Consultant Gynaecologist and Laparoscopic Surgeon
Mwanza Womens’ Clinic
P.O.Box 11016, Mwanza, Tanzania
Minimal access surgery is increasingly becoming the preferred approach to surgical treatment. Experience in the last 15-20 years has established the efficacy and indeed safety of laparoscopic surgery in general surgical and gynaecologic practice. Laparoscopic treatment in acute gynaecologic emergencies raises questions of safety and feasibility when compared to open laparotomy. The objectives of this study were to review the literature on the use of laparoscopy in the treatment of gynaecologic emergencies so as to determine its role in current and future practice. The findings of this study indicate that laparoscopic surgery for gynaecologic emergencies is feasible and safe. Further studies are needed to establish safety of laparoscopic surgery for non-obstetric emergencies in late pregnancy.
Traditionally, the use of laparoscopy in gynaecology had been restricted to the diagnosis of chronic pelvic pain, infertility and sterilization procedures. Later, its use in the diagnosis and treatment of ectopic pregnancy became firmly established. More recently, in the last 21 Years or so, with the infectious popularity of Minimal Access Surgery, laparoscopy is becoming the preferred method of surgery for an even wider range of gynaecologic conditions, from tubal reconstructive surgery to radical hysterectomy for cervical cancer. There is almost no gynaecologic surgery that has not been attempted laparoscopically. The main advantages of laparoscopic surgery are smaller, cosmetically acceptable wounds, less pain, less morbidity and shorter hospitalization. Laparoscopy is increasingly being used in the diagnosis and treatment of gynaecologic surgical emergencies, including those involving trauma and the critically ill patients when diagnosis is not obvious. Minimal access, in managing an acute abdomen invariably raises questions about its feasibility, safety and efficacy. These must be judged against standard open surgery. The challenges posed minimal access surgery in acute surgical emergencies include the haemodynamic status of the patient, the potential for complications related to abdominal entry techniques and the anaesthetic considerations in these situations. Severe abdominal distension and the presence of previous multiple abdominal surgical scars make the laparoscopic approach extremely risky while haemodynamic instability may present enormous challenges for anaesthesia. This paper aims at reviewing the current status of laparoscopic surgery in the management of gynaecologic surgical emergencies, its efficacy, indications, the challenges involved and the future trends in its use.
The objectives of this study were to review the medical literature on the use of laparoscopic surgery for the treatment of gynaecologic surgical emergencies. Specifically, this paper will review work that has been done on the feasibility, efficacy and complications of the laparoscopic approach, so as to define its role in the current management of gynaecologic emergencies.
Review of the literature using the springer-link and PubMed searches.
There are many reported studies and case-reports looking at management of a wide range of acute gynaecological surgical emergencies laparoscopic approach. While case-reports have highlighted ground-breaking surgeries, the larger studies have looked at many areas related to applicability of laparoscopic approach in the general gynaecologic practice. These areas include feasibility of the laparoscopic surgery in these clinical settings, its accuracy and efficacy and the complications and challenges involved.
Feasibility of emergency laparoscopy
Several studies have demonstrated the feasibility and safety of laparoscopic surgery for the acute abdomen in the setting of general surgical practice,1,2,3 as well as in gynaecology.4,5,6,7 In an extensive evidence-based review of the literature on the role of laparoscopy for acute surgical abdominal conditions, Dimitrios Stefanidi and his colleagues concluded that laparoscopy could be performed safely in the majority of cases and that it was associated with a low morbidity and mortality.8 Majority of these studies agree that patients for laparoscopic management need to be hemodynamically stable. However, there are recent case-reports of patients presenting with life threatening massive hemoperitoneum where laparoscopy was life-saving.12,13
Indications for emergency laparoscopy
The commonest indication for the laparoscopic approach has been acute non-specific lower abdominal pain where laparoscopy is undertaken in favour of clinical observation. This reflects the established role diagnostic laparoscopy in providing accurate diagnosis and hence expediting definitive treatment.2,8 There are equally other studies in which laparoscopy has been undertaken as the primary route of surgical management for clinically established surgical emergency. These include adnexal torsion, tubo-ovarian abscess, peritonitis and of cause ectopic pregnancy.4,9,10 There are studies suggesting that subsequent fertility is significantly higher in laparoscopically treated women presenting with gynaecologic emergencies, making need for future fertility an emerging indication for laparoscopic treatment9,11 The use of Laparoscopy in management of non-obstetric complications in pregnancy is another recent addition to the increasing use of minimal access surgery. Laparoscopy has been done as late a third trimester of pregnancy12,1319,20. These early do not suggest untoward effects to the mother or baby.
Efficacy and Accuracy
Most studies agree that laparoscopy has a very high diagnostic accuracy, even when compared to open laparotomy. Laparoscopy also provides a better view of the abdominal cavity and when used in the non-specific acute abdomen, it reduces delay to treatment and morbidity. Studies looking laparoscopic treatment of general surgical acute abdomen including gynaecologic conditions report diagnostic accuracy ranging from 88% to 99%1,3,8. Majority of underlying causes of the acute abdomen in gynecologic and general surgery are amenable to laparoscopic treatment. Conversion rates to open laparotomy in most studies ranged from as low as 4% to 33%1,2,,3,14. The main predictors for conversion appear to be surgeons’ inexperience, obesity and a large free peritoneal fluid on Ultrasound scanning10. In younger women wishing fertility conservation, laparoscopy was shown to be superior to open laparotomy in ovarian conservation, especially in the treatment of ovarian torsion10,
Morbidity and complications
Treatment using the laparoscopic approach appears to be associated with reduced morbidity, early recovery and a shorter hospital .1,3,5,15, Interestingly, conversion to open laparotomy does not appear to increase morbidity.
Complications reported are mainly related to access technique and devices. Those reported include visceral and vascular injuries, and those related to the incision area like acute herniation8,16,17,. Other infrequent complications include prolonged ileus, intra-abdominal abscess, pneumonia and pulmonary embolism. One case is reported of aortic puncture with a port-closure device following laparoscopically assisted vaginal hysterectomy18
Minimal access surgery has evolved enormously in the last twenty years and is now frequently being used in treatment of gynecologic emergencies diagnostic and therapeutic procedures. Studies reviewed here demonstrate that laparoscopic surgery for almost all gynecological surgical emergencies is not only feasible, but safe and effective. Its wide-spread use is still being restricted by the necessity for special expertise in minimal access surgery, issues related to its cost-effectiveness and the necessary infrastructural facility adjustments to the apparent high-tech equipments and operating room set-up. Expertise requires training, and one study has demonstrated that it is feasible to integrate well structured laparoscopic surgery training into a residency program 21. Unfortunately, the apparent benefits of laparoscopic surgery in terms reduced morbidity and quicker recovery have not been associated with lower costs, the two studies sited here showing that there are added cost to treatment compared to open surgery2,8 . This must be related to the cost of equipment, supplies and the professional fees associated with the treatment. Technically, the major advantages of laparoscopic surgery is that it provides adequate visualization of the entire abdominal cavity and localization of pathology, allows more precise irrigation of peritoneal cavity under pressure. It also averts delays in instituting appropriate surgical management and avoids extensive pre-operative studies. These, together with reduced morbidity, smaller, cosmetically acceptable wounds and early recovery will continue to be the major driving force to its wide-spread use and demand. The laparoscopic approach appears to be the most appropriate for women in child-bearing age because of their high frequency of negative appendicitis and improved fertility preservation9,15. Complications associated with minimal access surgery need specific strategies which should include training of surgeons, modification of techniques and newer entry devices in the setting of the acute abdomen16 . The use of target incisions is helpful in difficult cases and when necessary, surgeons should not resist converting to open surgery.
An emerging role for laparoscopic surgery is in the management of life threatening acute abdominal conditions with-inconclusive pre-operative studies. In the two case-reports sited here, laparoscopic treatment was successfully even though both patients were hemodynamically unstable12,13. Equally impressive is the use of laparoscopy for gynecologic emergencies during pregnancy. This is an area that needs further studies.
In conclusion, there is undeniable evidence that laparoscopic surgery for the management of gynaecological emergencies is a feasible, safe and effective challenging alternative to open surgery. Its added value in reduced morbidity, shorter hospital stay and cosmesis has helped to establish its place in contemporary and future gynaecologic practice. The use of laparoscopy in pregnancy needs further studies to establish safety for both the baby and pregnant woman.
I would like to acknowledge the assistance and encouragement I received from Prof R.K. Mishra, who, as Director of the training in Diploma in Minimal Access Surgery guided and supervised this work. This review, and indeed the whole training would not have been possible without him and the fabulous team at the World Laparoscopy Hospital.
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- Minig L, Velasco A, Lamm M, et al Evaluation of laparoscopic management of gynecologic emergencies by residents In press, Int J Obstet Gynecol, On-line publication 28.06.2010