Lecture number 6

“Characteristics of endoscopic research methods. Punctures "

Endoscopy (Greek endō inside + skopeō to examine, examine) is a method of visual examination of hollow organs and body cavities using optical instruments (endoscopes) equipped with a lighting device. If necessary, endoscopy is combined with targeted biopsy and subsequent morphological examination of the material obtained, as well as with X-ray and ultrasound examinations. The development of endoscopic methods, the improvement of endoscopic technology and their widespread introduction into practice are important for improving the early diagnosis of precancerous diseases and tumors of various localization on early stages their development.

Modern medical endoscopes are complex optical-mechanical devices. They are equipped with light and image transmission systems; are completed with instruments for biopsy, foreign body extraction, electrocoagulation, drug administration and other manipulations; with the help of additional devices, they provide obtaining objective documentation (photography, filming, video recording).

Depending on the purpose, they are distinguished:

viewing;

biopsy;

operating rooms;

special endoscopes;

endoscopes designed for adults and children.

Depending on the design of the working part, endoscopes are divided:

on rigid ones, which retain their shape during the study;

flexible, the working part of which can be flexed smoothly in the anatomical canal.

The light transmission system in modern endoscopes is made in the form of a light guide consisting of thin fibers that transmit light from a special light source to the distal end of the endoscope into the cavity under study. In rigid endoscopes, the optical system that transmits the image of an object consists of lens elements.

In the optical system of flexible endoscopes (fibroscopes), flexible bundles are used, consisting of regularly laid fiberglass threads with a diameter of 7-12 microns and transmitting an image of an object to the eyepiece end of the endoscope. Fiber-optic endoscopes produce a raster image.

The variety of functional purposes of endoscopes determines the difference in their design. For instance, duodenoscope with a lateral arrangement of the optical system at the end of the endoscope facilitates examination and manipulation of the duodenal papilla, esophagogastroduodenoscope with an end position of the optical system allows for examination and therapeutic interventions in the lumen of the esophagus, stomach and duodenum.

IN last years endoscopes of small (less than 6 mm) diameter have become widespread for the study of thin anatomical canals and hard-to-reach organs, for example ureterorenoscopes, different types bronchoscopes with fiber optics.

Promising development video endoscopes, in which instead of an optical channel with a fiber bundle, a system with a special photosensitive element - a CCD matrix is \u200b\u200bused. Due to this, the optical image of the object is converted into electrical signals transmitted through an electric cable inside the endoscope into special devices that convert these signals into an image on a television screen.

Flexible two-channel operating endoscopes are widely used. The presence of two instrumental channels makes it possible to simultaneously use various endoscopic instrumentation (for capturing education and its biopsy or coagulation), which greatly facilitates surgical interventions.

After the examination, the endoscope should be thoroughly rinsed and cleaned. The instrument channel of the endoscope is cleaned with a special brush, after which it is washed and dried with compressed air using special devices.

All valves and valves of accessory instruments are disassembled, washed and dried thoroughly before assembly. Endoscopes are stored in special cabinets or on tables in a position that prevents deformation of the working parts or their accidental damage.

Endoscopes are sterilized in various means (glutaraldehyde solution, 6% hydrogen peroxide solution, 70% ethyl alcohol) at a temperature not exceeding 50 ° due to the danger of sticking optical elements.

The most widespread endoscopy is used in gastroenterology:

esophagoscopy;

gastroscopy;

duodenoscopy;

intestinoscopy;

colonoscopy;

sigmoidoscopy;

choledochoscopy;

laparoscopy;

pancreatocholangioscopy;

fistuloscopy.

In the diagnosis and treatment of diseases of the respiratory system, such endoscopic methods are widely used as:

laryngoscopy;

bronchoscopy;

thoracoscopy;

mediastinoscopy.

Other methods of endoscopy allow for informative studies of individual systems, for example urinary(nephroscopy, cystoscopy, ureteroscopy), nervous (ventriculoscopy, myeloscopy), some organs (for example, uterus - hysteroscopy), joints (arthroscopy), vessels (angioscopy), cardiac cavities (cardioscopy), etc.

Due to the increased diagnostic capabilities of endoscopy, it has turned in a number of branches of clinical medicine from an auxiliary to a leading diagnostic method. The great possibilities of modern endoscopy have significantly expanded the indications and sharply narrowed contraindications to the clinical use of its methods.

Conducting a planned endoscopic examination shown :

1. to clarify the nature of the pathological process, suspected or established using other methods of clinical examination of the patient,

2. obtaining material for morphological research.

3. In addition, endoscopy makes it possible to differentiate between diseases of an inflammatory and neoplastic nature,

4. and also reliably exclude the pathological process that was suspected during the general clinical examination.

Emergency endoscopy is used as a means of emergency diagnosis and therapy for acute complications in patients with chronic diseases in an extremely serious condition, when it is impossible to conduct a routine study, and even more so surgery.

Contraindication to endoscopy are:

violations of the anatomical patency of hollow organs to be examined,

severe disorders of the blood coagulation system (due to the risk of bleeding),

as well as such disorders of the activity of the cardiovascular and respiratory systems, in which endoscopy can lead to life-threatening consequences for the patient.

The possibility of endoscopy is also determined by the qualifications of the doctor performing the study and the technical level of the endoscopic equipment that he has.

Training patients for endoscopy depends on the objectives of the study and the patient's condition. Routine endoscopy is performed after clinical examination and psychological preparation of the patient, in which the task of the study is explained to him and the basic rules of behavior during endoscopy are introduced.

With emergency endoscopy, it is possible to carry out only the psychological preparation of the patient, as well as to clarify the main details of the anamnesis of the disease and life, to determine contraindications for the study or the prescription of drugs.

Medical preparation of the patient is primarily aimed at ensuring optimal conditions for the implementation of endoscopic examination and consists in relieving the patient's psychoemotional stress, conducting anesthesia during manipulations, reducing the secretory activity of the mucous membranes, and preventing the occurrence of various pathological reflexes.

Technique endoscopy is determined by the anatomical and topographic features of the examined organ or cavity, the model of the endoscope used (rigid or flexible), the patient's condition and the objectives of the study.

Endoscopes are usually inserted through natural openings. In carrying out such endoscopic examinations, such as thoracoscopy, mediastinoscopy, laparoneoscopy, choledochoscopy, the opening for the introduction of the endoscope is created with special trocars, which are inserted through the thickness of the tissues.

A new trend in endoscopy is the use of flexible endoscopes for the study of internal and external fistulas - fistuloscopy. Indications for fistuloscopy are external intestinal fistulas with a diameter of at least 3 mm; internal intestinal fistulas, located at a distance of 20-25 cm from the anus; a high degree of narrowing of the intestinal lumen, when it is not possible to examine the narrowing itself and the overlying sections of the intestine with the help of endoscopes of other designs.

The combination of endoscopy with X-ray research methods is becoming more widespread. The combination of laparoneoscopy with puncture cholecystocholangioscopy, cystoscopy with urography, hysteroscopy with hysterosalpingography, bronchoscopy with isolated bronchography of individual lobes and segments of the lung makes it possible to fully reveal the nature of the disease and establish the localization and length of the pathological process, which is extremely important for determining the need for surgical intervention or endoscopy. ...

Research methods are being developed that use a combination of endoscopy with ultrasound methods, which facilitates the diagnosis of cavities located next to the investigated organ, and the detection of calculi in the biliary or urinary tract. The ultrasonic probe-probe introduced through the manipulation channel of the endoscope also makes it possible to determine the tissue density, the size of the pathological formation, i.e. to obtain information that is extremely important for the diagnosis of a tumor process. Since the probe is positioned in close proximity to the object under examination with the help of the endoscope, the accuracy of the ultrasound examination is increased and the interference possible during the examination in the usual way is eliminated.

Endoscopic diagnosis can be difficult due to local causes (pronounced deformation of the examined organ, the presence of adhesions) or the general serious condition of the patient. Various complications of endoscopy can be associated with the preparation or conduct of the study: they arise in the examined organ or other body systems, depend on the underlying or concomitant diseases and appear during the study or some time later.

Most often, complications are associated either with anesthesia (individual intolerance to drugs), or with a violation of the technique of endoscopic examination. Failure to comply with mandatory endoscopy techniques can lead to organ injury up to its perforation. Less often, other complications are possible: bleeding after a biopsy, trauma to varicose veins, aspiration of gastric contents during an emergency examination, etc.

Laparoscopy

Laparoscopy(Greek lapara belly + skopeō observe, explore; synonym: abdominoscopy, ventroscopy, peritoneoscopy, etc.) - endoscopic examination of organs abdominal and small pelvis.

It is used in cases where the cause and nature of the disease of the abdominal organs cannot be established with the help of modern clinical laboratory, X-ray and other methods.

The high information content, relative technical simplicity and low invasiveness of laparoscopy have led to its widespread use in clinical practice, especially in children and elderly and senile people.

Not only diagnostic laparoscopy, but also therapeutic laparoscopic techniques are widely used: drainage of the abdominal cavity, cholecystomy, gastro-, jejunostomy and colonostomy, dissection of adhesions, some gynecological operations, etc.

The indications for diagnostic laparoscopy are:

diseases of the liver and biliary tract;

tumors of the abdominal cavity;

suspicion of an acute surgical disease or damage to the abdominal organs, especially if the victim is unconscious;

ascites of unknown origin.

Indications for therapeutic laparoscopy may occur:

with obstructive jaundice;

acute cholecystitis and pancreatitis;

conditions in which the imposition of fistulas on various parts of the gastrointestinal tract is shown: (obstruction of the esophagus);

maxillofacial injury;

severe brain damage;

tumor obstruction of the pylorus;

burns of the esophagus and stomach.

Contraindications to laparoscopy are:

blood clotting disorders;

decompensated pulmonary and heart failure;

coma;

suppurative processes on the anterior abdominal wall;

extensive adhesions of the abdominal cavity;

external and internal hernias;

flatulence;

severe obesity.

For laparoscopy, special instruments are used:

a needle for imposing a pneumoperitoneum;

trocar with puncture sleeve abdominal wall;

laparoscope;

puncture needles;

biopsy forceps;

electrodes;

electric knives and other instruments that can be passed either through the manipulation channel of the laparoscope, or through a puncture of the abdominal wall.

Laparoscopes are based on the use of rigid optics, their optical tubes have different directions of view - direct, lateral, at different angles. Are being developed fibrolaparoscopes with a controlled distal end.

Diagnostic laparoscopy in adults, it can be performed under local anesthesia; all laparoscopic operations, as well as all laparoscopic manipulations in children, are performed, as a rule, under general anesthesia. In order to prevent possible bleeding, especially with liver damage, vikasol, calcium chloride are prescribed 2-3 days before the examination. The gastrointestinal tract and the anterior abdominal wall are prepared as for abdominal surgery.

The first stage of laparoscopy is the imposition of a pneumoperitoneum... The abdominal cavity is punctured with a special needle (such as a Leriche needle) at the lower left point of the Calca (Fig. 14).

Fig. 14. Classic Calca points for the imposition of a pneumoperitoneum and the introduction of a laparoscope: the insertion sites of the laparoscope are indicated by crosses, the puncture site for the imposition of pneumoperitoneum is indicated by a circle, the projection of the round ligament of the liver is shaded.

3000-4000 cm3 of air, nitrous oxide or carbon monoxide are injected into the abdominal cavity. Depending on the task of the study, for the introduction of the laparoscope, one of the points is selected according to the Kalka scheme, most often above and to the left of the navel. A 1 cm long skin incision is made with a scalpel, the subcutaneous tissue and the aponeurosis of the rectus abdominis muscle are dissected. Then the anterior abdominal wall is pierced with a trocar with a sleeve, the trocar is removed, and a laparoscope is inserted through its sleeve.

Inspection of the abdominal cavity is carried out sequentially from right to left, examining the right lateral canal, liver, subhepatic and suprahepatic space, subphrenic space, left lateral canal, small pelvis.

If necessary, you can change the position of the patient for a more detailed examination. By the color, nature of the surface, the shape of the organ, overlays, the type of effusion, it is possible to establish the nature of the lesion: liver cirrhosis, metastatic, acute inflammatory process (Fig. 15a, b), necrotic process, etc. To confirm the diagnosis, a biopsy (usually a puncture) is performed.

Various therapeutic procedures performed during laparoscopy are widely used: drainage of the abdominal cavity, microcholecystostomy), etc. After the end of laparoscopy and removal of the laparoscope from the abdominal cavity, gas is removed, the skin wound is sutured with 1-2 sutures.

Fig. 15a). Laparoscopic picture in some diseases and pathological conditions of the abdominal organs - gangrenous cholecystitis.

Fig. 15b). The laparoscopic picture in some diseases and pathological conditions of the abdominal organs is fibrous peritonitis.

Complications are rare. The most dangerous are instrumental perforation of the gastrointestinal tract, damage to the vessels of the abdominal wall with the occurrence of intra-abdominal bleeding, infringement of hernias of the anterior abdominal wall. As a rule, with the development of such complications, an emergency operation is indicated.

Colonoscopy

Colonoscopy (Greek kolon colon + skopeō observe, examine; synonym: fibrocolonoscopy, colonofibroscopy) - a method of endoscopic diagnosis of diseases of the colon. It is an informative method for the early diagnosis of benign and malignant tumors colon, ulcerative colitis, Crohn's disease, etc. (Fig. 16,17).

During colonoscopy, it is also possible to perform various therapeutic manipulations - removal of benign tumors, stopping bleeding, extracting foreign bodies, recanalisapia of bowel stenosis, etc.

Fig. 16. Endoscopic picture of the colon in normal conditions and with various diseases: the mucous membrane of the large intestine is normal.

Fig. 17. Endoscopic picture of the colon in normal conditions and with various diseases: sigmoid colon cancer - necrotic tumor tissue is visible in the center of the visual field.

Colonoscopy is performed using special devices - colonoscopes. Colonoscopes KU-VO-1, SK-VO-4, KS-VO-1 are produced in the Russian Federation (Fig. 18). Colonoscopes of various Japanese firms are widely used.

Fig. 18. Colonoscopes special KS-VO-1 (left) and universal KU-VO-1 (right).

The indication for colonoscopy is the suspicion of any disease of the colon. The study is contraindicated in acute infectious diseases, peritonitis, as well as in the late stages of heart and pulmonary failure, severe disorders of the blood coagulation system.

Preparation for a colonoscopy in the absence of persistent constipation includes taking the patients on the eve of the study in the afternoon (30-50 ml) of castor oil, after which in the evening they produce two cleansing enemas with an interval of 1-2 hours; they are repeated on the morning of the study day.

With severe constipation, 2-3 days of preparation is necessary, including an appropriate diet, laxatives and cleansing enemas.

In diseases accompanied by diarrhea, laxatives are not given, it is enough to use small-volume (up to 500 ml) cleansing enemas.

Emergency colonoscopy for patients with intestinal obstruction and bleeding can be performed without preparation. It is effective when using special endoscopes with a wide biopsy channel and active irrigation of the optics.

Colonoscopy is usually performed without premedication. Patients with severe pain in the anus are shown local anesthesia (dicain ointment, xylocaineel). In case of severe destructive processes in the small intestine, massive adhesions in the abdominal cavity, it is advisable to carry out a colonoscopy under general anesthesia, which is mandatory for children under 10 years of age. Complications of colonoscopy, the most dangerous of which is bowel perforation, are very rare.

Ultrasound examination (ultrasound) Is a painless and safe procedure that creates an image internal organs on the monitor due to the reflection of ultrasonic waves from them.

At the same time, media of different density (liquid, gas, bone) are displayed on the screen in different ways: liquid formations look dark, and bone structures - white.

Ultrasound allows you to determine the size and shape of many organs, such as the liver, pancreas, and see the structural changes in them.

Ultrasound is widely used in obstetric practice: to identify possible fetal malformations on early dates pregnancy, the condition and blood supply of the uterus and many other important details.

This method, however, is not suitable and therefore not used for examining the stomach and intestines.

Laparoscopic operations is a modern method of performing surgical operations. Laparoscopic surgery, as a minimally invasive surgery, allows surgeons to perform operations through small incisions (less than one centimeter in length) compared to large incisions in traditional "open" surgery. The advantage of laparoscopic surgery for patients is: reduced pain, reduced hospital stay, improved cosmetic outcome and faster recovery from surgery. Due to improved treatment outcomes, reduced treatment costs and patient requirements, laparoscopic surgery has become widely used in the treatment of various surgical diseases over the past two decades. Advances in instruments, video technology, and laparoscopic equipment have accelerated the development of laparoscopic surgery. In some hospitals, more than 50% of operations are performed laparoscopically, and it is expected that more than 70% of operations can be performed using the laparoscopic approach, without additional technical improvements.

The history of the development of laparoscopic operations
The modern era of the development of laparoscopic operations traditionally begins with the first laparoscopic operation to remove the gallbladder (laparoscopic cholecystectomy) in 1987. However, in fact, laparoscopic operations began to be performed in 1806. For several decades of the twentieth century, gynecologists used laparoscopy to diagnose and perform simple surgeries such as tubal ligation to regulate fertility.

1901 Georg Kelling performed the first laparoscopic operation on animals, describing the creation of a pneumoperitoneum (the introduction of air into the abdominal cavity) and the placement of trocars (hollow tubes).

1910 Hans Christian Jacobaeus (Sweden) reports the first human laparoscopic surgery. Over the next few decades, many researchers have refined and popularized laparoscopic surgery.

1983 - The first laparoscopic appendicitis surgery was performed by Semm as part of a gynecological operation.

1985 Muhe (Germany) performed the first successful laparoscopic gallbladder removal in humans. However, due to the fact that the first operation was not known for a long time, the first laparoscopic cholecystectomy is attributed to Mouret (France), which was reported in 1987.

1991 - Gaegea introduces laparoscopic fundoplication (suturing the stomach to the diaphragm around the esophageal opening) for gastroesophageal reflux.

1992 - A National Institutes of Health Conference concluded that laparoscopic cholecystectomy is an alternative to open surgery to remove the gallbladder.

2005 Laparoscopic appendicitis removal performed by Rao and Reddy in India.

2007 - The first endoscopic surgery (NOTES) was performed in the United States of America to remove the gallbladder through natural openings without visible external scars.

What are the benefits of laparoscopic surgery?

Laparoscopic surgery has several advantages over traditional, open surgery. They include:

1.Small incisions, which improve the cosmetic result of the operation, as small scars remain.
2. Less postoperative pain syndrome, reduced need for pain medications.
3. The patient's stay in the hospital is reduced.
4.Takes less time to recover from laparoscopic surgery. Patients return earlier to work and to their usual lifestyle.
5. Reducing tissue trauma, reducing the need for blood transfusions, as well as reducing the risk of complications associated with the formation of incisional hernia and wound infection.
6.Reduce the risk of postoperative intestinal obstructionassociated with the formation of adhesions in the abdominal cavity.
7. Laparoscopic operations allow diagnostics in unclear situations.

What are the disadvantages of laparoscopic surgery?
Disadvantages of laparoscopic surgery include:

1. Increased costs associated with the need for modern equipment, the cost of its maintenance and development of tools. These costs can be offset by a reduction in the patient's hospital stay.
2. In many cases, laparoscopic surgery takes longer than traditional open surgery.
3.Laparoscopic surgery does not eliminate the risk of life-threatening complications such as trauma blood vessels or intestines.
4. The need for general anesthesia, while some of the open alternative surgeries can be performed under epidural or local anesthesia.
5. Sometimes the intensity of postoperative pain associated with a large number of incisions increases. Also, carbon dioxide can irritate the peritoneum, the membrane lining the abdominal cavity, and cause shoulder pain.
6. The inability to perform a quick and complete examination of some areas of the abdominal cavity, for example, with trauma to the abdominal organs.
How is laparoscopic surgery performed?

The abdominal wall is a barrier between the surgeon and the abdominal organs, thus the primary advantage of laparoscopy is minimal trauma to the abdominal wall. Access to the abdominal cavity is performed either with a Veress needle or through Hasson mini-incisions. Then carbon dioxide is injected into the abdominal cavity under a pressure of 15 mm. rt. Art. Carbon dioxide creates a work area by raising the abdominal wall above the viscera. A long rigid endoscope (laparoscope) and a light source are inserted and used to view the abdominal organs.

Enlarged images of the work area are broadcast on one or more television screens, allowing the surgeon, nurses, assistants and anesthesiologists to visually monitor the progress of the operation.

Several plastic hollow tubes with a diameter of 5 to 12 millimeters with an airtight valve, called trocars, are placed in a specific order to allow easy insertion, removal and replacement of instruments.

The number of additional insertion sites for trocars is associated with the complexity of the laparoscopic operation. Laparoscopic instruments are similar to surgical instruments used in open surgery, but differ markedly in length (approximately 30 centimeters in length). Laparoscopic scissors, clamps, retractors, and other instruments are inserted through trocars to manipulate tissue.

Surgical staplers and electrosurgical devices, which cut and join tissue, are used to remove organs or staple segments of the intestine. The use of these complex devices (trocars, staplers), which are partially disposable, is the reason for the high economic costs of laparoscopic operations.

In some cases, gasless laparoscopic surgery is performed, in which the abdominal wall is lifted with retractors without the introduction of carbon dioxide. Modern laparoscopes with a built-in camera, which converts the image into digital signals and transmits it to the monitor screen with high resolution, makes it possible to obtain high quality images. The use of the latest technologies, including vessel sealing devices that cut blood vessels without bleeding, and an ultrasound-activated scalpel, enable complex laparoscopic surgery.

Why is laparoscopic surgery more difficult for the surgeon?
While small incisions are an advantage for the patient, laparoscopic surgery has some limitations for the surgeon. During laparoscopic surgery, the 3D working area is replaced with a 2D image on the monitor screen during open surgery, with the accompanying loss of information. Limited vision and lighting, lack of a sense of volume and depth, can lead to perception errors. Bleeding makes it difficult to see and is more difficult to stop.

Laparoscopic surgery allows the surgeon to assess only the superficial anatomy without the ability to directly feel or touch organs and other anatomical structures. This is compensated for by ultrasound examination, but the inability to use the arm to stop bleeding allows the surgeon to readily assess only the superficial anatomy, without the ability to feel or "palpate" organs and other anatomical structures.

Laparoscopic devices have less freedom of movement and may be inconvenient to manipulate. The laparoscopic suture requires good coordination of the movements of the surgeon. The difficulty level of laparoscopic surgery can be compared to eating with chopsticks with the hands. The surgeon must proficiently use the position of the body, the placement of additional retractors, the position of the operating table, and the various angles when excising, stitching and removing tissue. Extensive preparation is often necessary to compensate for the small size of the incisions.

The surgeon must recognize any mechanical difficulties and use additional equipment in emergencies. Due to the fact that laparoscopic operations require certain skills of the surgeon, some surgeons are not proficient in laparoscopic procedures. Thus, more complex laparoscopic operations require a highly trained surgeon.

What stage of laparoscopic surgery can be the most stressful for the surgeon and life-threatening for the patient?
The main cause of serious complications during laparoscopic surgery is the primary access to the peritoneum for the introduction of carbon dioxide. Standard use of a large-bore needle (Veress needle) is the easiest and fastest way to force air into the abdomen, but can also injure the bowel or vessel, causing bleeding and air embolism (entry of air bubbles into the bloodstream).

The incidence of intestinal injuries during laparoscopic operations is low and ranges from 0.025 to 0.2%. However, an unrecognized bowel injury can lead to delayed bowel perforation and peritonitis (inflammation of the peritoneum, the membrane covering the abdominal cavity) with a mortality rate of about 5%. In some cases, bowel injury can be recognized by the appearance of intestinal contents after insertion of a trocar or if the intestinal mucosa is visible after insertion of the laparoscope.

Injury to the intestines is not as life threatening as injury to a large blood vessel, which can lead to massive bleeding and death. With the patient supine, the aorta and lower vena cava can be located at a distance of several centimeters from the abdominal wall. The incidence of injuries to large blood vessels is less than 0.05%. Injuries to large vessels are diagnosed by the appearance of visible bleeding or hypotension (low blood pressure). If massive bleeding occurs, immediate blood transfusion is required and a transition from laparoscopic surgery to open laparotomy is required.

To reduce the risk of injury to the intestines or blood vessels, additional needle insertion techniques have been developed to force air into the abdominal cavity. In 1971, Hasson proposed an open method for inserting trocars under direct visual control. Newer optical trocars, which allow the surgeon to see the layers of the abdominal wall as they are inserted, are safer, but do not completely eliminate the risk of complications.

Why is it sometimes necessary to switch from laparoscopic surgery to open surgery?
Any laparoscopic surgery may require a "conversion" or transition to traditional, open surgery. The reason for the transition to open surgery may be: bleeding, inadequate vascular isolation, massive adhesions in the abdominal cavity and the inability to successfully complete laparoscopic surgery.

Risk factors for going from laparoscopic to open surgery include previous abdominal surgery, past peritonitis, bloating, and cancer. Some patients with chronic diseases The lungs may not tolerate pneumoperitoneum (pumping air into the abdominal cavity), which may necessitate conversion to open surgery after the initial attempt at laparoscopic access. If the operation cannot be completed laparoscopically, then the surgeon's decision to go to open surgery should not be regarded as a complication or failure, but as a way to ensure maximum safety for the patient. Thus, patients always sign an informed consent about the possibility of converting laparoscopic surgery into open surgery. Patients should understand that first a laparoscopic approach will be performed, and if necessary, the surgeon will proceed to open surgery.

How are removed organs or tumors removed during laparoscopic surgery?
Small organs that are removed (such as the appendix, the lymph nodes, gall bladder) is removed through a standard 12 mm incision through which the laparoscope is inserted. Usually, the tumor or organ is placed in a special pouch for safe removal from the patient's abdominal cavity.

If during laparoscopic surgery the organ or tumor to be removed is large and cannot be removed through the 12 mm trocar incision, there are several methods that include:

1. removal of an organ or tissue in parts
2.Placement of the removed organ or tissue in a special bag, followed by grinding (morcellation)
3. making a larger incision for organ removal (especially if tissue is needed for histological examination).
When removing large specimens, the key decision for the surgeon is whether to use advanced strategies and try to complete the operation as much as possible through the laparoscopic approach (do an additional mini laparotomy to remove the specimen), or perform laparoscopic surgery using the hand-assisted technique.

What is hand-assisted laparoscopic surgery?

If a large incision is needed to retrieve the removed organ, there is a laparoscopic technique that allows the surgeon to use the arm in the working area. This enables the surgeon to manipulate it and palpate or feel tissues and organs as in an open operation. This technique is called hand-assisted laparoscopic surgery.

To prevent a decrease in the concentration of carbon dioxide in the patient's abdominal cavity, a special access port called a hand port (a sealed sleeve that allows the arm to be inserted) must be created. The incision length for the hand port is 8 centimeters. Some surgeons believe that hand-assisted laparoscopic surgery can significantly shorten the operation time compared to purely laparoscopic surgery, and also provide more room for action in the event of complications (for example, massive bleeding). But for the hand port, a long incision is required.

How is laparoscopic surgery used for both diagnosis and treatment?
Diagnostic laparoscopic operations:

Diagnostic laparoscopic operations long time used in gynecology to determine the causes of chronic abdominal pain, the cause of pelvic pain, or infertility. Laparoscopic operations are used in general surgery in the diagnosis of exacerbation of chronic abdominal pain, the cause of which is unclear after computed tomography (CT) or other methods radiation diagnostics... Laparoscopic surgery is used to biopsy abnormalities found on computed tomography to determine the stage and extent of cancers. Also, laparoscopic operations are used to diagnose damage to internal organs or bleeding in case of abdominal trauma. Diagnostic laparoscopic surgery helps to avoid unnecessary surgery in patients with incurable disease.

For treatment:

Surgeries that only require tissue dissection or stitching (Nissen fundoplication, adhesion dissection) are ideal laparoscopic surgeries since there is no need to remove organs or tissues and large incisions are not required.

More complex laparoscopic operations require the removal of organs or tissues, especially in the treatment of malignant tumors. Sometimes the removed organ can be removed from the patient's abdomen without the need to widen the incisions. In other cases, the organ is removed after widening the incisions at the end of laparoscopic surgery or using a manual port.

What postoperative complications can be avoided with laparoscopic surgery?
Postoperative hernias occur in about 10% of cases after traditional open operations... Since laparoscopic operations require shorter incisions, the incidence incisional hernias significantly lower, and the risk of developing postoperative infectious complications is also reduced.

Are there any contraindications for laparoscopic surgery?
An absolute contraindication to laparoscopic surgery is the patient's state of health: instability of basic vital signs (pulse, pressure, respiratory rate, etc.) or if a long stay in the operating room is undesirable for the patient. Previous operations with the development of adhesions in the abdominal cavity, chronic liver failure (cirrhosis of the liver), bleeding, large body weight, acute inflammation, pregnancy and chronic cardiopulmonary diseases are relative contraindications for laparoscopic surgery. In patients with peritonitis, laparoscopic surgery may increase the risk of spreading the infection.

The ability to accurately diagnose the abdominal organs allows you to identify various diseases at an early stage. This has become easier with the advent of laparoscopy. Modern method, which includes a diagnostic and surgical direction. It is carried out exclusively in a stationary mode and has its own characteristics.

Laparoscopy is used to diagnose and treat the abdominal and pelvic organs. It allows you to examine the most inaccessible internal parts of the body. But this requires special preparation and the operation itself is carried out using a special method. What is laparoscopy, what is its value?

Laparoscopy: what is it?

Laparoscopy is a surgical procedure done with a special illuminated tube. It differs from conventional surgery in that a much smaller incision is made and such an operation is easier to transfer.

Laparoscopy is a modern and very effective method, with its help you can carry out a number of necessary procedures:

• Check the abdominal cavity and pelvic area in women for the presence of various formations, take their samples;
• To determine such difficultly accessible conditions as an ectopic pregnancy;
• Partially determine the cause of infertility;
• Check for metastases, cancerous tumors;
• Take a biopsy;
• Determine the damage to internal organs as a result of trauma;
• Operate inguinal hernia and other simple operations;
• Make a dressing;
• In case of serious damage and the need to remove cysts in the uterus, ovaries, gallbladder, spleen;
• Get ahead of the causes of sudden abdominal pain.

Recently, this method has been used very actively, it is especially popular in gynecology.

Indications and contraindications for laparoscopy

Laparoscopy is very popular, but this method is a little more expensive than the usual surgical one, so not everyone is available. It is used in all traditional operations on the abdominal organs at the request of the patient. This procedure is distinguished by its simplicity, information content and versatility.

Indications for laparoscopy:

• Infertility or problems conceiving and carrying a child;
• Obstruction of the fallopian tubes;
• Ectopic pregnancy;
• Various formations on the ovaries and their appendages: fibroids, polyps, cysts and others;
• severe form;
• Diseases of the internal organs caused by the inflammatory process;
• Malignant formations in various organs of the abdominal cavity;
• Definitions of the etymology of abdominal and liver pain.

The operation is quite easy and its efficiency is over 90%. But there are also a number of contraindications that are presented to diseases acute form... Absolute contraindications are:

• Bronchial asthma and other diseases of the respiratory system at the stage of exacerbation;
• Insufficient blood clotting;
• Disturbances in the work of the cardiovascular system;
• Shock states;
• Period of menstruation;
• High unstable hypertension;
• Acute infectious diseases.

Relative contraindications are represented by the following conditions:

• and ovaries;
• Large size of pathological formations;
• More than one liter of blood in the abdomen as a result of bleeding;
• A large number of adhesions in the postoperative period;
• Obesity of the third and fourth stages.

Laparoscopy is performed only when vital signs are normal and there is no way to harm while it is being performed. In addition, before the procedure, a series of laboratory research... With relative contraindications, the doctor determines the possibility of surgery and can prescribe it if necessary.

Preparation and course of the operation

Laparoscopy is newest method diagnosis and operation, but it requires a special approach and special training.

Before receiving a referral for surgery, the patient must undergo a series of examinations:

• Coagulogram - to determine blood clotting;
• A blood test, including samples for the norms of sugar, bilirubin and total protein;
• General analyzes of urine and blood;
• Tests for hepatitis, HIV and AIDS;
• Electrocardiography;
• X-ray;
• Vaginal swab (in the case of gynecological surgery);
• Ultrasound of the lower pelvic organs (in case of surgery on the lower organs).

All these tests can be passed in one day, after which you can go to a therapist with the results. He gives an opinion and direction for laparoscopy. If the treatment involves a gynecological nature, then instead of a therapist, women go to a gynecologist. After all procedures, the patient gives written consent to the operation.

Before the operation itself, a number of procedures are required:

• With the help of an enema, cleanse the intestines for a better view; on the day of the operation, it is unacceptable to consume liquid and food
• If the operation is performed in the lower pelvis. It is worth shaving off your pubic hair;
• Do not drink any medications the day before;
• Use means to prevent pregnancy a month before the procedure.

Laparoscopy is performed routinely in a stationary mode. For diagnostic purposes, the procedure is performed under local anesthesia, with the surgical method - under general anesthesia.

During the operation, the desired area is treated with an antiseptic, an incision is made, the diameter of which is 5-10 mm. A laparoscope is led into the hole and carbon dioxide is released. The abdominal cavity is raised and the visibility of the internal organs is quite good. Then surgeons carry out actions depending on the pathology. The duration of such a procedure also depends on the location, size and characteristics of the disease, from 30 minutes to hours.

After graduation, gas is released from the cavity, the incisions are sutured, and the patient calmly comes out of anesthesia.

Complications after laparoscopy are extremely rare. They appear as follows:

• Various injuries of internal organs as a result of the introduction of instruments;
• Bleeding as a result of injury to large vessels;
• Headache and dizziness as a result of anesthesia.

The percentage of such complications is observed in no more than 1% of patients. A doctor will be able to eliminate such side effects. Rehabilitation after surgery does not take long. The stitches are removed after seven days. After that, for a few more months you should not be zealous with physical activity, until complete renewal.

State of the art modern medicine allows some surgical operations without large cuts. Laparoscopy is one such method that allows you to examine and operate on internal organs. The procedure is widely used in gynecology, both in our country and abroad.

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What is the essence of the method

Laparoscopic intervention - popular method of diagnosis and treatmentmany diseases and processes affecting the genitourinary sphere.

This is a low-traumatic operation, which is performed through a small incision in the anterior abdominal wall using high-precision instruments and a special video camera.

The advantage of this procedure is that after it complications rarely occur recovery is quick, and within a few days the patient can live an active and fulfilling life.

You should not be afraid of the procedure: the doctor informs in advance about all important aspects:

• what tests need to be done before laparoscopy;
• what manipulations are carried out during the procedure;
• how long will it take to recover;
• what regimen to follow and what you can eat after laparoscopy.

Feature of diagnostic laparoscopy

Diagnostic laparoscopy is differentfrom the usual purpose of holding. In the first case, it means first examination and identification of pathology, and then its elimination, in the second case, the operation is performed immediately.

Within the framework of one procedure, the doctor can both find the cause of the ailment and eliminate it, but this is not always the case. Example: During diagnostic laparoscopy, a cyst may be detected. To remove it, you need a separate operation.

The diagnostic procedure is highly accurate, as powerful equipment is used that can multiply the area under study. An examination is made not only of the abdominal cavity, but also of the surrounding space.

Medical examination

Laparoscopy is requiredin cases where:

• the patient complains of pain in the pelvic region or in the abdomen;
• neoplasms of unknown origin appeared;
• the cause of the obstruction of the fallopian tubes is unknown;
• you need to determine the causes of infertility;
• it is necessary to check whether the fallopian tubes passable along the entire length.

To clarify the diagnosis do laparoscopy in the following situations:

• the woman has (or is regularly) pains in the abdomen, while there is a suspicion that they are caused by internal bleeding, appendicitis, adhesions or;
• upon examination, the doctor or the patient herself discovered a tumor;
• fluid is present in the abdominal cavity;
• another study showed pathological changes in the outer tissues of the liver;
• for whatever reason, you need to artificially make the fallopian tubes impassable.

Other situations are possible when laparoscopy in gynecology provides accurate information about the state of the organ.

Important!When an internal organ is examined, the doctor has the opportunity to take a tissue sample to conduct a more thorough analysis after the procedure.

Features of preparation

The specialist tells the patient in advance what laparoscopy is, why it is needed in a particular case, and how long it will take.

The patient is also notified in advance of possible complications after the procedure or during it.

Preparation for laparoscopy differs depending on whether or not emergency or planned intervention.

If there is an emergency surgery, they measure the pressure, check the blood for coagulability and determine the group (in case a transfusion is needed). Before the scheduled procedure, blood and urine tests, cardiogram and fluorography are done.

Preparation of the patient for laparoscopy begins after the test results are ready. During the day, you need to reduce the amount of food and liquid consumed. The last meal should be no later than 5 pm. In the evening and in the morning, an enema is done, the remaining preparatory manipulations are also carried out in the morning, before the operation. On the day of the laparoscopy do not eat or drink!

Laparoscopy

Laparoscopy in gynecology in almost all cases is done under general anesthesia. Exceptions are diagnostic procedures or short-term interventions. They can be performed with anesthesia to a limited part of the body. In such cases, regional anesthesia or spinal epidural anesthesia is practiced.

Important!General anesthesia is not used during the procedure if the woman cannot tolerate a particular drug.

When choosing an anesthetic and calculating its amount, the anesthesiologist takes into account the patient's gender, weight, height, age and existing chronic diseases.

First, anesthesia is administered, then the woman is connected to an artificial respiration apparatus and a catheter is inserted. When the anesthetic works, three small holes (incisions) are made in the peritoneum or other area.

How the incisions are made depends on the type of operation. For example, to remove a cyst, an incision is made lower part the front wall of the abdomen.

The hole for the video camera is larger than the others, usually under or above the navel. A camera and instruments are passed through the incisions into the cavity. A special gas is pumped into one of the holes so that the tools can be moved. After completing these actions, an image appears on the monitor. Focusing on it, the surgeon performs manipulations in the body cavity.

The duration of the operation dependsfrom the nature of the pathologists, usually diagnostic laparoscopy lasts from 15 minutes to 1 hour. When the procedure is over, remove the instruments and the chamber, pump out the gas. Two holes are sutured, and in the third, a drainage tube is installed to remove the contents of wounds, abscesses, as well as postoperative residues in the form of bloody particles from the peritoneum. In this case, it is imperative to install drainage, because it prevents peritonitis.

Since the procedure takes place under general anesthesia, pain is not felt, but it is may arise laterwhen the anesthetic wears off.

Postoperative period

Recovery after laparoscopy in most patients proceeds quickly and without complications. Already in the first few hours, starting from the time when the anesthesia ceases to work, you can turn in bed, sit down and go to bed on your own.

After 5-7 hours, if the patient feels well, she can begin to walk.

In the first 5-6 hours, painful sensations persist in the lower back and abdomen, but you should not be afraid of this. If the pain is mild, you can do without analgesics, otherwise it is recommended to take a pill.

On the day of laparoscopy and the next day, some patients have a fever - usually it does not exceed 37.5 degrees. Discharge in the form of ichor and transparent mucus from the genital tract is possible. They usually stop after 1 or 2 weeks, but if this does not happen, you need to see a doctor.

How to eat after the procedure

A special diet after the procedure is recommended due to the weakening of the intestines. On the first day, he is not able to fully perform his functions. In addition, nausea and vomiting sometimes occur. The reason is that the body has not yet fully recovered from anesthesia, and the intestines and other organs have been irritated by laparoscopic instruments and gas.

You can drink after the procedure no earlier than 2 hours later. For 1 time allowed drink 2-3 sips ordinary or mineral water, strictly without gas! The next portion can be drunk in an hour, and so on.

The rate of consumed water is increased gradually, bringing it to the usual volume in the evening. If the next day there is no bloating and nausea, you can start eating light food, but only on the condition that active intestinal motility is present. Water is allowed to drink without restrictions.

If the nausea and vomiting persist, the patient is left in the hospital and measures are taken to keep the intestines working. Treatment includes stimulation, a fasting diet and the introduction of electrolytes through a dropper

Consequences and complications

The negative consequences of laparoscopy are rare and mainly arise due to the individual characteristics of the organism.

Possible consequences

Most dangerousphenomena:

• pneumothorax;
• subcutaneous emphysema with mixing or compression of the mediastinal organs;
• perforation of the wall or damage to the outer lining of the intestine;
• gas embolism (the result of the ingress of carbon dioxide into the vessel);
• massive bleeding resulting from trauma to a vein, artery, or large vessel.

Long-term complications after laparoscopy -adhesions, which, depending on localization, can lead to infertility, dysfunction of the gastrointestinal tract. Adhesions are formed both against the background of the existing pathology and as a result of the inept actions of the surgeon, but more often they are due to the characteristics of the organism.

It is extremely rare, but it also happens that during the procedure a small vessel is damaged or the liver capsule ruptures, and this goes unnoticed. In the postoperative period, slow bleeding develops. In such a situation, repeated surgical intervention is required.

Non-dangerous consequences- a small amount of gas or hematoma in the places where the instruments were inserted. Such formations dissolve on their own.

Care of seams

Sutures after laparoscopy are lubricated with antibacterial drugs daily, and if necessary, several times a day. The doctor tells you in detail how to do this. Use first alcohol solution, and then brilliant green or, if there is a burning sensation, hypertonic solution.

For processing you need to use gauze swab,but by no means cotton wool, as its particles can catch on the seam and provoke inflammation. If the wound is not sealed, it will heal faster, but in this case the risk of injury increases, so the final decision remains with the doctor. The stitches are removed through 7 days after the procedure, and when using self-absorbable threads, this is not necessary.

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 the gynecologist D.O. Ott. Later, domestic and foreign scientists developed and introduced laparoscopy for diagnosis and treatment. various diseases abdominal cavity. For the first time, a laparoscopic gynecological operation was performed in 1944 by R. Palmer.

LAPAROSCOPY SYNONYMS

Peritoneoscopy, ventroscopy.

RATIONALE OF LAPAROSCOPY

Laparoscopy provides significant better overview 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 visualizing all floors of the abdominal cavity and retroperitoneal space, and, if necessary, carry out surgical intervention.

PURPOSE OF LAPAROSCOPY

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

LAPAROSCOPY INDICATIONS

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

• Planned indications:

1. tumors and tumor-like formations of the ovaries;
2. genital endometriosis;
3. malformations of internal genital organs;
4. pain in the lower abdomen of unclear 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 pedicle or rupture of a tumor-like formation or tumor of the ovary, as well as torsion of subserous myoma;
5. differential diagnosis between acute surgical and gynecological pathology.

CONTRAINDICATIONS OF LAPAROSCOPY

Contraindications to laparoscopy and laparoscopic operations depend on many factors and primarily 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. diseases of the cardiovascular 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 hepato-renal failure;
6. ovarian cancer and BMT (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 abdominal and pelvic organs;
4. late pregnancy (more than 16-18 weeks);
5. suspicion of a malignant nature of the formation of the uterine appendages.

• Also, contraindications for performing planned laparoscopic interventions are:

1. existing or transferred less than 4 weeks ago acute infectious and colds;
2. grade III – IV purity of vaginal contents;
3. inadequate examination and treatment of a married couple at the time of the alleged endoscopic examinationplanned for infertility.

PREPARATION FOR LAPAROSCOPIC EXAMINATION

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

Before laparoscopic intervention, great importance should be given to talking with the patient about the upcoming intervention, its features, and possible complications. The patient should be informed about the possible transition to celiac disease, about the possible expansion of the volume of the operation. Written informed consent from the woman 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. Medical preparation depends on the nature of the underlying disease and the planned operation, as well as on the concomitant extragenital pathology. METHOD

Laparoscopic interventions are performed in a confined 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 pneumoperitoneum, gas (carbon dioxide, nitrous oxide, helium, argon) is injected into the abdominal cavity, which raises the abdominal wall. Gas is injected 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 ensuring the specified requirement are:

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

All of the above conditions are met by 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 for the application of pneumoperitoneum!

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

Fig. 7-62. Needle Veresh.

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

Along with the convenience of laparoscopy, pneumoperitoneum has a number of important disadvantages and side effectsincreasing the risk possible complications with laparoscopy:

• compression of the venous vessels of the retroperitoneal space with impaired blood supply to the lower extremities and a tendency to thrombus formation;
• violations of arterial blood flow in the abdominal cavity;
• cardiac disorders: decrease 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 the previous operations. The most common place for the introduction of the Veress needle and the first trocar is the navel - the point of the shortest access to the abdominal cavity. Another most frequently used point for the introduction 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 about the topography of the epigastric artery. In the presence of previous operations on the abdominal organs, for the primary puncture, a point is chosen as far as possible from the scar.

You can enter the Veress needle through the posterior fornix of the vagina if there are no pathological formations in the posterior 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 dissecting the skin, the abdominal wall is lifted by hand, a pin or a ligature (to increase the distance between the abdominal wall and the abdominal organs) and a Veress needle or trocar is inserted into the abdominal cavity at an angle of 45–60 °. The correct insertion of the Veress needle into the abdominal cavity is checked different ways (drip test, syringe test, hardware test).

Some surgeons prefer direct puncture of the abdominal cavity 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 a trocar, however, the nature of the damage, given the diameter of the instrument, varies in severity.

Fig. 7-64. Direct insertion of the central trocar.

The technique of open laparoscopy is indicated when there is a danger of damage to internal organs during adhesions 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. In recent years, to prevent damage to the abdominal cavity organs when entering the abdominal cavity during the adhesions process, an optical Veress needle or video trocar has been used (Fig. 7–65).

Fig. 7-65. Veress optical needle.

After puncture of the anterior abdominal wall with a Veress needle or trocar, gas insufflation is started, first slowly at a rate of no more than 1.5 l / min. With the correct position of the needle after the injection of 500 ml of gas, hepatic dullness disappears, the abdominal wall rises evenly. Usually 2.5-3 liters of gas are injected. Obese or large patients may require 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) - gasless laparoscopy. The anterior abdominal wall is lifted using various devices. This method is indicated for patients with cardiovascular insufficiency, ischemic disease heart and arterial hypertension stage II – III, a history of myocardial infarction, heart defects, after undergoing heart surgery.

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

Chromosalpingoscopy. For 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 the uterine cavity. In the process of introducing a dye, the process of filling the fallopian tube with it and the flow of blue into the abdominal cavity are analyzed. The cervix is \u200b\u200bexposed 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 slope of the cannula nose must match the slope of the uterine cavity. A methylene blue syringe is connected to the distal end of the cannula. Under pressure, blue is injected into the uterine cavity through a cannula, and during laparoscopy, the flow of methylene blue into the fallopian tubes and abdominal cavity is assessed.

INTERPRETATION OF LAPAROSCOPY RESULTS

The laparoscope is inserted into the abdominal cavity through the first trocar. First of all, the area under the first trocar is examined to exclude any damage. Then, first, the upper abdomen is examined, paying attention to the state of the diaphragm, and the state of the stomach is assessed. In the future, all parts of the abdominal cavity are gradually examined, paying attention to the presence of effusion, pathological formations and the prevalence of adhesions. For a thorough revision of the abdominal and pelvic organs, 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 into the iliac regions. If necessary, the fourth trocar is placed in the midline of the abdomen at a distance of 2/3 from the navel to the bosom, but not below the 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 kind surgical intervention, may be accompanied by unforeseen complications that pose a threat not only to the health, but also to the patient's life.

Specific complications typical for 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 entry of gas into various tissues other than the abdominal cavity. This can be the subcutaneous fat layer (subcutaneous emphysema), preperitoneal air injection, air ingress into 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 extraction 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 injury to the main retroperitoneal vessels is associated with the occurrence of massive intra-abdominal bleeding and an increase in the mesenteric root hematoma. In such a situation, an emergency midline laparotomy and the involvement of vascular surgeons in the operation are necessary.

Damage to the vessels of the anterior abdominal wall occurs most often with the introduction of additional trocars. The cause of such damage 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... If such complications occur 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 abdominal organs, the intestines are most often damaged; damage to the stomach and liver is rarely observed. More often, 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 respect, electrosurgical injuries are the most dangerous. Perforation in the burn area occurs on a delayed basis (5–15 days after surgery).

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

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 with a flow of gas that can penetrate into the lumen of the vessels being crossed. The onset of gas embolism is manifested by sudden hypotension, cyanosis, cardiac arrhythmia, hypoxia, resembles clinical picture myocardial infarction and thromboembolism pulmonary artery... Often this condition is fatal.

Damage to the main retroperitoneal vessels is one of the most dangerous complications that can pose an immediate threat to the patient's life. Most often, injury to the great vessels occurs at the stage of access to the abdominal cavity with the introduction of a Veress needle or the first trocar. The main reasons for this complication are considered inadequate pneumoperitoneum, perpendicular insertion of the Veress needle and trocars, and excessive muscular effort by the surgeon when inserting the trocar.

For the prevention of complications during laparoscopy:

• a careful selection of patients for laparoscopic surgery is required, 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 the operated objects and sufficient space in the abdominal cavity are required;
• only functional endosurgical instruments and equipment should be used;
• adequate anesthesia is needed;
• a differentiated approach to the methods of hemostasis is needed;
• the speed of the surgeon's work should correspond to the nature of the stage of the operation: quick execution of routine techniques, but careful and slow execution of critical manipulations;
• in case of technical difficulties, serious intraoperative complications and unclear anatomy, one should proceed to immediate laparotomy.