How is a laparoscopic salpingo-oophorectomy performed?

Updated: Feb 06, 2018
  • Author: Stacie M Ward, MD; Chief Editor: Christine Isaacs, MD  more...
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Answer

Answer

The patient is transferred to the operating room table and placed under general anesthesia. The patient is then placed in the dorsal lithotomy position.

A pelvic examination is performed under anesthesia to determine uterine position, size, shape, mobility, and to assess the adnexa. A Foley catheter is placed to gravity to drain the urinary bladder throughout the procedure. The patient's abdomen, perineum, and vagina are prepped in a sterile fashion and the patient is draped.

A speculum is positioned to visualize the cervix and a uterine manipulator is then placed to aid with visualization and manipulation of the uterus during the case. Attention is then turned back to the abdomen for the placement of intra-abdominal trocars. Usually, the first incision is made with the scalpel in the infraumbilical fold. For a closed technique, the abdominal wall is tented while a Veress needle is carefully placed.

Once intraperitoneal placement is confirmed, the abdomen is insufflated with CO2 gas. After insufflation, the Veress needle is removed and a trocar placed. The laparoscope is then introduced to confirm intraperitoneal placement.

The remaining trocars may now be placed under direct visualization. Care must be taken to prevent injury to blood vessels, especially the inferior epigastrics. Often transillumination of the abdominal wall can aid in avoiding injury to vessels. Additional trocars are placed depending on surgeon preference in the right lower quadrant, left lower quadrant, and/or midline suprapubic according to surgeon preference.

The peritoneal cavity should be inspected. See the images below.

Normal female pelvis: uterus with right ovary, fal Normal female pelvis: uterus with right ovary, fallopian tube, and infundibulopelvic ligament.
Uterus displaced to the left to expose the uteroov Uterus displaced to the left to expose the uteroovarian ligament.
Flimy omental adhesion to anterior abdominal wall. Flimy omental adhesion to anterior abdominal wall.

For a prophylactic salpingo-oophorectomy, pelvic washings need to be collected and sent to pathology.

The uteroovarian ligament with the Fallopian tube are clamped, just distal to the uterine cornua, ligated, and transected with a vessel sealing device. See the image below.

Clamped uteroovarian ligament and fallopian tube. Clamped uteroovarian ligament and fallopian tube.

When performing a prophylactic salpingo-oophorectomy the surgeon should remove the fallopian tubes to the level of the uterine cornua. [4]

The ureter should now be identified. In contrast to laparotomy, the ureter can usually be readily identified without reflection of the peritoneum. It is normally seen at the pelvic brim and can be followed inferiorly into the pelvis. See the image below.

Ureter in relationship to the infundibulopelvic li Ureter in relationship to the infundibulopelvic ligament.

Once the ureter is located and at a safe distance from the infundibulopelvic ligament, the infundibulopelvic ligament is clamped, ligated, and transected with a vessel sealing device. See the images below.

Clamp across infundibulopelvic ligament. Clamp across infundibulopelvic ligament.
Transection of left infundibulopelvic ligament. Transection of left infundibulopelvic ligament.
Salpingo oophorectomy laparoscopic photo with land Salpingo oophorectomy laparoscopic photo with landmarks noted. Clamping and transection down the left broad ligament.
Salpingo oophorectomy laparoscopic photo. Clamping Salpingo oophorectomy laparoscopic photo. Clamping and transection down the left broad ligament.
Salpingo oophorectomy laparoscopic photo with land Salpingo oophorectomy laparoscopic photo with landmarks noted. Clamping of the left utero-ovarian ligament and fallopian tube.

In prophylactic salpingo-oophorectomies, the infundibulopelvic ligament should be taken at the level of the pelvic brim. [4] The remaining mesosalpinx is dissected and hemostasis achieved.

The ovary and tube may be placed in a laparoscopic specimen bag and removed through a port site. If the ovary is unable to be fit through a port site, one incision site can be extended to allow removal of the ovary and tube.

Once hemostasis is ensured, the instruments and trocars are removed, the abdomen is desufflated, and the incisions are closed.


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