Gynecological Endoscopy skills for both Laparoscopy and Hysteroscopy

1. INTRODUCTION TO ENDOSCOPIC
SURGERY
Dr. Mohamed Hesham Anwar
Prof. Obstetrics & Gynecology
AL AZHAR UNIVERSITY
GYNECOLOGICAL ENDOSCOPY…..
LAPAROSCOPY HYSTEROSCOPY

2. Gynecological Endoscopy
• Endoscopy in obstetrics and gynaecology
has many branches:
» Laparoscopy
» Hysteroscopy.
» Colposcopy
» Falloposcopy
» Fetoscopy

3. Operative Laparoscopy
Successful operative laparoscopy
requires 3 essential ingredients:
1. Surgical skill
2. Well designed &
equipped Operating
Room
3. Surgical team

4. LAPAROSCOPY
• Outline:
• Definition
• Instruments
• The Procedures
• Indications and contraindications
• Complications

5. 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.

6. Instruments
1. Verres needle:
used to inflate air to the
peritoneal cavity
(pneumoperitoneum)
through the umbilicus
where there is the
thinnest abdominal
wall.

7. 2. Electronic laparoflator: INSUFFLATOR
– Used to insufflate through the verres needle.
– Maintains constant intra-abdominal pressure without
exceeding the safety limit.
– Some types have heating system to prevent lowering
the patient body temperature.

8. 3. Trocars:
– Permit access to the
intraperitoneal cavity in which
other instruments can pass.
– The trocar used should be
adapted to the diameter of
the telescope selected.

9. 4. Telescope:
– There are different sizes and angels,
each with a different use.
– They are used to visualize the
peritoneal cavity.

10. 5. Camera
equipment.
6. Light source.

11. There are two types:
- Disposable
- Reusable
They can be either atraumatic
or grasping foreceps.
7. Forceps and scissors:

13. 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.
Instruments

14. 1. Preparation of the patient:
– Inform the patient about the
therapeutic benefits and potential risks
(informed consent).
– Intestinal preparation: Simple
intestinal emptying, for better viewing
and preventing injuries.
– Place the patient in the dorsolithotomy
position.
Procedure

15. a. The abdominal wall is lifted by hand or by grasping forceps
b. Pnemoperitoneum is created by verres needle introduced to the
umbilical area (less subcutaneous and preperitoneul tissue).
c. The needle is inserted in an oblique angle toward the uterine
fundus
d. The negative pressure will allow the underlying structures to fall
away.
e. After making sure that the needle is in correct position, air flow
can be increased to 2.5 liters per minute till a pressure of
15mmHg
2. Creation of pneumoperitoneum:

16. 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.
3. Trocar introduction

17. A. The omentum, bowel and bifurcation of pelvic vessels should be
evaluated to avoid injuries caused during the introduction of
Verres needle or trocar.
B. The site of introduction of other
trocars should be verified by finger
palpation and transillumination of
abdominal wall to avoid injury to
epigastric vessels.
C. Identify if there is any bleeding
4. Viewing the peritoneal cavity:

18. LapSim Basic Skills
http://surgical-science.com
camera &
instrument
navigation;
coordination;
grasping;
lifting,
grasping &
transfer;
cutting,
clip applying;
suturing;
precision &
speed

19. After the procedure
CO2 gas must be
evacuated completely
to reduce post-operative
pain
In operative procedures:
- 1 or 2 bottles of Ringer’s lactate are
used to wash the peritoneal cavity after
laparoscopy.
- Leave 500/1000 cc of ringer’s lactate to
reduce the incidence of post operative
pain.

20. Used as a diagnostic tool
– Infertility: status of the fallopian tube (morphology and
functionality) and any pathological condition e.g.
adhesions.
– Ovarian cysts or tumors.
– Ectopic pregnancy.
– PID: tubal abscess or adhesions.
– Endometriosis: define the sites of implants and
endometrial cysts.
Indications

21. Diagnostic
Laparoscopy
for Gynecological
Pelvic Disorders

22. Gynecologic Disorders:
 Chronic pelvic pain
 Ectopic pregnancy
 Pelvic inflammatory disease
 Endometriosis
 Adhesions
 Ovary: cysts, torsion
 Fallopian tube: torsion,
salpingitis
 Uterus: fibroid, leiomyomata
 Pelvic congestion syndrome
 Infertility

23. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD
BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
 > 40% of gynaecological diagnostic laparoscopies
are done for CPP
 Combining the results of published series of
laparoscopies for CPP shows that :
*No visible pathology is detected in 35% (range . 3±92%) of patients
*Endometriosis is diagnosed in 33% (range . 2±80%)
*Adhesive disease is found in 24% (range . 0± 52%)
 A negative laparoscopy is not synonymous with no diagnosis or no disease
 A meticulously performed negative laparoscopy means that a woman does not
have endometriosis-associated or adhesion-associated pain
Chronic Pelvic Pain

24. Ectopic pregnancy
Photograph courtesy of Dr. Syed
 Laparoscopy should be regarded as a therapeutic
rather than diagnostic tool for suspected ectopic
pregnancy.
 Transvaginal ultrasound has replaced laparoscopy for
diagnosis of ectopic pregnancy.
 Laparoscopy has diagnostic role if probable tubal
pregnancy or diagnosis in doubt.
 Large uncontrolled studies have demonstrated that >
80% of ectopic pregnancies can be managed
laparoscopically
 The most commonly used procedures at laparoscopy
are salpingectomy and salpingotomy.
The role of laparoscopy in the management of ectopic pregnancy. Martin Christopher Sowter, MD, MRCOGa,
Jonathan Frappell, FRCS, FRCOG Reviews in Gynaecological Practice #2 (2002) 73-82

25. Pelvic Inflammatory Disease
Clinical diagnosis of PID is often difficult especially when
symptoms are mild, as frequently when the primary
organism is C. trachomatis.
Laparoscopy is the gold standard for the diagnosis of PID –
should be used when diagnosis is uncertain, especially in
young women for whom the preservation of fertility is
important.
Sellors et al. reported that only by resorting to diagnostic
laparoscopy were they able to demonstrate that PID was
the cause of acute pelvic pain in 46% of a group of 95
women.
Laparoscopy should be considered for patients who have
not responded to antibiotic therapy within 48 to 72 hours.
The role of laparoscopy in the management of pelvic pain in women of
reproductive age. Maria Grazia Porpora, M.D. FERTILITY AND
STERILITY Vol. 6M, No. 5, November 1997.

26. Tubo-ovarian Abscess
Most commonly isolated pathogens from a
tubo-ovarian abscess are C. trachomatis and
peptostreptococci.
At laparoscopy the peritoneal cavity (pelvis and
abdomen) is inspected carefully.
The surgical steps include adhesiolysis,
aspiration of the abscess cavity, dissection and
excision of necrotic tissue, tubal lavage, and
irrigation of the peritoneal cavity before
completion of the procedure.
Laparoscopic surgery combined with adequate
broad-spectrum antibiotic therapy has proven
successful in the treatment of more than 95% of
patients.

27. Endometriosis
Endometriosis is a histologically-defined
disease :“the presence of ectopic tissue which
possesses the histological structure and
function of the uterine mucosa”. ( Sampson 1921)
Laparoscopy has largely replaced laparotomy
as the diagnostic procedure for any patient
suspected of having endometriosis.
Based on visual appearance endometriosis are
classified as atypical (red, yellow, white or
clear) or typical (black-brown, black or
puckered black stellate) lesions.
The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's
Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.

28. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical
Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
Brownish lesion on the ovary
White fibrotic lesion on the uterosacral
ligament
Peritoneal pocket of endometriosis Red stellate lesions in the cul-de-sac
Endometriosis presents with a variety of appearances that may make visual
diagnosis difficult and inaccurate.

29. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical
Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
Visually misdiagnosed
as endometriosis:
 Haemangiomas, old suture, ovarian
carcinoma, residual carbon deposits
from prior surgery, ectopic pregnancy,
…
 Histological confirmation of visually
diagnosed endometriosis ranges from
9-90%, depending on characteristics
of the lesions
Apparent classic endometriotic lesion that was
actually a suture granuloma.
Endometriosis

30. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical
Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
 Laparoscopic evaluation requires detailed
visualization of all sites of endometriosis:
 A study of 716 women with endometriosis
found these anatomical distributions:
cul-de-sac and uterosacrals ( 69%)
ovaries ( 45%) ovarian fossae ( 33%)
and uterovesical fold ( 24% ) Chocolate fluid from needle puncture
of a suspected occult endometrioma.
Endometriosis
ovaries (all surfaces)
ovarian fossae
pelvic peritoneum (cul-
de-sac, periureteral,
bladder peritoneum)
uterine ligaments
sigmoid colon
appendix
fallopian tubes
rectovaginal septum

31. Adhesions
Pre-operative history of PID, endometriosis,
perforated appendix, prior surgery or
inflammatory bowel disease.
Presently the only definitive way to diagnose
adhesions is by surgical visualization usually via
laparoscopy instead of laparotomy.
Laparoscopic studies reveal adhesions on
average in 24% of CPP patients and 17% of
non-CPP patients.
The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's
Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.

32. Adenomyosis
Endometrial cells penetrate the
myometrium causing either
localized (adenomyoma) or diffuse
overgrowth.
Adenomyomas that penetrate the
uterine cavity become submucosal
tumors.
An enlarged uterus from
adenomyosis is often misdiagnosed
as being from fibroids

33. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical
Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
 Most ovarian cysts are
haemorrhagic corpora lutea or
follicle cysts.
 They are usually asymptomatic and
when they cause pain it is almost
always acute.
 Laparoscopic evaluations of patients
with CPP reveal ovarian cysts on
average in only 3% of all cases.
Paratubal cyst
Ovarian Cysts

34. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical
Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.
Even when the surgeon is ‘certain’
that the ovary is benign, it is
essential that tissue be sent for
histological evaluation.
Open the cyst and inspect the
lining for papillary structures or
excrescences.
If these are noted, then a
laparotomy should be done .
Ovarian Cysts

35. Ovarian Cyst
Adhesions
between the
omentum and
uterus

36. Ovarian Cysts
The nature of the fluid is characteristically diagnostic :
chocolate (usually endometrioma or haemorrhagic corpus luteum)
sebaceous (teratoma), or mucinous (mucinous cystoma).
Mucinous cyst Teratoma
Dermoid cyst

37. Adnexal Torsion
A rare gynecologic emergency that
nearly always occurs unilaterally.
Common causes are benign ovarian
tumors and cysts; malignant processes
are rare.
Relapse or bilateral adnexal torsion can
cause sterility interfering with fertility.
In 30% of the patients, there is torsion
of a normal adnexa, while the majority
of the cases are associated with ovarian
pathology.
Adnexal torsion in very young girls: diagnostic pitfalls. Marieke Emontsa, Heleen Doornewaardb, J.(Co’tje)
F. Admiraala,* European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 207-210.

38. Adnexal Torsion
Conservative management by laparoscopy
is the best approach when tissues are viable
and should be carried out promptly to
preserve the adnexa
(basic principles of conservative
management are to untwist the structure
and treat the underlying cause ‘ie - ovarian
cyst’).
Once untwisted, the organ must be
observed to ensure color change to normal,
confirming viability and blood supply.
Adnexal torsion in very young girls: diagnostic pitfalls. Marieke Emontsa, Heleen Doornewaardb, J.(Co’tje) F.
Admiraala,* European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 207-210.

39. Endosalpingiosis
Endosalpingiosis is the presence of
fallopian tubal glandular epithelium in
an ectopic location.
Visually it appears as white to yellow,
opaque or translucent, punctate, cystic
lesions.
Endosalpingiosis is generally not
recognized by gynaecologists at the time
of laparoscopic evaluation or is
misdiagnosed as endometriosis.
The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's
Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000

40. Leiomyomata (fibroids)

41. Infertility

42. 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
- 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.

43. Adhesiolysis
Myomectomy

44. 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.
Management of Ectopic Pregnancy:

45. Salpingectomy
(it is the standard for ectopic pregnancy)
- Ruptured tube
- Multiple recurrence of ectopic pregnancy.
- Size of ectopic > 5 cm

46. Tubal sterilization by:
- Bipolar coagulation.
- Clips (filshie clips) and rings
- Before doing this you should
consult the patient about 3 things
- Chance of irreversibility
- Failure rate 1/200
- Bleeding may occur and we
may shift to laparatomy.
Ring sterilization

47. Laparoscopic hysterectomy.

48. 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

49. - 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

50. 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.
Complications

51. Conclusion:
Laparoscopy provides a vital tool for diagnosing
pelvic pain – it provides first hand visual
comprehension of the problem as well as an
immediate opportunity to continue with therapeutic
surgical correction.

52. HYSTEROSCOPY
• Definition
• Instruments
• The Procedures
• Indications and contraindications
• Complications

53. 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.

54. Instruments
1. Distention media of the
uterine cavity (RL / CO2
distention)
2. Light source.
xenon light source gives
the best image quality

55. 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).

56. 5. Hysteroscope:
There are 2 types of hysteroscopes:
Diagnostic
Therapeutic

57. Hysteroscopy Trainer –
3rd generation system (2003)
Tasks • cannulation Skills • advance (endoscope) through
endocervical canal
• exploration (Visual & • navigate, visualize endometrial cavity,
Haptic) identify & palpate lesion
• resection (myoma) • hold endoscope proximally, extend loop
distally, contact lesion, activate diathermy,
retract loop to excise: repeat –
Metrics
– % of the myoma resected
– # perforations
 mechanical
 electrosurgical
– timesec

58. 1. Preparation of the patient:
– Detailed history and complete physical examination
– It is preferable to do the procedure in the first part of the menstrual
cycle, because there is less mucus (better viewing) and no chance
of encountering early pregnancy
– Informed consent
– Patient is placed in lithotomy position
– Accurate bimanual examination to asses the uterine (position,
morphology, volume).
Procedure
2. Technique:
– Clean cervix with antiseptics
– Cervical forceps is placed on the front labia
– Light source & CO2 gas supply are connected to the instrument
– Insert hysteroscope into the cervical canal, which dilates from
the gas pressure.

59. 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 (Asherman’s syndrome)
- Submucous fibroids.
- Endometrial polyps.
- Uterine malformation (it cannot differentiate between sepatate
and bicorneate uterus)<- this can be done by laparoscopy.
Indications

60. 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

61. – 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

62. Hysteroscopic Surgeries and
Endometrial Polypectomy

63. 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.
Indications

64. Uterine polyp
Uterine anomaly

65. Intrauterine Adhesions

66. Endometrial Ca.

67. Contraindications
• Pregnancy.
• Current or recent pelvic infection.
• Current vaginitis, cervicitis and
endometritis.
• Recent uterine perforation.
• Active Bleeding.

68. Complications related to distention media:
due to CO2 insufflation:
- Cardiac arrhythmia due to excessive absorption.
- Gas embolism.
- use hysteroflator that insufflate pressure of 100-120 mmHg
constantly without exceeding the safety limit.
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.

69. - Late onset Complications:
- Infections: like acute PID, so we give prophylactic antibiotics.
- Vaginal discharge: common after ablative procedures and it is self limiting.
- Adhesion formation:
- Common after myomectomy when 2 fibroids are located opposite to each
other in the uterine wall.
- To prevent the adhesions it is better to remove the fibroids in stages, and
give estrogen (to build up the endometrial) therapy directly after
resection. And also we can use IUCD.

70. • 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. Also estrogen use after
adhesiolysis cause the emdometrium to build
up and prevent adhesions to reoccur

71. YOU WILL REMEMBER
A LITTLE OF WHAT YOU HEAR,
SOME OF WHAT YOU READ,
CONSIDERABLY MORE OF WHAT YOU SEE,
BUT
ALMOST ALL OF WHAT YOU UNDERSTAND.