Laparoscopy - Indications and Complications

Indications
1.	Chronic pelvic pain (>6 months) 2.	Acute pelvic pain a.	Suspected ectopic pregnancy b.	Suspected ovarian torsion (N/V, acute pain) c.	Suspected hemorrhagic/ruptured ovarian cyst d.	Postoperative bleeding (e.g. post-TVH) e.	Suspected acute PID 3.	Tubal sterilization 4.	Trying to conceive with male factors and ovulatory factors previously addressed 5.	Operative a.	Hysterectomy b.	Ovarian cystectomy c.	Oophorectomy d.	Endometriosis ablation or resection e.	Hysterosalpingostomy f.	2nd look procedures g.	Burch retropubic urethropexy and/or paravaginal repair h.	Colpopexy – uterosacral/sacral i.	Myomectomy

Complications

 * 1) Inability to visualize pelvis and carry out procedure via laparoscopy
 * 2) Trochar/Verres needle complications
 * 3) Bowel perforation
 * 4) Bladder perforation
 * 5) Bleeding
 * 6) Pulmonary or CO2 embolus
 * 7) Preperitoneal (subperitoneal) CO2
 * 8) Post operative incisional hernias
 * 9) Cautery/Laser/Thermal injury
 * 10) Uterine perforation, bleeding
 * 11) Wound dehiscence/hernia

Prevention of Complications

 * 1) Inability to visualize pelvis and carry out procedure via laparoscopy
 * 2) Perform preoperative mechanical bowel prep
 * 3) Be familiar with open laparoscopy techniques and left epigastric or left upper abdominal insufflation and small (5mm) laparoscope insertion
 * 4) Avoid preperitoneal (subperitoneal) insufflation
 * 5) Make incision the correct size for trochar so as to avoid CO 2 loss
 * 6) Be aware of smoke evacuation techniques
 * 7) Be aware of techniques to clean lens without removing laparoscope from abdomen
 * 8) Trochar/Verres needle complications
 * 9) Bowel perforation
 * 10) Avoid previous midline/vertical incisions for Verees and trochar placement
 * 11) Check for correct working mechanism for shielding of trochar point and blunt trochar of veress
 * 12) Bladder perforation
 * 13) Visualize superior limits of bladder on abdominal peritoneum (instill fluid into bladder if needed)
 * 14) Bleeding
 * 15) Postoperative incisional bleeding/hematoma:
 * 16) Cauterize skin incision bleeding of trochar sites before proceeding with trochar placement
 * 17) Major vessel injury/hemorrhage
 * 18) Be familiar with the anatomy of major vessels in relation to the umbilicus and abdominal wall
 * 19) Hub of trochar needs to remain in sagittal midline plane at a 45-60 degree angle pointed toward the pelvic hollow.
 * 20) Check omentum for bleeding after entry.
 * 21) Pulmonary or CO2 embolus
 * 22) Do not continue insufflating if gas pressure is >10cmH2O.
 * 23) Preperitoneal (subperitoneal) CO2
 * 24) Feel for Verres needle tip free mobility after inserting
 * 25) Do not continue insufflating gas if pressure is >10.
 * 26) Post operative incisional hernias
 * 27) Close fascial defects away from the midline if greater than 5 mm and midline defects if >12 mm
 * 28) Cautery/Laser/Thermal injury
 * 29) Identify and avoid key structures
 * 30) Uterine perforation, bleeding
 * 31) Determine version and flexion position of the uterus
 * 32) Gently sound uterus
 * 33) Gradually dilate internal uterine os to size of uterine manipulator
 * 34) Set guard on uterine manipulator so length of manipulator does not exceed uterine sounding depth
 * 35) Wound dehiscence/hernia
 * 36) Close fascial incisions of > 5 mm off of the midline with suture
 * 37) Close fascial incisions of >10-11 mm in midline with suture