Classical gynaecological surgery through the laparoscope

Laparoscopy is a way of access not a technique (H. Reich)

 

The way of access, this is the key to understand laparoscopic surgery be it with the classical gas pneumoperitoneum be it gasless. We cumulate the complications because we have the complications of the way of access and these of the surgical act itself. So why perform endoscopic surgery. The patients are the only motivation. It has been shown over and over that the patient and only the patien benefits from this type of surgery.

  • Shorter hospital stay, if compared with laparotomy.
  • Less medication (painkillers and antibiotics) in the postoperative course.
  • Less delay to return to normal activity.
  • Shorter absence out of the working environment.
  • Smaller scars, a psychological advantage. 
  • Smaller scars and less wound problems.
  • Less adhesions. It has been verified that only up to 15% de novo adhesions occur but the overall percentage of adhesions depends on the site where the operation is performed.

Fig. 4 illustrates the bipolar dissection of the uterine artery on the left side of the uterus. The bipolar forceps of the Robi series is made in a way that it allows for grasping and dissecting. The artery is exposed whilst the uterus is pulled to the right and the artery will be coagulated and cut with scissors close to the uterus.Remark that there is very little bloodspill one of the advantages of the magnification X 20 of the scopes that allow for prevention of coagulation of the bleeders
  
If you look at fig. 2  you see the end phase of a total laparoscopic hysterectomy. It took about the same time to arrive at this point as with a laparotomic hysterectomy, about one hour of surgical time and the end site is very similar. Note the two lateral stitches according to Te Linde, these bring the sacrouterine ligaments up to the vagina and also the fascia of the vagina under the bladder. The central stitch is just a closure. One treat is used in normal circumstances.This patient will however leave the hospital some three days earlier. This corresponds with the time patients stay in the hospital after vaginal hysterectomy. So vaginal hysterectomy should be reconsidered and applied whenever possible.
  
Fig 3 gives the picture of a ruptured tube where the amniotic sac was still present in the distal end of the tube and was dislocated by lavage under pressure (500 mm Hg). Another example of a golden standard in endoscopy. This patient was slipping into an hypovolemic shock but the use of large clot aspirator equipment and high flow insufflators reduced the duration of the operation to 9 min after induction before the bleeding was controlled. The next day she walked the ward.

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ETCA prefers Karl Storz endoscopic equipment

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ZNA STER Site Stuivenberg
Department Gynaecological Surgery
Department General Surgery


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