Laparoscopy

Laparoscopy is a method of direct optical examination of the abdominal cavity organs.

Depending on the time of execution, laparoscopy can be planned and performed in an emergency, before surgery and in the early or late postoperative periods.

Currently, operative gynecology can identify three main areas of laparoscopic research - diagnostic, therapeutic and control.

Medical laparoscopy can be conservative and operative. Conservative therapeutic laparoscopy is the implementation of non-invasive methods of treatment under the control of a laparoscope (medication, tissue cleavage, etc.). Operative therapeutic laparoscopy is a surgical intervention, accompanied by a violation of integrity of organs and tissues (tissue dissection, drainage of cavities, coagulation of bleeding sites, etc.). At present, a new trend in laparoscopy has appeared - its use to monitor the course of healing processes, the effectiveness of performing surgical intervention on the genitals, the long-term results of treatment (control laparoscopy).

Diagnostic laparoscopy is the final, not the initial, stage of diagnosis. The practical doctor should not forget about the leading importance of methods of clinical diagnosis, when the diagnosis is established by history in more than half the cases. However, excessive long-term examination, unreasonable repeated and long-term unsuccessful treatment of patients without verification of the diagnosis is unacceptable, which leads to neglected forms of the disease, reduces the body's immune forces, worsens the prognosis of treatment.

The great possibilities of modern endoscopy significantly expanded the indications for laparoscopy and sharply narrowed the contraindications. In general terms, the indication for laparoscopy is the impossibility of diagnosing with conventional clinical studies or the need for a differential diagnosis.

[1], [2], [3], [4], [5], [6],

Laparoscopy: indications

Indications for diagnostic laparoscopy are: suspicion of ectopic pregnancy; determination of the condition of the fallopian tubes before the operation concerning tubal infertility; identification of the nature of the developmental defect of the internal sex organs; suspicion of external genital endometriosis (ovaries, pelvic peritoneum, sacrum-uterine ligaments); suspected tumor-like formation of ovaries; clarification of the location of the intrauterine contraceptive (if suspected of being in the abdominal cavity); persistent pain syndrome of unknown origin; suspicion of ovarian apoplexy; suspicion of rupture of the ovarian cyst; suspicion of a torsion of the leg of the ovarian tumor or the leg of the sub-serous myomatous node; suspicion of tubo-ovarian formation; assessment of the severity and extent of damage to the uterus when it is perforated; impossibility of excluding acute surgical pathology.

Preparation of patients for laparoscopy

Preparation of patients for laparoscopy is the same as for laparotomy.

For anesthesia, the method of choice is endotracheal anesthesia, which allows both diagnostic manipulations and surgical interventions.

The operation of laparoscopy begins with the imposition of pneumoperitoneum. To create a pneumoperitoneum, use carbon dioxide or nitrous oxide. These chemical compounds are easily and quickly resorbed, unlike oxygen and air, do not cause patients a feeling of pain or discomfort (on the contrary, nitrous oxide has an analgesic effect) and do not form emboli (for example, carbon dioxide, having penetrated into the bloodstream, actively combines with hemoglobin ). The optimal place for gas insufflation into the abdominal cavity is the point. Located in the zone of intersection of the midline of the abdomen with the lower edge of the umbilical ring (when choosing the point of gas insufflation, take into account the location of the epigastric vessels, the aorta, the inferior vena cava, in this respect the region surrounding the umbilical ring within a radius of 2 cm is considered to be the most safe). The gas is pumped into the abdominal cavity using a Veress needle. The peculiarity of the design of the Veress needle is the presence of a blunt spring mandril that protrudes beyond the needle in the absence of resistance from the outside. This design protects the abdominal cavity from damage with the tip of the needle. The gas is injected into the abdominal cavity by means of a laparoflator, which ensures control of the pressure and velocity of the gas flow.

The introduction of the first ("blind") trocar is the most crucial stage in the technique of laparoscopy. The current level of development of laparoscopic techniques involves the use of two types of trocars that ensure the safety of "blind" administration:

• trocar with a protective mechanism - resemble the design of the Veresh needle - in the absence of resistance from the outside, the point of the trocar is blocked by a blunt fuse;
• "Visual" trocars - the advance of the trocar through all layers of the anterior abdominal wall is controlled by the telescope.

The introduction of additional trocars is strictly controlled by vision.

In all cases of laparoscopy, endotracheal anesthesia or combined anesthesia (long-term epidural in combination with endotracheal anesthesia) is necessary, and the method of choice should be combined anesthesia, which provides not only adequate anesthetic protection but also therapeutic effect (cupping of the intestinal paresis, improvement of cardiac function -vascular system and kidneys, optimization of cerebral blood flow parameters), which is important in patients with purulent intoxication.

Technique for performing laparoscopy

The technique of performing laparoscopy is different for people who have a history of operation on pelvic organs, and previously not operated patients. In typical cases, the Veresha needle inserted through the lower hemisphere of the navel is used to create the pneumoperitoneum. In the case of performing laparoscopy after one or more of the intracranial lesions (especially the lower-median or complicated post-operative period), as well as the expressed adhesion process, which is almost always present in purulent inflammation of the uterine appendages, it is preferable to introduce the Veresh needle into the region of the left hypochondrium or mesogastrium. This is due to the fact that the costal arch forms a natural arch creating a free space between the parietal peritoneum and the intra-abdominal organs. The location of the introduction of the optical trocar depends on the type of the previous incision of the anterior abdominal wall: in transverse holocaust, this may be a near-buccal region, with the median incision, a point distant from the upper corner of the rumen by 2-5 cm.

Before the introduction of the optical trocar, a gas sample must be conducted, the purpose of which is to make sure there are no adhesions. For this, a syringe half-filled with a solution produces a puncture of the anterior abdominal wall at the site of the alleged introduction of the trocar. When receiving gas from the abdominal cavity, the test can be considered negative (no adhesions). The sample is repeated many times, changing the direction of needle pricking, after which an optical trocar is introduced.

Further, with the horizontal position of the operating table, a revision of the abdominal cavity organs is performed, with obligatory examination of the parietal and visceral peritoneum, the appendix, the liver, the gallbladder, the pancreas region, the intestinal loops to exclude the acute surgical pathology of these organs (purulent appendicitis, pancreatic necrosis, etc.). ), as well as the detection of intestinal and subdiaphragmatic abscesses. If an exudate is found, the latter is aspirated with mandatory collection of material for bacteriological examination.

Then they begin to audit the internal genital organs. For better visualization, it is necessary to "cannulate" the uterus (except for obstetric patients), which allows you to move it and fix it in the most convenient position.

In almost all cases, inflammatory changes in the internal genitalia are accompanied by an adhesive process up to the adhesive pelvioperitonitis. Therefore, the first step in the operation is adhesion.

Dissection of adhesions can be made by an acute route with subsequent coagulation of bleeding vessels or with the use of monopolar coagulation in the "cutting" mode, which leads to preventive hemostasis. The latter procedure requires constant monitoring of the instrument, since any, even a short-term touch of it to the surrounding organs (large vessels, loops of the intestine) can lead to complications (burn, bleeding).

When the septa is severed, it is possible to open the cavities of the tubo-ovarian formations, therefore, adhesion must be accompanied by a multiple washing of the pelvic cavity with a warm physiological solution with the addition of antiseptics (dioxidin, chlorhexidine).

With purulent salpingitis, an adequate amount of intervention is the adhesion, sanitation and transvaginal (through the colpotomy orifice) drainage of the small pelvis.

In cases of purulent salpingo-oophoritis and pelvic-peritonitis with the formation of a blocked abscess in the rectum-uterine cavity, mobilization of the uterine appendages, emptying the abscess, sanitation and active aspiration drainage through the colpotomy orifice is considered to be an adequate benefit.

With the formed pyosalpinx, it is necessary to remove the fallopian tube or pipes, since the possibility of restoring its (their) function is not likely to be later, and the risk of progression or recurrence of the purulent process, as well as the ectopic pregnancy is great. It is better to remove the focus of purulent inflammation and orient the patient to treatment by extracorporeal fertilization than in the subsequent long-term attempts to rehabilitate the organ that has lost its functions.

When pyovar small, up to 6-8 cm in diameter and the presence of intact ovarian tissue, it is advisable to produce a purulent formation and form the stump of the ovary with catgut or (better) vikril sutures. If there is an abscess of the ovary, it is removed.

Indications for the removal of the appendages of the uterus are irreversible purulent-necrotic changes in them. In the presence of a formed purulent tubo-ovarian formation (tubo-ovarian abscess), removal is performed by bipolar coagulation of ligaments and vessels followed by their intersection (funnel-pelvic ligament, own ovary ligament, uterine tube and mesovarium and mesosalpinx). Bipolar coagulation gives reliable hemostasis and is safe to use, does not form a scab, but only vapors the tissues, leading to denaturation of the protein and obliteration of the vessels.

The optimal method of extracting the removed organs and tissues (tube, ovary, appendages) is the posterior colpotomy, which is then used to adequately drain the cavity of the small pelvis. Anatomical prerequisites for transvaginal drainage:

• rectal-uterine depression - the most low-lying anatomical abdominal formation, in which, due to gravity, exudate accumulates;
• there are no large cell spaces and organs adjacent to the wound.

The incision is safer to carry out from the abdominal cavity using a clamp inserted into the posterior fornix region transvaginally. The gripping clamp under the control of the laparoscope is inserted into the Douglas space, a removable tissue is placed between the jaws, which is extracted through the vagina. At large sizes of education, it is necessary to widen the incision of the vaginal wall to the required size.

When extracting necrotic tissues, difficulties may arise, since clamping leads to their fragmentation. In this case, the use of a plastic bag inserted through the colpotomy wound into the pelvic cavity is indicated. The tissue to be removed is placed in the bag, the "neck" is grasped by the clamp, and the bag is taken out together with the contents. In the absence of a package, it can be replaced with a medical rubber glove.

All operations must be completed by repeated thorough rinsing of the pelvic cavity and revision of the extrahepatic space to prevent the pus and blood from flowing there and removing one or two drainage tubes through the colpotomy wound.

Aspiration-washing drainage is shown practically in all cases, therefore it is expedient to use double-lumen silicone drainage tubes with subsequent connection to the aspiration-washing system.

Active aspiration is expedient to be carried out with the help of OP-1 apparatus in order to create favorable conditions for repair and active evacuation of exudate. To do this, one or two double-lumen tubes of silicone rubber with a diameter of мм mm with a perforated end are inserted into the cavity of the small pelvis and outward through the colpotomy orifice, or, in the absence of conditions for colpotomy, through additional counterparts in the hypogastric areas. Surgical suction is connected (OP-01). Aspiratsionno-rinsing drainage (AGSH) is carried out by injecting a solution of furacilin (1: 5000) through a narrow tube lumen at a rate of 20 drops per minute and aspirating under a pressure of 30 cm of water column for 2-3 days (depending on the severity of the process) with a periodic jet washing tubes with the presence of purulent "plugs".

This method of treatment is considered a method of pathogenetic therapy, which affects the primary focus. Wherein:

1. active erosion and mechanical removal of the infected and toxic contents of the abdominal cavity;
2. hypothermic action of chilled furacilin stops further growth of microbial invasion, promotes removal of edema in the affected organ and surrounding tissues, prevents the entry of toxins and microorganisms into the circulatory and lymphatic systems;
3. a reliable outflow of the washing liquid at negative pressure excludes the possibility of accumulating the solution in the abdominal cavity, allows cleaning the peritoneum of fibrin, necrotic detritus, and reducing edema and infiltration of tissues.

With pronounced purulent-necrotic changes in the internal genital organs and a pronounced adhesive process, after separation of the splices, large wound surfaces are formed, which leads, on the one hand, to the production of a significant amount of wound secretion, and on the other, promotes the formation of gross cicatricial changes in the tissues. In the early postoperative period (especially without aspiration-flushing drainage), formation of serous or purulent cavities with subsequent activation of the process is possible, which leads to a prolonged course of the disease, relapses and complete lack of prospects for restoring the reproductive function.

In these cases, repeated (dynamic) laparoscopy is indicated, the purpose of which is to separate the newly formed splices, carefully sanitize the small pelvis and create a hydroperitoneum as one of the methods for preventing adhesion.

Repeated laparoscopy is performed on the 3rd, 5th, 7th day after the first operation. Under intravenous anesthesia, through the same punctures, the optical and manipulative trocars are "stupidly" introduced, all the stages of the operation are consistently performed. The last operation ends with the creation of a hydroperitoneum (polyglucin 400 ml, hydrocortisone 125 mg).

Laparoscopy: contraindications

Contraindications to laparoscopy are:

1. cardiovascular diseases in the stage of decompensation;
2. pulmonary insufficiency;
3. acute hepatic-renal insufficiency;
4. diabetes mellitus in the stage of decompensation;
5. hemorrhagic diathesis;
6. acute infectious diseases;
7. extensive adhesion process in the abdominal cavity.

Complications of laparoscopy

When carrying out laparoscopy, the complications that arise are the result of "blind" manipulation and occur both at the stage of superposition of the pneumoperitoneum and at the stage of the introduction of the first trocar.

With the introduction of Veresk's needle, complications such as injuries of the intestine, omentum, major vessels, subcutaneous emphysema occur most often.

Complications of the introduction of the first "blind" trocars can be extensive injuries of the parenchymal organs, intestines, large vessels.

When entering the abdominal cavity, it is possible to injure the intestine, especially when introducing the first (optical) trocar. In this case, as a rule, the soldered small intestine is wounded. The wounding of the distal parts of the intestine is possible when the capsule of the purulent tubo-ovarian formation separates from the intimately adjacent part of the intestine in patients with complicated forms of purulent process.

Immediate recognition (examination, the appearance of intestinal discharge, in doubtful cases - the introduction of a solution of methylene blue in the rectum) serves the prevention of severe complications. With sufficient experience of the doctor, defects can be eliminated by laparoscopy in accordance with all the rules of surgery (depending on the degree of damage to the intestine, mucosal and / or serosymmetric sutures from the vikril are superimposed). If there is any doubt about the possibility of carrying out such an operation with a laparoscopic method, or if the intestine is injured at the beginning of the operation, laparotomy should be performed immediately.

Bladder injury by trocars is possible if the technique of surgery is not observed in patients with an unblooded bladder or when the instrument slips. As a rule, the bottom or back wall of the organ is injured. The wound of the bladder should immediately be sutured with two rows of mucous-muscular and muscular-muscular separate catgut sutures (or one set of catgut sutures, the other - vikrilovyh). Subsequently, the Foley catheter is inserted into the bladder.

The wound of ureters can occur at the intersection of the funnel-pelvic ligament, especially with its inflammatory infiltration. Another place of injury of the ureter may be a parameter in the infiltration of parametric fiber in patients with complicated forms of purulent inflammation. The ureter in this case can be displaced and fixed with an inflammatory infiltrate.

It should always be borne in mind the possibility of injury to the ureters, so a strict rule should be visual control, and if necessary, the isolation of the ureter from the inflammatory infiltrate.

In case of suspicion of ureteral injury, intravenous injection of methylene blue is performed, with confirmation of the diagnosis - immediate laparotomy, stitching of the ureter wall with its parietal wound or the imposition of ureterocystoanastomosis when it crosses on the ureteral catheter or stent.

In the postoperative period, antibacterial, infusion, resorption therapy is continued, followed by rehabilitation for 6 months.

The results of treatment are assessed taking into account the patient's state of health, temperature response, blood parameters, dynamic laparoscopy data. With a favorable course of the inflammatory process as a result of conservative-surgical treatment, the patient's condition and clinical-laboratory parameters (temperature, number of leukocytes) are normalized within 7-10 days. With properly performed rehabilitation, the outcome of purulent salpingitis is clinical recovery, which, however, does not exclude reproductive problems in patients.

The consequences of acute acute inflammation remain serious: progression of the disease is observed in 20% of women, its relapse - in 20-43%, infertility - in 18-40%, chronic pelvic pain syndrome - in 24%, and cases of ectopic pregnancy.

Therefore, patients with purulent salpingitis after arresting acute inflammation require long-term rehabilitation aimed at preventing the recurrence of the disease and restoring fertility.

[7], [8], [9], [10], [11], [12], [13]