Practical Manual of Minimally Invasive Gynecologic and Robotic Surgery

A Clinical Cook Book 3E

Resad Paya Pasic, Andrew I. Brill, Resad Paya Pasic, Andrew I. Brill

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781351006484
• Edition: 3
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

This third edition has been extensively updated to provide the gynecologic surgeon with a state-of-the-art and practical resource that can be used to review or learn about commonly performed surgical procedures in minimally invasive gynecology. To meet the needs of both novice and experienced surgeons, the text is engineered to cover the clinical decision-making, key instrumentation, and technical cascade for each surgical procedure. Wherever possible, discussion is focused on methods to optimize outcome and reduce risk. The content in this latest edition has been substantially bolstered by the addition of chapters covering vaginal hysterectomy, tissue retrieval in laparoscopic surgery, single port laparoscopy, robotic hysterectomy, robotic myomectomy, robotic sacralcolpopexy, radical robotic hysterectomy, and hemostatic agents for laparoscopic surgery.

Chapter 1

Patient Preparation

Shan Biscette and Andrew I. Brill

Although laparoscopic surgery is by its very nature minimally invasive, it must always be considered to be major surgery. Therefore, it is important to carefully prepare the patient for surgery both psychologically as well as physically. The surgeon must also possess adequate training and experience in the operative techniques that are necessary to complete the proposed surgical procedure in a safe and efficient manner. The decision to perform any surgical procedure in a minimally invasive fashion must be consistent with the best interests of the patient. When indicated by either the patient’s condition or surgeon experience, the decision to perform a laparotomic alternative can also serve the patient. Primum non nocere!

Patient evaluation for minimally invasive surgery

Initial patient evaluation should consider the indications and contraindications for laparoscopic surgery. Given the variations of surgeon experience as well as surgical pathology, there are no hard and fast rules; even the term absolute contraindication must be considered as a guideline, rather than an admonition.

Traditionally established absolute contraindications

There are few absolute contraindications for laparoscopic surgery. With the availability of advanced anesthesia techniques, even some of these may be considered relative.

•Patients with severe cardiac disease (class IV) may not tolerate the deep Trendelenburg positions necessary for operative laparoscopy or the variable amounts of pneumoperitoneum that are frequently required for satisfactory vision and instrument movement (see Chapter 4).

•A hemodynamically unstable patient with the need for control of active bleeding is best approached by laparotomy. However, many surgeons believe that they can rapidly enter an abdomen safely by laparoscopy, such as in the midst of a ruptured ectopic pregnancy.

•Intestinal obstruction with distended bowel is best approached by laparotomy. However, by adopting open laparoscopy techniques for peritoneal entry, it may be possible to employ laparoscopy in this circumstance.

Traditionally established relative contraindications

•Multiple previous abdominal surgeries must be considered a possible contraindication, depending on both the chosen technique for peritoneal access and the experience of the operating surgeon. However, utilization of left upper quadrant insufflation techniques or open laparoscopy may afford safe entry even in the event of multiple previous surgeries (see Chapter 5).

•Morbid obesity may be daunting for the inexperienced laparoscopist. However, with the use of operative techniques described in Chapter 5, patients with body mass index (BMI) as high as 60+ often may in fact be candidates for laparoscopy.

•Pregnancy beyond 5 months’ gestation must be approached with a great deal of caution as the pelvis is almost completely filled with the gravid uterus. Whereas some surgeons have advocated gasless laparoscopy techniques for more advanced pregnancies, some studies have demonstrated that pneumoperitoneal CO2 gas and hypercarbia do not adversely affect the fetus.

•Severe, chronically ill patients may present problems for general endotracheal anesthesia. Nevertheless, given the judgment of the anesthesiologist, it may be possible to cautiously move forward with a laparoscopic surgery.

•If malignancy is a possibility, the outcome should not be compromised by the use of laparoscopic surgery. If a mass is known to be malignant and the surgeon does not have the necessary skills to laparoscopically remove it without rupture or dissemination, then laparotomy should be the method of choice.

Informed consent

Appropriately conducted informed consent should fulfill more than the established legal doctrine to address risk and benefit. It needs to also be humanistic by addressing the significant emotional and social needs of the situation. A full understanding of the surgical procedure develops personal ownership of the proposed surgery and can help alleviate anxiety before the operation. The utilization of exemplary video, still images, plastic models, and artwork can be very useful for explaining in layman’s terms both the underlying pathology as well as the proposed surgery. The patient should be given ample time to integrate new information and ask any questions. It is always best, if possible, to have a member of the family or a close friend present during these discussions. Because of nervousness and apprehension, patients frequently forget the information that has been explained to them, and the support person can then help fill in the blanks. The patient should be honestly informed of the alternative surgical and nonsurgical methods including watchful waiting. She should be told that general anesthesia is typically employed, which necessitates the use of a tube being placed into her throat which may cause soreness. She should be seen preoperatively by the anesthesiologist to explain the procedure and risks of the selected anesthesia regimen. It can be useful to develop an informed consent sheet specific to laparoscopic surgery that is written in layman’s language. The anticipated position during surgery and the method used to create a pneumoperitoneum should be explained. The placement and locales of trocars need to be identified, including the possibility of injury to underlying bowel, blood vessels, or the urinary tract. The general risks of surgery must be explained, including transfusion and death. It is important to never promise that surgery will be accomplished by laparoscopy. Rather, it is better to explain that if surgery can be performed by laparoscopy, there will be certain comparative advantages including quicker recovery, less pain, less infection, and less scarring. She also should be informed about the anticipated postoperative course, including the degree and nature of any pain that may or may not be expected. Importantly, the patient should be encouraged to call the office at any hour for nausea, vomiting, fever, vexing constipation, or any abdominal or pelvic pain that is progressive despite the proper use of prescribed analgesics. Any of these symptoms may be indicative of a visceral injury.

Preoperative labs and preparation

The patient should be seen within 1–2 weeks of the surgery at which time a review of the history and a physical exam should be conducted that at least cover the following:

1.Weight

2.Blood pressure and pulse

3.Auscultation of the lungs and heart

4.Palpation of the abdomen for organomegaly and hernias

5.Complete bimanual pelvic examination including Papanicolaou smear if indicated

Many hospitals require laboratory tests within 1 or 2 weeks of the surgical procedure. Most laparoscopy requires a minimum of laboratory tests usually consisting of only hemoglobin with hematocrit and urinalysis. A coagulation profile may be needed for any patient with a history of bleeding problems. Patients who have other medical problems may also need further evaluation by their general medical doctor who may require other laboratory testing, such as a multipanel test.

Patients who are over 40 years old may benefit from a chest x-ray if one has not been obtained within the last 2 years. It is important to review her medicines and to inquire about the use of aspirin. Many patients do not consider aspirin a drug and neglect to inform the doctor of its chronic use. If the patient has been taking aspirin, it should be discontinued for 7–10 days prior to surgery.

It is recommended to eat lightly for 24 hours and be nil by mouth for at least 12 hours prior to surgery. Recent studies have shown that bowel preparation for routine gynecologic procedures is not necessary and may have little to no benefit in improving visualization or decreasing complications. In cases where pelvic adhesive disease is suspected and possible bowel resection is anticipated, consideration should be placed on the practice preferences of potential consulting specialists when deciding on bowel preparation.

Day of surgery

Patient preparation extends beyond the preoperative period and well into the day of surgery. Since most laparoscopic surgery is performed on an outpatient basis, it is recommended that surgery be started in the morning, if possible. The patient is instructed to arrive at least 1.5 hours prior to surgery to allow adequate time for the...