Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD.
Dr. Asna Samreen M.B.B.S (MRCOG)
Nice Hospital, Hyderabad.
During diagnostic hystero-laparoscopy, also called as pelvicoscopy, always insert the abdominal laparoscpic ports, establish a pneumoperitonium and insert the laparoscope prior to hysteroscopy.
Pelvicoscopy with bilateral ovarian drilling involves the following steps:
1. Port placements
2. Diagnostic laparoscopy
3. Hysteroscopy
4. Chromopertubation
5. Ovarian drilling
PORT PLACEMENT:
1. Diagnostic laparoscopy can be done using 1 port, 2 ports or 3 ports. In this task analysis, we will use 3 ports with contra lateral positioning.
2. Using baseball diamond concept, one 10mm port is placed in the umbilicus and two 5mm ports are placed contra-laterally are distance of 7.5 cm from the umbilicus.
3. Before inserting check the Veress needle action by pressing the blunt tip of the needle against a hard surface and checking the action of the red indicator.
4. For the umbilical port placement, evert the umbilicus by applying two Alleys forceps on lateral margins of umbilicus.
5. Then a stab incision is given in the midline on the superior or inferior crease of the umbilicus.
6. Now, hold the Veress needle as a dart in the right hand and lift up the abdominal wall by holding suprapubically. Insert the Veress needle at a 90° angle to the abdominal wall and keep the direction of the needle towards the pelvis.
7. There will a sensation of initial resistance and then giving away at two places. Once the peritoneum in pierced confirm it by connecting 5ml syringe to the Veress needle and then aspirate. If nothing is aspirated, then push some saline into the cavity and then aspirate again, if the peritoneal cavity has been reached then no fluid should be aspirated back. Hanging drop test and plunger test can also be done.
8. Once the position of the needle is confirmed, attach the needle to the insufflator with initial flow rate of 1L/min with Preset Pressure of 12 to 15mm of Hg.
9. Once the pressure is achieved, enlarge the incision in a curved fashion and insert a 10mm port perpendicular to the abdominal wall. Now, remove the trocar and insert a 30° telescope,
through the cannula, into the abdominal cavity keeping the light source cable at 12’o clock position and CCD cable at 6’o clock position.
10. Once the port is inserted, the flow rate can be increased to >/= 6L/min.
11. Now to put a 5mm port 7.5 cm lateral to the umbilical port, by first making a stab wound on the skin and then inserting the port perpendicular to the skin, under the direct vision via laparoscope. Similarly, put another port 7.5 cm lateral to the umbilicus on the contra lateral side.
DIAGNOSTIC LAPAROSCOPY:
1. Once the abdominal ports are placed, proceed with diagnostic laparoscopy.
2. Start by inspecting the abdominal and pelvic cavities for any abnormalities, adhesions and endometriosis.
3. Inspect the uterus, fallopian tubes, ovaries, the pouch of Douglas and uterosacral ligaments for any congenital anomalies, any visible myomas, cysts, adhesions of the tube, hydrosalpinx ect.
4. Once the abdominal and pelvic cavities are inspected, proceed with the diagnostic hysteroscopy.
HYSTEROSCOPY:
1. Place the patient in flat lithotomy position.
2. Insert a Foley’s catheter and drain the bladder.
3. Before inserting the hysteroscope, do a bimanual examination to check the position of the uterus. (This step can be bypassed in case the hysteroscopy is done as a part of diagnostic laparoscopy, as the position of the uterus can be assessed visually via laparoscope. )
4. Inspect the vaginal vault and then gently introduce a Sim’s speculum to visualize the cervix. Inspect the cervix for any erosions or any other pathology.
5. Grasp the cervix with tenaculum and in case of nulliparous patient, you may need to dilate the cervix using Hegar’s dilators. Do not dilate the cervix beyond the diameter of hysteroscope, as it may cause leakage of distending medium.
6. Insert the hysteroscope into the external os, under direct vision and remove the speculum and tenaculum.
7. Inspect the cervical canal for any anomalies during the entry.
8. During entry with a 30° hysteroscope, in anteverted uterus, the light source cable should be at 6 O’ clock position and in retroverted uterus, the position of the cable should be at 12 O’ clock position.
9. Connect the proximal irrigation channel of the hysteroscope sheath to the distension medium source and make sure the direction of the inlet channel is upwards.
10. The distension media that are used in hysteroscopy are: carbon dioxide (used in strictly diagnostic hysteroscopy), Normal saline (most commonly used), 1.5% glycine (mainly used for monopolar operative hysteroscopy), 32% dextran 70 in dextrose (rarely used).
11. Now connect the irrigation channel to constant pressure variable flow pump, which creates a continuous flow in uterine cavity giving a clear view. The pressure for uterine dilatation is usually between 80 to 120mm of Hg.
12. The uterine cavity distends in a distal to proximal fashion and the cervical canal is the last to dilate.
13. Once inside the uterus, if the tip of the 30° telescope is placed 2 to 3 cms away from the fundus, the cavity can be examined by simply rotation the light source cable without rotating the entire telescope and a panoramic view can be obtained by maintaining the endocervical canal in the center of the image.
14. Inspect the endometrial cavity for any anomaly like adhesions, polyps, myomas etc.
15. To visualize left ostium, turn the light source cable to right and vice versa.
16. At this point endometrial biopsy can be taken using hysteroscopic biopsy forceps or by using a small curette.
17. During the procedure a strict inflow/outflow charting of the distention medium has to be maintained and fluid deficit calculated to avoid complications such as hyponatraemia or hypervolaemia.
CHROMOPERTUBATION:
1. At this point, to check the tubal patency, chromopertubation test can be done and the spillage of the dye in the peritoneal cavity can be visualized through the laparoscope.
2. To perform chromopertubation, inject methylene blue dye diluted in NS solution into the uterine cavity using a 10ml syringe and observe the spillage of the dye into the peritoneal cavity, via the laparoscope. If the dye enters the peritoneal cavity through both the tubes, then the fallopian tubes are said to be patent but if the dye doesn’t pass through the any of the tubes, into the peritoneal cavity then that tube may be occluded.
3. At this point salpingoscopy can be performed, using a 2.8mm salpingoscope, to visualize the fallopian tubes for patency.
4. Once the tubal patency is established, proceed to the laparoscopic ovarian drilling.
LAPAROSCOPIC OVARIAN DRILLING:
1. Hold the right ovary with a non-traumatic grasper and stabilize it.
2. Then, using a tritome needle with monopolar current at 40W, drill the ovarian stroma at various places, especially targeting the cysts.
3. During drilling ‘rule of 4’s’ is applied i.e, 4 drills are made in each ovary with a contact time of the tritome to ovary being not more than 4 secs , the drills should be 4mm deep and 4mm wide and the current should not be more than 40W.
4. Similarly, drill the other ovary.
5. Then perform the peritoneal lavage and suction with NS.
6. Now remove the ports, reduce the pneumo-peritoneum and close the port sites.