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Culdoscopy
Correspondence Culdoscopy To
the
Editor:
I have read with great interest the article on c~uldoscopy published by R. W. TeLinde and F. Rutledge in the January, 1948, issue of the JOURNAL. As far back as 1936, I introduced the first instrument designed for this type of examination and named it colpolaparoscope. Having gained considerable experience with colpolaparoscopy (method of entering the abdominal cavity through the fornix vaginae), I wish to state that I am in complete agreement with the aforementioned authors, that colpolaparoscopy (c. 1.) is a useful adjunct to the diagnostic armamentarium in gynecology. However, it should be stressed that, in addition to colpolaparocentesis as a therapeutic measure in conditions associated with ascites, I used the operative colpolaparoscope for minor surgical procedures such as the dissection of adnexial adhesions, fimbriolysis, and the securing of biopsies. My instrument was manufactured in Vienna, in 1936, by the Leiter Company. It is equipped with an elaborate optical system, and a device which prevents the lenses from becoming soiled within the abdominal cavity. The lenses are covered during the introduction of the instrument. (Fig. la.) With the instrument in situ, the rod equipped with the optical system is rotated within its sheath clockwise 180 degrees. Thus the lenses are set free. (Fig. 1B.) Two close-up pictures of the proximal part of the instrument, demonstrating this mechanism, are attached; also a picture of all the component parts of the instrument (Fig. 2). A.
B. Fig.
1.
Only when the examiner is certain that the cul-de-sac of Douglas is free should the brusque penetration in knee-chest position be attempted. In all other cases, the anatomic approach to the pelvic cavity through a 1 cm. wide incision in the posterior fornix, with exposure of the rectovaginal space and the peritoneal reflection, is preferable. This approach was advocated by me in presentations before the Viennese Medical Society, 193’7, and the New York Academy of Medicine, 1947, and described in Wien. klin. Wchnschr. 59: 50, 1947. The delay in publication was due to the war and postwar conditions. By the ana1071
CORREBPONDENC:I<
1072
tomic approach to the cavity of Douglas, its contents, such as blood or exudat.e, will U!JI c:seape the attention of the examiner, and injuries to a riscus and extra- or rrtropcritonr:rl emphysema will be avoided. Failures to penetrate into the abdomen, as encouni~~red ti\ ltock in one out of every six of his cases, may thereby be markedly reduced,
Fig.
2.
(I) in Trendelenburg We have used two methods of introduction of the instrument: position with the operating table tilted at an angle of 45”, with air insufflation and an rr1 intrauterine probe, which keeps the uterus in position; (2) in knee-chest position. either case the instrument should be inserted with its promixal end directed toward the center of an imaginary line, which connects the promontory wit+ the umbilicus. There are two definite and strong indications for performing a colpolaparoscopy: (1) all instances suggestive of ectopic pregnancy (peritubal hematoma, hematomole, early (2‘1 tubal abortion, etc.) where otherwise, a diagnosis cannot be made with certainty; cases of ovarian or tubal carcinoma or cancers of adjacent pelvic organs. In these two categories, a definite diagnosis can be established and a lifesaving operat,ion performed without delay. Episodes, such as torsion of the uterus or adnexa or bleeding from a ruptured corpus luteum, can be diagnosed and treated surgically. Furthermore, it is help ful in avoiding unnecessary laparotomies in cases of subacute and chronic inflammations, in small fibroids, which by virtue of their localization are often mistaken for ovarian tumors, in endometriosis, etc. There is also a definite place for examination in cases of sterility due to ovarian conditions, such aa infantilism or adnexial adhesions, both of which can easily be visualized, and the latter sometimes successfully treated with t,he However, in order to guard the new method against becoming operative colpolaparoscope. discredited, it should never be performed indiscriminately. The method is definitely contraindicated in febrile conditions or infectious diseases of the genital tract and its adjacent organs. The valuable contributions by TeLinde and Rock will hasten the introduction of the procedure into gynecology. May I add that the foregoing communication is not intended to detract from the valuable work of Dr. Decker. EMANUEL KIAFTEN, M.D. 333 CENTRAL NEW YORK Feb. 14, 1948
PARK,
WEST .
the
Editor:
I have read with great interest the article on c~uldoscopy published by R. W. TeLinde and F. Rutledge in the January, 1948, issue of the JOURNAL. As far back as 1936, I introduced the first instrument designed for this type of examination and named it colpolaparoscope. Having gained considerable experience with colpolaparoscopy (method of entering the abdominal cavity through the fornix vaginae), I wish to state that I am in complete agreement with the aforementioned authors, that colpolaparoscopy (c. 1.) is a useful adjunct to the diagnostic armamentarium in gynecology. However, it should be stressed that, in addition to colpolaparocentesis as a therapeutic measure in conditions associated with ascites, I used the operative colpolaparoscope for minor surgical procedures such as the dissection of adnexial adhesions, fimbriolysis, and the securing of biopsies. My instrument was manufactured in Vienna, in 1936, by the Leiter Company. It is equipped with an elaborate optical system, and a device which prevents the lenses from becoming soiled within the abdominal cavity. The lenses are covered during the introduction of the instrument. (Fig. la.) With the instrument in situ, the rod equipped with the optical system is rotated within its sheath clockwise 180 degrees. Thus the lenses are set free. (Fig. 1B.) Two close-up pictures of the proximal part of the instrument, demonstrating this mechanism, are attached; also a picture of all the component parts of the instrument (Fig. 2). A.
B. Fig.
1.
Only when the examiner is certain that the cul-de-sac of Douglas is free should the brusque penetration in knee-chest position be attempted. In all other cases, the anatomic approach to the pelvic cavity through a 1 cm. wide incision in the posterior fornix, with exposure of the rectovaginal space and the peritoneal reflection, is preferable. This approach was advocated by me in presentations before the Viennese Medical Society, 193’7, and the New York Academy of Medicine, 1947, and described in Wien. klin. Wchnschr. 59: 50, 1947. The delay in publication was due to the war and postwar conditions. By the ana1071
CORREBPONDENC:I<
1072
tomic approach to the cavity of Douglas, its contents, such as blood or exudat.e, will U!JI c:seape the attention of the examiner, and injuries to a riscus and extra- or rrtropcritonr:rl emphysema will be avoided. Failures to penetrate into the abdomen, as encouni~~red ti\ ltock in one out of every six of his cases, may thereby be markedly reduced,
Fig.
2.
(I) in Trendelenburg We have used two methods of introduction of the instrument: position with the operating table tilted at an angle of 45”, with air insufflation and an rr1 intrauterine probe, which keeps the uterus in position; (2) in knee-chest position. either case the instrument should be inserted with its promixal end directed toward the center of an imaginary line, which connects the promontory wit+ the umbilicus. There are two definite and strong indications for performing a colpolaparoscopy: (1) all instances suggestive of ectopic pregnancy (peritubal hematoma, hematomole, early (2‘1 tubal abortion, etc.) where otherwise, a diagnosis cannot be made with certainty; cases of ovarian or tubal carcinoma or cancers of adjacent pelvic organs. In these two categories, a definite diagnosis can be established and a lifesaving operat,ion performed without delay. Episodes, such as torsion of the uterus or adnexa or bleeding from a ruptured corpus luteum, can be diagnosed and treated surgically. Furthermore, it is help ful in avoiding unnecessary laparotomies in cases of subacute and chronic inflammations, in small fibroids, which by virtue of their localization are often mistaken for ovarian tumors, in endometriosis, etc. There is also a definite place for examination in cases of sterility due to ovarian conditions, such aa infantilism or adnexial adhesions, both of which can easily be visualized, and the latter sometimes successfully treated with t,he However, in order to guard the new method against becoming operative colpolaparoscope. discredited, it should never be performed indiscriminately. The method is definitely contraindicated in febrile conditions or infectious diseases of the genital tract and its adjacent organs. The valuable contributions by TeLinde and Rock will hasten the introduction of the procedure into gynecology. May I add that the foregoing communication is not intended to detract from the valuable work of Dr. Decker. EMANUEL KIAFTEN, M.D. 333 CENTRAL NEW YORK Feb. 14, 1948
PARK,
WEST .