Transvaginal Hydrolaparoscopy, a New Technique for Pelvic Assessment

Transvaginal Hydrolaparoscopy Bajzak et al

Transvaginal Hydrolaparoscopy, a New Technique for Pelvic Assessment Krisztina I. Bajzak, M.D., Wendy K. Winer, R.N., BSN, CNOR, and Thomas. L. Lyons, M.D.

Abstract Transvaginal hydrolaparoscopy is based on classic culdoscopy. With alterations in equipment and method, the procedure holds promise for evaluation of pelvic pathology. We performed transvaginal hydrolaparoscopy in the operating room just before operative laparoscopy in 15 patients, to evaluate the feasibility of this procedure. Excellent images of the cul-de-sac, fimbriae, and caudal surface of the uterus, ovaries, and pelvic sidewall were obtained. We believe this is a practical and convenient office diagnostic procedure. (J Am Assoc Gynecol Laparosc 7(4):562–565, 2000)

and became competitive with culdoscopy. Of many reasons cited for the superiority of laparoscopy, the most common are better visualization of the upper pelvis, discomfort of knee-chest position, and capacity and ease of performing a wider range of minor procedures. Eventually, due to perceived problems, culdoscopy became all but extinct. However, some maintained that the two were complementary rather than competitive.3 Culdoscopy and its equipment were modified for application to modern practice of gynecology, yielding THL. Visualization of ovulation was reported using this instrument.4 Microlaparoscopy was investigated regarding its potential for pelvic assessment in the office setting, but has not received widespread acceptance, possibly due to the inconvenience of patient sedation in the office setting. Transvaginal hydrolaparoscopy offers a feasible alternative as an office diagnostic procedure, using only local anesthesia, with additional potential for minimally invasive ovarian sampling. We performed THL in women in the operating room, just before operative laparoscopy, to assess the quality of visualization of pelvic pathology.

Transvaginal hydrolaparoscopy (THL) is based on the principles of culdoscopy. Decker first reported culdoscopy in 1944.1 It was a diagnostic procedure performed in the knee-chest position under regional or local anesthesia. Controlled gas insufflation was used for distention, and the diameter of the scope was 0.31 inches (7.9 mm). Clyman modified the original instrument, yielding better light transmission, an improved lens system, and operative attachments.2 His instrument was designed for spontaneous air pneumoperitoneum. The original instrument had a collar to limit trocar penetration, and this was excluded on the modified panculdoscope. Operative and diagnostic culdoscopy were revolutionary, providing the first widely performed and minimally invasive alternative to conventional pelvic surgery by laparotomy. The procedure thus became “an invaluable asset in the study of obscure pelvic disorders.”1 As the number of possible operative interventions increased, so too did the diameter of the instrument (up to 11 mm) and amount of analgesia required. With accompanying advancements in equipment (fiberoptic light source, controlled gas insufflators, etc.) and safer general anesthesia, laparoscopy was introduced

From the Center for Women’s Care and Reproductive Surgery, Atlanta, Georgia (all authors). Address reprint requests to Krisztina I. Bajzak, M.D., Suite 6107, 9104 Babcock Boulevard, Pittsburgh, PA 15237; fax 412 366 3082. Supported by an unrestricted educational grant from Circon Corporation, Stamford, Connecticut. Accepted for publication July 6, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, November 2000, Vol. 7 No. 4 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.

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Materials and Methods

Results

To date, we have performed THL in 15 women just before operative laparoscopy. Preoperative diagnoses included endometriosis, pelvic pain, adnexal mass, and suspected adhesive disease. Most procedures were performed under general anesthesia, with one performed under local anesthesia.

Pictures obtained in this manner are quite striking in clarity and magnification, and even superior, at times, to visualization at laparoscopy (Figures 2 and 3). Especially well seen are fimbriae; caudal surfaces of ovaries, uterus, and broad ligaments; and pelvic sidewalls. Use of a fluid medium in particular adds to the clarity, allowing tissues to be observed without irritation that can accompany carbon dioxide pneumoperitoneum.5 None of our patients experienced complications related to THL.

Operative Procedure With the patient in Trendelenburg position, the posterior lip of the cervix was grasped with a tenaculum (after injecting 1% lidocaine at the site if the patient was awake) and gentle upward traction was placed to expose the posterior fornix. A modified Veress needle, loaded into a dilating obturator and sheath, was introduced by holding it flush with the posterior cul-de-sac, between uterosacral ligaments. With minimal pressure, the Veress needle popped easily into the cul-de-sac of the peritoneal cavity. The dilating sheath was advanced over the needle. The needle was removed and warm normal saline, about 300 ml, was instilled through a side port. At this point, the dilator was removed, leaving the sheath in place, through which the telescope was advanced. Both 30-degree and 70-degree telescopes are available (Figure 1). The diameter of the telescope was 2.7 mm and the diameter of the sheath 3.5 mm. A conventional laparoscopic fiberoptic light source and camera were used.

Discussion Transvaginal hydrolaparoscopy differs from conventional culdoscopy in many ways. First, the lithotomy position with slight Trendelenburg may be more acceptable to patients than knee-chest position. The quality of pictures is certainly improved by advancements in equipment. Smaller instrument diameter should improve patient tolerance of the procedure, and require only local anesthesia. Finally, fluid medium for distention is more conducive to examination of tissues. It adequately maintains distention in the cul-de-sac, despite mild Trendelenburg position. This was the case in our patients, who subsequently underwent laparoscopy in which fluid was seen pooling in the cul-de-sac on entry into the abdomen. Although excess fluid was aspirated at the conclusion of laparoscopic procedures, it is anticipated that the 300 ml of normal saline used during THL would be rapidly absorbed by the peritoneal surface. Ultimately, THL may compare favorably with microlaparoscopy for several reasons. Reported pain scale scores during microlaparoscopy are in the range of 5 out of 10, excluding pain mapping.6,7 There is every reason to believe that THL will be at least as well tolerated. Fluid distention medium should cause less peritoneal irritation than carbon dioxide. An improved view of the caudal surface of ovaries, uterus, pelvic sidewall, fimbriae, and cul-de-sac is provided, and in general, this is where most pelvic pathology is located.8 Patients suspected or known to have dense adhesions of the cul-de-sac are not considered eligible for the procedure, to decrease the risk of bowel injury. Inability to tolerate Trendelenburg position is also considered a contraindication.

FIGURE 1. Left to right: speculum, modified Veress needle, obturator, sheath, and two telescopes.

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B

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FIGURE 2. (A) Vascular adhesion involving the pelvic sidewall. (B) Classic red-brown endometriosis. (C) Tip of the appendix. (D) Ovarian adhesions and endometriosis.

A

B

FIGURE 3. (A) Adhesion of the right ovary to the pelvic sidewall seen at THL. (B) The same adhesion seen at laparoscopy.

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Potential applications of THL are many and may include assessment of ovarian cysts, chronic pelvic pain, and pelvic adhesive disease, especially fimbrial adhesions and tubal patency. Perhaps the most exciting possibility is screening for ovarian cancer by serial visual assessment and ovarian biopsy. We intend to investigate THL as a diagnostic procedure in the office setting and submit the resulting series for evaluation of feasibility, indications, contraindications, and complications.

4. Gordts S, Campo R, Brosens I, et al: Endoscopic visualization of the process of fimbrial ovum retrieval in the human. Hum Reprod 13:1425–1428, 1998 5. Buhur A, O Taskin, Burak F, et al: Effects of duration of CO2 insufflation on peritoneal microcirculation assessed by free radical scavengers and total glutathion levels during operative laparoscopy. J Am Assoc Gynecol Laparosc 4:S16–S17, 1997 6. Palter SF, Olive DL: Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Am Assoc Gynecol Laparosc 3:359–364, 1996

References 1. Decker A, Cherry TH: Culdoscopy. A new method in the diagnosis of pelvic disease: Preliminary report. Am J Surg 64:40–44, 1944

7. Palter SF, Olive DL: Office laparoscopy under local anesthesia for infertility: Utility, acceptance, and costbenefit/outcome analyses. Fertil Steril 64:S8–9, 1995

2. Clyman MJ: Culdoscopy. Surg Clin North Am 37: 1357–1366, 1957

8. Helsa JS, Rock JA: Endometriosis. In TeLinde’s Operative Gynecology, 8th ed. Edited by JA Rock, JD Thompson. Philadelphia, JB Lippincott, 1997, p 586

3. Roland M: Culdoscopy and laparoscopy: Competitive or complementary technics? Fertil Steril 4:361–376, 1970

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