3. History
1805, Bozzini, an obstetrician, using candlelight through
a tube attempted to examine urethra and vagina
1910, Jacobaeus, performed laparoscopy using a
cystoscope
1920s & 1930s, Kalk, a gastroenterologist, popularised
diagnostic laparoscopy
Origin of modern laparoscopic surgery- Kiel School in
Germany, headed by Semm, a gynaecologist.
Dr. Camran Nezhat - “FATHER OF MODERN
LAPROSCOPIC SURGERY” introduce video
laparoscopy
Litynski G.S. JSLS 1997; 1(2): 185-188
1901: George Kelling, Dresden,
Saxony (Germany) performed 1st
experimental laparoscopy on dog,
calling it ‘Celioscopy’
4. ADVANTAGES
Reduced postoperative morbidity - pain, chest & wound
complications
Ellstrom M. Acta Obstet Gynecol Scand 1998;77: 923-928
Accelerated recovery ACOG 2009, Cochrane Database Syst Rev. 2009
8;(3):CD003677
Lesser adhesion formation Audebert AJ. Fertil
Steril. 2000;73(3):631-5.
Better cosmesis
Reduced contact with body fluids & disease
transmission
Reduced incidence of ventral hernia-
11% in midline vs 4.7% in transverse scar vs 0.7% after laparoscopy.
Le Huu Nho R. J Visc Surg. 2012;149:3-14
MAGNIFICATION PRECISION DOCUMENT-
ATION
5. DISADVANTAGE
Expensive equipment
Learning curve
Limitation of intact organ retrieval(tumours)
Trocar related injuries to vessels and viscera
Counter-intuitive motion
Diathermy burns
Hemostasis more difficult
Insufflation related postoperative pain Williams Gynecology 2nd Edition A guide to laparoscopic
surgery
7. IMAGING SYSTEM
TRIPLE CHIP CAMERA (HD)
CAMERA 3D
LIGHT CORD(fibre-optic)
Xenon (300 watt)
500 hrs (Best illumination by powerful sources)
Minimum heat conduction to the telescope body- “cold light”
MONITOR &
RECORDING
SYSTEM
8. INSUFFLATOR
Initially low flow & then increased, preferably to 3-6 L/ min.
Throughout insufflation, vitals are closely monitored.
Pressure 12-15mmHg
Pressure gauge automatically stops gas flow on reaching pre-selected
pressure
Rapid insufflation- dysrhythmias & post-operative pain
Total
Volume of
Gas
Flow
RateAbdomina
l
Pressure
Cylinder
Pressure
9. SURGICAL INSTRUMENTATION
LAPAROSCOPE : Two channels
a) Optical viewing channel
b) Light channel
Head on
0°
in careful
study of
adhesions &
ovarian
surfaces
30°
Endocameleon
0-120°
10. SURGICAL INSTRUMENTATION
Most commonly
used for operative
as well as
diagnostic
purpose
10 mm
Mainly used for
diagnostic
purpose , can be
used for operative
purpose
5mm
Very delicate
MINIlaproscopy
As a fetoscope
Diagnostic purpose
Also in operative
< 5 mm
LAPAROSCOPE OPERATING
LAPAROSCOPE
• Used in sterilisation
procedures
• Single incision
• Restricted view
11. MINILAPAROSCOPY
O'Donovan defined these miniature
scopes as-
Minilaparoscope – Diameter < 5mm
Conventional minilaparoscopy: 5-
3.5mm
Modern minilaparoscopy: 3.4-2mm
Microlaparoscopy: <2mm
Smaller incisions mean lesser pain
and faster recovery & less chances of
hernia.
Conventional minilaparoscopy
(5mm) when compared with
modern minilaparoscopy(2.9mm),
diagnostic accuracy, operative
difficulty, operating time, intra-
op complications, post-op pain,
hospital stay, patients'
acceptance are comparable
except quality of image and size
of projected image on screen,
which were better in 5mm
Group.
Roy K.K et al., BJOG 2013
13. Trocars & Cannulas
Pyramidal-
Less force; better cutting
Lesser visceral injury
Increased abdominal wall vessel injury &
incisional hernia
Woolcott R. Aust N Z J Obstet Gynaecol.
1997;37:216
Conical-
Greater force required
Lesser vessel injury & hernias
Increases risk of visceral injury
Blunt-
Open technique
Re-introduction of displaced cannula
14. ENERGY SOURCES
MONOPOLAR BIPOLAR
Hand piece (Active electrode) is
at the surgical site
Ground pad (Return electrode)
is elsewhere on body
Current passes through large
amount of tissue
DISADVANTAGES
Large volumes of tissues are
injured
Distant burns can occur
Interferes with pace makers
Active & return electrode are
located in same instrument
More limited area of thermal
spread
Useful for coagulation only
Separate instrument for
cutting
e.g. Robi, Bipolar grasping
forceps(Kleppinger)
Brill A.I. Obstet Gynecol Clin N Am 2011;38:687-702
16. Ligasure Vessel Sealing System (LVSS)
The Ligasure System (Valleylab,
Boulder, Colorado) (coviedion)
Higher current and lower voltage (180 V)
Melt vessel collagen and elastin to form a
translucent seal
Vessels as large as 7 mm in diameter can
be sealed
The need to use scissors greatly
slows the speed, especially compared
to the ultrasonic coagulator
17. En-seal
SurgRx Enseal handpiece
The gold I-blade - When the handpiece handle is
squeezed, the I-blade advances simultaneously with
energy delivery, so it close the bipolar jaws and cut the
sealed tissue .“one-step process” which greatly speeds
up the seal–divide cycle
NANOPARTICLE acts as thermostatic switch to
regulate amount of current passing in the tissues with
which it is in contact.
When temp rises to damaging levels, the conductive
nanoparticle interrupts the flow, also when temp dips
below optimal level it switches back on
the gold I-blade
18. Ultrasonic Energy Source
Harmonic
Cutting is achieved mechanically
by blade(Active) which oscillates at
55,000 Hz
Active blade pushes the tissue
against the tissue pad; tissue is
sheared between the two
“MAX” setting- rapid transection
“MIN” setting- vessel sealing
Available as Harmonic Ace,
Scalpel
Lyons S.J Minim Invasive Gynecol.2013;301-307
19. COMPARISON OF ADVANCE ENERGY SOURCES
Device
Safety:
Minimal
thermal
spread
Reliability
: Efficacy
on
vessels
≤7 mm
Residual
tip
temperat
ure
Efficiency
:
Treatment
time
Consistenc
y:
Independen
t of user
Utility:
Multiple
uses
Harmonic Excellent Poor(3-5) Poor Excellent Poor Excellent
Gyrus PK Poor Poor Good Excellent Fair Fair
LigaSure V Good Excellent Excellent Good Excellent Fair
EnSeal Fair Excellent Excellent Poor Excellent Poor
•THUNDERBEAT – uses bipolar & ultrasonic energy simultaneously . minimal
lateral spread like harmonic & vessels sealing capacity like bipolar with good
residual tip temperature
Newcomb WL, et al.. Surg Endosc. 2009;23:90–96.
21. Lateral Thermal Spread
Greatest with Monopolar diathermy- 1 cm
Least with ultrasonic devices
0.6mm to 1.5 mm with Harmonic for arteries & veins
respectively
4.5 mm to 6.3 mm with Ligasure, for arteries & veins
respectively
Thunderbeat similar to Harmonic
Similar for PKS system & Ligasure
Kenneth S.K.Law. J Minim Invasive Gynecol 2013; 308-318
Sutton P A. Br J Surg 2010;97:428-433
Hruby GW. J Urol. 2007;178:2689-2693
22. CDC recommends Sterilisation or High Level Disinfection
Steps involved-
1. Dismantling- To remove debris from crevices
2. Decontamination- visible blood & tissue is wiped off, then
soaked in 0.5% chlorine for 10 minutes
3. Pre-cleaning- with an enzymatic product viz. protease
recommended
4. Cleaning- with soft brush, detergent & water
5. Rinsing- under running water
6. Drying
CDC guidelines 2008
Comprehensive laparoscopic Surgery 2nd edition, IAGES
Maintenance Of Instruments
23. 6. Sterilisation- 2 methods are commonly used
a) Steam Sterilisation-
Autoclaving at 134° for 30 minutes
All insulated instruments, tubings, cords should be doubly wrapped in
cloth
b) Ethylene Oxide Gas Sterilisation-
Non-corrosive to optics
Permeates porous material
High cost
Longer process
c) Low Temperature Plasma Sterilizer
heat & moisture sensitive equipment
25-50min cycle
Keep the instrument in it after plastic covering CDC guidelines 2008
Comprehensive laparoscopic Surgery 2nd edition, IAGES
Maintenance Of Instruments
24. High Level Disinfection with 2% Glutaraldehyde (Cidex Plus)
for 20-30 minutes
Good alternative to sterilisation in case of telescopes, and fibre-
optic light cords; as easily damaged
The length of time that commercially available glutaraldehyde
solutions may be used varies, usually from 14-30 days. It ought to
be tested daily with the manufacturer’s test strip
Solutions should be replaced any time they become cloudy
Use of sterile drapes over camera and cord is another
alternative CDC guidelines 2008
Comprehensive laparoscopic Surgery 2nd edition, IAGES
Maintenance Of Instruments
25. PRE-OPERATIVE BOWEL PREPARATION
Restrict use in cases requiring recto-sigmoid dissection with suspected
adhesions
Bowel preparation provides statistical improvement in surgical view and
bowel handling; but not clinically significant
Given the significant discomfort caused , fasting only is a preferable
alternative
Won H. Obstet Gynecol. 2013; 121(3):538-46
Sodium phospate more effective than polyethylene glycol
Itani KM. Am J Surg. 2007;193(2):190-4
NaP enema equally effective, less side effects compared to NaP solution
Yang LC. J Minim Invasive Gynecol. 2011;18(2):149-56
26. ANESTHESIA
GA preffered with endo tracheal tubing
GA after SPA – for radical surgery
IV SEDATION + LA – Sterilization procedure, for diagnostic laparoscopy
(pain scoring)
POSITIONING
Steep, head-down (15-20°) (Trendelenburg position) – bowel displaced
up
Low lithotomy position of legs
Adequate padding (avoid common peroneal nerve injury)
Knees in slight flexion(<90°)
(avoid sciatic nerve stretching)
Hips in slight abduction(<45°)(avoid femoral nerve injury)
Left arm by side of patient(avoid brachial nerve injury)
Post operative intraperitoneal bupivacaine administration is beneficial
for patients undergoing diagnostic minilaparoscopy.
KK Roy et al., Arch Gynecol Obstet (2014) 289:337–340
27. VERESS DIRECT OPEN
• Held in a pen holding manner
• Non- dominant hand elevates the
abdomen
• First perpendicularly- resistance
followed by a give felt(1st click), as
passes through sheath
• Then at 45°- click is felt as passes
• Trocar grasped against thenar
eminence
• Index/middle finger extended over
sheath & acts as a guard (like holding
a gun)
• Non-dominant hand elevates the ant
abd wall
• Initially perpendicular, then downward
twisting force
Indication:
Previous lower abd surgery,
pregnancy, children, obesity
28. Mean intra abdominal pressure – 6.5mmHg (0.2-
10)1
After lifting of abdomen – negative
Pre set pressure – 12-15mmHg
VERESS INSERTION TESTS
The double click test
Manometer test
Syringe aspiration
Instillation & aspiration of saline
Syringe barrel flow test
The hanging drop test
Percussion test- loss of liver dullness
Free movement test- (not recommended)
Manometer test- (Most reliable test)
• Insufflation pressure should be low -<10mm Hg
•Incorrect if pressure high & flow low
•If pressure rises initially or vigorously; pre-peritoneal dissection
Teoh B et al. J Minim Invasive Gynecol 2005;12:153-8
1Sanchez NC et al., Am Surg. 2001 Mar;67(3):243-8
29. ADEQUATE PNEUMOPERITONEUM
HIP (20-25mm Hg) till primary & secondary trocar insertion
followed by decreasing to 12-15 mm Hg RCOG green top
guidelines 2008
HIP increases gas bubble, splinting of ant abdo wall &
increases distance b/w umbilicus & aortic bifurcation from .6
cm to 5.6 cm
Volume = 1-4 lt
Thin built = 1-2 lt
Mod obese with relaxed abd walls = 5-6 lt
30. FAILED ENTRY- 2 attempts
Open laparoscopy
Entry from palmer’s point
SCARRED ABDOMEN
• Alternate sites of entry, Direction almost 90°
PALMER’S POINT
3 cm below left subcostal border in mid-clavicular line
Stomach emptied, Exclude splenomegaly or gastric surgery
OPTICAL TROCAR/VISUAL ENTRY SYSTEM
Abdominal layers entered under laparoscopic vision
Hollow trocar with transparent tip
Allows clear optical entry
Minimise size of entry wound and reducing force
Non-superior to other, do not avoid visceral and vascular injury
RCOG Green Top Guidelines 2008
31. “No evidence that they
decrease entry-related
vascular or visceral
complications”
A systematic Review. Vilos GA. J Obstet
Gynaecol Can. 2007;433-65.
Shielded Trocars
With a shield that partially retracts & exposes a sharp tip as
it encounters resistance
As it enters the cavity, shield springs forward & covers the
tip.
Health devices 1998;27:376-98
32. RADIALLY EXPANDING ACCESS SYSTEM
Rapidly expanding access system (STEP TM)
Uses pneumoperitoneum needle with
expandable sleeve
Post insufflation, needle removed, outer
sleeve left
Direct dilatation of sleeve results in creation
of port
Separates rather than cuts muscle fibres
Not recommended over traditional trocars.
Have blunt tips, may provide some protection from injuries,
Force required for entry is significantly greater than with disposable trocars.
(SOGC I-A)
33. • 28 RCT with 4860 individual evaluated 14
comparisons.
• Using an OPEN-ENTRY technique compared to a
Veress Needle demonstrated a reduction in the
incidence of failed entry, Peto OR 0.12
• DIRECT-TROCAR ENTRY when compared with
Veress Needle entry
lower rates of failed entry (OR 0.2)
extraperitoneal insufflation (OR 0.18)
omental injury (OR 0.28).
• Studies excluding patients with previous abdominal
surgery and women with a raised body mass index
CHOCHRANE
REVIEW 2013
LAPROSCOPIC ENTRY
34. - NITROUS OXIDE pneumoperitoneum - decrease
post‐operative pain in patients with low anaesthetic
risk.
- HELIUM pneumoperitoneum - decreases
cardiopulmonary changes
- No advantage over CO2
- Safety of NO & He has yet to be established.
- Future trials should include more patients with high
anaesthetic risk.
CHOCHRANE
REVIEW 2013
PNEUMOPERITONEUM
CO2 - most commonly used
Safe, rapidly cleared by the
lungs
No optical distortion
Supresses combustion
Readily available & inexpensive
35. SECONDARY PUNCTURE
INCISION SITE-
Lower side port-
2 cm above & medial ASIS(5cm above, 8cm
lateral to PS)
15cm from operative site
Upper side port-
At intersection of vertical line from left lower port &
horizontal line from umbilicus or
At level of umbilicus, >6cm away from midline
Forming 30-60º angle with operative site
Triangulation- Instruments provide opposing action
Non-midline incision more than 7mm & midline more than
10 mm requires deep sheath closure
36. PORT POSITIONS
One of the most common cause of stressful surgery is wrong port position
“BASEBALL DIAMOND CONCEPT” of port position
Define : Target site
Primary Port – should be away from TARGET SITE
In cases of enlarged uteri where the fundus approaches the level of the umbilicus, it
may be necessary to place the ports higher on the abdominal wall to ensure proper
distance for visualization and instrument operation
Secondary port in diamond/ baseball ground fashion
INSTRUMENT ELEVATION ANGLE from surface -15-30º
Half of the instrument in & half out (Type 1 liver mech.)
37. Laparoendoscopic Single-site Surgery
(LESS)
Single Incision Laparoscopic Surgery (SILS)
Single intra-umbilical 20-25 mm incision
Trocar insertion by open method
Reduced post-operative pain, improved cosmesis
Special instruments & ports required
Disadv- Learning curve, swording, increased chances of
capacitative coupling
Sobolewski C. Obstet Gynecol Clin N Am 2011; 741-755
Comparable in the efficacy and safety
No advantage in cosmesis or pain compared to
conventional
May have longer operative time for adnexal surgery, but
not for hysterectomy.
Meta- analysis. Song T. Am J Obstet Gynecol. 2013 Jul 13
A systematic Review & Meta-analysis. Murji A. Obstet Gynecol
2013;121:819–28
Elbert Khiangte. Indian J Surg 2011 73(2):142–145
38. DIAGNOSTIC LAPAROSCOPY
SYSTEMIC APPROCH NEEDED WITH PRE OPERATIVE CHECK LIST
1. EXAMINE THE TROCAR / VERRES INSERTION SITE & CHECK FOR ANY BOWEL / VASCULAR
INJURY
2. UTERUS FROM ANT, POST ASPECTS & POD
3. UTEROSACRAL LIGAMENT & BROAD LIGAMENT
4. OVARIES ( GLOBAL VIEW INCLUDING UNDERSURFACE)
5. URETER WHEN OVARY IS LIFTED UP
6. FALLOPIAN TUBE WITH T-O RELATIONSHIP
7. APPENDIX
8. UPPER ABDOMEN
9. CHROMOPERTUBATION
39. COMPLICATIONS OF LAPAROSCOPY
In Finland, 256 complications in 70 607 laparoscopic procedures -
3.6/1000
Major complications 1.4/1000
In Netherlands 145 complications from 25 764 laparoscopies - 5.7/1000
84 women (3.3/1000) – need of Laparotomy
57% - laparoscopic entry
Laparoscopy having similar surgical outcome & less complication but
more cost in comparison to laparotomy
Jansen Fwet al.; Br J Obstet Gynaecol 1997;104:5
Harkki-Siren P et al.; Obstet Gynecol
Lee M et al.; Int J Gynecol Cancer. 2011 F
40. LAPROSCOPY & OBESITY
Anaesthesia risks
Thick abdominal wall-
• Difficulty in trocar-cannula insertion
• Impedes port movement
• Requires higher insufflation pressures
Thick omentum & mesentry-impairs visibilty and manipulation
• Wound infection decreases by 70-80% by laparoscopy
Meta-Analysis- Shabanzadeh DM. Ann Surg 2012;256(6):934-45
• Laparoscopic surgery associated with lower complication rate, lower
SSI, postoperative hospitalization than laparotomy
Tinelli R et al. , Anticancer Res. 2014 May;34(5):2497-502
41. 50% of major complications due to access, prior to intended surgery.
Jansen FW. Am J Obstet Gynecol.2004;190:634–8
Overall rate of major complications: 1.1 to 1.4 per 1000
A meta-analysis. Molloy D. Aust N Z J Obstet Gynaecol. 2002;42:246-254
Intestinal injuries : 0.6 to 4.4/1,000 procedures
Urological injuries : 0.3/1,000 procedures
Vascular injuries :0.9 to 3.1/1,000 procedures in various studies
30-50% of bowel injuries & 13-50% of vascular injuries undiagnosed
Jansen FW et al., Am J Obstet Gynecol 2004; 190:634.
J Gynecol Endosc Surg 2009;1:4-11.
Harkki-Siren P. Obstet Gynecol. 1997;89:108–112.
ENTRY COMPLICATIONS
42. VASCULAR INJURIES
Mortality rate of 12-23% Baggish MS.J Gynecol Surg. 2003;19:63–7; Chapron CM. J AmColl Surg.1997;185:461–465.
Majority occur during veress or primary trocar entry
Distal aorta, right common iliac & IVC particularly prone
Minor- inferior epigastric vessels, during placement of secondary cannulas
Injuries can be hidden behind omentum or retroperitoneum
Major vessel injury
First goal is to obtain pressure – laparotomy
Skilled vascular surgeon called
Inferior epigastric injury-
Cautery less useful
Foley’s catheter or suture ligation done-
removed after 12-24 hours
COG 2009
43. Bowel Injuries
Rate- 0.2-1.5/1000 in diagnostic to 1.5-
2.4/1000 in advanced surgery
Half occur during entry- small intestine
mostly
Recto-sigmoid common site, if injury is
during surgery
Diagnosis often delayed in electrosurgical
injuries- 2-7 days
Patient presents with peritonitis
Small perforations may be repaired
laparoscopically, larger may require
laparotomy or colostomy
Brosens I. Gynaecol Endosc. 2001;10:141–145.
COG 2009
44. UROLOGICAL INJURIES
To avoid- bladder drained pre- procedure
Bladder injury- during bladder dissection at cervico-vaginal junction
Ureteric injury- near infundibulo-pelvic ligament or uterine artery
Pre operative stenting- helps to identify ureter easily & decreases
incidence of injury, Limit to high risk cases with distorted anatomy
To detect- 5 ml indigocarmine dye injected i.v. & cystoscopy done intra-op
Bladder injuries: <5mm heal spontaneously with continuous drainage
Larger require suturing
Makai G. COG 2009
Combined incidence after laparoscopic hysterectomies- 4.3-4.8%
Obstet gynecol 2009;113(1):6-10, AJOG 2005:1599-1604
Ureteral injuries- 3.4 per 1000
Bladder injuries- 3.4 per 1000 Finnish cohort study- Hum Reprod. 2008;23(4):840-845
Ureter injuries : 1.2%(range 0.6%–4%)- 70 % diagnosed post operatively
P. F. Janssen, MD; JMIG 2011
45. ELECTROSURGICAL COMPLICATIONS
Direct thermal burns
› Due to accidental pressing of foot pedal
Current diversion injuries-
occurs mainly with monopolar
› Insulation Defects
› Direct Coupling
› Capacitative Coupling
Insulation Defects-
› Zone of high current density created
› To prevent instrument should be kept fully visible
› Away from vital structures
INSULATION DEFECTS
46. Direct Coupling-
Activated electrode touches
another uninsulated metal
conductor like laparoscope or
cannula
Eliminated by avoiding use of
noninsulated & monopolar
instruments together
Capacitative Coupling-
Monopolar electrodes emit a
surrounding charge
Generally, it dissipates to
abdominal wall
If dispersion blocked due to
plastic cannula, then couples to
bowel or conductive cannula
DIRECT COUPLING
CAPACITATIVE COUPLING
47. Injury Prevention
Use the lowest possible voltage (interrupted preferred, lesser coagulation
mode)
Never use 2 energy sources simultaneously
Keep activated electrode in operative field at all times
Refrain use till instrument blade has cooled (remove when not using)
Manually pulse device or irrigate pedicle to prevent thermal spread
Monitor the quality of the insulation of instruments
Whenever possible use bipolar energy sources over the monopolar
When desired tissue effect is not accomplished, check ground pad or for
coupling
Lipscomb G.H. Obstet Gynecol Clin N Am 2010;37:369-377
49. HISTORY
First attemt for visualisation of abdominal organ-
Bozzini 1806 – illumination of urethra by candle
Pantaleoni 1869 introduced hysteroscopy for diagnosis of intrauterine
ds.
Rubin 1925 : used cystourethroscope to look into uterus. Used water to
distend Uterus and to wash lense, used carbondioxide
1990s : Hysteroscopic surgical procedures became popular ,
demonstrated equivalent or better results than traditional laparoscopic
surgery of uterus
50. High cost
Flexible Fragility
Endoscopes problem in sterilization
Rigid Oº , 12º, 30º..
Diagnostic
Operative
Resectoscope
HYSTEROSCOPE
51. TYPES
Rigid hysteroscope
4-mm scope offers the sharpest and
clearest view
Narrow, 3.5 mm - minimal dilation of
the cervix.
Ideal for office hysteroscopy
Flexible hysteroscope
• Can deflect over a range of 120-160°
• New equipment replaces image fiber
bundle with a video chip, eliminating
unwanted ground glass artifact (Moire
effect)
• Directed biopsies,transcervical
tubocornual recanalization, chorionic
villus sampling, IUD retrieval
52. DISTENSION MEDIA
Gas Liquid
CO2
HMW LMW
32% dextran
Electrolyte Non electrolyte
- Normal Saline - 2.2%,1.5%
Glycine
- Ringer lactate - 3%Sorbitol
- 5%Mannitol,
5%dextrose
Easily available
Physiological resorption by
peritoneum
Osmolality similar to blood
Disadv . Mixes with blood
Constant perfusion
Intravasation syndrome
Nontoxic
Transmits light
Good view
Does not mix with blood
Not used Commonly
53. TYPE ADVANTAGES DISADVANTAGES AND
SAFETY PRECAUTIONS
Carbon dioxide gas Ease of cleaning and
maintaining equipment
Clear view of cavity
Risk of air embolization
, To minimize it keep flow rate
100ml/min & IU pressure
<100mmhg with Hysteroscopic
Insufflator.(Laproscopic Insufflator
not used)
Electrolyte-poor fluid
(eg, glycine, 1.5%;
sorbitol, 3%; and
mannitol, 5%)
Used with Monopolar
devices
Excessive absorbtion leads to
hyponatremia, hyperammonemia
& decreased osmolality, cerebral
edema,
Electrolyte-containing
fluid
(0.9% NaCl)
Readily available, isotonic
Media of choice during
diagnostic hysteroscopy &
Operative cases where
mechanical & Bipolar energy
Chances of pulmonary edema &
CHF reduced with this media but
still possible.
ACOG 2011
54. MEDIA DELIVERING & CONTROL SYSTEM
Gravity fall system Pressure cuff Electronic
Suction +
irrigation pump
1 to 1.5 m above the uterus
= 70 to 100 mm Hg
app. 80-110mmHg
No precise pressure
control
Violation of the integrity
of the myometrium
Excessive extravasation
Flow Rate= 50-200ml/min
Inflow pressure = <150mmhg
Suction pressure= 0.2-0.4bar
HYSTEROMAT
Flow Rate
Pressure
Suction
Infusion pump
55. Best time- 1st half of menstrual cycle
Isthmus hypotonic
Endometrium proliferative
Less cervical mucus
Less risk of unexpected pregnancy
Positioning : low dorsolithotomy
Preparation of cervix : for cervical stenosis
Misoprostol 200-400mcg sl/pv 30min - 6 hrs before procedure
Laminaria tent intarcervical 2-h
Inj. Vasopressin Intracervical 0.05 U/mL, 4 cc at 4 and 8 o'clock
Phillips DR et al, J Am Assoc Gynecol Laparosc, 1996
Cooper NAM et al., A systematic review and meta-analysis.
2010
56. HYSTEROSCOPY
o Hysteroscopy is considered the gold standard for diagnosis of intrauterine lesions
o Transvaginal sonography / HSG and are most commonly used for UTERINE CAVITY
ABNORMALITY
INDICATIONS :
Abnormal uterine bleeding
Post Menopausal bleeding
Abnormal HSG/USG
Uterine abnormalities (septae)
Suspected intra- uterine pathology (polyps,
myomas,adhesions,foreignnbodies)
Recurrent Pregnancy loss
Before IVF
Unexplained infertility
CONTRAINDICATIONS
• Acute PID
• Active herpes infection
• Pregnency
• Medically Unstable
patient
Endometrial polyp
Cystic endometrial
changes
57. OFFICE HYSTEROSCOPY
Hysteroscopy done at outpatient basis without anaesthesia/
analgesia & cervical dilatation
Vaginoscopical approach (no-touch) : Most popular approach: first
proposed by BETTOCCHI AND SELVEGGI in 1996
<3.5mm rigid hysteroscope / flexible hysteroscope
Patient can herself observe normal and abnormal findings
Routine prophylactic antibiotic not recommended
Vaginoscopic approach, preserves integrity of hymen
No need for use of speculum and tenaculum
Vaginal cavity distended using distension media
Decreased patient discomfort (99.1%)
No assistants required
ACOG 2011 ; Kerkvoorde et al 20
58. OUTPATIENT HYSTEROSCOPY
NSAIDs 1 hour before hysteroscopy: reduce pain in immediate postoperative
period
Routine cervical preparation before outpatient hysteroscopy: not be used
Miniature hysteroscopes (2.7mm with 3–3.5mm sheath) should be used for
diagnostic outpatient hysteroscopy, significantly reduce discomfort
experienced
Flexible hysteroscopes : less pain during outpatient hysteroscopy
Rigid hysteroscopes may provide better images, fewer failed procedures,
quicker examination time and reduced cost
Uterine distension with normal saline appears to reduce incidence of
vasovagal episodes, improved images, completed more quickly compared
with carbon dioxide
Operative outpatient hysteroscopy, using bipolar electrosurgery, requires use
of normal saline to act as both distension and conducting medium
RCOG Green-top Guideline No. 59 (2011)
LOR
B
A
A
B
A
GPPAvailable evidence fails to show whether paracervical block is inferior, equivalent, or
superior to alternative analgesic techniques in terms of efficacy and safety for women
undergoing cervical dilatation and uterine interventions
59. OUTPATIENT HYSTEROSCOPY
Topical application of local anaesthetic to ectocervix where
application of a cervical tenaculum is necessary
Local anaesthetic into or around cervix reduces pain during
hysteroscopy. Routine administration of intracervical or
paracervical LA recommended in postmenopausal women
Conscious sedation should not be routinely used in outpatient
hysteroscopic procedures, it confers no advantage in terms of
pain control and satisfaction over LA.
Vaginoscopy reduces pain during diagnostic rigid outpatient
hysteroscopy
Routine cervical dilatation is associated with pain, vasovagal
reactions and uterine trauma and should be avoided
LOR
A
A
A
A
C
RCOG Green-top Guideline No. 59 (2011)
61. OPERATIVE HYSTEROSCOPE
Used for minor surgery (Small endometrial polyp or pedunculated
fibroid)
Telescope passes through external sheath
Diameter of extension sheath ranges between 3.5 and 7mm
Extension sheath allows passage of both operative instrument and
liquid distension media
62. RESECTOSOCPE
Telescope (12º or 30º)
Inner sheath
Outer sheath
Cautery lead
Inflow and outflow connection
Light source
BIPOLAR ENERGY (NORMAL
SALINE )
UNIPOLAR ENERGY (1.5%
GLYCINE)
CONVENTIONAL
- 4mm Telescope
- 9mm with Outer sheath
MINI RESECTOSCOPE
2.9mm telescope
5mm with Outer sheath
64. Meta-analysis-Submucous fibroid
Pritts et al. 2009 - studies regarding the effect of
fibroids on fertility and of myomectomy in improving
outcomes.
They concluded that fertility outcomes are decreased
in women with submucosal fibroids
Removal seems to confer benefit in terms of
pregnancy rates.
64
65. Cochrane review
Hysteroscopic myomectomy might increase the odds of
clinical pregnancy in women with unexplained subfertility
and submucous fibroids, but the evidence is at present
not conclusive.
Hysteroscopic removal of endometrial polyps suspected
on ultrasound in women prior to IUI might increase the
clinical pregnancy rate J. Bosteels, “Hysteroscopy for
treating subfertility associated with suspected major uterine
cavity abnormalities,” Cochrane Database of Systematic
Reviews, no. 1, Article ID CD009461, 2013
65
66. Metroplasty
Most studies of metroplasty for a septate uterus
combine women with recurrent miscarriage and
infertility, and no study has been published that
randomizes infertile women to treatment versus no
treatment. For this reason controversy exists as to
whether infertile women should undergo metroplasty
C. R. Kowalik, M. Goddijn, M. H. Emanuel et al., “Metroplasty
versus expectant management for women with recurrent
miscarriage and a septate uterus,” Cochrane Database of
Systematic Reviews, no. 6, Article ID
66
67. Reproductive Outcome following Hysteroscopic
Monopolar Metroplasty: An Analysis of 203 Cases
Ensieh Shahrokh Tehraninejad
Int J Fertil Steril. 2013 Oct-Dec; 7(3): 175–180.
Evaluate the reproductive outcome of women with
history of infertility or recurrent miscarriage following
hysteroscopic septum resection
Term deliveries increased significantly from 2.5 to
33.5%.
67
68. HYSTEROSCOPY & ENDOMETRIAL CANCER
Total of 756 studied patients, 79 presented a positive peritoneal
cytology. The diagnostic hysteroscopy did not signifi cantly increase
the risk of abdominal dissemination of tumor cells. The peritoneal
cytology was positive among 38 patients in the group who underwent
this intervention versus 41 patients in the control group (odds ratio
[OR], 1.64; 95% confi dence interval [CI], 0.96-2.80). Thus, no formal
evidence is currently available concerning the role of diagnostic
hysteroscopy on the frequency of peritoneal dissemination of tumor
cells or on the vital prognosis of the patients presenting with
endometrial carcinoma.
Hysteroscopy appears to be associated with an increased rate of
malignant cytology after controlling for confounders of stage and
grade. Further, there appears to be an association between
hysteroscopy and upstaging patients due to cytology alone(II-2)
71. Hysteroscopic Complications
2.7% to 3.8% of all hysteroscopies
A multicenter study in the Netherlands
0.13% - diagnostic hysteroscopy
0.96% - operative hysteroscopy
Highest rate of complications seen with hysteroscopic
adhesiolysis (4.5%)
Propst AM, et al. Obstet Gynecol 2008
Jansen FW, et al. Obstet Gynecol 2007
Hulka JF, et al. J Am Assoc Gynecol Laparosc 2
72. PERFORATION
Midline uterine - no significant morbidity
Lateral uterine - retroperitoneal hematoma
Cervical perforations - significant immediate or
delayed bleeding
Recognition of perforation
Loss of uterine distension
Rapid increasing in fluid deficit
Sudden uterine bleeding
MANAGMENT
With small dilator little risk to surrounding organ or major bleeding – conservative
management
With large dilator or electrical energy - laparoscopy needed
Perforation has occurred , abandoned procedure and repeat hysteroscopy after 4- 6
weeks
Prevention:
• pelvic examination to determine uterine
position
• Pink myometrium becomes visible
• Resection to be done till both ostia seen
simultaneously
• Laparoscopic guidance or USG guidance
73. COMPLICATIONS(cont.)
Vasovagal attack
Proper evaluation particularly to rule
out preexisting heart disease
Instillation of LA in cervical canal
may reduce incidence
Routine administration of intracervical
or paracervical LA is not indicated to
reduce incidence
(Level A) RCOG 2011
Air Embolism
OT assistant must keep a watch on
Fluid bottle and inform surgeon before
changing it to prevent entry of air
bubble into uterus
Mx - Left lateral decubitus position with the
head tilted downward 5 degrees f/b IJV
catheter
False passage
Vaginal misoprostol 400ug 2-3 hrs
before procedure
Office hysteroscopy
Cooper NAM et al., A systematic review and meta-analysis.
2010
74. FLUID OVERLOAD
Appropriate delivery system -
Hysteromet
infusion pressure < mean arterial
pressure
Absorption pressure ratio (APR) < 1.
Avoid entering into vascular channels
Keep operating time minimal, < 45
minutes.
Monitor fluid deficit at an extremely close interval
automated fluid monitoring system facilitates early
recognition
Preoperative use of GnRH agonists : reduced fluid
deficit among premenopausal women
Intracervical Vasopressin 8ml (0.05U/L)- dec. fluid
absorption & also force of dilatation
Incidence 0.38%-3.3%
Hypoosmolarity and hyponatremia---
cerebral edema and death
Pulmonary edema & Coagulopathy
ACOG 2011, AAGL 2007
Correctional of Hyponatremia –
• < 48hrs : hypertonic saline + loop diuretics
1–2 mEq/L/h, but by no more than12 mEq/L
in the first 24 hours
• > 48hrs : rapid correction not recommended
TERMINATE PROCEDURE when fluid
deficit of :
Electrolyte-poor fluids 750 mL -
elderly
with cardiovascular or renal
compromise
Electrolyte poor fluid 1,000–1,500 mL
Electrolyte solution - 2,500 mL
Outpatient setting - discontinuing
procedures at a lower fluid deficit
75. TAKE HOME MESSAGE
Laparoscopy has grown rapidly & become technique of choice
Basic knowledge of instruments & energy sources is necessary before any surgery
Primary incision for laparoscopy should be vertical from base of umbilicus
Manometer test : most reliable test for veress entry
Direct trocar entry : less minor complication & failed entry
For failed entry/ scarred abdomen – open technique / palmer point entry
Non-midline incision ≥ 7mm & midline ≥10 mm requires deep sheath closure
Harmonic : poor maintenance of residual tip temperature & minimal thermal spread
Ligasure : adequate maintenance of residual tip temperature but more lateral thermal spread
Whenever possible use bipolar energy sources over mono-polar in lowest possible voltage
76. TAKE HOME MESSAGE
Hysteroscopy done in 1st half of menstrual cycle
For outpatient hysteroscopy vaginoscopic approach is preferred
Miniature hysteroscopes (2.7mm with 3–3.5mm sheath) - significantly reduce patient discomfort
Local Anaesthesia
Intra cervical - reduces vasovagal symptoms, decreases the pain
Para cervical - significantly decreases the pain, not reduces vasovagal symptoms
Distension media
Normal saline 0.9% – diagnostic, operative hysteroscopy with instrument / with bipolar
Glycine 1.5% - monopolar energy