Accessory trocar sites facilitate complex technique
We usually use three accessory sites. Two of them are lower-quadrant ports that are placed 2 cm medial and 2 cm cephalad to the anterior superior iliac spine. This area generally lies well away from the inferior epigastric vessels and remains above the area of the ilioinguinal and iliohypogastric nerves, making it a safer point of insertion.15 One trocar is 5 mm in size and the other is 10 mm. The larger one is used to extract the specimen.
We place an additional 5-mm port lateral to the rectus muscle at the level of the umbilicus. This allows the principal surgeon to use two instruments (a toothed forceps and scissors) comfortably while the assistant holds the laparoscope and assists with a grasper.
Does the type of trocar matter?
No randomized studies have directly compared all types of trocars. Options include:
- a pyramidal tip (as in reusable trocars) or shielded tip
- radial expansion
- visible entry
- blunt (Hasson-type) trocar.
Safety data on direct comparison of trocars are limited, but it appears that a radially expanding trocar may offer less port-site pain and potentially less bleeding than a traditional cutting trocar.16 Moreover, the rate of hernia at the port site appears to be relatively low with a radially expanding trocar, even when fascia is left unclosed at a 10-mm site.17
None of these trocars appears to be clearly superior at avoiding visceral or vascular injury.
Technique of laparoscopic cyst removal
A video clip of the surgery is linked to this article in the Video Library at www.obgmanagement.com. In this case, a trocar was inserted in the left upper quadrant, and a laparoscopic cystectomy was initiated using the trocars already specified.
The peritoneal cavity and adnexa were inspected, followed by pelvic washings, as detailed in TABLE 2 . Next, the ovarian cortex was incised ( FIGURE 1A ) with scissors using bipolar or unipolar energy, typically at a low power setting, such as 12 to 15 watts.
It was relatively easy to develop a tissue plane between the cortex and underlying dermoid cyst using simple or aqua-dissection ( FIGURE 1B and C ). The cyst was enucleated without rupture and inserted into a specimen bag through a 10-mm port ( FIGURE 1D ). (The specimen bags generally are available in 10-mm and 15-mm sizes.) Once the trocar was removed, the entire specimen was brought out through the incision ( FIGURE 1E ).
Cystic masses can generally be carefully aspirated using a laparoscopic needle or angiocath, or they can be incised and drained using a standard suction device. Manufacturers of most specimen bags do not recommend the morcellation of tissue within the bag because of the potential for rupture of the bag with tumor spillage or injury to underlying structures.
Occasionally, the mass remains too large to remove after drainage of the cyst fluid. Remedies include enlarging the port site with a scalpel or using a gallbladder speculum to increase the diameter of the port site ( FIGURE 1E ). If possible, the incision should be large enough to deliver the entire bag intact. Use of excessive force will rupture the bag and may cause the specimen to be lost or malignant cells to be inadvertently spilled (in the case of a cancer diagnosis).
TABLE 2
Take these 10 steps to safe laparoscopic surgery
| Examine the anesthetized patient |
| Enter the abdomen |
| Inspect the mass and peritoneal surfaces, including the diaphragm. Biopsy sites suspicious for metastasis and obtain frozen section |
| Perform pelvic and abdominal washings |
Closely inspect adnexa. If findings are not suggestive of malignancy, proceed with laparoscopy. If findings indicate obvious malignancy
|
Perform cystectomy or oophorectomy
|
| Inspect for hemostasis |
| Place cyst/ovary in endopouch |
| Open bag at abdominal wall and remove for frozen section |
| Reinspect and close |
Avoid:
|
FIGURE 1 Laparoscopic cyst removal
Begin by incising the cortex using scissors with or without an energy source.
Dissect the cyst free from the cortex using sharp dissection.
Remove the cyst from the ovary.
Place the cyst in a specimen bag, and …
… bring it to the surface for extraction. The abdominal incision may have to be enlarged to accommodate the specimen.
CASE 1: OUTCOME
The patient’s cyst is removed intact and she is discharged home. Rupture of a dermoid cyst is not associated with any problems as long as copious irrigation is used to aspirate the cyst content.18 Other cysts, such as endometriomas, may not be as easily dissected, and rupture is inevitable.