basics in gyne laparoscopy

Basic Principles in Basic Principles in Gyne- LaparoscopyGyne- Laparoscopy

DR.C.SURESH BABUDR.C.SURESH BABUPROFESSORPROFESSOR

DEPT.OF OBGYNDEPT.OF OBGYNCollege of Medicine, Abha, KKU, KSACollege of Medicine, Abha, KKU, KSA

INTRODUCTIONINTRODUCTION KALK(1930) – FATHER OF INTERNALKALK(1930) – FATHER OF INTERNAL LAPAROSCOPYLAPAROSCOPY HOPE(1937) – FIRST GYNEACOLOGICAL HOPE(1937) – FIRST GYNEACOLOGICAL

REPORT ON ECTOPIC PREGNANCYREPORT ON ECTOPIC PREGNANCY BOESCH (1936)- COAGULATION BOESCH (1936)- COAGULATION PALMER (1943) –COLD LIGHT ENDOSCOPE.PALMER (1943) –COLD LIGHT ENDOSCOPE. FRANGENHEIM (1952)– CO2 INSUFFLATIONFRANGENHEIM (1952)– CO2 INSUFFLATION JORDEN PHILIPS – SPREAD OF JORDEN PHILIPS – SPREAD OF

LAPAROSCOPE THROUGHOUT THE WORLDLAPAROSCOPE THROUGHOUT THE WORLD SEMM (1970)-LAPAROSCOPIC SEMM (1970)-LAPAROSCOPIC

HYSTERECTOMYHYSTERECTOMY

BASIC PREREQUISITESBASIC PREREQUISITES

GOOD KNOWLEDGE ABOUT GOOD KNOWLEDGE ABOUT SURGICAL ANATOMYSURGICAL ANATOMY

GOOD AT CONVENTIONAL GOOD AT CONVENTIONAL SURGERIESSURGERIES

REASONABLE TRAININGREASONABLE TRAINING

GOOD EXPERIENCEGOOD EXPERIENCE

ANATOMYANATOMY

LAPAROSCOPY SET UPLAPAROSCOPY SET UP

BASIC REQUIREMENTS:BASIC REQUIREMENTS:

1.TWO ASSISTANTS1.TWO ASSISTANTS

2.WELL TRAINED SISTER2.WELL TRAINED SISTER

3.OT TECHNICIAN3.OT TECHNICIAN

4. ALL LAPAROSCOPIC 4. ALL LAPAROSCOPIC INSTRUMENTSINSTRUMENTS

5.TWO MONITORS5.TWO MONITORS

6.CO-OPERATIVE ANAESTHETIST6.CO-OPERATIVE ANAESTHETIST

Verres NeedleVerres Needle

Gas InsufflatorGas Insufflator

INSTRUMENTSINSTRUMENTS

Trocar & CannulaTrocar & Cannula

CameraCamera

LaparoscopeLaparoscope

Xenon Light SourceXenon Light Source

Uterine ElevatorUterine Elevator

EquipmentsEquipments

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

Patient PositioningPatient Positioning

Low lithotomy position

30 degree Trendelenburg

Urinary catheter

NG tube (?)

Uterine cannulation

Trocar Placement for Trocar Placement for SurgerySurgery

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 UPOT SET UP

INDICATIONS FOR INDICATIONS FOR LAPAROSCOPYLAPAROSCOPY

Diagnostic:Diagnostic: 1] Infertility1] Infertility 2] Suspected Ectopic pregnancy2] Suspected Ectopic pregnancy 3] Misplaced Copper T3] Misplaced Copper T 4] Chronic pelvic pain etc.,4] Chronic pelvic pain etc., Therapeutic:Therapeutic: 1] Myomectomy1] Myomectomy 2] LAVH, TALH2] LAVH, TALH

Therapeutic IndicationsTherapeutic Indications

3] Ovarian Drilling in PCOD3] Ovarian Drilling in PCOD 4] Ovarian Cystectomy4] Ovarian Cystectomy 5] Retrieval of misplaced copper T5] Retrieval of misplaced copper T 6] Cauterisation of Emdometriotic 6] Cauterisation of Emdometriotic

spotsspots 7] Radical Hysterectomy for cancer 7] Radical Hysterectomy for cancer

cervix etc.,cervix etc.,

LAPAROSCOPYLAPAROSCOPY General AnesthesiaGeneral Anesthesia

Trendlenberg’s positionTrendlenberg’s position

Lights should be offLights should be off

Well trained staffWell trained staff

Electrical technical assistantElectrical technical assistant

Anatomical ReviewAnatomical Review

1. Medial tubal A.

2. Lateral tubal A.

3. Uterine A.

4. Ovarian A.

Laparoscopic Laparoscopic SalpingectomySalpingectomy

Main Risk:Main Risk: devascularization of the ovary devascularization of the ovary Operate close to the tube, away from Operate close to the tube, away from

ovarian vessels and suspensory ligamentovarian vessels and suspensory ligament

1.1. Proximal tube divisionProximal tube division Isthmus is held upwards and Isthmus is held upwards and

outwardsoutwards Isthmus is cauterizedIsthmus is cauterized Take care not to cauterized the Take care not to cauterized the

internal ovarian A. and ovarian internal ovarian A. and ovarian branch of the uterine A.branch of the uterine A.

Divide tube with scissorsDivide tube with scissors

2.2. Mesosalpinx DivisionMesosalpinx Division Divide the mesosalpinx Divide the mesosalpinx

with scissorswith scissors

Cauterize and divide Cauterize and divide the infundibulo-ovarian the infundibulo-ovarian ligaments and the ligaments and the lateral tubal A. lateral tubal A.

3.3. Extraction of the tubeExtraction of the tube Remove tube through an Remove tube through an

extraction bagextraction bag Verification of hemostasisVerification of hemostasis Careful lavageCareful lavage Removal of equipmentRemoval of equipment Suture/ Steri-strip Suture/ Steri-strip

laparoscopic incisionslaparoscopic incisions

Caution:

• Endometriosis

• Utero-peritoneal fistula

Positive methyline blue test

Positive methyline blue test

Normal left adnxa

Normal left adnxa and Douglas pouch

Mild fimbrial adhesion Fimbria

Fine band of adhesion

FimbriaFine adhesion

Fimbria

Broad band of adhesion

Moderate adhesion

DouglasPouch

Severe Adhesions

Dr.Sherbiny

Hydrosalpin

x

Adhesiolysis of the left tube with micro- scissor

Uterus

L. Ovary

L. Tube

R .Ovary

R .tube

Cutting band of adhesion

Phimosis of the fimbrial end: Dilatation with Maryland forceps

Dr.Sherbiny

Phimosis with methyline Blue jet

Phimosis: delayed methyline blue spill

Free methyline blue spill

Dilatation with Maryland forceps

Classic bluish black endometriotic implants

Typical Endometriosis

Black Endometriosis               Blue Endometriosis

Black Blue

Atypical Endometriosis

White Endometriosis

Peritoneal Defect

Red Endometriosis(Flam-like)Yellow Brown Endometriosis

Red Endometriosis (Pink)

Yellow Brown EndometriosisClear Endometriosis

Endometriotic Endometriotic CystCyst = =

Endometrioma Endometrioma

PCO

Laparoscopic ovarian drilling with Laparoscopic ovarian drilling with either diathermy or laser is an either diathermy or laser is an effective treatment for effective treatment for anovulation in women with anovulation in women with clomiphene-resistant PCOS. clomiphene-resistant PCOS.

PCOS: PCOS: Laparoscopic Laparoscopic DDrillingrilling

RCOG Guidelines : Grade A

58National Institute of Clinical Excellency (NICE) 2004

Tubal bipolar coagulation

Cutting of the medial part of the tube

Salpingostomy Salpingost

omyLaparoscopic tubal occlusion & salpingostomy of Hydrosalpinges prior to IVF to improve pregnancy rate

COMPLETE SPECIMENNCOMPLETE SPECIMENN

ADVANTAGES ADVANTAGES

QUICK RECOVERYQUICK RECOVERY EARLY ORAL FEEDINGEARLY ORAL FEEDING EARLY AMBULATIONSEARLY AMBULATIONS BLADDER DYSFUNCTION IS LESSBLADDER DYSFUNCTION IS LESS POSTOPERATIVE COMPLICATIONS POSTOPERATIVE COMPLICATIONS

ARE LESSARE LESS

COMPLICATIONSCOMPLICATIONS

1] Bowel injury1] Bowel injury 2] Vascular injury2] Vascular injury 3] Bladder injury 3] Bladder injury 4] Cautery burns to surrounding 4] Cautery burns to surrounding

organsorgans 5] Anesthesia complications5] Anesthesia complications 6] Surgical emphysema etc.,6] Surgical emphysema etc.,

THANK THANK YOUYOU