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Describe peritoneal cavity access and entry with laparoscopy; Highlight pelvic anatomy with laparoscopic pelvic survey; Describe the approach to salpingectomy
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Family Medicine & Primary Care Specialty
Obstetrics & Gynecology Specialty
Obstetrics & Gynecology (General) Subspecialty
Mayo Clinic
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Past Notes
(mellow music)
<v ->Hello, my name is Zaraq Khan.</v>
I'm an associate professor of obstetrics and gynecology
at the Mayo Clinic in Rochester.
I chair the division of reproductive endocrinology
and infertility, and have joint appointment
in minimally invasive gynecologic surgery as well.
And today I'm very happy to present a very interesting case
to you guys and highlight operative laparoscopy
and an approach to bilateral salpingectomy
for bilateral hydrosalpinx.
In this case,
we aim to show the approach and entry techniques
into the abdomen,
and also go over certain telltale signs
of why a hydrosalpinx should be removed,
and in an ideal situation,
how to keep as much ovarian potential
and ovarian function as possible.
I hope that you find this video informative and interesting,
and I hope that you can take some tips and tricks
highlighted in this video and incorporate them
into your daily surgical practice.
Thank you, and have a great day.
(mellow music)
<v ->So we're gonna access this abdomen</v>
for an operative laparoscopy
with bilateral salpingectomy for bilateral hydrosalpinges.
And that's one of those oxymorons in fertility surgery,
where we actually make the patient infertile
to make them fertile with IVF.
So with both bilaterally blocked fallopian tubes,
there really isn't a really good mechanism
of opening the tubes up and then keeping the tubes open.
One of the things that we think about is,
with bilaterally blocked fallopian tubes,
the patient has tubal factor infertility (correction).
So most likely they're gonna require IVF in order
to get to their goal of a pregnancy anyway.
However, with both tubes swollen,
nobody will be willing to do an embryo transfer
since there's excellent data to show that
if there's hydrosalpinx connected to the uterus
there's reduction of embryo implantation by 50%, 50.
So that's one of the cases where we actually
make people infertile, so remove their tubes
to make them fertile through IVF.
And this is what we're doing for this patient.
So again, highlighting how we enter this abdomen
for a laparoscopic approach.
There are several different ways
of entering laparoscopically.
Probably a common one used is the Veress needle.
However, there is another technique that I'm using here
that's called an Optiview direct entry,
where we visualize, we take a five laparoscope
with zero degree angle,
insert it into the five millimeter trocar.
And then the next thing we're gonna do is we're gonna
directly enter the abdomen
while visualizing going through various layers.
Here we can see we've entered the abdominal cavity already,
as we can see omental fat here.
And we can see we're probably
through and through the omentum
because I can see a layer of omentum right above me as well.
So one of the things we can do at this point
if we're not sure is we can start insufflation of the gas
on low pressure.
So gas on, on low pressure, please.
The most important thing is to look
at your opening pressure,
and it's four to five millimeters of mercury,
which is perfect.
That means we're in the abdominal cavity
and we're not in the preperitoneal space
because opening pressure in that scenario
will be in the teens, 15, 16, 12, 14.
However, we can see here that even though we're in,
we're most likely in the layers of the omentum.
And in order to show that, you can look at the upper abdomen.
And if you can see the liver, which I can here,
that already tells me that I'm not in the lesser sac.
So we can go ahead and go to high flow on gas
and we can go ahead and inflate the balloon.
So the first thing we look at is where we enter to make sure
there's no injury right under where we entered,
and we can see an intact omentum there.
We're gonna get our gas on high flow.
We can start seeing the pneumoperitoneum being created
and the omentum separating from the interior abdominal wall
and falling down as we see here.
So one of the things that we start with
is we start with an upper abdominal survey.
I'm gonna increase the lights here
and actually clean the camera a little bit
and get these lights off our screens.
That way we will be able to see a little bit better.
So all these small little things can help you visualize
and get a better view in laparoscopic surgery.
Here we see,
and there's still a little bit of fogging.
Typically that is because the scope is cold.
So some of the tips and tricks are you can take
the abdominal wall and gently sweep that scope
against the abdominal wall.
What you don't want to do is to sweep it against any fat
or omentum because it'll make it even more blurred.
So you can see it cleaned up the visualization
just a little bit, which is great.
And we would wait for the scope to warm up
and then we will have better visualization.
So we start with the upper abdominal survey
and look right in the midline and take pictures.
We can see the liver there
divided by the falciform ligament.
On the left side,
we see the left lobe of the liver and the stomach
wrapping around with an NG tube,
very nicely placed with a deflated stomach.
The spleen would be up there in the left upper quadrant,
which we can see right now.
And the heart is right above the diaphragm in that area.
We do not see any evidence of endometriosis
or adhesive disease.
We see that the liver edge is normal
and the gallbladder is visualized in that area right here.
And then we see the notching from the ribs anteriorly.
And as we snake behind,
we're looking at the dome of the liver
as well as the right diaphragm.
And it's really important to rule out any endometriosis
or adhesive disease.
Other things that can cause adhesions here
classically are called
Fitz-Hugh-Curtis syndrome-like adhesions
where there are violet, string-like filmy adhesions
that are classically seen
after pelvic inflammatory disease or PID.
As we sort of now get more into going towards the pelvis,
we will appropriately position the patient in Trendelenburg.
I usually like an angle of about 21 to 24 or 25 degrees,
depending on the patient's BMI, age and respiratory status.
Most of our younger patients have
a sound cardiovascular system and they can tolerate
a fairly steep Trendelenburg.
And I think that positioning further allows you to perform
pelvic laparoscopy and surgery with ease, because again,
it is all about visualization.
Thank you.
At this point,
we're gonna go ahead and start placing
our left and right lower quadrant trocars, at least,
because we're gonna need some accessory trocars
to complete a pelvic survey,
get the omentum out of the pelvis
and assess the fallopian tubes.
So I'm gonna hand the camera over to my assistant.
And some anatomic landmarks for placement
of these lateral sites for the left and right side,
I look at the anterior superior iliac spine
on the lateral side
and go about one finger breadth medial to that,
which is about two centimeters for me.
Once we look at the anatomy
of the intraabdominal structures,
we will reconfirm and make sure that that would be
a safe place for us to enter.
So on this patient, because of her BMI,
it is hard to delineate anterior wall anatomy.
But you can see this fold is the medial umbilical ligament,
which is the obliterated hypogastric vessel on each side.
However, the lateral ligament,
we can barely see it right there
that. The red line is a vessel.
It's the inferior epigastric vessel.
That meets the lateral umbilical ligament.
And when we put our port, we want to be lateral to that
so we don't get into bleeding.
The way to look and assess and do that carefully is to first
visually poke in where you were going to go into.
And you can see that that is lateral
to the blood flow there.
However, in a patient with very high BMI
where there's fat obscuring,
a lot of adipose tissue obscuring
a lot of our visualization
we can still look at the insertion of the round ligament,
which is this structure coming into the deep inguinal canal.
And as long as you are lateral to it,
you will be okay because where the round ligament inserts
into deep inguinal ring,
the lateral umbilical ligaments arise
just medial to that insertion,
as it's seen here in this beautiful anatomy.
So now that we have confirmed that we are lateral
to our epigastric vessels,
we're going to go ahead and first inject the skin
with some local 0.25% bupivacaine without epinephrine
for preemptive analgesia prior to making our incision.
I've seen people do several different things.
Some surgeons prefer to inject after making the incisions,
some inject before making the incisions.
Really in the gynecologic surgery literature
there's not much data to show that one helps
versus the other.
However, in the general surgery literature
and minimally invasive general surgery,
the data really is clear in preemptive analgesia,
which is injecting local before making an incision.
As you can see with a five millimeter camera,
the advantage of using a five millimeter camera is that
we don't have to then close fascia at that port site.
However, the disadvantage of using
the five millimeter camera really
is that we have to constantly go back and forth
and make sure that the camera is clean,
there's no fog, that the camera is lined
with our anti humidifier or FRED.
And that's gonna be really important.
Then we go ahead and place our second trocar.
And as you can see,
that is being placed lateral to the insertion
of the round ligament into the deep inguinal canal.
And as you can see,
we're getting some more steep Trendelenburg.
So even without touching the omentum,
you can start seeing that it's trying to come down.
Good, table down.
And you can see that the omentum is falling off
without us even touching it with the bowel.
But when we do that,
we can clearly sweep all these structures up
and it really does help us sort of with manipulation
throughout the case.
So here we can see there's a filmy adhesion
between the omentum and the adnexa.
That could be classic of PID
or pelvic inflammatory disease history.
This filmy adhesion is very classic of that.
And as you can see,
the fallopian tube is dilated, it's sausage-like,
and the finger-like projections of the fimbriated ends
are phimosed or almost sort of scarred within the tube.
That causes that tubal obstruction.
There you go.
So because we're gonna need to do
a complete operative laparoscopy,
I will place my third port
for the actual operative procedure.
And I like to use a paramedian port.
There are several surgeons that will use
a suprapubic trocar as well.
And I think it is what preference you're used to
and what you're trained with.
For me as a right-handed person
standing on the left side of the table,
it gives me more ergonomics when I'm standing on one side
rather than stretched across.
And so I really can stay on one side and ergonomically work
on the left side when I place a paramedian port.
The important part about a paramedian port is it has to be
placed in a way where if you put the instruments
through both ports, they should triangulate
both towards the pelvis,
which helps with suturing and helps with ambidextrous motion
of both your instruments.
So here I'm gonna measure 10 centimeters
from my lateral port and 10 centimeters from my camera port,
and mark somewhere right in the level of the belly button
or slightly above for my operative port.
I'm gonna inject again with bupivacaine,
0.25% without epinephrine.
We'll make a five millimeter incision,
and then we will insert our final trocar
that will help me complete this operative laparoscopy.
All right,
so now is when we can start with the operative part
of the procedure.
In my right hand, I have a monopolar cautery device
and L hook.
And in my left hand, I have an
atraumatic bowel grasper or Schneider.
And what my goal first is to take down
all these filmy adhesions between the bowel and the adnexa
or the omentum and the adnexa.
It is as simple as traction and countertraction
and just breaking these adhesions down
right in the midline.
Now what's important to look at first
is to do a complete pelvic survey.
A pelvic survey includes by starting with taking pictures
of the deep inguinal ring, which is right here.
So look down here, from the uterus arises the round ligament
that continues to travel and course through the pelvis
and enters the deep inguinal ring right here.
We want to look at this because if there's a big opening
or something like that, like femoral hernia,
that could be cause of pain as well.
And we see that that's looking normal.
Next, we continue to move counterclockwise
and look at the vesicouterine folds.
Bladder is gonna be up there with the uterus down here.
And this is the fold between the bladder and the uterus
called the vesicouterine fold or the anterior cul-de-sac,
which is as normal as it can be.
No evidence of endometriosis or disease there.
Continuing our pelvic survey to the left side,
we're gonna follow the round ligament
arising from the uterus, going,
coursing all the way laterally and entering
the deep inguinal ring here.
Again, no hernia is noted there and looks wonderful.
We can antevert the uterus.
In my cases, I like to use a uterine manipulator.
As you can see,
my assistant can very easily manipulate the uterus
with just motions of the manipulator.
And I think that becomes very, very handy
and helpful as well.
We can see the dilated sausage-like tube here
with the fimbriated ends present.
However, a previous chromopertubation
revealed bilateral blockage with complete hydrosalpinx.
So this is what we will be addressing today,
removing this fallopian tube.
Behind that fallopian tube
we see an ovary hiding on that side,
which looks normal on appearance.
Once we get the tube out,
we will perform lysis of adhesions around the ovary
to see it better as well.
The next thing we look at is the posterior cul-de-sac
or the rectal, which is rectum right here,
rectovaginal, vagina right here with the manipulator here,
rectovaginal space or the pouch of Douglas,
which is a bowl like structure right here.
And you can see this is widely patent, open,
no obliteration. We can take a picture, zoom in,
and we will look at the peritoneum very closely
and see if there's any evidence of endometriosis,
which we do not see in this case.
There's a little bit of white area there that sometimes
can be subtle for endometriosis
and if need be, we will biopsy that area.
Next, I look at the uterosacral ligaments,
and the uterosacral ligament here on the left side
is right here and on the right side is right here.
Those ligaments are free of fibrosis and disease.
And I don't see any evidence of endometriosis in them,
which is excellent for the patient.
Moving on finally to the right adnexa,
we again see a dilated tube with phimosed ends
that are completely encased in those filmy adhesions.
And behind that, we do see a normal appearing ovary
just encased in adhesions there.
So the final thing I do on a pelvic survey
is move rightwards towards the appendix.
As we had alluded to, the appendix is an innocent bystander,
but can be affected with endometriosis quite a bit
because it gets stuck in the pelvis
and then disease starts to grow on it or into it.
Here, we see that the appendiceal tip is normal.
I would always like to see the tip of the appendix
to make sure it's normal.
And then going on looking at the shaft
and then finally its insertion and all of that looks
very normal and healthy so we're gonna let the appendix be.
So for our next steps,
we're gonna now address how we remove
these two fallopian tubes.
And technically, I like to use an instrument
called LigaSure device,
which is bipolar rather than the monopolar L hook here,
because it leads to better hemostasis.
Because I'm gonna be removing these tubes
I'm okay with touching and pinching on these tubes.
I would never do that in a tube
that I would otherwise not remove.
So we can see the scar tissue around the fallopian tubes.
So our first goal would be to just do lysis of adhesions
still around the adnexa to make sure that we can
at least mobilize the fallopian tube out of its pocket here,
where it's stuck with the ovaries.
We will continue to do ovariolysis
after we remove the fallopian tubes,
but we can see here that the fallopian tube
is completely phimosed, the fimbriated end,
and it's completely sort of obliterated
and merged into the ovary here with scar tissue.
So one of the things we like to do at this point
is we can start our salpingectomy using a LigaSure device.
One of the important things about doing the salpingectomy
is to make sure that we can preserve
as much ovarian function as possible.
So as a reproductive surgeon,
one of my passions is to preserve the uterus if possible,
and to maintain ovarian function as best as we can.
In order to maintain ovarian function here,
we wanna make sure that this
infundibulopelvic ligament, this IP vessel
that is going into the ovary,
when we're getting into this knuckle,
we wanna make sure that we're hugging the fallopian tube
and not out here, because we can get that vessel
and reduce the blood flow to the ovary in the process.
That again will cause reduction in ovarian reserve,
which we do not want for our patients.
Because this patient, for example,
after bilateral salpingectomy
is gonna need IVF to get pregnant.
So we start with our LigaSure device.
The button fires bipolar energy, which means energy
current flowing between the jaws of the LigaSure,
and it seals and then cuts the tissue around it.
Now what's interesting here is
is the tube is still sort of merged
into the ovary quite a bit.
So we are gonna get one more bite here and try to see
if we can mobilize it a little bit more.
Here that tube is still stuck.
So usually for these tubes,
I'll start proximal and then go distal.
So if we can retrovert the uterus a little bit, please.
Wonderful.
And then here what's most important is to get the tube
as close to the uterus as possible.
We do not want what's called a cornual ectopic pregnancy.
So if you leave a little nubbin of tube,
the biggest risk factor for a cornual ectopic pregnancy
is salpingectomy on the same side.
And that's one thing we want to avoid in these patients.
So we try to hug the uterus as much as possible
to grab the fallopian tube.
And then once we start having a leading edge on the tube,
we will walk along the fallopian tube there.
So we can see, we have a leading edge on the fallopian tube.
That's the utero-ovarian ligament, which again,
supplies blood to the ovary.
So you want to make sure that you're staying way away
from the utero-ovarian ligament.
And if possible,
this is the time when you start hugging the fallopian tube
on the mesosalpinx.
One thing we don't want in a patient
where we want to preserve her ovarian reserve
is to go further down.
We want to really hug the tube, if at all possible,
to cause minimal damage to the blood vessels
in the mesosalpinx.
Reason for that being that there's collateral blood supply
and sharing a blood supply with the ovary.
We can see, we have a little bit of a plane here.
Now, there are several other energy devices
one can use to take the mesosalpinx down.
One can use a LigaSure device like I am.
You can use a Harmonic scalpel.
You can use just simple monopolar
and bipolar cautery as well.
And you can see here,
the tube is now beginning to peel off
from the fallopian tube
and we can gently continue our dissection with that.
Here we know that the IP is further rather high.
So we would go right in this space
and hug the fallopian tube to get it all out.
That's the phimosed end of the fallopian tube.
That's completely scarred in and blended with the ovary.
And this is classic for pelvic inflammatory disease
in my opinion.
When I fire my LigaSure,
I'm still staying away from the ovary.
As a reproductive surgeon
I wanna save every last egg possible on the ovary.
So that's one of the important things that we can do
that would benefit the patient.
Here we can see we're almost done with the fallopian tube
on that side, and you can see that very dilated, deformed,
abnormal looking tube that has now been completely removed
from the uterus.
Again, the goal being two things.
One is here, you do not want to compromise
that infundibulopelvic ligament
and get that knuckle away from it.
The second thing up there is you do not want to compromise
the utero-ovarian ligament right here,
which has blood supply to the ovary.
The third thing is once you want to, you get the tube,
you have to hug the uterus.
And finally, you wanna walk the mesosalpinx
very close to the tube
and leave all this mesosalpinx in place
because all of this mesosalpinx has blood supply
to the ovary as well.
And we want to preserve that as much as possible.
Now we will mirror what we did on that side,
on the left side.
And the left side might be a little bit easier
because there's less scarring of the fallopian tube
with the ovary.
The first things I can do is I can just take
these filmy adhesions and just take them down
just with the knife part of the LigaSure.
The next thing I will do is I'll start proximally again.
Usually I will do distal as well,
but because in these cases,
the distal part of the tube is almost always scarred
with the ovary,
it's always nice to get a head start on the proximal
and then walk distal in these scenarios.
So again, we're hugging the uterus,
making sure that we don't have any remnant of tube left.
And then we will start walking down on the tube.
I'll do one more slight buzz here because I can see the
utero-ovarian ligament is still far away from me.
And the utero-ovarian ligament in this scenario
is right here down there.
Once the tube is separated,
we'll start taking some of the mesosalpinx down.
Now, usually the angle here is not the best,
but I can still manage to just get the mesosalpinx
next to the tube
and we'll do that to continue our salpingectomy.
So here we can see I'm having problems with my angle.
So I'm going to re-strategize, change my strategy,
go from proximal to distal,
because I think that will help me a little bit more.
We can see here that there is some scar tissue noted here
between the pelvic side wall and the ovary.
Know that we will address all that scar tissue
around the ovary after we remove the fallopian tubes.
What's making this difficult is the deposit
of adipose tissue right here, which is confusing.
But if you follow the infundibulopelvic ligament,
which is right here, and if I move this around,
you can almost see that vessel coursing upwards like this
into the ovary.
And if I move this,
I want you to appreciate that vessel
moving into the ovary right there.
So if we stay away from that vessel high up here,
I think we will still be just fine
in removing our fallopian tube
without causing damage to the infundibulopelvic ligament.
So it's really important to understand and know
that we do not want that damage to occur
to those structures,
especially the infundibulopelvic ligament,
Which carries all the blood supply to the ovary.
So here we can see that this we can connect
because that tube is almost getting separated.
Again, you wanna hug the tube away from the mesosalpinx,
preserve as much of that mesosalpinx as one can.
And continue to follow the tube here.
I think it's nice to see a salpingectomy for a hydrosalpinx
'cause it's very different from say,
a bilateral salpingectomy for contraception
in normal appearing tubes.
You can see the architecture,
the course of the tube is tortuous,
and it's got some adhesions and scar tissue around it.
So it always is a little bit more interesting
than just a conventional salpingectomy for contraception.
Here we can see here that that's the ovaries
right down here, the white structure here.
We do see an attachment still of the tube with the adnexa.
And I'm gonna assess that from each side to see what it is
and then we'll look around.
To me, that's just the tube connecting
and there's no vital structures there.
So what we're gonna do is we can untwist that,
right like that, perfect.
And then we're gonna go right in between the tube
and the infundibulopelvic ligament there.
A little bit more of the tube that's being stubborn
and persistent, right there.
And that's just a little bit of a paratubal cyst with it.
So this will complete our salpingectomy portion.
We will wait for a little bit
and first do some lysis of adhesions around the ovary
to see if we find any endometriosis.
Best that I can see and evaluate,
we have not seen any disease.
So we'll start with this site first.
You can see that there's some scar tissue around the ovary
in that area, but that to me is more consistent
with post PID-like filmy scar tissue.
You can see there's very filmy adhesions around the ovary.
And what I'm gonna do is I'm gonna first try and see
if I can take some of that down with some gentle cautery.
Now again, I don't wanna go very over-zealous
because if I'm going to cauterize more,
I'm gonna need to open the retroperitoneum
to identify the ureter,
but I don't see a need of doing that in this case
because I don't think she has any further disease process.
All I'm trying to do is just open these little pockets
to see if there's any evidence of endometriosis or disease
since this patient did present with pelvic pain.
Now, hydrosalpinx in itself can be a cause of pelvic pain,
but you can see here, there's no endometriosis.
This is just filmy adhesions.
And I can take them down, but if I take them down bluntly
she's gonna get more bleeding.
So at this point,
I'm just gonna make sure that there's good hemostasis
and we leave the ovary the way it is.
So what I do for lysis of adhesions, really,
I think of it in two ways.
So if patient is having endometriosis, yes,
I think those adhesions need to be taken down.
Anatomy needs to be restored.
With adhesions like this for PID, if you take the source,
which is the enlarged tubes out,
I really am not gonna dissect more
unless absolutely necessary.
So we'll get that little pinpoint bleeding area,
but I don't see any disease there.
And that's what my goal was to explore in that area.
Now let's look at the other side real quick.
And we're gonna get the ovary here.
And see again there's something very similar where the ovaries
are scarred to the side wall here,
but we don't see any evidence of disease.
And this one was easier to dissect out because that was
a less dense adhesion between the ovary
and the pelvic side wall.
Perfect.
So this patient then in summary
does not have any endometriosis,
had bilateral hydrosalpinges,
most likely due to pelvic inflammatory disease,
as we could see sequelae of that.
And then finally,
what we're gonna need to do is we'll remove
these fallopian tubes.
Once I push the bag in,
See, this is a 5 Endo bag,
so my assistant's gonna go in and open the bag.
So we see that the bag has opened.
Next we're going to try and put these specimens in the bag
one at a time.
And then the other specimen in the bag as well.
And then what I do is just wiggle it upwards
to the abdominal wall and then start closing the bag.
So now we have the tubes secured.
And then we can easily remove these tubes
through a five millimeter port.
So we deflate the balloon so that the trocar is
getting ready to come out.
And then we can gently wiggle or if need be,
tease the fallopian tubes out.
Tubes usually would come out without any trouble.
It's usually more for harder objects,
like large fibroids or very large ovarian cysts
where we would actually have to increase the size
of the port to really morcellate those pieces of specimen
out of the abdomen.
So here I'm using a curved Kelly clamp without teeth
to enter into the bag and ideally grab one of the tubes
so I can pull it out.
Now in the process, you may fragment some of the specimens.
So it's really important to know and understand
that if you want surgical margins
or if you want an intact specimen,
you may not want to do this
and you may want to use a larger bag
and make your incision larger
to remove the specimens intact.
There we go.
We're almost done with this case.
I just wanna show the final anatomy and highlight
what we've done for this patient.
So we can see here both pelvic side walls
are free of disease.
There's no endometriosis.
Both ovaries are normal in appearance.
They just have, encased in filmy adhesions
most likely from PID.
We can see a normal appearing pelvis,
look up, normal appearing uterus now
with no fallopian tubes.
And that completes our case for bilateral salpingectomy.
We're gonna remove that small piece of tube
that's still charred out there.
But otherwise this concludes this case.
Thank you.
(mellow music)
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