only patients with a strong desire for fertility and/or acceptance of only one functioning tube should undergo this type of procedure.

Surgical Procedure

For the removal of an ectopic pregnancy, a solution of vasopressin should be injected. A 1- to 2-cm longitudinal incision at the level of the tube along the ectopic pregnancy opposite the mesosalpinx is then performed using scissors, bipolar or monopolar, or a carbon dioxide laser. Widening the margins of the incisions, the pregnancy can be removed either with suction-irrigation followed by hydrodissection or with smooth grasping forceps. Any specimen must be extracted, preferably through an endobag. Hemostasis should be accurately checked. Irrigation and suction of free blood and tissue debris are recommended in order to prevent persistent trophoblastic tissue.

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