Laparoscopy

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

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

Currently, in operative gynecology, three main areas of laparoscopic research can be distinguished: diagnostic, therapeutic and control.

Therapeutic laparoscopy can be conservative and operative. Conservative therapeutic laparoscopy is the implementation of non-invasive treatment methods under the control of a laparoscope (delivery of medicinal substances, tissue injections, etc.). Operative therapeutic laparoscopy is a surgical intervention accompanied by a violation of the integrity of organs and tissues (tissue dissection, drainage of cavities, coagulation of bleeding areas, etc.). Currently, a new trend has emerged in laparoscopy - its use to monitor the course of healing processes, the effectiveness of surgical intervention on the genitals, and remote treatment results (control laparoscopy).

Diagnostic laparoscopy is the final, not the initial stage of diagnostics. A practicing physician should not forget about the leading importance of clinical diagnostic methods, when the diagnosis is established based on anamnesis data in more than half of cases. However, excessively long examinations, unjustified multiple and long-term unsuccessful treatment of patients without verification of the diagnosis are unacceptable, which leads to advanced forms of the disease, reduces the body's immune forces, and worsens the prognosis of treatment.

The great possibilities of modern endoscopy have significantly expanded the indications for laparoscopy and sharply narrowed the contraindications. In general, an indication for laparoscopy is the impossibility of making a diagnosis using conventional clinical examinations or the need for differential diagnosis.

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Laparoscopy: indications

Indications for diagnostic laparoscopy are: suspected ectopic pregnancy; determination of the condition of the fallopian tubes before surgery for tubal infertility; identification of the nature of malformations of the internal genital organs; suspected external genital endometriosis (ovaries, pelvic peritoneum, uterosacral ligaments); suspected tumor-like formation of the ovaries; clarification of the location of the intrauterine contraceptive (if it is suspected that it is located in the abdominal cavity); persistent pain syndrome of unknown genesis; suspected ovarian apoplexy; suspected rupture of an ovarian cyst; suspected torsion of the ovarian tumor pedicle or the pedicle of a subserous myomatous node; suspected tubo-ovarian formation; assessment of the severity and degree of damage to the uterus during its perforation; impossibility to exclude acute surgical pathology.

Preparing patients for laparoscopy

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

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

The laparoscopy operation begins with the imposition of pneumoperitoneum. Carbon dioxide or nitrous oxide is used to create pneumoperitoneum. 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 (thus, carbon dioxide, having penetrated the bloodstream, actively combines with hemoglobin). The optimal place for gas insufflation into the abdominal cavity is a point located in the area of intersection of the midline of the abdomen with the lower edge of the umbilical ring (when choosing a point for gas insufflation, the location of the epigastric vessels, aorta, inferior vena cava is taken into account; in this regard, the area surrounding the umbilical ring within a radius of 2 cm is considered the safest). Gas is pumped into the abdominal cavity using a Veress needle. The Veress needle design features a blunt spring mandrel that protrudes beyond the needle in the absence of external resistance. This design protects the abdominal organs from damage by the needle tip. Gas is injected into the abdominal cavity using a laparoflator, which controls the pressure and gas flow rate.

The introduction of the first ("blind") trocar is the most important stage in the technique of laparoscopy. The current level of development of laparoscopic technology provides for the use of two types of trocars, ensuring the safety of "blind" introduction:

• trocars with a protective mechanism - resemble the design of the Veresh needle - in the absence of external resistance, the tip of the trocar is blocked by a blunt safety device;
• "visual" trocars - the advancement of the trocar through all layers of the anterior abdominal wall is controlled by a telescope.

The introduction of additional trocars is performed strictly under visual control.

In all cases of laparoscopy, endotracheal anesthesia or combined anesthesia (long-term epidural in combination with endotracheal anesthesia) must be performed, and the method of choice should be combined anesthesia, as it provides not only adequate anesthetic protection, but also a therapeutic effect (relief of intestinal paresis, improvement of cardiovascular and renal function, optimization of cerebral blood flow), which is important in patients with purulent intoxication.

Technique of performing laparoscopy

The technique of performing laparoscopy varies in patients with a history of pelvic surgery and in patients who have not had any previous surgery. In typical cases, a Veress needle is inserted through the lower hemisphere of the navel to create pneumoperitoneum. In the case of performing laparoscopy after one or more previous laparotomy (especially lower-midline or complicated postoperative period), as well as in the case of a pronounced adhesive process, which is almost always present in purulent inflammation of the uterine appendages, it is preferable to insert the Veress needle into 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 place of insertion of the optical trocar depends on the type of the previous incision of the anterior abdominal wall: in the case of a transverse laparotomy, this may be the umbilical region; in the case of a midline incision, this may be a point 2-5 cm from the upper corner of the scar.

Before inserting the optical trocar, it is necessary to conduct a gas test, the purpose of which is to ensure the absence of adhesions. To do this, a syringe half filled with solution is used to puncture the anterior abdominal wall at the site of the proposed trocar insertion. If gas is obtained from the abdominal cavity, the test can be considered negative (absence of adhesions). The test is performed repeatedly, changing the direction of the needle puncture, after which the optical trocar is inserted.

Next, with the operating table in a horizontal position, the abdominal organs are inspected with mandatory examination of the parietal and visceral peritoneum, appendix, liver, gall bladder, pancreatic region, intestinal loops to exclude acute surgical pathology of these organs (purulent appendicitis, pancreatic necrosis, etc.), as well as to identify interintestinal and subdiaphragmatic abscesses. If exudate is detected, the latter is aspirated with mandatory collection of material for bacteriological examination.

Then they begin to inspect the internal genital organs. For better visualization, it is necessary to "cannulate" the uterus (with the exception of obstetric patients), which allows it to be moved and fixed in the most comfortable position.

In almost all cases, inflammatory changes in the internal genital organs are accompanied by an adhesive process, up to adhesive pelvic peritonitis. Therefore, the first step of the operation is adhesiolysis.

Adhesion dissection can be performed by a sharp method with subsequent coagulation of bleeding vessels or by using monopolar coagulation in the "cutting" mode, which leads to preventive hemostasis. In this case, the latter procedure requires constant monitoring of the instrument, since any, even short-term, contact with surrounding organs (large vessels, intestinal loops) can lead to complications (burn, bleeding).

When separating adhesions, the cavities of tubo-ovarian formations may be opened, therefore adhesiolysis should be accompanied by repeated rinsing of the pelvic cavity with warm saline solution with the addition of antiseptics (dioxidine, chlorhexidine).

In case of purulent salpingitis, adequate intervention volume includes adhesiolysis, sanitation and transvaginal (through the colpotome opening) drainage of the small pelvis.

In cases of purulent salpingo-oophoritis and pelvic peritonitis with the formation of an encapsulated abscess in the rectouterine pouch, adequate treatment is considered to be mobilization of the uterine appendages, emptying of the abscess, sanitation and active aspiration drainage through a colpotome opening.

When pyosalpinx has formed, it is necessary to remove the fallopian tube or tubes, since the possibility of restoring its (their) function in the future is unlikely, and the risk of progression or relapse of the purulent process, as well as ectopic pregnancy, is high. It is better to remove the focus of purulent inflammation and orient the patient to treatment by in vitro fertilization than to subsequently carry out long-term attempts to rehabilitate an organ that has lost its functions.

In case of small pyovara (up to 6-8 cm in diameter) and the presence of intact ovarian tissue, it is advisable to enucleate the purulent formation and form an ovarian stump with catgut or (better) vicryl sutures. In case of an ovarian abscess, it is removed.

Indications for removal of uterine appendages 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 with their subsequent intersection (infundibular-pelvic ligament, proper ovarian ligament, uterine part of the tube and vessels of the mesovarium and mesosalpinx). Bipolar coagulation provides reliable hemostasis and is safe to use, does not form a scab, but only vaporizes tissues, leading to protein denaturation and vascular obliteration.

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

• the rectouterine pouch is the lowest-lying anatomical formation of the peritoneum, in which exudate accumulates due to gravity;
• there are no large cellular spaces and organs adjacent to the wound.

The incision is safer to make from the abdominal cavity using a clamp inserted into the posterior fornix transvaginally. The grasping clamp is inserted into the Douglas space under laparoscope control, the tissue to be removed is placed between the branches and extracted through the vagina. If the formation is large, it is necessary to widen the vaginal wall incision to the required dimensions.

Difficulties may arise when removing necrotic tissue, as grasping it with a clamp leads to its fragmentation. In this case, the use of a plastic bag inserted through a colpotome wound into the pelvic cavity is indicated. The tissues to be removed are placed in the bag, its "neck" is grasped with a clamp, and the bag together with the contents is removed. If a bag is not available, it can be replaced with a medical rubber glove.

All operations must be completed with repeated thorough lavage of the pelvic cavity and revision of the suprahepatic space to prevent pus and blood from flowing there and the removal of one or two drainage tubes through the colpotome wound.

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

Active aspiration should be performed using the OP-1 device in order to create favorable conditions for reparation and active evacuation of exudate. For this purpose, one or two double-lumen silicone rubber tubes with a diameter of 11 mm are inserted into the pelvic cavity with a perforated end and brought out through the colpotomy opening (or, if there are no conditions for colpotomy, through additional counter-openings in the hypogastric sections). A surgical suction device (OP - 01) is connected. Aspiration-washing drainage (AWD) is performed by introducing a furacilin solution (1:5000) through the narrow lumen of the tube at a rate of 20 drops per minute and aspiration under a pressure of 30 cm of water column for 2-3 days (depending on the severity of the process) with periodic jet washing of the tubes in the presence of purulent "plugs".

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

1. active washing out and mechanical removal of infected and toxic contents of the abdominal cavity is carried out;
2. the hypothermic effect of cooled furacilin stops further growth of microbial invasion, helps relieve swelling in the affected organ and surrounding tissues, prevents the entry of toxins and microorganisms into the circulatory and lymphatic systems;
3. reliable outflow of washing fluid under negative pressure eliminates the possibility of accumulation of solution in the abdominal cavity, allows to clear the peritoneum from fibrin, necrotic detritus and reduce swelling and tissue infiltration.

In case of pronounced purulent-necrotic changes of the internal genital organs and pronounced adhesive process after separation of adhesions, 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 hand, promotes the formation of coarse cicatricial changes in tissues. In the early postoperative period (especially without aspiration-washing drainage), the formation of serous or purulent cavities with subsequent activation of the process is possible, which leads to a protracted course of the disease, relapses and complete hopelessness of restoring reproductive function.

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

Repeat laparoscopy is performed on the 3rd, 5th, 7th day after the first operation. Under intravenous anesthesia, optical and manipulation trocars are “bluntly” inserted through the same punctures, all stages of the operation are performed sequentially. The last operation ends with the creation of 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 liver and kidney failure;
4. diabetes mellitus in the decompensation stage;
5. hemorrhagic diathesis;
6. acute infectious diseases;
7. extensive adhesions in the abdominal cavity.

Complications of laparoscopy

When performing laparoscopy, complications that arise are a consequence of “blind” performance of manipulations and occur both at the stage of applying pneumoperitoneum and at the stage of inserting the first trocar.

When inserting a Veress needle, the most common complications are injuries to the intestines, omentum, main vessels, and subcutaneous emphysema.

Complications of the introduction of the first “blind” trocar may include extensive injuries to parenchymal organs, intestines, and large vessels.

When entering the abdominal cavity, the intestine may be injured, especially when the first (optical) trocar is inserted. In this case, as a rule, the fused small intestine is injured. Injury to the distal sections of the intestine is possible when separating the capsule of a purulent tubo-ovarian formation from the intimately adjacent section of the intestine in patients with complicated forms of the purulent process.

Immediate recognition (inspection, appearance of intestinal discharge, in doubtful cases - introduction of methylene blue solution into the rectum) serves as a preventive measure against the most severe complications. With sufficient experience of the doctor, defects can be eliminated by laparoscopy according to all the rules of surgery (depending on the degree of intestinal damage, mucomuscular and/or serous-muscular sutures made of vicryl are applied). If there are doubts about the possibility of performing such an operation by the laparoscopic method, as well as in case of intestinal injury at the beginning of the operation, it is necessary to immediately perform a laparotomy.

Bladder injury with trocars is possible due to non-compliance with the surgical technique in patients with an unemptied bladder or due to instrument slippage. As a rule, the bottom or back wall of the organ is injured. The bladder wound should be immediately sutured with two rows of mucomuscular and muscular-muscular separate catgut sutures (or one row of catgut sutures and one row of vicryl sutures are applied). A Foley catheter is then inserted into the bladder.

Ureteral injury may occur when the infundibulopelvic ligament is crossed, especially when it is inflammatoryly infiltrated. Another site of ureteral injury may be the parametrium when parametrium tissue is infiltrated in patients with complicated forms of purulent inflammation. In this case, the ureter may be displaced and fixed by the inflammatory infiltrate.

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

In case of suspected ureteral injury, intravenous administration of methylene blue is performed; if the diagnosis is confirmed, immediate laparotomy is performed, suturing of the ureteral wall in case of its parietal injury or application of ureterocystoanastomosis in case of its intersection on a ureteral catheter or stent.

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

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

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

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

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