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Basics in gyne laparoscopy

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Information about Basics in gyne laparoscopy

Published on March 8, 2014

Author: sureshbabuchad

Source: slideshare.net

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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

ANATOMY

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

Verres Needle

Gas Insufflator

INSTRUMENTS

Trocar & Cannula

Camera

Laparoscope

Xenon Light Source

Uterine Elevator

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

Hydrosalpinx

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

PCO

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

COMPLETE SPECIMENN

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.,

THANK YOU

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