LAPAROSCOPY DIAGNOSTIC & SALPINGECTOMY d r . A n o m S u a r d i k a S p O G (K) R S U P S a n g l a h D e n p a s a r / Fak. K e d o k t e r a n UNUD LAPAROSCOPY INDICATIONS
1. Infertility 2. Pelvic pain 3. Pelvic inflammatory disease 4. Suspected pelvic masses 5. ectopic pregnancy
• The evaluation of pelvic pain & infertility focuses on identification of endometriosis, adhesions, or tubal blockage • Laparoscopy~ way to acces • Complete screening
DIAGNOSTIC LAPAROSCOPY- HYSTEROSCOPY 1. Hysteroscopy Diagnostic • Evaluation of cervix • Evaluation of Uterine cavity (adhesion, polyp) • Evaluation of OTI 2. Laparoscopy Diagnostic • Evaluation of Uterus • Evaluation of Tube, tube patency test • Evaluation of Ovarium • Evaluation of structural adhesion, endometriosis foci • Evaluation of Perihepatic adhesion
WHEN WE DO SALPINGECTOMY?
• Total salpingectomy is required when a tubal pregnancy has ruptured and a substantial hemoperitoneum has occurred conservative operation should not be attempted • In case of hydrosalfing and non reconstructive tubal as a part of Diagnostic laparoscopy in infertility case. We do removal of fallopian tube before start the IVF procedure ECTOPIC PREGNANCY CASE TECHNIQUE 1 MESOSALPINGEAL INCISION
1. First, following abdominal entry, the affected fallopian tube is identified, and atraumatic forceps grasp, elevate, and extend the tube 2. Proximal portion of the fallopian tube is desiccated and transected 3. mesosalpinx under the fallopian tube is sequentially coagulated and transected until the fallopian tube is freed ECTOPIC PREGNANCY CASE
Techniques of laparoscopic salpingectomy using bipolar cautery and excision. ECTOPIC PREGNANCY CASE TECHNIQUE 2
A.Endoscopic l o o p l i g a t i o n B.Looped portion of tube excised Hydrosalpinx
Transvaginal sonogram of hydrosalpinx. Incompletesepta, which are folds of the dilated tube, are seen within this fusiform, fluid-filled structure. HYDROSALPINX CASE
A. The isthmic portion of the tube is coagulated and cut close to the uterus B. While the tube is under traction, the mesosalpinx is coagulated and cut. C. Sharpscissors (inset) or the ultra-pulse CO2 laser are used for cutting. D. The Endoloop is passed around the tube & the mesosalpinx is ligated with one suture. E. The mesosalpinx is cut above the tube. An adequate stump remains to prevent the ligature from slipping HYDROSALPINX CASE
(A) Salpingectomy is achieved with an automatic stapling device. The first application of thestapling device is to the proximal portion of the tube across the mesosalpinx. The tube is under traction. (B) The second application completes the salpingectomy (inset). A view of the mesosalpinx after the tube has been removed. HYDROSALPINX CASE Step by Step (DISTAL TO PROXIMAL APPROACH)
1. Grasp the fimbriated or distal end and elevate it toward the anterior abdominal wall. This provides the most separation from the ovary to delineate the mesosalpinx. 2. Use the Harmonic scalpel or scissor to ligate/cut as close as possible to the tubal lumen 3. Continue medially, staying as close to the body of the tube as possible 4. Continue all the way to the cornua of the uterus, where the tube is then transected HYDROSALPINX CASE
1. Elevating distal portion of tube to transect 3. Transecting tube at uterine cornua. mesosalpinx.
2. Transecting mesosalpinx in a proximal direction, staying close to body of the tube.
HYDROSALPINX CASE Step by Step (PROXIMAL TO DISTAL APPROACH)
1. In cases where the distal end is significantly damaged or scarred, it may be easier to approach the salpingectomy from proximal to distal. 2. Transect the tube near the cornua, then grasp and elevate the transected tube. Care should be taken as the mesosalpinx can be fragile and tear easily while elevating the tube, leading to bleeding 3. Dissect laterally along the tube, staying as close to the body of the tube as possible 4. As the ampulla is neared, regrasping and elevating at that point can provide more directed traction. Traction on the tube medially can assist in keeping the area of dissection away from ovarian vessels 5. Take care in the last 1 to 2 cm of the tube, as the mesosalpinx can merge with the IP ligament, particularly if the tube is scarred close to the ovary. Damage of ovarian vessels at this point can result in bleeding that is difficult to control without sacrificing the ovarian blood flow. HYDROSALPINX CASE Step by Step (PROXIMAL TO DISTAL APPROACH)
6. After the tube is removed, the mesosalpinx should be observed for bleeding. This can often be venous oozing, so lowering the intra- abdominal pressure can help tovisualize this. 7. Use pinpoint cautery either with monopolar or bipolar forceps to obtain full hemostasis. 8. In some settings, the distal aspect of the tube can be involved in dense adhesions to the ovary, bowel, uterus, or pelvic sidewall. Clearly finding a plane between the tube and other organs may be difficult to discern. 9. In these cases, use a medial to lateral approach to remove as much of the tube as possible. Open the remaining distal portion of the tube lengthwise, exposing the lumen. Excise the majority of the tubal structure that can be identified, leaving a small portion remaining. HYDROSALPINX CASE
1. Transecting tube at cornua for a proximal to 3. Traction medially on tube helps to clarify distal approach distal mesosalpinx and keep dissection away from ovarian vessels.
2. Elevating tube and transecting mesosalpinx close along body of tube.
PEARLS AND PITFALLS Excise the complete tube, do not leave a proximal or distal segment Keep the dissection plane as close to the tube as possible to limit ovarian collateral vessel damage Care should be taken to avoid the ovarian vessels at the distal end of the tube where the mesosalpinx join the Ip ligament
REFERENCE muon Ilmiah Berkolo IV ertilitas Endoktrin Reproduksi Indonesia Timur
dr. Anom Suardika, Sp.OG (K) Atas partisipasinya scbagai
PEMBICARA .: Worl(shop LaJ,·aroslcoJ,i Advance Aston HotelJayapura- RSUDJayapura, 6 Desember 2017 No. 606/1011 KTJPR I X 12017 Peserta16 SKP , Pembicara 8 SKP ,Panitia I Moderator 2 SKP
Ketua Panltla PRESIDEN of IGES lDKJA Endoskopy Glnekologl HIFERllndonesla Tlmur
_.,. Prof. Dr. dr. WACHYlJ HADISAPUTRA,SpOG (k) DR. dr. IRYAWANPERMADI, SpOG{k) marlaw .. , SpOG (KFER)
., ,