Laparoscopy is a difficult operation. What are the consequences after laparoscopy? What are the disadvantages of this operation

Laparoscopy is gaining popularity every year, and this method is preferred by doctors of different areas of medicine. Its implementation requires modern equipment that allows you to make accurate incisions and visually control the process in order to avoid erroneous actions of the surgeon.

This technique becomes safe only in the hands of professionals. They should not only know what laparoscopy is, but also have extensive experience in operating in this way. Learning this technique requires a lot of time and diligence. Most often, laparoscopy is used by gynecologists, but it has also found wide application in other areas of medicine.

Areas of use

Laparoscopy is a minimally invasive method for diagnosing and surgical treatment. In the process of its implementation, all surgical manipulations are performed through a small (about 10-15 mm) opening in the abdominal cavity using special tools. And to visualize what is happening during the procedure allows the laparoscope, which is equipped with a video system.

Most often, laparoscopy is resorted to when performing such operations:

removal of the gallbladder or stones in it;
ovarian cystectomy;
myectomy;
operations on the small and large intestines;
appendectomy;
resection of the stomach;
removal of the umbilical cord and inguinal hernia;
liver cystectomy;
resection of the pancreas;
adrenalectomy;
elimination of obstruction of the fallopian tubes;
elimination of varicose veins of the spermatic cord;
surgical methods obesity treatment.

With the help of the laparoscopic method, it is possible to perform all traditional operations and at the same time maintain the integrity of tissues. abdominal wall. In addition, laparoscopy is also used for diagnostic purposes in such cases: serious damage to the abdominal organs with irritation of the peritoneum, pathologies of the hepatobiliary system, pathologies of internal organs caused by injuries.

The list is continued by the outpouring of blood into the body cavity, ascites of the abdominal cavity, purulent inflammation of the peritoneum, neoplasms in the internal organs. Laparoscopy is performed both in a planned manner and in emergency cases. Hydrosalpinx is a pathology of the fallopian tubes caused by the accumulation of transudate in their lumen.

Laparoscopy is an operation, so the risk serious complications inevitable

Gynecological practice

In gynecology, a combination of hysteroscopy and laparoscopy often occurs when it is necessary to make an accurate diagnosis and immediately implement a number of therapeutic actions. So, hysteroscopy allows you to diagnose, take material for histological analysis, or immediately eliminate minor defects in the uterus (septa or polyps). And laparoscopy, unlike the first procedure, allows you to remove even tumors. It can completely replace abdominal surgery.

These diagnostic manipulations are indispensable when a woman is examined for infertility. If during hysterosalpinography obstruction of the fallopian tubes was confirmed, then, according to indications, under general anesthesia, laparoscopy of the hydrosalpinx is done. After its removal, the chances of successfully getting pregnant increase to 40-70%. If the removal of the tube was required, then the woman can resort to IVF.

Contraindications

With all its advantages, laparoscopy has a number of absolute and relative contraindications. It is absolutely impossible to perform such a procedure in such cases:

acute blood loss;
proliferation of connective tissue strands in the peritoneum;
purulent cavities on the walls of the peritoneum;
pain in the abdomen and severe flatulence;
incisional hernia at the site of the scar;
severe cardiovascular pathologies;
brain damage;
hepatic and kidney failure;
pronounced pathologies respiratory system;
malignant formations appendages.

In addition, there are a number of other restrictions:

carrying a child for up to 16 weeks;
benign tumor from large muscle tissue;
suspicion of oncopathology of the pelvic organs;
acute respiratory infection in acute stage;
an allergic reaction to anesthetics or other drugs.

In such cases, laparoscopy is not completely ruled out, but they are looking for best options for each individual patient.

Preparing for the operation

If emergency laparoscopy is recommended, preparation is limited to cleansing the gastrointestinal tract with an enema and emptying the bladder. The most necessary analyzes are given - clinical analysis blood and urine, RW, check the heart on an electrocardiogram and evaluate blood clotting on a coagulogram.

Preparation for the planned diagnostics is carried out in more detail and for a long time. Within 3-4 weeks, the patient is carefully examined. It all starts with the collection of anamnesis, since the success of the operation largely depends on it. The doctor must find out such nuances: the presence of injuries, injuries or previous operations, chronic diseases and medications accepted on an ongoing basis, allergic reactions for medicines.

Then consultation with specialists of a narrow profile (cardiologist, gynecologist, gastroenterologist) is recommended. In addition, all necessary laboratory research and, if necessary, additional diagnostic procedures(ultrasound, MRI).

The success of the operation depends on compliance with the following rules:

3-5 days before the operation, it is forbidden to drink alcohol;
within 5 days, take drugs that reduce gas formation;
just before the operation, clean the intestines with enemas;
on the day of laparoscopy, take a shower and shave the hair in the necessary places;
no later than 8 hours before the operation, you should refrain from eating;
release bladder 60 minutes before laparoscopy.

If there is a need to perform an emergency laparoscopy, then menstruation is not a contraindication for this. If the operation is planned, then it can be carried out starting from the 6th day of the cycle.

As a rule, laparoscopy takes from 30 minutes to 1.5 hours

Performing laparoscopy

In connection with the planned operation, patients are often worried about how the laparoscopy goes, under what anesthesia and how long the sutures heal. Performing a laparoscopy includes the following steps. The imposition of pneumoperitoneum - for these purposes, a Veress needle is used. Manipulation involves injecting carbon dioxide into the abdominal cavity to improve visualization and instrument movement.

The introduction of tubes: when the required amount of gas is injected into the peritoneum, the Veress needle is removed, and hollow tubes (tubes) are inserted into the existing puncture sites. Trocar insertion: As a rule, 4 trocars are inserted during therapeutic laparoscopy, the first one being blind. They are necessary for the further introduction of special instruments (preparation probes, spatulas, clamps, aspirators-irrigators).

Visual inspection of the abdominal cavity is carried out using a laparoscope. The image is transmitted from the camera to the control unit, and from it the video is displayed on the monitor screen. After examining the insides, specialists decide on further treatment tactics. In the process, biomaterial can be taken for further research. At the end of the operation, the tubes are removed, gas is removed from the peritoneum and sutured subcutaneous tissue channel.

Diagnostic laparoscopy is performed under local anesthesia, medical - under general anesthesia. In many cases, doctors prefer spinal anesthesia because it does not require the patient to be put into a medical sleep and does not cause significant harm to the body.

Recovery period

Postoperative period, as a rule, passes quickly and without pronounced complications. After a few hours, you can and even need to move. You can drink and eat in the usual amount only in a day. The discharge from the surgery department takes place the next day. It hurts in the lower abdomen, as a rule, only the first 2-3 hours after the manipulation.

In some patients, the temperature rises slightly (37.0-37.5 ° C). If the operation was performed on the gynecological part, then within 1-2 days bloody issues. On the first day, patients may experience indigestion, and on subsequent days with a violation of the stool (diarrhea or constipation).

In the photo you can see postoperative scars

Patients who were examined in this way due to the inability to have children, may try to become pregnant as early as a month after the procedure. If a benign tumor was removed in the process, then you can try to conceive a child only after six months. Removal of sutures after laparoscopy is carried out after 7-10 days. The attending physician decides. If the seam does not heal for a long time, then the period may increase to one month, and throughout this time they should be properly looked after.

Content

The laparoscopy operation has recently become widely practiced among gynecologists involved in surgery, so many women are afraid when they are prescribed such an operative study, they do not understand what it means, fearing pain and serious complications. However, laparoscopy in gynecology is considered one of the most sparing methods of surgical intervention, it has a minimum of unpleasant consequences and complications after use.

What is laparoscopy in gynecology

The method that causes the least amount of trauma, damage during diagnosis or operation, with the smallest number of invasive penetrations - this is what laparoscopy of the uterus and ovaries in gynecology is. To get to the female genital organs without making an extensive incision, three or four punctures are made in the abdominal wall, after which special instruments called laparoscopes are inserted into them. These instruments are equipped with sensors and illumination, and the gynecologist "with his own eyes" evaluates the process taking place inside, coupled with the diagnosis of genital female organs.

Indications

Laparoscopy is widely used, since it is considered in gynecology to be the most convenient way of simultaneous diagnosis and surgical intervention for the treatment of pathological processes of unclear etiology. Gynecologists assess "live" the condition of the female genital organs, if other research methods have not been effective for an accurate diagnosis. Laparoscopy is used for such gynecological pathologies:

if a woman has infertility, the exact cause of which gynecologists cannot identify;
when gynecological therapy with hormonal drugs was ineffective for conceiving a child;
if you need to perform operations on the ovaries;
with endometriosis of the cervix, adhesions;
with constant pain in the lower abdomen;
with suspicion of myoma or fibroma;
for tying the tubes of the uterus;
with ectopic pregnancy, tubal rupture, breakthrough bleeding and other dangerous pathological processes in gynecology, when an emergency intracavitary gynecological operation is necessary;
when twisting the legs of an ovarian cyst;
with severe dysmenorrhea;
with infections of the genital organs, accompanied by the release of pus.

On what day of the cycle do

Many women do not attach importance to what day menstrual cycle an operation is scheduled, and they are surprised by the questions of the gynecologist inquiring about when the last menstruation was. However, preparation for laparoscopy in gynecology begins with clarifying this issue, since the effectiveness of the procedure itself will directly depend on the day of the cycle at the time of the operation. If a woman is menstruating, there is a high probability of infection in the upper layers of the uterine tissue, in addition, there is a risk of provoking internal bleeding.

Gynecologists recommend doing laparoscopy immediately after ovulation, in the middle monthly cycle. With a 30-day cycle, this will be the fifteenth day from the start of menstruation, with a shorter one, the tenth or twelfth. Such indications are due to the fact that after ovulation, the gynecologist can see what reasons prevent the egg from leaving the ovary for fertilization, we are talking about the diagnosis of infertility.

Training

In gynecology, laparoscopy can be scheduled or performed urgently. In the latter case, there will be practically no preparation, because gynecologists will strive to save the patient's life, and this situation does not imply a long collection of tests. Immediately before the operation, blood and urine are taken from the patient, if possible, and studies are carried out after the fact, after laparoscopy. When carrying out laparoscopy in a planned manner, preparation includes collecting data on the current state of the patient and restricting the diet.

Analyzes

Patients are surprised at the extensive list of necessary tests before laparoscopy, however, before any abdominal gynecological surgery, the following studies must be done:

take a KLA, as well as conduct blood tests for sexually transmitted diseases, syphilis, AIDS, hepatitis, ALT, AST, the presence of bilirubin, glucose, assess the degree of blood clotting, establish a blood group and Rh factor;
pass OAM;
make a general smear from the walls of the cervix;
conduct an ultrasound of the pelvic organs, make a fluorogram;
provide the gynecologist with an extract on the presence of chronic ailments, if any, notify about the constantly taken medications;
make a cardiogram.

When the gynecologist receives all the results of the research, he checks the possibility of carrying out laparoscopy on a predetermined day, specifying the scope of the future gynecological operation or diagnostic examination. If the gynecologist gives the go-ahead, then the anesthesiologist talks to the patient, finding out if she has an allergy to narcotic drugs or contraindications to general anesthesia during the procedure.

Diet before laparoscopy in gynecology

In gynecology, there are the following dietary rules before laparoscopy:

7 days before laparoscopy, you should refrain from any products that stimulate gas formation in the stomach and intestines - legumes, milk, certain vegetables and fruits. Reception of low-fat meat, boiled eggs, porridge, sour-milk products is shown.
For 5 days, the gynecologist prescribes the intake of enzymatic agents, activated carbon to normalize digestion.
On the eve of the procedure, you can only eat pureed soups or liquid cereals, you can’t have dinner. It is necessary to do a cleansing enema in the evening, if the gynecologist has prescribed it.
Immediately before laparoscopy, you can not eat or drink anything so that the bladder is empty

Does it hurt to do

Women who are afraid of pain often ask gynecologists if they will be in pain during a laparoscopy. However, in gynecology, this method is considered the most painless and fastest invasion. Laparoscopy is done under general anesthesia, so you will just fall asleep and not feel anything. Before the operation, for the most emotional patients, gynecologists prescribe sedatives and painkillers, conduct preliminary conversations, telling what gynecological procedures will be performed.

How do they do

Laparoscopy begins with general intravenous anesthesia. Then the gynecologists treat the entire abdomen with antiseptic solutions, after which incisions are made on the skin in the navel and around it, into which trocars are inserted, which serve to inject carbon dioxide into the abdominal cavity. Trocars are equipped with video cameras for visual control, allowing the gynecologist to see the state of the internal organs on the monitor screen. After the manipulations, gynecologists suture small sizes.

Recovery after laparoscopy

Some gynecologists prefer that the patient regain consciousness after laparoscopy right on the operating table. So you can check general state patient and prevent complications. However, in most cases, the patient is transferred to a stretcher and taken to the ward.

Gynecologists suggest getting out of bed as early as 3-4 hours after laparoscopy so that the woman walks to stimulate blood circulation. The patient is observed for another 2-3 days, after which he is discharged home for further rehabilitation. You can return to work in about a week, but physical activity should be limited.

Food

Immediately after the operation, the patient is not allowed to eat anything - you can only drink clean water without gas. On the second day, it is allowed to drink low-fat broths and unsweetened tea. And only on the third day is it allowed to take mashed potatoes, porridge, mashed meatballs or meatballs, meat puree, yogurt. Since the intestines are very close to the genitals, the most sparing diet is needed during healing, which will not contribute to gas formation, increased peristalsis.

sexual rest

Depending on the purpose for which the gynecologists performed the intervention, the doctor will determine the period of absolute sexual abstinence. If laparoscopy was performed to remove adhesions to conceive a baby, then gynecologists recommend starting sexual life as early as possible to increase the likelihood of becoming pregnant, because after a couple of months the fallopian tubes can again become impassable. In all other cases, gynecologists may prohibit having sex for 2-3 weeks.

Contraindications

Laparoscopy has few contraindications. These include:

intensive process of dying of the body - agony, coma, state clinical death;
peritonitis and other serious inflammatory processes in the body;
sudden cardiac arrest or respiratory failure;
severe obesity;
hernia;
the last trimester of pregnancy with a threat to the mother and fetus;
hemolytic chronic diseases;
exacerbation of chronic diseases of the gastrointestinal tract;
the course of SARS and colds. You will have to wait for a full recovery.

Effects

Given the low invasiveness of the gynecological procedure, the consequences of laparoscopy, if performed correctly, are small and include the body's response to general anesthesia and the individual's ability to restore previous functions. The entire system of the female genital organs still works, since penetration into the abdominal cavity is as gentle as possible and does not injure them. The scheme of laparoscopy can be seen in the photo.

Complications

As with any penetration into the abdominal cavity, there are complications with laparoscopy. For example, after punctures, when a laparoscope is inserted, blood vessels may burst and a small hemorrhage may begin, and carbon dioxide in the abdominal cavity may enter the tissues and contribute to subcutaneous emphysema. If the vessels are not sufficiently clamped, then blood can enter the abdominal cavity. However, the professionalism of the gynecologist and a thorough revision of the abdominal cavity after the procedure will reduce the likelihood of such complications to zero.

Price

Since laparoscopy is an intervention under general anesthesia, the cost of this gynecological procedure is high. The breakdown of prices in Moscow is shown in the following table:

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Attention! The information provided in the article is for informational purposes only. The materials of the article do not call for self-treatment. Only a qualified doctor can make a diagnosis and make recommendations for treatment, based on individual characteristics specific patient.

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Laparoscopy - Examination of the abdominal organs using an endoscope inserted through the anterior abdominal wall. Laparoscopy - one of the endoscopic methods used in gynecology.

The method of optical examination of the abdominal cavity (ventroscopy) was first proposed in 1901 in Russia by gynecologist D.O. Ottom. Subsequently, domestic and foreign scientists developed and introduced laparoscopy for the diagnosis and treatment of various diseases of the abdominal cavity. For the first time, a laparoscopic gynecological operation was performed in 1944 by R. Palmer.

SYNONYMS OF LAPAROSCOPY

Peritoneoscopy, ventroscopy.

RATIONALE FOR LAPAROSCOPY

Laparoscopy provides a significant best review organs of the abdominal cavity in comparison with the incision of the anterior abdominal wall, due to the optical magnification of the examined organs several times, and also allows you to visualize all floors of the abdominal cavity and the retroperitoneal space, and, if necessary, perform surgery.

PURPOSE OF LAPAROSCOPY

Modern laparoscopy is considered a method of diagnosing and treating almost all gynecological diseases, it also allows differential diagnosis between surgical and gynecological pathology.

INDICATIONS FOR LAPAROSCOPY

Currently, the following indications for laparoscopy have been tested and put into practice.

Planned readings:

tumors and tumor-like formations of the ovaries;
genital endometriosis;
malformations of the internal genital organs;
pain in the lower abdomen of unknown etiology;
creation of artificial obstruction of the fallopian tubes.

Indications for emergency laparoscopy:

ectopic pregnancy;
ovarian apoplexy;
PID;
suspicion of torsion of the leg or rupture of a tumor-like formation or ovarian tumor, as well as torsion of subserous fibroids;
differential diagnosis between acute surgical and gynecological pathology.

CONTRAINDICATIONS OF LAPAROSCOPY

Contraindications to laparoscopy and laparoscopic operations depend on many factors and, first of all, on the level of training and experience of the surgeon, the equipment of the operating room with endoscopic, general surgical equipment and instruments. There are absolute and relative contraindications.

Absolute contraindications:

hemorrhagic shock;
diseases of the cardiovascular and respiratory systems in the stage of decompensation;
uncorrectable coagulopathy;
diseases in which it is unacceptable to place the patient in the Trendelenburg position (consequences of brain injury, damage to cerebral vessels, etc.);
acute and chronic liver failure;
ovarian cancer and RMT (with the exception of laparoscopic monitoring during chemotherapy or radiation therapy).

Relative contraindications:

polyvalent allergy;
diffuse peritonitis;
pronounced adhesive process after previous operations on the organs of the abdominal cavity and small pelvis;
late pregnancy (more than 16-18 weeks);
suspicion of a malignant nature of the formation of uterine appendages.

Also, contraindications to the implementation of planned laparoscopic interventions are:

existing or transferred less than 4 weeks ago acute infectious and catarrhal diseases;
degree III-IV of the purity of the vaginal contents;
inadequate examination and treatment of a married couple by the time of the proposed endoscopic examination planned for infertility.

PREPARATION FOR LAPAROSCOPIC EXAMINATION

The general examination before laparoscopy is the same as before any other gynecological surgery. When taking an anamnesis, it is necessary to pay attention to diseases that may be a contraindication to laparoscopy (cardiovascular, pulmonary pathology, traumatic and vascular diseases brain, etc.).

Great importance before laparoscopic intervention should be given to a conversation with the patient about the upcoming intervention, its features, and possible complications. The patient should be informed about the possible transition to abdominal surgery, about the possible expansion of the scope of the operation. The woman's written informed consent for the operation must be obtained.

All of the above is due to the fact that among patients and doctors of non-surgical specialties there is an opinion about endoscopy as a simple, safe and small operation. In this regard, women tend to underestimate the complexity of endoscopic examinations, which have the same potential risk as any other surgical intervention.

With a planned laparoscopy on the eve of the operation, the patient limits her diet to the intake of liquid food. A cleansing enema is prescribed in the evening before the operation. Drug preparation depends on the nature of the underlying disease and the planned operation, as well as on concomitant extragenital pathology. METHODOLOGY

Laparoscopic interventions are carried out in a limited closed space - the abdominal cavity. For the introduction of special instruments into this space and the possibility of adequate visualization of all organs of the abdominal cavity and small pelvis, it is necessary to expand the volume of this space. This is achieved either by creating a pneumoperitoneum or by mechanically lifting the anterior abdominal wall.

To create a pneumoperitoneum, gas (carbon dioxide, nitrous oxide, helium, argon) is injected into the abdominal cavity, which raises the abdominal wall. Gas is administered by direct puncture of the anterior abdominal wall with a Veress needle, direct puncture with a trocar, or open laparoscopy.

The main requirement for gas insufflated into the abdominal cavity is safety for the patient. The main conditions that ensure this requirement are:

absolute non-toxicity of gas;
active absorption of gas by tissues;
no irritating effect on tissues;
inability to embolize.

All of the above conditions correspond to carbon dioxide and nitrous oxide. These chemical compounds are easily and quickly resorbed, unlike oxygen and air, they do not cause pain or discomfort in patients (on the contrary, nitrous oxide has an analgesic effect) and do not form emboli (for example, carbon dioxide, having penetrated into the bloodstream, actively combines with hemoglobin ). In addition, carbon dioxide, acting in a certain way on the respiratory center, increases the vital capacity of the lungs and, therefore, reduces the risk of secondary complications from the respiratory system. It is not recommended to use oxygen or air to apply pneumoperitoneum!

The Veress needle consists of a blunt, spring-loaded stylet and a sharp external needle (Fig. 7–62). The pressure applied to the needle leads as it passes through the layers of the abdominal wall to immerse the stylet inside the needle, allowing the latter to pierce the tissue (Fig. 7–63). After the needle passes through the peritoneum, the tip pops out and protects the internal organs from injury. Gas enters the abdominal cavity through an opening along the lateral surface of the tip.

Rice. 7-62. Veress needle.

Rice. 7-63. The stage of conducting the Veress needle.

Along with the convenience in carrying out laparoscopy, pneumoperitoneum has a number of important disadvantages and side effects that increase the risk possible complications at laparoscopy:

compression of the venous vessels of the retroperitoneal space with impaired blood supply lower extremities and a tendency to thrombosis;
violations of arterial blood flow in the abdominal cavity;
disorders of cardiac activity: a decrease in cardiac output and cardiac index, the development of arrhythmia;
compression of the diaphragm with a decrease in the residual capacity of the lungs, an increase in dead space and the development of hypercapnia;
rotation of the heart.

Immediate complications of pneumoperitoneum:

pneumothorax;
pneumomediastinum;
pneumopericardium;
subcutaneous emphysema;
gas embolism.

The choice of the puncture site of the abdominal wall depends on the height and complexion of the patient, as well as on the nature of previous operations. Most often, the place for the introduction of the Veress needle and the first trocar is chosen at the navel - the point of the shortest access to the abdominal cavity. The other most commonly used point for the insertion of the Veress needle in gynecology is the area 3-4 cm below the edge of the left costal arch along the midclavicular line. The introduction of the Veress needle is, in principle, possible anywhere on the anterior abdominal wall, but it is necessary to remember the topography of the epigastric artery. In the presence of previous operations on the abdominal organs, a point is chosen for the primary puncture, as far as possible from the scar.

It is possible to insert a Veress needle through the posterior fornix of the vagina if there are no pathological formations in the retrouterine space.

At the time of puncture of the anterior abdominal wall with a Veress needle or the first trocar, the patient should be on the operating table in a horizontal position. After skin incision, the abdominal wall is lifted with a hand, claw or ligature (to increase the distance between the abdominal wall and abdominal organs) and a Veress needle or trocar is inserted into the abdominal cavity at an angle of 45–60°. The correctness of the introduction of the Veress needle into the abdominal cavity is checked in various ways (drip test, syringe test, hardware test).

Some surgeons prefer direct abdominal puncture with a 10 mm trocar without the use of a Veress needle, which is considered a more dangerous approach (Fig. 7–64). Damage to internal organs is possible both with a Veress needle and with a trocar, however, the nature of the damage, given the diameter of the instrument, varies in severity.

Rice. 7-64. Direct introduction of the central trocar.

The technique of open laparoscopy is indicated for the risk of damage to internal organs during adhesive processes in the abdominal cavity due to previous operations and unsuccessful attempts to insert a Veress needle or trocar. The essence of open laparoscopy is the introduction of the first trocar for optics through the minilaparotomic opening. AT last years to prevent damage to the abdominal organs when entering the abdominal cavity during the adhesive process, a Veress optical needle or a video trocar is used (Fig. 7–65).

Rice. 7-65. Veress optical needle.

After puncture of the anterior abdominal wall with a Veress needle or trocar, gas insufflation begins, first slowly at a rate of not more than 1.5 l/min. With the correct position of the needle after the introduction of 500 ml of gas, hepatic dullness disappears, the abdominal wall rises evenly. Usually 2.5-3 liters of gas are injected. Patients with obesity or a large physique may need more gas (up to 8-10 liters). At the time of insertion of the first trocar, the pressure in the abdominal cavity should be 15–18 mm Hg, and during the operation it is sufficient to maintain the pressure at the level of 10–12 mm Hg.

Mechanical lifting of the abdominal wall (laparolifting) - gas-free laparoscopy. The anterior abdominal wall is raised using various devices. This method is indicated for patients with cardiovascular insufficiency, ischemic disease hearts and arterial hypertension stages II–III, a history of myocardial infarction, heart defects, after heart surgery.

Gas-free laparoscopy also has a number of disadvantages: the space for performing the operation may be insufficient and inadequate for convenient operation, it is quite difficult to perform the operation in obese patients in this case.

Chromosalpingoscopy. In all laparoscopic operations for infertility, it is mandatory to perform chromosalpingoscopy, which consists in the introduction of methylene blue through a special cannula inserted into the cervical canal and uterine cavity. In the process of introducing a dye, the process of filling the fallopian tube and the flow of blue into the abdominal cavity are analyzed. The cervix is exposed in mirrors and fixed with bullet forceps. A special uterine probe designed by Cohen with a cone-shaped limiter is inserted into the cervical canal and the uterine cavity, which is fixed to the bullet forceps.

The location of the cannula depends on the position of the uterus, the inclination of the cannula nose should coincide with the inclination of the uterine cavity. A syringe with methylene blue is connected to the distal end of the cannula. Under pressure, blue is injected into the uterine cavity through a cannula, and laparoscopy evaluates the flow of methylene blue into the fallopian tubes and abdominal cavity.

INTERPRETATION OF LAPAROSCOPY RESULTS

The laparoscope is inserted into the abdominal cavity through the first trocar. First of all, the area located under the first trocar is examined to exclude any damage. Then, first, the upper sections of the abdominal cavity are examined, paying attention to the condition of the diaphragm, and the condition of the stomach is assessed. In the future, all parts of the abdominal cavity are examined step by step, paying attention to the presence of effusion, pathological formations and the prevalence of the adhesive process. For a thorough revision of the abdominal cavity and small pelvis, as well as for performing any operations, it is necessary to introduce additional trocars with a diameter of 5 mm or 7 mm under visual control. The second and third trocars are inserted in the iliac regions. If necessary, the fourth trocar is installed along the midline of the abdomen at a distance of 2/3 from the navel to the womb, but not lower than horizontal line connecting the lateral trocars. For examination of the pelvic organs and their adequate assessment, the patient is placed in the Trendelenburg position.

COMPLICATIONS OF LAPAROSCOPY

Laparoscopy, like any type of surgical intervention, can be accompanied by unforeseen complications that threaten not only the health, but also the life of the patient.

Specific complications characteristic of laparoscopic access are:

extraperitoneal gas insufflation;
damage to the vessels of the anterior abdominal wall;
damage to the digestive tract;
gas embolism;
damage to the main retroperitoneal vessels.

Extraperitoneal insufflation is associated with the introduction of gas into tissues other than the abdominal cavity. This can be a subcutaneous fat layer (subcutaneous emphysema), preperitoneal air injection, air entering the tissue of the greater omentum or mesentery (pneumomentum), as well as mediastinal emphysema (pneumomediastinum) and pneumothorax. Such complications are possible with incorrect insertion of the Veress needle, frequent removal of trocars from the abdominal cavity, defects or damage to the diaphragm. The patient's life is threatened by pneumomediastinum and pneumothorax.

The clinical picture of the injury of the main retroperitoneal vessels is associated with the occurrence of massive intra-abdominal bleeding and the growth of hematoma of the root of the mesentery of the intestine. In such a situation, an emergency median laparotomy and the involvement of vascular surgeons in the operation are necessary.

Damage to the vessels of the anterior abdominal wall most often occurs with the introduction of additional trocars. The reason for the occurrence of such injuries is considered to be the wrong choice of the point and direction of trocar insertion, anomalies in the location of the vessels of the abdominal wall and (or) their varicose veins. In the event of such complications, therapeutic measures include pressing the vessel or stitching it in various ways.

Damage to the gastrointestinal tract is possible with the introduction of a Veress needle, trocars, dissection of adhesions, or careless manipulation of instruments in the abdominal cavity. Of the organs of the abdominal cavity, the intestines are most often damaged, damage to the stomach and liver is rarely observed. More often, the injury occurs when there is an adhesive process in the abdominal cavity. Often, such lesions remain unrecognized during laparoscopy and manifest themselves later as diffuse peritonitis, sepsis, or the formation of intra-abdominal abscesses. In this regard, electrosurgical injuries are the most dangerous. Perforation in the burn area occurs delayed (5–15 days after surgery).

If damage to the gastrointestinal tract is detected, suturing of the damaged area by laparotomy is indicated, or by laparoscopy by a qualified endoscopist surgeon.

Gas embolism is a rare but extremely serious complication of laparoscopy, which is observed with a frequency of 1-2 cases per 10,000 operations. It occurs during direct puncture with a Veress needle of one or another vessel, followed by the introduction of gas directly into the vascular bed or when a vein is injured against the background of a tense pneumoperitoneum, when gas enters the vascular bed through a gaping defect. Currently, cases of gas embolism are more often associated with the use of a laser, the tip of which is cooled by a gas flow that can penetrate into the lumen of the crossed vessels. The occurrence of a gas embolism is manifested by sudden hypotension, cyanosis, cardiac arrhythmia, hypoxia, resembles clinical picture myocardial infarction and thromboembolism pulmonary artery. Often this condition leads to death.

Damage to the main retroperitoneal vessels is one of the most dangerous complications which may pose an immediate threat to the life of the patient. The most common injury main vessels occurs at the stage of access to the abdominal cavity with the introduction of the Veress needle or the first trocar. The main reasons for this complication are inadequate pneumoperitoneum, perpendicular insertion of the Veress needle and trocars, and excessive muscle effort by the surgeon when inserting the trocar.

To prevent complications during laparoscopy:

careful selection of patients for laparoscopic surgery is necessary, taking into account absolute and relative contraindications;
the experience of the endoscopist surgeon must correspond to the complexity of the surgical intervention;
the operating gynecologist must critically evaluate the possibilities of laparoscopic access, understanding the limits of resolution and limitations of the method;
full visualization of operated objects and sufficient space in the abdominal cavity are required;
only serviceable endosurgical instruments and equipment should be used;
adequate anesthetic support is needed;
a differentiated approach to methods of hemostasis is needed;
the speed of the surgeon's work should correspond to the nature of the stage of the operation: the rapid implementation of routine techniques, but the careful and slow implementation of responsible manipulations;
with technical difficulties, serious intraoperative complications and unclear anatomy, an immediate laparotomy should be performed.

Laparoscopy in gynecology is a minimally invasive, without a layer-by-layer incision of the anterior abdominal wall, an operation performed using special optical equipment for examining the uterus and ovaries. Such diagnostics are carried out for the purpose of visual analysis of the state of the reproductive organs and targeted treatment of pathologies.

Laparoscopy in gynecology is a method that causes the least amount of trauma, damage during diagnosis or surgery, with the smallest number of internal penetrations.

In one laparoscopic session, the doctor:

performs diagnostics of gynecological diseases;
clarifies the diagnosis;
provides the necessary treatment.

The study allows the doctor to examine in detail the internal reproductive organs through a mini camera. In order to perform medical manipulations in a timely manner, special instruments are introduced into the abdominal cavity along with the camera.

In what cases is it carried out and for what?

Laparoscopy in gynecology is used to diagnose and solve problems in the field of female diseases.

This low-traumatic method allows surgeons to:

remove affected areas, adhesions or organs;
perform a tissue biopsy;
perform ligation, resection or plastic tubing;
put stitches on the uterus, etc.

Indications for carrying out

The operation finds its application in the following indications:

severe pain of unclear etiology in the lower abdomen;
suspected ectopic pregnancy;
inefficiency hormone therapy with infertility;
myomatous lesion of the uterus;
clarification of the causes of infertility;
surgical treatment of endometriosis, fibroids, etc.;
preparation for IVF;
biopsy of affected tissue.

Contraindications for laparoscopy

Before the operation, the gynecologist should carefully study the patient's medical record, as there are a number of contraindications to laparoscopy of the uterus (including the cervix) and appendages.

Absolute contraindications

It is forbidden to do laparoscopy for patients with such a pathology as:

acute infections of the reproductive organs;
diseases of the heart, blood vessels, lungs (severe forms);
blood clotting disorder;
acute disorders of the liver or kidneys;
significant depletion of the body;
bronchial asthma;
hypertension;
hernia of the white line of the abdomen and anterior abdominal wall;
coma;
shock state.

Patients who have had ARVI are allowed a month after recovery.

Relative contraindications

The attending physician analyzes the risks and decides whether it is advisable to perform laparoscopy in patients with these diagnoses:

abdominal operations in a six-month history;
extreme obesity;
pregnancy for a period of 16 weeks;
tumors of the uterus and appendages;
a large number of adhesions in the pelvis.

Operation types

There are two types of laparoscopy in gynecology: planned and emergency. Planned is carried out both for the purpose of research and for the treatment of pathologies. Diagnostic surgery often turns into a therapeutic one. An emergency operation is performed if there is a threat to the patient's life for an unexplained reason.

planned diagnostic laparoscopy carried out for the following purposes:

clarification of such diagnoses as "obstruction of the fallopian tubes", "endometriosis", "adhesive disease" and other causes of infertility;
determination of the presence of tumor-like neoplasms in the small pelvis to determine the stage and the possibility of treatment;
collection of information about anomalies in the structure of the reproductive organs;
finding out the causes of chronic pelvic pain;
biopsy for polycystic ovary syndrome;
tracking the effectiveness of treatment of inflammatory processes;
control over the integrity of the uterine wall during resectoscopy.

Planned therapeutic laparoscopy is carried out for:

surgery of the pelvic organs in the presence of endometriosis, cysts, tumors, sclerocystosis, fibroids;
performing temporary or complete sterilization (tubal ligation);
treatment of uterine cancer;
removal of adhesions in the pelvis;
resection of the reproductive organs.

Emergency therapeutic laparoscopy is performed when:

interrupted or progressing tubal pregnancy;
apoplexy or rupture of an ovarian cyst;
necrosis of the myomatous node;
acute pain syndrome in the lower abdomen of unclear etiology.

Laparoscopy and the menstrual cycle

The menstrual cycle after laparoscopy has a number of features:

The regularity of menstruation after laparoscopy is restored within two to three cycles. Under the condition of successful treatment of endometriosis, uterine fibroids and polycystic ovaries, the disturbed menstrual cycle is leveled and, as a result, the reproductive function is restored.
Normally, menstrual flow should first appear in the next day or two after surgery and last about four days. This is due to a violation of the integrity of the internal organs and is the norm, even if the discharge is quite a lot.
The next cycle may shift, the discharge may become unusually scarce or plentiful for a while.
A delay of up to three weeks is considered acceptable, more than a probable pathology.
If menstruation is accompanied severe pain, an urgent consultation with a gynecologist is necessary to prevent postoperative complications. Also, the brown or green color of the discharge and an unpleasant odor should alert - these are signs of inflammation.

How to prepare for surgery

Preparing for gynecological laparoscopy includes several stages. First, a consultation with a therapist is required in order to identify contraindications.

Then research is carried out:

blood ( general analysis, coagulogram, biochemistry, HIV, syphilis, hepatitis, Rh factor and blood type);
urine (general);
pelvic organs through ultrasound, taking a smear for flora and cytology;
cardiovascular system (ECG);
respiratory system (fluorography).

Here is how to prepare the patient before the operation:

eat at least 8-10 hours before;
no later than 3 hours, it is allowed to drink a glass of non-carbonated water;
exclude nuts, seeds, legumes from the diet for 2 days;
cleanse the intestines in the evening and in the morning with laxatives or enemas.

In emergency laparoscopy, preparation is limited to:

examination by a surgeon and an anesthesiologist;
urine (general) and blood tests (general, coagulogram, blood type, Rh, HIV, hepatitis, syphilis);
refusal of food and liquid intake for 2 hours;
bowel cleansing.

A planned operation is prescribed after the 7th day of the menstrual cycle, since in the first days there is increased bleeding of the tissues of the reproductive organs. Urgent laparoscopy is performed on any day of the cycle.

Ter-Ovakimyan A.E., Doctor of Medical Sciences, tells in detail about why laparoscopy is done and how to prepare for the procedure on the MedPort. ru".

Execution principle

The execution principle is as follows:

The patient is given anesthesia.
An incision (0.5 - 1 cm) is made in the navel, into which the needle is inserted.
Through the needle, the abdominal cavity is filled with gas, so that the doctor can freely manipulate surgical instruments.
After removing the needle, a laparoscope penetrates into the hole - a mini camera with illumination.
The rest of the instruments are inserted through two more incisions.
The enlarged image from the camera is transferred to the screen.
Diagnostic and surgical manipulations are carried out.
Gas is expelled from the cavity.
Installed drainage tube, through which there is an outflow of postoperative fluid residues from the abdominal cavity, including blood and pus.

Drainage is a mandatory prevention of peritonitis - inflammation of the internal organs after surgery. The drainage is removed within 1-2 days after the operation.

Photo gallery

Photos give an idea of how the operation is carried out.

Entering tools The principle of laparoscopy laparoscopic procedures. Inside view Incisions in the healing stage

Features of transvaginal laparoscopy

Features of transvaginal laparoscopy are that this method is more gentle, but it is used only to diagnose pathologies. Treatment of identified diseases is possible through traditional laparoscopy.

Transvaginal surgery is carried out in several stages:

Anesthesia (local or general) is administered.
The posterior wall of the vagina is punctured.
Through the opening, the pelvic cavity is filled with a sterile liquid.
A backlit camera is placed.
The reproductive organs are being examined.

Hydrolaparoscopy is most often prescribed for patients with infertility of unknown origin.

Postoperative period

After the operation, there are:

pain in the abdomen and lower back (disturb from several hours to several days, depending on the type of operation and the amount of surgical intervention);
discomfort when swallowing;
nausea, heartburn, vomiting;
temperature rise to 37.5°C.

walk 5-7 hours after surgery to restore blood circulation and activate bowel function;
drink water in small sips after at least two hours;
eat food the next day, giving preference to easily digestible foods;
within a week, observe restrictions on fatty, spicy, fried foods;
avoid sunlight for up to three weeks;
2-3 months do not lift heavy objects and limit yourself to charging instead of active sports;
maintain sexual rest for 2-3 weeks;
baths and saunas to be replaced with showers for a period of 2 months;
give up alcohol.

Possible Complications

Laparoscopy in gynecology is associated with some risks and complications.

Possible, but rare:

massive bleeding as a result of injury to the vessel;
gas embolism;
violation of the integrity of the intestinal wall;
pneumothorax;
emphysema - the ingress of gas into the subcutaneous tissue.

Complications arise when the first instrument is inserted (without camera control) and the abdominal cavity is filled with gas.

Postoperative consequences:

suppuration of the sutures due to a decrease in immunity or improper asepsis;
the formation of an adhesive process in the pelvis, which can cause infertility and intestinal obstruction;
the appearance of postoperative hernias.
development of peritonitis.

Complications during surgery and its consequences are rare. Their appearance depends on the quality of the preoperative examination of the patient and the qualifications of the surgeon.

The video was prepared by the MedPort. ru".

Recovery after surgery

After laparoscopic surgery, the patient expects a long recovery, while:

discharge from the hospital occurs 3-5 days after the operation, if there are no complications;
full rehabilitation after diagnosis takes about a month, after treatment - no more than four months, subject to the doctor's recommendations;
conception can be planned 1-2 months after the diagnostic operation and 3-4 months after the surgical one;
scars heal completely after 3 months.

Diagnostic Benefits

The procedure has the following advantages:

less traumatic - instead of a cavity incision, three small punctures are performed;
fast holding - about 30 minutes;
full preservation of fertility;
invisible postoperative scars instead of a long scar.

What is the price?

Prices for laparoscopy vary depending on its type, volume of treatment and region:

Video

The video illustrates the procedure of laparoscopy in the treatment of infertility. Represents the "Drkorennaya" channel.

The endoscopic direction in surgery is developing with great strides. If earlier with the help of this technique only diagnostic procedures were possible to confirm or exclude any organic or functional diseases, today the era of minimally invasive methods of treatment is coming.

Laparoscopy is performed using specialized instruments

Laparoscopy is called surgical operation aimed at diagnostic search or treatment surgical pathology organs of the abdominal cavity and small pelvis in women. It is carried out today more often, but it can not always fully replace laparotomic interventions. What is laparoscopy, in what cases is this method necessary and informative - this will be discussed in the article.

Disadvantages of laparoscopic interventions

The disadvantages of the operation relate only to unreasonable appointment. This refers to situations where it is more appropriate to use laparotomic intervention, and instead, laparoscopic manipulations are performed. For example, purulent inflammation of the gallbladder, which was complicated by peritonitis.

Among the disadvantages of laparoscopic interventions is the fact that the range of motion performed by the endoscopist surgeon is very limited.

The required force during laparotomic operations is calculated intuitively, by touch. It's not easy to learn this.

The visualization itself also has some features. This technical problem is faced not only by young specialists, but also by experienced endoscopists. The surface and depth in the abdominal cavity are distorted through endoscopes.

Young specialists may not calculate the force with which it is necessary to act on tissues. Sometimes this leads to rough, violent movements, which, in turn, is a risk factor for the development of adhesive disease. This is another disadvantage. In addition, not every hospital has the ability to organize this type of care, especially in the periphery.

The essence and benefits of the intervention

Laparoscopy as a diagnostic method is valued because it allows you to visualize the pathology of the abdominal cavity or small pelvis. It involves the use of an optical technique – a laparoscope. How is laparoscopy performed?

An optical device is inserted into the abdominal cavity after a series of punctures have been made through the abdominal wall.

Their number may vary depending on the purpose of the operation itself. Hence, another advantage of the method is low trauma.

There are the following types of laparoscopy:

diagnostic;
medical;
medical and diagnostic.

Based on the name, it is easy to guess what this or that type of intervention is intended for. During laparoscopy, one variety can smoothly flow into another.

If we compare laparotomic surgery with laparoscopy, then the pros and cons are obvious.

The first advantage is the time during which the procedure itself is done to the patient, as well as the time of disability. Usually, patients do not stay in the hospital for more than five to six days with uncomplicated surgery.
The second advantage is atraumaticity, which is provided by small incisions. This is necessary for the introduction of optical technology. Unlike laparotomic incisions, healing is much faster.

Laparoscopy and laparotomy

The third advantage - a disfiguring large postoperative scar is not formed. After all, the presence of cosmetic defects can be very worrying for patients, especially women.

What is laparoscopy in relation to internal organs? Unlike large-scale laparotomies, in this case there is no rough effect on the fiber, intestinal loops. Therefore, the risk of developing adhesions and adhesive disease is minimized. But they are possible. It depends on the skill of the endoscopist surgeon during the intervention, as well as on how adequately and competently the postoperative period is carried out.

The use of video systems significantly improves this method of research or treatment. It allows you to enlarge the picture dozens of times, as well as adjust the clarity of the image and the brightness and contrast of colors.

When is laparoscopy indicated and contraindicated?

There are quite clear indications and contraindications for laparoscopy. After all, this is not the most harmless intervention. If you think about it: laparoscopy - what is it in relation to the human body.

Despite the fact that this procedure is usually carried out for diagnostic purposes, it is an invasive intervention, an operation in essence.

This means that preparation and anesthesiology allowance are needed. To do such a manipulation without reason is to expose yourself to unnecessary risk.

Among the indications for laparoscopy, emergency and planned are divided. In what situations is laparoscopic intervention urgently needed?

The clinic of the "acute abdomen", which makes one suspect appendicitis, when there is no possibility for an unambiguous exclusion of gynecological or urological pathology.

Patients with " sharp belly» need urgent surgical care

Thrombosis of mesenteric (mesenteric) vessels.
Atypical clinic acute inflammation gallbladder or cholecystopancreatitis.
Differential diagnosis for suspected pancreatitis, intestinal obstruction.
Possible clinical symptoms cancerous tumor.

Thus, the indications for laparoscopy are delineated. It is worth considering the conditions when this intervention is not recommended or even strictly prohibited.

There are absolute and relative contraindications for laparoscopy. Such acute conditions are considered absolute, such as:

myocardial infarction;
terminal stages of insufficiency of the function of the heart, liver, kidneys and other vital organs.

More specific are situations with fecal fistulas, multiple scars after operations on the anterior abdominal wall.

Relative contraindications can be considered:

high blood pressure in hypertension;
uncontrolled attacks of bronchial asthma;
acute pneumonia;
the presence of angina pectoris and other serious lesions of the heart and coronary vessels.

Why take risks if you can stabilize the condition, and then calmly conduct a diagnosis?

Preparation and methodology

Laparoscopy is performed on an empty stomach

The preparatory stage for laparoscopy is no less important than the procedure itself. The most important thing is bowel cleansing. What is provided for this?

It should be noted that on the day of the study, you can not eat.

The next step is premedication. It is necessary to eliminate the sympathetic influence on cardiovascular system. Anesthetic management can be performed both locally and with the help of general anesthesia. Everything will depend on the specific clinical situation, the diagnostic task, as well as on the desire of the patient. But you need to understand that surgeons themselves give preference to local anesthesia.

How is laparoscopy done? The first step is to search for the necessary points for the puncture of the anterior abdominal wall. Calc points are used for average patients with normosthenic physique. They are found 30 mm above the umbilical line and below it. From midline receding 5 mm to the side. The search for other points for a puncture is necessary already during pregnancy, a dense physique.

Then, for normal clear visualization, inflation of the abdominal cavity is provided. For this purpose, chemically inert gases are used. Gas-free laparoscopy is possible. Everything will depend on the specific diagnostic or clinical task.

The laparoscope contains an optical system and a camera

Examination with the help of endoscopic technique is carried out first panoramic (in other words, overview). That is, the quadrants of the abdomen are indicated, and the actual examination is carried out, starting from the lower right (hepatopancreatobiliary) zone in a clockwise direction. There is also a second option. This is a targeted inspection of a particular area.

When diagnosing, doctors often have to resort to surgical intervention. Then a wider range of surgical instruments is used, as well as additional punctures or mini-incisions of the anterior abdominal wall.

The opinions of doctors and patients regarding laparoscopy usually do not differ. This intervention, due to its advantages, is used more often and is becoming the "gold" standard in the diagnosis and treatment of a large number of diseases.