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Laparoscopy

Laparoscopy (peritoneoscopy) (from the Greek. Peritonaion - peritoneum and skopeo - I examine, research; synonym: ventroscopy, peritoneoscopy, kelioscopy, abdominoscopy, celioscopy, etc.) is an endoscopic study of the abdominal cavity through a puncture of the abdominal wall.

Laparoscopy can sometimes replace trial laparotomy.

Contraindications are acute inflammatory diseases of the abdominal cavity, extensive adhesions, especially intestinal adhesions with the anterior abdominal wall, flatulence, cardiopulmonary insufficiency of any origin, severe neuroses.

Equipment. Kelling (G. Kelling), Bernheim (V. Bernheim) and others developed the original systems of peritoneoscopes, but usually use a thoracoscope.

Equipment. Preparing the patient - as before laparotomy (see). After injection of morphine or pantopon, sometimes chlorpromazine and muscle relaxants, the patient is placed on the table. The puncture site is determined by the intended localization of the process.

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The anterolateral sections of mesogaster are more convenient and safe for puncture outwards from the rectus abdominis and the white line below the navel (Fig. 1). The surgical field and the hands of the surgeon are treated as usual. Peritoneoscope sterilized by the general rules. Under local anesthesia (in children under general anesthesia), a 1-cm skin incision is made with a pointed scalpel, and a peritoneoscope trocar is injected through it.


Fig. 1. Areas for puncture of the abdominal wall during peritoneoscopy (shaded).

laparoscopy
Fig. 2. Laparoscopy (schematically). The abdominal wall is raised at the navel; An optical system is inserted through the trocar tube.

For greater security, you can pre-enter into the abdominal cavity with a stupidly beveled needle of 1.5-2 liters of air filtered through sterile cotton wool, or, after anesthetizing the skin in the navel area, grab it with bullet forceps and lift the abdominal wall, or take the Kocher clips and pull the edges of the skin incision.

Injects a trocar, the stylet is removed. When ascites release fluid. If air is not yet injected, it is blown through a trocar; lifting the abdominal wall behind the skin prevents the return of air.

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An optical system is introduced through the trocar tube (Fig. 2). To inspect the area of ​​the cecum of the patient turn on the left side. To inspect the upper abdominal cavity, lower the leg end of the table.

Laparoscopy data can be supplemented by inserting a light source into the stomach (through the mouth) and into the sigmoid colon (through the anus), and, having extinguished the peritoneoscope illuminator, to examine the walls of these organs "to the light".


Fig. 3. Anterior margin of the liver (cancer metastases).

Laparoscopy of the pelvic cavity produce, giving the patient the position of Trendelenburg. At the end of laparoscopy, the air is released (the remainder is absorbed after 4-7 days) and the trocar is removed. On the skin impose a seam.

During laparoscopy, the front edge of the liver (Fig. 3), the bottom of the gallbladder, the anterior wall of the stomach, the greater omentum, the large and small intestine, and pelvic organs are available for inspection. An unlarged spleen is not visible.

The tip of the peritoneoscope can be used to determine the density of the examined formation, and with a biopsy forceps, you can take a piece of tissue.

During laparoscopy, it is possible to dissect the adhesions (strands) with an electric scooter, search for and remove small foreign bodies, and inject drugs.

Complications. Emphysema of the abdominal wall is observed more often in obese people in cases where a short needle is taken to inject air. Possible (accident) bleeding, injured parenchymal and hollow organs. In the latter case, it is necessary urgent celiac incision, so laparoscopy cannot be performed on an outpatient basis.

Laparoscopy in gynecology . In addition to the described technique of laparoscopy, a modification of L. - culdoscopy is also used in gynecology. This method is otherwise called Douglasoscopy and pelvioscopy. An endoscope (a special peritoneoscope or thoracoscope) is inserted into the abdominal cavity not through the anterior abdominal wall, as in peritoneoscopy (laparoscopy), but through an incision in the posterior vaginal fornix.

Indications - various gynecological diseases, when a careful study by conventional methods failed to establish the diagnosis. Culdoscopy is indicated for ovarian tumors in the initial stage, with differential diagnosis between ovarian tumors and uterus tumors or inflammatory diseases of the appendages, between genital and extragenital tumors, with difficulty in diagnosing ectopic pregnancy, various ovarian dysfunctions (Stein-Leventhal syndrome, etc.), anomalies and malformations of the genitalia, tuberculosis and endometriosis of the genital organs and to find out some of the causes of infertility in women. Culdoscopy is preferable to use in the diagnosis of ectopic pregnancy, when ovarian tumors are suspected in the initial stage and when there are contraindications to laparoscopy.

It is more expedient to use laparoscopy in tumor-like formations of considerable size to determine the stage of tumor spread in women who have not had sex, and in cases where there are contraindications to culdoscopy.

Some authors during L. produce biopsy, puncture of tumors and other manipulations. Most domestic authors speak out against this, since such interventions are often not effective and are contrary to the principle of ablasticity.

Contraindications to the use of culdoscopy and L. in general: the general severe condition of the patient, heart defects in the stage of decompensation, angina pectoris, recent myocardial infarction, pronounced sclerotic changes in the brain and heart vessels in elderly people (especially in the presence of hypertensive disease), severe lung diseases with violation of their function.

Especially should be considered inflammatory processes and adhesions in the lower abdomen. Culdoscopy is also contraindicated in virgins, if there are tumors, inflammatory infiltrates or massive adhesions in the Douglas pocket, with a fixed bend of the uterus posteriorly, a narrow and long vagina. Excessive obesity of the anterior abdominal wall is not an obstacle to laparoscopy.

Peritoneoscopy is performed in gynecological patients in the Trendelenburg position, the technique (see above) has no features. During laparoscopy, the uterus, tubes, ovaries, intestines and other abdominal organs are clearly visible (Fig. 5).

examination of the pelvic organs
Fig. 5. Examination of the pelvic organs with a peritoneoscope (schematically). Right in the corner - a view of the internal genital organs of a woman:
1 - fallopian tube;
2 - the ovary;
3 - the uterus.

Complications with endoscopy are very rare. The most formidable of them is air embolism when creating an artificial pneumoperitoneum. If you create the pneumoperitoneum correctly and use carbon dioxide or nitrous oxide, and not air or oxygen, these complications can be avoided. Sometimes when creating a pneumoperitoneum, subcutaneous or intermuscular emphysema is formed, which passes quickly. Among other rare complications, injuries of the intestine and other internal organs are described, as well as exacerbations of inflammatory processes in the small pelvis. Proper selection of patients, as well as the consideration of contraindications prevents these complications. After endoscopic examination for 2–3 days, phrenicus is observed in patients, a symptom that usually passes quickly without any treatment.