Published on March 8, 2014
Basic Principles in GyneLaparoscopy DR.CHADUVULA SURESH BABU PROFESSOR DEPT.OF OBGYN College of Medicine, Abha, KKU, KSA
INTRODUCTION KALK(1930) – FATHER OF INTERNAL LAPAROSCOPY HOPE(1937) – FIRST GYNEACOLOGICAL REPORT ON ECTOPIC PREGNANCY BOESCH (1936)- COAGULATION PALMER (1943) –COLD LIGHT ENDOSCOPE. FRANGENHEIM (1952)– CO2 INSUFFLATION JORDEN PHILIPS – SPREAD OF LAPAROSCOPE THROUGHOUT THE WORLD SEMM (1970)-LAPAROSCOPIC HYSTERECTOMY
BASIC PREREQUISITES GOOD KNOWLEDGE ABOUT SURGICAL ANATOMY GOOD AT CONVENTIONAL SURGERIES REASONABLE TRAINING GOOD EXPERIENCE
LAPAROSCOPY SET UP BASIC REQUIREMENTS: 1.TWO ASSISTANTS 2.WELL TRAINED SISTER 3.OT TECHNICIAN 4. ALL LAPAROSCOPIC INSTRUMENTS 5.TWO MONITORS 6.CO-OPERATIVE ANAESTHETIST
Trocar & Cannula
Xenon Light Source
E quipments Laparoscopic Tools Video monitor
1. Bipolar grasper 2. Atraumatic grasper 3. Grasping forceps 4. Toothed forceps 5. Sharp-tipped monopolar device 6. 5-10mm suction-irrigation device 7. Scissors
P atient P ositioning Low lithotomy position 30 degree Trendelenburg Urinary catheter NG tube (?) Uterine cannulation
T rocar P lacement for Surgery A) 12mm optical trocar placed at umbilical level B) and C) 5mm lateral operative trocars placed 3 fingerbreadths above the symphysis pubis
Peritoneum is inflated with CO2 Needle inserted at the umbilical level (primarily used) OR at Palmer’s point (3cm below costal margin in midclavicular line) Pressure should not exceed 14 mmHg- respiratory compromise
OT SET UP
INDICATIONS FOR LAPAROSCOPY Diagnostic: 1] Infertility 2] Suspected Ectopic pregnancy 3] Misplaced Copper T 4] Chronic pelvic pain etc., Therapeutic: 1] Myomectomy 2] LAVH, TALH
Therapeutic Indications 3] Ovarian Drilling in PCOD 4] Ovarian Cystectomy 5] Retrieval of misplaced copper T 6] Cauterisation of Emdometriotic spots 7] Radical Hysterectomy for cancer cervix etc.,
LAPAROSCOPY General Anesthesia Trendlenberg’s position Lights should be off Well trained staff Electrical technical assistant
Anatomical Review 1. Medial tubal A. 2. Lateral tubal A. 3. Uterine A. 4. Ovarian A.
L aparoscopic Salpingectomy M Risk: devascularization of the ovary ain Operate close to the tube, away from ovarian vessels and suspensory ligament
1. Proximal tube division Isthmus is held upwards and outwards Isthmus is cauterized Take care not to cauterized the internal ovarian A. and ovarian branch of the uterine A. Divide tube with scissors
2. M esosalpinx Division Divide the mesosalpinx with scissors Cauterize and divide the infundibulo-ovarian ligaments and the lateral tubal A.
3. Extraction of the tube Remove tube through an extraction bag Verification of hemostasis Careful lavage Removal of equipment Suture/ Steri-strip laparoscopic incisions Cautio n: • Endometriosis • Utero-peritoneal fistula
Normal left adnxa Normal left adnxa and Douglas pouch Positive methyline blue test Positive methyline blue test
Fine adhesion Fimbria Fine band of adhesion Mild fimbrial adhesion Fimbria Broad band of adhesion Douglas Pouch Moderate adhesion Fimbria
Severe Adhesions Dr.Sherbiny
Uterus L. Ovary L. Tube Adhesiolysis of the left tube with micro- scissor
Cutting band of adhesion R .t ube R .Ovary
Phimosis: delayed methyline blue spill Dilatation with Maryland forceps Phimosis with methyline Blue jet Dr.Sherbiny Free methyline blue spill Phimosis of the fimbrial end: Dilatation with Maryland forceps
Typical Endometriosis Black Endometriosis Blue Endometriosis Black Blue Classic bluish black endometriotic implants
Atypical Endometriosis Yellow Brown Endometriosis Red Endometriosis(Flam-like) Peritoneal Defect White Endometriosis
Yellow Brown Endometriosis Clear Endometriosis Red Endometriosis (Pink)
Endometriotic Cyst = Endometrioma
PCOS: Laparoscopic Drilling Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS. RCOG Guidelines : Grade A 58 National Institute of Clinical Excellency (NICE) 2004
Tubal bipolar coagulation Salpingostom y Cutting of the medial part of the tube Salpingostom y Laparoscopic tubal occlusion & salpingostomy of Hydrosalpinges prior to IVF to improve pregnancy rate
ADVANTAGES QUICK RECOVERY EARLY ORAL FEEDING EARLY AMBULATIONS BLADDER DYSFUNCTION IS LESS POSTOPERATIVE COMPLICATIONS ARE LESS
COMPLICATIONS 1] Bowel injury 2] Vascular injury 3] Bladder injury 4] Cautery burns to surrounding organs 5] Anesthesia complications 6] Surgical emphysema etc.,
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