How is laparoscopy done? What is laparoscopy in gynecology: indications, preparation and consequences

Content:

What are the advantages of laparoscopy over conventional surgery?

The main advantages of laparoscopy are as follows:

• Less tissue trauma compared to large incisions during conventional surgery
• Recovery is several times faster and easier. Within a few hours after the operation, the patient can walk and take care of himself.
• Reducing the risk of infection, suture separation, adhesion formation after surgery
• No big ugly scars

What surgeries and examinations can be performed using laparoscopy?

Laparoscopic surgery is performed to remove or restore patients internal organs. The following types of laparoscopy are currently available:

• Removal of the gallbladder cholelithiasis and cholecystitis
• Removal of the appendix for appendicitis
• Removal or restoration of kidneys, Bladder and ureters
• Removal or ligation of the fallopian tubes for the purpose of sterilization
• Removal
• Treatment
• Treatment
• Hernia treatment
• Operations on the stomach
• Examination of the liver and pancreas
• Examination and removal
• Removal
• Removal adhesions in the fallopian tubes
• Detection and control of internal bleeding

How to prepare for laparoscopy?

Usually, surgeons discuss preparation for surgery with each patient separately.

• Refrain from eating and drinking at least 8 hours before the operation
• Shave belly (for case of men)
• Take an enema a few hours before surgery (in some cases)

Before the operation, be sure to tell the surgeon what medications you are taking. Certain medicines (aspirin, birth control pills) can affect blood clotting and therefore are strictly contraindicated during or before laparoscopy.

Possible complications and consequences of laparoscopy

Dangerous complications after laparoscopy are extremely rare. Most people tolerate this surgery well and recover quickly from it. Be sure to discuss with your doctor how the operation will go in your case and ask him to explain what the risks might be.

When should you see a doctor?

Before leaving the hospital, the doctor should tell you when to return for a follow-up examination or removal of stitches.

Recovery after laparoscopy

Typically, recovery after laparoscopy occurs within a few days, which is much faster than after conventional surgery, during which a large incision is made.

In some cases, a person may go home the same day after surgery.

After laparoscopy, you may be concerned about:

Pain in the area of ​​postoperative wounds and in the abdomen

After laparoscopy, incisions can be quite severe pain that get stronger with every move. This is completely normal. Usually, such pain does not require special treatment. If you find it hard to endure the pain - tell your doctor about it - he will prescribe you an anesthetic.

Also, after laparoscopy, there may be pain in the middle part of the abdomen, pain in the lower abdomen (in the uterus and ovaries), pain in the lower back. Usually such pains pass within 2-3 days. In order to reduce pain, try to rest more. If the pain becomes unbearable, consult a doctor, as this may be a sign of a complication after surgery.

Bloating, nausea, weakness

Bloating is often observed after various operations, including after laparoscopy. In order to eliminate severe bloating, it is recommended to take medications based on simethicone in the first days after laparoscopy.

Also, after laparoscopy, weakness, mild nausea, lack of appetite, frequent urge to urinate. Usually these symptoms disappear quickly, within 2-3 days and do not require any treatment.

Stitches after laparoscopy

Incisions made during laparoscopy heal quickly and usually without complications. Removal of sutures is possible 10-14 days after the operation or even earlier.

In the first few months, small purple scars may remain at the site of the incisions, which fade and become invisible over the next few months.

Diet after laparoscopy

For several hours or the entire first day after laparoscopy, it is recommended to refrain from eating. You can drink non-carbonated mineral water.

On the 2nd and 3rd day, you can start eating easily digestible foods: fat-free kefir, yogurt, crackers, broth, lean meat, fish, rice.

In the following days, depending on how you feel, you can return to normal nutrition.

Before returning home, try to further discuss with your doctor the diet after surgery.

Physical activity after laparoscopy

Sex after laparoscopy

Return to sex after laparoscopy is possible within 1-2 weeks after surgery. However, further discuss this issue with your doctor if in your case the operation was performed for a gynecological disease.

Recovery of menstruation and vaginal discharge after laparoscopy

After laparoscopy performed for the treatment of gynecological diseases, scanty mucous or bloody discharge from the vagina may occur, which can persist for 1-2 weeks. Such discharges should not cause concern.

Laparoscopy (from the Greek. "I look at the womb") came to replace the usual abdominal surgery. Apply it on the organs of the small pelvis and abdominal cavity. Now, for a detailed diagnosis, surgery or treatment, just a few tiny incisions are enough. So low-impact and safe method surgery quickly won the trust of both patients and doctors themselves. It allows you to accurately establish a complex diagnosis, quickly perform surgical procedures, and restore the functions of internal organs. In this case, patients are often discharged a couple of hours after the procedure.

What it is

Laparoscopy refers to a progressive technique in modern surgery. It is based on a small surgical intervention. Instead of a scalpel and abdominal incisions, two or three small incisions are made on the anterior wall of the abdomen and special instruments are used - trocar manipulators and a laparoscope. Through one hole in the abdomen, the doctor inserts a small tube with a laparoscope, a video camera and a lighting device are located on it. Everything that the camera shoots, it sees on the monitor. To improve access to the internal organs, the peritoneal cavity is filled with carbon dioxide, followed by removal.

Modern technologies make it possible to equip the microcamera with digital matrices. Thanks to this, the image becomes as clear as possible, diagnostics and other manipulations are facilitated. All other instruments are manipulators, substitutes for conventional surgical devices.

With their help, they move to the affected area, remove and sew up organs, get rid of tumors, cysts, etc. The operation is performed under general anesthesia. After it, the openings in the abdominal cavity are sutured, as a rule, this requires two or three stitches. The patient can be discharged after a few hours, if the condition allows.

When she's needed

Laparoscopy is needed in two cases: for diagnosis and operations. Diagnostic is used to examine organs in the pelvis and peritoneum, confirming a complex diagnosis. Therapeutic is needed for surgical interventions: removal of adhesions, cysts, tumors, foci of endometriosis, etc. Therapeutic laparoscopy can be planned or emergency. For the patient himself, these types differ only in the method of anesthesia: local anesthesia is more often used for diagnosis, and general anesthesia for operations.

For diagnostics

For examination, this method is rarely used. In most cases, diagnoses are made on the basis of anamnesis, clinic, and test results. But there are cases when the treatment does not give the desired result or it is impossible to establish a diagnosis using other methods. In such a situation, laparoscopy is used.

The indication for such a procedure is:

1. Defects of the internal genital organs. Invasion allows you to establish the nature of the disease, methods of treatment, to refute the fact of defects.
2. Suspicion of an ectopic pregnancy. Such an examination is possible until the 16th week of pregnancy and only if other methods are helpless.
3. For infertility, if long-term treatment gives no results.
4. Diagnosis of malignant and benign tumors.
5. With persistent pain in the abdomen and pelvis with an unexplained cause.
6. The likelihood of fibroids, ruptured ovarian cysts, endometriosis, ovarian apoplexy.
7. To determine the patency of the fallopian tubes.

This method of research can be used for any suspicion of pathology of the abdominal organs, if non-invasive methods are ineffective. Also, with the help of manipulators and a laparoscope, the doctor can take part of the biomaterial from inaccessible places for analysis, which other diagnostic methods do not allow.

In oncology

Laparoscopy is effective for removing tumors located in the pelvis and peritoneum. It is used in oncology for both operations and diagnostics. This method is applicable even if the tumor is located inside the organ; for this, several technologies are combined at once. To view the structure of tissues in detail and determine the place of formation, angiography (examination of blood vessels) is used and computed tomography. The resulting images are displayed on the screen as a 3D model. The surgeon then uses manipulators to remove the tumor, part of the organ, or the entire organ.

In gynecology

This technology has found the greatest application in the gynecological industry. Today, most of all surgical interventions on the internal genital organs are performed by laparoscopy. This allows you to eliminate many causes of infertility, restore the functioning of the genitourinary system, and clarify the diagnosis. The tangible advantage is the fast rehabilitation period female patients.

Laparoscopy can be prescribed to a woman in such cases:

• with infertility with an unexplained cause;
• with polycystic;
• to eliminate foci of endometriosis;
• with myoma;
• anomalies in the structure of the pelvic organs;
• removal of the uterus or part of it;
• removal of the ovary for tumors;
• elimination of adhesions in the reproductive system.

In most cases, surgery is necessary due to infertility. This method of surgery identifies and eliminates almost any cause of this problem. Also, by laparoscopy, a woman can be temporarily or permanently sterilized, for this, protective clamps are applied to the fallopian tubes or they are completely removed.

In emergency situations, this method of operating is also applicable. For example, when a cyst is ruptured, the surgeon quickly removes the consequences of the rupture and applies internal sutures. An ectopic pregnancy is removed without serious consequences with the establishment of its cause and the possibility of a second normal pregnancy.

In other areas

This innovative method is gradually replacing open surgery, so they are trying to expand its scope. It is effective not only in the treatment of gynecological problems, men also often need such manipulations. They can prescribe therapeutic laparoscopy for the treatment of the intestines, stomach, kidneys, and removal of the gallbladder. In addition, a minimally invasive method helps to establish a diagnosis in diseases of the pancreas and liver, remove the appendix. A separate niche is occupied by the treatment of the spine by punctures of the abdominal cavity. Laparoscopic operations on the spine are performed for such diseases of the lumbosacral region as hernias, injuries, osteochondrosis, and tumors.

Who and where performs this operation

All manipulations are carried out by an experienced surgeon, he is assisted by the rest of the medical staff. The procedure is carried out only in the operating room, in a hospital setting. Since the technique is already quite popular, it is used in many clinics. For this medical institution must be properly equipped. As a rule, these are private clinics. In major cities state institutions may also have expensive equipment, but this is rare.

How to prepare

For a planned invasion or diagnosis, the attending physician prescribes a series of tests. A preliminary examination is carried out no earlier than 14 days before the scheduled procedure. Among such studies, the patient must pass:

• blood and urine tests;
• cardiogram;
• fluorography;
• blood test for clotting.

For a week before the planned operation, you need to give up products that provoke gas formation: cabbage, carbonated drinks, dairy products, cereals (except). The doctor may prescribe enzyme preparations to prepare the abdominal organs. For a few days it is forbidden to take drugs that reduce blood clotting (Aspirin, Coumadin, Warfarin, Heparin). All medications taken should be reported to the doctor.

12 hours before the invasion, you can not drink and eat, with intense thirst can slightly moisten the lips and mouth with warm . In the evening and in the morning, a cleansing enema is done, it can be replaced with medicines to cleanse the intestines. Before the operation, you need to take a shower with antibacterial soap, remove hair from the abdomen. Also, lenses, all jewelry, and dentures are removed before the operating table.

How is the procedure

Regardless of the reason for laparoscopic intervention (treatment or examination), such an operation always looks the same. The difference is only the processes inside the abdominal cavity, which are carried out by the surgeon. First, the patient is injected with drugs that enhance the effect of the painkiller. In the operating room, the anesthesiologist puts anesthesia, throughout the procedure, the specialist will monitor the patient's pulse, pressure, and the amount of oxygen in the blood. All data is output to a computer.

The surgeon applies an antiseptic and makes 2-3 incisions: one under the navel for the laparoscope, others on the sides for manipulators. Tools are inserted into these holes. abdominal cavity nitrous oxide (N2O) or warm humidified carbon dioxide (CO2) is injected. The wall of the abdomen rises and gives easy access to the internal organs. This part of the procedure is absolutely safe, gases do not irritate blood vessels and tissues, and are not toxic. Moreover, CO2 has a beneficial effect on the respiratory system, and N2O has an additional analgesic effect.

The image from the laparoscope is transmitted to monitors, the surgeon can examine all organs in detail, detect problem areas. With the help of tools, he performs an operation: removes tumors, cysts, organs or their affected parts. After surgical procedures, the doctor once again examines the area of ​​work. Then the manipulators are removed, stitches and a bandage are applied to the holes. The patient is taken to the recovery room. If diagnostics were carried out, a person can be discharged after 3-4 hours, after operations, observation in the hospital is necessary for another 2-3 days.

Possible Complications

The technique of laparoscopy is extremely complex, and it requires an experienced specialist with well-developed skills. Adverse consequences may be due to improper insertion of trocars. In this case, there may be injuries to internal organs such as the intestines, bladder, ureters, blood vessels. Most of these complications are resolved immediately during surgery, the affected organs are sutured. If the wound of the organs cannot be eliminated by laparoscopy, the doctor is forced to perform a laparotomy - an opening of the anterior wall of the abdomen.

Improper patient preparation increases the risk negative consequences. Thus, a full bladder is very often damaged by the introduction of instruments. At the same time, in addition to the main operation, the patient is urgently put two rows of stitches on the affected organ. If the patient took medication before the procedure and did not warn the doctor about it, the composition of these drugs may unpredictably affect anesthesia. In some cases, the invasion has to be urgently completed. However, such consequences occur with any surgical intervention.

With laparoscopy, the risk of infection, divergence of sutures, and the formation of adhesions is significantly lower.

In the first few hours after the invasion, rest is recommended. The duration of bed rest depends on the degree of complexity of the operation, the presence of complications, the patient's condition. The attending physician will set the time of the rehabilitation period and the date of discharge, and will give recommendations. At home, it is important to fully comply with the doctor's advice. The recommendations may include nutritional rules, if laparoscopy was performed on the gastrointestinal tract, in which case one of the Pevzner diets will have to be followed for 2 weeks. Within a month after the invasion, regardless of its type and purpose, alcohol, too fatty and spicy foods, spicy, canned, are excluded.

Personal hygiene is very important. You can bathe in the shower, take a bath only after 14 days. After each exercise, antiseptic treatment of sutures and dressing or bandage is needed. For the treatment of wounds, it is allowed to use:

• hydrogen peroxide 3%;
• fucorcin;
• alcohol solution of brilliant green.

The stitches are removed on the day set by the doctor, usually after 7-14 days. This should only be done by a paramedic in the dressing room. In the first month after the procedure, you need to limit physical exercise, exclude sports, lifting weights. Slow walks are allowed. You also need to refrain from sex in the first 14-30 days, depending on the disease. After examination by the doctor and with his permission, it will be possible to return to the usual way of life.

If during the rehabilitation period there are frequent pains in the abdomen, consciousness is confused, vomiting occurs, the stool is broken - this should be reported to the doctor. It is also important to monitor the condition of the seams, they should not have swelling, redness, itching, or any discharge.

Additional questions

Swollen belly after laparoscopy. What to do

During the operation, gas is injected into the peritoneal area for precise manipulations. After the invasion, it is pumped out, but there is a chance that some will remain inside. This is not scary, it can be absorbed by tissues, excreted from the body. As a rule, such a symptom disappears on its own after a few days and does not require intervention. To facilitate well-being, the doctor can prescribe sorbents, enzymatic preparations. The main thing is to avoid self-medication.

Delayed menstruation after the procedure

In women, the cycle may shift after such manipulations. Menstruation is delayed up to several weeks. If it does not occur in a month, you need a consultation or a doctor in charge.

Bleeding in women after laparoscopy

If a woman has bloody issues from the vagina, this is an occasion to urgently call an ambulance. While help is coming, you need to apply a cold compress to the lower abdomen and observe bed rest.

When can you get pregnant after surgery

You can plan conception only after the course of medication is over. If surgery took place on the uterus, for example, with fibroids, you will have to wait at least six months with pregnancy. Manipulations on other organs require a time of 1.5-2 months. In any case, examination and permission of doctors will be required. Untimely pregnancy can lead to divergence of internal and external seams, ectopic pregnancy, loss of the child.

It is very strange to see how many women still do not know that now most operations can be performed in a gentle way, without an incision, with a short recovery period and with a minimal likelihood of adhesions and relapses. Currently, most operations are performed by a (minimally invasive) laparoscopic approach.

In this section, we will be able to answer some questions:

So what is laparoscopy?

- this is an examination of the abdominal cavity through a hole in the abdominal wall using the optical system of the laparoscope. The operation is carried out under the control of an endovideo camera, the image from which is transmitted to a color monitor with a sixfold increase, using special instruments inserted inside through small holes - punctures with a diameter of about 5 mm.

The laparoscope is a metal tube with a diameter of 10 or 5 mm with a complex system of lenses and a light guide. The laparoscope is designed to transmit images from the bands human body using lens or rod optics and having a rigid outer tube. The laparoscope is the first link in the image transmission chain. In the general case, the laparoscope consists of an outer and an inner tube, between which an optical fiber is laid to transmit light from the illuminator into the body cavity. The inner tube contains an optical system of miniature lenses and rods.

Endocamera designed to display a color image of the surgical field from various endoscopic devices - laparoscopes, cystourethroscopes, rectoscopes, hysteroscopes, flexible endoscopes, etc. during surgical operations and diagnostic manipulations.

A bit about the history of the development of laparoscopy

In our country, as well as throughout the world, the development of laparoscopy continues. Unfortunately, in the outback, such operations are still the exception, not the rule, although laparoscopy has existed in the world for more than 100 years.

The first experience of laparoscopy was described as early as 1910, and until the middle of the twentieth century, laparoscopy was diagnostic in nature, it developed, more and more sophisticated equipment was created, and safe lighting systems were developed.

• Consultation of Doctor of Medical Sciences, Professor of Obstetrician-Gynecology
• Preoperative examination in 1 day!
• Expert ultrasound of the pelvic organs with dopplerometry
• Conducting simultaneous operations by combined teams, if necessary (gynecologists, urologists, surgeons)
• Postoperative management
• Histological examination in the leading institutions of Russia
• Consultation on the results and selection of preventive measures
• Preconception preparation

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 by several times, and also allows you to visualize all floors of the abdominal cavity and 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:

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

• Indications for emergency laparoscopy:

1. ectopic pregnancy;
2. ovarian apoplexy;
3. PID;
4. suspicion of torsion of the leg or rupture of a tumor-like formation or ovarian tumor, as well as torsion of subserous fibroids;
5. 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:

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

• Relative contraindications:

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

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

1. existing or transferred less than 4 weeks ago acute infectious and catarrhal diseases;
2. degree III-IV of the purity of the vaginal contents;
3. 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 of possible complications during 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 the introduction of the trocar, anomalies in the location of the vessels of the abdominal wall and (or) their varicose expansion. 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 is a low-traumatic operation that is performed to diagnose or treat many diseases. To carry out this procedure, special instruments are used, with the help of which they penetrate into the peritoneum through small holes. It is important to know what laparoscopy is, how it is performed, whether there are any contraindications and what possible complications after laparoscopy.

The surgeon performs this procedure through small incisions in the anterior wall of the abdomen using special instruments and a small video camera. The whole process is displayed on the monitor screen.

Laparoscopic examination is prescribed to clarify the diagnosis in case of difficult diagnosis of diseases of the peritoneal organs and the pelvic area, since others diagnostic methods unable to provide such detailed information. Laparoscopic surgery should only be performed by a qualified, experienced surgeon. Previously, he must inform the patient about laparoscopy, what to do, what tests to take, how to prepare and how long the rehabilitation period after the operation will take.

Recently, this method has become popular among surgeons. The main advantage of the method is a fairly quick recovery of the patient and return to the usual way of life.

Types of laparoscopy and indications for carrying out

When is laparoscopy prescribed? The most important thing that the surgeon pays attention to is the test results, the presence of chronic diseases, age and what is the indication for laparoscopy.

There are such types of laparoscopic surgery:

1. Planned.
2. Emergency.

An emergency (urgent) operation by the laparoscopic method is prescribed in the following situations:

• with apoplexy;
• in case of torsion of the ovary or the presence of a fibrous node of the uterus;
• purulent and infectious diseases organs in acute form;
• with an ectopic pregnancy.

Usually laparoscopic interventions are planned.

Laparoscopy and gynecology

The most commonly used laparoscopy in gynecology. It is carried out for the examination and treatment of many gynecological pathologies. For example, diagnostic laparoscopy prescribed for infertility. And laparoscopic operations in gynecology help to get rid of, for example, ovarian cysts.

You can learn more about removing a cyst using a lapar in the article ""

Also in gynecology, laparoscopy is used:

• to remove tumors and stimulate ovulation in polycystic;
• with infertility of unknown origin;
• to eliminate the adhesive process of the small pelvis;
• to remove foci of endometriosis. After this operation, in 65% of cases, pregnancy occurs within six months;
• for complete or temporary sterilization. For the latter, a protective clamp is applied to the fallopian tubes;
• with myoma, when conservative treatment did not bring effect, there are nodules on the leg or when the patient is tormented by regular spotting;
• pathological and abnormal structures of the pelvic organs;
• at the initial stage of uterine cancer, while cutting off the nearest lymph nodes;
• for incomplete or complete excision of the body of the uterus;
• for removing benign tumors large sizes. In this case, it is possible to excise the ovary with or without preservation of the fallopian tube;
• incontinence due to stress.

For diagnostic purposes, to assess the patency of the fallopian tubes, establishing the cause of infertility, GST or laparoscopy is prescribed. So what is actually more effective: HST or laparoscopy?

Hysterosalpingography or HSG is an x-ray of the uterus and tubes. Before the procedure, a gynecological examination of the woman is performed. If necessary, the procedure is carried out with local or general anesthesia.
Many who have done laparoscopy consider this method of diagnosis more effective. However, you should always follow the doctor's prescriptions, and not the recommendations of friends.

Other applications

In addition to diagnosing and treating gynecological diseases, laparoscopic surgery is performed on the following internal organs:

• gallbladder;
• intestines;
• stomach and others.

Indications for the procedure for pathologies of internal organs:

• treatment of kidneys, bladder and ureters;
• removal of the appendix;
• removal of the gallbladder with cholelithiasis or cholecystitis;
• to stop internal bleeding;
• hernia removal;
• stomach surgery.

With help this method removal of any internal organ or part thereof.

Thanks to the introduction of a miniature camera into the abdominal cavity, the surgeon sees everything that happens inside

Contraindications for laparoscopy

Despite the fact that this surgical intervention is less traumatic, there are some contraindications to laparoscopy.

Conventionally, all contraindications can be divided into:

1. Absolute
2. Relative.

Absolute contraindications

The absolute contraindications of the method include:

• stroke or myocardial infarction;
• pathologies of the cardiovascular and respiratory systems;
• poor clotting;
• hemorrhagic shock;
• renal and liver failure;
• coagulopathy that cannot be corrected.

Remember! In the presence of one of the above diseases, the doctor will not prescribe a laparoscopy.

Relative contraindications

It is important to note the following relative contraindications:

• infectious diseases of the pelvic organs;
• diffuse peritonitis;
• neoplasms on the ovary larger than 14 cm;
• cancer of the ovaries and fallopian tubes;
• adhesions;
• concerns about malignant neoplasms in uterine appendages;
• polyvalent allergy;
• large fibroids;
• pregnancy after 16 weeks.

In addition, this procedure is not effective in the following conditions:

• if in the peritoneum formed a large number of dense adhesions;
• with organ tuberculosis reproductive system small pelvis;
• advanced endometriosis in severe form;
• large hydrosalpinx.

After the ultrasound diagnostics, passing all the tests, the specialist, taking into account all the factors, decides whether it is possible to do laparoscopy for each specific patient. Since in certain cases it is rather difficult to achieve the desired result after laparoscopy, laparotomy is prescribed for treatment.

Preparation for laparoscopy

Before prescribing and carrying out a planned operation, the doctor tells the patient in detail what a lapar is, why it is performed, how to prepare for laparoscopy, the approximate duration of the operation and possible negative complications after the operation.

Preliminary preparation

Before laparoscopy, the patient must undergo a mandatory examination and do the following laboratory tests:

• blood and urine analysis;
• analysis to establish blood clotting;
• fluorography and cardiogram.

During an emergency operation, it is imperative to check the blood for clotting and group and measure the pressure.

Patient preparation

After the examination and the results obtained, the patient begins to prepare for laparoscopy. Most often, planned procedures are prescribed in the morning. The day before surgery, the patient should limit the evening meal. In the evening and in the morning before the operation, the patient is given an enema. On the day of the operation, it is forbidden not only to eat, but also to drink.

Surgical instruments for laparoscopy

How is laparoscopy performed?

How is the operation itself carried out? The doctor makes small incisions through which he inserts special microinstruments. The location of the incisions depends on the operated organ. For example, to remove a cyst, they are produced in the lower abdomen. During laparoscopy of the stomach, gallbladder or other internal organs, incisions are made at the location of the organ. The next step is to inflate the patient's abdomen with gas to move the instruments freely in the peritoneum. The preparation of the patient is completed, and the doctor proceeds to the operation. In addition to small incisions, the doctor makes one slightly larger incision through which the video camera will be inserted. Most often it is done in the navel (above or below). Once the camera is properly connected and all the tools have been entered, an enlarged image is displayed on the screen. The surgeon, focusing on him, carries out the necessary actions in the patient's body. It's hard to say right away how long such an operation takes. The duration can vary from 10 minutes to an hour.

After the operation, a drain is mandatory. it necessary procedure after laparoscopy, which is designed to remove postoperative blood residues, the contents of abscesses and wounds from the peritoneum to the outside. Installing a drain helps prevent possible peritonitis.

Does laparoscopy hurt? The operation is performed under general anesthesia. Before the introduction of sleeping pills, the anesthesiologist takes into account the age characteristics, height, weight and gender of the patient. After the anesthesia has worked, so that various sudden situations do not occur, the patient is connected to an artificial respiration device.

What is transvaginal hydrolaparoscopy

Quite often, patients are faced with the term transvaginal hydrolaparoscopy. What does this term mean? This is a procedure that allows you to examine in more detail all the internal genital organs. A probe is inserted into the uterus through incisions, which allows you to examine the organs of the reproductive system, and even perform a micro-operation, if necessary.

Is laparoscopy dangerous?

From many patients you can hear: "I'm afraid of laparoscopy!". Is it worth it to be afraid, is this procedure dangerous?

First, laparoscopy is primarily an operation, which means that there are risks that can happen with any surgical intervention. However, this operation is not considered dangerous, since during its implementation there is a lower risk of developing any complications than after other types of operations. Therefore, there is no need to be afraid of this operation. The main thing is to follow all the recommendations of the doctor during preparation for surgical intervention and during rehabilitation.

Advantages of the method

What is better laparoscopy or abdominal surgery? The main advantages of the method are:

1. Short recovery period after surgery.
2. Minor tissue damage.
3. After laparoscopy, the risk of formation of adhesions, infection or divergence of sutures is several times less than after band surgery.

Adhering to all the doctor's advice, postoperative period will be short and painless. And do not be afraid, because laparoscopy is the most minimally invasive operation.