Case: 26 year old G0 has a pelvic evaluation (laparoscopy and hysteroscopy) to identify and treat a possible pelvic factor that is reducing her fertility. Following surgery, the fertility surgeon stated that the only abnormal finding was minimal endometriosis on the ovaries and adjacent fallopian tubes, which was removed using a CO2 laser (with char free ultrapulse power settings). Following surgery the woman has significant lower back pain for several days.
Question: What could account for this sudden yet transient increase in lower back pain?
Answer: Lower back pain can be due to many different conditions.
If a great deal of surgery was performed behind the uterus, within or around the cul de sac of Douglas, then the inflammation of healing can cause a generalized lower back discomfort.
If the patient is repositioned on the operating room (OR) table in such a manner that the buttocks are extending well beyond the end of the table then the lower back may become acutely flexed and the woman may have postoperative lower back pain.
If intraoperative bleeding occurs and hemostasis (control of bleeding) is not completely achieved then free blood that may pool in the pelvis behind the uterus may cause inflammation and lower back pain. Free blood in the abdomen or pelvis more often causes a generalized abdominal discomfort.
Nonsteroidal anti-inflammatory agents are generally effective in any of these clinical situations. Most fertility surgeons take great care to avoid hyper-flexing the patient’s lower back when positioning her on the OR table and control any abdominal or pelvic bleeding meticulously.
Case: 36 year old G0 has a pelvic evaluation (laparoscopy and hysteroscopy) to identify and treat a pelvic factor that may be associated with her reduced reproductive potential (fertility). Following surgery she notices that it is very difficult for her to move her left arm or hold anything in her left hand (like a cup of coffee).
Question: How might this sudden onset of weakness in the left arm be associated to her surgery?
Answer: The patient’s left arm may be positioned during her surgery either at her side or extended outward and placed onto an arm board.
Most fertility surgeons who perform laparoscopic pelvic surgery will place the patient into Trendelenburg’s position (in which the head is lowered and the rest of the body and legs are on an inclined plane upwards) during the operative laparoscopy. This allows the intraabdominal organs such as bowel to move upward out of the pelvis toward the top of the patient’s abdomen.
When a patient is moved into Trendelenburg’s position she may move along the OR table (under the force of gravity) toward the top of the table. As the patient moves on the OR table, the arm boards that hold the arms in place may become dislodged and force the arm into an unusual (hyper-extended) position.
Alternatively, if the arm is extended outward on the side (of the patient) that the surgeon stands on while (s)he operates, then the surgeon may inadvertently lean on the arm during surgery to cause it to become hyper-extended.
Whenever the arm is hyper-extended the Brachial nerve may be damaged as it courses through the shoulder. This damage to the Brachial nerve may result in weakness of the arm and hand such as is described in this case. The nerve often recovers somewhat slowly within several weeks of the damage. If there is a suspicion of damage to a nerve, then a neurological consultation is generally in order.
Positioning the patient’s left arm at her side rather than extending the arm during laparoscopic fertility surgery should avoid many of these sorts of injuries.
Case: 40 year old G1 P1 has difficulty ambulating (walking) immediately following an operative laparoscopy for lysis of pelvic adhesions and vaporization of moderate (stage III) endometriosis. The difficulty with walking is associated with difficulty picking up the right foot (the right foot appears to be dragging on the floor when walking).
Question: Why would a postoperative woman have this problem with walking after an operative laparoscopy?
Answer: The common peroneal nerve is the motor nerve of the leg that allows dorsiflexion of the foot (flexion of the foot at the ankle with movement of the toes of the foot toward the shin bone). This nerve usually is located along the lateral (outer) aspect of the lower leg (over the fibula bone).
The legs are commonly placed into stirrups during operative laparoscopy. The use of Allen’s stirrups with soft padding helps to cushion the lower legs and reduces the pressure on the lateral and posterior calf muscles. Careful positioning of the legs within the Allen’s stirrups further reduces the chance of damage to the peroneal nerve (or the lateral aspect of the lower leg).
When the common peroneal nerve is damaged the patient may develop “foot drop.” Foot drop is due to an inability to dorsiflex the foot at the ankle, so that the foot looks like it is dragging. Foot drop in this clinical context often resolves spontaneously within a few days.
Case: 25 year old G0 with a well defined rounded filling defect within the uterine cavity on hysterosalpingogram undergoes an operative hysteroscopy to remove the mass. A continuous flow system and resectoscope is selected to perform the surgery.
Question: What are the advantages of a continuous flow system for operative hysteroscopy?
Answer: The continuous flow of distending media through the uterine cavity is very useful to clear the uterus of tissue fragments, blood, and debris whenever performing operative hysteroscopy.
If a continuous flow system is not used for operative hysteroscopy, then blood and tissue fragments usually collect in the cavity and the surgeon’s visibility can be tremendously reduced.
The type of distending medium used during operative hysteroscopy can also be very important. Each of the available solutions has a set of advantages and disadvantages. Most of the significant disadvantages of a solution that is used for operative hysteroscopy relate to the potential complications that are associated with absorption of the fluid into the patient’s circulation during the procedure.
Case: 38 year old G0 is undergoing a pelvic evaluation (laparoscopy and hysteroscopy) during her infertility evaluation. Following hysteroscopy the surgeon’s attention is directed toward the abdomen (and the laparoscopic portion of the procedure). A Verres needle is passed into the abdominal wall at a level immediately below the umbilicus (belly button) yet proper placement of the Verres needle with the tip inside the abdominal cavity cannot be confirmed.
Question: If the proper placement of the tip of the Verres needle cannot be confirmed what acceptable options are available to the surgeon?
Answer: Proper placement of the Verres needle in the abdominal wall is sometimes difficult to confirm. There are several techniques available to confirm that the tip of the needle is within the abdominal cavity. If these tests are performed and proper placement cannot be confirmed then the surgeon should not proceed with the case (insufflation of the abdomen with CO2 gas).
The Verres needle can be removed and a second entry into the abdominal cavity may be attempted. If the surgeon repeatedly is unable to confirm proper placement, then an alternative method of entry should be considered.
An open laparoscopy is one in which the skin is incised with a scalpel and this incision is then carried down through the subcutaneous fat to the fascia. The fascia is opened and this incision is then further carried down through the preperitoneal fat to the peritoneum. The peritoneum is then opened and the laparoscopic trocar can be placed under direct visualization. The skin incision with an open laparoscopy is generally a little larger than with “closed” or conventional laparoscopy.
It is possible that a laparoscopic entry cannot be safely accomplished with any available technique due to the specific characteristics of the abdominal wall and the presence of underlying (bowel) adhesions. In these situations, a laparotomy is required for entry into the abdomen.
The possibility of a difficult or impossible abdominal entry via laparoscopy should ideally be reviewed preoperatively, especially when the surgeon anticipates difficulty. The patient’s desire to precede with laparotomy versus abandon the procedure should be reviewed for elective (non emergency) cases.