1. Placement of Hasson cannula
Note: The patient should remain supine with no degree of Trendelenburg before the insertion of all trocars to prevent injury to the aorta, the vena cava, and the iliac vessels.
a. Umbilicus: The depths of the umbilicus must be thoroughly cleaned with cotton swabs and betadine to remove all lint and powder.
b. Vertical infraumbilical skin incision: The surgeon elevates the skin of umbilicus at 6 o’clock with a toothed forceps, while the assistant spreads the umbilicus open with a tonsil clamp. The surgeon makes a vertical incision through the skin starting near the base of the umbilicus. The surgeon spreads the subcutaneous tissues with tonsil clamps to identify the white anterior fascia.
e. Vertical fascial incision: Using two S clamps, the assistant separates the subcutaneous tissue and exposes the fascia. The surgeon identifies, grasps, and elevates the white anterior fascia with two straight Kocher clamps and incises in the midline with scalpel. The surgeon spreads the incision with the tonsil clamp. The rectus muscles should be visible. The surgeon places two stay sutures through the fascia for later fixation of the Hasson cannula.
d. Vertical incision in posterior sheath: Using two S clamps, the assistant separates the areolar tissue to expose the posterior sheath. The surgeon identifies, grasps, and elevates the white posterior sheath with two tonsil clamps. The surgeon carefully incises the posterior sheath with scissors. (Occasionally the peritoneum is incised at the same time.)
e. Vertical incision in peritoneum: Using two S clamps, the assistant separates the areolar tissue to expose the peritoneum. The surgeon identifies, grasps, and elevates the white peritoneum with two tonsil clamps, being observant for underlying bowel adhesions.
The surgeon incises the peritoneum vertically with scissors. In obese patients, the peritoneum may be entered bluntly with the index finger. Neither technique guarantees prevention of bowel injury.
f. Insertion of Hasson cannula: With confirmation of intraabdominal entry, an S retractor is placed thorough the opening and the Hasson cannula is inserted using the retractor as a guide. Insufflate the abdomen with CO2 to a pressure of 18 mm Hg, not to exceed 20 mm Hg. Insert the laparoscope and check for bleeding.
g. Depth adjustment of Hasson cannula: Withdraw the laparoscope into the cannula. Loosen the screw and, holding the acorn tip snugly against the abdomen, withdraw the cannula until the edge of the peritoneum comes into view; then insert the cannula inward 0.5 cm, tighten the screw, and fix the stay sutures.
2. Placement of trocars lateral to deep epigastric vessels
a. Identify deep epigastric vessels: On the video screen, the surgeon identifies the right, deep epigastric vessels. The deep epigastric vessels are marked with the surgeon’s left hand, and the anterior superior iliac spine is marked with the index finger of the surgeon’s left hand. The abdominal wall is transilluminated between the deep epigastric vessels and the anterior superior iliac spine to identify superficial blood vessels. The skin is incised in a clear area.
b. The surgeon inserts the 5-mm trocar through the fascia and peritoneum, keeping the sharp point under constant visual control. The trocar is directed toward the uterus. The trocar is never directed laterally or inferiorly toward the iliac vessels. The sharp stylet is removed, and the calibrated probe is inserted.
c. The procedure is repeated for the left lower quadrant trocar with the deep epigastric vessels marked with the index finger of the surgeon’s left hand and the left anterior superior iliac spine marked with the thumb of the surgeon’s left hand. The suction irrigator is inserted.
3. Bipolar forceps test: The surgeon identifies a fine, superficial blood vessel on the bladder peritoneum and tests the bipolar forceps.
4. Three-step laparoscopic examination
a. Step 1: abdominal examination in supine position
(1) The gall bladder, liver, diaphragms, stomach, omentum, spleen, splenic flexure, transverse colon, hepatic flexure, ascending colon, cecum, and vermiform appendix are examined. Endometriosis, adhesions, malrotation of the bowel, or inflammatory disease are looked for.
(2) A calibrated probe is placed through the right lower quadrant portal to elevate the liver for examination of the gall bladder. The suction irrigator is placed through the left lower quadrant portal to lift the liver to examine the stomach. The omentum is moved to examine the spleen, splenic flexure of the colon, transverse colon, and hepatic flexure of the colon. The left lower quadrant suction irrigator is lain in the right colic gutter, and the cecum is gently lifted and rotated medially. The mobility of the right colon and the status of the vermiform appendix are ascertained.
(3) Where detailed examination of the transverse colon and jejunum is required, the surgeon should stand between the patient’s legs and use two atraumatic instruments to run the bowel.
b. Step 2: examination of small bowel and left colon
(1) With the patient in the steep Trendelenberg position, the surgeon examines the distal 150 cm of ileum, descending colon, sigmoid colon, rectum, rectovaginal pouch of Douglas, and uterosacral ligaments. The ileum is checked for endometriosis, Crohn’s disease, adhesions, and Meckel’s diverticulum. The surgeon examines the descending colon, sigmoid colon, and rectum for endometriosis, malignancy, diverticulitis, and adhesive disease, and the rectovaginal pouch and uterosacral ligaments for endometriosis.
(2) Starting at the ileal-cecal junction, the surgeon uses two instruments to gently elevate the loops of small bowel out of the pelvis to a position above the sacral promontory.
(3) With the uterus anteverted, the surgeon uses two instruments to elevate the sigmoid colon out of the pelvis and put the rectum on stretch for examination. The rectum points like an arrow to any deep rectal endometriosis adherent to the uterosacral ligaments or uterus.
(4) The surgeon examines the rectovaginal pouch for endometriosis. The rectal probe may be used with advantage to differentiate between an open, partially obliterated, and obliterated rectovaginal pouch, and between rectal and pararectal endometriosis. Rectal lesions can be palpated between the rectal and abdominal probes. Deep peritoneal endometriosis can be grasped with a pair of toothed ovarian biopsy forceps, elevated and evaluated for size and depth of invasion.
c. Step 3: alpha sequence examination of the pelvis
(1) Alpha sequence: The surgeon examines the anterior abdominal wall, round ligaments, bladder, anterior uterus, posterior uterus, and uterosacral ligaments; then the left anterior broad ligament, fallopian tube, ovary, ureter, and posterior broad ligament; and last, the right anterior broad ligament, fallopian tube, ovary, ureter, and posterior broad ligament.
(2) The surgeon examines for endometriosis, malignancy, fibroids, salpingitis isthmica nodosa, hydrosalpinx, pelvic adhesions, and congenital anomalies: inguinal hernias, peritoneal pockets, deep recesses in the lateral pelvic wall(s), medial displacement of the ureter(s), and pelvic kidney.
(3) With the uterus retroverted into the rectovaginal pouch, the surgeon examines the anterior abdominal wall, round ligaments, bladder, anterior uterus, and uterine fundus.
(4) With the uterus anteverted, the surgeon examines the posterior uterus, the uterosacral ligaments, and the rectovaginal pouch for a second time.
(5) Then the surgeon examines the left fallopian tube from the cornual angle laterally. The left ovary is examined on all surfaces, elevating it with the contralateral instrument and holding it with the ipsiiateral instrument. Still holding the ovary and tube, the surgeon lifts the sigmoid colon medially with the right lower quadrant instrument and examines the left pelvic wall and posterior broad ligament. The surgeon locates the pulsations of the hypogastric artery. Usually the ureter runs lateral to the hypogastric artery in the posterior pelvis. The relation of the ureter to the hypogastric artery, the infimdibulopelvic ligament, and the uterosacral ligament should be noted.
(6) The surgeon examines the right fallopian tube, the right ovary, the right pelvic wall and broad ligament, the right hypogastric artery, and the ureter in same sequence.
5. Proceed to laparoscopic surgery.
The surgeon checks for complete hemostasis; all trocars are withdrawn under direct visualization and the pneumoperitoneum is decompressed. Fascial sutures are tied on all 10-mm incisions. The skin is closed with inverted 5-0 Vicryl subcuticular sutures or with interrupted nylon skin sutures.
The laparoscopic photographs, preadmission note, and the American Fertility Society Revised Classification form are assembled. The surgeon dictates the operative report immediately in the same sequence as the three-step abdominal—pelvic laparoscopic examination.