A laparoscope is a type of endoscope. Laparoscopic surgery refers to endoscopic procedures performed within the sealed pelvic or abdominal cavity for diagnostic or therapeutic purposes. Carbon dioxide (CO2) gas is introduced into the cavity to create an operational space, and a laparoscope connected to a cold light source is inserted into the abdominal cavity through a trocar. The laparoscope is connected to an imaging system, which displays the pelvic and abdominal organs on a monitor. When used for disease diagnosis, it is referred to as diagnostic laparoscopy. When surgical instruments are introduced into the pelvic or abdominal cavity through the trocars and manipulated externally to treat conditions under real-time visualization on the monitor, it is referred to as operative laparoscopy.
With ongoing advancements in laparoscopic equipment and surgical techniques, various modern approaches have emerged, including 3D laparoscopy, 4K laparoscopy, laparoendoscopic single-site surgery (LESS), transvaginal natural orifice transluminal endoscopic surgery (vNOTES), and robot-assisted laparoscopy. The appropriate surgical approach should be selected based on specific indications. As a minimally invasive surgical technique, laparoscopy offers advantages such as reduced trauma, faster recovery, less postoperative pain, and shorter hospital stays. It has become a standard treatment modality for managing gynecological conditions.
Indications
These include:
- Acute abdominal conditions (e.g., ectopic pregnancy, ruptured ovarian cysts, ovarian torsion).
- Pelvic masses.
- Endometriosis.
- Evaluation of the cause of unexplained acute or chronic abdominal and/or pelvic pain.
- Infertility.
- Gynecological complications (e.g., locating and removing misplaced intrauterine contraceptive devices or addressing uterine perforation).
- Various benign gynecological conditions with surgical indications.
- Staging surgery for endometrial cancer.
Laparoscopic surgery for cervical and ovarian cancer remains controversial. After thorough preoperative evaluation and with the patient's informed consent, it may be cautiously considered for the surgical treatment of early-stage cervical cancer (lesion diameter <2 cm), comprehensive staging or re-staging surgery for early-stage ovarian cancer, and preoperative evaluation in advanced ovarian cancer.
Contraindications
Absolute Contraindications:
- Severe cardiovascular or cerebrovascular diseases and impaired pulmonary function.
- Significant coagulopathy.
- Strangulated intestinal obstruction.
- Large abdominal or diaphragmatic hernias.
Relative Contraindications:
- Excessively large pelvic masses.
- Pregnancy beyond 16 weeks of gestation.
- Extensive intra-abdominal adhesions.
- Late-stage metastatic gynecological malignancies.
Preoperative Preparation
A thorough medical history is obtained to ensure accurate diagnosis and confirmation of laparoscopic surgical indications.
Preoperative evaluations follow the same protocol as for standard gynecological abdominal surgeries.
Bowel and vaginal preparations align with those for gynecological abdominal surgeries.
Proper preparation of the abdominal skin, with particular attention to cleaning the umbilicus, is performed.
During the surgery, the patient is typically positioned in a 15°–25° Trendelenburg position (head down, pelvis elevated) to facilitate intestinal displacement toward the upper abdomen, thereby improving exposure of the pelvic surgical field.
Anesthetic Options
General anesthesia is commonly employed.
Procedure Steps
Surgical Site Disinfection
Routine disinfection of the abdominal area is performed, and, if necessary, disinfection of the vulva and vagina is also carried out. A urinary catheter is placed. For patients with a history of sexual activity, a uterine manipulator may be inserted vaginally to facilitate surgical procedures. However, for patients with malignant tumors, the use of a manipulator carries a risk of tumor dissemination and should be employed with caution.
Artificial Pneumoperitoneum
The patient is initially placed in a supine position. A skin incision is made at the intended trocar insertion site to accommodate the diameter of the trocar sheath, cutting through the superficial fascia. The abdominal wall is lifted, and a Veress needle is introduced perpendicularly at a 90° angle through the incision into the abdominal cavity. The Veress needle is connected to an automatic CO2 insufflation device to introduce CO2 gas at a flow rate of 1–2 L/min. After insufflating 1 L of gas, the patient is repositioned into the Trendelenburg position (head-down, pelvis-elevated, with an inclination of 15°–25°). Insufflation continues until intra-abdominal pressure reaches 12–15 mmHg, after which the Veress needle is withdrawn.
Inserting the Laparoscope
With the abdominal wall lifted, the trocar is inserted through the skin incision. A sense of breakthrough indicates passage through the fascial and peritoneal layers. The trocar's inner core is removed, and the imaging system and cold light source are activated. The laparoscope is inserted through the sheath into the abdominal cavity. Once pelvic organs are visualized, the CO2 insufflation device is connected, and laparoscopic procedures commence.
Laparoscopic Exploration
The pelvic and abdominal cavity are routinely inspected in an orderly sequence.
Laparoscopic Surgery
Under laparoscopic visualization, additional trocar insertion sites (second, third, and fourth sites) are selected based on the type of surgery and are adjusted to avoid abdominal wall blood vessels. Appropriate surgical instruments are inserted through these trocars for the procedure.
Basic Surgical Skills
Laparoscopic surgery requires the following competencies:
- Thorough knowledge of anatomical structures as visualized laparoscopically.
- Mastery of techniques to track and expose the surgical field with a laparoscope.
- Familiarity with the use of various energy-based surgical instruments.
- Skills in tissue dissection, cutting, suturing, knot-tying, and hemostasis under laparoscopic guidance.
- Proficiency in using specimen retrieval bags to remove tissue.
Principles of Surgical Operation
Adherence to oncological principles (where applicable), asepsis, and minimally invasive techniques is essential. Procedures should follow natural anatomic planes during laparoscopic manipulation.
Completion of Surgery
The pelvic and abdominal cavities are irrigated with saline to check for bleeding or organ injury. If necessary, a pelvic drainage tube is placed. The pneumoperitoneum is released, and the laparoscope and trocar sheaths at all puncture sites are removed. The trocar incision sites are sutured.
Complications and Prevention/Management
Hemorrhagic Injury
Vascular Injury
Injuries may include damage to major vessels, such as the abdominal aorta or inferior vena cava during trocar insertion, or injuries to the iliac or inferior vena cava vessels during lymphadenectomy. Injury to abdominal wall vessels may also occur at the secondary or tertiary trocar sites. Major vascular injuries are life-threatening and require immediate laparoscopic or open surgical intervention for hemostasis and vascular repair. Familiarity with retroperitoneal vascular anatomy, advanced open surgical skills, and proficient laparoscopic techniques can reduce the risk of such injuries.
Bleeding in the Surgical Field
This is the most common complication in laparoscopic surgery, particularly during hysterectomy or surgery for severe endometriosis. Surgeons should have an in-depth understanding of anatomy and surgical techniques, as well as expertise in using energy-based devices and instruments.
Nerve Injury
Nerve Injury caused by Improper Positioning
Excessive flexion or external rotation of the hips in the lithotomy position can result in injury to the femoral or sciatic nerves and their branches. Pressure from the surgeon leaning on the patient's abducted arm can cause injury to the brachial plexus and its branches. Positioning the patient correctly while awake or adducting the arms can mitigate such risks.
Nerve Injury caused by Improper Operation
Examples include obturator nerve or genitofemoral nerve injury during pelvic lymphadenectomy or lumbar sympathetic trunk injury during para-aortic lymphadenectomy. Obturator nerve injury is the most common; if the nerve is partially or completely severed during surgery, tension-free end-to-end anastomosis should be performed immediately.
Organ Injury
Injuries may involve organs adjacent to the reproductive tract, such as the bladder, ureters, or intestines. These injuries are often caused by abnormal anatomy due to surrounding tissue adhesions, improper use of energy devices, or lack of surgical proficiency. Any injuries should be repaired promptly to prevent further complications.
Pneumoperitoneum-Related Complications
These include subcutaneous emphysema and pneumothorax. Subcutaneous emphysema often resolves spontaneously without specific intervention. Pneumothorax is rare but, if identified during surgery, requires immediate cessation of gas insufflation and evacuation of thoracic gas through the existing trocar site. In severe cases, closed thoracic drainage may be necessary. Some patients may experience abdominal discomfort and shoulder pain after surgery due to CO2 stimulation of the diaphragm, which typically resolves within a few days.
Other Complications
Incision-Related Issues
These include incision dehiscence and incisional hernias.
Port Site Metastasis (PSM)
PSM may occur due to contamination of the trocar site during surgical manipulation or specimen retrieval, or dissemination caused by pneumoperitoneum pressure. This may result in implantation of endometrial or tumor cells at the trocar site.
Postoperative Infection