Laparoscopy of the fallopian tubes: indications and contraindications
Laparoscopy is an innovative technique for the diagnosis and treatment of internal organs located in the abdominal cavity and small pelvis. The procedure is carried out using endoscopic equipment - a laparoscope. To gain access to the internal organs, the doctor makes several punctures on the patient's skin, it is through them that the necessary instruments are introduced. Laparoscopy does not take much time, as a rule, the duration of the operation is 15-40 minutes. Although this indicator directly depends on the complexity of the intervention. Sometimes the period of the operation is extended for several hours.
Content:
- Laparoscopy for ectopic pregnancy
- Why is laparoscopy better than laparotomy?
- From the history of the operation
- Fallopian tube structure
- Equipment for laparoscopy of fallopian tubes
- Laparoscopy options
- Laparoscopy technique
- Preparing a woman for laparoscopy
- Indications for laparoscopy of the fallopian tubes
- Contraindications
- Narcosis
- Postoperative rehabilitation
- Consequences and complications of tubal laparoscopy
Laparoscopy for ectopic pregnancy
Infertility is an urgent problem in modern society. WHO cites the following statistics: more than 10% of women of reproductive age are unable to conceive a child due to health problems.
The diagnosis of "infertility" is made when a married couple has a regular sex life for 12 months, does not protect themselves, but pregnancy does not occur.
The causes of infertility can be varied:
- 30% of families cannot conceive a child due to a man's health problems.
- 60% of families cannot get pregnant due to health problems.
- 10% of families cannot become parents because both sexual partners have health problems.
- The cause of female infertility in 50% of cases is one or another pathology of the fallopian tubes.
Doctors talk about primary infertility if a woman has never become pregnant and cannot conceive a child at the present time. The diagnosis of "secondary infertility" is exposed to those representatives of the beautiful half of humanity who have already had a pregnancy, but are not able to conceive a child at the time of going to the doctor.
If we consider the reasons that lead to tubal infertility, then obstruction of the uterine appendages comes to the fore (about 40% of all cases). Obstacles that form in the fallopian tubes prevent the egg from moving normally to the uterine cavity after fertilization and implanting into it. Therefore, in some cases, the ovum settles in the fallopian tube. If an ectopic pregnancy is not diagnosed in time, then this will lead to rupture of the epididymis with subsequent internal bleeding. And if a woman is not provided with emergency surgical assistance at this moment, then this can cause death.
In order to prevent serious health problems while carrying a child, you must adhere to the following recommendations:
- If there is a delay in the next menstruation, then you should undergo an ultrasound scan, which will confirm the fact of pregnancy and allow you to determine the place in which the embryo is located.
- Immediately you need to go to the doctor's office in the event that an ectopic pregnancy is detected during the ultrasound examination.
- It has been found that women who smoke are more likely to have an ectopic pregnancy.
- You should immediately consult a doctor if the following symptoms are observed during pregnancy: painful sensations appear in the lower abdomen at rest or during emptying of the bladder and intestines. It is also necessary to sound the alarm when bleeding from the vagina appears.
- Laparoscopy is an effective method for eliminating ectopic pregnancy.
Another method of surgical intervention used for ectopic pregnancy is laparotomy. It involves a cavity incision of the abdominal cavity and the elimination of the existing pathology. However, after the introduction of laparoscopic methods of treatment into surgical practice, laparotomy has become extremely rare.
Why is laparoscopy better than laparotomy?
- Laparoscopy is a minimally invasive operation; after it is carried out, three small punctures remain on the woman's body, which eventually become invisible. After the laparotomy, the woman will have a noticeable suture.
- Laparoscopy acts as not only a therapeutic, but also a diagnostic technique. Laparotomy is an exclusively therapeutic technique.
- The recovery period after the performed laparoscopy takes 2-3 days. After the laparotomy, the woman will be discharged home no earlier than 5-7 days.
- The long-term rehabilitation period after laparoscopy is 7-12 days. After a laparotomy, it lasts about 30 days.
- During laparoscopy, the doctor displays the desired image on the monitor, which is enlarged 40 times, which minimizes the risks of damage to adjacent tissues and organs. During the laparotomy, the doctor relies only on his own eyes and on skin sensitivity.
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If, during laparoscopy, a rupture of the fallopian tube occurs or a blood vessel bursts, then the bleeding is easily stopped by cauterization (coagulation) of the existing damage, the imposition of clips and small sutures. If a similar situation occurs during a laparotomy, then to stop bleeding, an organ resection will be required, in this case, the uterine appendage.
- Laparoscopic equipment does not injure organs and tissues. During a laparotomy, the doctor uses a variety of instruments (mirrors, dilators, scalpels, etc.) that can damage blood vessels, organs and tissues.
- Adhesions after laparoscopy appear much less frequently than after laparotomy.
The success of the operation largely depends on a number of factors:
- Surgeon's skill;
- The scale of the intervention;
- The presence of other pathologies;
- The state of health of a woman;
- The severity of the course of the disease, which is corrected with the help of surgery.
From the history of the operation
Although laparoscopy is a modern surgical technique, it was invented over a century ago.
For the first time, examination of the abdominal organs using a tube with a mirror was performed on a dog. It happened in 1901. After another 9 years, the doctor G. H. Jacobeus performed a similar operation on a person. It ended in success, after which a new concept appeared in medical terminology - laparoscopy.
In 1929, the laparoscope was supplemented with a lens that made it possible to enlarge the image. This is the merit of Heinitz Kalka, a well-known hepatologist in Germany. Over the next several decades, the method of surgical intervention using endoscopic equipment has undergone various improvements.
A real breakthrough was made by Japanese engineers in 1987, when they equipped the equipment with a video camera. This made it possible to monitor in real time on the monitor all the surgeon's manipulations on the diseased organ.
Today laparoscopy occupies a leading position in all developed countries of the world as a diagnostic and therapeutic procedure.
Fallopian tube structure
A woman has two fallopian tubes in her body. Their length is 10-12 cm, and their diameter is no more than 5 mm. They extend from the uterus to the ovaries. Eggs and sperm cells move along the cavity of the tubes, and their meeting and fertilization also happens there.
From the inside, the fallopian tubes are lined with three layers:
- The inner surface of the tubes is represented by a mucous membrane consisting of ciliated epithelium. On it are cilia that are in constant motion. It is due to their synchronous vibrations that the egg moves systematically to the uterus and enters its cavity.
- The middle layer is represented by circular and longitudinal muscles. They contract all the time, helping to push the egg to the uterine cavity.
- Above, from the side of the peritoneum, the uterus is covered with a mucous membrane. It produces fluid that protects the fallopian tubes, keeping them in good working order. If inflammation develops in the appendages, then the serous membrane immediately reacts to it, changing its consistency. Its surface becomes denser, cloudy and rough.
The pipes have 3 sections:
- Interstitial, which passes into the uterine wall.
- Isthmic, which is located in the center.
- The ampullar, which is at the end of the pipe, has the widest diameter and ends with a funnel.
The funnel has fimbriae at its end - these are the villi that are located above the ovary. They capture the egg and push it into the fallopian tube. If at this time there is a male sperm, then fertilization occurs. After the sperm is fully incorporated into the shell of the egg, a zygote is formed.
The zygote, passing through the fallopian tube, is continuously dividing and enlarging. At the same time, the mucous layer of the tube produces a fluid that feeds the zygote until it penetrates into the uterine cavity.
A week after the fertilization happened, the egg is introduced into the mucous layer of the uterus, where it will grow in the future.
Equipment for laparoscopy of fallopian tubes
Laparoscopic equipment is represented by the following set of instruments:
- Trocars are instruments used to puncture the peritoneum. Water and gas come out of them.
- Scissors, stilettos, retractors - are necessary for dissecting tissues, breeding them.
- Needles and needle holder. With their help, stitches are applied.
- Needle Veresh. It serves to introduce gas.
- Electrodes with which tissues are coagulated.
- Clamps, which are needed to clamp the blood vessels.
- Clips that are designed to stop bleeding.
What is endoscopic equipment:
- Inside the laparoscope is an endoscopic camera that broadcasts video to a computer screen. The image is transferred under multiple magnification.
- A monitor that allows the doctor to see all of his actions that he performs inside the abdominal cavity.
- A light bulb that illuminates the area to be operated.
- An insufflator is a device that allows you to remove gas from the peritoneal cavity.
- An aspirator-irrigator, through which saline is supplied to wash the affected area.
Laparoscopy options
It is possible to perform laparoscopy as a separate operation, and as an auxiliary technique during other interventions. So, laparoscopy can accompany vaginal surgery, hysteroscopy, etc. It can be planned and emergency.
Varieties of laparoscopy:
- A procedure carried out for the purpose of diagnosis. With its help, you can find the cause that provoked infertility in a woman, assess the nature of the pathology. During the diagnosis, it is possible to perform therapeutic measures, for example, excision of adhesions.
- The procedure carried out with a therapeutic purpose: elimination of the cause that provoked infertility after the diagnosis.
- Repeated laparoscopy. It is carried out in order to control the previous type of intervention.
Laparoscopy technique
Laparoscopy is performed in a hospital operating unit. The operation is performed by a gynecologist surgeon. A prerequisite for a successful surgical intervention is complete sterility.
Before going to surgery, a woman needs to remove all pubic hair, urinate and wash herself.
On the operating table, the patient is given anesthesia, then the area where the operation will be performed is treated with alcohol and iodine.
With the help of trocars, the doctor makes 3 or 4 incisions in the abdominal wall, each of which does not exceed 5-10 mm.
They are necessary to supply the equipment to the peritoneal cavity:
- A Veress needle is inserted into the navel through the first puncture, through which carbon dioxide flows. This allows you to expand the internal cavity of the peritoneum and gives a better view.
- The second puncture is required to insert a video camera. After that, the doctor is able to visualize all his manipulations on the monitor.
- Laparoscopic instruments enter the abdominal cavity through 3 and 4 punctures.
The operation ends with the extraction of all instruments and suturing. The average duration of the procedure is 20-30 minutes if it has a diagnostic focus. Therapeutic laparoscopy takes from half an hour to 1.5 hours.
Robotic operation
Da Vinci is the name for modern robotic surgeons that are capable of performing laparoscopic operations. The technique was "dubbed" in honor of the famous artist Leonardo Da Vinci, because it was he who first created the drawing of the robot, which was found among his works.
The surgeon controls the robot by pressing the pedals and levers. It regulates the work of all 4 hands: 3 of them are laparoscopic instruments, and one is an endoscope.
This procedure has several advantages:
- Any inaccuracy during the operation is excluded, since the "hands" of the robot do not tremble and are not able to perform sharp movements;
- Blood loss and tissue injury during the operation will be minimal, since the robot arm has 7 degrees of freedom of action (the laparoscope in the hands of the surgeon has only 3 degrees);
- The risk of infection during surgery is minimal;
- The patient recovers in a short period of time.
Preparing a woman for laparoscopy
Preparation is an important step before laparoscopy.
It allows you to minimize the risk of complications and includes the following measures:
Pre-surgery examination
- Delivery of a general blood test. The study allows you to detect inflammation, anemia. Possible blood sampling from a vein or from a finger.
- Delivery of a general urine test. The study provides information on whether a woman has certain diseases, for example, diabetes mellitus, kidney inflammation, etc. For the analysis, you need to collect a portion of morning urine.
- Blood donation for biochemical analysis. Blood is taken from a vein. The analysis provides information about a woman's health status.
- Determination of the Rh factor and blood group. This test is done in case a blood transfusion is required during or after surgery.
- Blood test for HIV and syphilis.
- Passage of fluorography or x-rays of the lungs.
- Ultrasound of the pelvic organs.
- Taking a smear from the vagina. This study allows you to identify possible infectious diseases of the genital area.
- Taking an ECG. The study provides information about the work of the heart.
After the woman has passed all the tests, the doctor will give her the following recommendations:
- Compliance with a diet. 2-3 days before the planned intervention, you need to eat light meals. You should refuse products that increase gas formation in the intestines, these include plums, apples, legumes, pears, cabbage, beets, potatoes. You can not drink water with gas, alcohol should be excluded. They load the intestines and for a long time such foods as pork, lard and smoked meat are digested. The menu can include vegetable soups, chicken broth, chicken, fish, cereals.
- Take a shower and wash yourself well the night before.
- Before a night's rest and in the morning of the day of surgery, a woman needs to do an enema to cleanse the intestines.
- The last meal should be no later than 18-00 pm on the eve of the procedure.
- It is important to exclude taking Aspirin a few days before the operation. If a woman took any medications, then she must definitely warn her attending physician about this.
Psychological preparation of the patient
It is important that the woman has the correct psychological attitude for the upcoming operation. Excessive worries and experiences can negatively affect the state of her health. So, jumps in blood pressure, headaches, etc. are not excluded. If the doctor shows interest in the patient's health, and does not show an indifferent attitude, then this allows her to tune in to a positive mood.
Premedication stage
This is a very important preparation step. Thanks to him, it is possible to achieve the following goals:
- Prepare the patient's body in physiological terms;
- Reduce the level of anxiety in the patient;
- To minimize the risks of complications after surgery;
- Improve the quality of subsequent anesthesia.
In order to achieve the described effects, the following drugs can be used:
- Seduxen, Alzolam, Diazepam are hypnotics that allow you to make your sleep better;
- Corvalol, Valerian, Valocordin - these drugs help to reduce the level of anxiety, reduce nervousness;
- Analgin, Promedol, Baralgin - drugs that have an analgesic effect;
- Suprastin, Zirtek, Tavegil - drugs that reduce the severity of allergic reactions;
- Atropine, Platyphyllin are anticholinergic drugs that are widely used in anesthesiology.
Surgical field treatment
This stage includes the following steps:
- Morning shower;
- Pubic hair removal;
- Treatment of the pubic area with alcohol;
- In the operating unit, the area of surgical intervention is additionally wiped with iodine.
Indications for laparoscopy of the fallopian tubes
The main task of laparoscopy is to normalize the patency of the fallopian tubes.
Depending on the scale of the operation, the following options can be used:
- Task: Removal of small adhesions. Implementation: salpingolysis.
- Task: normalizing the epididymis funnel. Implementation: fimbrioplasty.
- Task: to restore the patency of the fallopian tube funnel. Implementation: salpingostomy.
- Sometimes it is required to remove many adhesions not only in the fallopian tube, but also in the abdominal cavity.
- During laparoscopy, it is possible to remove endometriotic growths, cysts, uterine fibroids.
- Surgery to remove an ectopic pregnancy. In this case, either complete removal of the fallopian tube is possible, or its incision and removal of the embryo. However, most often doctors cut out the entire fallopian tube, since the formation of an embryo in it greatly damages it, so there is a high risk that the next pregnancy will also be ectopic.
- Sterilization of the patient. The tubes can be removed for women who no longer want to have children. However, it should be understood that resection is an irreversible process.
Laparoscopy of the fallopian tubes is performed when there is a need to restore the normal form of the appendage, as well as to eliminate the existing pathological formations. In the future, this will allow the woman to conceive a child. Sometimes it happens that the fallopian tubes cannot be repaired, for example, when they are severely deformed. In this case, they are deleted.
If a year after the operation, the couple cannot conceive a child naturally, then IVF should be resorted to.
In general, tubal laparoscopy is not recommended for every patient. For example, when a wife is over the age of 35 and she cannot conceive a child for a long time (more than a year), then she is shown to undergo IVF, since laparoscopy will be ineffective in this case. While for young women suffering from tubal infertility, laparoscopy allows conceiving a child in 80-95% of cases.
Contraindications
A comprehensive examination before the operation allows you to identify contraindications to its implementation. If you neglect this stage, then serious health complications and even the death of a woman on the operating table are possible.
Laparoscopy can never be performed in the following cases:
- Cancer of the female reproductive system;
- Renal and hepatic impairment;
- Hernia of the esophageal opening of the diaphragm;
- Hernia of the white line of the abdomen;
- Blood clotting disorder;
- Extreme exhaustion of the body;
- Coma.
In addition, there are temporary contraindications to laparoscopy, after the elimination of which it is possible to perform an operation on the fallopian tubes:
- Obesity (grade 3 and 4);
- Diabetes;
- Menstrual bleeding;
- Hypertonic disease;
- Abnormalities in blood and urine parameters;
- Infectious diseases, for example, ARVI, influenza, etc.
Narcosis
Laparoscopy requires the introduction of general anesthesia, therefore an anesthesiologist must be present in the operating unit. After the injection of the drug, the woman falls asleep and does not feel pain. To monitor all vital signs at this time, various sensors are connected to the patient's body.
Anesthesia is administered intravenously or delivered through a mask by inhalation. Intravenous anesthesia lasts about 20 minutes. If the operation has not yet been completed, the anesthesiologist will administer an additional dose of the drug.
Inhalation anesthesia is carried out by the endotracheal or mask method. In the first case, the patient is immersed in sleep, after which a tube is inserted into her larynx through which the narcotic substance enters. This type of inhalation anesthesia requires the patient to be connected to a ventilator. Also, the advantage of the endotracheal method is that there is no risk of gastric contents entering the respiratory tract, and the doctor is able to qualitatively control the delivery of the dose of the drug.
As for mask anesthesia, it is used when it is not possible to connect a woman to a ventilator. However, this increases the risk that gastric contents can enter the airways, leading to damage. Mask anesthesia is used mainly when the operation lasts a few minutes and is not difficult for the surgeon.
Do not forget that the introduction of anesthesia is always associated with a number of complications, including:
- Development of acute respiratory or heart failure;
- Development of laryngeal edema;
- Myocardial infarction;
- Respiratory depression;
- Vomiting urge.
Postoperative rehabilitation
Rehabilitation after surgery is different for all patients and depends on a number of factors:
- The method of anesthesia used;
- Duration of laparoscopy, its type and scope of operation;
- The age of the patient, her state of health, the presence of other diseases.
When the laparoscopy is completed, the woman is under medical supervision.
At the same time, such parameters are assessed:
- Color of the skin. If the patient's condition is stable, then the skin should have a pale pink tint.
- Body temperature should not exceed 37.5 ° C.
- Blood pressure level and pulse. These indicators should be the same as before the start of the laparoscopy.
- A woman should perform about 17 breathing movements per minute.
- It is important that the patient does not experience urinary retention.
A woman should be prepared for the fact that after coming out of anesthesia, she may experience hallucinations, weakness and dizziness will be present, nausea and vomiting are possible.
There may also be some discomfort in the navel and lungs. It is due to the fact that carbon dioxide is injected into the abdominal cavity, the remains of which are retained after the operation. These residues are excreted through the pulmonary system. In order for the gas to escape faster, the next day after the operation, the patient should begin to move, including getting out of bed and walking.
To normalize bowel function, you need to eat right - often, but in small portions. Within 24 hours after the operation, you need to drink as much water as possible, broths and juices are allowed. All dishes must be gently cooked - boiled or stewed. The emphasis should be on protein foods and carbohydrate foods high in fiber.
Foods to include on the menu:
- Fruit;
- Vegetables and puree soups based on them;
- Meat products: chicken breast, lean fish;
- Cereals: rice, buckwheat, oatmeal;
- Wholemeal bread;
- Juice, still water, weak tea, jelly, compote.
The following products should be excluded from the menu:
- Salt, spices, spices;
- Marinades;
- Fatty fish and meat;
- Lard and smoked meat delicacies;
- Chocolate, confectionery;
- Foods that increase the formation of gas in the intestines;
- Astringent fruits and berries;
- Coffee, spirits, gas water.
If a woman feels well and adheres to all the doctor's recommendations, then she can be discharged from the hospital after 2-3 days.
Before letting the patient go home, the doctor must provide her with the following information:
- The first sexual intercourse should happen no earlier than one month after laparoscopy. The same period is valid for intense physical activity.
- A woman will be able to start working as early as a week after the operation, provided that her health is not disturbed.
- You need to talk to your gynecologist about the possibility of conceiving a child. As a rule, experts consider the optimal time for conception to be 2-3 months after the procedure, but not more than 6 months. In the future, the results will be minimized, as the risk of new adhesions formation increases.
- The woman will have to carefully monitor whether she is pregnant or not, regularly do tests. The fact is that after the laparoscopy, the risk remains that she may have an ectopic pregnancy.
Consequences and complications of tubal laparoscopy
The following symptoms should alert a woman and force her to immediately consult a doctor:
- Hyperemia of the tissues surrounding the seams;
- The appearance of purulent or bloody discharge from wounds;
- Severe abdominal pain;
- Increased body temperature;
- Hoarseness of voice that gets worse.
As for complications after surgery, they are extremely rare - in 7% of cases.
The following dangers may lie in wait for a woman:
- Violation of the structure of internal organs due to their damage by laparoscopic equipment.
- Postoperative bleeding.
- Blood clots.
- Formation of subcutaneous emphysema.
The author of the article: Lapikova Valentina Vladimirovna | Gynecologist, reproductologist
Education: Diploma in Obstetrics and Gynecology received at the Russian State Medical University of the Federal Agency for Healthcare and Social Development (2010). In 2013 completed postgraduate studies at N. N. N. I. Pirogova.
