ENDOCOPY IN GYNAECOLOGY and it's advantage and disadvantage

ENDOSCOPY IN
GYNAECOLOGY
COMPETENCY NO: OG38.1

OBJECTIVES
To Learn About Laparoscopy Under The Following Headings.
 Introduction
 History
 Advantages & Limitations
 Laparoscopic Equipment & Techniques
 Operation Theater Set Up
 Complications
 Operative Laparoscopic Procedures
To Learn About Hysteroscopy Under The Following Heading.
◦ Introduction
◦ History Of Hysteroscopy
◦ Parts Of Hysteroscopy
◦ Alignment Of Hysteroscopy
◦ Indications
◦ Contraindications
◦ Procedure Proper
◦ Complications
◦ Hysteroscopic Appearances

Introduction
◦ Endoscopy is visualization of Interior of viscus, space or organ with the
help of a narrow Telescope.
◦ Endoscopes are used to visualize Peritoneal cavity (Laparoscopy) or
uterine cavity (Hysteroscopy)
◦ Initially – Primitive tool- For Diagnostic & simple procedures
◦ Evolved into coordinated system for repair / removal of abdominal &
pelvic organs.

Advantages of Laparoscopy :
Faster Recovery
Improved cosmesis
Less postoperative pain
Diminished adhesion formation
Equivalent surgical results

Limitations in Laparoscopy :
1. Learning curve is steep
2. Surgical steps – More Difficult
3. Indirect palpation of tissue
4. Finite number of ports
5. Restricted movement
6. Replacement of 3D Vision by 2D video images
7. Expensive Instruments / Longer operating time

LAPAROSCOPIC EQUIPMENT &
TECHNIQUES

Veress Needle
◦ Used for creating Pneumoperitoneum
◦ Helps in separating internal organs & tissues from abdominal wall, so that the
trocar can be inserted safely without causing any injuries to surrounding
structures.
◦ 3 sizes : 80/ 100/ 120mm
◦ Should be checked for Patency & spring action, before using it.
◦ It has a Spring Loaded tip, that retracts as it pierces the abdominal wall,
allowing blunt tip to engage on entry into peritoneal cavity.
◦ To avoid damage to Bowel/ other Intra-abdominal organs.

Gas
◦ MC used gas for Insufflation is CO2.
◦ Non-combustible
◦ Gas insufflator must provide continuous flow rate of gas, in order to
maintain IAP between 10-15mmhg
◦ High IAP helps in increasing distance between trocar & retroperitoneal
vessels
◦ Display must always remain within surgeon’s vision, as it helps in
providing important information regarding Patient’s IAP, Flow rate &
Total volume of CO2, which has been insufflated.

Insufflator
◦Insufflator Display :
◦Surgeon should always be able to see.
◦ Patient’s IAP (Actual value)
◦ Flow Rate
◦ Total volume of co2 insufflated
◦ Gas Reserve

Laparoscopic Access Equipment
◦ 2 Types :
◦ 1st Generation : Central Trocar & Encasing outer sheath/ cannula
◦ 2nd
Generation : Visual Access Method

1st
Generation
1. Removable central Trocar
2. Encasing outer cannula
After placed inside body cavity, Central trocar is removed, laparoscope &
other operating instruments are placed.
Proximal end : Accommodate palm of surgeon’s Dominant hand
Distal end : Pointed / sharp / conical / Bevelled / pyramidal cutting blade tip.
Pyramidal Tips : Sharp edges – Damage smaller blood vessels / other organs
Blunt Trocar Tips : Blood vessels are pushed aside & protected / Needs greater
pressure during insertion.

◦ OPTICAL ACCESS TROCARS : Helps in visualizing layers of abdominal
wall during placement.
◦ MC sizes : 5-10mm.
◦ Trocars have 2 types of Valves : For prevent of escape of GAS.
◦ Trumpet valves : Protect Telescope from contamination by tissue &
Blood particles during insertion. Grip the instruments & prevents its
smooth movement.
◦ Flap valve Trocars : Generally preferred.

2nd
Generation
◦ Endo TIP - Endoscopic Threaded Imaging port
◦ Sheath with screw threading
◦ Allows safe peritoneal entry, under direct vision.
◦ Inserted with Telescope inside, so that as the sheath is
screwed in, Tissue layers can be visualized &
therefore injury to internal organs can be avoided.
◦ Safe in cases, where dense adhesions are suspected.
With previous H/O Laparotomy
◦ Screwed Endo TIP prevents it from Slipping out of the
intra peritoneal space.

Laparoscopic
Telescope
Inserted through Cannula, in order to
visualize abdominal cavity.
◦ Sizes : 2-10mm
◦ Optical Axis : 0 – 45 degrees
◦ 2 Types viewing Angles :
◦ 0 Degree straight forward
◦ 30 Degree Forward – Oblique Telescope

Cameras
◦ 2 components :
◦ Camera Head with cables
◦ Camera control unit
◦ High Definition Digital cameras are now available
that are compatible with High- Definition Flat screen
Monitors, having Increased Resolution capabilities.
◦ Before starting the surgery, Camera has to be WHITE
Balanced, by showing white object with light source
on.
◦ Point the camera fitted to Telescope with light on to
a white object & move towards & away from it.
There should be No Glare / Glare that disappears
very Quickly.

Light Source
◦ High Intensity Light source :
1. Quartz Halogen
2. Xenon
3. LED bulbs
◦ Beam of light is transmitted through fiber optic cables
◦ Light Transmission occurs by Total Internal Reflection
◦ After Repeated use, some optical fibers break. Seen as Black
spots.
◦ Distal end of Fiber optic cable should never be placed on /
under Drapes.
◦ Heat generated form intensity of light may cause BURNS to
patient / Ignite the drapes.

Suction – Irrigation
cannula
◦ Helps to make Operating field clear
◦ Normal saline / Ringer Lactate for Irrigation.
◦ Heparinized saline can be used to dissolve blood clot
to facilitate proper suction, in presence of Excessive
Intra-abdominal bleeding, thus maintaining Clear
vision.
◦ Tip should be dipped inside the fluid, otherwise the
gas would be sucked out & visibility will be lost.

Ancillary Instruments
◦ Add Image

Pre-operative Preparation :
◦ Informed consent
◦ Pre-operative medications
◦ Bowel preparation
◦ Bladder catheterization
◦ DVT Prophylaxis
◦ Patient positioning

Surgical steps
◦ Open Laparoscopy : Hasson’s Technique
◦ Mini laparotomy incision – Vertical / Horizontal in sub-umbilical region
◦ Rectus sheath is incised to enter Peritoneal cavity
◦ Blunt tip trocar with sleeve placed vertically through the incision
◦ Obturator is withdrawn, CO2 is attached to cannula, to establish
Pneumoperitoneum.
◦ Laparoscope is then inserted
◦ Reduce the risk of complications associated with Blind insertion of
veress needle.

Veress needle insertion
◦ Small sub-umbilical incision – 3-4mm
◦ Abdomen is maximally lifted
◦ Needle should be held by the shaft, in the form of a Dart.
◦ Should be directed towards centre of pelvic cavity at an angle of 45 degree to
horizontal
◦ At the time of insertion, 2 distinct POPS are felt
◦ 1st
– Anterior Rectus fascia
◦ 2nd
– Posterior fascia & Peritoneum

Confirmation of proper placement
of veress needle
Sound of air Palmer’s test Hanging drop test
Measurement of Intra-
abdominal pressure
with CO2 Insufflator
Loss of Liver Dullness
Intra peritoneal
placement can be
ascertained by :
Uniform distension of
Abdomen & loss of Liver
Dullness.
Extra peritoneal :
Distension will be
confined to
Hypogastrium &
pressure recorded is
High.

Lee Huang
Point
It lies between
umbilicus and
xiphoid process and
used for primary
port insertion in
case of suspected
umbilical adhesions
due to previous
surgery or large
abdominopelvic
masses.

◦ After introducing Telescope, Intra- peritoneal entry is confirmed & gas
tubing is connected.
◦ All secondary cannulae are inserted under vision.
◦ Care should be taken to avoid injury to Major vessels of Abdominal
wall.

CO2 Insufflation
◦ Purpose is to raise the abdominal wall away from the underlying structures, so that
surgeon can safely insert sharp trocar into gas filled abdominal cavity, without causing
any harm to underlying structures.
◦ Rapidly absorbed by blood, will be converted to Carbonic acid, dissociates into H+,
HCO3, which prevents GAS EMBOLISM.
◦ Carbonic Acid in peritoneal surfaces can cause PAIN in postop period.
◦ Gasless Laparoscopy : Mechanical lifting arm, Obviating need for Distension using gas.
◦ Favor in patients with cardio pulmonary risk factors.

◦ Rate : 3L/min
◦ Produces an IAP of 10-15 mmhg
◦ Higher intra abdominal wall pressure of 20mmhg, set to facilitate insertion of Trocar & as
well as to increase the distance between Trocar & Retro peritoneal vessels.
◦ Higher pressure is avoided during surgical procedure :
◦ compromise Diaphragmatic movement
◦ Decrease venous return by compressing IVC
◦ Increase incidence of Gas Embolism.

◦ Hence, after insertion of Trocar, pressure is reduced to 12-15mmhg
◦ Insufflation tubing with a 0.3 micron-filter is recommended to prevent
Intra-peritoneal contamination with Bacteria, microparticles, Debris
from Insufflator & Gas Tank.

Insertion of Primary Trocar &
Cannula
◦ MC- 5 / 10mm
◦ Inserted aiming at the hollow of sacrum
◦ Patient should be in supine horizontal position, without Trendelenburg tilt
◦ Trendelenburg tilt – Likely to bring Aortic Bifurcation more anteriorly / More likely to get
injured.

Secondary Trocars
◦ Lateral to inferior epigastric vessels on both sides.
◦ Identified by Trans illumination & intra peritoneal observation.

Operating instruments
◦ Graspers
◦ Scissors
◦ Forceps
◦ Myoma Fixation screw / Spiral
◦ Needle Drivers
◦ Morcellators
◦ Uterine Manipulators

◦ Major difficulties in Laparoscopic surgeries is to remove large volumes of tissues such as
Fibroids, ovarian tissues / even uterus from the peritoneal cavity.
◦ Methods of Tissue Removal : Supra pubic mini laparotomy / Transvaginal Extraction
through colpotomy.
◦ Electromechanical Morcellator : Novel Instrument for removing large masses, thus
avoiding Need for Colpotomy / Mini laparotomy
◦ Variable speed of Motor drives the rotation of sharp outer sleeve.
◦ Cylindrical pieces of tissue can be removed very easily.
◦ Tissue structure is minimally damaged, enabling a reliable Histological Examination.

◦ Uterine Manipulator – Improve access
to Uterus / Fallopian tubes / ovaries /
anterior & posterior cul-de-sacs.

Click icon to add picture
commonly known
as ‘Endobags’ are
used in laparoscopic
specimen extraction
to avoid spillage and
contamination

Complications :
1. Pneumoperitoneum Related Complications
2. Complications of Electrosurgery
3. Vascular injuries
4. Urinary Tract injuries
5. Gastrointestinal injury
6. Neurological injuries
7. Incisional Hernia

Pneumoperitoneum Related Complications :
◦ Gas Embolism :
• Capnograph will show Increased End-Tidal CO2 level when there is Hypercarbia
• Anesthesiologist should monitor : End Tidal CO2, Heart Rate, Heart sounds , Color
of Blood, so that Early signs of CO2 Retention can be diagnosed.
• Sudden Unexplained Hypotension/ Cardiac Arrythmia / Cyanosis / Heart
Murmurs should raise the suspicion of Gas Embolism.
• Sudden Drop in CO2 Level, when there is GAS / Pulmonary Embolism.
• If suspected / Diagnosed, Immediately Evacuate CO2 from the peritoneal cavity
• Large Bore central Venous Line can be inserted, so that gas can be aspirated
from the heart.

◦ Cardiac Arrythmias – Due to Hypercarbia / Acidemia
Maintaining low IAP (<12mmhg) reduces incidence of Hypercarbia.
◦ Gastric Reflux & Aspiration – Therefore Cuffed Endotracheal Tube
should be used.
◦ Extra peritoneal Insufflation – Sub cutaneous Emphysema /
Pneumomediastinum / Pneumothorax (Intercostal Drainage to be
done)

Complications of Electrosurgery :
◦ Direct / Indirect Electrical Trauma
◦ Direct Thermal Injury : When Vaporization / Coagulation extends to
neighboring structures like Bowel / Ureter / urinary bladder.
◦ To avoid unintended activation of Electrodes, Electrosurgical instruments
should not be retained inside the abdomen when not in use.
◦ Thermal Injury should be managed Immediately.
◦ If zone of coagulative necrosis is identified at the time of Laparoscopy, wide
excision & Repair is done, as area of thermal damage might extend wider
than the area of Necrosis.

Vascular injuries -
0.1- 6.4 per 1000
◦ ◦Most Acutely Life Threatening
◦ ◦Aorta / vena cava/ Illiac vessels
◦ ◦Minor vessels – Bipolar / Hemostatic clips /
suturing techniques
◦ ◦Inferior Epigastric artery – Tamponade -
Foley’s catheter, inflating balloon, placing it
on Tension, Securing it with a clamp placed
at abdominal wall.
◦ ◦Major vessels – Immediate Laparotomy,
Manual compression, Repair, Transfusion,
Assistance vascular surgeon to repair Injury.

Urinary Tract Injuries
◦ Bladder Injury
◦ Ureteric Injury

Bladder Injury
◦Rare during laparoscopy.
◦Occurs during laparoscopic access (insertion of primary or secondary trocar
insertion).
◦Prior pelvic surgery is a major risk factor.
◦Foley’s catheter should be inserted to deflate bladder to prevent injury.
◦Gaseous distension of urinary bag and hematuria indicates bladder injury.
◦Detected by instillation of methylene blue or indigo carmine dye in bladder
◦Bladder injury by veress needle may be left for conservative management.
Larger irregular defects should be closed by absorbable sutures.

Ureteric Injury
◦During difficult dissection or by thermal energy.
◦The best way to prevent ureteric injury is by identification of ureter
◦by anatomic landmarks and by peristalsis.
◦Ureter should be dissected and mobilized.
◦Surgeon should confirm the integrity of ureter at the end of surgery.

Gastro intestinal Injuries
◦At the time of laparoscopic entry of trocar or veress needle
◦Small bowel is the most common site of injury
◦Stomach, colon, liver may also get injured (subcostal insertions)
◦Bowel injuries go unrecognized intraoperatively
◦Usually patients present with peritonitis following discharge
◦Suspected, if volume of gas is increasing over period of time.
◦In electrosurgical gut injuries, margins of gut should be inverted and sutured to
healthy tissue.
◦Resection anastomosis may be required if extent of injury is large.
◦The diagnosis of delay is a major cause of morbidity and mortality

Neurological Injury
◦ Due to Improper Positioning of patient
◦ Common Peroneal Nerve can get Compressed against stirrup.
◦ Excessive Flexion / External Rotation of Hip can overstretch Femoral / sciatic
Nerve.
◦ Recovery can be hastened by Physiotherapy.

OPERATIVE LAPAROSCOPIC
PROCEDURES

Operative Laparoscopy
◦ Adhesiolysis
◦ Tubal sterilization
◦ Ovarian cystectomy
◦ Oophorectomy
◦ Salpingectomy
◦ Salpingostomy
◦ Hysterectomy

Advanced procedures :
◦ Repair of Pelvic organ prolapse (In young women)
◦ Tubal Re-anastomosis
◦ Myomectomy
◦ Radical Hysterectomy
◦ Lymphadenectomy

Diagnostic Laparoscopy : Evaluation of patients
Acute pelvic pain
Abdominal pain
Ovarian torsion
Ovarian cyst rupture
Ectopic pregnancy
Appendicitis
Pelvic Inflammatory disease

Chronic pelvic pain & Infertility
Identify Pelvic adhesions
Endometriosis
Uterine fibroids
Adnexal masses

Diagnostic Laparoscopy
Assessment
Systematic Approach :
B/L Ovaries
Fallopian tubes
Uterus
Uterosacral ligaments
Round Ligament
Ureters
Appendix
Upper Abdominal Organs
Hernia
Endometriosis
Adhesions

PARTS OF HYSTEROSCOPE
◦ TELESCOPE
◦ CAMERA
◦ LIGHT SOURCE
◦ OPERATING SHEATHS
◦ DISTENSION MEDIA

1.TELESCOPE
HAS 3 PARTS
◦ EYE PIECE
◦ BARREL
◦ OBJECTIVE LENS
.

VIEWS OF ANGLE
VARIETY OF VIEWING
ANGLES
0 DEGREE –STRAIGHT
ON 30 -FOREOBLIQUVIEW
12,15, AND 70 DEGREES .

2.CAMERA
◦An endoscopic microchip camera coupled directly to
the telescope with digital recorders
◦Endocscopic camera lenses range in focal length
from 25-38mm

3.LIGHT GENERATOR
◦ Three types of generator – tungsten, metal hallide, xenon
◦ Xenon light generator provides best illumination for video techniques.
◦ Quality and power of light is determined by three factors- wattage, remote light
generator, connecting fiberoptic light cable

LIGHT GENERATOR MACHINE CONNECTING CABLE

4. OPERATING SHEATHS
TWO TYPES
1.DIAGNOSTIC SHEATHS
2.OPERATIVE SHEATHS

4A. DIAGNOSTIC SHEATH
◦ Its required to deliver distension media into the uterine cavity
◦ The telescope fits into the sheath and is secured by water tight seal with 1mm Clearance between inner
wall and telescope for dissension media transmission
◦ Diameter -4-5mm

4B. OPERATIVE SHEATHS
◦ Ranging diameter 7-10mm
◦ Standard operative sheath allows space for instllation media, the 3-4mm telecope and operative
instruments
◦ Disadvantage – inability to flush the uterine cavity with distension media and difficulty manuplating
operative tools within the cavity

OPERATIVE SHEATH
SHEATH
OPERATIVE SYSTEM

5.DISTENSION MEDIA
◦Ideal distension media is non toxic ,
hypoallergenic and rapidly cleared while
allowing clear visualization
◦Choice of distension medium depends on
whether diagnostic or operative
hysteroscopy is planned
◦Media can be divided into liquid or gas

DISTENSION PRESSURE
◦The thick muscle of uterine wall requires minimum
pressure of 40mmhg to distend the cavity
sufficiently for visulaisation.
◦Intra uterine pressure of 125-150mmhg maybe
reqiured if there is uterine bleeding.

INDICATIONS
a. DIAGNOSTIC indications
◦ ABNORMAL UTERINE BLEEDING
◦ INFERTILITY
◦ RECURRENT SPONTANEOUS ABORTION

DIAGNOSTIC HYSTEROSCOPY
• SENSITIVITY
91%
• SPECIFICITY
82%

b. Therepeutic indications
◦Myomectomy
◦Polypectomy
◦Septum resection
◦Lysis of adhesions
◦Cannulation of fallopian tube
◦Sterilization
◦Endometrial ablation.

CONTRAINDICATIONS
◦ Pregnancy
◦ Current or recent pelvic infection
◦ Current vaginitis cervicitis nd endometritis
◦ Recent uterine perforation
◦ Active bleeding
◦ Medical Conditions-IHD ,bleeding diathesis

PROCEDURE PROPER
◦ Diagnostic hysteroscopy
◦ lithotomy position bimanual examination
◦ Empty the bladder
◦ Drape the perineum
◦ Verify instrument anf distension media
◦ Cevix is visualised with speculum
◦ Tenaculum is applied to the anterior lip of the cervix
◦ Dilate the cervix if required.

CONTINUED….
◦ Place the hysteroscope in the external os with distension media flowing insert under direct visualisation;
contertraction is applied using tenaculum.
◦ Inspect the endocervical canal during entry of hysteroscopy.
◦ Once inside the cavity remove speculum with scope insitu.
◦ Inspect cavity and tubal ostia.

COMPLICATIONS
(a) Due to fluid overload
Fluid deficit - Isotonic -2500;1500ml
Hypotonic-1000;750 ml
Clinical features - Hyponatremia
Prevention – Use isotonic fluid
monitor fluid deficit
Intrauterine pressure 70- 80mmhg
Operating period to 1 hour to less.

(b)DUE TO PROCEDURE
◦ PERFORATION.
◦ INTRA OPERATIVE AND POST OPERATIVE BLEEDING
◦ GAS EMBOLISM
◦ INFECTION
◦ HEMATOMETRA

SUMMARY
LAPAROSCOPY
◦ It is a very good option for MIS in cases
which fit into the criteria of selection
◦ Selection of the case is very important
◦ Procedure related complications must
be kept in mind as it is not completely
risk free
◦ Newer methods like robotic
laparoscopy, SILS and NOTES are up
and coming and with due exposure
can be used for suitable cases.
HYSTEROSCOPY
◦ Hysteroscope can be used for
diagnostic and therapeutic purpose.
◦ Selection of cases is important for
successful intervention.
◦ Office hysteroscope can be done in
clinic with good results and very much
accepted by patients.
◦ one has to be familiar with
complications and should always aim for
prevention and early diagnosis and
treatment.

REVIEW QUESTIONS
HYSTEROSCOPY IS NOT ADVISED FOR THE FOLLOWING PATIENTS
1. Patients with submucosal fibroids.
2. Patients with endometrial tuberculosis
3. Patients with acute genital tract infection
4. Patients with misplaced IUD
ANSWER:3

WHICH GAS IS USED IN A LAPAROSCOPE?
1. NO
2. O2
3. CO2
4. Atmospheric air
ANSWER:3

Hysteroscopy is indicated in the management of the following clinical scenarios except
1. Asherman Syndrome
2. Endometrial polyp
3. Septate Uterus
4. Cervical Cancer
ANSWER: 4

WHAT IS THE NAME OF THE DEVICE USED TO SEAL BLOOD VESSELS DURING A
LAPAROSCOPIC SURGEY.
1. Harmonic Scalpel
2. Monopolar Cautery
3. Bipolar Cautery
4. Ultrasonic Scalpel
ANSWER:1

CASE SCENARIO
A 25 year old A2 woman presents to you foe evaluation after a recent missed abortion.
Her records reveal that a D/C was performed after the first abortion. You suspect that the
patient has intrauterine adhesions.
What is the IOC?
ANSWER: HYSTEROSCOPY

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