The operating room setup varies to some extent. Each OR (and each surgeon) has their own “routine” which they are comfortable with. I will present my routine for comparison sake.
The positioning of the patient is important so as to avoid musculoskeletal and neurologic complications. I position a woman for pelvic evaluation (hysteroscopy and laparoscopy) with the buttocks slightly (few centimeters) extending beyond the end of the table (after the foot of the table is lowered or removed). The back of the woman is viewed to assure that it is flat on the table once her legs have been placed in Allen's universal stirrups at this position. If the back is acutely flexed, the woman is repositioned to avoid postoperative lower back discomfort. I routinely tuck the patient's left arm at her side since I always stand on the left and if the arm is extended and placed on an arm board then (brachial) nerve damage is possible if the arm board becomes dislodged or I inadvertently lean on the arm board during the case. I also tape the left hand's fingers into a fist to avoid injury when the foot of the bed is raised at the end of the case. No joint in the leg is flexed over 60 degrees to avoid (femoral) nerve compression (associated with extreme flexion, abduction, and lateral rotation at the hip). I also am very careful to avoid excessive pressure on the lateral aspect of the lower legs within the Allen's stirrups (which helps avoid peroneal nerve damage and “foot drop”). I generally like the thigh of the leg to be roughly parallel to the floor when the table is flat to allow for greater range of motion of instruments entered into the lower laparoscopic ports. The patient is then prepped (including placement of a foley catheter) and draped in the usual sterile fashion.
I begin my pelvic evaluation for infertility with a hysteroscopy. The visibility with the continuous flow systems is often far superior to other systems (partially because the cavity can be flushed of endometrial debris if present) and I have not had difficulty with the additional dilatation of the cervix that is required for the entry of a continuous flow hysteroscopic system. Therefore, I routinely use a continuous flow hysteroscope. I dilate the cervix and place the hysteroscope into the cavity (using a safe routine that I have established) once the equipment has been assembled (and checked).
The selection of the uterine distending medium for continuous flow hysteroscopy is very important.
I use 5% Dextrose in Water (D5W) as my standard solution since it is an accepted intravenous (IV) solution, it is nonionic (can not carry an electrical charge), there is extensive clinical experience with it as an IV solution, I have found no reports in the world literature of serious morbidity or mortality attributed to the use of D5W when used for hysteroscopy, and the osmolarity of the solution (about 250 mOsm/L) is relatively close to that of blood serum (about 290 mOsm/L).
Additional acceptable hysteroscopic solutions include other non-ionic hypo-osmolar low viscosity fluids (1.5% Glycine or Sorbitol), electrolyte containing ionic iso-osmolar solutions (Normal Saline (NSS) or Ringer's Lactate (RL)) and non-ionic hyper-osmolar solutions (32% Dextran 70 = Hyskon).
Ionic solutions such as NSS and RL can carry an electrical charge and therefore cannot be effectively used when a resectoscope (the electrical operative hysteroscopy instrument that I use) is used for electrical operative hysteroscopy.
1.5% Glycine is a commonly used standard hysteroscopic distending medium. 1.5% Glycine is a nonionic solution with an osmolarity (200 mOsm/L) that is less than D5W or serum. Glycine has an intravascular half life of about 85 minutes after which it is absorbed intracellularly. Hyperammonemia due to oxidative deamination in the liver and kidneys is associated with the use of glycine, which can cause encephalopathy. Additionally, an occasional patient may have a decrease in visual acuity (or temporary blindness) possibly due to the effect of glycine as an inhibitory neurotransmitter in the retina. These complications appear to be proportional to the absorption or intravasation of Glycine into the circulation and limit the volume of use of this distending medium.
Sorbitol (2.7%) and mannitol (0.54%) are 6 carbon alditol isomers that are commercially available together in solution (“Cytal”). This solution has a lower osmolarity (178 mOsm/L) than 1.5% Glycine or D5W. The Sorbitol is metabolized in the liver to fructose and glucose while the mannitol is mainly filtered through the kidney and excreted unchanged in the urine. One disadvantage for the use of Cytal is caramelization of the sugars during electrocautery.
32% Dextran 70 is a syrup like slick solution with a high osmolarity. This solution draws free water into it (able to draw in greater than 4-6 times its own volume) so the volume used must be highly restricted to avoid volume overload. Typically, one will restrict the total volume used to 250-500cc. Uncommon but very serious potential complications of Dextran include ARDS, DIC, anaphylactic shock and renal failure. This solution is not often used for operative hysteroscopy today.
Whenever one of the hypotonic distending media (D5W, 1.5% Glycine, Sorbitol) is used for continuous flow hysteroscopy there must be an accurate and continuous tabulation of the amount of solution going into the hysteroscope and the amount of solution returning from the hysteroscope. The hypo-osmolar low viscosity fluids all have the potential for causing excess “free water” (proportional to their degree of hypo-osmolarity) and water intoxication if intravasated (or absorbed) in volumes that exceed the body's ability to excrete the excess water load.
Generally, for every liter (1000 cc) of D5W infused IV the expansion of the extracellular volume in the circulation is about 83 cc (due to distribution of the volume into the various body spaces), which decreases the plasma osmolarity by about 2%. The body's reaction to even this small decrease in osmolarity is to completely suppress the antidiuretic hormone (ADH) release from the brain's pituitary gland and cause a maximal water diuresis (usually greater than 750 cc of urine per hour).
Once the hysteroscopic portion of the case is completed, I request a final tabulation of inflow and outflow volumes for the distending media.
I direct my attention to the laparoscopy once the hysteroscopy is complete. A uterine manipulator is placed through the cervix. I typically invert the umbilicus and insert a Verres needle through this site (while holding up the umbilicus). Alternative sites for Verres needle insertion (rarely used) include the left infracostal midclavicular line or the left periumbilical midclavicular line. Insufflation of the abdomen with CO2 gas so as to create a pneumoperitoneum is accomplished after “confirming the proper placement” of the Verres needle. Note that absolute certainty of placement of the Verres needle is not possible given the blind nature of its entry. Many of the laparoscopic injuries that occur do so at the time of Verres needle insertion. Failure to achieve an adequate pneumoperitoneum is the most common reason for procedural failure.
Once the pneumoperitoneum is created, the Verres needle is replaced by a trocar and sleeve. Again, the trocar insertion is blind and the direction of insertion is typically towards the hollow of the sacrum. The diameter of the umbilical (main) trocar is 10-12 mm so that this instrument can cause considerable injury if not placed properly and atraumatically into the abdominal cavity. The presence of adhesions (scar) that elevates the bowel to the anterior abdominal wall is a consistent source of concern for laparoscopic surgeons. I always try to enter the trocar through the abdominal wall (while holding the inverted umbilicus up with clamps) so that the tip of the trocar and its outer sheath are just inside the inner abdominal wall and then confirm an atraumatic entry with the laparoscope before going on.
If abundant adhesions are anticipated such that the surgeon believes that the complication rate with the blind Verres needle and trocar insertion is unacceptably high, then “open laparoscopy” may be chosen. Hasson introduced this technique in 1971, in which the direct insertion of the trocar without the creation of a prior pneumoperitoneum is accomplished by performing a cut down under direct observation of the layers of the abdominal wall. Suture holds the layers of the inner abdominal wall (fascia and peritoneum) to the trocar sleeve to prevent the release of gas through the incision site during the case. Extreme care must be exercised in making the peritoneal incision since bowel injury to adherent bowel may occur under direct observation as well.
Accessory trocar sites are usually required during the laparoscopic case. Typically I use two additional sites for placement of 5 mm (or uncommonly 10 mm) trocars in the suprapubic midline and left lower quadrant. All accessory trocars have the advantage of being able to be inserted under direct observation so injury is less common. One injury associated with placement of the accessory trocars is laceration of the deep inferior epigastric vessels within the abdominal wall (which may be difficult to see either directly or via transillumination). Injury to the inferior epigastric vessels can be consistently avoided by placement of the additional trocars either lateral to the internal inguinal ring or medial to the umbilical ligaments (two structures that are usually easy to identify under direct laparoscopic observation).
Tools that are selected for the performance of the laparoscopic surgery should allow the surgeon to minimize postoperative adhesion formation. The surgical principles as discussed above are very important in terms of achieving the desired outcome. Gentle tissue handling during laparoscopy takes a great deal of time to develop. Avoidance of bleeding with gentle tissue handling is important and so is careful hemostasis using (selective) bipolar cautery. Continuous irrigation and aspiration of the tissues to remove char and minimize drying should be second nature to the laparoscopic infertility surgeon. Use of cutting instruments that minimize lateral tissue damage is also a primary concern.
Once the case has been completed, the instruments are removed from the abdomen allowing for the efflux of CO2 gas. I usually take an additional 5 or so minutes to move the abdominal wall and contents about with only one remaining trocar sleeve in place to try to allow any trapped gas to escape. Incisions are closed with subcuticular stitches so as to avoid cosmetically unpleasant “railroad” type skin scars. The fascia is closed on any incision in the fascia greater than 5 mm.
In the immediate postoperative recovery time period, common problems include:
- Nausea and vomiting, most likely related to the CO2 gas or the narcotic pain medications used perioperatively. Zofran is often the most effective anti emetic agent for post laparoscopic vomiting. The nausea and vomiting does not typically persist for more than 12 hours postop.
- Shoulder pain, due to retained CO2 gas which if trapped under the diaphragm (at base of the lungs) causes irritation of the phrenic nerve to cause the sensation of shoulder pain. Lying on one's abdomen with a pillow under the hips and lower abdomen (or the knee chest position) may allow the CO2 gas to recollect in the pelvis rather than under the lungs and reduce this discomfort.
- Subcutaneous crepitance, crackling under the skin over the abdomen and extending superiorly to the chest and neck or inferiorly to the buttocks and thighs. Typically this is a minor complication due to escape of the gas into the abdominal wall. A rare patient develops a very low blood pressure (not related to blood loss) and usually responds immediately to a bolus of IV solution.
- Incisional pain, usually mild but the internal (visceral) pain after surgery can be intense and may require narcotics or anti inflammatory agents. Reportedly a heating pad applied to the abdomen may also be helpful.
- Leakage of fluid, if a large volume of fluid is left in the abdomen at the conclusion of the case (I rarely leave this fluid here but some surgeons do this as a routine) then leakage through the incision sites is common for up to 2 days.
- Postoperative urinary retention, which occurs more often in cases that last longer than 2 hours. If the patient is not able to void within 4-5 hours postop (and after removal of the foley catheter) then she should be straight catheterized for the residual volume of urine and she should try to void spontaneously once again. I do not allow my patients to go home until either they can void spontaneously or they have an indwelling foley catheter placed (for about 1 day).
The surgeon should be called if there is a fever (greater than 100 degrees) or chills, heavy or prolonged vaginal bleeding, heat or swelling of the incision sites, frequency or burning on urination, severe pelvic pain, persistent nausea or vomiting, faintness or dizziness, inability to spontaneously urinate.
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