Endoscopy in gynaecology rabi
-
Upload
rabi-satpathy -
Category
Health & Medicine
-
view
352 -
download
1
Transcript of Endoscopy in gynaecology rabi
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