McGill University Student Projects - Laparoscopy
by Sophy Yeung, supervised by Togas Tulandi MD, OBGYN.net Editorial Advisor
Reprinted with permission from Molson Medical Informatics Project at McGill University
Note: All laparoscopic pictures reproduced with permission from "Atlas of Laparoscopic and Hysterectomy Techniques" 
(Ed. T.Tulandi), W.B.Saunders, London, 1999. 
(click images for full size)

Glossary of terms will open in a new window by clicking any hyperlinked term.

THE LAPAROSCOPE
The laparoscope is the "camera" with only a diameter of 5-10mm (0.5-1cm) and in a straight rod. It uses a high intensity light, such as xenon or halogen, and 3-chip technology. It is inserted in the abdomen so that the surgical team can observe the inside of the abdomen on a high resolution video screen. The laparoscope is moved to direct the view seen. A video recorder can be used to record the surgery and photographs can be made with a video-printer (see diagram 1).

There is also available three-dimensional display technology that provides depth perception and may help the surgeon to orient.

Minilaparoscopes of diameters from 1.9 to 2.8 mm have also been developed and are renewing the interest in performing laparoscopy under local anesthesia.

TROCARS
Trocar sites are the small entry sites made though abdomen for the entry of surgical instruments. After a small incision is made in the skin, the trocar is the instrument inserted to penetrate the abdominal wall. Trocars of different sizes can create entry sites ranging from 5 to 20mm in diameter. The diameter size depends on whether the removal of a specimen is anticipated and its size (e.g. 15 or 20mm would likely be necessary for the removal of something as large and solid as a uterus).

There are usually three trocar sites (see diagram 3).
The one at the umbilicus (the "belly button") is termed the primary trocar (usually 10mm). It is inserted at a 45° angle from horizontal (to avoid the aortic bifurcation) (in obese patients, the angle can be safely increased). The primary trocar site (after creating a pneumoperitoneum) is where the laparoscope will be inserted into the abdomen. The laparoscope can then be used to observe the inside of the abdomen as the other (secondary) trocar sites (usually 5mm) are penetrating through. This is to ensure no major blood vessel is hit or other inadvertent injury happens. The secondary sites are often above the pubic hair line.

PNEUMOPERITONEUM
The abdomen is distended with carbon dioxide gas (see diagram 3) to create a space for surgical procedures and better visualization of organs. An abdomen inflated with gas is termed a pneumoperitoneum. Carbon dioxide gas is infused under pressure through the primary trocar site; usually 2 to 3 L is adequate. The pressure inside the abdomen should not exceed 20mmHg. The trocar sites can be kept sealed with valves to maintain the pneumoperitoneum (so air does not leak out). However, valves can interfere with frequent insertion and removal of surgical instruments, so they are not preferred in the secondary trocar sites. Thus, a high flow insufflator that administers up to 10 L of gas per minute is necessary to maintain the pneumoperitoneum.

SUCTION IRRIGATOR
A suction-irrigator (see diagram 4) is invaluable to laparoscopic surgery. The irrigator can effectively deliver pressure of up to 800 mmHg, which can be used to separate tissues, adhesions, or to flush out an ectopic pregnancy from the Fallopian tube.

Treatment of Ectopic Pregnancy 1: Salpingostomy

Salpingostomy remains the most definite treatment of ectopic pregnancy, despite the increasing popularity of methotrexate treatment.

This procedure requires three trocar sites. One of the secondary sites is 10mm for removal of the specimen.

SALPINGOSTOMY: INSPECTION
Because a hemoperitoneum could be encountered, to avoid staining the lens with blood, the laparoscope should be inserted into the abdomen slowly (see diagram 6).

If there is a hemoperitoneum, a suction-irrigator can suck out the blood and then irrigate the pelvic organs with physiological saline or Ringer's lactate solution, which essentially "bathe" the organs (see diagram 7).

Observe to ensure that the irrigating solution is free from blood. This is termed "under-water" inspection, which can allow identification of bleeding points. If bleeding is observed, hemostasis is necessary.

Once visibility is ensured, the ectopic pregnancy is now to be identified (see diagram 8).

SALPINGOSTOMY: INCISION
A needle is used to inject a solution of vasopressin (which constricts the blood vessels to minimize bleeding) into the Fallopian at the site of the ectopic pregnancy (see diagram 9).

A 10-15mm incision is made longitudinally (along its length). Either laser, unipolar needle electrocautery or scissors can be used for cutting (see diagram 10).

The ectopic pregnancy inside the Fallopian tube can then be seen (see diagram 11).

SALPINGOSTOMY: FLUSHING AND EXTRACTION
The ectopic pregnancy is flushed out with high-pressure irrigation (see diagram 12).

The specimen is removed by grasping it with a "claw" forceps, or placed in a bag that can automatically open inside the abdomen, and then removed from the abdomen (see diagram 13 and 14).

SALPINGOSTOMY: HEMOSTASIS AND HEALING
Bleeding points should then be inspected for, which can be coagulated with micro-bipolar forceps. If the bleeding persists, sutures (stitches) might be needed in the mesovarium (see diagram 15).

The incision in the tube is left open to heal (by secondary intention).

Before concluding the operation, approximately 0.5 to 1 L of Ringer's lactate solution in the abdomen is used to inspect "under water" for absence of bleeding.

SALPINGIOSTOMY VIDEO 

This laparoscopic salpingostomy video demonstrates the incision of the ampullary wall with unipolar needle electrocautery at the site of the ectopic pregnancy, followed by suction-irrigation, flushing out of the products of conception and extraction with claw forceps.

Treatment of Ectopic Pregnancy 2: Salpingectomy

If the ectopic pregnancy has ruptured or bleeding persists, salpingectomy is an option. This procedure involves excision of segment of the Fallopian tube involved in the ectopic pregnancy. The tubal segment to be removed is coagulated (see diagram 16) and cut off with bipolar forceps (see diagram 17 and 19). The mesovarium is also coagulated and cut off in the same manner (see diagram 18).

Copyright Molson Medical Informatics Project at McGill University - 2000