Laparoscopic Ablation and Fulguration of Endometriosis of Cul-De-Sac

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  This video demonstrates Laparoscopic Ablation and Fulguration of Endometriosis of Cul-De-Sac and the application of interceding which acts as a mechanical adhesive barrier. Ablation/fulguration of ovarian tissue during laparoscopy isn't recommended. Surgical excision is the most common and effective treatment for endometriosis of the ovary (endometrioma cyst). Surgical removal at the time of laparoscopy has been shown to improve pain without damaging the ovaries. A laparoscopy is a surgical procedure that may be used to diagnose and treat various conditions, including endometriosis. By laparoscopic surgery, it is also possible to remove cysts, implants, and scar tissue caused by endometriosis. Laparoscopy for endometriosis is a low-risk and minimally invasive procedure.  For more information please contact:  World Laparoscopy Hospital  Cyber City, Gurugram, NCR DELHI  INDIA 122002  Phone & WhatsApp: +919811416838, + 91 9999677788

Transcript

00:00hello friends this patient has severe endometriosis and she was already operated before for the left

00:09sided endometrioma and now we have the pelvic endometriosis and the small sub serous few

00:16fibroids are also there actually this is a case of primary infertility so we have to see that how

00:22can it is possible to just eliminate all the endometriosis so we will start the procedure

00:28here this is the abdomen and we will apply two alice forceps on the either side these alice forceps

00:34are just to retract the crease of the umbilicus and here we will enter through the various needle

00:41so one small stab wound is given over the inferior crease of umbilicus this is just a small stab wound

00:50and after that with the various needle it will be introduced inside so you will just lift the

00:58abdominal wall and the various needle it will give you a two click sound this is first click

01:04second click and it is entered inside then we have to use one syringe and this is irrigation test

01:12just to make it sure that it is in correct plane then suction test and after that hanging drop test will

01:20be done so that it will confirm the access of the various needle inside the abdominal cavity as we can

01:28see hanging drop is sucked in then we are attaching here the striker laproflator that is a very high

01:37capacity insufflator with the co2 warmer and now we will start insufflating and we have to see that the

01:47preset pressure will be 15 actual pressure will slowly reach to 15 and initial flow rate should be maintained

01:56one liter per minute because if more than one liter it will be risky if it enters into any vein there may be

02:03air embolism so one liter per minute gas is introduced and slowly slowly pneumo petronium is building up

02:12and we will wait till the pressure reaches to the 15 so i should be on the insufflator and slowly the

02:20pneumo petronium is being increased now we will make take our time and initially it should be one liter per

02:29minute but once the one liter gas is in then you can increase the flow to three liter per minute but as we

02:36know that with the eye of the various needle more than three liter per minute more than 2.5 liter per

02:43minute cannot pass so maximum flow rate is possible only 2.5 but that 2.5 also may be risky because

02:54if it is going at a rate of 2.5 there may be air embolism so initially always it should be one liter per

03:01minute but once you are conformed with the this completely percussion and you will see that there

03:11is a tympanic sound all over and once you are conformed that this gas is going into the abdominal cavity

03:18then you may increase it to 3 liter per minute and slowly we can see here that abdominal cavity is

03:24enlarging and the abdomen is distending and gas is going in now the co2 warmer has an advantage

03:32that it will not allow the hypothermia and there is one more advantage that your telescope will not

03:40become foggy repeatedly if your insufflator doesn't have co2 warmer then called cold co2 if it is leaking

03:48a lot especially more than 10 liter per minute leak is there then there may be hypothermia

03:55and this cold co2 because once the liquid co2 converted into the gas co2 then it becomes cold

04:03and that can make your telescope also cold and if the telescope is cold as we know that there may be

04:10fogging so we have to wait and warm co2 should be introduced with the various needle inside the

04:17abdomen so this is little patience is required and slowly you should your eye should be on the

04:24um quadro manumatic indicator in the insufflator there are four reading that is preset pressure

04:32actual pressure flow rate and total amount of gas used that is called as quadro manumatic indicator

04:39and you should always look at quadro manumatic indicator so that actual pressure should reach to

04:45the preset pressure now it is over insufflation is complete now various needle is taken out and then with

04:52the knife you can give over the inferior crease of umbilicus a smiling incision of 11 mm a smiling

05:00incision has advantage that patient won't have any scar postoperatively and with the 11 number of the

05:07knife keeping the sharp edge of the knife outside you can give the smiling incision so here it is going

05:15the smiling and once 11 number of the decision is given then you can take a mosquito forcep and with

05:23that you can dilate the obliterated with low intestinal tract and once you will dilate it then your telescope

05:31can go easily and by a screwing movement pyramidal shape trocar can be introduced so this is dilating the

05:39with low intestinal tract and then this is a trocar now as usual you will hold it like a pistol

05:45middle finger wrap around the air inlet and with supporting the abdominal wall with the screwing

05:50movement you can enter inside and the index finger should must be pointed towards the sharp end

05:57so here it is done and now we will attach the tubing of the insufflator and now the rate of the flow of

06:04the insufflator should be increased to 10 liter per minute 6 to 10 liter per minute and only in the

06:11emergency when you have the any bleeding then it can be increased to 40 liter per minute but initially

06:18it should be that much only now we will take the this uh telescope that is a 10 millimeter 30 degree

06:26telescope here we are using and here we will use the this striker um 1588 camera that is a completely

06:35high definition camera and now this telescope is in and we will do the initial diagnostic laparoscopy

06:42and after that we will put the another port so this is just telescope will be attached already white

06:50balancing and focusing of the telescope is done so now you can attach easily and once you enter

06:56sometime if fogging happens you should take it out and again dip it into the hot water in the flask

07:03and so that the fogging can be minimized so initially once you enter little fogging is always there for

07:10that you have to warm your telescope now we are just taking the time to warm the telescope in the flask

07:18and after that again telescope tip should be cleaned and white balancing should be done and again telescope

07:25will be introduced inside meanwhile patient head is going down you will ask your anesthetist to tilt the

07:31table so patient head is going down and patient will be in the lithotomy position and tender and berg

07:38position so this way we can see now head is completely going down so all the bowel of the pelvic area

07:45should just drop towards the upper abdomen and after that it will be easy to put the second and third port

07:52so this second port we are putting 7.5 centimeter lateral and below the umbilical port according to baseball

08:00diamond concept and we will put one port here so this is the incision given and now the trocar will be

08:10introduced and this is the second port

08:12after that we will do diagnostic laparoscopy once your two instrument is inside then you have a better

08:31diagnostic laparoscopy because you can lift the barbell and all the small bubbles should be pushed above the

08:38saccal pulmonary so that you can see the uterus and ovary so now again telescope is cleaned and introduced

08:45inside and then this is one of the grasper and you will just try to push all the bubbles above the

08:52saccal pulmonary so that you can see the uterus ovary and tube because in normal condition entire uterus ovary

09:00and tube is hidden by the small bubble so here we can see this is all the small bubble and you will keep

09:06on pushing it towards the upper abdomen and slowly slowly you will you will go towards the pelvis

09:14and look for the uterus meanwhile your assistant will put a uterine manipulator to lift the uterus

09:21it is important in the gynae procedure that we should have uterine manipulator so that uterus can be

09:27antiverted and after that you can locate it and you can easily check for endometriosis so this is the

09:35initial just diagnostic you can see the cecum you can see the appendix you may look for the this

09:44ureter also in those situation and if there is any other pathology this is saccal pulmonary as we can see

09:50and appendix was also visible now left side this is all momentum is pushing up and left side sigma

09:57add colon also is visible so just you will do the initial few minutes so that if any other problem is

10:04there and sometime it may be intestinal endometriosis now here uterine manipulator is lifting the uterus up

10:12inside we can see both the tube looks normal there is no hydrosalpines that is very good because

10:18patient attendant has wanted to have the tubectomy done or just the clipping of the tube but it is

10:26normal here we can see this is severe endometriosis and left and right ovary is completely adhered with the

10:32ovarian fossa so first thing what you should do to try to separate the all the ovary and the tissue away from the

10:40utero-saccal ligament and we can see here rectum also has endometriosis and deep endometriosis of the

10:48utero-saccal ligament and it is adhered with the utero-saccal ligament so with the ambidextivity you have to

10:54separate it and both the hand you will separate away from each other these things should must be

11:00mobilized during the procedure it is important that you have to maintain ambidextivity and you can use

11:09the different energy sources like in this case we have used the monopolar for falgration harmonic for

11:17just dissection of the nodule and sometime bipolar for hemostasis so this is again for a time being the

11:24surgery is being interrupted because we have to wait for the gynecologist to just do the antiversion

11:33and sometime tubal potency test so we have to introduce the this uh fsv camera this is the

11:41baseball diamond concept we can see here target is endometriosis and thumb is on the telescope and this

11:47is the one snuff box is one port and then another snuff box is another port so ipsilateral and the

11:57contralateral both the type of port position can be used in the laparoscopy and here this waiting time

12:03is just for the um assistant to put a uterine manipulator and just injecting the methylene blue

12:10dye to do the tubal potency test again start the falgration here we can see the all

12:17the these adhesions were separated and this is falgration this is a spatula and with the heel of

12:24the spatula you can just falgrate the posterior wall of uterus utero cycle ligament ovarian fossa

12:33this falgration is very good because if you'll do the falgration then you will have the uh no recurrence

12:40or rare recurrence of endometriosis so this in falgration you have the uh you have to change

12:47the electro surgical generator into the falgration mode and in falgration mode the voltage increases

12:54and the frequency decreases the electro surgical generator as we know has a 500 kilohertz to 3.3

13:02megahertz frequency so that frequency is minimum in the falgration but voltage is high so that electron

13:09can jump in the air medium and it will do the one millimeter thickness burn over the posterior wall of

13:17uterus utero sacral and on the rectum and this way a small small fibroid also you can remove and you can

13:24burn but here the main purpose of endometriosis is to prevent reoccurrence so now we can see that both

13:33the ovary is free and this falgration of the endometriosis is being carried out one of the problem of

13:40falgration is that later it may be the adhesion again adhesion can develop with the rectum or with

13:47the ovary so in those situation after doing two three time falgration again suction irrigation should be

13:54performed again falgration should be done and at the end of the procedure we should put intercede

14:01intercede is a reoxygenated cellulose that is also a mechanical adhesive barrier so that is a regular practice we use it

14:10and we have an encouraging result using intercede as a mechanical adhesive barrier so this is falgration

14:17again suction irrigation will be carried out and all the burn char tissue will be sucked and this you have

14:24to repeat multiple time so that you can just eliminate entire endometriosis now here the assistant

14:32will put a hysteroscope and through the cervix to see that inside is okay or tube is patent or not

14:39and that way you can do the methylene glue test also so they hear it is a sound and this is a sims

14:46speculum and the cervix is held by a valse alum and it is dilating and after that you can introduce the

14:53hysteroscope minimum five number of hager dilator is required to do this procedure that's why before the

15:01surgery same day in the morning you should give prostaglandin and 400 microgram mesoprost or two

15:09tablets should be put vaginally so that you have a cervical little softening and then you can dilate it

15:16with the hager dilator and that hager dilator should dilate the cervix up to five number or maximum six

15:24number of the uh seems this hager's number hager's dilator number so now it is done and it is dilated

15:34after that you can take a telescope that is four mm telescope and this four mm hysteroscope will be

15:40introduced to the cervix and then you will do the tubal potency test this tubal potency test and

15:47hysteroscopy is a routine part we should perform for any patient who is of infertility because without

15:55injecting dye to the cervix it is not possible to check the tube here this is our gynecologist who

16:01is doing this job and you will be in the laparoscopic area and a female gynecologist will be used to just

16:08do the this hysteroscopy and the tubal potency test so now this is the almost dilated and now you will

16:17change the telescope and attach the hysteroscope with the fluid and this is the hysteroscope now

16:24which is the attach the fluid of the suction irrigation will be changed and attached to the

16:29seat of the hysteroscope and then you can introduce it in so this way it is very useful and there is one

16:36more advantage that during the hysteroscopy hydro dissection happened and sometime if the tube is

16:42blocked also it get opened and that opening of the tube is possible by hysteroscopy although this

16:49patient tube is almost structure is there so unfortunately it was blocked but sometime it has

16:56an encouraging effect although in this patient as we have seen in the pelvis the ivf is the only option

17:04because endometriosis has destroyed the shape of the tube but we have not cut the tube reason being

17:12that sometime after hysteroscopy and dilatation it start working and here cutting the tube or clipping

17:20the tube will not have any advantage because this patient doesn't have hydrosalpines in hydrosalpines

17:28we should remove the tube otherwise it is better to leave it because we have experienced that many

17:33patients after endometriosis surgery or hysteroscopy which in them previously even the ivf was failed

17:42but some of the patient after hysteroscopy and laparoscopy they get pregnancy because that dilatation

17:49and the pressure over the cervix by hysteroscope creates the opening of the tube so now it is over

17:57and now this is the hysteroscope will is arranged and it is fixed with all the white balancing and

18:03focusing of the hysteroscope is being performed and now this telescope is being introduced into the

18:10cervix of the patient and here slowly you can enter in once you enter in take care that light cable should

18:17be down and the flow of the fluid should be at 180 millimeter of mercury pressure and normal saline can be

18:26used for hysteroscopy so slowly we are doing the hysteroscopy here and laparoscopically you will

18:32watch and you will see from above but unfortunately the tube were blocked and nothing came out and nothing

18:40was spilling from the uh this fimbrial end of the tube and this slowing screwing movement diagnostic

18:48hysteroscopy was also performed and you can see right and left ostea also by changing it but nothing came

18:55inside and now we will do again suction irrigation and then again we can do the inter-seed application

19:04so this is the irrigation and the tubes were no hydrosalpins but unfortunately proximal end of the tube

19:11it was patent it was sorry proximal end of the distal end of the tube was okay but proximal end of the tube

19:24was completely obstructed and here this is inter-seed that is re-oxygenated cellulose which you can spread

19:31all over and you should always spread it in a way when it is dry because consistency of this inter-seed is just

19:38like a tissue paper by seeing it looks like a mesh but by feel it is like a tissue paper so you should

19:47try to spread it in between the uterus and ovary and ovarian focia and rectum and posterior wall of

19:55uterus all will be covered by this inter-seed it is little expensive but it helps to prevent the adhesion

20:04and slowly you can again lift it up again keep on spreading it so this inter-seed is very useful to

20:12prevent the adhesion post-operative adhesion in cases of severe endometriosis and in these cases

20:20one thing also should be kept in mind that patient should must be asked for taking the gnrh post-operatively

20:28so that that also inhibits the recurrence so we are planning that we will allow at least six month

20:35gnrh or three month and after that patient will try to conceive so this is little saline is kept over the

20:42inter-seed and extra of the fluid will be sucked out and that way you can easily make it immediately

20:49stick with the posterior cul-de-sac uterocycle ligament rectum and ovarian fossa once your inter-seed is

20:58nicely spreaded then you should ask your assistant to drop the uterus through the uterine manipulator

21:05and here uterus is getting dropped now this is a endobag you can put a gloves endobag you can introduce it

21:16in and all the cut tissue resected tissue of the endometriosis you can just put into the endobag

21:23and it should be taken out

21:37now this mouth of the endobag is in the cannula and then cannula will be taken out

21:42after that this is port closure here we are using various needle for the port closure port closure

21:50is very important in laparoscopic surgery because there may be the hernia if you will not close the

21:55port carefully so this port closure is under vision of the telescope and there is a loop of the various

22:03needle which will pull the suture and the suture will be pulled with the suture and that gives you

22:09the beautiful approximation so slowly the port will be this suture will be pulled out and you can tie the

22:17knot to close the port so this was the end of the surgery and we have done one uh telescopic port and two

22:27ipsilateral port for this surgery so now this is finished and post-operatively we will give g and a

22:34gnrh to the percent and we will recommend that if she doesn't conceive for few months then ivf can be tried

22:42so thank you very much for watching this video have a nice day

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