4. Surgical Technique

A. Safety Steps - Trocar Insertion

The success of a C*I*S*H* procedure depends on creation of an adequate pneumoperitoneum (at least 12 mm Hg). Injury to the abdominal wall, large vessels, bowel, or ureters is a constant concern, particularly in patients with a previous laparotomy.

After general anesthesia with endotracheal intubation, the patient is placed in a modified lithotomy position. She is prepared vaginally and abdominally, and sterile drapes are placed. We then proceed as follows.

  1. Palpation of the aorta: The aorta and its bifurcation are palpated through the umbilicus. The location and distance from the abdominal wall are appreciated.
  2. Needle flow test: Patency, functionability of the snap mechanism, and the flow resistance of the inflow tube and needle system are determined, with the CO2 gas flow set at 1 L/min. The gas flow resistance should not exceed 6-8 mm Hg. This pressure must be the same after the needle has perforated the parietal peritoneum.
  3. Snap test: While inserting the Veress needle vertically into the umbilicus, one can observe the snap mechanism three times: at the skin, the fascia, and the parietal peritoneum. If the needle is introduced at 45°, the snap mechanism cannot function optimally and the needle tip works like a scalpel.
  4. Hiss test: If the needle is placed correctly and the abdominal wall is elevated, air is brought through the needle, causing a hissing sound. The insufflator then indicates negative abdominal pressure.
  5. Aspiration test: Saline solution 5 ml is injected through the needle and aspirated. If fluid is not aspirated, the surgeon may be sure that the needle lies properly (otherwise blood or bowel content is immediately visible). With the needle safely in place, CO2 gas is insufflated until an intraabdominal pressure of 12 mm Hg is reached and the insufflator shuts off.
  6. Sounding test: Once the pneumoperitoneum has been established, a sounding needle (120 mm long and 0.8 mm thick) can be inserted 2-3 cm below the umbilicus and slowly advanced. When aspirating gas through a small column of saline in a syringe, gas bubbles through the fluid if the needle tip is free, otherwise bubbling stops, indicating the interference of underlying structures, such as bowel or adhesions. The needle is advanced in different directions, looking for a free space above the contents of the abdomen into which a trocar is to be inserted.
  7. Trocar insertion: Having established an adequate pneumoperitoneum, a small vertical intraumbilical incision is made through the skin. A 5 mm conical trocar is inserted in a Z fashion through the rectus muscle avoiding the linea alba. Care is taken to not damage the fascia, thereby avoiding possible hernia formation at the end of the procedure. The incision closes in different layers to prevent omental or intestinal prolapse.

A complete 360° abdominopelvic inspection is carried out. The diagnosis and indication for surgery are confirmed. Dilation is accomplished with trocars of 5 mm to 11 mm and a 10 mm laparoscope inserted. Three 5 mm ancillary trocars are inserted suprapubically in Z fashion under direct visualization: two lateral to the deep epigastric vessels and one off-center through the left or right rectus muscles.
The patient is placed in a 15° Trendelenburg position. The bowel is displaced cephalad out of the pelvic cavity. The C*I*S*H* can now be safely started. The uterus and adnexa are isolated from adhesions by adhesiolysis, as indicated.

B. Abdominal Portion of C*I*S*H*

If the adnexa are to be removed with the uterus, we proceed as follows:

If the adnexa are to be left in situ, ligatures are placed around the uteroovarian ligament and a cut is made beween them. The pedicles are secured with additional Roeder loops. The last loop is always a 0 catgut loop (catgut swells when wet!). The uterus is now freed to the level of the large vessels.

C. Vaginal Portion of C*I*S*H*

The initially inserted uterine manipulator is removed, and single-tooth tenacula are placed at the 9 and 3 o'clock positions.

The cervical wound is surprisingly dry. A tampon of SURGICEL is inserted into the cervical defect to prevent oozing and infection. SURGICEL is bactericidal.
The larger the diameter of the C*U*R*T used, the larger the caliber of the cervical vessels from which bleeding can occur. In this and in cases of a very congested cervix a cerclage suture of 0-Vicryl placed high around the cervical remnant together with a SURGICEL tampon is sufficient to stop all bleeding. Coagulation, cauterization, fulgeration, and additional sutures are not recommended. It only leads to delayed healing.

The use of prophylactic antibiotics is debatable. In hundreds of cases with or without antibiotics prophylaxis a difference in morbidity has not been observed. In difficult and prolonged cases prophylaxis my be advisable.

D. Removal of Surgical Specimen

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P.F. Vietz, M.D.
Westminster, MD. 21157 (USA)

September 1997