During challenging laparoscopic procedures maintaining clear vision is critical to the outcome – A Gynaecological case report using a unique Laparoscope lens cleaning device OpClear®
A 44 year para 1 (LSCS) old woman presented to her GP with sudden onset and worsening pain in her right iliac fossa. She was referred to the oncall surgical team with a suspected diagnosis of a perforated appendix. A subsequent CT of the abdomen & pelvic revealed an inflammatory mass in the right adnexa which appeared to be related to the ovary (figure1). The appendix was seen superiorly to this abnormality and appeared normal. She was then referred to the oncall gynaecology team with a diagnosis of a right tubo-ovarian abscess. The oncall team commenced her on intravenous antibiotics and requested a pelvic ultrasound. A transvaginal scan was undertaken but was difficult given the patient’s body mass index of 53 (weight 131kg). Nonetheless the sonographer reported a 76mm complex cystic structure (figure2), with a medium to large amount of free fluid in the pouch of Douglas (POD). The uterus and left ovary were reported as normal. After 24 hours the patient was switched to oral antibiotics, she continued to improve clinically and was subsequently discharged home.
Of note, earlier in the year she had been referred for investigation and management of her heavy menstrual bleeding. She was keen to pursue surgical options but given her morbid obesity, she was advised that this would only be possible if she lost a significant amount of weight. One week following her discharge she was re-admitted with a recurrence of right iliac fossa pain. A repeat pelvic ultrasound revealed an increase in size of the pelvic mass to 86x50x92mm, again with free fluid but this time low level mobile echoes were also visible (figure 3). After discussions with microbiology she was once again commenced on intravenous antibiotics but to be continued for 10 days. If after 10 days a further pelvic ultrasound showed no change in size, she was to be booked for elective surgery.
Ten days later she was clinically well, but a repeat ultrasound suggested no change in the size of her adnexal mass. She was therefore booked for elective surgery and consented for a laparoscopic and or open incision and drainage of her tubo-ovarian abscess. However she was very insistent that if at all possible could her “womb be removed at the same time”, as her family was complete and her periods were “terrible”. She was therefore consented for a total laparoscopic hysterectomy and removal of fallopian tubes and right ovary.
Under general anaesthesia, a 20mm pneumoperitoneum was created with a standard verres entry technique. A 12mm trochar was then inserted into the umbilicus to facilitate the use of the OpClear® device with a 10mm zero degree laparoscope. The OpClear® was primed prior to insertion into the abdomen. Given the patient’s morbid obesity the anaethestist was reluctant to have a steep trendelenberg “head down” position, because of the increase in ventilation pressures. This further increased the technical complexity of laparoscopic surgery. Despite the difficulties insertion of the laparoscope into the abdomen revealed a right tubo-ovarian mass, with a large pseudocyst and fluid in the POD. To facilitate the surgery and retract the bowel, four 5mm ports (two in each lower quadrant) were inserted. The right adnexa was mobilised with blunt dissection and utilising the Thunderbeat TM device. The Opclear® significantly and consistently maintained good surgical acuity. With the adnexa excised the decision was taken to go on and perform a total laparoscopic hysterectomy as per the patient’s request. This was only made in the context of a reliable surgical field of view. Given the adiposity, proximity of the bowel, adhesions from the previous LSCS , this was a high risk procedure, with potential bowel, bladder and ureteric complications.
The dissection of the left adnexa and reflection of the bladder was unremarkable, however the right uterine artery started to bleed when divided by the Thunderbeat TM device. It retracted. Once again good surgical acuity provided by the OpClear® device facilitated identification of the bleeding vessel and the adjacent anatomy. Once haemostasis was secured a colpotomy was performed, the uterus and specimen were removed vaginally and then the vault was closed with intracorporeal laparoscopic suturing using the Stratofix TM suture. As a precaution given the proximity of the right ureter a retrograde pyelogram was performed. This showed good fill and spill with no suggestion of ureteric compromise.
Post operatively, the patient made an unremarkable recovery and went home 48 hours later.
Patient’s view
“As soon as I woke up, I had no pain in the right side, it was heaven. I’m so grateful. I’m over the moon. I’ve had three years of agony and pain from my periods, affecting my life, work and relations with my husband. I feel I’ve been given a new lease of life.” Mrs SE
Surgeon’s view
“This was technically challenging surgery. The patient’s morbid obesity significantly complicated the surgery. Without a constant clear image created by OpClear®, I would not have had the confidence to proceed with a total laparoscopic hysterectomy. In my opinion the improved surgical acuity delivered by the Opclear® device significantly reduced the risk of conversion to
an open procedure. Conversion to laparotomy would have increased the patient’s risk of w
ound infection, venous thromboembolism, a longer in patient stay and a much longer return to normal activities. This is an excellent example of medical device innovation, delivering real quality improvements for the patient, the hospital and commissioners of healthcare.” Mr A Alexander Taylor, Consultant
