The surgeon who is knowledgeable about all aspects of laparoscopy should position the patient in the lithotomy position modified to conform to the special requirements of the procedure. The legs are not placed in the standard 90° flexion, as in the classic dorsal lithotomy position, but are positioned at 45°flexion from the hip. It is extremely important to have the buttocks at least 4 inches off the end of the operating table to facilitate manipulation of the cervical and intrauterine instruments into an advantageous position for maximum visualization of the internal genitalia. The operating table should be slanted to a 15° Trendelenburg position to displace the intestines out of the pelvis and into the upper abdomen. It is more comfortable for the operating surgeon to have the patient's arms down at her sides than extended on an arm board. We frequently insert the needle for intravenous infusion into the forearm, then place the arm at the patient's side and secure it with a draw sheet that has been previously placed underneath the patient.

Anesthesia for laparoscopy can be either general or local. If general anesthesia is used, it should be administered by the same standard techniques as used for major abdominal operations. One should not attempt to achieve surgical planes of anesthesia with tranquilizers or narcotics.

If local anesthesia is used, it should be accompanied by intravenous sedation prior to the operative procedure. We prefer to sedate the patient with 50 mg meperidine (Demerol) and 10 mg diazepam (Valium) after she is placed on the operating table. In general, we limit our use of local anesthesia to laparoscopy sterilization procedures and other short diagnostic procedures that do not require extensive intraperitoneal manipulation of the tubes or ovaries.

A bimanual pelvic examination should precede all laparoscopy procedures.

The procedure is started by grasping the anterior lip of the cervix with a wide-mouthed Jacobs tenaculum attached to a Rubin intrauterine cannula. Exposure of the cervix should be obtained with a narrow curved Sims posterior retractor rather than a wide, flat, posterior vaginal retractor. The large retractors produce pain, sometimes initiating a cycle of pain and anxiety that may make local anesthesia ineffective.

If local anesthesia is used, the inferior rim of the umbilicus is thoroughly infiltrated with 1% Xylocaine solution in a semicircular manner from the 9 o'clock position around to the 3 o'clock position on the umbilicus. The first injection of Xylocaine should be given at the 6 o'clock position on the inferior rim of the umbilicus, and the needle should be advanced underneath the skin as shown. In addition, approximately 2 mL should be infiltrated into the rectus fascia and muscles.

Adequate countertraction on the anterior abdominal wall is necessary. Although some rely on a large pneuoperitoneum to provide adequate countertraction, we elevate the lower midline of the abdomen for this purpose. We have found that placement of the two towel clips, one each at the 5 and 7 o'clock positions on the inferior rim of the umbilicus, offers the best method of countertraction for insertion of the pneumoperitoneum needle and the trocar. After the towel clips have been placed, a 2-mm incision is made in the inferior rim of the umbilicus.

The towel clips are elevated slightly and a 17-gauge Tuohy epidural needle is advanced through the 2-mm incision down the fascia.

No attempt is made to penetrate the fascia with the initial insertion of the Tuohy needle.

The needle is tapped against the fascia several times at a 90° angle to the plane of the body. The towel clips are further elevated for countertraction, and the needle is pushed through the rectus fascia with a short quick motion that advances the needle through the peritoneum. This technique reduces the possibility that the needle will slide off the rectus fascia and into the subcutaneous space.

The pneumoperitoneum needle is immediately attached to the gas line from the carbon dioxide machine. The gas is allowed to flow and the pressure is observed to ensure that it is approximately 15 mm Hg. We have found the gas pressure method to be the most accurate way to determine proper placement of the pneumoperitoneum needle. Other techniques are the water-drop test and the saline-syringe test. With the gas pressure method, using a large-bore 17-gauge needle, a pressure greater than 15 mm Hg is an indication that the pneumoperitoneum needle is not in the free peritoneal space but is either up against a piece of bowel, in the omentum, or in the supraperitoneal space. It should be further adjusted by advancing it, twisting the bore 180° or withdrawing it slightly until such time as the pressure manometer indicates a pressure of less than 15 mm Hg. There are times when the gas line or the needle itself has an intrinsic obstruction that results in elevated false gas pressure readings. In these cases, one would accept a gas pressure of 10 mm Hg above the baseline pressure. Generally, for sterilization procedures such as the Silastic band operation, no more than 2 liters of carbon dioxide are needed. In electrocoagulation of the Fallopian tubes or other surgical procedures, however, a higher volume of gas is needed in order to obtain a larger displacement of bowel away from the pelvic organs to reduce the possibility of gastrointestinal burns. For diagnostic procedures, it is better to use at least 4-5 liters of gas for maximum displacement of bowel. Therefore, it is better to perform diagnostic and more extensive surgical procedures under general anesthesia, as few patients can tolerate 5 liters of gas in the peritoneal cavity under local anesthesia.

The 2-mm incision is extended to 1 cm.

The laparoscope trocar and sleeve are inserted through the umbilicus incision in a twisting corkscrew technique that involves pushing the trocar down to the rectus fascia; with a short twisting corkscrew motion, the trocar is pushed through the rectus fascia while pulling up on the towel clips for countertraction. By using the short thrust and corkscrew motions, the surgeon advances the instrument progressively through the rectus fascia, avoiding a sudden thrust that might slip and contact the intra-abdominal or retroperitoneal organs.

The trocar is removed from the sleeve, the gas hose is connected to the gas port on the trocar, and the laparoscope is advanced down the trocar sleeve into the pelvis. The angle of the insertion of the laparoscope through the sleeve and through the abdominal wall should be approximately 15-20° to the plane of the patient and not at 90° angle, to avoid touching the lens against the surface of the bowel and the omentum. Such contact produces a pink or yellow blur instead of the recognizable abdominal structures. By holding the laparoscope in the right hand and moving the left hand between the patient's legs and grasping the Jacobs tenaculum and Rubin cannula, the uterus can be manipulated to either side or in the anterior-posterior plane for maximum visualization of all the internal genitalia.

By depressing the Rubin cannula and Jacobs tenaculum, the surgeon can move the uterus into an anteflex position, thereby making the cul-de-sac, broad ligament, tubes, and ovaries visible. When maximum visualization of the structures is achieved, a nurse or assistant holds the Rubin cannula and Jacobs tenaculum in the desired position while the laparoscopist moves his left  hand up to support the operating laparoscope and his right hand to perform the surgery (obviously, the reverse is true for those surgeons who are left-handed).

Multi-incision Technique

Multi-incision laparoscopy is useful in most advanced surgical techniques. These cases include egg retrieval for in vitro fertilization, ovarian biopsy, extensive lysis of adhesions, extensive fulguration of endometriosis, the occasional removal of an intraperitoneal foreign body, laparoscopy-assisted vaginal hysterectomy, and resection of ectopic pregnancy.

The first step in the insertion of a second instrument is to transilluminate the lower abdominal wall and select an avascular site for the incision of the second-incision trocar. We prefer the left and right lower quadrants where it is more advantageous to have the second-incision instrument at a right angle to the first-incision observation instrument. In all cases, however, an avascular area of the lower abdomen should be selected with special care to avoid the inferior epigastric artery and vein lateral to the rectus muscle.

A 6-mm incision is made over the avascular area down to the fascia, and the fascia is lightly incised with the scalpel.

The second-incision trocar and sleeve are held in a dagger fashion with the thumb on top of the trocar and the fingers wrapped around the trocar sleeve.

The second-incision trocar and sleeve are inserted through the second-incision down to the fascia. At this point, the surgeon looks through the laparoscope or the attached video screen and slowly advances the second-incision instrument until it has perforated the peritoneum. Occasionally, it may be helpful to use the first-incision instrument as a source of countertraction by using it to elevate the anterior abdominal wall against the area where the second-incision trocar and sleeve are penetrating the peritoneum.

The second-incision trocar is withdrawn from the second-incision sleeve and is now ready to receive operative instruments.

The Rubin cannula and Jacobs tenaculum are held by a nurse or assistant in the most advantageous position. The surgeon holds the laparoscope with his left hand and the second-incision instrument with his right hand. Note, that as shown, an operating laparoscope is used for the first incision. This allows a second instrument to be inserted into the abdominal cavity to facilitate the desired surgery without a second incision. The ovary or Fallopian tube can be stabilized for biopsy or lysing peritubal adhesions.