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Gynecological Endoscopy

Done by:

essa tawfeeQ Nawal akbar

mohammed jawaD Mohammed dhamen

Supervised by: Dr. Majda

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Operative LaparoscopyOperative Laparoscopy

Successful operativeSuccessful operativelaparoscopy reuires threelaparoscopy reuires threeessential in!redients:essential in!redients:

"# Sur!ical skill$

%# & well desi!ned andeuipped Operatin! 'oom$

(# & sur!ical team#

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Gynecological Endoscopy

Endoscopy in obstetrics and gynaecology

has many branches:

Laparoscopy

Hysteroscopy.

Colposcopy

Falloposcopy

Fetoscopy

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Outline

Laparoscopy

Definition

Instruments

The Procedures

Indications and contraindications

Complications

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Laparoscopy

Definition:

It is a technique which allows viewing

(Diagnostic) and surgical maneuvers

(Therapeutic) to be performed in abdominal

organs through a surgical incision of < 1cm with

help of pneumoperitoneum.

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)nstruments

1. Verres needle:

used to inflate air to theperitoneal cavit

(pneumoperitoneum)

through the umbilicus

where there is the

thinnest abdominal

wall.

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2. Electronic laparoflator:

!sed to insufflate through the verres needle.

"aintains constant intra#abdominal pressure withoute$ceeding the safet limit.

%ome tpes have heating sstem to prevent loweringthe patient bod temperature.

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. Trocars!

&ermit access to theintraperitoneal cavit in which

other instruments can pass.

The trocar used should beadapted to the diameter ofthe telescope selected.

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". Telescope!

There are different sizes each with a

different use.

They are used to visualize the peritonealcavity.

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5. Camera5. Camera

euipment.euipment.

!. "ight source.!. "ight source.

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There are two tpes:

# Disposable

# 'eusable

They can be either atraumatic

or grasping foreceps.

#. Forceps and scissors#. Forceps and scissors::

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*# +ipolar elecrtosur!ey#

,# -nipolar electrosur!ery#

".# Laser#

""# -ltrasound system#

"%# Suction and irri!ation system#

"(# Suture#

"/# Laparoscopic ba!#

"0# 1issue morcellator: used to remove lar!e specimenslike myomas or an entire uterus in small pieces#

"2# -terine manipulator: used to mobili3e or stabili3e theuterus and adne4a#

)nstruments)nstruments

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1.1. &reparation of the patient:&reparation of the patient:

Inform the patient about theInform the patient about the

therapeutic benefits and potential risstherapeutic benefits and potential riss(informed consent).(informed consent).

Intestinal preparation: %impleIntestinal preparation: %imple

intestinal empting for better viewingintestinal empting for better viewing

and preventing in*uries.and preventing in*uries. &lace the patient in the dorsolithotom&lace the patient in the dorsolithotom

position.position.

5rocedure5rocedure

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a. The abdominal wall is lifted b hand or b grasping forceps

b. &nemoperitoneum is created b verres needle introduced to theumbilical area (less subcutaneous and preperitoneul tissue).

c. The needle is inserted in an oblique angle toward the uterinefundus

d. The negative pressure will allow the underling structures to fallawa.

e. +fter maing sure that the needle is in correct position air flow

can be increased to ,.- liters per minute till a pressure of1-mmg

$. Creation of pneumoperitoneum!$. Creation of pneumoperitoneum!

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a. /nce the intra#abdominal

pressure reaches 1- mmg

the main trocar is introducedafter removal of veress

needle.

b. The position of the trocar

must be verified b insertingthe laparoscope and viewing

the pelvic cavit.

(# 1rocar introduction

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+. The omentum bowel and bifurcation of pelvic vessels should beevaluated to avoid in*uries caused during the introduction of0erres needle or trocar.

. The site of introduction of othertrocars should be verified b finger

palpation and transillumination of

abdominal wall to avoid in*ur to

epigastric vessels.

2. Identif if there is an bleeding

/# 6iewin! the peritoneal cavity:

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+fter the procedure+fter the procedure

2/2/,, gas must begas must be

evacuated completelevacuated completel

to reduce post#operativeto reduce post#operative

painpain

In operative procedures:In operative procedures:

# 1 or , bottles of 'inger3s lactate are# 1 or , bottles of 'inger3s lactate areused to wash the peritoneal cavit afterused to wash the peritoneal cavit afterlaparoscop.laparoscop.

# 4eave -5561555 cc of ringer3s lactate to# 4eave -5561555 cc of ringer3s lactate toreduce the incidence of post operativereduce the incidence of post operativepain.pain.

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!sed as a diagnostic tool!sed as a diagnostic tool

Infertilit: status of the fallopian tube (morpholog andInfertilit: status of the fallopian tube (morpholog and

functionalit) and an pathological condition e.g.functionalit) and an pathological condition e.g.adhesions.adhesions.

/varian csts or tumors./varian csts or tumors.

7ctopic pregnanc.7ctopic pregnanc.

&ID: tubal abscess or adhesions.&ID: tubal abscess or adhesions.

7ndometriosis: define the sites of implants and7ndometriosis: define the sites of implants and

endometrial csts.endometrial csts.

)ndications)ndications

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Ovarian CystOvarian Cyst

AdhesionsAdhesionsbetween thebetween the

omentum andomentum and

uterusuterus

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Ectopic pregnancy

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# "anagement of ovarian cst b:# "anagement of ovarian cst b:

# Drainage.# Drainage.

# /varian cstectom.# /varian cstectom.

# /varian drilling of the corte$ and stroma to# /varian drilling of the corte$ and stroma to

decrease androgens in the ovariesdecrease androgens in the ovaries

# 2orrecting ovarian torsion.# 2orrecting ovarian torsion.

# +s a treatment of endometriosis# +s a treatment of endometriosis

# removal of the endometrial cst# removal of the endometrial cstcauteri8ation of endometrial spots andcauteri8ation of endometrial spots and

adhesiolsisadhesiolsis

&s a therapeutic tool&s a therapeutic tool

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Movie

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"anagement of infertilit:"anagement of infertilit:

# +dhesiolsis# +dhesiolsis

# Treat the cause (endometriosis &2/%)# Treat the cause (endometriosis &2/%) "omectom for fibroids: used for subserosal and"omectom for fibroids: used for subserosal and

intramural fibroids onl not used for submucosal fibroids.intramural fibroids onl not used for submucosal fibroids.

"anagement of &ID: b draining tubal abscess and"anagement of &ID: b draining tubal abscess and

adhesiolsis.adhesiolsis.

&s a therapeutic tool&s a therapeutic tool

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&dhesiolysis&dhesiolysis

MyomectomyMyomectomy

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%alpingotom%alpingotom

!sed to preserve the tubes for desired!sed to preserve the tubes for desiredreproductivit.reproductivit.

Done if the patient is hemodnamicalDone if the patient is hemodnamicalstablestable

If si8e < - cmIf si8e < - cm

4ocation must be ampullar infundibular4ocation must be ampullar infundibularor isthmic.or isthmic.

2ontralateral tube either normal or absent.2ontralateral tube either normal or absent.

Mana!ement of ectopic pre!nancy:Mana!ement of ectopic pre!nancy:

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#alpingotomy#alpingotomy

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# %alpingectom (it is the standard for ectopic

pregnanc)

# 'uptured tube

# "ultiple recurrence of ectopic

pregnanc.

# %i8e of ectopic 9 - cm


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# Tubal sterili8ation b:

# ipolar coagulation.

# 2lips (filshie clips) and rings

# efore doing this ou should consult thepatient about three things

# 2hance of irreversibilit

# ailure rate 16,55

# leeding ma occur and we ma shift tolaparatom.

# 4aparoscopic hsterectom.


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$ing sterilization$ing sterilization

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7ontraindications7ontraindications

1.1. ;enerali8ed peritonitis;enerali8ed peritonitis

,.,. povolemic shocpovolemic shoc

.. %evere cardiac disease%evere cardiac disease=.=. emoglobin less than > g6d4emoglobin less than > g6d4

-.-. !terine si8e 9 1, ws.!terine si8e 9 1, ws.

?.?. "ultiple previous abdominal procedures"ultiple previous abdominal procedures

>.>. 7$treme bod weight7$treme bod weight

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# &neumoperitoneum:

# 7$traperitonel emphsema due to failure ofintroducing verres needle correctl into the peritonealcavit and not checing the negative pressure on themachine.

# ;as ma e$tend to the mediastinum and compromisecardiac function

# &neumoomentum: and put the patient on thetrendlenberg

# In*ur to abdominal organs

# ;I: if the intestine is distended or adherent to theabdominal wall (prevented b good intestinalpreparation) and putting the patient on thetelendelenburg position.

# ladder in*ur: prevented b empting the bladder.

7omplications7omplications

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lood vessel in*ur:lood vessel in*ur:

# &elvic omental and mesentric&elvic omental and mesentric

# &revented b introducing the verres needle in&revented b introducing the verres needle in

an angle.an angle.

# In obese patients ou can insert the needle inIn obese patients ou can insert the needle in

straight manner because of the thic fatt laer.straight manner because of the thic fatt laer.


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HysteroscopyHysteroscopy

DefinitionDefinition

)nstruments)nstruments

1he 5rocedures1he 5rocedures

)ndications and contraindications)ndications and contraindications


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8ysteroscopy

%efinition%efinition::

It is a technique which allows viewing and surgicalIt is a technique which allows viewing and surgicalmaneuvers to be performed in the uterine cavit.maneuvers to be performed in the uterine cavit.

It has man advantages that made it wide spreadIt has man advantages that made it wide spread

and fundamental diagnostic method in dailand fundamental diagnostic method in dailgnecological practice.gnecological practice.

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Instruments

1. Distention media

of the uterinecavity !"#

distention$

#. %ight source.

&enon lightsource gives thebest image

'uality

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(. !amera E'uipment

). Endoscope

*e&ible: high cost andfragile cannot beautoclaved.

rigid: gives di+erentdirection of the vie,.

- /0 1#/0 (/ best

for diagnosticpurpose$.

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5. &ysteroscope:5. &ysteroscope:

There are , tpes of hsteroscopes:There are , tpes of hsteroscopes:

%iagnostic%iagnostic

TherapeuticTherapeutic

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'.'. (reparation of the patient:(reparation of the patient:

Detailed histor and complete phsical e$aminationDetailed histor and complete phsical e$amination

It is preferable to do the procedure in the first part of theIt is preferable to do the procedure in the first part of themenstrual ccle because there is less mucus (better viewing)menstrual ccle because there is less mucus (better viewing)

and no chance of encountering earl pregnancand no chance of encountering earl pregnanc

Informed consentInformed consent

&atient is placed in lithotom position&atient is placed in lithotom position

+ccurate bimanual e$amination to asses the uterine (position+ccurate bimanual e$amination to asses the uterine (positionmorpholog volume).morpholog volume).

5rocedure5rocedure

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,. Technique:,. Technique:

2lean cervi$ with antiseptics2lean cervi$ with antiseptics

2ervical forceps is placed on the front labia2ervical forceps is placed on the front labia

4ight source @ 2/, gas suppl are connected to the4ight source @ 2/, gas suppl are connected to the

instrumentinstrument

Insert hsteroscope into the cervical canal whichInsert hsteroscope into the cervical canal whichdilates from the gas pressure.dilates from the gas pressure.

5rocedure5rocedure

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!sed as a diagnostic tool:

# +bnormal uterine bleeding caused b:

# submucous and intramural moma.

# endometrial polps.

# endometrial atroph.# 7ndometrial tumors.

# Infertilit related to:

# Intrauterine adhesions (+sherman3s sndrome)

# %ubmucous fibroids.

# 7ndometrial polps.# !terine malformation (it cannot differentiate between sepatateand bicorneate uterus)

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!sed as a therapeutic tool!sed as a therapeutic tool

7ndometrial ablation (using laser):7ndometrial ablation (using laser):

+bnormal uterine bleeding but we should role+bnormal uterine bleeding but we should role

out cancerous or pre cancerous cause ofout cancerous or pre cancerous cause of

bleeding.bleeding.

+lso used in patients with high ris for+lso used in patients with high ris forhsterectom or the patient does not want tohsterectom or the patient does not want to

do the surger.do the surger.steroscopic Sur!eries andsteroscopic Sur!eries and

9ndometrial 5olypectomy9ndometrial 5olypectomy


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7orrect uterine malformation like septate uterus by

resection of the septum# bicorneate uterus is corrected by

laparotomy usin! metroplasty;# 5olypectomy#

)ntrauterine adhesions#

Myomectomy: 1he main indication for hysteroscopic

myomectomy is &-+ caused by submucous myomas ininfertile patients


8ysteroscopic Sur!eries and8ysteroscopic Sur!eries and

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8ysteroscopic Sur!eries and8ysteroscopic Sur!eries and

9ndometrial 5olypectomy9ndometrial 5olypectomy

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-sed as a therapeutic tool

< 'emoval of forei!n bodies and )-7D#

< =allopian tube catheteri3ation

< to canali3e the tube#

< to place intra tubal device for reversible

sterili3ation#


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!terine polp!terine polp

!terine anomal!terine anomal

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Intrauterine +dhesionsIntrauterine +dhesions

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7ndometrial 2a.7ndometrial 2a.

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7ontraindications7ontraindications

&regnanc.&regnanc.

2urrent or recent pelvic infection.2urrent or recent pelvic infection.

2urrent vaginitis cervicitis and2urrent vaginitis cervicitis and

endometritisendometritis..

'ecent uterine perforation.'ecent uterine perforation.

+ctive leeding.+ctive leeding.

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< Complications related to distention media!< due to C%$ insufflation!

< Cardiac arrhythmia due to e&cessi'e a(sorption.

< Gas em(olism.

< )e use hysteroflator that insufflate pressure of 1**+1$* mmHgconstantly ,ithout e&ceeding the safety limit.

< due to fluid!

< H-) de&tran/

< 0naphylactic reaction

< Pulmonary edema

< 0dult D2


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+ L-) saline/+ Fluid o'erload! pre'ented (y 3eeping the operating time

to minimum.

+ 0'oid entering 'ascular channels.

+ Close monitoring of fluid (alance.

+ If you e&ceed 1*** ml of infused fluid stop the procedure.

+ Intraoperati'e complications!

+ 4terine perforation 516/

+ Hemorrhage either from!

+ Perforation+ Tenaculum used to hold the cer'i&.

+Trauma.

+ Thermal damage.


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< Late onset!

< Infections! li3e acute PID7 so ,e gi'e prophylactic anti(iotics.

< 8aginal discharge! common after a(lati'e procedures and it is selflimiting.

< 0dhesion formation!

< Common after myomectomy ,hen $ fi(roids are located opposite toeach other in the uterine ,all.

< To pre'ent the adhesions it is (etter to remo'e the fi(roids in stages7 andgi'e estrogen to (uild up the endometrial/ therapy directly afterresection. 0nd also ,e can use I4CD.


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visit us atvisit us at

www.essara.com)gyn.htmlwww.essara.com)gyn.html

Download the slides @ post ourDownload the slides @ post our

2omments opinions and questions2omments opinions and questions

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Movie

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>ait ??

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&sherman Syndrome: )t is defined as intrauterine adhesions

7ause can be iatro!enic after hysteroscopic

myomectomy; and can due to infection#

)t can be treated by hysteroscopic adhesiolysis

followed by insertin! )-7D to make the uterine

walls apart from each other# >e can also use

estro!en after adhesiolysis and this wall cause the

emdometrium to build up and prevent adhesions to

reoccur

jaida

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