Laparoscope

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Laparoscope

Definition

A laparoscope is a telescope-like endoscope used to view the abdominal cavity for diagnosis and treatment during a minimally invasive surgical procedure called laparoscopy .

Purpose

A laparoscope is used to directly examine the abdominal and pelvic organs to diagnose certain conditions and—depending upon the condition—to perform therapeutic surgery. Laparoscopes are commonly used in gynecologic laparoscopy to examine the outside of the uterus, the Fallopian tubes, and the ovaries—particularly in pelvic pain cases where the underlying cause of pain could not be determined using diagnostic imaging (e.g., ultrasound; computed tomography). Gynecologic conditions diagnosed using laparoscopy include endometriosis, ectopic pregnancy , ovarian cysts or tumors, pelvic inflammatory disease, pelvic abscess , infertility , uterine fibroids, and cancer . Laparascopes are used in general surgery to examine abdominal organs such as the gallbladder , bile ducts, liver , appendix, and intestines (external surface). Laparoscopy can identify appendicitis , cholecystitis, cirrhosis, hernias, ascites, and abdominal cancers.

During the laparoscopic procedure, certain conditions can be treated surgically using special laparoscopic instruments and devices designed to be used with laparoscopes. For example, appendectomy, cholecystectomy, biopsy of the ovary or liver, hernia repair, and removal of endometriotic tissue or cysts, can all be performed laparoscopically. Medical devices that can be used in conjunction with laparoscopy include surgical lasers and electrosurgical units. Other procedures that can be performed laparoscopically include hysterectomy, oophorectomy, tubal ligation, and lymphadenectomy. Laparoscopic surgery is now preferred over open surgery for several types of procedures due to its minimally invasive nature and associated lower complication rate.

A relatively new type of laparoscope is the microlaparoscope—a smaller laparoscope used to perform microlaparoscopy in the physician's office. Common clinical applications of microlaparoscopy in gynecology include pain mapping (e.g., endometriosis), and sterilization and fertility procedures. Common applications in general surgery include evaluation of chronic and acute abdominal pain (e.g., appendix), basic trauma evaluation, biopsies, and evaluation of abdominal masses.

Laparoscopes are most commonly used by gynecologists, urologists, and general surgeons for abdominal and pelvic applications. In addition to expanding applications in these areas, orthopedic surgeons are now using laparoscopes for spinal applications, and cardiac surgeons for minimally invasive heart surgery.

Description

Laparoscopes are rigid, telescope-like endoscopes used during laparoscopic procedures for either viewing or operating. Viewing laparoscopes typically range from 5 to 10 mm in diameter, and operating laparoscopes usually range from 8 to 12 mm in diameter. Operating laparoscopes have a separate instrument channel in their shaft where laparoscopic surgical instruments can be inserted to perform therapeutic procedures. Viewing laparoscopes do not have an instrument channel and are used primarily for diagnosis. Microlaparoscopes of approximately 2 mm in diameter are available for diagnostic procedures performed in the physician's office. Although most laparoscopes are rigid, some manufacturers supply semi-flexible or flexible laparoscopes to increase the viewing range. The size and type of laparoscope chosen depends upon the type of procedure being performed, the patient's size and age, and the patient's medical condition.

Laparoscopes have an optical system of lenses, prisms, and mirrors to provide magnification of tissue and organs, a wide field of view, and high image resolution. A bundle of illuminating fibers are located in the laparoscope's shaft surrounding the lenses and are connected to a separate fiber-optic light source that provides light during the procedure. Most laparoscopes have integral cameras or allow connection of a camera for transmitting images during the procedure. The images from the laparoscope are transmitted to one or more viewing monitors, which the surgeon uses to visualize the internal anatomy and guide any surgical procedures. Video and photographic equipment are used to document the procedure.

Operation

Laparoscopy is typically performed in the hospital under general anesthesia , although some laparoscopic procedures can be performed using local anesthesia and conscious sedation. Once the patient is under anesthesia, a urinary catheter is inserted to collect urine during the procedure. As the procedure begins, a small incision is made just below the navel and a cannula or trocar is inserted into the incision to accommodate the insertion of the laparoscope. Other incisions (one or two) may be made in other areas of the abdomen to allow for insertion of other laparoscopic instrumentation. A laparoscopic insufflation device is used to inflate the abdomen with carbon dioxide gas to create a space in which the laparoscopic surgeon can maneuver the instruments.

Once the laparoscope is inserted, the surgeon manipulates it to view the anatomical areas of interest. Depending on the surgeon's preference and the type of

procedure, an eyepiece can be attached to the scope for direct viewing, or television/video cameras can be attached for viewing on a monitor. Instruments such as forceps, graspers, and manipulators can be used in conjunction with operating laparoscopes. For example, a uterine manipulator would be used in gynecologic procedures involving the uterus (e.g., hysterectomy).

After laparoscopic diagnosis and treatment are completed, the laparoscope, cannula, and other instrumentation are removed, and the incision is sutured and bandaged.

Complications related to the use of a laparoscope can occur during laparoscopy. The most serious complication is laceration of a major abdominal blood vessel resulting from improper positioning, inadequate insufflation (inflation) of the abdomen, abnormal pelvic anatomy, or too much force during scope insertion. Thin patients with well-developed abdominal muscles are at higher risk, since the aorta may only be an inch (2-3 cm) or so below the skin. Obese patients are also at higher risk because more forceful and deeper needle and scope penetration is required. There is also a risk of bleeding from vessels, and adhesions that may require repair by open surgery if bleeding cannot be stopped using laparoscopic instrumentation. In laparoscopic procedures that use electrosurgical devices, burns to the incision site are possible due to conduction of electrical current through the laparoscope due to a fault or malfunction in the equipment.

Any abdominal surgery, including laparoscopy, carries the risk of unintentional organ injury (punctures and perforations). For example, the bowel, bladder, ureters, or fallopian tubes may be injured during the procedure by the laparoscope itself. These injuries are often unavoidable due to the patient's anatomy or medical condition. Patients at higher risk for bowel injury include those with chronic bowel disease, pelvic inflammatory disease, a history of pervious abdominal surgery, or severe endometriosis. Some types of laparoscopic procedures have a higher risk of organ injury. For instance, during laparoscopic removal of endometriosis adhesions or ovaries, the ureters may be injured due to its proximity to each other.

Several clinical studies have shown that the complication rate during laparoscopy is associated with surgeon experience. Surgeons experienced in laparoscopic procedures have fewer complications than surgeons performing their first 100 cases.

Maintenance

The success of the laparoscopic procedure is highly dependent upon the condition of the laparoscope and its associated accessories. Improper disinfection, sterilization, and handling of laparoscopic equipment can result in equipment damage, unnecessary wear, and ultimately surgical errors. All clinical staff using laparoscopes and related equipment should be well-trained and familiar with disassembling and assembling scopes and accessory parts (e.g., couplers; adapters; instrumentation) so that defects in equipment can be recognized before a complication occurs or equipment malfunctions. Manufacturers of laparoscopic equipment usually provide maintenance guidelines, including cleaning techniques, for their scopes and accessories. The hospital biomedical engineering department and/or the scope manufacturer will implement actual repairs to equipment. The introduction of disposable accessories (e.g., trocars; couplers) has simplified preparation for procedures and minimized maintenance needs.

Health care team roles

Laparoscopy may be performed by a gynecologist, general surgeon, gastroenterologist, or other physician, depending upon the patient's condition. An anesthesiologist is required during the procedure to administer general and/or local anesthesia and to perform patient monitoring. Nurses and surgical technicians/assistants aid with scope positioning, video system adjustments and image recording, and laparoscopic instrumentation. Clinical staff trained in the daily maintenance, disinfection, and sterilization of laparoscopes are required to sterilize equipment between procedures and make sure all scopes are in working order.

Training

Physicians and surgeons using laparoscopes should be well-trained in laparoscopic techniques. A surgeon skilled and experienced in open surgical techniques cannot necessarily transfer those skills to laparoscopic techniques because a different skill set is involved in minimally invasive surgery. Organizations focused on laparoscopy, and laparoscope manufacturers, offer clinical training in laparoscopic surgery.

KEY TERMS

Ascites —Accumulation of fluid in the abdominal cavity; Laparoscopy may be used to determine its cause.

Cannula —A small tube inserted into the incision site through which laparoscopes and instruments are inserted; used in conjunction with a trocar.

Cholecystitis —Inflammation of the gallbladder; often diagnosed using laparoscopy.

Electrosurgical device —A medical device that uses electrical current to cauterize or coagulate tissue during surgical procedures; often used in conjunction with laparoscopy.

Endometriosis —A disease involving occurrence of endometrial tissue (lining of the uterus) outside the uterus in the abdominal cavity; often diagnosed and treated using laparoscopy.

Hysterectomy —Surgical removal of the uterus; often performed laparoscopically.

Insufflation —Inflation of the abdominal cavity using carbon dioxide; performed prior to laparoscopy to give the surgeon space to maneuver surgical equipment.

Oophorectomy —Surgical removal of the ovaries; often performed laparoscopically.

Trocar —A small sharp instrument used to puncture the abdomen at the beginning of the laparoscopic procedure.

Resources

BOOKS

Soderstrom, Richard M. "Laparoscopic Equipment." In Operative Laparoscopy 2nd ed. Ed. Richard M. Soderstrom. Philadelphia: Lippincott-Raven, 1998, 1-9.

Soderstrom, Richard M., ed. Operative Laparoscopy, 2nd ed. Philadelphia: Lippincott-Raven, 1998.

Soderstrom, Richard M., Carl J. Levinson, Barbara S. Levy. "Complications of Operative Laparoscopy." In Operative Laparoscopy, 2nd ed. Ed. Richard M. Soderstrom. Philadelphia: Lippincott-Raven, 1998, 257-267.

PERIODICALS

Boike, Guy M., and Brian Dobbins. "New Equipment for Operative Laparoscopy." Contemporary OB/GYN no. 2 (April 1998). <http://consumer.pdr.net/consumer/psrecord.htm>.

Pritts, Elizabeth A., David L. Olive, Tracey Gilhuly, and Steven F. Palter. "The Role of Microlaparoscopy in the New Era of Gynecology." Contemporary OB/GYN (April 15, 1999). <http://consumer.pdr.net/consumer/psrecord.htm>.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th Street SW, P.O. Box 96920, Washington, DC 20090-6920. <http://www.acog.org>.

Society of American Gastrointestinal Endoscopic Surgeons (SAGES). 2716 Ocean Park Boulevard, Suite 3000, Santa Monica, CA 90405. (310) 314-2404. <http://www.endoscopy-sages.com>.

Society of Laparoendoscopic Surgeons. 7330 SW 62nd Place, Suite 410, Miami, FL 33143-4825. (305) 665-9959. <http://www.sls.org>.