Page 41 - WJOLS - Laparoscopic Journal

Vaduneme K Oriji

testosterone levels (hyperandrogenemia) and the presence is retained in the bladder in the theater and anesthesia
of polycystic ovaries as recognized at the ESHRE/ASRM administered.
consensus meeting in Rotterdam in 2003. A refined definition
of the PCOS also was agreed and this encompasses a ANESTHESIA
description of the morphology of the polycystic ovary. It
was agreed that the criteria fulfilling sufficient specificity An intravenous access is secured with maintenance of water
and sensitivity to define the polycystic ovary (PCO) are the and electrolyte balance.
presence of 12 or more follicles measuring 2 to 9 mm in General anesthesia with endotrachial intubation and close
3
diameter and increased ovarian volume (>10 cm ). If there monitoring is recommended.
is a follicle greater than 10 mm in diameter, the scan should
be repeated at a time of ovarian quiescence to calculate Patient Position
1,2
volume and area. Patients presenting with this description Patient should be in steep Trendelenburg’s and Lithotomy
are termed to be clomiphene citrate resistant if they fail to position. 5
ovulate after 3 to 4 cycles of treatment with CC. Some of
these patients are offered LOD while others are offered Position of Surgical Team
other chemotherapeutic agents such as gonadotrophins, The surgeon stands to the left of the patient with camera
metformin, GnRHa to overcome the problem of anovulation man on his right. Monitor should be placed opposite the
and infertility in the CC resistant women. 2-5
surgeon to maintain co-axial alignment. One assistant should
stand between the patient’s legs to do uterine manipulation
EVOLUTION OF LOD
if required and the instrument trolley should be towards the
Ovarian wedge resection was the mode of treatment for left leg of the patient with a scrubbed assistant.
women with PCOS prior to the ‘70s when CC was
introduced as an ovulation induction agent. Physicians Port Positions and Ovarian Drilling
thought that it was the increased ovarian size that resulted
in the anovulation and infertility and so wedge resection The patient is cleaned, painted with antiseptic lotion and
was considered appropriate. This was a major breakthrough draped. The light cable, insuffilation tube, electrosurgical
as it resulted in about 80% ovulation and 50% conception cautery wires, suction irrigation tube and Veress needle
rates. However, many of the women later reverted back to should be checked. Focusing and white balancing of the
the anovulatory state and the development of postoperative telescope is done, then pneumoperitoneum is created by
pelvic adhesions was thought to be the cause of the low Veress needle using the inferior crease of the umbilicus.
2
pregnancy rates. With the advent of CC, which had the Once pneumoperitoneum has been created then 10 mm or
advantage of cost and low monitoring, and high ovulation 5 mm port is introduced into the abdominal cavity through
and pregnancy rates, a group of women was identified that the inferior crease of the umbilicus for a 5 mm or 10 mm
failed to ovulate with CC. Laparoscopic ovarian drilling was telescope. Another 5 mm port is introduced into the
introduced in the ‘90s as another surgical method of abdominal cavity under vision through the left iliac fossae
ovulation induction with the aim of minimising the pelvic and a diagnostic laparoscopy with chromotubation for tubal
adhesions caused by open surgery. This has met with certain patency done. Thereafter, an atraumatic grasper is used to
degree of success with respect to restoring ovulation and hold the utero-ovarian ligament to stabilize the ovary to
2,4
fertility with reduction in chances of pelvic adhesion. perform the ovarian drilling. Laparoscopic treatment
options include multiple ovarian punch biopsy, ovarian

OPERATIVE CARE AND TECHNIQUE OF THE LOD electrocauterization and laser vaporization or photo-
5,6
coagulation, harmonic scapel. About 4 to 5 holes drilled
Preoperative Preparation into each ovary is adequate 2-4,7,9 and are relatively easy to
Patient is screened for medical diseases through the history, perform with the procedure lasting about 30 minutes in
physical examinations and ancillary investigations, and experienced hands. These options of drilling into the ovary
usually for infertility if present. Patient will undergo an have similar success rate in inducing ovulation and achieving
overnight fast prior to surgery. An indwelling urinary catheter pregnancy. 8
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JAYPEE