Beruflich Dokumente
Kultur Dokumente
Done by:
essa tawfeeQ
Nawal akbar
mohammed jawaD
Mohammed dhamen
Operative Laparoscopy
Successful operative
laparoscopy requires three
essential ingredients:
1. Surgical skill;
2. A well designed and
equipped Operating Room;
3. A surgical team.
Gynecological Endoscopy
Endoscopy in obstetrics and gynaecology
has many branches:
Laparoscopy
Hysteroscopy.
Colposcopy
Falloposcopy
Fetoscopy
Outline
Laparoscopy
Definition
Instruments
The Procedures
Indications and contraindications
Complications
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.
Instruments
1. Verres needle:
used to inflate air to the
peritoneal cavity
(pneumoperitoneum)
through the umbilicus
where there is the
thinnest abdominal
wall.
2. Electronic laparoflator:
3. Trocars:
4. Telescope:
5. Camera
equipment.
6. Light source.
Instruments
8. Bipolar elecrtosurgey.
9. Unipolar electrosurgery.
10. Laser.
11. Ultrasound system.
12. Suction and irrigation system.
13. Suture.
14. Laparoscopic bag.
15. Tissue morcellator: used to remove large specimens
like myomas or an entire uterus in small pieces.
16. Uterine manipulator: used to mobilize or stabilize the
uterus and adnexa.
Procedure
1. Preparation of the patient:
2. Creation of pneumoperitoneum:
3. Trocar introduction
a. Once the intra-abdominal
pressure reaches 15 mmHg
the main trocar is introduced
after removal of veress
needle.
b. The position of the trocar
must be verified by inserting
the laparoscope and viewing
the pelvic cavity.
B.
C.
Indications
Used as a diagnostic tool
Ovarian Cyst
Adhesions
between the
omentum and
uterus
Ectopic pregnancy
As a therapeutic tool
- Management of ovarian cyst by:
- Drainage.
- Ovarian cystectomy.
- Ovarian drilling of the cortex and stroma to
decrease androgens in the ovaries
- Correcting ovarian torsion.
- As a treatment of endometriosis
- By removal of the endometrial cyst,
cauterization of endometrial spots and
adhesiolysis
Movie
As a therapeutic tool
Management of infertility:
- Adhesiolysis
- Treat the cause (endometriosis, PCOS)
Myomectomy for fibroids: used for subserosal and
intramural fibroids only, not used for submucosal fibroids.
Management of PID: by draining tubal abscess and
adhesiolysis.
Adhesiolysis
Myomectomy
Salpingotomy
Indications
- Salpingectomy (it is the standard for ectopic
pregnancy)
- Ruptured tube
- Multiple recurrence of ectopic
pregnancy.
- Size of ectopic > 5 cm
Indications
- Tubal sterilization by:
- Bipolar coagulation.
- Clips (filshie clips) and rings
- Before doing this you should consult the
patient about three things
- Chance of irreversibility
- Failure rate 1/200
- Bleeding may occur and we may shift to
laparatomy.
- Laparoscopic hysterectomy.
Ring sterilization
Contraindications
1.
2.
3.
4.
5.
6.
7.
Generalized peritonitis
Hypovolemic shock
Severe cardiac disease
Hemoglobin less than 7 g/dL
Uterine size > 12 wks.
Multiple previous abdominal procedures
Extreme body weight
Complications
- Pneumoperitoneum:
- Extraperitonel emphysema due to failure of
introducing verres needle correctly into the peritoneal
cavity and not checking the negative pressure on the
machine.
- Gas may extend to the mediastinum and compromise
cardiac function
- Pneumoomentum: and put the patient on the
trendlenberg
- Injury to abdominal organs
- GI: if the intestine is distended or adherent to the
abdominal wall (prevented by good intestinal
preparation) and putting the patient on the
telendelenburg position.
- Bladder injury: prevented by emptying the bladder.
Complications
Blood vessel injury:
- Pelvic, omental and mesentric
- Prevented by introducing the verres needle in
an angle.
- In obese patients you can insert the needle in
straight manner because of the thick fatty layer.
Hysteroscopy
Definition
Instruments
The Procedures
Indications and contraindications
Complications
Hysteroscopy
Definition:
It is a technique which allows viewing and surgical
maneuvers to be performed in the uterine cavity.
It has many advantages that made it wide spread
and fundamental diagnostic method in daily
gynecological practice.
Instruments
1. Distention media
of the uterine
cavity (CO2
distention)
2. Light source.
xenon light
source gives the
best image
quality
3. Camera Equipment
4. Endoscope
flexible: high cost and
fragile cannot be
autoclaved.
rigid: gives different
direction of the view.
- 0, 12, 30 (best
for diagnostic
purpose).
5. Hysteroscope:
There are 2 types of hysteroscopes:
Diagnostic
Therapeutic
Procedure
1.
Procedure
2. Technique:
Indications
Used as a diagnostic tool:
- Abnormal uterine bleeding caused by:
- submucous and intramural myoma.
- endometrial polyps.
- endometrial atrophy.
- Endometrial tumors.
- Infertility related to:
- Intrauterine adhesions (Ashermans syndrome)
- Submucous fibroids.
- Endometrial polyps.
- Uterine malformation (it cannot differentiate between sepatate
and bicorneate uterus)<- this can be done by laparoscopy.
Indications
Used as a therapeutic tool
Endometrial ablation (using laser):
Abnormal uterine bleeding but we should role
out cancerous or pre cancerous cause of
bleeding.
Also used in patients with high risk for
hysterectomy or the patient does not want to
do the surgery.steroscopic Surgeries and
Endometrial Polypectomy
Indications
Correct uterine malformation like septate uterus by
resection of the septum. (bicorneate uterus is corrected by
laparotomy using metroplasty).
Polypectomy.
Intrauterine adhesions.
Myomectomy: The main indication for hysteroscopic
myomectomy is AUB caused by submucous myomas in
infertile patients
Indications
Used as a therapeutic tool
- Removal of foreign bodies and IUCD.
- Fallopian tube catheterization
- to canalize the tube.
- to place intra tubal device for reversible
sterilization.
Uterine polyp
Uterine anomaly
Intrauterine Adhesions
Endometrial Ca.
Contraindications
Pregnancy.
Current or recent pelvic infection.
Current vaginitis, cervicitis and
endometritis.
Recent uterine perforation.
Active Bleeding.
Complications
-
due to fluid:
-
HMW (dextran)
Anaphylactic reaction
Pulmonary edema
Adult RDS
Complications
- LMW (saline)
- Fluid overload: prevented by keeping the operating time
to minimum.
- Avoid entering vascular channels.
- Close monitoring of fluid balance.
- If you exceed 1000 ml of infused fluid stop the procedure.
- Intraoperative complications:
- Uterine perforation (<1%)
- Hemorrhage either from:
- Perforation
- Tenaculum used to hold the cervix.
-Trauma.
- Thermal damage.
Complications
-
Late onset:
-
Adhesion formation:
-
visit us at
www.essara.com/gyn.html
Download the slides & post your
Comments, opinions and questions
Movie
Wait !!
Asherman Syndrome:
It is defined as intrauterine adhesions
Cause can be iatrogenic (after hysteroscopic
myomectomy) and can due to infection.
It can be treated by hysteroscopic adhesiolysis
followed by inserting IUCD to make the uterine
walls apart from each other. We can also use
estrogen after adhesiolysis and this wall cause the
emdometrium to build up and prevent adhesions to
reoccur