Laparoscopy, Gynecologic


Laparoscopy, Gynecologic

Synonym/acronym: Gynecologic pelviscopy, gynecologic laparoscopy, pelvic endoscopy, peritoneoscopy.

Common use

To visualize and assess the ovaries, fallopian tubes, and uterus toward diagnosing inflammation, malformations, cysts, and fibroids and to evaluate causes of infertility.

Area of application

Pelvis.

Contrast

Carbon dioxide (CO2).

Description

Gynecologic laparoscopy provides direct visualization of the internal pelvic contents, including the ovaries, fallopian tubes, and uterus, after insufflation of carbon dioxide (CO2). It is done to diagnose and treat pelvic organ disorders as well as to perform surgical procedures on the organs. In this procedure, a rigid laparoscope is introduced into the body cavity through a 1- to 2-cm periumbilical incision. The endoscope has a microscope to allow visualization of the organs, and it can be used to insert instruments for performing procedures such as biopsy (e.g., biopsy of suspected endometrial lesions) and tumor resection. Under general or local anesthesia, the peritoneal cavity is inflated with 2 to 3 L of CO2. The gas distends the abdominal wall so that the instruments can be inserted safely. Advantages of this procedure compared to an open laparotomy include reduced pain, reduced length of stay at the hospital or surgical center, and reduced time off from work.

This procedure is contraindicated for

  • high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alert Patients with bleeding disorders, especially those associated with uremia and cytotoxic chemotherapy.
  • high alert Patients with cardiac conditions or dysrhythmias.
  • high alert Patients with advanced respiratory or cardiovascular disease.
  • high alert Patients with intestinal obstruction, abdominal mass, abdominal hernia, or suspected intra-abdominal hemorrhage.

Indications

  • Detect ectopic pregnancy and determine the need for surgery
  • Detect pelvic inflammatory disease or abscess
  • Detect uterine fibroids, ovarian cysts, and uterine malformations (ovarian cysts may be aspirated during the procedure)
  • Evaluate amenorrhea and infertility
  • Evaluate fallopian tubes and anatomic defects to determine the cause of infertility
  • Evaluate known or suspected endometriosis, salpingitis, and hydrosalpinx
  • Evaluate pelvic pain or masses of unknown cause
  • Evaluate reproductive organs after therapy for infertility
  • Obtain biopsy specimens to confirm suspected pelvic malignancies or metastasis
  • Perform tubal sterilization and ovarian biopsy
  • Perform vaginal hysterectomy
  • Remove adhesions or foreign bodies such as intrauterine devices
  • Treat endometriosis through electrocautery or laser vaporization

Potential diagnosis

Normal findings

  • Normal appearance of uterus, ovaries, fallopian tubes, and other pelvic contents

Abnormal findings related to

  • Ectopic pregnancy
  • Endometriosis
  • Ovarian cyst
  • Ovarian tumor
  • Pelvic adhesions
  • Pelvic inflammatory disease
  • Pelvic tumor
  • Salpingitis
  • Uterine fibroids

Critical findings

  • Ectopic pregnancy
  • Foreign body
  • Tumor with significant mass effect

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Factors that may impair clear visualization

    • Gas or feces in the gastrointestinal (GI) tract resulting from inadequate cleansing or failure to restrict food intake before the study.
    • Retained barium from a previous radiological procedure.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.

  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated.
    • Patients who are in a hypoxemic or hypercapnic state will require continuous oxygen administration.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the abdominal and pelvic organs.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, or sedatives.
  • Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Ensure that this procedure is performed before any barium studies.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect coagulation (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort. Inform the patient that the procedure is performed in a surgery department by an HCP and support staff and takes approximately 30 to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications.
  • Inform the patient that a laxative and cleansing enema may be needed the day before the procedure, with cleansing enemas on the morning of the procedure, depending on the institution’s policy.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Complications of the procedure may include bleeding and cardiac arrhythmias. Patients with acute infection or advanced malignancy involving the abdominal wall are at increased risk for infection because organisms may be introduced into the normally sterile peritoneal cavity.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has complied with dietary, fluid, and medication restrictions for at least 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined.
  • Ensure that nonallergy to anesthesia is confirmed before the procedure is performed under general anesthesia.
  • Assess for completion of bowel preparation according to the institution’s procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Obtain and record baseline vital signs.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
  • Administer medications, as ordered, to reduce discomfort and to promote relaxation and sedation.
  • Place the patient on the laparoscopy table. If general anesthesia is to be used, it is administered at this time. Place the patient in a modified lithotomy position with the head tilted downward. Cleanse the abdomen with an antiseptic solution, and drape and catheterize the patient, if ordered.
  • The HCP identifies the site for the scope insertion and administers local anesthesia if that is to be used. After deeper layers are anesthetized, a pneumoperitoneum needle is placed between the visceral and parietal peritoneum.
  • CO2 is insufflated through the pneumoperitoneum needle to separate the abdominal wall from the viscera and to aid in visualization of the abdominal structures. The pneumoperitoneum needle is removed, and the trocar and laparoscope are inserted through the incision.
  • The HCP inserts a uterine manipulator through the vagina and cervix and into the uterus so that the uterus, fallopian tubes, and ovaries can be moved to permit better visualization.
  • After the examination, collection of tissue samples, and performance of therapeutic procedures (e.g., tubal ligation), the scope is withdrawn. All possible CO2 is evacuated via the trocar, which is then removed. The skin incision is closed with sutures, clips, or sterile strips and a small dressing or adhesive strip is applied. After the perineum is cleansed, the uterine manipulator is removed and a sterile pad applied.
  • Observe/assess the incision site for bleeding, inflammation, or hematoma formation.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet, fluids, and medication, as directed by the HCP.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Instruct the patient to restrict activity for 2 to 7 days after the procedure.
  • Instruct the patient in the care and assessment of the incision site.
  • If indicated, inform the patient of a follow-up appointment for the removal of sutures.
  • Inform the patient that shoulder discomfort may be experienced for 1 or 2 days after the procedure as a result of abdominal distention caused by insufflation of CO2 into the abdomen and that mild analgesics and cold compresses, as ordered, can be used to relieve the discomfort.
  • Emphasize that any persistent shoulder pain, abdominal pain, vaginal bleeding, fever, redness, or swelling of the incisional area must be reported to the HCP immediately.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include cancer antigens, Chlamydia group antibody, CT abdomen, CT pelvis, HCG, MRI pelvis, Pap smear, progesterone, US pelvis, and uterine fibroid embolization.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.