Basics in gyne laparoscopy

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Basics in gyne laparoscopy

  1. 1. Basic Principles in GyneLaparoscopy DR.C.SURESH BABU PROFESSOR DEPT.OF OBGYN College of Medicine, Abha, KKU, KSA
  2. 2. INTRODUCTION         KALK(1930) – FATHER OF INTERNAL LAPAROSCOPY HOPE(1937) – FIRST GYNEACOLOGICAL REPORT ON ECTOPIC PREGNANCY BOESCH (1936)- COAGULATION PALMER (1943) –COLD LIGHT ENDOSCOPE. FRANGENHEIM (1952)– CO2 INSUFFLATION JORDEN PHILIPS – SPREAD OF LAPAROSCOPE THROUGHOUT THE WORLD SEMM (1970)-LAPAROSCOPIC HYSTERECTOMY
  3. 3. BASIC PREREQUISITES  GOOD KNOWLEDGE ABOUT SURGICAL ANATOMY  GOOD AT CONVENTIONAL SURGERIES  REASONABLE TRAINING  GOOD EXPERIENCE
  4. 4. ANATOMY
  5. 5. LAPAROSCOPY SET UP BASIC REQUIREMENTS: 1.TWO ASSISTANTS 2.WELL TRAINED SISTER 3.OT TECHNICIAN 4. ALL LAPAROSCOPIC INSTRUMENTS 5.TWO MONITORS 6.CO-OPERATIVE ANAESTHETIST
  6. 6. Verres Needle
  7. 7. Gas Insufflator
  8. 8. INSTRUMENTS
  9. 9. Trocar & Cannula
  10. 10. Camera
  11. 11. Laparoscope
  12. 12. Xenon Light Source
  13. 13. Uterine Elevator
  14. 14. Equipments Laparoscopic Tools Video monitor
  15. 15. 1. Bipolar grasper 2. Atraumatic grasper 3. Grasping forceps 4. Toothed forceps 5. Sharp-tipped monopolar device 6. 5-10mm suction-irrigation device 7. Scissors
  16. 16. Patient Positioning  Low lithotomy position  30 degree Trendelenburg  Urinary catheter  NG tube (?)  Uterine cannulation
  17. 17. Trocar Placement for Surgery A) 12mm optical trocar placed at umbilical level B) and C) 5mm lateral operative trocars placed 3 fingerbreadths above the symphysis pubis
  18. 18.  Peritoneum is inflated with CO2  Needle inserted at the umbilical level (primarily used) OR at Palmer’s point (3cm below costal margin in midclavicular line)  Pressure should not exceed 14 mmHg- respiratory compromise
  19. 19. OT SET UP
  20. 20. INDICATIONS FOR LAPAROSCOPY         Diagnostic: 1] Infertility 2] Suspected Ectopic pregnancy 3] Misplaced Copper T 4] Chronic pelvic pain etc., Therapeutic: 1] Myomectomy 2] LAVH, TALH
  21. 21. Therapeutic Indications      3] Ovarian Drilling in PCOD 4] Ovarian Cystectomy 5] Retrieval of misplaced copper T 6] Cauterisation of Emdometriotic spots 7] Radical Hysterectomy for cancer cervix etc.,
  22. 22. LAPAROSCOPY  General Anesthesia  Trendlenberg’s position  Lights should be off  Well trained staff  Electrical technical assistant
  23. 23. Anatomical Review 1. Medial tubal A. 2. Lateral tubal A. 3. Uterine A. 4. Ovarian A.
  24. 24. Laparoscopic Salpingectomy Main Risk: devascularization of the ovary  Operate close to the tube, away from ovarian vessels and suspensory ligament
  25. 25. 1. Proximal tube division  Isthmus is held upwards and outwards Isthmus is cauterized Take care not to cauterized the internal ovarian A. and ovarian branch of the uterine A. Divide tube with scissors   
  26. 26. 2.   Mesosalpinx Division Divide the mesosalpinx with scissors Cauterize and divide the infundibulo-ovarian ligaments and the lateral tubal A.
  27. 27. 3. Extraction of the tube  Remove tube through an extraction bag Verification of hemostasis Careful lavage Removal of equipment Suture/ Steri-strip laparoscopic incisions     Caution: • Endometriosis • Utero-peritoneal fistula
  28. 28. Normal left adnxa Normal left adnxa and Douglas pouch Positive methyline blue test Positive methyline blue test
  29. 29. Fine adhesion Fimbria Fine band of adhesion Mild fimbrial adhesion Fimbria Broad band of adhesion Douglas Pouch Moderate adhesion Fimbria
  30. 30. Severe Adhesions Dr.Sherbiny
  31. 31. Hydrosalpinx
  32. 32. Uterus L. Ovary L. Tube Adhesiolysis of the left tube with micro- scissor
  33. 33. Cutting band of adhesion R .Ovary
  34. 34. Phimosis: delayed methyline blue spill Dilatation with Maryland forceps Phimosis with methyline Blue jet Dr.Sherbiny Free methyline blue spill Phimosis of the fimbrial end: Dilatation with Maryland forceps
  35. 35. Typical Endometriosis Black Endometriosis Blue Endometriosis Black Blue Classic bluish black endometriotic implants
  36. 36. Atypical Endometriosis Yellow Brown Endometriosis Red Endometriosis(Flam-like) Peritoneal Defect White Endometriosis
  37. 37. Yellow Brown Endometriosis Clear Endometriosis Red Endometriosis (Pink)
  38. 38. Endometriotic Cyst = Endometrioma
  39. 39. PCO
  40. 40. PCOS: Laparoscopic Drilling Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS. RCOG Guidelines : Grade A 58 National Institute of Clinical Excellency (NICE) 2004
  41. 41. Tubal bipolar coagulation Salpingostom y Cutting of the medial part of the tube Salpingostom y Laparoscopic tubal occlusion & salpingostomy of Hydrosalpinges prior to IVF to improve pregnancy rate
  42. 42. COMPLETE SPECIMENN
  43. 43. ADVANTAGES      QUICK RECOVERY EARLY ORAL FEEDING EARLY AMBULATIONS BLADDER DYSFUNCTION IS LESS POSTOPERATIVE COMPLICATIONS ARE LESS
  44. 44. COMPLICATIONS       1] Bowel injury 2] Vascular injury 3] Bladder injury 4] Cautery burns to surrounding organs 5] Anesthesia complications 6] Surgical emphysema etc.,
  45. 45. THANK YOU

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