A laparoscopy involves inserting a laparoscope (a tube about 10 mm wide and similar to a small periscope) into the peri-toneal cavity through a 2-cm (0.75-inch) incision below the um-bilicus to allow visualization of the pelvic structures (Fig. 46-7). Laparoscopy may be used for diagnostic purposes (eg, in cases of pelvic pain when no cause can be found) or treatment. La-paroscopy also facilitates many surgical procedures, such as tubal sterilization, ovarian biopsy, myomectomy, and lysis of adhe-sions (scar tissue that can cause pelvic discomfort). A surgical instrument (intrauterine sound or cannula) may be positioned in-side the uterus to permit manipulation or movement during la-paroscopy, affording better visualization. The pelvic organs can be visualized after the injection of a prescribed amount of carbon dioxide intraperitoneally into the cavity. Called insufflation, this technique separates the intestines from the pelvic organs. If the patient is undergoing sterilization, the fallopian or uterine tubes may be electrocoagulated, sutured, or ligated and a segment re-moved for histologic verification (clips are an alternative device for occluding the tubes).
After the laparoscopy is completed, the laparoscope is with-drawn, carbon dioxide is allowed to escape through the outer can-nula, the small skin incision is closed with sutures or a clip, and the incision is covered with an adhesive bandage. The patient is carefully monitored for several hours to detect any untoward signs indicating bleeding (most commonly from vascular injury to the hypogastric vessels), bowel or bladder injury, or burns from the coagulator. These complications are rare, making laparoscopy a cost-effective and safe short-stay procedure. The patient may experience abdominal or shoulder pain related to the use of car-bon dioxide gas.
Hysteroscopy (transcervical intrauterine endoscopy) allows di-rect visualization of all parts of the uterine cavity by means of a lighted optical instrument. The procedure is best performed about 5 days after menstruation stops, in the estrogenic phase of the menstrual cycle. The vagina and vulva are cleansed, and a paracervical anesthetic block is performed or lidocaine spray is used. The instrument used for the procedure, a hysteroscope, is passed into the cervical canal and advanced 1 or 2 cm under di-rect vision. Uterine-distending fluid (normal saline solution or 5% dextrose in water) is infused through the instrument to dilate the uterine cavity and enhance visibility.
Hysteroscopy is most commonly indicated as an adjunct to a D & C and laparoscopy in cases of infertility, unexplained bleed-ing, retained intrauterine device (IUD), and recurrent early preg-nancy loss. Treatment for some conditions (eg, fibroid tumors) can be accomplished during this procedure. Hysteroscopy is con-traindicated in patients with cervical or endometrial carcinoma or acute pelvic inflammation. Endometrial ablation (destruction of the uterine lining) is performed with a hysteroscope and laser beam in cases of severe bleeding not responsive to other therapies. Performed in an outpatient setting, this rapid procedure is an al-ternative to hysterectomy for some patients. Hysteroscopy, a safe procedure with few complications, has been found to be useful for evaluating endometrial pathology. Uterine perforation can occur.
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