Ceana H. Nezhat, MD

Despite marked advances in non-invasive diagnostic         imaging, accurate diagnosis of pelvic disease frequently depends on         direct visualization. Microlaparoscopy provides a definitive diagnosis with         low morbidity and cost and is appropriate for diagnostic procedures such         as evaluation of chronic pelvic pain

 and other indications as         summarized in Table 1. It is also useful in diagnosing endometriosis,         ruptured cysts, and inguinal hernia. Second-look microlaparoscopy         can be done after ovarian cancer treatment or adhesiolysis to assess recurrence.         In addition, it allows accurate diagnosis of peritoneal factor         causes of infertility, including tubal adhesions,

 and         results of chromopertubation.

 The feasibility of         sterilization reversal versus referral for in vitro fertilization can         also be determined.

Therapeutic options can be limited in         microlaparoscopy, especially if the procedure is performed under local         anesthesia in an office setting. Although the optical quality of         the microlaparoscope is good, the field of view is smaller than larger         diameter scopes. Newly developed 2-3 mm suction irrigators are resolving         the problem of performing peritoneal lavage (Figure 2) without         a larger port. Most bleeders can be controlled with small diameter         coagulating devices (Figure 3). Small diameter instruments such as         graspers and scissors are currently available, with improved versions in         development, but are delicate and need to be handled with care.         Also, it can be difficult to remove bulky tissue through small         trocars.

Table                     1. Indications for Diagnostic Microlaparoscopy

Pain Mapping
                         Differential Diagnosis:


                 Figure 3. 2.7 mm BICAP® Probe

However, microlaparoscopy is highly         efficacious in many cases, and careful patient selection is key to the         success of the procedure. It is not an entirely painless procedure, but         discomfort is usually well tolerated. Patients with psychiatric         illnesses, especially anxiety disorders, may be unable to tolerate         the stress of being alert during the operation. Any contraindication for         laparoscopy is a contraindication for microlaparoscopy.

The general principle of the procedure deviates         little from standard laparoscopy and can be performed in various         settings, but is commonly done in a hospital minor procedure room. When         done in the office treatment room, adequate monitoring, resuscitation         equipment, and rapid access to a tertiary care center must always         be available.

After the equipment and supplies are on         hand (Table 2), the patient empties her bladder and is placed in         the dorsal lithotomy position. A blood pressure cuff and pulse oximeter         are applied, and a Hep-Lock needle (18-22 gauge) is inserted. If         necessary, a paracervical block is administered and a uterine         manipulator inserted. Bupivacaine or lidocaine (5-10 ml) is injected         with a 25-27 gauge needle through all layers of the abdomen at the         Veress needle insertion site.

Table                     2. Recommended Equipment & Supplies

Figure 4. Reusable Small                 Diameter Trocar and Veress Needle

Patient comfort is an important factor         - especially regarding the introduction of trocars. A disposable         cannula with the Veress needle trocar can be used. The reusable         small diameter cannula with disposable or reposable Veress needle trocar         consistently remains sharp and is a reasonably priced alternative         (Figure 4). The Veress needle trocar and cannula are introduced         while the abdominal wall is manually elevated, and the uterus held down         by the intrauterine manipulator. The Veress needle trocar is         removed, leaving the cannula in place, and the microlaparoscope         inserted. The extension tube is connected to the CO

         insufflator, and about 500-600 ml is passed into the peritoneal cavity.         The insufflation rate should allow adequate visualization of the organs         to be examined. Intra-abdominal pressure is kept at 8-10 mm Hg, with a         maximum of 15 mm Hg. Only small volumes (500-2000 ml) of gas are infused          so patient discomfort and vagal stimulation are minimized.         Ancillary tools for manipulation, aspiration, culturing, or biopsies are         inserted through secondary 2-3 mm trocars. A laser fiber can be passed         through an ancillary 3 mm port permitting vaporization of small         endometrial implants and incision of minimal adhesions.[

 At         procedure's end, the gas is removed and the incision is closed with         adhesive strips. The patient is then monitored, and is usually         discharged within 2-4 hours.

Before introducing microlaparoscopy         into the office setting, the physician must first obtain adequate         training, become familiar with new equipment, learn proper patient         selection, and have a staff trained in administering and monitoring         analgosedation. It is advisable to perform the first few         microlaparoscopy cases under general anesthesia, which allows the         surgeon to become familiar with the scope and its placement, and to         become comfortable with the microlaparoscopic video image of the         surgical field.

Microlaparoscopy has the potential to         significantly impact diagnostic evaluation, and its role in the         ambulatory setting is now being explored.  Advantages to         the patient include less overall pain, shorter procedure time,         fewer anesthesia risks, increased participation during surgery, and         faster recovery. The surgeon benefits from decreased scheduling and         preoperative delays, hospital paperwork and travel time. Local         anesthesia is safer, allows the surgeon to communicate with the patient during         the procedure, and offers a shorter and less morbid post-operative         recovery.

    1. Nezhat C, Nezhat F, Luciano A, Siegler A, Metzger D, Nezhat CH, editors: Operative Gynecologic Laparoscopy: Principles and Techniques. New York: McGraw-Hill, 1995.

    2. Palter SF, Olive DL: "Office microlaparos-copy under local anesthesia for chronic pelvic pain." J Am Assoc Gyne Laparos, 1996, 3:359-364.

    3. Faber BM, Coddington CC III: "Micro-laparoscopy: a comparative study of diagnostic accuracy." Fertil Steril 1997, 67:952-954.

    4. Haeusler G, Lehner R, Hanzal E, Kainz C: "Diagnostic accuracy of 2 mm microlaparoscopy." Acta Obstet Gyne Scand 1996, 75:672-675.

    5. Feste JR: "Use of optical catheters for diagnostic office laparoscopy." J Reprod Med 1996, 41:307-312.

    6. Dorsey JH, Tabb CR: "Mini-laparoscopy and fiber-optic lasers." Obstet Gyne Clin N Am 1991, 18:613-617.

Dr. Nezhat is clinical assistant professor of OB/GYN, and co-director, Stanford Endoscopy Center for Training and Technology, Stanford University School of Medicine, Stanford, CA. He is also clinical associate professor of OB/GYN, Mercer University School of Medicine in Macon, GA, and Director, Center for Special Pelvic Surgery, in Atlanta, GA.

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