Posted by Article on 10/27/2002, 12:10 pm
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Hi Friends, The link below contains a lot of info regarding laparoscopy. Love, Sue ******* A couple excerpts follow. Patient Risk Factors Obesity It is well appreciated that obesity increases the risk of any abdominal surgery. For laparoscopy, increased weight takes on a special significance. Women with a body mass index (BMI) greater than 25 kg/m2 are classified as overweight, and those with a BMI greater than 30 kg/m2 are considered obese. In an average-sized woman of approximately 160 cm (64 in), these cutoff points correspond roughly to weights of 73 kg (160 lb) and 91 kg (200 lb), respectively. In women who are overweight, and even more so in those who are obese, every aspect of laparoscopy becomes more difficult and potentially more risky. Placement of laparoscopic instruments becomes much more difficult and often requires special techniques. Bleeding from abdominal wall vessels may become more common since these vessels become difficult to locate. Many intra-abdominal procedures become increasingly difficult because of a restricted operative field secondary to retroperitoneal fat deposits in the pelvic sidewalls and increased bowel excursion into the operative field. This second problem probably is related to increased volume of bowel, decreased elevation of a heavier anterior abdominal wall by the pneumoperitoneum, and the inability to place many obese patients in steep Trendelenburg because of ventilation considerations. Weight loss prior to elective surgery in overweight and obese patients would be ideal. Unfortunately, significant weight loss may take years and, more often than not, is impossible. A more realistic approach is to inform the patient of the increased risk associated with obesity and to limit the extent of advanced laparoscopic procedures that are attempted in obese patients. Although no certain weight exists at which laparoscopy is contraindicated, many surgeons hesitate to perform all but the simplest laparoscopic procedures in patients weighing over 136 kg (300 lb). Lysis of adhesion Adhesions may form due to prior infection, such as a ruptured appendix or pelvic inflammatory disease (PID), endometriosis, or previous surgery. Adhesions may contribute to infertility or chronic pelvic pain. Adhesions may be lysed by blunt or sharp dissection. Aquadissection may aid in the development of planes prior to lysing. Any of the power instruments may be utilized for cutting and coagulation. Unipolar electrosurgery, such as the fine unipolar needle, should be limited to adhesions 1-2 cm from the ureter and bowel due to the unpredictable nature of current arcing. Other power techniques may be safer choices for adhesiolysis near the bowel. Adhesions may reform after lysis, although this can be reduced with good hemostasis. Surgeons frequently utilize intraperitoneal anti-inflammatory solutions of steroids and dextran-70, but these have not proven beneficial in controlled trials. Although proven to decrease adhesions in clinical trials, barrier methods have been disappointing in terms of improving pain relief or future fertility. Abdominal scars As noted above, previous surgery is associated with a greater than 20% risk of adhesions of bowel or omentum to the anterior abdominal wall. For this reason, many laparoscopists adjust their techniques in these patients to minimize risk of bowel injury. Of special concern are incisional scars immediately adjacent to the umbilicus, since bowel adherent underneath the umbilicus may be at risk for injury regardless of the technique used. Although Pfannenstiel and abdominal incisions distant to the umbilicus also may be associated with adhesions, in many laparoscopists' experience, these incisions appear to represent less of a risk than incisions near the umbilicus. In addition to location, the width and depth of the scar should be evaluated, since a wide or retracted scar may suggest that a postoperative wound infection had occurred. It is common wisdom that postoperative infections may be associated with an increased risk of intra-abdominal adhesion formation, although no data are available to support this observation. If the dome of the bladder is involved in the infectious process, it may cause progression of the bladder dome higher behind the anterior abdominal wall, thus increasing the risk of bladder injury at the time of suprapubic trocar placement. Abdominal wall thickness Although abdominal thickness correlates with patient weight, short stature or truncal obesity may increase abdominal wall thickness out of proportion to patient weight. Routine evaluation of the abdominal wall prior to laparoscopy is important since the success of trocar insertion may depend on altering the technique based on abdominal wall thickness. Contraindications: Determination of absolute contraindications to laparoscopy remains controversial. For years, previous abdominal surgery and intestinal obstruction were regarded as contraindications to laparoscopy because of an increased risk of iatrogenic bowel perforation. Recent reports, however, suggest that morbidity is lower with the laparoscopic approach than with laparotomy. In gynecology, the most commonly suggested contraindication is hemodynamic instability resulting from an unruptured ectopic pregnancy. Following appropriate fluid resuscitation, however, laparoscopy is a safe approach. Another traditional contraindication was pregnancy. In the last few years, several large series have documented the safety of laparoscopy during pregnancy with the use of an open technique. Finally, disagreement is ongoing as to whether a known gynecologic malignancy is a contraindication to laparoscopy. Several case reports and series have suggested that laparoscopy may increase the risk of intraperitoneal spread of cancer cells. Although few absolute contraindications exist for laparoscopy, several risk factors are well appreciated. AND MUCH MORE..........

Link: Gynecologic Laparoscopy