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DIAGNOSTIC LAPAROSCOPY

Diagnostic laparoscopy provides a minimally invasive surgery (MIS) option for thorough evaluation of the peritoneal cavity and pelvic organs. It often is performed to evaluate pelvic pain or causes of infertility, to diagnose endometriosis, or to ascertain the qualities of a pelvic mass. Importantly, systematic evaluation of the peritoneal cavity is performed during every laparoscopy, either diagnostic or operative.

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Video 44-01: Introduction to Diagnostic Laparoscopy

Barbara L. Hoffman, MD, and Derek Wu

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PREOPERATIVE

Consent

During the informed consent process for diagnostic laparoscopy, a surgeon reviews procedure goals, including diagnosis and possible treatment of identified pathology. Among others, this includes permission for lysis of adhesions, peritoneal biopsy, and excision or ablation of endometriosis. A patient also is informed that diagnostic laparoscopy may reveal no apparent pathology.

Laparoscopy typically is associated with few complications. Of these, organ injuries caused by puncture or by electrosurgery burn are the most common major complications and are summarized in Chapter 41 (p. 875). The possible need to complete the diagnostic evaluation via laparotomy also is discussed. Reasons for conversion include failure to gain abdominal access, organ or vessel injury during entry, or extensive adhesions. In general, such conversion during diagnostic laparoscopy is uncommon.

Patient Preparation

Compared with laparotomy, laparoscopy usually is associated with lower rates of postoperative infection and venous thromboembolism (VTE). Thus, for diagnostic laparoscopy, antibiotics generally are not required, and VTE prophylaxis is implemented for those with risk factors (Table 39-10, p. 834). For most patients, bowel preparation also is not administered. However, if extensive adhesiolysis is anticipated and the risk of colorectal injury is thereby increased, bowel preparation can be considered. An empty rectum can aid intraoperative proctosigmoidoscopy and bowel manipulation needed for repair.

INTRAOPERATIVE

Instruments

Several instruments are especially helpful during diagnostic evaluation, and most are found in a standard laparoscopy instrument set. Of these, atraumatic graspers move abdominal organs gently but precisely. A uterine manipulator that allows chromopertubation also is considered if performing diagnostic laparoscopy for infertility evaluation. If this is planned, 10 mL of methylene blue is mixed with 100 to 150 mL of sterile saline for injection through the cervical cannula of the manipulator. On rare occasion, methylene blue may induce acute methemoglobinemia, particularly in patients with glucose-6-phosphate dehydrogenase deficiency.

Surgical Steps

ANESTHESIA AND PATIENT POSITIONING

Most laparoscopic surgery is performed in an operating room with general anesthesia. Peritoneal pain created by the intraabdominal pneumoperitoneum merits this degree of anesthesia. Following anesthesia induction, the patient is placed in low lithotomy position to permit access to the cervix and allow uterine manipulation. The patient’s arms are tucked at her sides. Even for anticipated short ...

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