1. Gynecological Endoscopy Done by: essa tawfeeQNawal akbar mohammed jawaDMohammed dhamen Supervised by: Dr. Majda Done by: essa tawfeeQNawal akbar mohammed jawaDMohammed dhamen Supervised by: Dr. Majda

2. Operative Laparoscopy Successful operative laparoscopy requires three essential ingredients: 1. Surgical skill; 2. A well designed and equipped Operating Room; 3. A surgical team. Successful operative laparoscopy requires three essential ingredients: 1. Surgical skill; 2. A well designed and equipped Operating Room; 3. A surgical team.

3. Gynecological Endoscopy  Endoscopy in obstetrics and gynaecology has many branches:  Laparoscopy  Hysteroscopy.  Colposcopy  Falloposcopy  Fetoscopy  Endoscopy in obstetrics and gynaecology has many branches:  Laparoscopy  Hysteroscopy.  Colposcopy  Falloposcopy  Fetoscopy

4. Outline  Laparoscopy  Definition  Instruments  The Procedures  Indications and contraindications  Complications  Laparoscopy  Definition  Instruments  The Procedures  Indications and contraindications  Complications

5. Laparoscopy  Definition : It is a technique which allows viewing (Diagnostic) and surgical maneuvers (Therapeutic) to be performed in abdominal organs through a surgical incision of < 1cm with help of pneumoperitoneum.  Definition : It is a technique which allows viewing (Diagnostic) and surgical maneuvers (Therapeutic) to be performed in abdominal organs through a surgical incision of < 1cm with help of pneumoperitoneum.

6. Instruments 1. Verres needle: used to inflate air to the peritoneal cavity (pneumoperitoneum) through the umbilicus where there is the thinnest abdominal wall. 1. Verres needle: used to inflate air to the peritoneal cavity (pneumoperitoneum) through the umbilicus where there is the thinnest abdominal wall.

7. 2. Electronic laparoflator:  Used to insufflate through the verres needle.  Maintains constant intra-abdominal pressure without exceeding the safety limit.  Some types have heating system to prevent lowering the patient body temperature. 2. Electronic laparoflator:  Used to insufflate through the verres needle.  Maintains constant intra-abdominal pressure without exceeding the safety limit.  Some types have heating system to prevent lowering the patient body temperature.

8. 3. Trocars:  Permit access to the intraperitoneal cavity in which other instruments can pass.  The trocar used should be adapted to the diameter of the telescope selected. 3. Trocars:  Permit access to the intraperitoneal cavity in which other instruments can pass.  The trocar used should be adapted to the diameter of the telescope selected.

9. 4. Telescope:  There are different sizes each with a different use.  They are used to visualize the peritoneal cavity. 4. Telescope:  There are different sizes each with a different use.  They are used to visualize the peritoneal cavity.

10. 5. Camera equipment. 6. Light source. 5. Camera equipment. 6. Light source.

11. There are two types: - Disposable - Reusable They can be either atraumatic or grasping foreceps. There are two types: - Disposable - Reusable They can be either atraumatic or grasping foreceps. 7. Forceps and scissors:

13. 8. Bipolar elecrtosurgey. 9. Unipolar electrosurgery. 10. Laser. 11. Ultrasound system. 12. Suction and irrigation system. 13. Suture. 14. Laparoscopic bag. 15. Tissue morcellator: used to remove large specimens like myomas or an entire uterus in small pieces. 16. Uterine manipulator: used to mobilize or stabilize the uterus and adnexa. 8. Bipolar elecrtosurgey. 9. Unipolar electrosurgery. 10. Laser. 11. Ultrasound system. 12. Suction and irrigation system. 13. Suture. 14. Laparoscopic bag. 15. Tissue morcellator: used to remove large specimens like myomas or an entire uterus in small pieces. 16. Uterine manipulator: used to mobilize or stabilize the uterus and adnexa. InstrumentsInstruments

14. 1.Preparation of the patient:  Inform the patient about the therapeutic benefits and potential risks (informed consent).  Intestinal preparation: Simple intestinal emptying, for better viewing and preventing injuries.  Place the patient in the dorsolithotomy position. 1.Preparation of the patient:  Inform the patient about the therapeutic benefits and potential risks (informed consent).  Intestinal preparation: Simple intestinal emptying, for better viewing and preventing injuries.  Place the patient in the dorsolithotomy position. ProcedureProcedure

15. a.The abdominal wall is lifted by hand or by grasping forceps b.Pnemoperitoneum is created by verres needle introduced to the umbilical area (less subcutaneous and preperitoneul tissue). c.The needle is inserted in an oblique angle toward the uterine fundus d.The negative pressure will allow the underlying structures to fall away. e.After making sure that the needle is in correct position, air flow can be increased to 2.5 liters per minute till a pressure of 15mmHg a.The abdominal wall is lifted by hand or by grasping forceps b.Pnemoperitoneum is created by verres needle introduced to the umbilical area (less subcutaneous and preperitoneul tissue). c.The needle is inserted in an oblique angle toward the uterine fundus d.The negative pressure will allow the underlying structures to fall away. e.After making sure that the needle is in correct position, air flow can be increased to 2.5 liters per minute till a pressure of 15mmHg 2. Creation of pneumoperitoneum:

16. a.Once the intra-abdominal pressure reaches 15 mmHg the main trocar is introduced after removal of veress needle. b.The position of the trocar must be verified by inserting the laparoscope and viewing the pelvic cavity. a.Once the intra-abdominal pressure reaches 15 mmHg the main trocar is introduced after removal of veress needle. b.The position of the trocar must be verified by inserting the laparoscope and viewing the pelvic cavity. 3. Trocar introduction

17. A.The omentum, bowel and bifurcation of pelvic vessels should be evaluated to avoid injuries caused during the introduction of Verres needle or trocar. B.The site of introduction of other trocars should be verified by finger palpation and transillumination of abdominal wall to avoid injury to epigastric vessels. C.Identify if there is any bleeding A.The omentum, bowel and bifurcation of pelvic vessels should be evaluated to avoid injuries caused during the introduction of Verres needle or trocar. B.The site of introduction of other trocars should be verified by finger palpation and transillumination of abdominal wall to avoid injury to epigastric vessels. C.Identify if there is any bleeding 4. Viewing the peritoneal cavity:

18. After the procedure CO 2 gas must be evacuated completely to reduce post-operative pain In operative procedures: - 1 or 2 bottles of Ringer’s lactate are used to wash the peritoneal cavity after laparoscopy. - Leave 500/1000 cc of ringer’s lactate to reduce the incidence of post operative pain. After the procedure CO 2 gas must be evacuated completely to reduce post-operative pain In operative procedures: - 1 or 2 bottles of Ringer’s lactate are used to wash the peritoneal cavity after laparoscopy. - Leave 500/1000 cc of ringer’s lactate to reduce the incidence of post operative pain.

19. Used as a diagnostic tool  Infertility: status of the fallopian tube (morphology and functionality) and any pathological condition e.g. adhesions.  Ovarian cysts or tumors.  Ectopic pregnancy.  PID: tubal abscess or adhesions.  Endometriosis: define the sites of implants and endometrial cysts. Used as a diagnostic tool  Infertility: status of the fallopian tube (morphology and functionality) and any pathological condition e.g. adhesions.  Ovarian cysts or tumors.  Ectopic pregnancy.  PID: tubal abscess or adhesions.  Endometriosis: define the sites of implants and endometrial cysts. IndicationsIndications

20. Ovarian Cyst Adhesions between the omentum and uterus

21. Ectopic pregnancy

22. - Management of ovarian cyst by: - Drainage. - Ovarian cystectomy. - Ovarian drilling of the cortex and stroma to decrease androgens in the ovaries - Correcting ovarian torsion. - As a treatment of endometriosis - By removal of the endometrial cyst, cauterization of endometrial spots and adhesiolysis - Management of ovarian cyst by: - Drainage. - Ovarian cystectomy. - Ovarian drilling of the cortex and stroma to decrease androgens in the ovaries - Correcting ovarian torsion. - As a treatment of endometriosis - By removal of the endometrial cyst, cauterization of endometrial spots and adhesiolysis As a therapeutic tool

23. Movie

24.  Management of infertility: - Adhesiolysis - Treat the cause (endometriosis, PCOS)  Myomectomy for fibroids: used for subserosal and intramural fibroids only, not used for submucosal fibroids.  Management of PID: by draining tubal abscess and adhesiolysis.  Management of infertility: - Adhesiolysis - Treat the cause (endometriosis, PCOS)  Myomectomy for fibroids: used for subserosal and intramural fibroids only, not used for submucosal fibroids.  Management of PID: by draining tubal abscess and adhesiolysis. As a therapeutic tool

25. AdhesiolysisAdhesiolysis Myomectomy

26. Salpingotomy  Used to preserve the tubes for desired reproductivity.  Done if the patient is hemodynamicaly stable  If size < 5 cm  Location must be ampullary, infundibular or isthmic.  Contralateral tube either normal or absent. Salpingotomy  Used to preserve the tubes for desired reproductivity.  Done if the patient is hemodynamicaly stable  If size < 5 cm  Location must be ampullary, infundibular or isthmic.  Contralateral tube either normal or absent. Management of ectopic pregnancy:

27. Salpingotomy

28. - Salpingectomy (it is the standard for ectopic pregnancy) - Ruptured tube - Multiple recurrence of ectopic pregnancy. - Size of ectopic > 5 cm - Salpingectomy (it is the standard for ectopic pregnancy) - Ruptured tube - Multiple recurrence of ectopic pregnancy. - Size of ectopic > 5 cm IndicationsIndications

30. - Tubal sterilization by: - Bipolar coagulation. - Clips (filshie clips) and rings - Before doing this you should consult the patient about three things - Chance of irreversibility - Failure rate 1/200 - Bleeding may occur and we may shift to laparatomy. - Laparoscopic hysterectomy. - Tubal sterilization by: - Bipolar coagulation. - Clips (filshie clips) and rings - Before doing this you should consult the patient about three things - Chance of irreversibility - Failure rate 1/200 - Bleeding may occur and we may shift to laparatomy. - Laparoscopic hysterectomy. IndicationsIndications

32. Ring sterilization

34. ContraindicationsContraindications 1.Generalized peritonitis 2.Hypovolemic shock 3.Severe cardiac disease 4.Hemoglobin less than 7 g/dL 5.Uterine size > 12 wks. 6.Multiple previous abdominal procedures 7.Extreme body weight 1.Generalized peritonitis 2.Hypovolemic shock 3.Severe cardiac disease 4.Hemoglobin less than 7 g/dL 5.Uterine size > 12 wks. 6.Multiple previous abdominal procedures 7.Extreme body weight

35. - Pneumoperitoneum: -Extraperitonel emphysema due to failure of introducing verres needle correctly into the peritoneal cavity and not checking the negative pressure on the machine. -Gas may extend to the mediastinum and compromise cardiac function -Pneumoomentum: and put the patient on the trendlenberg - Injury to abdominal organs -GI: if the intestine is distended or adherent to the abdominal wall (prevented by good intestinal preparation) and putting the patient on the telendelenburg position. -Bladder injury: prevented by emptying the bladder. - Pneumoperitoneum: -Extraperitonel emphysema due to failure of introducing verres needle correctly into the peritoneal cavity and not checking the negative pressure on the machine. -Gas may extend to the mediastinum and compromise cardiac function -Pneumoomentum: and put the patient on the trendlenberg - Injury to abdominal organs -GI: if the intestine is distended or adherent to the abdominal wall (prevented by good intestinal preparation) and putting the patient on the telendelenburg position. -Bladder injury: prevented by emptying the bladder. ComplicationsComplications

36. Blood vessel injury: -Pelvic, omental and mesentric -Prevented by introducing the verres needle in an angle. -In obese patients you can insert the needle in straight manner because of the thick fatty layer. Blood vessel injury: -Pelvic, omental and mesentric -Prevented by introducing the verres needle in an angle. -In obese patients you can insert the needle in straight manner because of the thick fatty layer. ComplicationsComplications

37. HysteroscopyHysteroscopy  Definition  Instruments  The Procedures  Indications and contraindications  Complications  Definition  Instruments  The Procedures  Indications and contraindications  Complications

38. Hysteroscopy  Definition:  It is a technique which allows viewing and surgical maneuvers to be performed in the uterine cavity.  It has many advantages that made it wide spread and fundamental diagnostic method in daily gynecological practice.  Definition:  It is a technique which allows viewing and surgical maneuvers to be performed in the uterine cavity.  It has many advantages that made it wide spread and fundamental diagnostic method in daily gynecological practice.

39. Instruments 1.Distention media of the uterine cavity (CO 2 distention) 2.Light source. xenon light source gives the best image quality 1.Distention media of the uterine cavity (CO 2 distention) 2.Light source. xenon light source gives the best image quality

40. 3. Camera Equipment 4. Endoscope flexible: high cost and fragile cannot be autoclaved. rigid: gives different direction of the view. - 0°, 12°, 30° (best for diagnostic purpose). 3. Camera Equipment 4. Endoscope flexible: high cost and fragile cannot be autoclaved. rigid: gives different direction of the view. - 0°, 12°, 30° (best for diagnostic purpose).

41. 5. Hysteroscope: There are 2 types of hysteroscopes: DiagnosticTherapeutic

42. 1.Preparation of the patient:  Detailed history and complete physical examination  It is preferable to do the procedure in the first part of the menstrual cycle, because there is less mucus (better viewing) and no chance of encountering early pregnancy  Informed consent  Patient is placed in lithotomy position  Accurate bimanual examination to asses the uterine (position, morphology, volume). 1.Preparation of the patient:  Detailed history and complete physical examination  It is preferable to do the procedure in the first part of the menstrual cycle, because there is less mucus (better viewing) and no chance of encountering early pregnancy  Informed consent  Patient is placed in lithotomy position  Accurate bimanual examination to asses the uterine (position, morphology, volume). Procedure

43. 2. Technique:  Clean cervix with antiseptics  Cervical forceps is placed on the front labia  Light source & CO2 gas supply are connected to the instrument  Insert hysteroscope into the cervical canal, which dilates from the gas pressure. 2. Technique:  Clean cervix with antiseptics  Cervical forceps is placed on the front labia  Light source & CO2 gas supply are connected to the instrument  Insert hysteroscope into the cervical canal, which dilates from the gas pressure. Procedure

44. Used as a diagnostic tool: - Abnormal uterine bleeding caused by: - submucous and intramural myoma. - endometrial polyps. - endometrial atrophy. - Endometrial tumors. - Infertility related to: - Intrauterine adhesions (Asherman’s syndrome) - Submucous fibroids. - Endometrial polyps. - Uterine malformation (it cannot differentiate between sepatate and bicorneate uterus)<- this can be done by laparoscopy. Used as a diagnostic tool: - Abnormal uterine bleeding caused by: - submucous and intramural myoma. - endometrial polyps. - endometrial atrophy. - Endometrial tumors. - Infertility related to: - Intrauterine adhesions (Asherman’s syndrome) - Submucous fibroids. - Endometrial polyps. - Uterine malformation (it cannot differentiate between sepatate and bicorneate uterus)<- this can be done by laparoscopy. IndicationsIndications

45. Used as a therapeutic tool Endometrial ablation (using laser):  Abnormal uterine bleeding but we should role out cancerous or pre cancerous cause of bleeding.  Also used in patients with high risk for hysterectomy or the patient does not want to do the surgery. steroscopic Surgeries and Endometrial Polypectomy Used as a therapeutic tool Endometrial ablation (using laser):  Abnormal uterine bleeding but we should role out cancerous or pre cancerous cause of bleeding.  Also used in patients with high risk for hysterectomy or the patient does not want to do the surgery. steroscopic Surgeries and Endometrial Polypectomy IndicationsIndications

46.  Correct uterine malformation like septate uterus by resection of the septum. (bicorneate uterus is corrected by laparotomy using metroplasty).  Polypectomy.  Intrauterine adhesions.  Myomectomy: The main indication for hysteroscopic myomectomy is AUB caused by submucous myomas in infertile patients  Correct uterine malformation like septate uterus by resection of the septum. (bicorneate uterus is corrected by laparotomy using metroplasty).  Polypectomy.  Intrauterine adhesions.  Myomectomy: The main indication for hysteroscopic myomectomy is AUB caused by submucous myomas in infertile patients IndicationsIndications

47. Hysteroscopic Surgeries and Endometrial Polypectomy

48. Used as a therapeutic tool - Removal of foreign bodies and IUCD. - Fallopian tube catheterization - to canalize the tube. - to place intra tubal device for reversible sterilization. Used as a therapeutic tool - Removal of foreign bodies and IUCD. - Fallopian tube catheterization - to canalize the tube. - to place intra tubal device for reversible sterilization. IndicationsIndications

49. Uterine polyp Uterine anomaly

50. Intrauterine Adhesions

51. Endometrial Ca.

52. ContraindicationsContraindications  Pregnancy.  Current or recent pelvic infection.  Current vaginitis, cervicitis and endometritis.  Recent uterine perforation.  Active Bleeding.  Pregnancy.  Current or recent pelvic infection.  Current vaginitis, cervicitis and endometritis.  Recent uterine perforation.  Active Bleeding.

53. -Complications related to distention media: -due to CO2 insufflation: -Cardiac arrhythmia due to excessive absorption. -Gas embolism. -We use hysteroflator that insufflate pressure of 100-120 mmHg constantly without exceeding the safety limit. -due to fluid: -HMW (dextran) -Anaphylactic reaction -Pulmonary edema -Adult RDS -Complications related to distention media: -due to CO2 insufflation: -Cardiac arrhythmia due to excessive absorption. -Gas embolism. -We use hysteroflator that insufflate pressure of 100-120 mmHg constantly without exceeding the safety limit. -due to fluid: -HMW (dextran) -Anaphylactic reaction -Pulmonary edema -Adult RDS ComplicationsComplications

54. - LMW (saline) - Fluid overload: prevented by keeping the operating time to minimum. - Avoid entering vascular channels. - Close monitoring of fluid balance. - If you exceed 1000 ml of infused fluid stop the procedure. - Intraoperative complications: - Uterine perforation (<1%) - Hemorrhage either from: - Perforation - Tenaculum used to hold the cervix. -Trauma. - Thermal damage. - LMW (saline) - Fluid overload: prevented by keeping the operating time to minimum. - Avoid entering vascular channels. - Close monitoring of fluid balance. - If you exceed 1000 ml of infused fluid stop the procedure. - Intraoperative complications: - Uterine perforation (<1%) - Hemorrhage either from: - Perforation - Tenaculum used to hold the cervix. -Trauma. - Thermal damage. ComplicationsComplications

55. -Late onset: -Infections: like acute PID, so we give prophylactic antibiotics. -Vaginal discharge: common after ablative procedures and it is self limiting. -Adhesion formation: -Common after myomectomy when 2 fibroids are located opposite to each other in the uterine wall. -To prevent the adhesions it is better to remove the fibroids in stages, and give estrogen (to build up the endometrial) therapy directly after resection. And also we can use IUCD. -Late onset: -Infections: like acute PID, so we give prophylactic antibiotics. -Vaginal discharge: common after ablative procedures and it is self limiting. -Adhesion formation: -Common after myomectomy when 2 fibroids are located opposite to each other in the uterine wall. -To prevent the adhesions it is better to remove the fibroids in stages, and give estrogen (to build up the endometrial) therapy directly after resection. And also we can use IUCD. ComplicationsComplications

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57. Movie

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59.  Asherman Syndrome:  It is defined as intrauterine adhesions  Cause can be iatrogenic (after hysteroscopic myomectomy) and can due to infection.  It can be treated by hysteroscopic adhesiolysis followed by inserting IUCD to make the uterine walls apart from each other. We can also use estrogen after adhesiolysis and this wall cause the emdometrium to build up and prevent adhesions to reoccur  Asherman Syndrome:  It is defined as intrauterine adhesions  Cause can be iatrogenic (after hysteroscopic myomectomy) and can due to infection.  It can be treated by hysteroscopic adhesiolysis followed by inserting IUCD to make the uterine walls apart from each other. We can also use estrogen after adhesiolysis and this wall cause the emdometrium to build up and prevent adhesions to reoccur