Larger specimens may be removed by inserting a larger cannula through an incision in the cul-desac (posterior culdotomy) or by extending one of the laparoscopy incisions. With the exception of culdotomy (colpotomy), extension of the umbilical incision may be the most cosmetic approach because incisions up to 3 cm in length can be concealed successfully. When the umbilical location is selected, removal of the tissue can be directed from an endoscope positioned in one of the ancillary ports. Electronic morcellators are available to remove large tissue specimens by reducing them to smaller sections (Fig. 23.19). These are especially useful for laparoscopic myomectomy and laparoscopic supracervical hysterectomy.
Incision Management Dehiscence and hernia risk appear to significantly increase when the fascial incision is larger than 10 mm in diameter (98,99). Closure of the fascia should take place under direct laparoscopic vision to prevent the accidental incorporation of bowel into the incisions, and the peritoneum should be included to reduce the risk of Richter’s hernia. A small-caliber laparoscope passed through one of the narrow cannulas can be used to direct the fascial closure using curved needles or a ligature carrier especially designed for this purpose.
Figure 23.19 Electromechanical morcellator. This device is positioned in the peritoneal cavity and attached to the power generator (inset). The blunt obturator is removed; a grasping instrument inserted through the lumen is used to withdraw the tissue, which is cut by a cylindrical blade. The motor is activated by a foot pedal.
Complications After laparoscopic surgery patients usually experience a rapid recovery. Pain diminishes, gastrointestinal function improves quickly, and fever is extremely unusual. Therefore, if a patient’s condition is not improving, possible complications of anesthesia or surgery should be considered. Laparoscopic procedures can be complicated by infections, trauma, or hemorrhage, and by problems associated with anesthetic use. The incidence of infection is lower than with procedures performed by laparotomy. Problems associated with visualization in conjunction with the change in anatomic perspective may increase the risk of damage to blood vessels or vital structures such as the bowel, ureter, or bladder.
A review of laparoscopic tubal sterilization in 9,475 women found no deaths from complications of anesthesia (100,101). The potential risks of general anesthesia include hypoventilation, esophageal intubation, gastroesophageal reﬂux, bronchospasm, hypotension, narcotic overdose, cardiac arrhythmias, and cardiac arrest. These risks can be exacerbated by some of the inherent features of gynecologic laparoscopy. For example, the Trendelenburg position, in combination with the increased intraperitoneal pressure provided by pneumoperitoneum, places greater compression on the diaphragm, increasing the risk of hypoventilation, hypercarbia, and metabolic acidosis. This position, combined with anesthetic agents that relax the esophageal sphincter, promotes regurgitation of gastric content, which in turn can lead to aspiration, bronchospasm, pneumonitis, and pneumonia. Parameters of cardiopulmonary function associated with both CO2 and N2O insufﬂation include reduced PO2,O2 saturation, tidal volume, and minute ventilation and increased respiratory rate. The use of intraperitoneal CO2 as a distention medium is associated with an increase in PCO2 and a decrease in pH. Elevation of the diaphragm may be associated with basilar atelectasis, resulting in right-to-left shunt and ventilation–perfusion mismatch (102).