OSCAR D. ALMEIDA, JR, MD
At the turn of the twentieth century, crude techniques and instrumentation made laparoscopic evaluation cumbersome and challenging to the clinician. Primitive laparoscopes with inferior lighting and image transmission, poor anesthetic methods, and untested laparoscopic techniques produced limited useful data. During the past quarter century, tremendous advances in laparoscopy have been achieved in both gynecologic and general surgery.
Minimally invasive microlaparoscopic surgery continues to revolutionize and redefine contemporary medicine as laparoendoscopic surgeons invade the 21st century. The availability of this technology in operative medicine will force surgeons to perform procedures in a more minimally invasive and cost-effective manner. Myriad technique and instrumentation changes mark the developments that have led to microlaparoscopy. The advances in microlaparoscopy noted today have arisen primarily from continued progress in fiberoptic technology. Microlaparoscopy uses small-caliber laparoscopes, 2 mm or less in diameter, made of microfiber-optic bundles measured in micrometers. The current 2-mm microlaparoscopes have a 50000-fiber image bundle that produces enhanced resolution and a 75° field of view, comparable to a standard 10-mm rod lens laparoscope (Figure 1) .
In addition to the microlaparoscopes, laparoscopic instruments have similarly been miniaturized. These include 2-mm trocars that can be attached to a Veress needle prior to creating the pneumoperitoneum. Once the pneumoperitoneum is achieved, the Veress needle is removed leaving the 2-mm trocar in place. This precludes the necessity of a “second-pass” trocar placement and allows the immediate insertion of the microlaparoscope. Open laparoscopy was introduced to reduce the risk of blind entry into the peritoneal cavity. Today the availability of microlaparoscopy has made open laparoscopy obsolete. Injury to the bowel with open laparoscopy has been reported to occur at the same rate as that with blind entry using a 2-mm cannula . In cases of suspected bowel perforation, the diagnosis can be immediately confirmed without producing further damage to the bowel. Bowel perforations resulting from 2-mm instrumentation can be managed conservatively without suturing, provided that the site of injury is not actively leaking stool or bleeding .
A complement of 2-mm microinstruments is available . Probes with centimeter markings are useful for measuring tubal length during assessments for potential tubal anastomosis. Other uses include probing tissues, structures, and lesions during conscious pain mapping. Injection-aspiration needle cannulas are helpful for awake laparoscopic procedures. Grasping forceps with serrated and atraumatic jaws, monopolar cautery scissors, bipolar forceps, and 2-mm Endoloops are available for operative microlaparoscopic procedures.
In addition to the traditional hospital and outpatient operating room, microlaparoscopy has burst into the physician’s office [5-7], intensive care unit , and emergency room . Many procedures, both diagnostic and operative, can be performed with microlaparoscopy alone (Tables 1 and 2). Other operative microlaparoscopic-assisted procedures may require at least 1 larger trocar for the removal of a surgical specimen, such as the ovary, appendix, or gallbladder, or to accommodate a larger laparoscopic instrument like a stapling device. The technique of microlaparoscopic-assisted vaginal hysterectomy (MAVH) was recently introduced .
Using an efficacious conscious-sedation protocol , a systematic evaluation of the pelvic and abdominal cavities can be performed while the patient is comfortably awake. Heating and humidifying the carbon dioxide gas for the pneumoperitoneum will enhance patient comfort during awake microlaparoscopic procedures . The protocol for conscious sedation is summarized in Table 3. Traditional laparoscopy with patients under general anesthesia for the evaluation of chronic pelvic pain in women has a major flaw. The primary limitation of this procedure has always been the use of general anesthesia, because it does not allow intraoperative patient feedback. Unfortunately, not all visible lesions, such as endometriosis and adhesions, account for all of the patient’s symptoms. In addition, deep lesions may exist that are not readily visible through the laparoscope and can be missed if the procedure is performed without intraoperative patient feedback. Conscious pain mapping has added an innovative diagnostic dimension previously absent in gynecology. By using the technique of conscious pain mapping [12-16] in select cases, the patient can provide crucial information by helping the surgeon locate the source of her pain as areas in question are systematically probed.
In gynecologic surgery, microlaparoscopy has been utilized for the evaluation and treatment of patients with chronic pelvic pain, endometriosis, pelvic adhesions, ovarian cysts, pelvic inflammatory disease, as well as both infertility and undesired fertility. Patients with an ectopic pregnancy who desire medical therapy with methotrexate will occasionally experience pain because of necrosis of the villi. In this situation, the pain is difficult to differentiate from rupture of the tubal pregnancy. Microlaparoscopy with the patient under local anesthesia can be used to obtain a rapid diagnosis in these circumstances and possibly prevent an unnecessary procedure using general anesthesia. Women with polycystic ovarian syndrome who are resistant to medical therapy, those for whom medical therapy may be cost-prohibitive, and those who have concerns about multiple gestations may benefit from microlaparoscopic ovarian drilling . Reproductive endocrinologists will appreciate the availability of minimally invasive microlaparoscopy for infertility work because of the decreased risk of adhesion formation. In assisted reproductive technology (ART), gamete intrafallopian transfer (GIFT) and tubal embryo transfer (TET) have been reported in which microlaparoscopy was used with the patient under local anesthesia with conscious sedation. Many of these procedures can be performed safely and efficaciously in the physician’s office. Advantages of office laparoscopy are summarized in Table 4.
The field of general surgery has embraced microlaparoscopy. Similar to some gynecologic procedures, several general surgeries are being performed using microlaparoscopy in addition to one or more larger instruments. A microlaparoscopic-assisted procedure of increasing acceptance among general surgeons is laparoscopic cholecystectomy. With the exception of a large trocar for removal of the gallbladder, the remainder of the trocars can be 2 mm in diameter. Both general surgeons and gynecologists are performing microlaparoscopic-assisted appendectomies. This procedure has been reported in the awake patient [18,19].
The use of microlaparoscopy in the field of endoscopy continues to grow. Microlaparoscopy has crept into the intensive care unit and emergency room. In the intensive care unit, a postoperative or severely debilitated patient may develop an acute abdomen with an obscure diagnosis. Due to their underlying clinical status, they may not be easily transferred to a traditional hospital operating room. In select patients, a “quick-look” minimally invasive “triage diagnosis” can be obtained at the bedside, possibly avoiding an unnecessary trip to the operating room but providing critical information for the surgeon and internist.
Emergency room laparoscopy is a viable option in select cases of both blunt and penetrating abdominal trauma. Hemodynamically stable patients may be candidates for diagnostic microlaparoscopy with conscious sedation in the emergency room. Depending on the findings, some patients may avoid an exploratory laparotomy in the operating room.
The primary limitations with microlaparoscopy arise from the moderate learning curve for laparoendoscopic surgeons who are used to larger, less delicate laparoscopic tools. Although microlaparoscopy can be performed with the patients under general anesthesia, many procedures can be safely and effectively performed with conscious sedation in the physician’s office, intensive care unit, emergency room, and traditional hospital or outpatient operating room. As we begin the 21st century, microlaparoscopy will continue to play an ever-increasing role in the arena of minimally invasive surgery.
Figure 1. Comparison of the minimally invasive 2-mm microlaparoscope (top) to a traditional 10-mm rod lens laparoscope (bottom).
Figure 2. Dr Oscar D. Almeida, Jr, performs conscious pain mapping.
Address reprint requests to: Oscar D. Almeida, Jr, MD, FACOG, FACS, Clinical Associate Professor of Obstetrics and Gynecology, University of South Alabama College of Medicine, 6701 Airport Blvd, Ste B-127, Mobile, AL 36608, Tel: 251 639 1847, Fax: 251 639 9290, E-mail: email@example.com
After obtaining his undergraduate degree in Zoology from California State University at Long Beach, Dr Almeida received his medical degree at the University of South Alabama College of Medicine. Currently a clinical associate professor in the Department of Obstetrics and Gynecology at the University of South Alabama, his special interests lie in the evaluation and treatment of chronic pelvic pain and endometriosis through microlaparoscopy. Dr Almeida has pioneered several techniques and published extensively in the field of microlaparoscopy, office laparoscopy, and conscious pain mapping. He wrote the first textbook on the subject, Microlaparoscopy, published in 2000 by John Wiley & Sons, Inc, New York.
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10. Almeida OD Jr. A new microlaparoscopic technique: microlaparoscopic assisted vaginal hysterectomy (MAVH). J Am Assoc Gynecol Laparosc. 2001;8(3):S3.
11. Almeida OD Jr, Val-Gallas, Browning JL. A protocol for conscious sedation in microlaparoscopy. J Am Assoc Gynecol Laparosc. 1997;4(5):591-594.
12. Almeida OD Jr. Awake microlaparoscopy with the Insuflow® device. JSLS. 2002;6:199-201.
13. Almeida OD Jr, Val-Gallas JM. Conscious pain mapping. J Am Assoc Gynecol Laparosc. 1997;4(5):587-590.
14. Almeida OD Jr, Val-Gallas JM, Rizk B. A novel classification for conscious pain mapping. Egypt J Fertil Steril. 1997;1:53-58.
15. Almeida OD Jr. Microlaparoscopic conscious pain mapping in the evaluation of chronic pelvic pain: a case report. JSLS. 2002;6:81-83.
16. Howard FM. Conscious pain mapping. In: Howard FM, ed. Pelvic Pain: Diagnosis & Management. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000:67-74.
17. Almeida OD Jr, Rizk B. Microlaparoscopic ovarian drilling under local anesthesia. Mid East Fertil Soc J. 1998;3(2):189-191.
18. Almeida OD Jr, Val-Gallas JM, Rizk B. Appendectomy under local anesthesia following conscious pain mapping with microlaparoscopy. Hum Reprod. 1998;13(3):588-590.
19. Almeida OD Jr, Val-Gallas JM. Conscious pain mapping of the appendix with microlaparoscopy for the evaluation of women with chronic pelvic pain. Middle East Fertil Soc J. 1999;4(3):233-236.
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