Content

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

What is laparoscopy in gynecology

A method that causes the least amount of trauma and damage during diagnosis or surgery, with the smallest number of invasive penetrations - this is what laparoscopy of the uterus and ovaries is in gynecology. To reach the female genital organs without a large incision, three or four punctures are made in the abdominal wall, after which special instruments called laparoscopes are inserted. These instruments are equipped with sensors and lighting, and the gynecologist “with his own eyes” evaluates the process occurring inside, coupled with the diagnosis of the female genital organs.

Indications

Laparoscopy is widely used, since it is considered in gynecology the most convenient way to simultaneously carry out diagnostics and surgical intervention for the treatment of pathological processes of unknown etiology. Gynecologists evaluate “live” the condition of a woman’s genital organs if other research methods have not proven effective for an accurate diagnosis. Laparoscopy is used for the following gynecological pathologies:

• if a woman is diagnosed with infertility, the exact cause of which gynecologists cannot identify;
• when gynecological therapy with hormonal drugs was ineffective for conceiving a child;
• if you need to perform surgery on the ovaries;
• with endometriosis of the cervix, adhesions;
• with constant pain in the lower abdomen;
• if you suspect myoma or fibroma;
• for ligation of uterine tubes;
• in case of ectopic pregnancy, tubal ruptures, breakthrough bleeding and other dangerous pathological processes in gynecology, when emergency intracavitary gynecological surgery is necessary;
• when the pedicle of an ovarian cyst is twisted;
• with severe dysmenorrhea;
• for infections of the genital organs accompanied by the discharge of pus.

On what day of the cycle is it done?

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

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

Preparation

In gynecology, laparoscopy can be prescribed routinely or performed urgently. In the latter case, there will be practically no preparation, because gynecologists will strive to save the patient’s life, and this situation does not involve a long collection of tests. Immediately before the operation, the patient's blood and urine are collected, if possible, and studies are carried out after the fact, after laparoscopy. When performing laparoscopy as planned, preparation includes collecting data on the patient’s current condition and restricting the diet.

Analyzes

Patients are surprised by the extensive list of necessary tests before laparoscopy, but before any abdominal gynecological surgery it is necessary to do the following tests:

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

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

Diet before laparoscopy in gynecology

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

• 7 days before laparoscopy, you should abstain from any foods that stimulate gas formation in the stomach and intestines - legumes, milk, some vegetables and fruits. The intake of lean meat, boiled eggs, porridge, and fermented milk products is indicated.
• For 5 days, the gynecologist prescribes the use of enzymatic agents, activated carbon, to normalize digestion.
• The day before the procedure, you can only eat pureed soups or liquid porridges; you cannot have dinner. You need to do a cleansing enema in the evening if the gynecologist prescribed it.
• Immediately before laparoscopy, you should not eat or drink anything to keep your bladder empty.

Does it hurt to do

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

How they do it

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

Recovery after laparoscopy

Some gynecologists prefer that the patient regain consciousness after laparoscopy directly on the operating table. This way you can check the general condition of the patient and prevent complications. However, in most cases, the patient is transferred to a gurney and taken to the ward.

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

Nutrition

Immediately after the operation, the patient is not allowed to eat anything - she can only drink clean water without gas. On the second day, you are allowed to drink low-fat broths and unsweetened tea. And only on the third day are you allowed to eat pureed foods, porridge, pureed meatballs or cutlets, pureed meat, and yoghurts. Since the intestines are very close to the genitals, during healing you need the most gentle diet that will not contribute to gas formation or increased peristalsis.

Sexual rest

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

Contraindications

Laparoscopy has few contraindications. These include:

• intensive process of dying of the body - agony, coma, state of clinical death;
• peritonitis and other serious inflammatory processes in the body;
• sudden cardiac arrest or difficulty breathing;
• severe obesity;
• hernia;
• the last trimester of pregnancy with a threat to the mother and fetus;
• hemolytic chronic diseases;
• exacerbation of chronic gastrointestinal diseases;
• the course of ARVI and colds. We'll have to wait for a full recovery.

Consequences

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

Complications

As with any penetration into the abdominal cavity, there are complications with laparoscopy. For example, after punctures during the insertion of a laparoscope, blood vessels may burst and a slight hemorrhage may begin, and carbon dioxide in the abdominal cavity can enter the tissue and contribute to subcutaneous emphysema. If the vessels are not sufficiently compressed, blood can enter the abdominal cavity. However, the professionalism of the gynecologist and a thorough examination of the abdominal cavity after the procedure will reduce the likelihood of such complications to zero.

Price

Since laparoscopy is an intervention under general anesthesia, the cost of this gynecological procedure is high. The price breakdown for Moscow is given in the table below:

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

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Diagnostic laparoscopy, like no other type of examination, allows the most gentle way to identify and eliminate many serious gynecological diseases.

Often this study helps to detect diseases of the female genital area at an early stage, when it is still possible to completely cure the disease, and when other diagnostic methods turn out to be of little information. At the same time, it is possible to completely preserve women's health.

What is the method of diagnostic laparoscopy, who is it indicated for, how is it performed and what are the advantages?

Laparoscopy refers to a minor surgical intervention without the usual incision in the abdominal wall. This minimally invasive (low-traumatic) operation is performed using special endoscopic equipment with an optical system.

A laparoscope is a rigid endoscope equipped with an optical system, a lighting device and precise surgical micro-instruments.

The laparoscope is inserted into the abdominal cavity through micro-incisions. During an operation using it, air is pumped into the abdominal cavity, which improves the visualization of organs and their pathologies. Images of all examined organs are displayed on the screen.

The laparoscope examination is performed under intravenous anesthesia. This operation allows you to examine and directly examine the smallest defects of the pelvic organs.

The method allows you to make an accurate diagnosis and find the optimal method of treating the identified gynecological disease.

During laparoscopy, a layer-by-layer tissue incision is not made, which significantly facilitates its course and the subsequent postoperative period.

Advantages of diagnostic laparoscopy:

• minimal blood loss;
• short period of hospital stay;
• clear visualization of the organs being examined;
• adhesions are excluded;
• rapid postoperative recovery (usually 3-7 days);
• absence of severe postoperative pain;
• minimal cosmetic defects after the intervention.

When is diagnostic laparoscopy performed?

Diagnostic laparoscopy in gynecology is not prescribed for every patient. There must be special reasons for such interference. Most often, this diagnostic method is used if other diagnostic methods have proven ineffective in establishing or clarifying the diagnosis.

Typically, this type of minimally invasive intervention is prescribed for:

1. suspected of having an ectopic (ectopic) pregnancy;
2. suspicion of a tumor-like process in the ovarian area, to identify the stage of this process (to clarify the possibility and scope of future surgery);
3. infertility of unknown etiology;
4. the need for a biopsy for newly identified ovarian tumors or polycystic disease;
5. clarifying the location and nature of genital abnormalities;
6. prolapse or prolapse of the genital organs;
7. diagnosis of tubal obstruction in infertility (if other gentle diagnostic methods turned out to be ineffective);
8. carrying out sterilization;
9. identifying the causes of chronic pelvic pain (especially with endometriosis);
10. monitoring the integrity of the uterine wall during operations to excise it (during hysteroresectoscopy);
11. study of the effectiveness of treatment of inflammation of the female genital area.

Emergency diagnostics

In addition to planned, in gynecology there is also an emergency (unplanned) type of laparoscopic diagnosis. This type of study is carried out in case of sudden situations that threaten the health or life of a woman.

An emergency diagnostic method may be necessary when:

1. Suspicion of the development of acute conditions in the pelvis when clarifying the following diagnoses:
   • perforation of the uterus;
   • torsion of the cyst legs;
   • apoplexy, tumors or necrosis of the ovary or myomatous node;
   • rupture of an ovarian cyst;
   • preserved tubal pregnancy or suspicion of incipient tubal abortion;
   • suspected pelvioperitonitis due to inflammatory, tumor or purulent formations in the fallopian tube.
2. Symptoms of “acute abdomen” for unknown reasons, including when gynecological pathologies are suspected.
3. Lack of effect and increasing worsening condition in the treatment of acute inflammation of the uterine appendages.
4. Loss of the intrauterine device inside the body.

Often, simultaneously with diagnosis during laparoscopy, it is also possible to treat the identified pathology. This type of laparoscopy is already therapeutic and can be performed with suturing the uterus, restoring tubal patency, dissecting adhesions, emergency removal of uterine nodes, etc.

It is convenient that such manipulations are performed simultaneously with diagnostic laparoscopy.

Contraindications for diagnostic laparoscopy

Relative contraindications are considered to be those that are in effect at the moment, but can be overcome. Such contraindications are the following situations:

1. suspected malignant neoplasms in the uterus;
2. after recent abdominal operations;
3. general infectious diseases;
4. diffuse peritonitis;
5. obesity;
6. high degree of exhaustion of the body;
7. polyvalent (to several components) allergies;
8. pregnancy period over 16 weeks;
9. large ovarian tumors (more than 14 cm in diameter);
10. expanded uterine fibroids (more than 16 weeks).

Absolute contraindications

1. States of shock (including nervous shock) or coma.
2. Hemorrhagic shock after acute pathologies (ovarian apoplexy, rupture of a tube or cyst, etc.).
3. Stroke, heart attack.
4. Chronic pathologies of the cardiovascular or respiratory systems in the stage of decompensation.
5. Severe blood diseases (including coagulopathies with uncorrectable coagulation disorders).
6. Severe adhesions in the abdominal cavity (after serious interventions or prolonged inflammation).
7. Acute renal-liver failure.
8. Malignant tumors of the fallopian tubes or ovaries.
9. If tilting the head end of the operating table is contraindicated for the patient (after injuries or diseases of the brain, with a sliding diaphragmatic hernia or non-closure of the esophageal hiatus, etc.)

Laparoscopy for diagnostic purposes will not be effective if:

• tuberculosis of the genital organs;
• advanced severe endometriosis;
• the presence of a large number of adhesions in the peritoneal area;
• large size.

Often, after diagnostic laparoscopy, patients are prescribed laparotomy, which allows the newly identified disease to be cured with minimal trauma.

Preparation for laparoscopy

Properly carried out preparatory measures help to avoid serious complications during and after the intervention.

Main stages of preparation:

1. The right psychological attitude. You should not be afraid of this manipulation, but you need to be aware of the upcoming difficulties or possible pain. The attending physician, a specially printed “memo”, or competent information from the Internet can help a woman with this. The patient should be aware of possible risks or complications from the insertion of a laparoscope. Correct psychological perception helps to easily endure the procedure itself and the recovery period after it.
2. When compiling a patient’s medical history, all previous and existing diseases and her intolerance to certain medications must be taken into account.
3. Preparatory activities in the form of consultation with a gynecologist and doctors of other specialties (cardiologist, neurologist, surgeon, etc.) and the necessary hardware studies: MRI, pelvic ultrasound, fluorography (valid for 6 months), electrocardiography (valid for 1 month), X-ray, etc. This may require repeated studies or medical consultations.
4. Conducting laboratory research. In this case, 2 weeks before the expected date of manipulation, the patient is prescribed a series of tests: examination for syphilis, HIV and hepatitis (valid for 3 months), vaginal smear for flora (valid for 10 days). No earlier than 10 days before surgery, the patient must also undergo a general urine and blood test, and the blood is examined for coagulability and biochemistry.
5. At the same time, the department usually stores blood of the same type and Rh as the patient’s (in case of unexpected complications during laparoscopy).
6. Carrying out preparatory drug therapy. Some women during this period (if the prothrombin index is too high) are prescribed blood-thinning drugs. You should not disturb the systematic use of such drugs, as this can cause complications during this manipulation.
7. The point about dieting is important. Usually, 2 weeks before the study, the patient is advised to switch to a plant-fermented milk diet. 3-4 days before a laparoscope examination, a woman is advised to exclude from her diet foods that cause bloating and overly burden the digestive system (baked goods, legumes, smoked meats, alcohol, sweets). At the same time, medications that eliminate gas formation (chamomile infusion, activated carbon tablets) are prescribed.
8. The day before the study, the patient is recommended to reduce portions of food and liquid. A cleansing enema is also often prescribed. This procedure is all the more necessary since the effect of anesthesia during laparoscopy often has a relaxing effect on the intestines at the time of the examination.
9. Before the operation itself, the patient takes a shower with detergents. This also removes hair from the groin area.
10. On the day of surgery, the patient should not eat or drink anything.

Some patients consider endoscopic operations to be completely safe. This is largely true, but one should not neglect proper preparation and strictly follow medical prescriptions.

Scheme of diagnostic laparoscopy

Typically laparoscopy includes the following steps:

1. The patient is given intravenous (in rare cases, local) anesthesia. In this case, the dose is calculated and the choice of drug is made taking into account the age, weight and condition of the patient. Sometimes the patient is connected to an artificial respiration apparatus to ensure complete and regular breaths, eliminating stopping or breathing disturbances.
2. The doctor makes a micropuncture with a Veress needle (a device with a needle and a stylet) before inserting the laparoscope. The puncture location depends on the organ being examined (in gynecology, the lower abdomen).
3. The patient's abdomen is inflated using a special gas injected. This gas is non-toxic, does not cause allergies and is perfectly absorbed by tissues. The gas used for laparoscopy is usually argon, nitrous oxide or carbon dioxide. This is necessary for convenient movement of instruments in the peritoneum.
4. After introducing the gas, the specialist makes an incision and inserts the laparoscope. This is a modern device that does not allow injury to internal organs. Then the specialist makes several holes (in the navel area) for introducing micromanipulators and a video camera. After the instruments are inserted into the abdominal cavity, the camera is connected, which allows you to obtain an enlarged image of the organs being examined on the screen.
5. The surgeon examines the necessary organs. The examination time can take from 10 minutes to an hour. Particular attention is paid to examining adhesions, pathological formations, and fluid.
6. If this is necessary, a biopsy of the changed area of ​​the organ is performed and a section of its tissue is taken for histological examination. In some cases, the cyst is also punctured and fluid is taken from it to be sent to the laboratory.
7. At the end of the procedure, drainage must be installed. This is necessary for the free release of pathological fluids (blood residues, contents of ulcers, discharge from wounds). This is necessary to prevent peritonitis due to the entry of contents with pathogenic microflora into the abdominal cavity.

Alternative types of research

Hysteroscopy and transvaginal hydrolaparoscopy are also used to diagnose pelvic pathology in women. What are their characteristics?

Similar to diagnostic laparoscopy, but the device for examining the reproductive organs is inserted through the vagina. Then the instruments necessary for the study are inserted through the cervix into the uterine cavity. The image of all organs is also transmitted through a video camera to the monitor screen.

This procedure allows you to examine the pelvic organs, including the uterus and cervical canal. In addition, hysteroscopy does not require preparation and has almost no contraindications.

Hysteroscopy is often used simultaneously with diagnostic laproscopy. This allows for simultaneous diagnosis of pathology and its necessary treatment. With hysteroscopy it is also possible to perform minor surgical interventions.

The modern study called “transvaginal hydrolaparoscopy” is not known to everyone. This type of diagnosis is used for a detailed examination of the internal reproductive organs. In this case, a special probe is inserted into the uterus through micro-incisions, which allows you to examine the organs of the reproductive system with micro-operation, if necessary.

Diagnostic laparoscopy for infertility

Often, women who are unsuccessfully trying to become mothers, after ineffective treatment, are offered a diagnostic laparoscopy.

Sometimes during laparoscopy, the doctor simultaneously performs the following operations:

• restoration of patency of the fallopian tubes (sometimes this increases the risk of ectopic pregnancies);
• in case of ectopic pregnancy - removal of the fertilized egg while preserving the uterine (fallopian) tubes with the fullness of all their functions;
• dissection of adhesions between internal organs that interfere with normal reproductive function;
• for endometriosis – removal of heterotopia (fragments of overgrown endometrium), which often allows restoring female fertility.

Possible complications of diagnostic laparoscopy

The most common complications of diagnostic laparoscopy:

• injuries to the intestines, reproductive organs or urinary organs;
• gas embolism;
• internal bleeding;
• hernia formation;
• respiratory or cardiac problems;
• damage to blood vessels or abdominal organs;
• thrombosis or damage to peritoneal vessels;
• subcutaneous emphysema (accumulation of gas in the subcutaneous layer of fat).

Typically, complications after laparoscopy are associated with improper preparation for the intervention, underestimation of contraindications, or low professional level of the doctor.

Some complications resolve on their own, while others require medication or surgery.

Diagnostic laparoscopy is a modern and extremely safe type of examination. The diagnostic introduction of a laparoscope can work wonders by revealing previously unexplored causes of most serious gynecological diseases.

Laparoscopy is a minimally invasive operation, without a layer-by-layer incision of the anterior abdominal wall, which is performed using special optical (endoscopic) equipment to examine the abdominal organs. Its introduction into practice has significantly expanded the capabilities of general surgical, gynecological and urological doctors. The vast experience accumulated to date has shown that rehabilitation after laparoscopy, compared with traditional laparotomy access, is much easier and shorter in duration.

Application of the method in the gynecological area

Laparoscopy in gynecology has become especially important. It is used both for the diagnosis of many pathological conditions and for surgical treatment. According to various sources, in many gynecological departments, about 90% of all operations are performed using laparoscopic access.

Indications and contraindications

Diagnostic laparoscopy can be planned or emergency.

Indications

Routine diagnostics include:

1. Tumor-like formations of unknown origin in the ovarian area (you can read more about ovarian laparoscopy in ours).
2. The need for differential diagnosis of tumor formation of the internal genital organs with that of the intestine.
3. The need for a biopsy for the syndrome or other tumors.
4. Suspicion of an undisturbed ectopic pregnancy.
5. Diagnosis of patency of the fallopian tubes, carried out in order to determine the cause of infertility (in cases where it is impossible to carry it out using more gentle methods).
6. Clarification of the presence and nature of developmental anomalies of the internal genital organs.
7. The need to determine the stage of the malignant process to decide on the possibility and scope of surgical treatment.
8. Differential diagnosis of chronic pelvic pain with other pain of unknown etiology.
9. Dynamic monitoring of the effectiveness of treatment of inflammatory processes in the pelvic organs.
10. The need to control the preservation of the integrity of the uterine wall during hysteroresectoscopic operations.

Emergency laparoscopic diagnosis is carried out in the following cases:

1. Assumptions about possible perforation of the uterine wall with a curette during diagnostic curettage or instrumental abortion.
2. Suspicions:

- apoplexy of the ovary or rupture of its cyst;

- progressive tubal pregnancy or disrupted ectopic pregnancy such as tubal abortion;

- inflammatory tubo-ovarian formation, pyosalpinx, especially with destruction of the fallopian tube and the development of pelvioperitonitis;

— necrosis of the myomatous node.

1. An increase in symptoms over 12 hours or the absence of positive dynamics within 2 days in the treatment of an acute inflammatory process in the uterine appendages.
2. Acute pain syndrome in the lower abdomen of unknown etiology and the need for differential diagnosis with acute appendicitis, perforation of the ileal diverticulum, terminal ileitis, acute necrosis of the fat suspension.

After clarifying the diagnosis, diagnostic laparoscopy often turns into therapeutic laparoscopy, that is, it is performed on the ovary, suturing the uterus in case of its perforation, emergency in case of necrosis of the myomatous node, dissection of abdominal adhesions, restoration of patency of the fallopian tubes, etc.

Planned operations, in addition to some of those already mentioned, are plastic surgery or tubal ligation, planned myomectomy, treatment of endometriosis and polycystic ovaries (you will find the features of treatment and removal of ovarian cysts in the article), hysterectomy and some others.

Contraindications

Contraindications can be absolute and relative.

Main absolute contraindications:

1. The presence of hemorrhagic shock, which often occurs with rupture of the fallopian tube or, much less frequently, with ovarian apoplexy, and other pathologies.
2. Uncorrectable bleeding disorders.
3. Chronic diseases of the cardiovascular or respiratory systems in the stage of decompensation.
4. It is inadmissible to give the patient a Trendelenburg position, which consists of tilting (during the procedure) the operating table so that its head end is lower than the foot end. This cannot be done if a woman has a pathology associated with the vessels of the brain, residual consequences of a brain injury, a sliding hernia of the diaphragm or esophagus, and some other diseases.
5. Established malignant tumor of the ovary and fallopian tube, except when it is necessary to monitor the effectiveness of radiation or chemotherapy.
6. Acute renal-liver failure.

Relative contraindications:

1. Increased sensitivity to several types of allergens simultaneously (polyvalent allergy).
2. Assumption of the presence of a malignant tumor of the uterine appendages.
3. Diffuse peritonitis.
4. Significant, which developed as a result of inflammatory processes or previous surgical interventions.
5. An ovarian tumor with a diameter greater than 14 cm.
6. Pregnancy beyond 16-18 weeks.
7. over 16 weeks.

Preparation for laparoscopy and the principle of its implementation

The operation is performed under general anesthesia, therefore, in the preparatory period, the patient is examined by the operating gynecologist and anesthesiologist, and, if necessary, by other specialists, depending on the presence of concomitant diseases or doubtful issues in terms of diagnosing the underlying pathology (surgeon, urologist, therapist, etc.) .

In addition, additional laboratory and instrumental studies are prescribed. Mandatory tests before laparoscopy are the same as for any surgical intervention - general blood and urine tests, biochemical blood tests, including blood levels of glucose, electrolytes, prothrombin and some other indicators, coagulogram, determination of group and Rh factor, hepatitis and HIV .

Fluorography of the chest, electrocardiography and pelvic organs is performed again (if necessary). On the evening before the operation, food intake is not allowed, and on the morning of the operation, food and liquids are not allowed. In addition, a cleansing enema is prescribed in the evening and morning.

If laparoscopy is performed for emergency reasons, the number of examinations is limited to general blood and urine tests, coagulogram, determination of blood group and Rh factor, and electrocardiogram. Other tests (glucose and electrolyte levels) are performed only when necessary.

It is prohibited to eat and drink 2 hours before emergency surgery, a cleansing enema is prescribed and, if possible, gastric lavage is performed through a tube in order to prevent vomiting and regurgitation of gastric contents into the respiratory tract during induction of anesthesia.

On what day of the cycle is laparoscopy performed? During menstruation, tissue bleeding is increased. In this regard, a planned operation, as a rule, is scheduled for any day after the 5th – 7th day from the beginning of the last menstruation. If laparoscopy is performed as an emergency, then the presence of menstruation does not serve as a contraindication for it, but is taken into account by the surgeon and anesthesiologist.

Direct preparation

General anesthesia for laparoscopy can be intravenous, but, as a rule, it is endotracheal anesthesia, which can be combined with intravenous anesthesia.

Further preparation for the operation is carried out in stages.

• An hour before the patient is transferred to the operating room, while still in the ward, premedication is administered as prescribed by the anesthesiologist - the introduction of the necessary drugs that help prevent some complications at the time of induction of anesthesia and improve its course.
• In the operating room, the woman is equipped with a drip for intravenous administration of the necessary drugs, and monitor electrodes, in order to constantly monitor cardiac function and blood saturation with hemoglobin during anesthesia and surgery.
• Carrying out intravenous anesthesia followed by intravenous administration of relaxants for total relaxation of all muscles, which creates the possibility of introducing an endotracheal tube into the trachea and increases the possibility of viewing the abdominal cavity during laparoscopy.
• Inserting an endotracheal tube and connecting it to an anesthesia machine, which provides artificial ventilation and the supply of inhalational anesthetics to maintain anesthesia. The latter can be carried out in combination with or without intravenous drugs for anesthesia.

This completes the preparation for the operation.

How is laparoscopy done in gynecology?

The principle of the technique itself is as follows:

1. The application of pneumoperitoneum is the injection of gas into the abdominal cavity. This allows you to increase the volume of the latter by creating free space in the abdomen, which provides visibility and makes it possible to freely manipulate instruments without a significant risk of damage to neighboring organs.
2. Insertion of tubes into the abdominal cavity - hollow tubes intended for passing endoscopic instruments through them.

Application of pneumoperitoneum

In the navel area, a skin incision with a length of 0.5 to 1.0 cm is made (depending on the diameter of the tube), the anterior abdominal wall is lifted behind the skin fold and a special needle (Veress needle) is inserted into the abdominal cavity at a slight inclination towards the pelvis. About 3 - 4 liters of carbon dioxide are pumped through it under pressure control, which should not exceed 12-14 mm Hg.

Higher pressure in the abdominal cavity compresses the venous vessels and disrupts the return of venous blood, increasing the level of the diaphragm, which “presses” the lungs. Reduced lung volume creates significant difficulties for the anesthesiologist in terms of adequate ventilation and maintenance of cardiac function.

Insertion of tubes

The Veress needle is removed after achieving the required pressure, and through the same skin incision, the main tube is inserted into the abdominal cavity at an angle of up to 60 degrees using a trocar placed in it (an instrument for puncturing the abdominal wall while maintaining the tightness of the latter). The trocar is removed, and a laparoscope is passed through the tube into the abdominal cavity with a light guide connected to it (for illumination) and a video camera, through which an enlarged image is transmitted to the monitor screen through a fiber-optic connection. Then, at two more corresponding points, skin measurements of the same length are made and additional tubes intended for manipulation instruments are inserted in the same way.

Various manipulation instruments for laparoscopy

After this, an audit (general panoramic examination) of the entire abdominal cavity is carried out, making it possible to identify the presence of purulent, serous or hemorrhagic contents in the abdomen, tumors, adhesions, fibrin layers, the condition of the intestines and liver.

The patient is then placed in a Fowler (on her side) or Trendelenburg position by tilting the operating table. This promotes intestinal displacement and facilitates manipulation during a detailed targeted diagnostic examination of the pelvic organs.

After a diagnostic examination, the issue of choosing further tactics is decided, which may include:

• implementation of laparoscopic or laparotomic surgical treatment;
• performing a biopsy;
• drainage of the abdominal cavity;
• completion of laparoscopic diagnosis by removing gas and tubes from the abdominal cavity.

Cosmetic sutures are placed across three short incisions, which subsequently dissolve on their own. If non-absorbable sutures are applied, they are removed after 7-10 days. The scars formed at the site of the incisions become almost invisible over time.

If necessary, diagnostic laparoscopy is converted into therapeutic laparoscopy, that is, surgical treatment is performed using the laparoscopic method.

Possible complications

Complications during diagnostic laparoscopy are extremely rare. The most dangerous of them occur during the introduction of trocars and the introduction of carbon dioxide. These include:

• massive bleeding as a result of injury to a large vessel of the anterior abdominal wall, mesenteric vessels, aorta or inferior vena cava, internal iliac artery or vein;
• gas embolism as a result of gas entering a damaged vessel;
• deserosis (damage to the outer lining) of the intestine or its perforation (perforation of the wall);
• pneumothorax;
• widespread subcutaneous emphysema with displacement of the mediastinum or compression of its organs.

Postoperative period

Scars after laparoscopic surgery

Long-term negative consequences

The most common negative consequences of laparoscopy in the immediate and late postoperative periods are adhesions, which can cause intestinal dysfunction and adhesive intestinal obstruction. Their formation can occur as a result of traumatic manipulations with insufficient experience of the surgeon or existing pathology in the abdominal cavity. But more often it depends on the individual characteristics of the woman’s body itself.

Another serious complication in the postoperative period is slow bleeding into the abdominal cavity from damaged small vessels or as a result of even a minor rupture of the liver capsule, which can occur during a panoramic examination of the abdominal cavity. This complication occurs only in cases where the damage was not noticed and repaired by the doctor during the operation, which occurs in exceptional cases.

Other consequences that are not dangerous include hematomas and a small amount of gas in the subcutaneous tissues in the area of ​​trocar insertion, which resolve on their own, the development of purulent inflammation (very rarely) in the wound area, and the formation of a postoperative hernia.

Recovery period

Recovery after laparoscopy is usually quick and smooth. Active movements in bed are recommended in the first hours, and walking after a few (5-7) hours, depending on how you feel. This helps prevent the development of intestinal paresis (lack of peristalsis). As a rule, after 7 hours or the next day the patient is discharged from the department.

Relatively intense pain in the abdomen and lumbar region persists only for the first few hours after surgery and usually does not require the use of painkillers. By the evening of the same day and the next day, subfebrile (up to 37.5 o) temperature and sanguineous, and subsequently mucous without blood, discharge from the genital tract are possible. The latter can last on average up to one, maximum 2 weeks.

When and what can you eat after surgery?

As a result of the effects of anesthesia, irritation of the peritoneum and abdominal organs, especially the intestines, by gas and laparoscopic instruments, some women in the first hours after the procedure, and sometimes throughout the day, may experience nausea, single, and less often repeated vomiting. Intestinal paresis is also possible, which sometimes persists the next day.

In this regard, 2 hours after the operation, in the absence of nausea and vomiting, only 2 to 3 sips of still water are allowed, gradually increasing its intake to the required volume in the evening. The next day, in the absence of nausea and bloating and in the presence of active intestinal motility, as determined by the attending physician, you can drink ordinary non-carbonated mineral water in unlimited quantities and easily digestible foods.

If the symptoms described above persist the next day, the patient continues treatment in a hospital setting. It consists of a starvation diet, stimulation of intestinal function and intravenous drip administration of solutions with electrolytes.

When will the cycle be restored?

The next period after laparoscopy, if it was done in the first days after menstruation, as a rule, appears at the usual time, but the bleeding may be much more abundant than usual. In some cases, menstruation may be delayed by up to 7-14 days. If the operation is performed later, then this day is considered the first day of the last menstruation.

Is it possible to sunbathe?

Staying in direct sunlight is not recommended for 2-3 weeks.

When can you get pregnant??

The timing of a possible pregnancy and attempts to achieve it are not limited in any way, but only if the operation was purely diagnostic in nature.

Attempts to achieve pregnancy after laparoscopy, which was performed for infertility and was accompanied by the removal of adhesions, are recommended after 1 month (after the next menstruation) throughout the year. If the fibroid was removed, no earlier than six months later.

Laparoscopy is a low-traumatic, relatively safe and low risk of complications, cosmetically acceptable and cost-effective method of surgical intervention.

Laparoscopy is a minimally traumatic method of diagnostics and surgical intervention.

Laparoscopy is carried out by penetrating the abdominal cavity to the pelvic organs using several punctures, and then inserting manipulative instruments through them.

The manipulators are equipped with micro-instruments, lighting and micro-cameras, which allow visually controlled operations without making large incisions, which reduces the risk of postoperative complications, minimizes surgical tissue trauma and shortens rehabilitation time.

When performing laparoscopy, so that the abdominal wall does not interfere with examination and operations, it is raised by pumping air into the abdominal cavity - pneumoperitoneum is applied (the abdomen is inflated).

The operation is accompanied by incisions and painful stimulation, so it is performed under anesthesia.

Indications

Laparoscopy is very widely used in gynecology:

• for infertility of unknown cause, which was not identified during a detailed non-invasive study.
• if hormonal therapy for infertility is ineffective,
• during operations on the ovaries (sclerocystosis, ovarian cysts, ovarian tumors),
• if you suspect endometriosis, adhesive disease,
• for chronic pelvic pain,
• with endometriosis of the uterine appendages, ovaries, pelvic cavity,
• with myomatous lesions of the uterus,
• during tubal ligation, ectopic pregnancy, tubal rupture,
• with ovarian torsion, cysts, ovarian apoplexy, internal bleeding,
• during pelvic examination.

Contraindications to laparoscopy

Laparoscopy in gynecology is absolutely contraindicated

• for severe cardiovascular and pulmonary diseases,
• in a state of shock, in a state of coma,
• with severe exhaustion of the body,
• for disorders in the coagulation system.

Surgery by laparoscopy is also contraindicated for hernias of the white line of the abdomen and anterior abdominal wall, and for hernias of the diaphragm.

Planned laparoscopy is contraindicated for acute respiratory viral infections; it is necessary to wait at least a month from the moment of illness. Surgery is also prohibited for severe changes in blood and urine tests, for bronchial asthma, and for hypertension with high blood pressure.

Preparation

Laparoscopy operations can be planned or emergency.

During emergency operations, preparation may be minimal if we are talking about saving the patient’s life.

For planned operations, a full examination is required, including all tests:

• blood (general, biochemistry according to indications, for hepatitis, syphilis and HIV, for coagulation),
• blood for glucose.

Blood type and Rh factor testing is required.

Before the operation, a gynecological smear, ECG and fluorography, ultrasound of the gynecological organs are required, and if there are chronic diseases, a physician’s opinion on the safety of anesthesia.

Before the operation, the surgeon explains the essence of the procedure and the scope of the intervention, and the anesthesiologist examines and identifies the presence of allergies and contraindications to anesthesia.

If necessary, medication and psychoprophylactic preparation for surgery are prescribed.

In the absence of contraindications to surgery and anesthesia, the woman signs a written consent to the operation separately for this type of anesthesia.

Carrying out the operation

Planned operations are usually scheduled for the morning, and before that a light diet is prescribed for several days, and in the evening before the operation, a bowel cleansing is performed with an enema.

It is forbidden to eat food, and after 22.00 and water, and in the morning the enema is repeated. Drinking and eating are prohibited before the operation.

If there is a risk of thrombosis, elastic leg bandaging or wearing anti-varicose compression stockings is indicated before surgery.

The essence of laparoscopic surgery

Depending on the volume of the operation and its location, three or four punctures are used.

One of the trocars (a device for puncturing the abdominal cavity and carrying instruments) is inserted under the navel, the other two are inserted on the sides of the abdominal cavity. At the end of one trocar there is a camera for visual inspection, at the other there is a light installation, a gas blower and instruments.

Carbon dioxide or nitrous oxide is injected into the abdominal cavity, the volume and technique of the operation are determined, an audit of the abdominal cavity is carried out (its thorough examination) and manipulations begin.

On average, laparoscopic operations last from 15-30 minutes to several hours, depending on the volume. Anesthesia can be inhalational and intravenous.

At the end of the operation, an inspection is carried out again, the blood or fluid that accumulated during the operation is removed. Carefully check the closure of the vessels (for bleeding). Eliminate the gas and remove the instruments. Sutures are placed at the trocar insertion sites on the skin and subcutaneous tissue, and cosmetic sutures are applied to the skin.

After laparoscopy

The patient regains consciousness on the operating table, doctors check her condition and reflexes, and is transferred to the recovery room on a gurney.

During laparoscopy, early rising from bed and intake of food and water are indicated; the woman is lifted to the toilet and to activate blood circulation within a few hours.

Discharge takes place two to five days after the operation, depending on the extent of the intervention. Sutures are cared for every day with antiseptics.

Complications

The percentage of complications during laparoscopy is low, much lower than during operations with large incisions.

When a trocar is inserted, there may be injuries to internal organs, damage to blood vessels with bleeding, and when gas is injected, there may be subcutaneous emphysema.

Complications also include internal bleeding due to insufficient clamping or cauterization of blood vessels in the area of ​​the operating area. All these complications are prevented by strict adherence to the technique and careful inspection of the abdominal organs during surgery.

• Compared to abdominal and highly traumatic operations in gynecology, laparoscopy has a number of undoubted advantages, especially at a young age: there are practically no scars left from the operation,
• less risk of postoperative complications and adhesions,
• the rehabilitation period is significantly reduced.

Lecture No. 6

“Characteristics of endoscopic research methods. Punctures"

Endoscopy (Greek endō inside + skopeō consider, 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 obtained material, as well as with X-ray and ultrasound examinations. The development of endoscopic methods, improvement of endoscopic technology and their widespread introduction into practice are important for improving the early diagnosis of precancerous diseases and tumors of various localizations in the early stages of their development.

Modern medical endoscopes are complex optical-mechanical devices. They are equipped with light and image transmission systems; equipped with instruments for performing biopsies, removing foreign bodies, electrocoagulation, administering medications and other manipulations; with the help of additional devices they ensure the receipt of objective documentation (photography, filming, video recording).

Depending on the purpose there are different:

examination rooms;

biopsy;

operating rooms;

special endoscopes;

endoscopes intended for adults and children.

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

to hard ones that retain their shape during the study;

flexible, the working part of which can smoothly bend 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 being examined. In rigid endoscopes, the optical system that transmits the image of the object consists of lens elements.

The optical system of flexible endoscopes (fiberscopes) uses flexible bundles consisting of regularly laid fiberglass threads with a diameter of 7-12 microns and transmitting an image of the object to the ocular end of the endoscope. In endoscopes with fiber optics, the image is rasterized.

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

In recent years, endoscopes of small (less than 6 mm) diameter have become widespread for examining thin anatomical canals and hard-to-reach organs, for example ureterorenoscopes, various types bronchoscopes with fiber optics.

Promising development video endoscopes, in which, instead of an optical channel with a fiber flagellum, a system with a special light-sensitive element - a CCD matrix - is used. Thanks to this, the optical image of the object is converted into electrical signals that are transmitted via an electrical cable inside the endoscope to 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 instruments (for capturing the formation and its biopsy or coagulation), which greatly facilitates surgical interventions.

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

All valves and accessory valves are disassembled, washed and thoroughly dried before reassembly. 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 subjected to sterilization in various means (glutaraldehyde solution, 6% hydrogen peroxide solution, 70% ethyl alcohol) at a temperature not exceeding 50° due to the danger of unsticking the optical elements.

The most common uses of endoscopy in gastroenterology are:

esophagoscopy;

gastroscopy;

duodenoscopy;

intestinoscopy;

colonoscopy;

sigmoidoscopy;

choledochoscopy;

laparoscopy;

pancreatocholangioscopy;

fistuloscopy.

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

laryngoscopy;

bronchoscopy;

thoracoscopy;

mediastinoscopy.

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

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

Carrying out 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 allows you to differentiate diseases of inflammatory and tumor nature,

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

Emergency endoscopy is used as a means of emergency diagnosis and therapy for acute complications in patients with chronic diseases who are in extremely critical condition, when it is impossible to conduct a routine examination, much less surgical intervention.

Contraindication for 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 cardiovascular and respiratory systems in which endoscopy can lead to life-threatening consequences for the patient.

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

Preparation patients for endoscopy depends on the purpose of the study and the patient’s condition. Routine endoscopy is performed after a clinical examination and psychological preparation of the patient, during which the task of the study is explained to him and he is introduced to the basic rules of behavior during endoscopy.

During emergency endoscopy, it is possible to carry out only psychological preparation of the patient, as well as clarify the basic details of the medical history and life, and determine contraindications to the study or prescription of medications.

Medicinal preparation of the patient is primarily aimed at providing optimal conditions for endoscopic examination and consists of relieving the patient’s psycho-emotional stress, providing pain relief 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 topographical features of the organ or cavity being examined, the model of the endoscope used (rigid or flexible), the patient’s condition and the purposes of the study.

Endoscopes are usually inserted through natural openings. When conducting endoscopic examinations such as thoracoscopy, mediastinoscopy, laparoneoscopy, choledochoscopy, the hole for inserting the endoscope is created with special trocars, which are inserted through the thickness of the tissue.

A new direction in endoscopy is the use of flexible endoscopes for examining 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 up to 20-25 cm from the anus; a high degree of narrowing of the intestinal lumen, when using endoscopes of other designs it is not possible to examine the narrowing itself and the overlying parts of the intestine.

The combination of endoscopy with x-ray examination methods is becoming increasingly common. 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 most fully reveal the nature of the disease and establish the localization and extent of the pathological process, which is extremely important for determining the need for surgical intervention or endoscopic treatment measures .

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

Endoscopic diagnosis may be difficult due to local reasons (severe deformation of the organ being examined, 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 organ being examined 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 pain relief (individual intolerance to drugs) or with a violation of endoscopic examination technique. Failure to comply with mandatory endoscopy techniques can lead to organ injury, including perforation. Other complications are less common: bleeding after a biopsy, trauma to varicose veins, aspiration of gastric contents during an emergency examination, etc.

Laparoscopy

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

It is used in cases where, using modern clinical laboratory, radiological and other methods, it is not possible to establish the cause and nature of the disease of the abdominal organs.

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

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

Indications for diagnostic laparoscopy are:

diseases of the liver and biliary tract;

abdominal tumors;

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

ascites of unknown origin.

Indications for therapeutic laparoscopy may arise:

with obstructive jaundice;

acute cholecystitis and pancreatitis;

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

maxillofacial trauma;

severe brain damage;

tumor obstruction of the pylorus;

burns of the esophagus and stomach.

Contraindications to laparoscopy are:

bleeding disorders;

decompensated pulmonary and heart failure;

comatose state;

suppurative processes on the anterior abdominal wall;

extensive adhesions of the abdominal cavity;

external and internal hernias;

flatulence;

severe obesity.

Special instruments are used for laparoscopy:

needle for applying pneumoperitoneum;

trocar with a sleeve for puncturing the 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 viewing directions - straight, lateral, and at different angles. Under development fibrolaparoscopes with 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 usually performed under general anesthesia. In order to prevent possible bleeding, especially with liver damage, Vikasol and calcium chloride are prescribed 2-3 days before the examination. The gastrointestinal tract and anterior abdominal wall are prepared as for abdominal surgery.

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

Rice. 14. Classic tracing points for applying pneumoperitoneum and inserting a laparoscope: The insertion sites of the laparoscope are indicated by crosses, the puncture site for applying pneumoperitoneum is indicated by a circle, and the projection of the round ligament of the liver is shaded.

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

The abdominal cavity is examined sequentially from right to left, examining the right lateral canal, liver, subhepatic and suprahepatic space, subphrenic space, left lateral canal, and small pelvis.

If necessary, you can change the patient's position for a more detailed examination. By color, nature of the surface, shape of the organ, overlays, type of effusion, one can determine the nature of the lesion: cirrhosis of the liver, 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 laparoscopy is completed and the laparoscope is removed from the abdominal cavity, the gas is removed, the skin wound is sutured with 1-2 sutures.

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

Rice. 15b). The laparoscopic picture for 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, and strangulation of hernias of the anterior abdominal wall. As a rule, if such complications develop, emergency surgery 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 early diagnosis of benign and malignant tumors of the colon, nonspecific ulcerative colitis, Crohn's disease, etc. (Fig. 16,17).

During colonoscopy, it is also possible to perform various therapeutic procedures - removal of benign tumors, stopping bleeding, removal of foreign bodies, recanalization of intestinal stenosis, etc.

Rice. 16. Endoscopic picture of the colon in normal conditions and in various diseases: The colon mucosa is normal.

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

Colonoscopy is performed using special devices - colonoscopes. In the Russian Federation, colonoscopes KU-VO-1, SK-VO-4, KS-VO-1 are produced (Fig. 18). Colonoscopes from various Japanese companies have become widespread.

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

The indication for a colonoscopy is 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 colonoscopy in the absence of persistent constipation includes the patient taking castor oil during the day before the examination (30-50 ml), after which two cleansing enemas are performed in the evening with an interval of 1-2 hours; They are repeated in the morning on the day of the study.

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

For diseases accompanied by diarrhea, laxatives are not given; the use of small-volume (up to 500 ml) cleansing enemas is sufficient.

Emergency colonoscopy in 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. For patients with severe pain in the anus, local anesthesia (dicaine ointment, xylocaingel) is indicated. In case of severe destructive processes in the small intestine or massive adhesions in the abdominal cavity, it is advisable to perform 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 of internal organs on the monitor due to the reflection of ultrasonic waves from them.

At the same time, media of different densities (liquid, gas, bone) are depicted differently on the screen: liquid formations appear dark, and bone structures appear white.

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

Ultrasound is widely used in obstetric practice: to identify possible malformations of the fetus in the early stages of 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.