DIAGNOSTIC DIAGNOSTIC LAPAROSCOPYLAPAROSCOPY

Diagnostic laparoscopy remains one of the Diagnostic laparoscopy remains one of the most prevalent surgical procedure in most prevalent surgical procedure in gynaecologic practice.gynaecologic practice.

The longevity of the technique can be The longevity of the technique can be attributed to the high quality visualization of attributed to the high quality visualization of the pelvic and abdominal viscera with a the pelvic and abdominal viscera with a minimally invasive but safe surgical minimally invasive but safe surgical approach.approach.

Common indications include; evaluation of Common indications include; evaluation of acute peritoneal signs, unexplained infertility, acute peritoneal signs, unexplained infertility, chronic pelvic pain, and second-look surgery chronic pelvic pain, and second-look surgery after debulking of ovarian cancer.after debulking of ovarian cancer.

The differential diagnosis of a reproductive The differential diagnosis of a reproductive age women who present with with acute age women who present with with acute onset of pelvic pain and peritoneal signs are onset of pelvic pain and peritoneal signs are extensive extensive Ruptured ovarian cystRuptured ovarian cyst Torted adnexiaTorted adnexia Ectopic pregnancyEctopic pregnancy Pelvic inflammatory diseasePelvic inflammatory disease

The access of diagnostic laparoscopy to the The access of diagnostic laparoscopy to the peritoneal cavity facilitate surgical peritoneal cavity facilitate surgical intervention for any discovered pathology.intervention for any discovered pathology.

Pelvic abnormalities have been demonstrated Pelvic abnormalities have been demonstrated in 30-40% of women with infertility.in 30-40% of women with infertility.

Direct visualization of the abdomen and pelvis Direct visualization of the abdomen and pelvis with laparoscopy provides informations with laparoscopy provides informations regarding adhesions, tubal distorsion, regarding adhesions, tubal distorsion, clubbing of the fimbriated end, and evidence clubbing of the fimbriated end, and evidence of ovulation.of ovulation.

Common findings include adhesions from prior Common findings include adhesions from prior salpingitis , endometriosis, and anatomical salpingitis , endometriosis, and anatomical abnormalities.abnormalities.

Even 25% 0f infertile patients with negative Even 25% 0f infertile patients with negative radiographic findings have abnormalities.radiographic findings have abnormalities.

Pelvic pain represent 40% of indications od Pelvic pain represent 40% of indications od diagnostic laparoscopydiagnostic laparoscopy

Approximately 60-70% of diagnostic laparoscopy Approximately 60-70% of diagnostic laparoscopy for chronic pelvic pain have abnormal findings.for chronic pelvic pain have abnormal findings.

Endometriosis, pelvic adhesions, chronic pelvic Endometriosis, pelvic adhesions, chronic pelvic inflammatory diseases and ovarian cysts are the inflammatory diseases and ovarian cysts are the most common findings.most common findings.

Approximately 65-80% of women with positive Approximately 65-80% of women with positive findings at laparoscopy have clinical findings at laparoscopy have clinical improvement after operative management.improvement after operative management.

ProcedureProcedure

Although Diagnostic laparoscopy is not unique to Although Diagnostic laparoscopy is not unique to gynaecology, it has it’s one modalities and gynaecology, it has it’s one modalities and difficulties.difficulties.

The cul-de-sac hide some pathologies which are The cul-de-sac hide some pathologies which are difficult to visualize, thus the uterine manipulator is difficult to visualize, thus the uterine manipulator is of a great help.of a great help.

Chromotubation is another important aspect of Chromotubation is another important aspect of gynaecological diagnostic laparoscopygynaecological diagnostic laparoscopy

Diluted methylene blue solution is infused into the Diluted methylene blue solution is infused into the uterine cavity and tubal lumen to evaluate patency.uterine cavity and tubal lumen to evaluate patency.

Chromotubation has as well a therapeutic benefit , Chromotubation has as well a therapeutic benefit , since the rate of fertility is significantly improved.since the rate of fertility is significantly improved.

Steps of diagnostic laparoscopySteps of diagnostic laparoscopy Starts with uterine manipulatorStarts with uterine manipulator Patient prepped and draped for vaginal Patient prepped and draped for vaginal

acessacess Foley catheter is placedFoley catheter is placed Speculum placed to visulized osSpeculum placed to visulized os Bimanual examination and probing of the Bimanual examination and probing of the

uterine cavit preceed the procedure to uterine cavit preceed the procedure to avoid perforationavoid perforation

A single-tooth tenaculum is placed on the A single-tooth tenaculum is placed on the anterior lip of cervix to facilitate placement anterior lip of cervix to facilitate placement of the uterine manipulator UM.of the uterine manipulator UM.

Now drping of the abdomen for laparoscopyNow drping of the abdomen for laparoscopy

Pneumoperitonium initiated Pneumoperitonium initiated Repeated scopy if needed necessitate usin Repeated scopy if needed necessitate usin

Tenckhoff cath.Tenckhoff cath. Midline sheath is placed next for pelvic organ Midline sheath is placed next for pelvic organ

manipulationmanipulation If extensive pathology found another two If extensive pathology found another two

paramedian sheaths may be required.paramedian sheaths may be required. Landmarks identification in midline before Landmarks identification in midline before

placement of paramedian trocars. placement of paramedian trocars. The urachus running superiorly in the midline.The urachus running superiorly in the midline. The oliterated umblical arteries run lateral to the The oliterated umblical arteries run lateral to the

urachus.urachus. Inferior epigastric arteries are often not visible in Inferior epigastric arteries are often not visible in

the peritoneum, usually run superiorly1-2 cm the peritoneum, usually run superiorly1-2 cm lateral to the umbilical artery.lateral to the umbilical artery.

A systemic approach to surveying the A systemic approach to surveying the abdomen and pelvis is the best method to abdomen and pelvis is the best method to ensure pathology is not ovelooked.ensure pathology is not ovelooked.

Befor the patient is placed in trendilenburg Befor the patient is placed in trendilenburg position, the upper abdomen and position, the upper abdomen and diaphragm should be visulaized.diaphragm should be visulaized.

The anterior cul-de-sac is inspected first , The anterior cul-de-sac is inspected first , then the uterus is elevated..., this will give then the uterus is elevated..., this will give excellent view of the fallopian tubes.excellent view of the fallopian tubes.

Placing a prob into the ovarian fossa…Placing a prob into the ovarian fossa… Chromotubation is then performed.Chromotubation is then performed. According to the aim of the procedure , According to the aim of the procedure ,

the small bowel and the appendix should the small bowel and the appendix should be inspectedbe inspected