Laparoscopic Surgery Diploma Questions: Safe Entry, Hysterectomy, Myomectomy, and Hysteroscopy
Safe Entry Techniques
Question 1: Primary Entry Methods
Which four laparoscopic entry techniques are equally recommended as first-line approaches in patients without previous laparotomy or specific risk factors?
Answer: The four equally acceptable first-line techniques are: (1) blind trans-umbilical trocar insertion after Veress needle pneumoperitoneum, (2) open laparoscopy (Hasson technique), (3) left upper quadrant entry, and (4) direct trans-umbilical trocar insertion without prior pneumoperitoneum 1, 2, 3. No single technique has been proven superior to the others in preventing major complications 2.
Question 2: Veress Needle Angle
How should the angle of Veress needle insertion be adjusted based on patient body habitus?
Answer: The insertion angle must vary from 45 degrees in non-obese women to 90 degrees in obese women 1. This adjustment accounts for the different distances between the anterior abdominal wall and retroperitoneal vessels based on body mass index 1.
Question 3: Veress Needle Safety
What is the most reliable indicator of correct intraperitoneal Veress needle placement?
Answer: The Veress intraperitoneal pressure (VIP-pressure ≤10 mm Hg) is the most reliable indicator of correct placement 1. Multiple safety tests provide minimal useful information, and waggling the needle side-to-side must be avoided as this can enlarge a 1.6 mm puncture to a 1 cm injury in viscera or vessels 1, 3.
Question 4: Previous Laparotomy
What is the recommended entry technique for patients with previous midline laparotomy?
Answer: Initial entry must be performed at a distance from existing scars, with left upper quadrant (Palmer's point) laparoscopic entry being the most recommended technique 2, 3. Micro-laparoscopy in the LUQ is the most completely evaluated technique for this indication, though open laparoscopy at a distance from scars is also an option 2.
Question 5: Pneumoperitoneum Pressure
What intra-abdominal pressure should be achieved before primary trocar insertion using the Veress technique?
Answer: Adequate pneumoperitoneum is determined by pressure of 20-30 mm Hg, not by predetermined CO₂ volume 1. The high intraperitoneal pressure (HIP) technique, increasing pressure to 25 mm Hg immediately before trocar insertion, does not adversely affect cardiopulmonary function in healthy women 1, 3.
Hysterectomy
Question 6: Surgical Approach Selection
What is the preferred route for hysterectomy when indicated for benign conditions?
Answer: The least invasive route should always be performed, with vaginal or laparoscopic hysterectomy preferred over abdominal approach 4. Vaginal hysterectomy is associated with shorter operating times and faster return to normal activities, while laparoscopic hysterectomy offers shorter hospital stays and lower wound infection rates compared to abdominal hysterectomy 4. Abdominal hysterectomy should be avoided when less invasive options are available 4.
Question 7: Minimally Invasive Surgery in Endometrial Cancer
When is minimally invasive surgery recommended for hysterectomy in endometrial cancer?
Answer: Minimally invasive surgery (laparoscopic/robotic) is recommended for low- and intermediate-risk endometrial cancer and can be considered for high-risk disease 4, 5. This approach maintains oncologic safety while providing benefits of reduced hospital stay and faster recovery 4.
Question 8: Ovarian Conservation
In which patients can ovarian preservation be considered during hysterectomy for endometrial cancer?
Answer: Ovarian preservation can be considered in women <45 years old with <50% myometrial invasion, no obvious extra-uterine disease, and no family history of ovarian cancer risk 4. This avoids precipitating early menopause and associated cardiovascular risks 4.
Question 9: Hysterectomy Complications
What are the major long-term risks associated with hysterectomy that should influence treatment decisions?
Answer: Hysterectomy is associated with increased risk of cardiovascular disease, osteoporosis and bone fracture, dementia, and mood disorders, with increased mortality especially when performed at young age 4. Short-term complications include abscess, venous thromboembolism, ureteral/bowel/bladder injury, bleeding requiring transfusion, and vaginal cuff complications 4.
Question 10: Postoperative Care
What essential postoperative monitoring should be implemented after hysterectomy?
Answer: Daily VTE risk assessment with validated tools is mandatory, with pharmacological combined with mechanical prophylaxis for very high-risk patients 4. Urinary catheter use should be evaluated daily and removed as early as possible 4. Patients over 65 years require regular delirium screening with non-pharmaceutical interventions 4.
Myomectomy
Question 11: Hysteroscopic vs. Laparoscopic Myomectomy
Which myomectomy approach is indicated for submucosal fibroids versus intramural/subserosal fibroids?
Answer: Hysteroscopic myomectomy is indicated for submucosal fibroids, while laparoscopic or open myomectomy is performed for subserosal or intramural fibroids 4. Patients with significant intramural or subserosal fibroid burden causing bulk symptoms are less likely to experience relief from hysteroscopic myomectomy alone 4.
Question 12: Laparoscopic Myomectomy Benefits
What are the advantages of laparoscopic over open myomectomy?
Answer: Laparoscopic myomectomy is associated with shorter hospital stays and faster return to usual activities compared to open myomectomy, with similar operative times and postoperative complications when robotic-assisted techniques are used 4. Both procedures provide improved quality of life for up to 10 years 4.
Question 13: Hysteroscopic Myomectomy Risks
What are the major complications of hysteroscopic myomectomy?
Answer: Major risks include uterine perforation, fluid overload, need for blood transfusion, bowel or bladder injury, endomyometritis, and need for reintervention 4. Laparoscopic monitoring during hysteroscopic procedures can detect uterine perforation in real-time 6.
Basic Hysteroscopy
Question 14: Hysteroscopy Safety Precautions
What preoperative and intraoperative measures reduce complications during operative hysteroscopy?
Answer: Preoperative use of endometrial thinning agents, reduction of operating time, and avoiding cutting too deeply into the myometrium are essential precautions 7. Complications occur more frequently with operative versus diagnostic hysteroscopy and include uterine perforation, hemorrhage, fluid overload, gas embolization, and hyponatremia 7.
Question 15: Combined Hysteroscopy-Laparoscopy
What are the advantages of performing laparoscopy simultaneously with hysteroscopy?
Answer: Combined procedures allow laparoscopic confirmation of diagnosis, detection of causes of pelvic pain, identification of ovarian cysts/endometriosis/adhesions, and real-time monitoring for uterine perforation 6. This approach is safe, effective, reduces patient pain, and saves time and money while allowing simultaneous treatment of both intrauterine and pelvic pathology 6.