Gynaecological endoscopy and minimally invasive surgery
Introduction
This domain covers laparoscopic and hysteroscopic access, equipment and energy, indications, and the recognition and management of endoscopic complications.
Laparoscopic access
- Veress needle at the umbilicus in slim women, Palmer's point (left subcostal) after previous midline surgery, and open Hasson entry when adhesions are expected.
- Confirm entry with the saline drop test and by insufflation pressure; intra-abdominal pressure 12–15 mmHg; CO2 is standard because it is non-flammable and rapidly absorbed.
- Entry complications: major vessel injury (rare but lethal), bowel or bladder perforation, surgical emphysema and CO2 embolism.
Operative laparoscopy
- Energy: monopolar for cutting with caution near bowel and ureter, bipolar for vessel sealing, advanced bipolar and ultrasonic devices for pedicles.
- Hysterectomy types by ureteric dissection: type I to the infundibulopelvic ligament, type II to the uterine vessels, type III partial parametrectomy with ureter mobilised, type IV total with the ureter completely dissected.
- Ureteric injury complicates roughly 0.5–1% of pelvic operations; suspect it with flank pain, urinoma, rising creatinine or watery vaginal discharge.
Hysteroscopy
- Vaginoscopy or speculum with tenaculum; distension with 0.9% saline for bipolar surgery, glycine or sorbitol for monopolar.
- Fluid deficit limits: stop at 1000 mL with hypotonic media and 2500 mL with saline; use a fluid-management system.
- Complications: perforation, bleeding, fluid overload with hyponatraemia (TURP-like syndrome) and gas embolism. Manage hyponatraemia by stopping the procedure and restricting fluid; furosemide only if symptomatic.
- Common procedures: polypectomy, myomectomy, adhesiolysis, endometrial resection.
Worked example
During laparoscopic hysterectomy, bleeding starts from the pelvic side wall after bipolar sealing. The field is obscured, so the surgeon converts to laparotomy and finds a ureter divided 3 cm above the bladder. Management is intraoperative recognition, urology involvement, stenting or reimplantation, and full documentation. Conversion is a judgement, not a failure.
Traps
- Assuming a normal creatinine excludes ureteric injury in the first days.
- Continuing hysteroscopy after the fluid deficit limit is reached.
- Using monopolar energy close to bowel.
- Forgetting thromboprophylaxis and antibiotic prophylaxis in prolonged procedures.