A standard laparoscope is a 1 cm tube, which you insert through a tiny incision near a patient's umbilicus, and which you can use to inspect her abdomen. You can also do a variety of minor operations through it, including tying her tubes. Because a standard laparascope with its associated equipment costs about $3000, and is fragile, a simpler and more robust instrument, the ''Laprocator', has been extensively used by the JHPIEGO programme (Johns Hopkins Program of International Education in Gynaecology and Obstetrics), and is specially adapted for use under the difficult conditions of the developing world. It is only suitable for tubal ligation and diagnostic inspection of the peritoneal cavity, and not for the other procedures which are possible with a standard laparoscope. Unfortunately, like a standard laparoscope, it also needs special training, which is usually given at the JHPIEGO courses, a laprocator being given free to all those who pass the course, and who can demonstrate that they have adequate facilities. It is described here, so that it becomes more widely known. One contributor comments that a standard laparoscope with a separate ring applicator is smaller, safer, and easier to use than a laprocator, the only advantage of which is that JHPIEGO provides it free!
- A laprocator is robust, reliable, and relatively inexpensive, and is popular with patients. It has a bulb, not a fibreoptic light source; and you can use it with local anaesthesia, but you will find it more convenient with general anaesthesia. You will need a cylinder of carbon dioxide, but if you can get oxygen, you should be able to get this too.
If you are skilled and have a good team, laparoscopic ligation is quick, and safe, and can be done on outpatients. The incision is so small that it soon becomes almost invisible. If you use carbon dioxide and not air, there is no risk of air embolism. If you use rings or clips instead of diathermy, you will not injure the gut.
There are disadvantages. A laprocator is delicate, and the possible complications include burns, air embolism, and bleeding, and if you don't sterilize it properly, peritonitis.
You can introduce the laprocator through a small laparotomy incision, or you can use a special trocar called the Verres needle. If you are a beginner, start with the open laparoscopy method described below, which is safer and does not need a CO[,2] supply. The only disadvantage of the open method is that the skin incision is slightly longer, and needs two sutures instead of one.
Laparoscopy has caught the imagination of doctors and patients. Illogically perhaps, possessing one is likely to increase your interest in sterilization. If you demonstrate it at at health education talks (M 7.1), you can be sure that some mothers will come forward afterwards to have their tubes tied.
LAPROCATOR, JHPIEGO pattern (JHP), with Verres gas needle, and carbon dioxide supply, in case complete, one only.
USING THE LAPROCATOR INDICATIONS. (1) For sterilization. (2) For the diagnosis of PID, endometriosis, and the exclusion of ectopic pregnancy.
CONTRAINDICATIONS. (1) Most lower abdominal scars. If you are experienced you can do a laparoscopy, if the scar was for a lower-segment Caesarean section, because it seldom causes adhesions between the gut and the abdominal wall. (2) A history of chronic PID with possible adhesions. (3) Extreme obesity. Mild obesity is an indication for laparoscopy, because the incision does not have to be larger if a patient is mildly obese, as it does in a minilap.
EQUIPMENT. A laprocator, with its carbon dioxide supply; a uterine manipulator. If possible sterilize it in ''Cydex', otherwise immerse it in aqueous 0.5% chlorhexidine changed weekly.
ANAESTHESIA. (1) General anaesthesia. (2) Pethidine with diazepam (A 8.8). (3) Ketamine (A 8.1). (4) Local infiltration (A 6.7).
PREPARATION. Put the patient into the semilithotomy position, as for a minilap. Clean her abdomen, perineum, and vagina. Empty her bladder. Pass a uterine manipulator and attach it to her cervix. Move up to her abdomen. Wait until she is relaxed and not coughing. Tilt her head downwards.
LAPAROSCOPY [s7]WITH THE VERRES GAS NEEDLE If you are right-handed, stand on her left. Move your mask down your nose to prevent your breath clouding the lens. Hold her abdominal wall with your left hand, and insert the needle with your right hand. Hold it by the barrel, so that the blunt trocar is free to slide up and allow the cutting needle to enter. Make a nick in the lower border of her umbilicus, and insert the Verres needle through it almost at right angles to her skin, pointing it slightly towards her feet. Insert it firmly and feel it penetrate her rectus sheath and peritoneum.
Use the following methods to check that the end of the Verres needle is indeed in her peritoneal cavity: (1) You are able to move its point freely from side to side. Be careful as you do this, and don't use force, because you may tear adhesions. (2) When you lift up her abdominal wall, the pressure shown on the gauge falls, and a drop of saline, placed over the hub of the needle, is sucked in. (3) CO[,2] flows into her peritoneal cavity with little resistance. There will be a normal range of insufflation pressures for your machine, shown in green on the dial. If the pointer moves to the red area, the needle is probably in the wrong place. (4) A small volume of CO[,2] obliterates the normal dullness to percussion over her liver.
Let the CO[,2] flow into her peritoneal cavity. A multip who is being sterilized needs up to 4 litres (2 are usually enough). A nullip who is having a laparoscopy for diagnosis needs 2 or 3 litres. The insufflator does not measure volume, but carbon dioxide flows at the rate of a litre a minute, so allow it to flow for 2 minutes.
Remove the Verres needle, and enlarge the skin incision with a scalpel, until you have a 1.5 cm horizontal incision at the lower border of her umbilicus. Insert the trocar and cannula. Push it in almost at right angles to her skin, pointing slightly towards her feet. You will have to push quite hard, so keep the trocar sharp. A blunt trocar is dangerous, and much more difficult to control. Prevent it from going in too far by placing one finger alongside the cannula as a guard. When it is through her peritoneum, withdraw the trocar into the cannula, and insert the cannula fully. Withdraw the trocar fully and insert the laparoscope. Touch her gut to clear the objective lens.
Look for her tubes. Recognize them because: (1) They join her uterus at the cornua, whereas her round and ovarian ligaments join it below the cornua. (2) They are in the middle behind her round ligaments and in front of her ovarian ligaments. (3) They end in fimbriae. (3) You can pull them up to form a loop, much more easily than you can pull up a loop of her round or ovarian ligaments.
If you have difficulty manipulating her tubes, try inserting the gas needle in the midline 5 cm below her umbilicus. Turn the knob on it to prevent gas leaking. Use it to help you manipulate her tubes.
Apply one ring or two clips to each tube. Withdraw the laparoscope. Open the valve to expel the CO[,2], and remove the cannula. Close her skin with one catgut suture or a skin clip.
Fig 15-6 THE JHPIEGO LAPROCATOR. A, a view through the eyepiece. B, the instrument in use. 1, the patient's round ligaments. 2, her tubes. 3, her ovarian ligaments. See also Fig. 20-17.
OPEN LAPAROSCOPY [s7]WITH THE LAPROCATOR INDICATIONS. (1) Beginners. (2) The absence of a CO[,2] supply.
METHOD. Apply two tenaculum forceps to the floor of her umbilicus, one towards her head and the other towards her feet. Pull on them to lift her umbilicus away from her gut.
Make a horizontal incision with a scalpel through her umbilicus, her abdominal wall, and her peritoneum into her abdomen. All the layers of her abdomen are adherent here, so you will go through them as a single layer. Make the incision at least 2 cm long, and if necessary longer. When your are in her abdominal cavity, insert the laparoscope with its cannula, but without its trocar. Use two towel clips to tighten the skin around it and prevent gas leaking.
Fill her peritoneum with two litres of gas. If necessary, you can safely use air instead of CO[,2], because there is now no danger of air embolism.
Proceed as if you were using a laprocator by the closed method above. The skin incision is a bit longer, and you may need two sutures.
Using air for the pneumoperitoneum. The laprocator control box has a small air reservoir which is filled by a rubber pump. Switch the gas tube to the patient from the carbon dioxide output to the air output, and fill her abdomen with air through the cannula. Air is only slowly absorbed, so take care to let it all out when you have finished.
If you use air through the Verres needle for closed laparoscopy, remember the possibility of air embolism (uncommon). Also, if you allow air to get into the wrong place, for example into the extraperitoneal tissues, you will not be able to wait a few minutes and try again, because it takes hours to be reabsorbed.
DIFFICULTIES [s7]WITH THE LAPROCATOR If CO[,2] GOES INTO THE EXTRAPERITONEAL TISSUES, it will take a minute or two to be absorbed. Wait until it has gone and then try again.
If there is EXTENSIVE BLEEDING, because you have damaged her mesenteric vessels (rare), do a laparotomy and tie them, taking the precautions listed in Section 66.10.
If you have DAMAGED HER AORTA OR VENA CAVA, do a laparotomy. This should never happen if you go in below her umbilicus and keep in the midline. But it has happened!
If you CANNOT SEE HER TUBES, abandon the procedure, or do a laparotomy.
If you mistakenly put a RING ON AN IMPORTANT WRONG STRUCTURE, you can usually pull it off again by catching its edge with one prong of the laprocator forceps. If this fails do a laparotomy.
If you PERFORATE HER GUT with the trocar, do a laparotomy, oversew the perforation with two layers of 2/0 catgut, and give her antibiotics (2.9). There is no need for a proximal colostomy, unless her gut is diseased.
If you PERFORATE HER GUT with the insufflation needle, give her antibiotics and observe her closely. Don't do a laparotomy unless she develops signs of peritonitis.