If large volumes of ﬂuid are required, isotonic ﬂuids should be used to avoid ﬂuid overload and electrolyte imbalance. If electrosurgery is to be performed, small volumes of a nonelectrolytecontaining solution such as glycine or sorbitol can be used for hemostasis and irrigation. Heparin (1,000 to 5,000 U/L) can be added to irrigating solution to prevent blood from clotting and facilitate ﬂuid removal.
Uterine manipulation is an important component of the strategy to maximize visualization for most pelvic procedures, especially for myomectomy and hysterectomy. A properly designed uterine manipulator should have an intrauterine component, or obturator, and a method for attaching the device to the uterus. Articulation of the instrument permits acute anteversion or retroversion, both of which are extremely useful procedural maneuvers. If the uterus is large, longer and wider obturators can be used for more effective control. Two types of uterine manipulators are shown in Figure 23.12. A hollow channel attached to a port allows intraoperative instillation of liquid dye to aid in the identification of the endometrial cavity (during myomectomy) or to demonstrate tubal patency.
The forceps used during laparoscopy should, to the extent possible, replicate those used in open surgery. Disposable instruments generally do not have the quality, strength, or precision
Figure 23.12 Uterine manipulators. Top: The disposable “V-Care” device. At the tip is a balloon inﬂated to maintain the device in the endometrial cavity. Next to the tip is a cervical collar that serves to facilitate identification of the vaginal fornices and cutting of the vagina in laparoscopic total hysterectomy. The blue truncated cone maintains a seal so that gas will not leak out when culdotomy is performed. Bottom: The reusable Valtchev manipulator. The ring handle allows the surgeon to antevert the uterus.
of nondisposable forceps (Fig. 23.13). Instruments with teeth (toothed forceps) are necessary to securely grasp the peritoneum or the edge of an ovary for the removal of an ovarian cyst. Instruments designed to be minimally traumatic, like Babcock clamps, are needed to retract the fallopian tube safely. Tenaculum-like instruments are desirable to retract leiomyomas or the uterus. A ratchet is useful for holding tissue without arduous hand pressure. Graspers should be insulated if unipolar radiofrequency instruments are being used to attain hemostasis.
Figure 23.13 Laparoscopic instruments for grasping and manipulating tissue. A: (top and inset) are 5-mm diameter graspers with a curved tip, often called “Maryland” graspers. Other reusable tips (B) and (C) may be positioned in the same handle as is shown for (A). D: A 10-mm claw grasper, while (E) and (F) are 5-and 2-mm manipulating probes respectively. G: A 2-mm grasping forceps.
Cutting, Hemostasis, and Tissue Fixation
Cutting can be achieved by mechanical means or by using laser, radiofrequency electrical, or ultrasonic energy. The methods for maintaining or securing hemostasis include sutures, clips, linear staplers, energy sources, and topical or injectable substances. Secure apposition or tissue fixation may be accomplished with sutures, clips, or staples. With appropriate training, a skilled surgeon can obtain good results with any combination of these techniques for cutting, hemostasis, and tissue fixation. Studies in animals have not demonstrated any difference in injury characteristics when cutting is performed with either laser or radiofrequency energy and randomized controlled studies have shown no differences in fertility outcomes (59–61,94). Therefore, differences in results are likely to be caused by other factors, such as patient selection, extent of disease, and degree of surgical expertise.