أضيفت : 03/ديسمبر/2007 في 4:23مساء | IP Logged

Gynecological Endoscopy

Definition: Procedure that uses a narrow telescope to view the interior of a viscus space.

Benefits when used appropriately

1. Reduced pain
2. Improved cosmoses
3. Lower cost
4. Faster recovery

Gynecological Endoscopy: Endoscopy in obstetrics and gynaecology has many branches:

•         Laparoscopy

•         Hysteroscopy

•         Colposcopy

•         Falloposcopy and salpingoscopy

•         Fetoscopy

•         Cystoscope

Laparoscopy: 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.

Patient Preparation and Communication

1. She must understand rationale, alternatives, risks, and potential benefits of the selected approach.
2. She should know what would probably happen if the procedure were not done
3. Expectations and risks of diagnostic laparoscopy, as well as those of any other procedures that may be needed, must be explained.
4. The risks include those of anesthesia, infection (although uncommon), bleeding, and injury to the abdominal and pelvic viscera.
5. The patient should be given realistic expectations regarding postoperative disability.
6. The patient should be instructed to communicate immediately if any regression in her recovery.
7. After diagnostic or brief operative procedures, patients can be discharged on the day of surgery and usually require 24 to 72 hours away from work or school.
8. If extensive dissection is performed or the surgery lasts >2 hours, admission may be necessary
9. If the colon may be involved, mechanical bowel preparation should be performed to help improve visualization and minimize the need for a colostomy if the colon is entered.
10. The patient should arrange for a friend or family member to discuss the results of the procedure and to drive her home if she is discharged the same day.
11. Mild analgesia is often necessary.

Indications

Diagnosis

1. Endometriosis and adhesions: The standard method
2. Ectopic pregnancy: although u/s, in combination with serum assays of b-hCG and progesterone, can be used to diagnose ectopic pregnancy, usually allowing medical therapy to be given without laparoscopic confirmation
3. Infertility: status of the fallopian tube (morphology and functionality) and any pathological condition e.g. adhesions.
4. Ovarian cysts or tumors.
5. PID: tubal abscess or adhesions.

Limitations to diagnosis

1. The view is restricted,
2. Vision may be obscured if tissue or fluid becomes attached to the lens.
3. Soft tissues or the inside of a hollow viscus cannot be palpated. U/S, CT, or MRI, are superior.
4. Intraluminal contour of uterus can be demonstrated only by hysteroscopy or contrast imaging.
5. May disclose abnormalities that are not necessarily related to the patient's problem. Although endometriosis, adhesions, leiomyomas, and small cysts in the ovaries are common, they are frequently asymptomatic. Thus, diagnostic laparoscopy must be performed prudently, interpreting findings in the context of the clinical problem and other diagnoses.

Therapy:

Advantages:

1. Less likely than laparotomy to form adhesions.
2. Direct peritoneal trauma is reduced
3. Contamination of the peritoneal cavity is minimized.
4. The lack of exposure to air allows the peritoneal surface to remain more moist and, therefore, less susceptible to injury and adhesion formation.

Limitations:

1. Exposure of the operative field can be reduced,
2. Manipulation of the pelvic viscera is limited
3. The caliber of the suture required may be larger than otherwise desired.
4. In many cases, the cost of hospitalization increases, despite a shortened stay, because of prolonged operating room time and the use of more expensive surgical equipment and supplies.
5. Efficacy may be reduced because surgeons may not adequately replicate the abdominal operation.
6. In some patients, there is an increased risk for complications, which can be attributed to the innate limitations of laparoscopy, the level of surgical expertise, or both.
7. With an adequate combination of ability, training, and experience, however, operative time and complications are comparable to those of traditional abdominal surgery.

A.     Tubal Surgery

1. Sterilization: by suture, clips, or Silastic rings, but electrosurgical desiccation with bipolar energy is the technique used most often
2. Ectopic Gestation: salpingostomy, salpingectomy, and segmental resection of a portion of the oviduct

Salpingotomy

–        Used to preserve the tubes for desired reproductivity.

–        Done if the patient is hemodynamicaly stable

–        If size < 5 cm

–        Location must be ampullary, infundibular or isthmic.

–        Contralateral tube either normal or absent.

Salpingectomy (the standard for ectopic pregnancy)

                          - Ruptured tube

                          - Multiple recurrence of ectopic pregnancy.

                          - Size of ectopic > 5 cm

B.     Ovarian surgery

1. Ovarian Masses: Preoperative u/s is mandatory. For postmenopausal women, CA125 may be useful. The ovarian tumors should be assessed by frozen histologic section, and any malignancy should be managed by laparotomy
1. Sonolucent lesions with thin walls and no solid components are at very low risk for malignancy.
2. Lesions with ultrasonographic findings suggestive of mature teratoma (dermoid)
2. Oophorectomy and cystectomy are performed similar to those for laparotomy.
3. Ovarian torsion if there is no apparent necrosis, the adnexa should be untwisted. Otherwise, adnexectomy is indicated.
4. PCOS can be treated laparoscopically using electrosurgery and laser vaporization.

C.     Uterine Surgery

1. Myomectomy :

•          Although feasible, rarely performed, in part because

ü      Efficacy is not established.

ü      Requires more technical skills than many other endoscopic procedures.

•          The only leiomyomas that are clearly appropriate candidates for laparoscopic excision are those pedunculated or subserosal lesions that cause pain in association with torsion.

2. Hysterectomy

ü      Facilitation of vaginal hysterectomy

ü      Supracervical hysterectomy by dissection

ü      Amputation and mechanical removal of the fundus,

ü      Removal of uterus with assistance of laparoscope

ü      No advantage for women in whom vaginal hysterectomy is possible because the endoscopic approach is more expensive and has a higher risk for postoperative morbidity.

D.    Infertility Operations

1. Operations used to reconstruct the normal anatomic relationships altered by inflammatory process: fimbrioplasty, adhesiolysis, and salpingostomy
2.  Gamete or zygote intrafallopian transfer.
3. Mechanical infertility are probably equally effective to similar procedures performed by laparotomy. In patients with extensive adhesions, however, the effectiveness of all procedures is limited.

E.     Endometriosis

ü      Electrosurgical or laser ablative techniques may be used to treat endometriotic tissue that is adherent to the remaining ovary

ü      Multifocal endometriosis may be treated by mechanical excision or ablation

F.      Pelvic Floor Disorders

Laparoscopy can be used to guide procedures to treat pelvic floor prolapse, including enterocele repair, vaginal vault suspension, paravaginal repair, and retropubic cystourethropexy for urinary stress incontinence

G.    Gynecologic Malignancies

ü      Lymph node biopsies performed by laparoscopy can be coupled with vaginal hysterectomy for the management of early-stage endometrial cancer.

ü      The potential for laparoscopic lymphadenectomy has fostered a resurgence of interest in vaginal radical hysterectomy for stage I carcinoma of the cervix.

ü      Laparoscopy is also being investigated for the staging of early ovarian malignancy and for second-look surgery.

Contraindications

1. Generalized peritonitis
2. Hypovolemic shock
3. Severe cardiac disease
4. Hemoglobin less than 7 g/dL
5. Uterine size > 12 wks.
6. Multiple previous abdominal procedures
7. Extreme body weight

Complications

1.      Anesthetic and Cardiopulmonary Complications

1. Hypoventilation
2. Esophageal intubation
3. Gastroesophageal reflux
4. Bronchospasm
5. Hypotension
6. Narcotic overdose
7. Cardiac arrhythmias
8. Cardiac arrest

2.      Carbon Dioxide Embolus

ü      Carbon dioxide is the most widely used peritoneal distention medium, largely because of the rapid absorption of CO2 in blood

ü      The signs of CO2 embolus include sudden and otherwise unexplained hypotension, cardiac arrhythmia, cyanosis, and heart murmurs

3.      Cardiovascular Complications:

1. Arrhythmias
2. Hypotension

4.      Gastric Reflux:

5.      Emphysema:

1. preperitoneal insufflation subcutaneous emphysema
2. emphysema of the omentum or mesentery

6.      Electrosurgical Complications (thermal injury)

7.      Trauma: (Insufflation Needle -  Trocar - Dissection  - Thermal)

1. Hemmorrhage:
1. Great vessels (aorta and the vena cava, common iliac vessels and their branches)
2. Abdominal Wall Vessel Injury
3. Intraperitoneal Vessel Injury
2. Gastrointestinal trauma: (stomach, the small bowel, and the colon)

3. Urologic Injury (bladder and ureter)
4. Neurologic Injury

8.      Incisional Hernia and Wound Dehiscence

9.      Infection

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.

Patient Preparation

1. Most diagnostic hysteroscopy procedures are performed in the office or clinic, Whereas operative hysteroscopy is performed in an operating room or hospital surgicenter.
2. The patient should understand the rationale for either procedure as well as the anticipated discomfort, the potential risks, the expectant medical and surgical alternatives.
3. The patient must understand the nature of the procedure and the chance of therapeutic success.
4. Realistic estimate of success based on the operator's experience must be presented to the patient

Indications

Diagnostic hysteroscopy:

1. Unexplained abnormal uterine bleeding

•         Premenopausal

•         Postmenopausal

2. Selected infertility cases

•         Abnormal hysterography

•         Unexplained infertility

3. Recurrent spontaneous abortion

Operative hysteroscopy:

1. Foreign Body (e.g. string of intrauterine device)
2. Septum
3. Endometrial Polyps
4. Leiomyomas (limited by the location and size)
5. Menorrhagia that does not respond to medications (endometrial ablation or resection)
6. Sterilization: insertion of a plug, injection of a sclerosing agent
7. Synechiae (Asherman's syndrome)

Contraindications

1. Pregnancy.
2.  Current or recent pelvic infection.
3.  Current vaginitis, cervicitis and endometritis.
4.  Recent uterine perforation.
5.  Active Bleeding.

Complications

1. Anesthesia

–        Allergy (agitation, palpitations, pruritus, coughing, shortness of breath, urticaria, bronchospasm, shock, and convulsions)

–        Neurologic effects (paresthesia of the tongue, drowsiness, tremor, and convulsions)

–        Impaired myocardial conduction (bradycardia, cardiac arrest, shock, and convulsions)

2. Trauma:

–        Perforation (during dilation of the cervix or during the hysteroscopic procedure)

–        Bleeding (during or after hysteroscopy results from trauma to the vessels in the myometrium or injury to other vessels in the pelvis)

–        Thermal Trauma

3. Distention Media

–        Carbon Dioxide: emboli

–        Dextran 70 (hyperosmolar medium): allergic response, coagulopathy, and, if sufficient volumes are infused, vascular overload and heart failure

–        Low-Viscosity Fluids (1.5% glycine and 3% sorbitol): fluid and electrolyte disturbances. Because they are hypotonic

4. Late onset:

–        Infections: PID, so give prophylactic antibiotics.

–        Vaginal discharge: common after ablative procedures and it is self limiting.

–        Adhesion formation

Colposcopy

Definition

–        Literally translated, colposcopy means to look into the vagina (ie, colpo means vagina, scope means to look)

–        Endoscopic instrument that magnifies cells         of  the vagina and cervix in vivo to allow            direct observation and study of these tissues.

Indications

1. Any time a malignant lesion or precursor is suspected in the cervix, vagina, or vulva
2. Abnormal Papanicolaou test
3. Abnormal screening tests as HPV testing
4. Abnormal or suspicious cervix on naked-eye
5. Abnormal and unexplained intermenstrual or postcoital bleeding
6. Unexplained, persistent vaginal discharge
7. Personal history of in utero DES exposure, vulvar or vaginal neoplasia, or condylomata acuminata,
8. Sexual partners condylomata acuminata.

Contraindications

No absolute contraindications

1. Bleeding:  examination may be deferred until bleeding ceases for women who are menstruating.
2. Acute cervicitis or vulvovaginitis should be evaluated and treated before
3. Pregnancy: less liberal use of biopsy in the absence of warning signs of high-grade disease or cancer and avoidance of endocervical curettage.
4. Postmenopausal women who are not taking hormone replacement may benefit from a 3-week course of topical or oral estrogen before colposcopy.
5. Patients should avoid use of all intravaginal products for 24 hours before the examination

Complications

Rare

1. The most worrisome complication is inadequate or inaccurate evaluation leading to the missed diagnosis of invasive cancer
2. Overestimation of lesion severity
3. Bleeding can occur following biopsy
4. Infection of biopsy sites

TECHNIQUES OF INTRA-LUMINAL TUBAL ENDOSCOPY

Inta-luminal tubal endoscopy may be performed by the transvaginal (falloposcopy) or transabdominal (salpingoscopy) approach.

Falloposcopy: Transvaginal inta-luminal tubal endoscopy

Salpingoscopy: Transabdominal inta-luminal tubal endoscopy

Indication

1. Proximal  tubal obstruction (PTO)
2. PID
3. ectopic pregnancy,
4. unexplained infertility
5. prior to tubal surgery
6. some forms of assisted conception

Fetoscopy

Definition: Fetoscopy is a procedure that utilizes an instrument called a fetoscope to evaluate or treat the fetus during pregnancy.

1. External fetoscopy:  Resembles  a stethoscope, but with a headpiece.
2. Endoscopic fetoscopy: The second type of fetoscope is a fiber-optic endoscope.

Indication

External fetoscopy :

1. to auscultate (listen to) the fetal heart tones after about 18 weeks
2. It allows birth attendant to monitor fetus and ensure that baby is tolerating labor

Endoscopic fetoscopy:

1. Congenital diaphragmatic hernia (CDH)
2. Urinary tract obstruction
3. Twin/twin transfusion syndrome (TTTS)
4. Acardiac twin

Complications

1. Externalfetoscopy: Only possibility of missing an abnormal heart rate or rhythm

2. Endoscopic fetoscopy:
1. Infection in the fetus and/or mother
2. PROM
3. Premature labor
4. Fetal death