Culdoscopy

Culdoscopy MARTIN J. CLYMAN, M.D., F.A.C.S.*

MANY perplexing diagnostic problems confront every gynecologist. Any procedure, other than a laparotomy, that may provide additional accurate information in solving these problems is of immense value. Culdoscopy is such a procedure. Culdoscopyt is the transvaginal endoscopic visualization of the pelvic viscera through a cul-de-sac puncture with the patient in knee-chest posture. Many efforts in the past 50 years have been made to visualize the pelvic viscera through an endoscope by the vaginal and abdominal routes, but met with many difficulties. These historic aspects have been described at length by Decker.l The introduction of the knee-chest position by Decker and Cherry2 in 1944 made the procedure of culdoscopy feasible and practical for the gynecologist. Since the introduction of this procedure it has been used by many gynecologists both here and abroad and its popularity is increasing. The author's experience covers the period from 1946 through 1956 during which time over 960 culdoscopies were performed. INDICATIONS AND CONTRAINDICATIONS

This procedure should be used when any gynecologic problem is presented in which further information regarding the type of pelvic disease is desirable, but a laparotomy is not indicated. Where obvious disease is evident by the usual methods of gynecological examinations that demands a laparotomy, culdoscopy is not indicated. Culdoscopy has been found most useful in establishing the diagnosis of ectopic pregnancy, endometriosis, Stein-Leventhal syndrome, pelvic tuberculosis, salpingo-oophoritis, also in cases presenting pelvic pain From the Department of Obstetri."cs and Gynecology, Mount Sinai Hospital, New York City. * Clinical Assistant Professor of Obstetrics and Gynecology, Albert Einstein Medical School; Associate Attending Obstetrician and Gynecologist, Bronx Municipal Hospital; Assistant Attending Obstetrician and Gynecologist, The Mount Sinai Hospital; Associate Attending Gynecologist, Hospital for Joint Diseases; Assistant Attending Obstetrician and Gynecologist, St. Clare's Hospital, New York, N. Y. t Coelioscopy, douglasscopy and laparoscopy are used synonymously outside the U. S. A.

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with no apparent palpable pathology, and to obtain additional information in infertility studies. Contraindications include (1) vaginitis, (2) a fixed mass in the cul-desac, including fixed retroversion of the uterus, (3) a narrow senile, atrophic vagina, (4) patients who cannot assume the knee-chest posture because of pulmonary, cardiac or orthopedic disease, and (5) bleeding tendencies. PRELIMINARY ROUTINES; EQUIPMENT

Preparation of the Patient

The patient is usually admitted to the hospital the morning of the day the procedure is to be done, and is then discharged the following morning. She is instructed on the nature of the procedure, for orientation. Breakfast or lunch is withheld. The lower bowel is cleansed by an enema and the bladder is emptied. There is no need to shave the hair about the perineum and vulva as the majority of hairs are anterior to the operating area. What hair is present is matted to the sides with sterile lubricating jelly at the time of the procedure. The Knee-Chest Position

Placing the patient in knee-chest posture so that she is as comfortable as this position allows is all-important. If the patient is not relaxed the mucosal rugae in the posterior fornix of the vagina will not disappear. Puncture of the fornix under this situation will often result in failure of entry into the peritoneal cavity. Occasionally even on relaxation the rugae may be evident; these are easily "ironed out" by the rounded tip of a ring clamp. In the knee-chest position with the abdominal wall relaxed there is an intraperitoneal vacuum created of -12 to - 22 cm. of water. This is indirectly transmitted to the vagina and is manifested by its ballooning out when the perineum and posterior vaginal wall are retracted with a Sims speculum. The posterior fornix is spontaneously stretched in a concave fashion with the disappearance of the rugae and the approximation of the peritoneum of the cul-de-sac and the overlying vaginal mucosa which then presents a smooth surface. No special examining table or supporting device is necessary. However, the operating room table or a standard examining table that may be raised or lowered or tilted into the Trendelenburg position, with attached shoulder braces, is preferred. Thigh slings and special pelvic suspending devices and tables have been described. Special supporting devices have been described by Abarbane13 and Brown.4 A new table for culdoscopy has been recently described by Clauss." The important factors are to have the thighs perpendicular to the table, the knees separated about 6 or 8 inches, and the patient's back

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Fig. 385. Culdoscopy instruments: 1, Fore-oblique; 2, photographic; 3, operating; 4, diagnostic telescopes CACMI Co.); 5, 7Y2 inch No. 13 G. trocar; 6, screw-tip cervical cannulas with connector.

should be sharply inclined toward the table surface. The patient's position is made more comfortable by using foam rubber cushions for her knees and one or two soft pillows longitudinally placed on the table for her chest and head. This procedure may be performed in any adequate sized gynecologic examining room or any operating room. EquiPlllcnt

The Decker culdoscope* is the one used commonly in this country. The set consists of a cannula with a side stopcock; trocar; a right-angle vision straight telescope 0.26 inches in diameter with a working length of 1O:%: inches and a locking device; a flexible tube with Luer-Lok ends; a set of three cervical screw type cones; a conducting cord with a rotating contact (Fig. 385). In France, Palmer's Coelioscopet is used. This is a similar instrument but provides a larger (120 degree) visual angle and a stronger light source. In Germany, a similar instrument is made and is designated as a Douglasscope·t * Mfd. by American Cystoscope Makers, Inc., New York, N. Y. t Mfd. by A. Guerin, Paris, France. t Mfd. by Sass-Wolf & Co. M.B.A. Berlin W. 30, Germany.

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Sterilization is effected by immersion of all instruments in aqueous Zephiran 1 :1000 for at least one-half hour. The instruments are then wiped dry under sterile conditions and placed on the instrument table. Additional equipment consists of: A power source-a dry cell battery box· or a wet cell rechargeable battery box. t A 1O-cc. Luer-Lok local anesthesia syringet Aqeous Zephiran 1 :lOOO A straight and a eurved tonsillar needlet Two I-ounce medicine glasses A 5-cc. ampule of indigo carmine,§ 0.8% A 7*inch No. 13 special trocart solution Sims specula Sterile "lap" sheet Adjustable spotlight Cervical tenaculum, curved Two towel clips Xylocaine 1 % without Adrenalin Two towels Sterile 4 by 4 inch gauze squares Long narrow basin with hot water Sterile gloves Two extra No. 51 bulbs·

Analgesia and Anesthesia

Combinations of Demerol, scopolamine, Seconal, morphine and Pantopon have been used as analgesic agents. The author's current practice is to administer meprobamate 400 mg. on admission, to be repeated in four hours if the procedure is delayed. Demerol 75 to 100 mg. with Phenergan 25 mg. is given intramuscularly 45 minutes prior to the procedure. From 1946 until 1949 low spinal anesthesia with 40 mg. of procaine was used effectively. From 1949 to the present, local anesthesia with 1 per cent Xylocaine without Adrenalin has been used satisfactorily (Fig. 386). A diagnostic procedure should carry with it a minimum of risk. Selfinduction with trichlorethylene supplemented local anesthesia has been described. 3 General anesthesia with N 20-ether or intravenous Pentothal sodium is little used in this country today, but is used widely in European . clinics. General anesthesia makes the knee-chest position very difficult to maintain. PROCEDURE

The patient is placed in knee-chest posture. The buttocks, perineum, vulva and vagina are washed with aqueous Zephiran 1 :1000. The patient is then draped with sterile sheet with a central opening which is narrowed by a towel clip. A dry 2 by 2 inch gauze is placed over the anus. A Sims speculum is then inserted into the vagina and the outer two-thirds of the posterior vaginal wall is held in traction by an assistant. Residual Zephiran and mucus are removed from the vagina with a dry sponge. Any interfering vulvar hair is matted with a sterile jelly lubricant. The beam of the spotlight is placed in the axis of the vaginal vault. The posterior lip of the cervix is grasped with the tenaculum and held fixed by a

a

• American Cystoscope Makers, Inc., New York, N. Y. t National Electrical Instrument Co., New York, N. Y. t Becton-Dickinson & Co., Rutherford, N. J. (The trocar is a modification of catalogue No. 468LRT.) § Hynson, Westcott, & Dunning, Inc., Baltimore, Md.

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slight depressing action. The cervix is never pulled forward as this narrows the posterior fornix and decreases the chance of successfully puncturing the cul-de-sac. The tip of the needle only is inserted in the midline at the maximum point of concavity of the smoothed-out mucosa of- the posterior fornix. Prior to initiating the procedure the light should be checked. Failure of the light may be due to (1) a burned filament, (2) poor cord contact or (3) a central exposed wire of the lamp which may need elevation bya pin for proper contact. A wheal is then made by the insertion of 2 cc. of 1 per cent Xylocaine. Additional infiltration of 2 cc. into each parametrium makes the patient more comfortable. Care is taken to withdraw the plunger prior to injection to be certain one is not in a blood vessel. Mter a few minutes the posterior fornix is punctured by the No. 13 trocar in the midline through the above described wheal (Fig. 386). When the trocar is removed the "hissing" sound of air entering the peritoneal cavity will be heard. The standard trocar is then inserted with moderate pressure through this puncture site. The smaller trocar is used first to prevent the extraperitoneal admission of air as occasionally occurs when one fails to penetrate at the proper point initially with the standard trocar. Carbon dioxide gas was used initially but it was found that with respiration or straining much CO 2 was ejected and, on inspiration, air would enter the peritoneal cavity. Presently very few culdoscopists use CO 2 • The usual reasons for failure to enter the peritoneal cavity are: (1) the patient is not relaxed, resulting in tightening of her abdominal muscles which prevents the proper ballooning of the vagina; (2) adhesions or a fixed mass in the cul-de-sac; (3) puncturing too close to the cervix; (4) pulling on the cervix with the tenaculum, thereby narrowing the posterior fornix; (5) puncturing too far to either side of the midline; (6) using a dull trocar point. The standard trocar is removed from the cannula and the culdoscope is inserted. Before the latter is done, however, the distal half of the culdoscope is warmed by sterile hot water and dried rapidly. This prevents fogging of the distal lens surface due to condensation of the warm, moist intraperitoneal air on the cold surface. The cervical tenaculum is removed as it is of little aid and may cause discomfort to the patient. Various techniques can be utilized for good visualization of the uterus, fallopian tubes and ovaries. Frequently there is need for the cannula to be retracted to acquire a panoramic view of the pelvis. Since visualization is through a right-angle telescope, rotation of the instrument through 360 degrees brings into view all aspects of the pelvic organs. One may be an experienced gynecologist in identifying normal and pathological pelvic viscera at the operating table, but as viewed through the culdoscope a reorientation is needed. As the objective is brought

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Fig. 386. View of ballooned posterior fornix with central local anesthesia wheal and position of trocar at point of puncture.

closer to the objects being viewed the magnification is increased to 2,72 times at 1,72 inch distance. The fallopian tubes may be obscured by the ovaries but can be brought into view by pressure manipulation with the free hand under the patient's abdomen. The best way to obtain experience in culdoscopy is to use the procedure on patients who are to undergo pelvic surgery. The gynecologist can then compare what was visualized through the culdoscope with what is observed at laparotomy. In a relatively short time the operator can accurately diagnose with assurance any lesion that may be seen in the pelvis. It is important that the operator does not touch the peritoneal surface with the tip of the culdoscope during the examaination, as the heat of

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the lamp is interpreted as pain, resulting in unnecessary discomfort to the patient. Patency of the fallopian tubes can be determined by insertion of the cone-shaped screw-tip cannula with its flexible attachment into· the cervix, and instilling 6 to 7 cc. of indigo-carmine solution diluted 1:1 with normal saline. The blue dye can be seen to emerge out of the ostia of the fallopian tubes when patent. When obstructions are encountered along the course of the tube, the area proximal to the obstruction is dilated and bluish in color. When all observations are completed the culdoscope is removed and the cannula is held in place. The patient is then instructed to descend to the prone position and then to tighten her abdominal muscles with the operator's hand under the abdomen. This expels the air through the cannula which is manipulated in a rotary fashion at the same time. The cannula is then removed. No suture is required to close the puncture site. There may be a slight amount of residual air that may cause some shoulder discomfort similar to that experienced in a Rubin test. On rare occasions when much air is retained the patient may need to remain in bed for more than 24 hours. Careful instructions are given to the patient not to assume the ,kneechest posture, not to douche and not to have intercourse for one week. Culdoscopy as an Office Procedure

Budge6 reports 150 cases and Abarbane13 400 cases of culdoscopy performed as an office procedure. The author has performed the procedure 180 times in his office without complications. However, it is not recommended as an office procedure for the novice. COMPLICATIONS

1. Rectal Puncture. In the author's experience of 960 cases there were two instances of rectal perforation early in the "learning period." The vaginal mucosal opening was enlarged and the rectal perforation was closed with a purse-string suture and healed uneventfully. Budge6 reports two instances of puncture in a series of 150 cases. Abarbane13 reports five in a series of 400 cases. Thomsen7 in his questionnaire review covering 4816 culdoscopies, reports an incidence of 0.1 per cent. This accident is always extraperitoneal and no complications or fistula formation or infection has ensued. 2. Bleeding from Puncture Site. Bleeding was encountered in three of the author's series. Two cases were mild and were arrested by packing. A third case was moderate and was easily controlled with a suture. Buxton 8 had one instance of profuse bleeding requiring transfusion. Kelly and Rock 9 reported bleeding in three out of 492 cases. Abarbanel3 reports only one instance of profuse bleeding following intercourse six days after the procedure.

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3. Retroperitoneal Hematoma. Decker has had one case of retroperitoneal hematoma. Herman and DePietrolO report one in a case which the cul-de-sac was entered with difficulty. 4. Prolapse of Omentum through the Puncture Site. Sousal l had one prolapse of omentum through the incision in the cul-de-sac for culdoscopy. Kelly and Rock 9 report one instance. Gear12 reports a case of prolapsed appendices epiploica of the sigmoid colon. 5. Infection. AbarbaneP reported two cases of low grade pelvic cellulitis occurring after intercourse 24 hours after the procedure. 6. Retroperitoneal Emphysema. This was reported by Fortier13 in a case in which carbon dioxide was used under pressure and culdoscopy failed or difficulty was encountered. Herman and DePietrolO had a similar experience where puncture was done with difficulty. Kelly and Rock had one case. The author experienced one instance where failure to enter the peritoneal cavity occurred. 7. Retained Residual Air in Peritoneal Cavity. This is a rare, minor complication and results in abdominal discomfort and severe shoulder pain in the erect posture. The patient complains of a "bubble in her stomach." This may last two to four days depending on the quantity of residual air. It has not been eliminated by the use of CO 2• In the early days of this series, three cases necessitated hospitalization for 48 to 72 hours postculdoscopy. No instances of retroperitoneal hematoma, prolapse of omentum, or infection have been encountered by the author. Even in the most experienced hands, there will be a certain number of failures to puncture through the cul-de-sac into the peritoneal cavity. In a majority of these cases some adhesions or disease of the cul-de-sac are demonstrated at laparotomy. In the author's series of 960 culdoscopies, in 39 or 4.5 per cent there was a failure to enter the peritoneal cavity. Culdoscopy may be repeated several times in the same patient without complications if one desires to re-examine the pelvic organs. No deaths due to culdoscopy have ever been reported. ACCESSORY PROCEDURES

The Operating CUldo8cope. The instrument presently available* gives insufficient light and has a very small field of view. The author has cut adhesions with a micro-scissors and with a coagUlating' current. Ovarian biopsies have been obtained, however, with difficulty. Improvement of this instrument is desirable. Culdo8copic Photography. Three instruments are available for color or black and white photography: 1. The Cameron Pelvic Photoscopet14 has a good field of vision and excellent color photographs can be obtained. However, long exposures of % to 1 second are required for good color photographs. The image obtained is 6 mm. in diameter but can be enlarged ten times with good resolution for projection. It uses a 25 volt bulb. The diameter of the instrument is 1.25 cm., requiring a larger

* American Cystoscope Makers, Inc., New York,'N. Y. t Cameron Surgical Specialty Co., Chicago, Ill.

Fig. 387. A, Photograph showing: 1, Uterine fundus; 2, Stein-Leventhal ovaries; 3, . bladder; 4, sigmoid. B, Photograph showing: 1, qvary; 2, fallopian tube with adhesions; 3, fimbriated end adherent to lateral pelvic wall. e, Photograph showing: 1, Distal end of clubbed hydrosalpinx with, 2, bands of adhesions running onto posterior aspect of, 3, broad ligament; 4, ileum; 5, middle portion of hydrosalpinx. D, Photograph showing: 1, Fundus of uterus; 2, sigmoid colon; 3, ovary; 4, vermiform appendix; 5, ileum. H, Photograph showing: 1, Ovary, 2, ureter on lateral pelvic wall. F, Photograph showing: 1, Fundus of uterus with small fibroid; 2, ovary with inflammatory exudate on broad ligament; S, inflamed thickened fallopian tube.

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puncture site be made after the initial use of the standard culdoscopy trocar. This opening requires a suture for closure. 2. The photographic Douglasscope* is 8 mm. in diameter and has a double filament lamp that can be used for standard diagnostic purposes and for photographic use. The image is 12 mm. in diameter and the exposure time is 1/5 second with Anscochrome F color film. 3. The McCrea Endoscope and Camerat15 uses a 12 volt bulb and can be inserted through the standard culdoscopy cannula. However, the lens system magnifies excessively and tremendous heat is produced. The image is 24 by 24 mm., requiring 1 to 3 seconds for exposure. The culdoscopic pictures presented in Figure 387 are black and white reproductions of color photographs taken with the Cameron Pelvic Photoscope. * Sass-Wolf & Co. M.B.A. Berlin W. 30, Germany. t American Cystoscope Makers, Inc., New York, N. Y.

SUMMARY

1. Instrumentation, technique and possible complications of culdoscopy have been presented. 2. Culdoscopy is a relatively new and valuable diagnostic procedure for the gynecologist to obtain information regarding the female pelvic viscera by direct visualization. REFERENCES (Additional references are included in the reprints.) 1. Decker, A.: Culdoscopy. Philadelphia, W. B. Saunders Co., 1952. 2. Decker, A. and Cherry, T.: Culdoscopy-New Method in Diagnosis of Pelvic Disease. Am. J. Surg. 64: 40, 1944. 3. Abarbanel, A. R.: Transvaginal Pelvioscopy, Simplified and Safe Technique as an Office Procedure. Am. J. Surg. 90: 122, 1955. 4. Brown, A. B. and Bear, S. A.: Apparatus for Maintaining Anesthetized Patient inKnee-Chest Position (Especially During CUldoscopic Examination). Am. J. Obst. & Gynec. 66: 912, 1953. 5. Clauss, J.: Ein Neue Douglasskopiestuhl. Zentralbl. f. Gynaek. 78: 707, 1956. 6. Budge, B. C.: Office Culdoscopy. Northwest Med. 53: 132, 1954. 7. Thomsen, von Klaus: Die Stellung der Endoskopie der Gynakologie. Geburtsh u. Frauenh. 14: 925, 1954. 8. Buxton, C. L. and Herrmann, W.: Analysis of 100 culdoscopies. Am. J. Obst. & Gynec. 68: 786, 1954. 9. Kelly, J. V. and Rock, J.: Culdoscopy for Diagnosis in Infertility. Am. J. Obst. & Gynec. 72: 523, 1956. 10. Herman, L. and DePietro, J.: Broad Ligament Hematoma and Emphysema Following CUldoscopies. Obst. & Gynec. 5: 211, 1955. 11. Sousa, N. M.: Omental Prolapse through a Culdoscopic Incision. (Port.) Rev. clin. de Inst. Mat. (Lisbon) 4: 8, 1952. 12. Gear, E. J.: Unusual Complication of Culdoscopy. Am. J. Obst. & Gynec. 72: 667, 1956. 13. Fortier, Q. E.: Retroperitoneal, Mediastinal, and Cervical Emphysema Following Culdoscopy. Fert. & Steril. 5: 173, 1954. 14. Cohen, M. R. and Guterman, H. S.: Pelvic Photoscope. Obst. & Gynec. 1: 544, 1953. 15. McCrea, L. E.: Intravesical Photography in Color. Med. Rad. & Photog. (East. man Kodak Co.) 26: 86, 1950. »

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