DR.RABI SATPATHY MDASST.PROFESSORLaparoscopic SurgeonDEPT OF O&GS.C.B. Medical College, CuttackMob-09861281510

TYPES OF ENDOSCOPY IN GYNAECOLOGY

TWO MAIN TYPES:-

LAPAROSCOPY

HYSTEROSCOPY

LAPAROSCOPY

INTRODUCTION TO LAPAROSCOPY

Operative laparoscopy is today replacing conventional gynaecological surgery more & more for treating pathological conditions diagnosed at laparoscopy, so much so that in some centers 70% of gynaecological surgery is done laparoscopically. (Semm 1992)

Operative laparoscopy has become an extension of diagnostic laparoscopy , obviating the need for laparotomy.

In 1990, Harry Reich performed the first laparoscopic hysterectomy & Denis Querleu laparoscopic pelvic lymphadenectomy.Thus, major gynaecological surgeries are also being tackled laparoscopically today.

HISTORY OF LAPAROSCOPY

1806 - Philip Bozzini, built an instrument that could be introduced in the human body to visualize the internal

organs. He called this instrument "LICHTLEITER".

1853 - Antoine Jean Desormeaux, was a French surgeon who first introduced the 'Lichtleiter" of Bozzini to a patient. For many he is considered the "Father of Endoscopy".

1876 - Maximilian Nitze, modified Edison's light bulb invention and created the first optical endoscope with

built-in electrical light bulb as the source of illumination

1881 - Mikulicz and Leiter, adopted Max Nitze's principle of a rigid optical system and succeeded in

constructing the first useful clinical gastroscope.

HISTORY OF LAPAROSCOPY

Contd..1901- George Kelling, of Dresden coined the term "coelioskope" to describe the technique that used a cystoscope

to examine the abdominal cavity of dogs.

1911 - H.C. Jacobaeus, from Stockolm, used for the first time the term "laparothorakoskopie". Using this procedure on the thorax and abdomen. He also suggested employing similar

technique to examine body cavities endoscopically

1911 - Bertram M. Bernheim, from Johns Hopkins Hospital introduced laparoscopic surgery to the United States. He

named the procedure "organoscopy"

1918 - O. Goetze, developed an automatic pneumoperitoneum needle characterized for its safe introduction to the peritoneal cavity.

HISTORY OF LAPAROSCOPY

Contd..

1929 - Heinz Kalk, a german gastroenterologist, is considered the founder of the German School of Laparoscopy. Kalk developed a 135 degree lens system and a dual trocar approach. He used laparoscopy as a diagnostic method for

liver and gallbladder disease.

1934 - John C. Ruddock, an american internist described laparoscopic as a good diagnostic method, many times, superior than laparotomy. His instrument consisted of a

built-in forceps with electrocoagulation capacity.

1938 - J Veress, of Hungary, developed the spring-loaded needle. It main purpose was to perform therapeutic pneumothorax to treat patients suffering from tuberculosis. It current modifications makes the "Veress" needle a perfect tool to achieve pneumoperitoneum during laparoscopic

surgery.

kalk

Ruddock

HISTORY OF LAPAROSCOPY

Contd..

1944 - Raoul Palmer, of Paris performed gynecological examinations using laparoscopy and placing the patients in the Trendelemburg position, so air could fill the pelvis. He also stressed the importance of continuous intra-abdominal pressure monitoring during

a laparoscopic procedure.

1960 - Kurst Semm, a German gynecologist, who invented the automatic insufflator. His experience with

this new device was published in 1966.

1971 - Jordan M. Phillips, founded the American Association of Gynecological Laparoscopist with its goal

of providing education about this technology.

Palmer

Semm

HISTORY OF LAPAROSCOPY

Contd..1980 - Patrick Steptoe, from England started to perform laparoscopic procedures in the operating room under sterile

conditions.

1981 - The American Board of Obstetrics and Gynecology made laparoscopy training a required component of

residency training.

1982 - First solid state camera was introduced. This is the

start of "video-laparoscopy"

1987 - Phillipe Mouret, performed the first video-laparoscopic cholecystectomy in Lyons, France.

1994 - A robotic arm was designed to hold the laparoscope camera and instruments with the goal of improving safety, reducing resource utilization and improving efficiency and

versatility for the surgeon

1996 - First live broadcast of laparoscopic surgery via the internet.

Mouret

Robot Arm

Live

ARMAMENTARIUM

PRESENT DAY LAPAROSCOPY SETUP

Direct trocar entry through sub umbilical incision perpendicular to parities avoid two blind entry

and traverses the shortest distance and also quick penumoperitoneum is

established.

Energy sources

Electrical - unipolar, Bipolar, argon beamcoagulator.

LASER

Ultrasonic

Ligasure

Super Pulse

Recent development like versapoint is still being only used in Hysteroscopic surgery.

ALPHA -SEQUENCE OF LAPAROSCOPIC MOVEMENT

Temperature(oC) Tissue effect

37-43 Heating

43-45 Retraction

45-60 Denaturation of protein coagulation (>50 is reduction of enzyme activity)

90-100 Drying

>100 Boiling point of water, destruction of cell membrane

>150 Carbonization

>300 Vaporization

>500 Burning

No. of Operation(2500)

7% 4%7%

38%

35%

4%

3%

1%

1%

Ovarian Cyst (Epithelil)

Dermoid

Ectopic Pregnancy

PCO Drilling

Endometrioma

Hydro Salpinx / Pyosalpinx

Paraovarian Cyst

Heterotropic pregnency

Post Hysterectomy ovarian Cyst

Total Lapraroscopic Surgery in Adnexal masses

FORCEPS & APPARATUS FOR OPERATIVE LAPAROSCOPY

Classified into basic, intermediate & extensive by Martin(1988).

Basic: 1.Tubal sterilisation 2.Biopsies 3.Coagulation of mild endometriosis 4.Aspiration of small ovarian cysts.

Intermediate: 1.lysis of mild to moderate adhesions 2. Coagulation of moderate endometriosis 3.Exploration of small ovarian cyst 4.Uterine suspension 5.Salpingectomy 6.Salpingectomy for ectopic 7.Removal of Weck clips for reversal of sterilisation 8.Treatment of torted adnexa.

Extensive: 1.Cuff salpingostomy 2.Salpingotomy for ectopic 3.Lysis of extensive adhesions4.Excision of moderate to severe endometriosis 5.Eneucleation of ovarian cysts (endometriotic, dermoids) 6.Oophorectomy 7.Myomectomy 8.Tubal anastomosis 9.Hysterectomy 10.Pelvic or aortic lymphyadenectomy 11.Suspension operations for prolapse, stress incontinence etc.

INDICATIONS FOR OPERATIVE

LAPAROSCOPY

INDICATIONS FOR OPERATIVE

LAPAROSCOPY Contd..• Semm’s Organ specific classification(1992):

Operations on the tube: Conservative

1. Fimbriolysis

2. Salpingolysis

3. Salpingostomy

4. End to end anastomosis

5. Excision of Hydatid cyst

6. Treatment of pyosalpinx

7. Conservative surgery of tubal preg.

Operations of the tube : Total

1. Tubal sterilisation

2. Salpingectomy

SEMM’S CLASSIFICATION Contd..Operations of the Ovary: Conservative

1. Ovariolysis

2. Ovarian biopsy

3. Ovarian cyst puncture

4. Ovarian cyst eneucleation

5. Partial oophorectomy – wedge resection

6. Treatment of ovarian abscess

7. Excision of par-ovarian cyst

Operations of the ovary: Total1. Oophorectomy

2. Ovariotomy

Operations of the adnexa1. Operations for torted adnexa

2. Salpingo-oophorectomy

SEMM’S CLASSIFICATION Contd..Operations for endometriosis:

1. Fulguration of endometriotic implants on the uterosacral,ovaries,tubes,bladder bowel.

2. Excision of endometriosis of rectovaginal septum

3. Treatment of adenomyosis

Operations of the uterus:1. Treatment of uterine perforation

2. Myomectomy

3. Hysterectomy

Operations for ART:1. IVF-ET

2. GIFT

3. ZIFT

4. IPI

Adhesiolysis: Mild, moderate & severe adhesions

SEMM’S CLASSIFICATION Contd..

MISCELLANEOUS

1. Laparoscopic appendisectomy

2. Laparoscopic creation of new vagina

3. Laparoscopic sling for genital prolapse

4. Hydro laparoscopy

5. Laparoscopic cervicopexy

6. Laparoscopic Aortic/Pelvic lymphadenectomy.

7. LUNA

8. Laparoscopic retro-pubic suspension

9. Laparoscopic hernia repair

10. Modified Stamie-Pereira by endoscopy

11. Pre-sacral neurectomy.

ADVANTAGES OF LAPAROSCOPYSURGICAL GENTELNESS & ELEGANCE:

It is minimally invasive surgery, with minimal tissuen trauma & hence rapid return to normalcy.

No drying of tissues.

Magnification allows tissues to be identified & accurately treated gently with out damage to surrounding tissues.

Reduced oozing due to positive pressure of 10 – 15 mm of Hg & accurate haemostasis possible with electrosurgery, laser or fine sutures.

Less post-operative adhesions

EFFICIENCY:

Its results in terms of excision, functional recovery, & pregnancy rates are same as open surgery.

Allows rigorous elavuation by second look

COST EFFECTIVENESS:

Short hospitalisation, minimal post-opr discomfort & restriction , early return to work, cut down costs to hospital by 50 %.

DOCUMENTATION is cent percent and later on gives a chance for self-analysis and can be imparted on Education point of view.

Value of preoperative assessment for the disgnosis of malignancy in adnexal mass

The above table clearly indicate the superiorty of Laparoscopy over other

diagnostic modality.

Preoperative

assessment

Specificity (%) Sensitivity(%)

Abdominal

ultrasonograpgy

78 74

Vaginal ultrasonography 79 83

Doppler 89 92

CA 125 70 80

Laparascopy 97 100

1. EXPERTISE

2. SPECIFIC SOPHISTICATED EXPENSIVE INSTRUMENTS REQUIRED

3. TRAINED NURSES AND OTHER OT STAFF REQUIRED TO HANDLE THE INSTRUMENT

4. SURGERY TIME PROLONGED

5. THERE ARE RISKS OF ELECTRO SURGERY OR LASER , THAT MUST AVOIDED

DISADVANTAGES

COMPLICATIONS• Anaesthetic complications

• Haemorrhage

1. Inferior epigastric vessels

2. Omental vessels

3.Retro-peritoneal bleding

• Surgical Emphysema

• Injury to intestines

• Injury to ureter

• Infection

• Port Hernia

CONTRAINDICATIONS FOR LAPAROSCOPY

• ABSOLUTE1. Anaesthetic

2. Severe bleeding disorders

3. Pelvic mass arising from umbilicus

4. Ac. Peritonitis with severe distension

5. Patient refusing consent

6. Hemorrhagic shock

RELATIVE1. Prior laparotomies esp for intestinal fistula, major oncological surgeries

followed by radiotherapy

2. Extensive abdominal tuberculosis

3. Multiple scars

4. Obesity – over 100 kgs

5. Hiatal hernia

HYSTEROSCOPY

HISTORY OF HYSTEROSCOPYDésormeaux, in 1865, produced the first hystoscope

Pantaleoni in 1869 accomplished the first hysteroscopy using the instrument of Désormeaux. He isolated and cauterized an uterine polyp with silver nitrate.

Nitze, in 1879, drew and produced an endoscope using the modern beginnings.

S.Duplay and S.Clado, 1898

HISTORY Contd..Duplay and Clado, in 1898; David, in 1908; Heineberg, in 1914;

Rubin, in 1925; Seymour, in 1926; Van Mikulicz, in 1927; Gauss, in 1928; Schroeder, in 1934; Segond, in 1937; Fourestier, Gladu and Vulmiere, in 1952; Mohri and Mohri, in 1954; Norment, in 1956; Palmer, in 1957; Silander, in 1962; Marleschki, in 1966; Edstrom and Firestorm, in 1970; Lindemann and Mohr, in 1971; Porto and Gaujoux, in 1972; Vulmière, in 1972; Iglesias, in 1975; Lindemann, in 1976; Siegler and Kemman, in 1976; Hopkins, in 1976; March, in 1978 and Sugimoto, in1978-all of them contributed in some way to the technological progress of the method.

Hamou, in 1979, idealized the microhysteroscope with panoramic vision and of contact.

DIGNOSTIC INDICATIONS:

1. Abnormal uterine bleeding.

2. Habitual abortion.

3. Pathology uterine suspicion by other method

4. Follow-up of uterine surgery, complications of the curetage, trophoblastic disease, uterus-tubal implant.

5. GIFT, ZIFT, TET, FIVET.

6. Bone metaplasia of the endometrium.

7. Secondary amenorrhea and with negative estrogenic-

progestinic test.

8. Pelvic pain

9. Cancer.

INDICATIONS OF HYSTEROSCOPY

INDICATIONS Contd..SURGICAL INDICATIONS:

1) Adhesions.

2) Septum.

3) Polyps.

4) Sub mucous myoma with or without intramural component.

5) Dysfunctional uterine bleeding resistant to hormonal therapy

6) Tubal catheterization

7) Temporary (hydrogel P and intratubal device of Hamou) and definitive (silicone liquid) sterilization

8) Removal foreign body (intrauterine device).

ARMAMENTARIUM

THE HYSTEROSCOPIC SETUP

VARIOUS FORCEPS USED IN HYSTEROSCOPY

HYSTEROSCOPIC

PROCEDURES

HYSTEROSCOPIC

MYOMECTOMY

HYSTEROSCOPIC

POLYPECTOMY

TCER

HYSTEROSCOPY ALBUM

Uterine Septum A large polyp Myoma

Adenomysis Sterilisation Balloon Ablation

COMPLICATIONS OF HYSTEROSCOPY

Secondary to the gaseous distensionN2O (nitrous oxide) - lung clot, bradycardia and collapse

CO2 (carbon dioxide) - pain in the area of the scapula bone, due to the stimulation of the frenic nerve, that disappears spontaneously after some minutes. Hypercapnia, acidosis, arrhythmia and cardiac arrest are not more found now with the amount and pressure of the gas used, being recommended a maximum flow of 100 ml/min and a maximum pressure of 150 mmHg.

COMPLICATIONS Contd..

Secondary to the distension liquidOverload - excessive passage of liquid to the current blood, causing

dilution, hyponatremia, arterial hypertension and pulmonary edema, in the postoperative it can cause hypotension and mental confusion. It happens mainly when the operative procedure is long, high pressure of distention, depth of the myometrium dried up above 4 mm and in the luteal phase of the menstrual cycle for the largest vascularization of the endometrium

Anaphylaxis (solution of Hyskon).

Encephalopathy (glicina).

Hyperglycemia (glucose and sorbitol).

Hemolition (distilled water).

Air embolism.

COMPLICATIONS Contd..Infectious (average of 7 in 1000 inter- ventions, being rare in

the diagnostic).Endometritis Salpingitis

Pelvic inflammatory disease

TraumaticCervical trauma (laceration by Pozzi or during the dilation)Uterine trauma (perforation, more frequently happening in the surgical intervention)Intestinal trauma, vesical trauma, ureter and great vessels trauma (direct or indirect, this being caused by eletrocoagulation).

Haemorrhage (intra & post-operative)

Synaechia

COMPLICATIONS Contd..• Hematometra, criptomenorrhea and recurrent pain (it happens

mainly in the total ablation of the endometrium).

• Pregnancy after ablation of the endometrium, causes abnormal placental insert and IUGR

• Painful

• Vagal Reaction

• Bradycardia

• Sensorial alterations

• Syncope

• Cardiac arrest

• Anesthetic : Allergic reactions, Arrhythmia, Convulsions

• Flaws therapeutics ( 10% – 20%)

• vaginal secretion for 2 to 4 weeks

CONTRAINDICATIONS

ABSOLUTE

1. Active or recent pelvic infection.

2. Severe cervical stenosis.

3. Recent uterine perforation.

RELATIVE

1. Profuse bleeding

2. Pregnancy

3. Dense uterine synechiae

CONCLUSIONEndoscopes are a valuable addition towards Gynecological patient care on the ground of being minimally invasive, efficient & cost effective.The list of indications is increasing day by day as more sophisticated armamentarium & technology is being developed & made availableIf all our endoscopes were abandoned Gynecological surgery would perhaps not suffer a major setback, but, for present those who are neglecting endoscopy are losing an important dimension of modern practice.

Achievement of laparoscopic surgery is only possible when there is a full

balance between

Technology and Education

A MESSAGE TO THE FRESHERS

THANK YOU