Laparoscopy in gynecology. Laparoscopy in gynecology is a low-traumatic method of diagnosis and surgery Diagnostic laparoscopy of the abdominal cavity

Laparoscopy is a modern, low-traumatic method of performing surgical interventions and diagnostic studies of organs located in the abdominal cavity and pelvis.

Main stages of laparoscopy

General anesthesia is used to perform laparoscopy. Small incisions (about two centimeters long) are made on the skin, after which they are deepened using a blunt probe, thereby preventing damage to internal organs.
One operation usually requires three or four holes. The introduction of sterile surgical instruments is carried out through special tubes inserted into the holes.
To straighten the abdomen and provide maximum access to the internal organs, carbon dioxide is injected through one tube.
A video camera and surgical instruments are inserted into other tubes.
The video camera transmits the image of the operated organs to the monitor screen, which provides the doctor performing the operation with visual control over his actions.
After all necessary actions have been completed, the instruments are removed and sutures are applied to the incision sites.

Chromotubation during laparoscopy

In the case of laparoscopy in order to diagnose the patency of the fallopian tubes and determine the reasons that prevent pregnancy, along with an external examination of the fallopian tubes during laparoscopy, chromotubation (chromohydrotubation) is performed.

The essence of chromotubation is the introduction of a sterile solution of a dye into the patient’s uterus. In the absence of a violation of the patency of the fallopian tubes, normal flow of the solution through the tubes is observed.

Benefits of laparoscopy

Laparoscopy is characterized by minor tissue trauma, in contrast to conventional operations, for which large incisions are made.
The rehabilitation period after laparoscopy is easier and shorter. Within a few hours after laparoscopy, the patient is allowed to get up and walk.
The risk of complications (wound infection, adhesions, suture dehiscence) is significantly reduced.
After laparoscopy there are no large scars or scars.

Types of laparoscopic operations

Laparoscopy is used to perform surgical interventions aimed at removing or restoring affected organs. Today, the following operations are performed using this method:

remove the gallbladder (for patients with cholecystitis and cholelithiasis);
the appendix is removed;
remove the kidneys, bladder and ureter, or restore their functions;
the fallopian tubes are removed or tied (sterilization);
remove an ectopic pregnancy;
treat endometriosis;
treat PCOS (polycystic ovary syndrome);
treat hernias;
perform surgical interventions on the liver, stomach and pancreas;
examine and remove ovarian cysts;
remove uterine fibroids;
remove the adhesive process in the fallopian tubes;
diagnose and stop internal bleeding.

Preparation for laparoscopy

Preparation for laparoscopic surgery is discussed between the doctor and the patient individually. The following actions are recommended:

refusal to eat food 8 hours before the intervention;
administering a cleansing enema several hours before the operation;
epilation of the abdomen (if laparoscopy is performed on men).

Before the operation, the patient must inform the doctor about the medications he is taking. Due to the effect of some medications (aspirin, contraceptives) on hemocoagulation, their use before laparoscopy is strictly contraindicated.

Possible development of complications after laparoscopy

Laparoscopy is a method characterized by a minimal risk of developing dangerous complications. As a rule, this operation is easily tolerated, and recovery after laparoscopy is quick.

You should consult a doctor after discharge from the hospital as soon as possible if the following symptoms appear:

high temperature, chills;
fainting (loss of consciousness);
increased pain in the abdominal area, nausea, vomiting that does not stop for several hours;
swelling, suppuration or redness in the suture area;
bleeding from wounds;
urinary disorders

Recovery period after laparoscopy

Most often, the patient recovers within a few days after laparoscopy, and sometimes can even be discharged on the day of the operation.

After laparoscopy, the patient may complain of intense pain in the abdomen and in the area of postoperative wounds, which intensifies with movement. This is considered normal. To relieve pain, painkillers may be prescribed.

In some cases, bloating, nausea, and general weakness may occur. To eliminate severe bloating, medications that include simethicone are prescribed.

Feelings of weakness, nausea, loss of appetite and increased urge to urinate go away on their own within 2-3 days after laparoscopy.

Sutures after laparoscopy

Due to the small size of the incisions made for laparoscopy, they heal in a short time; complications develop in extremely rare cases.

Sutures are removed 10-14 days after laparoscopy, in some cases earlier. During the first months, small purple scars are observed at the site of the incisions, which should fade over time and become invisible.

Diet after laparoscopy

You must refrain from eating for several hours or the entire first day after laparoscopy. The use of non-carbonated mineral water is allowed.

On the second or third day, easily digestible foods are introduced into the diet: low-fat kefir, yogurt, crackers, unsaturated broth, lean meats, fish, and rice porridge are allowed.

Returning to a normal diet depends on the patient’s well-being.

Physical activity after laparoscopy

The first two to three weeks after laparoscopic surgery, the patient must limit any physical activity and sports. The return to the normal rhythm of life should occur gradually.

Sexual life after laparoscopy

Sexual intercourse after surgery can be resumed after 7-14 days, after consulting with a doctor, if laparoscopy was performed for gynecological diseases.

Menstruation and discharge after laparoscopy

After a laparoscopic operation aimed at treating or diagnosing gynecological diseases, scanty mucous or bloody vaginal discharge may be observed, which can last 10-14 days. This is not a cause for concern.

Severe bloody vaginal discharge may be a concern, as it may indicate internal bleeding.

After laparoscopy, menstrual irregularities may occur: menstruation may not occur on time and may be delayed for several days or weeks. This is also considered normal.

When to plan a pregnancy after laparoscopy

Laparoscopy is often prescribed as a diagnostic and therapeutic method for diseases that are accompanied by infertility (endometriosis, fibroids, adhesions, ovarian cysts, polycystic ovary syndrome, reconstruction of the fallopian tubes, etc.). If the operation was successful, you can plan a pregnancy a few months after the operation.

Due to the fact that not only surgery is used to treat infertility, but also conservative therapy, which involves taking medications that affect female reproductive function, pregnancy planning should be discussed with the attending physician who has studied the patient’s medical history.

Successful pregnancy depends on what factors caused infertility before treatment, as well as on how effective the treatment was.

Diagnostic laparoscopy is a minimally invasive surgical operation that allows a visual examination of the organs located in the abdominal cavity from the inside. This method is often used in gynecological practice, since it can be used to give an objective assessment of the condition of the uterus, ovaries and fallopian tubes.

With the help of diagnostic laparoscopy, it is possible to obtain more complete results than examination using a conventional abdominal wall. The use of special equipment using optics makes it possible to enlarge the organ under study many times over and examine the smallest changes in it. The uniqueness of the method lies in the fact that it allows you to examine not only the abdominal cavity, but also study the retroperitoneal area in detail, and, if necessary, carry out the necessary manipulations in them.

The use of diagnostic laparoscopy is considered a unique method that is successfully used to determine the nature of gynecological pathologies of various courses and their degree of development, and often as the main method of treatment.

Indications for diagnostic laparoscopy

Diagnostics are indicated in the following situations:

Diseases of organs that are acute and have vague symptoms requiring surgical intervention. In the case of acute pancreatitis - to clarify the pathomorphological disorders that have occurred in the condition of the pancreas and the peritoneum itself. The need has arisen to diagnose the viability of an organ, such as, for example, during spontaneous reduction of a previously strangulated abdominal hernia.
Gynecological disorders: inflammation (, adnexitis).
The appearance of jaundice. Differential diagnosis is necessary for the development of hepatic or subhepatic jaundice. The use of this method makes it possible to determine the cause of disturbances in the outflow of bile from the liver to the location of the duodenum, as well as the presence of obstruction of the bile ducts and major papilla in the duodenum.
Neoplasms in the pelvic organs (tumor).
Closed injury to organs located in the abdomen, closed injuries to various parts of the body and head, if there are no obvious signs of these injuries in the form of bleeding that has developed in the abdominal cavity or the presence of peritonitis. The use of this method is especially relevant in the case of the patient’s unconscious state due to alcohol or drug intoxication, coma and shock resulting from injury.
Abdominal injuries resulting from wounds to identify possible penetration and damage to any internal organ, abdominal hemorrhage or inflammation.
The presence of ascites with an unknown cause of formation.
Adverse symptoms of peritonitis in the postoperative period.
Formation of tumors in the abdominal cavity, to determine their size and boundaries of spread, as well as identifying existing metastases.

Despite the fact that diagnosis using laparoscopy is a fairly safe method and rarely leads to complications, it does have a number of contraindications and limitations.

Main contraindications

Contraindications to the use of the diagnostic method using laparoscopy depend on various factors, for example, the experience and professionalism of the surgeon, the availability of modern equipment and surgical instruments. In the case of existing contraindications, they are divided into absolute, when the use of such diagnostics is completely excluded, and relative, when, after eliminating the reasons for the prohibition, diagnostics are still carried out.

Absolute contraindications to the use of diagnostics using laparoscopy include:

hemorrhagic shock;
stages of serious disturbances in the functioning of blood vessels and the heart;
pathological condition caused by disorders in the form of uncorrectable coagulopathy;
renal failure and liver pathologies occurring in the acute stage;
RMT and ovarian tumor in, except for laparoscopic monitoring when using chemotherapy or radiation therapy.

Relative contraindications include the following conditions:

symptoms of polyvalent forms of allergies;
a common type of peritonitis;
adhesions obtained as a result of surgical interventions;
pregnancy period exceeding 4 months;
suspected tumors of the appendages.

Previously planned planned laparoscopic examinations are canceled in case of previous infections or colds that occur in an acute form and no more than a month ago, as well as if the vaginal microflora corresponds to the third or fourth degree of purity.

Technique of the operation

The procedure is carried out by introducing specially designed instruments into the abdominal cavity, with the help of which its volume is increased for a clearer examination of the organ under study. This is achieved using two methods, namely:

using a mechanical method of raising the peritoneal wall;
by creating a state of pneumoperitoneum.

In practice, the second method is more common, using gas injected into the abdominal cavity, whereby the peritoneal wall is lifted. The gas used, which is administered using special devices, must not cause harmful effects to health. Most often, from a safety point of view, carbon dioxide or nitrous oxide is used, and the tools for its introduction are a Veress needle, which is a cylinder with a blunt end containing a thin needle equipped with a spring. Using this device, you can almost painlessly make punctures and insert the cylinder itself into the abdominal cavity without injuring the organs and tissues located there.

Then gas is injected into the abdominal cavity through a tube, and a laparoscope with an LED and a video camera is inserted into it, designed to transfer the resulting images to a computer.

The use of laparoscopic diagnosis in gynecology

The use of laparoscopy for research in gynecological practice is considered a method that makes it possible to identify and subsequently treat most gynecological pathologies. Today, the main indications for the use of such diagnostics have been mastered and used in practice. These include emergency types of indications:

suspected pregnancy developing ectopically;
ovaries;
suspected cysts and their rupture;
in one of the organs located in the small pelvis.

Routine indications for gynecological examinations include the following conditions:

ovarian tumor;
development ;
disturbances in the structure of the internal genital organs;
pain, recurring or acute, felt in the lower abdomen.

The use of a method using diagnostic laparoscopy is necessary when determining the existing obstruction of the fallopian tube, as well as to identify the causes of a woman’s infertility when no obstruction of the tubes is detected.

Diagnostic laparoscopy for infertility

The use of the method makes it possible to almost accurately diagnose both the infertility condition itself and the cause that caused it. Using a camera, a specialist can look inside the patient’s body, see in detail the organs of interest to him and take a tissue sample for analysis. With the help of laparoscopy, it is possible to determine the causes of disorders that arise that lead to infertility. Most often this is caused by the following diseases:

endometriosis, which is essentially a process involving the proliferation of the uterine epithelium;
fibroids – which are a benign tumor;
inflammation occurring in the pelvic area;
, causing obstruction of the fallopian tube;
cystic formations on the ovaries;
and sclerocystis;
adhesive diseases occurring in the pelvic organs, resulting from surgery, inflammation, hemorrhage.

After identifying the disease that was one of the causes of infertility, you can immediately carry out the necessary dissection of adhesions, remove cysts and do much more that can be identified during the study. However, more often the diagnostic laparoscopy technique is performed to determine whether the fallopian tube remains sufficiently patent.

Often, patients do not take the method seriously, since it is an almost bloodless method of penetration that does not pose any particular danger. However, any intervention in the body, even one with minimal incisions, has some degree of risk, so you need to prepare for it as carefully as for any other operation, while following all medical recommendations.

First of all, it is worth saying that major gynecological diseases are diagnosed without surgical methods. But still, some points that are completely incomprehensible to the gynecologist require clarification. How can we clarify the gynecological picture if neither ultrasound nor tests help? In this case, the doctor prescribes performing diagnostic laparoscopy. This procedure allows you to study the condition of the internal organs of the small pelvis, and, in addition, simultaneously eliminate some gynecological problems, for example, remove adhesions. In addition, it should be noted that diagnostic laparoscopy is an absolutely painless procedure. And that makes it acceptable.

Some evaluation of the entire diagnostic laparoscopy procedure should be given. Laparoscopy It is performed under general anesthesia, which means the patient feels absolutely nothing. Next, three incisions are made in the abdominal wall; they are very small, about 7-10 cm each. Through them, laparoscopic equipment, and the entire research process is displayed on a twenty-inch screen. A specialist conducts the examination procedure, looking at this very screen, that is, everything is done almost blindly. But doctors who perform laparoscopic procedures usually have extensive experience in this matter. And patients should not worry about this at all.

Included laparoscopic equipment, there is a video camera that displays the image on the screen, also laparoscopic manipulator, with the help of which the doctor can examine in detail all the internal organs of the small pelvis, and it also allows them to be moved in some way. Of course, these movements are very relative in nature, but still this opportunity bears some fruit. But the main criteria for laparoscopic diagnosis lie in the field of visual examination. That is, the doctor first of all pays attention to structural changes in the internal organs of the pelvis. These structural changes may indicate the presence of tumor neoplasms, including those of an oncological nature. And also, with the help laparoscopy you can analyze the interaction of the internal organs of the female body.

List of the most common laparoscopic diagnostic procedures.

1. Laparoscopic examination of the ovaries.
2. Laparoscopic examination of the condition of cystic manifestations.
3. Laparoscopic examination of the condition and patency of the fallopian tubes.
4. Laparoscopic examination of uterine fibroids.

Among other things, it should be noted that laparoscopic diagnostics not indicated for all patients. Whatever the safety indicators of this procedure, it still involves surgical intervention in a woman’s body. And such interference can lead to some troubles. Therefore, experienced doctors try to resort to laparoscopy as a last resort.

List of indications for laparoscopic diagnostics:

1. Finding out the causes of infertility.
2. Clarification of the patency of the fallopian tubes, that is, not only the identification of obstruction, but also its elimination.
3. Confirmation of suspicions of acute diseases of the pelvic organs.
4. Confirmation of suspicion of ectopic pregnancy.
5. Confirmation of suspicion of appendicitis.
6. Detection of an ovarian cyst.
7. Detection of the presence of uterine fibroids.
8. Detection of endometriotic changes.
9. Clarification of forms of secondary dysmenorrhea, including severe ones.

I must say that performing laparoscopic diagnostics requires some preparation. A few days before, the patient should start taking activated charcoal to reduce gas formation in the intestines. On the day before surgery, she must stop eating no later than ten o'clock in the evening. The next morning an anesthesiologist will come to her and give her a sedative. Junior medical staff will cleanse the intestines, and the patient can be sent for diagnostics.

Laparoscopy - examination of the abdominal organs using an endoscope inserted through the anterior abdominal wall. Laparoscopy - one of the endoscopic methods used in gynecology.

The method of optical examination of the abdominal cavity (ventroscopy) was first proposed in 1901 in Russia by gynecologist D.O. Ottom. Subsequently, domestic and foreign scientists developed and introduced laparoscopy for the diagnosis and treatment of various diseases of the abdominal cavity. The first laparoscopic gynecological operation was performed in 1944 by R. Palmer.

SYNONYMS OF LAPAROSCOPY

Peritoneoscopy, ventroscopy.

RATIONALE FOR LAPAROSCOPY

Laparoscopy provides a significantly better overview of the abdominal organs in comparison with an incision of the anterior abdominal wall, thanks to the optical magnification of the examined organs several times, and also allows you to visualize all floors of the abdominal cavity and the retroperitoneal space, and, if necessary, perform surgical intervention.

PURPOSE OF LAPAROSCOPY

Modern laparoscopy is considered a method for diagnosing and treating almost all gynecological diseases, and it also allows for differential diagnosis between surgical and gynecological pathologies.

INDICATIONS FOR LAPAROSCOPY

Currently, the following indications for laparoscopy have been tested and put into practice.

Planned indications:

tumors and tumor-like formations of the ovaries;
genital endometriosis;
malformations of the internal genital organs;
pain in the lower abdomen of unknown etiology;
creation of artificial obstruction of the fallopian tubes.

Indications for emergency laparoscopy:

ectopic pregnancy;
ovarian apoplexy;
PID;
suspicion of torsion of the leg or rupture of a tumor-like formation or ovarian tumor, as well as torsion of subserous myoma;
differential diagnosis between acute surgical and gynecological pathologies.

CONTRAINDICATIONS FOR LAPAROSCOPY

Contraindications to laparoscopy and laparoscopic operations depend on many factors and, first of all, on the level of training and experience of the surgeon, the equipment of the operating room with endoscopic and general surgical equipment and instruments. There are absolute and relative contraindications.

Absolute contraindications:

hemorrhagic shock;
diseases of the cardiovascular and respiratory systems in the stage of decompensation;
uncorrectable coagulopathy;
diseases for which it is unacceptable to place the patient in the Trendelenburg position (consequences of brain injury, damage to cerebral vessels, etc.);
acute and chronic hepatic-renal failure;
ovarian cancer and RMT (with the exception of laparoscopic monitoring during chemotherapy or radiation therapy).

Relative contraindications:

polyvalent allergy;
diffuse peritonitis;
pronounced adhesive process after previous operations on the abdominal and pelvic organs;
late stages of pregnancy (more than 16–18 weeks);
suspicion of a malignant formation of the uterine appendages.

The following are also considered contraindications to performing planned laparoscopic interventions:

acute infectious and cold diseases existing or suffered less than 4 weeks ago;
degree III–IV purity of vaginal contents;
inadequate examination and treatment of the married couple at the time of the proposed endoscopic examination planned for infertility.

PREPARATION FOR LAPAROSCOPIC STUDY

The general examination before laparoscopy is the same as before any other gynecological operation. When collecting anamnesis, it is necessary to pay attention to diseases that may be a contraindication to laparoscopy (cardiovascular, pulmonary pathology, traumatic and vascular diseases of the brain, etc.).

Before laparoscopic intervention, great importance should be given to a conversation with the patient about the upcoming intervention, its features, and possible complications. The patient should be informed about the possible transition to transection and the possible expansion of the scope of the operation. The woman's written informed consent for surgery must be obtained.

All of the above is due to the fact that among patients and doctors of non-surgical specialties there is an opinion about endoscopy as a simple, safe and minor operation. In this regard, women tend to underestimate the complexity of endoscopic examinations, which have the same potential risk as any other surgical intervention.

During planned laparoscopy on the eve of surgery, the patient limits her diet to liquid food. A cleansing enema is prescribed the evening before surgery. Medication preparation depends on the nature of the underlying disease and the planned operation, as well as on concomitant extragenital pathology. METHODOLOGY

Laparoscopic interventions are performed in a limited, enclosed space - the abdominal cavity. To introduce special instruments into this space and allow adequate visualization of all organs of the abdominal cavity and pelvis, it is necessary to expand the volume of this space. This is achieved either by creating pneumoperitoneum or by mechanically elevating the anterior abdominal wall.

To create pneumoperitoneum, gas (carbon dioxide, nitrous oxide, helium, argon) is injected into the abdominal cavity, which lifts the abdominal wall. Gas is administered by direct puncture of the anterior abdominal wall with a Veress needle, direct puncture with a trocar, or open laparoscopy.

The main requirement for gas insufflated into the abdominal cavity is safety for the patient. The main conditions ensuring this requirement are:

absolute non-toxicity of the gas;
active absorption of gas by tissues;
no irritating effect on tissue;
failure to embolize.

All of the above conditions correspond to carbon dioxide and nitrous oxide. These chemical compounds are easily and quickly resorbed, unlike oxygen and air, they do not cause pain or discomfort in patients (on the contrary, nitrous oxide has an analgesic effect) and do not form emboli (for example, carbon dioxide, having penetrated the bloodstream, actively combines with hemoglobin ). In addition, carbon dioxide, acting in a certain way on the respiratory center, increases the vital capacity of the lungs and, therefore, reduces the risk of secondary complications from the respiratory system. It is not recommended to use oxygen or air to apply pneumoperitoneum!

The Veress needle consists of a blunt-ended, spring-loaded stylet and a sharp outer needle (Fig. 7–62). The pressure applied to the needle leads, as it passes through the layers of the abdominal wall, to immerse the stylet inside the needle, allowing the latter to pierce the tissue (Fig. 7–63). After the needle passes through the peritoneum, the tip pops out and protects the internal organs from injury. Gas enters the abdominal cavity through an opening along the lateral surface of the tip.

Rice. 7-62. Veress needle.

Rice. 7-63. Stage of guiding the Veress needle.

Along with the convenience of laparoscopy, pneumoperitoneum has a number of important disadvantages and side effects that increase the risk of possible complications during laparoscopy:

compression of the venous vessels of the retroperitoneal space with impaired blood supply to the lower extremities and a tendency to thrombus formation;
disturbances of arterial blood flow in the abdominal cavity;
cardiac dysfunction: decreased cardiac output and cardiac index, development of arrhythmia;
compression of the diaphragm with a decrease in residual lung capacity, an increase in dead space and the development of hypercapnia;
heart rotation.

Immediate complications of pneumoperitoneum:

pneumothorax;
pneumomediastinum;
pneumopericardium;
subcutaneous emphysema;
gas embolism.

The choice of puncture site for the abdominal wall depends on the patient’s height and build, as well as on the nature of previous operations. Most often, the navel is chosen as the place for inserting the Veress needle and the first trocar - the point of shortest access to the abdominal cavity. Another most commonly used point for inserting a Veress needle in gynecology is the area 3–4 cm below the edge of the left costal arch along the midclavicular line. Insertion of a Veress needle is, in principle, possible anywhere on the anterior abdominal wall, but it is necessary to remember the topography of the epigastric artery. If there have been previous operations on the abdominal organs, a point is selected for the primary puncture as far as possible from the scar.

You can insert a Veress needle through the posterior vaginal fornix if there are no pathological formations in the retrouterine space.

At the time of puncture of the anterior abdominal wall with a Veress needle or the first trocar, the patient should be on the operating table in a horizontal position. After dissecting the skin, the abdominal wall is lifted with a hand, a trench or a ligature (to increase the distance between the abdominal wall and the abdominal organs) and a Veress needle or trocar is inserted into the abdominal cavity at an angle of 45–60°. The correct insertion of the Veress needle into the abdominal cavity is checked in various ways (drop test, syringe test, hardware test).

Some surgeons prefer direct puncture of the abdominal cavity with a 10-mm trocar without the use of a Veress needle, which is considered a more dangerous approach (Fig. 7–64). Damage to internal organs is possible both with a Veress needle and with a trocar, but the nature of the damage, taking into account the diameter of the instrument, varies in severity.

Rice. 7-64. Direct insertion of the central trocar.

The open laparoscopy technique is indicated when there is a risk of damage to internal organs due to adhesions in the abdominal cavity due to previous operations and unsuccessful attempts to insert a Veress needle or trocar. The essence of open laparoscopy is the introduction of the first trocar for optics through the minilaparotomy opening. In recent years, to prevent damage to the abdominal organs when entering the abdominal cavity during the adhesive process, an optical Veress needle or video trocar has been used (Fig. 7–65).

Rice. 7-65. Veress optical needle.

After puncture of the anterior abdominal wall with a Veress needle or trocar, gas insufflation begins, first slowly at a rate of no more than 1.5 l/min. With the correct position of the needle, after introducing 500 ml of gas, hepatic dullness disappears, the abdominal wall evenly rises. Typically 2.5–3 liters of gas are administered. Obese or large patients may require larger amounts of gas (up to 8–10 liters). At the time of insertion of the first trocar, the pressure in the abdominal cavity should be 15–18 mm Hg, and during the operation it is sufficient to maintain the pressure at 10–12 mm Hg.

Mechanical lifting of the abdominal wall (laparolifting) - gasless laparoscopy. The anterior abdominal wall is raised using various devices. This method is indicated for patients with cardiovascular insufficiency, coronary heart disease and arterial hypertension stage II–III, a history of myocardial infarction, heart defects, and after heart surgery.

Gasless laparoscopy also has a number of disadvantages: the space for performing the operation may be insufficient and inadequate for convenient operation, and in this case it is quite difficult to perform the operation on obese patients.

Chromosalpingoscopy. In all laparoscopic operations for infertility, it is considered mandatory to perform chromosalpingoscopy, which consists of administering methylene blue through a special cannula inserted into the cervical canal and the uterine cavity. During the process of introducing the dye, the process of filling the fallopian tube with it and the entry of the blue into the abdominal cavity is analyzed. The cervix is exposed in the speculum and fixed with bullet forceps. A special uterine probe of the Cohen design with a cone-shaped stop, which is fixed to bullet forceps, is inserted into the cervical canal and uterine cavity.

The location of the cannula depends on the position of the uterus; the inclination of the cannula tip should coincide with the inclination of the uterine cavity. A syringe containing methylene blue is connected to the distal end of the cannula. Under pressure, blue is introduced into the uterine cavity through a cannula, and during laparoscopy, the flow of methylene blue into the fallopian tubes and abdominal cavity is assessed.

INTERPRETATION OF LAPAROSCOPY RESULTS

The laparoscope is inserted into the abdominal cavity through the first trocar. First of all, inspect the area located under the first trocar to exclude any damage. Then the upper parts of the abdominal cavity are examined first, paying attention to the condition of the diaphragm, and the condition of the stomach is assessed. Subsequently, all parts of the abdominal cavity are examined step by step, paying attention to the presence of effusion, pathological formations and the prevalence of adhesions. For a thorough inspection of the abdominal and pelvic organs, as well as to perform any operations, it is necessary to introduce additional trocars with a diameter of 5 mm or 7 mm under visual control. The second and third trocars are inserted in the iliac regions. If necessary, the fourth trocar is installed along the midline of the abdomen at a distance of 2/3 from the navel to the pubis, but not below the horizontal line connecting the lateral trocars. To examine the pelvic organs and assess them adequately, the patient is placed in the Trendelenburg position.

COMPLICATIONS OF LAPAROSCOPY

Laparoscopy, like any type of surgical intervention, can be accompanied by unforeseen complications that pose a threat not only to the health, but also to the life of the patient.

Specific complications characteristic of the laparoscopic approach are:

extraperitoneal gas insufflation;
damage to the vessels of the anterior abdominal wall;
damage to the gastrointestinal tract;
gas embolism;
damage to the main retroperitoneal vessels.

Extraperitoneal insufflation involves gas entering various tissues other than the abdominal cavity. This may be the subcutaneous fat layer (subcutaneous emphysema), preperitoneal air injection, air entry into the tissue of the greater omentum or mesentery (pneumomentum), as well as mediastinal emphysema (pneumomediasthenum) and pneumothorax. Such complications are possible with incorrect insertion of the Veress needle, frequent removal of trocars from the abdominal cavity, defects or damage to the diaphragm. Pneumomediastinum and pneumothorax pose a threat to the patient's life.

The clinical picture of injury to the main retroperitoneal vessels is associated with the occurrence of massive intra-abdominal bleeding and the growth of a hematoma of the root of the intestinal mesentery. In such a situation, an emergency midline laparotomy and the involvement of vascular surgeons in the operation are necessary.

Damage to the vessels of the anterior abdominal wall occurs most often with the introduction of additional trocars. The cause of such damage is considered to be the incorrect choice of point and direction of trocar insertion, anomalies in the location of the vessels of the abdominal wall and (or) their varicose veins. If such complications occur, treatment measures include pressing the vessel or suturing it in various ways.

Damage to the gastrointestinal tract is possible when inserting a Veress needle, trocars, cutting adhesions, or careless manipulation of instruments in the abdominal cavity. Of the abdominal organs, the intestines are most often damaged; damage to the stomach and liver is rarely observed. More often, injury occurs when there is an adhesive process in the abdominal cavity. Often such injuries remain unrecognized during laparoscopy and later manifest themselves as diffuse peritonitis, sepsis or the formation of intra-abdominal abscesses. In this regard, electrosurgical injuries are the most dangerous. Perforation in the burn area occurs delayed (5–15 days after surgery).

If damage to the gastrointestinal tract is detected, suturing of the damaged area using a laparomic approach or during laparoscopy by a qualified endoscopist surgeon is indicated.

Gas embolism is a rare but extremely serious complication of laparoscopy, which is observed with a frequency of 1–2 cases per 10,000 operations. It occurs during direct puncture of a particular vessel with a Veress needle, followed by the introduction of gas directly into the vascular bed, or when a vein is injured against the background of tension pneumoperitoneum, when gas enters the vascular bed through a gaping defect. Currently, cases of gas embolism are more often associated with the use of a laser, the tip of which is cooled by a flow of gas that can penetrate the lumen of the crossed vessels. The occurrence of gas embolism is manifested by sudden hypotension, cyanosis, cardiac arrhythmia, hypoxia, and resembles the clinical picture of myocardial infarction and pulmonary embolism. Often this condition leads to death.

Damage to the main retroperitoneal vessels is considered one of the most dangerous complications that can pose an immediate threat to the patient’s life. Most often, injury to the great vessels occurs at the stage of access to the abdominal cavity when inserting a Veress needle or the first trocar. The main reasons for this complication are considered to be inadequate pneumoperitoneum, perpendicular insertion of the Veress needle and trocars, and excessive muscle force of the surgeon when inserting the trocar.

To prevent complications during laparoscopy:

careful selection of patients for laparoscopic surgery is necessary, taking into account absolute and relative contraindications;
The experience of the endoscopist surgeon must correspond to the complexity of the surgical procedure;
the operating gynecologist must critically evaluate the possibilities of laparoscopic access, understanding the limits of resolution and limitations of the method;
full visualization of the operated objects and sufficient space in the abdominal cavity are necessary;
Only serviceable endosurgical instruments and equipment should be used;
Adequate anesthetic support is necessary;
a differentiated approach to hemostasis methods is needed;
the speed of the surgeon’s work must correspond to the nature of the stage of the operation: quickly perform routine techniques, but carefully and slowly perform important manipulations;
in case of technical difficulties, serious intraoperative complications and unclear anatomy, one should proceed to immediate laparotomy.

For a thorough examination of the peritoneal and pelvic organs, there are a number of invasive and minimally invasive procedures. Diagnostic laparoscopy occupies a special place in gynecological practice and emergency surgery.

Using this manipulation, you can examine the condition of the internal organs, and if necessary, you can immediately stop the bleeding, remove the detected tumor, or perform tissue excision. Laparoscopy of the abdominal cavity is well tolerated by patients. In any case, it is better than laparotomy, which involves a cavity incision.

The likelihood of complications can be reduced if the doctor correctly prescribes the diagnostic procedure, taking into account the relevant indications and contraindications. Laparoscopic examination of the abdominal cavity makes it possible to detect the filling of the abdomen with pathological fluids, identify neoplasms, proliferation of connective tissue cords, and determine the condition of the intestinal loops, pancreas and liver.

Indications

Diagnostic laparoscopy is indicated in the following cases:

A complex of symptoms collectively called “acute abdomen”. They occur against the background of injuries, acute diseases of an inflammatory-infectious nature, with peritoneal bleeding, with poor blood supply to the peritoneal organs, as well as with various gynecological diseases.
Closed abdominal injuries and all kinds of wounds in this area. This procedure helps diagnose penetrating wounds, internal organ injuries, peritoneal bleeding and other inflammatory complications.
Accumulation of up to several liters of fluid in the abdominal cavity for unknown reasons.
Postoperative aseptic inflammation or bacterial infection of the peritoneum with questionable clinical symptoms.
Neoplasms in the abdominal organs. Laparoscopy allows you to clarify the boundaries of the spread of a malignant tumor and identify the presence and spread of metastases.

Laparoscopy allows not only to diagnose adhesive cords in the peritoneum and pathological cavities in tissues or organs, but also allows for the collection of biological material, which is necessary to determine the nature of the neoplasm.

The use of laparoscopy in gynecology is mainly aimed at checking the patency of the fallopian tubes and identifying possible causes of female infertility

Contraindications

All contraindications to laparoscopic manipulations are divided into absolute and relative. Absolute conditions include a critical state of the body associated with acute blood loss, decompensated respiratory and cardiovascular failure, seriously impaired blood clotting mechanisms, conditions that do not allow the patient to be placed in a supine position at an angle of 45° with the pelvis raised relative to the head. Also Contraindications include severe renal and liver failure, fallopian tube cancer and ovarian cancer.

Relative contraindications include the following:

increased sensitivity of the body to several allergens at once;
inflammatory damage to the visceral and parietal layers of the peritoneum with the occurrence of multiple organ failure;
proliferation of connective tissue cords due to previous surgical interventions in the peritoneum and pelvis;
late periods of bearing a child (starting from 16 weeks);
suspicion of a malignant process in the uterine appendages.

This diagnosis is used with caution if the patient has suffered an acute infectious or cold disease within the last month.

Preparation

Preparation for laparoscopy begins with laboratory and instrumental studies:

clinical blood and urine analysis;
blood biochemistry;
blood clotting test;
identification of possible Rh conflict;
blood test for RW, HIV and hepatitis;
standard fluorogram of the chest organs;
heart cardiogram;
secondary ultrasound examination of the peritoneal and pelvic organs.

If emergency laparoscopy is performed, the number of preliminary tests is reduced. As a rule, they are content with an ECG, blood and urine tests, coagulation parameters, blood group and Rh.

All information you need about the diagnostic and treatment method can be obtained from your attending physician.

Direct preparation of the patient for the examination involves several steps. No later than 8 hours before the planned procedure, the patient must abstain from food. This will protect against vomiting and nausea during and after the procedure. If the patient takes certain medications on an ongoing basis, he should discuss this with his doctor.

Before the procedure, the patient must remove all jewelry, as well as dentures and contact lenses, if any. If additional bowel cleansing is required, special preparations like Fortrans are used. Anesthesia drugs are administered intravenously during laparoscopy, but combined anesthesia is more often used, in which anesthesia through the respiratory tract is added to intravenous administration.

Carrying out

Laparoscopic procedures are performed in an operating room. 60 minutes before the start of the examination, the patient must relieve himself. After this, premedication is carried out, after which the patient falls asleep under the influence of narcotic drugs, his muscles relax, and spontaneous breathing is absent.

The surgeon’s further manipulations are divided into 2 main stages:

Injection of carbon dioxide into the peritoneum. This allows you to create a free space in the abdomen, which provides access to visualization and allows you to freely move instruments without fear of damaging adjacent organs.
Insertion into the peritoneum of tubes, which are hollow tubes that pave the way for the surgical instruments needed during manipulation.

Gas injection

For abdominal access, a small incision (0.5–1.0 cm) is made in the navel area. The peritoneal wall is lifted and a Veress needle is inserted with a shift toward the pelvis. When the anterior abdominal wall is pierced with a needle, the blunt inner tip contracts and the outer cutting edge of the axis passes through its layers. After this, carbon dioxide is injected (3-4 liters).

It is important to control the pressure in the abdominal cavity so that the diaphragm does not compress the lungs. If their volume decreases, it becomes more difficult for the anesthesiologist to perform mechanical ventilation and maintain the patient’s cardiac activity.

After laparoscopy, medical staff monitors the patient for 2–3 days

Insertion of tubes

When the necessary pressure is created in the abdominal cavity, the Veress needle is removed. And then, through the same semilunar horizontal incision in the navel area (at an angle of 60°–70°), the main tube is inserted using a trocar placed in it. After removing the latter, a laparoscope equipped with a light guide and a video camera is passed through a hollow tube into the abdominal cavity, which allows you to visualize what is happening on the monitor.

In addition to the main tube, 2 additional tubes are inserted through small skin incisions at certain points on the anterior wall of the abdomen. They are necessary in order to introduce additional surgical instruments designed for a full panoramic examination of the entire abdominal cavity.

If the entire abdominal cavity is fully examined, then they begin by examining the upper sector of the diaphragm. Then the remaining departments are examined sequentially. This allows you to evaluate all pathological neoplasms, the degree of growth of the adhesive process and foci of inflammation. If it is necessary to study the pelvic area in detail, then additional instruments are introduced.

If laparoscopy is performed with a focus on gynecology, then the patient is tilted on the operating table on her side or in a supine position at an angle of 45° with the pelvis elevated in relation to the head. Thus, the intestinal loops are displaced and provide access for a detailed examination of the gynecological organs.

When the diagnostic stage of the manipulation ends, the specialists determine further tactics of action. It could be:

performing emergency surgical treatment that cannot be delayed;
collection of biological material for further histological examination;
drainage (removal of purulent contents);
the standard completion of diagnostic laparoscopy, which involves removing surgical instruments and gas from the abdominal cavity.

Cosmetic sutures are carefully placed on three small incisions (they resolve on their own). When classic postoperative sutures are applied, they are removed within 10 days. The scars that form at the site of the incisions usually cease to be noticeable over time.

Diagnostic laparoscopy can last from 20 minutes to 1.5 hours, depending on the purpose of the procedure and the changes detected

Consequences

Complications during abdominal laparoscopy are quite rare, but they do occur. The most dangerous of them arise when carbon dioxide is injected and surgical instruments are introduced, designed to penetrate the cavities of the human body through the integumentary tissue while maintaining their tightness during manipulation. These include:

heavy bleeding due to damage to large vessels in the abdominal cavity;
air embolism, which occurs due to air bubbles entering the bloodstream;
minor damage to the intestinal lining or complete perforation;
accumulation of air or gases in the pleural cavity.

Of course, abdominal laparoscopy has its disadvantages. However, in most cases, it was able to establish itself as a procedure with a low risk of complications in the early and late stages, and also proved to be highly informative, which is extremely important for an accurate diagnosis and selection of adequate treatment.