We rport a technique for safe laparoscopic access for gynaecological surgery in women who have had their abdominal wall reconstructed by plastic surgery. The abdominal wall incisions for placement of the trocars are made in the abdominoplasty scars and are cosmetically acceptable. In a limited series there appears to be no excess morbidity.
In our cancer centre, we are seeing more women who have been advised to have ovarian ablation for adjuvant treatment of their breast cancer. An increasing number of these women have undergone primary reconstruction of the breast when having their definitive surgical treatment of the cancer. The transverse rectus abdominis myocutaneous flap is considered the ‘gold standard’ for breast reconstruction.1 This, allied with the escalating incidence of breast cancer2 and a preferred use for surgical ovarian ablation for hormonal manipulation especially in ER-positive breast cancers, presented us with the need to manage women who had abdominal plastic surgery. Abdominoplasty and reconstructive surgery to the abdominal wall are considered contraindications to laparoscopic surgery, as the usual landmarks for entry are altered and there is significant scarring. A report suggested that the laparoscopic approach was possible,3 although this either used an approach through the relocated umbilicus or used Palmer's point in the left upper quadrant.
Following the use of the rectus abdominis as part of the breast reconstruction, the anterior abdominal wall is scarred by the abdominoplasty scar. The neo-umbilicus is relocated away from the original congenital cicatrix at the condensation of the rectus aponeurosis to a more cosmetically correct position and is often refashioned. Thus, it is not necessarily helpful either as a landmark or as an easy portal for entry as in normal laparoscopy. In addition, a non-absorbable mesh has often been inserted to prevent hernia formation. The significant scarring, the mesh and the relocation of the umbilicus (an important landmark for most laparoscopy) are the contraindications for laparoscopic surgery. We felt that the use of the left upper quadrant entry (Palmer's point) may jeopardise the vascular pedicle for the transverse rectus abdominis myocutaneous flap used for the right breast reconstruction (left superior epigastric pedicle). We have therefore developed the described technique. The women were warned of the risks of laparoscopic surgery given the above concerns about scarring. All women gave informed consent for the procedure including the novel technique.
Women who have been advised by the multidisciplinary breast team to have oophorectomy as part of their treatment are referred to our unit for discussion and surgery. In addition, there are women referred who have had plastic surgery and have coincidental gynaecological pathology. The procedure is described including possible complications and informed consent obtained. Under general anaesthetic, the woman is placed supine on the operating table and catheterised. A subcutaneous injection of 0.25% bupivicaine local anaesthetic is injected in the lateral 3 cm of the abdominoplasty scar. The choice of side is on the same side as the breast reconstruction, as the transverse rectus abdominis myocutaneous flap is taken from the contralateral side. In women who have just had an abdominoplasty, the choice of sides is at the surgeon's preference. Using sharp dissection, the scar is explored and the peritoneum identified. Langenbeck retractors aid adequate exposure. The peritoneal cavity is opened and a purse string suture (2-0 polyglactin) is inserted in the peritoneum and rectus sheath. The incision is lateral, and therefore, risk of damaging the inferior epigastric pedicle is extremely unlikely. As the peritoneal cavity is opened under direct vision, there is little or no concern relating to blind damage of underlying viscera. A disposable 10- to 12-mm port with a blunt obturator is placed as for a conventional Hassan entry. The adjustable plug or plastic cone is attached to the purse string and this allows an airtight close with entry wound for easy establishment of the pneumoperitoneum (TRISTAR Blunt Tip Trocar Ethicon Endosurgery 512B). Non-disposable versions of this trocar are available from other manufacturers. The abdominal cavity is then inflated with carbon dioxide to a pressure of 20 mmHg with the patient supine. Visual examination of the abdominal cavity is performed. Two further ports are inserted under direct vision. Their position is shown in Fig. 1. The first port is placed in the scar at the edge of the relocated umbilicus. A 5- or 10-mm port can be placed using the neo-umbilicus scar rather than through the cicatrix itself. The second operative port is placed in the midline in the scar of the abdominoplasty medial to the mesh. In patients without mesh, the second operative port can be placed in the contralateral iliac fossa in the line of the scar lateral to the inferior epigastric vessels. The mesh is usually easily seen using the laparoscope. Correct placement of these ports is facilitated by using a (green) 21-g hypodermic needle placed through the anterior abdominal wall. At the same time, as identifying the position of safe port placement, local anaesthetic is infiltrated into the anterior abdominal wall. The orientation of the view obtained using the telescope through the lateral 10-mm port can be difficult for some operators. We have therefore, on occasions, used a 10-mm port at the neo-umbilicus for the telescope that gives the typical panorama favoured for conventional gynaecological surgery. Following surgery, the specimen is retrieved in a bag via the lateral 10- to 12-mm port. This is then closed with the purse string. If a 10-mm port is used at the umbilicus, then the sheath and skin are closed with polyglactin.
Eight women have been operated with no problems in this fashion (Table 1). There has been no difference in morbidity or length of stay between these patients and those without abdominoplasty type scarring. We prefer this technique for women with abdominal plastic surgery to others as it is an open technique allowing direct placement of the initial port into the peritoneal cavity. The cosmetic result is acceptable as we use the previous scars. Overall, this allows us to perform minimal access gynaecological surgery for women who have undergone plastic surgery to the abdomen.
Table 1. Clinical details for laparoscopic experience with women having an abdominoplasty. All cases had an abdominoplasty with the umbilicus moved. The use of mesh has not been consistent across the series.
Cases 7 and 8 represent the same patient with a separation of the laparoscopic procedures by nine months.
Case 2—the hospital stay was due to a concurrent plastic surgery procedure—further breast reconstruction using the latissimus dorsi.