Home > Encyclopedia of Nursing & Allied Health > Laparoscopy

Definition

Laparoscopy is a minimally invasive surgical proce dure performed to examine the abdominal and pelvic organs.

Purpose

Laparoscopy is performed to directly examine the abdominal and pelvic organs to diagnose certain conditions and—depending upon the condition—to perform surgery. Laparoscopy is commonly used in gynecology to examine the outside of the uterus, the Fallopian tubes, and the ovaries—particularly in pelvic pain cases where the underlying cause of pain cannot 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. Laparoscopy is 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 development is microlaparoscopy performed in the physician's office using smaller laparoscopes. Common clinical applications 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.

Laparoscopy has been most commonly used by gynecologists, urologists, and general surgeons for abdominal and pelvic applications. In addition to expanding applications in these areas, laparoscopy is now being used by orthopedic surgeons for spinal applications and by cardiac surgeons for minimally invasive heart surgery.

Precautions

Patients should be carefully screened for allergies to anesthetic agents used for laparoscopy. Obese patients, very thin patients, and patients with abnormal anatomy have a higher risk of complications, and laparoscopy should be performed with caution in these patients. Preoperative imaging examinations may be helpful to visualize any anatomical abnormalities. Some daily medications, such as blood thinners or arthritis medications, may need to be stopped for a certain time period prior to the procedure. Any medications taken on a regular basis, including over-the-counter medicines, should be discussed with the physician and anesthesiologist. Patients who have had prior abdominal surgical procedures may have resulting scar tissue that would interfere with laparoscopy; thus, these patients are usually not considered good candidates for laparoscopic procedures.

Description

Laparoscopy is typically performed in the hospital under general anesthesia, although some laparoscopic procedures can be performed using local anesthesia. Once the patient is under anesthesia, a urinary catheter is inserted to collect urine during the procedure. To begin the procedure, 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.

Laparoscopes, which have integral cameras for transmitting images during the procedure, are available in various sizes depending upon the type of procedure being performed. The images from the laparoscope are transmitted to a viewing monitor, which the surgeon uses to visualize the internal anatomy and guide any surgical procedure. Video and photographic equipment are used to document the procedure.

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

Robotic systems are available to assist with laparoscopy. A robotic arm attached to the operating table may be used to hold and position the laparoscope in order to reduce unintentional camera movement that is common when a surgical assistant holds the laparoscope. The surgeon controls the robotic arm movement by foot pedal, voice-activated command, or handheld control panel.

Microlaparoscopy has become more common over the past few years. This procedure involves the use of smaller laparoscopes (e.g., 2 mm compared to 5 to 10 mm for hospital laparoscopy) with the patient undergoing local anesthesia with conscious sedation in a physician's office. Video and photographic equipment used are similar to that used for general laparoscopy.

Preparation

Because laparoscopy requires general anesthesia in most cases, the patient is required to fast for several hours before the procedure. Sometimes bowel cleansing is also required. The patient is screened by anesthesiology staff regarding allergies to medication and previous experiences (e.g., allergic reaction) with anesthesia.

Aftercare

Following laparoscopy, patients are required to remain in a recovery area until the immediate effects of anesthesia wear off and until normal voiding is accomplished after urinary catheter removal. Vital signs are monitored to ensure that no reactions to anesthesia have occurred and no internal injuries are present. For healthy patients undergoing elective procedures such as tubal ligation, diagnostic laparoscopy, or hernia repair, laparoscopy is usually an outpatient procedure and patients are discharged from the recovery area within a few hours after the laparoscopy. Due to the aftereffects of anesthesia, patients should not drive themselves home. Patients with more serious medical conditions, or patients undergoing emergency laparoscopy, may be kept in the hospital overnight or for a few days.

Discharged patients receive instructions regarding activity level, medications, and side effects of the procedure.

Depending upon the nature of the laparoscopic procedure and the patient's medical condition, daily activity may be restricted for a few days and strenuous activity restricted for several days to weeks. Pain-relieving medications are usually prescribed for several days following the procedure. In addition, antibiotics to prevent infection may also be prescribed. Patients are instructed to watch for signs of a urinary tract infection or unusual pain, which may indicate organ injury.

Complications

The most serious complication that can occur during laparoscopy is laceration of a major abdominal blood vessel resulting from improper positioning, inadequate insufflation (inflation) of the abdomen, abnormal pelvic anatomy, and too much force exerted during scope insertion. Thin patients with well-developed abdominal muscles are at higher risk, since the aorta may only be an inch or so below the skin. Obese patients are also at higher risk because more forceful and deeper needle and scope penetration is required. During laparoscopy, 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 caused by a fault or malfunction in the equipment.

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KEY TERMS

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

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.

Embolism—Blockage of an artery by a clot, air or gas, or foreign material. Gas embolism may occur as a result of insufflation of the abdominal cavity during 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.

Pneumothorax—Air or gas in the pleural space (lung area) that may occur as a complication of laparoscopy and insufflation.

Subcutaneous emphysema—A pathologic accumulation of air underneath the skin resulting from improper insufflation technique.

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

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Complications related to insufflation of the abdominal cavity include gas inadvertently entering a blood vessel and causing an embolism, pneumothorax, and subcutaneous emphysema. One common, but not serious, side effect of insufflation is pain in the shoulder and upper chest area for a day or two following the procedure.

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 laparoscopic procedure. Many times these injuries are 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 their proximity to each other.

During the recovery period following laparoscopy, complications may also occur. An organ injury may be overlooked, so patients should be monitored for any unusual pain, particularly in association with the bowel, as bowel injuries may not be apparent during the procedure. Other complications include urinary tract infection (resulting from catheterization) and minor infection of the incision site.

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.

Results

In diagnostic laparoscopy, the surgeon will be able to see signs of a disease or condition (e.g., endometriosis adhesions; ovarian cysts; diseased gallbladder) immediately, and can either treat the condition surgically or proceed with appropriate medical management. In diagnostic laparoscopy, biopsies may be taken of questionable areas, and laboratory results will govern medical treatment. In therapeutic laparoscopy, the surgeon performs a procedure that rectifies a known medical problem, such as hernia repair or appendix removal. Because laparoscopy is minimally invasive in comparison to open surgery, patients experience less trauma and postoperative discomfort, have fewer procedural complications, can return to daily activities sooner, and have a shorter hospital stay.

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 are needed during the procedure to assist with scope positioning, video system adjustments and image recording, and laparoscopic instrumentation.

Jennifer E. Sisk, M.A.