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Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD

Gynecology / Sep 29th, 2018 5:28 pm A⁺ | a^-

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.

7 COMMENTS

Dr. Sumona Chakravarti

May 23rd, 2020 7:46 am

This is a very informative Task Analysis for Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD. Explained all the steps of surgery are very clearly PCOD Needle with perfect explanations on this Article. This is very interesting to learn thank you !

Dr. Nithu Rani

May 23rd, 2020 7:50 am

Awesome Article, very interesting and full of information and very Impressive Task
Analysis of Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD. Thanks for posting.

Dr. Manjushree

May 23rd, 2020 7:56 am

Dr. Mishra your explaining power is too good so easy to understand .. thank you so much sir .. you made our basic Laparoscopy surgery so easy. Thanks posting this Task Analysis of Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD.

Dr. Sandeep Varma

May 23rd, 2020 8:01 am

You're so Awesome sir .. so clear so easy to understand.. you have a great quality of teaching in Laparoscopy surgery. Thanks for posting this Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD.

Dr. Shalini Kulkarni

May 23rd, 2020 8:03 am

Very good Article with a clear and simple explanation! Thank you soo much. I understand all step of Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling.Thanks for sharing.

Dr. Lucy

May 23rd, 2020 10:12 am

Great article, he described very clearly. Put a lot of effort into this article. We greatly appreciate it. Thanks for posting Task Analysis of Laparoscopic Procedures.

Dr. Mohammed Syeda

May 23rd, 2020 10:17 am

Thank you. Your article is inspiring and precise. Keep up the noble work! Thanks for uploading Diagnostic Hystero-Laparoscopy with Bilateral Ovarian Drilling for PCOD article.

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How to Perform and Implement Task Analysis of Laparoscopic and Robotic Procedures

Task analysis is a critical component of any complex surgical procedure, including laparoscopic and robotic surgeries. It involves breaking down the procedure into its constituent tasks, identifying the steps, skills, and cognitive processes required. Task analysis not only enhances the understanding of these intricate surgeries but also serves as a foundation for training, skill assessment, and continuous improvement in healthcare. In this essay, we will delve into how to conduct and implement task analysis for laparoscopic and robotic procedures.

Understanding the Significance of Task Analysis

Before we explore the procedure for task analysis, it's essential to recognize why it is of paramount importance in the realm of surgery, particularly for laparoscopic and robotic procedures.

1. Enhanced Learning and Training: Task analysis helps in developing structured training programs. It breaks down complex procedures into manageable components, making it easier for trainees to learn and practice each step methodically.

2. Skill Assessment: By understanding the tasks and sub-tasks involved, it becomes possible to assess the competence of surgeons and surgical teams. This is crucial for ensuring patient safety and quality care.

3. Workflow Optimization: Task analysis can reveal inefficiencies in surgical workflows. Identifying these bottlenecks allows for process improvements, potentially reducing surgical times and enhancing outcomes.

4. Error Reduction: Recognizing potential points of error is vital for preventing surgical complications. Task analysis can highlight critical steps where errors are more likely to occur, leading to proactive measures to mitigate risks.

Procedure for Task Analysis of Laparoscopic and Robotic Procedures:

Task analysis for laparoscopic and robotic procedures involves several steps:

Step 1: Define the Surgical Procedure

Begin by clearly defining the surgical procedure you wish to analyze. Whether it's a laparoscopic cholecystectomy or a robotic prostatectomy, having a specific procedure in mind is essential.

Step 2: Gather Expert Input

Engage experts in the field, including experienced surgeons, nurses, and other surgical team members. Their input is invaluable in identifying and detailing the tasks involved.

Step 3: Identify the Tasks and Sub-Tasks

Break down the surgical procedure into tasks and sub-tasks. For instance, in a laparoscopic cholecystectomy, tasks could include trocar placement, camera insertion, gallbladder dissection, and suturing. Sub-tasks under "trocar placement" might involve choosing trocar sizes, making incisions, and inserting trocars.

Step 4: Sequence the Tasks

Establish the chronological order of tasks. Determine which tasks are dependent on others and identify any parallel processes. Sequencing tasks is essential for understanding the flow of the procedure.

Step 5: Define Task Goals and Objectives

For each task and sub-task, define the goals and objectives. What should be achieved in each step? For instance, in gallbladder dissection, the goal might be to safely detach the gallbladder from the liver while preserving nearby structures.

Step 6: Skill and Equipment Requirements

Specify the skills and equipment required for each task. Consider the level of expertise needed, such as basic laparoscopic skills or advanced robotic manipulation. Document the instruments and technology involved.

Step 7: Cognitive Processes

Identify the cognitive processes involved, such as decision-making, spatial orientation, and problem-solving. Understanding the mental aspects of surgery is critical for training and error prevention.

Step 8: Consider Variations and Complications

Acknowledge potential variations in the procedure and anticipate complications. How would the surgical team adapt if unexpected issues arise? Task analysis should encompass both the standard procedure and potential deviations.

Step 9: Develop Training and Assessment Tools

Use the task analysis results to create structured training modules. These modules should align with the identified tasks, objectives, and skill requirements. Additionally, design assessment tools to evaluate the competence of trainees and surgical teams.

Step 10: Continuous Improvement

Task analysis is not a one-time endeavor. Regularly revisit the analysis to incorporate new techniques, technology, and best practices. Continuous improvement is vital for staying at the forefront of surgical care.

Implementing Task Analysis Results:

Once task analysis is complete, it's crucial to implement the findings effectively:

1. Training Programs: Develop and deliver training programs based on the task analysis. These programs should encompass both simulation-based training and real-life surgical experience.

2. Skill Assessment: Use the assessment tools developed during task analysis to evaluate the skills of surgical teams. This can be done through structured evaluations and objective metrics.

3. Quality Improvement: Task analysis can reveal areas for process improvement. Work with the surgical team to implement changes that enhance efficiency and patient outcomes.

4. Error Prevention: Utilize the identified points of error to develop strategies for error prevention. This might involve checklists, preoperative briefings, and enhanced communication protocols.

5. Research and Innovation: Task analysis can also guide research efforts, leading to the development of new techniques and technologies that improve surgical procedures.

In conclusion, task analysis is an indispensable tool in understanding, teaching, and advancing complex surgical procedures such as laparoscopic and robotic surgeries. By meticulously dissecting each task and sub-task, identifying skill requirements, and considering cognitive processes, healthcare professionals can enhance patient safety, optimize surgical workflows, and continually improve the quality of surgical care. Task analysis is not merely an analytical exercise; it is a pathway to excellence in surgical practice.

Task Analysis of Laparoscopic and Robotic Procedures