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Development of flexible culdoscopy
November 1999, Vol. 6, No. 4
TheJournal of the American Associationof Gynecologic Laparoscopists
Development of Flexible Culdoscopy John D. Paulson, M.D., Jim W. Ross, Ph.D., M.D., and Samir El-Sahwi, M.D.
Abstract Study Objective. To assess correlation between findings at standard laparoscopy and office flexible culdoscopy. Design. Observational study (Canadian Task Force classification II-1). Setting. University-affiliated hospital. Patients. Eleven women undergoing diagnostic laparoscopy to evaluate infertility. Interventions. Microlaparoscopy and flexible culdoscopy. In the first six cases laparoscopy was performed first followed by culdoscopy; in the last five cases the order was reversed. Measurements and Main Results. The number of endometriotic implants or adhesions was counted for both operative techniques. The flexible 2.2-mm culdoscope provided a view of the pelvis similar to the laparoscope. Correlation between the procedures was 100%. The flexible scope achieved better visualization than the standard rigid posterior cul-de-sac culdoscope. Conclusion. Flexible culdoscopy is a excellent procedure for diagnostic endoscopy. It correlates well with office laparoscopy, requires less anesthesia, and is better tolerated by patients. Several operative procedures are currently being tested through this mode of access. (J Am AssocGynecol Laparosc6(4):487-490, 1999)
Culdoscopy is an endoscopic procedure that permits visualization of the rectovaginal pouch and pelvic organs through a puncture in the posterior vaginal wall. Various terminologies have been used to describe the method over the past 50 years, including douglascopy, transvaginal peritoneoscopy, transvaginal pelviscopy, and transvaginal celioscopy. Von Ott in 1902 was the first to use the vaginal posterior colpotomy route for visualization, with a special table that allowed him to obtain 45-degree Trendelenburg position? With the aid of a mirror and artificial light, he visualized pelvic and abdominal organs for the first time. Use of Trendelenburg position for the next 30 years yielded little
success because of poor visualization. Decker and Cherry were the first to use the knee-chest (genupectoral) position. 2 This position creates an intraperitoneal vacuum of minus 12 to 22 cm H 2 0 that is indirectly transmitted to the vagina, creating ballooning out of the posterior cul-de-sac when the posterior vaginal wall is retracted. When a fiberoptic culdoscope was developed that minimized heat injury and allowed for better field of view, 3 culdoscopy became an important procedure for diagnosing pelvic pathologyY Ovarian biopsy was performed and ectopic pregnancy was diagnosed, ~-9 and the approach was used extensively for tubal ligations and infertility evaluation and treatment. 1~
From the Department of Obstetrics and Gynecology, Fallon Clinic, Institute for Advanced Endoscopic Training, Worcester, Massachusetts (Dr. Paulson); Center for Reproductive Medicine and Laparoscopic Surgery, S alinas, Caifornia (Dr. Ross); and Department of Obstetrics and Gynecology, Alexandria University School of Medicine, Alexandria, Egypt (Dr. El-Sahwi). Address reprint requests to John D. Paulson, M.D., Department of Obstetrics and Gynecology, Fallon Health Clinic, 100 Central Street, Worcester, MA 01608; fax 508 795 0854. Sponsored in part by a nonrestrictive educational grant from Ethicon Endo-Surgery, Cincinnati, Ohio. Special instrumentation was provided by Karl Storz Endoscopy, Culver City, California. Accepted for publication August 26, 1999.
487
Flexible Culdiscopy Paulson et al
In the late 1960s and early 1970s laparoscopy became the procedure of choice because of panoramic pelvic views, as the anterior uterus and inferior cul-desac wall remained hidden from view with culdoscopy. With modem flexible culdoscopes, panoramic pelvic views should be possible.
Results
Of the 11 patients, 8 underwent culdoscopy (Table 1). In three women the indication for surgery was infertility. Two of them had diagnostic laparoscopy first, at which severe cul-de-sac and adhesive disease was found. They did not have the characteristic ballooning of the posterior vaginal fomix when placed in knee-chest position. Because of this negative sign and laparoscopic findings, culdoscopy was not attempted. The third patient had a negative posterior fornix sign, so culdoscopy was not performed. At laparoscopy the Veress needle passed through small bowel adhering to the abdominal wall and it was impossible to place a cannula and sleeve, even at open laparoscopy. Minilaparotomy to examine the bowel revealed extensive bowel adhesions and an obliterated cul-de-sac. Total anterior and posterior pelvic examinations were carried out with culdoscopy. Correlation between culdoscopic and laparoscopic findings was 100%. With the flexible culdoscope, the anterior pelvis was completely visualized in all patients. There was no difficulty examining the ovaries, tubal fimbriae, or tubal os. A panoramic view of the upper abdomen was seen with 180-degree flexion of the culdoscope. Flexion also allowed examination of the inferior lining of the cul-de-sac where the culdoscope entered the pelvis. No gas or liquid was necessary to aid the examination, although warm saline did allow dilatation of the tubal ostia.
Materials and Methods
Eleven consecutive women were selected for culdoscopy in the Infertility Clinic of the Alexandria Medical School in Alexandria, Egypt. Patients with a pelvic mass, history of severe pelvic inflammatory disease, or suspected frozen cul-de-sac were excluded. Laparoscopy was performed in the usual manner using 5-mm laparoscope and midline 5-mm suprapubic port for suction and irrigation or probe placement. The pelvic contents were visualized and all pathology noted. Culdoscopy was performed with the patient in the knee-chest position. A tenaculum grasped the posterior lip of the cervix and a cul-de-sac puncture was made with a small, sharp, 3-mm cannula without a sleeve. This allowed room air to be pulled into the abdominal cavity due to negative pressure achieved, establishing pneumoperitoneum, and allowing viscera to slide down out of the pelvis. A 5.5-mm cannula with sleeve was introduced, the cannula was removed, and a 5-mm 30-degree rigid endoscope was placed through the sleeve. Posterior pelvic structures were visualized and a 2.2-mm flexible cystoscope was introduced. After examining the cul-de-sac, posterior pelvis, tubes including ostia, and ovaries, the flexible scope was flexed 180 degrees. A panoramic evaluation of the pelvis was performed, and the anterior cul-de-sac was inspected by bringing the scope over the anterior broad ligament. The camera head was placed in a position to allow partial reversal of orientation similar to laparoscopy, except the sides were reversed (right was left and left was right). Panoramic evaluation of the pelvis was accomplished and all pathologic sites were recorded. Then correlation between culdoscopic and laparoscopic findings was recorded. After the culdoscopic procedure was completed, air was pushed out of the abdominopelvic cavity by gently pushing down toward the pelvis before removing the culdoscopic sleeve. The first six patients had laparoscopy first and then culdoscopy. This order was reversed with the last five patients.
Discussion
Culdoscopy is simple procedure for the experienced laparoscopic surgeon, and with careful patient selection we believe it can be performed in the office under local anesthesia as shown by others. HIt requires the knee-chest position, but external gas is not necessary. The knee-chest position aids the examination in several ways. First, the bowel falls toward the diaphragm due to posterior attachment and suspension of the bowel mesentery. Bowel falling into the pelvic cul-de-sac is a major problem in office laparoscopy when the patient is in supine lithotomy position. In addition, the knee-chest position causes a negative suction effect when the vagina is opened. Ballooning of the posterior vaginal fomix before entry indicates that culdoscopy should be safe and helps direct placement of the vaginal cannula. No patient had serious
488
November 1999, Vol. 6, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 1. Patient Characteristics and Operative Findings Age (yrs)
Gravida/ Para
Preoperative Diagnosis
24
1/0
Infertility
37
3/3
27
0/0
Infertility, mild dysmenorrhea Infertility, pain, dyspareunia
20 39
0/0 2/2
20 28 31 41
0/0 0/0 1/1 4/4
34
]/1
37
3/3
Infertility Pelvic pain, dyspareunia Infertility Pelvic pain Pelvic pain Infertility, dyspareunia Infertility, pelvic pain Pelvic pain, dyspareunia
Findings LSC
CDS
Cul-de-sac endometriosis stage II Endometriosis stage II
Complications
No attempt, negative cul-de-sac sign
None
Endometriosis stage II
None
Abdominal, pelvic adhesions, unable to visualize Endometriosis stage II Endometriosis stage I
No attempt, negative cul-de-sac sign
None
Endometriosis stage I1 Endometriosis stage I
Uterine perforation None
Endometriosis stage II Endometriosis stage III Endometriosis stage Ill Abdominal wall adhesions
Endometriosis stage II Endometriosis stage III Endometriosis stage III No attempt, negative cul-de-sac sign
Endometriosis stage II
Endometriosis stage 11
None None None Perforation of small bowel with Veress needle None
Endometriomas stage Ill
Endometriomas stage Ill
None
complaints about the position when the indications were fully explained. Any electric proctology table has the connections and pads for the knee-chest position that can be set up in minutes. Local anesthesia is sufficient for culdoscopy, even operative cases, making it an excellent outpatient office procedure, n Women in this study had general anesthesia, but only because we were doing both laparoscopy and culdoscopy to verify that the two procedures were comparable diagnostically. We are in the process of performing outpatient culdoscopy under local anesthesia, which is well tolerated, even by obese patients. Originally, 7-mm cannulas were used in culdoscopy and the initial incision was often enlarged. In the present series a 3-mm sharp cannula was used with direct puncture technique. Since our initial cases, a graduated introducing cannula was developed, which we believe will be safer and easier to place than the sharp 3-mm one. Much has been written about the potential dangers of the vaginal approach with regard to infection. Prophylactic antibiotics, although not administered in our
study, should lessen the problem, as it does for vaginal hysterectomy. The major problem with culdoscopy has always been inadequate visualization. At first, the optics were less than ideal. The rigid culdoscope had a limited field of view and did not allow examination of the anterior pelvis, and the panoramic view of laparoscopy was the death knell for culdoscopy. Now with efforts to develop office procedures under local anesthesia, laparoscopy falls short. Conscious patients will not tolerate the several liters of CO2 necessary to expand the abdomen adequately to view the pelvis, and it is often difficult, if not impossible, to move bowel out of the pelvis without causing patient discomfort. Our results indicate that flexible endoscopes offer the gynecologist an easy, quick, and safe method of evaluating the pelvis. The only flexible endoscope available in this study was 2.2-mm. The entire pelvic cavity was examined, but a larger image would have been helpful. In our second study a larger flexible scope gave images comparable to 5-ram laparoscopes, allowing a much more satisfactory panoramic view. Even with the 2.2-mm
489
Flexible Culdiscopy Paulson et al
4. Fugo NW: Clinical evaluation of adnexal masses. W V Med J 66:35-37, 1970
flexible scope correlation with laparoscopic findings was excellent, suggesting that the diagnostic capabilities of flexible culdoscopy could possibly approach those of laparoscopy and be better than those of office laparoscopy. Patient selection is critical, especially for office procedures. If a positive cul-de-sac sign is not present, culdoscopy should not be done. Other excluding factors are several abdominal or pelvic surgeries, history of severe pelvic adhesions or pelvic inflammatory disease, and history of obliterated cul-de-sac. The potential indications for flexible culdoscopy are numerous. In infertile women the diagnosis of endometriosis, determination of tubal patency, egg retrieval, and simple fimbrioplasty are all possible. Office tubal ligations may be less difficult. Even simple ablation procedures for mild to moderate endometriosis are possible. If pain mapping proves to be helpful, culdoscopy could be simpler than laparoscopy. We are carrying out studies to explore these possibilities.
5. Lane E: Culdoscopy--Useful or useless? Int J Gynaecol Obstet 17:372-374, 1980 6. Karam K, Mroueh A: Ovarian biopsy in the evaluation of amenorrhea. Acta Obstet Gynecol Scand 57:301-311, 1978 7. Marshall JR, Hammond CB: Ovarian biopsy performed under culdoscopic visualization. Am J Obstet Gynecol 96:1022-1026, 1966 8. Paldi E, Timor-Tritsch I, Abramovici H, et al: Operative culdoscopy. Br J Obstet Gynaecol 82:318-320, 1975 9. Timor-Tritsch I, Paldi E: Tubal pregnancy treated by salpingectomy using operative culdoscopy. Acta Obstet Gynecol Scand 54:285-286, 1975 10. Castro OF: Vaginal fimbriectomy with the use of the culdoscope. Adv Plan Parent 12:69-78, 1977 ll. Cheng MC, Khew KS, Chen C, et al: Culdoscopic ligation as an outpatient procedure. Am J Obstet Gynecol 122:109-112, 1975
References
1. Von Ott D: Die Beleuchtung der Bauchhohle (Ventroskopie) als Methode bei Vaginaler Coeliotomie. Abl Gynakol 231:817-823, 1902
12. Diamond E: Diagnostic culdoscopy in infertility: A study of 4,000 outpatient procedures. J Reprod Med 21:23-30, 1978
2. Decker A, Cherry TH: Culdoscopy--A new method in the diagnosis of pelvic disease--Preliminary report. Am J Surg 54:40--44, 1944
13. Moghissi KS, Sim GS: Correlation between hysterosalpingography and pelvic endoscopy for the evaluation of tubal factor. Fertil Steril 26:1178-1181, 1975
3. Clyman M: A new panculdoscope--Diagnostic, photographic, and operative aspects. Obstet Gynecol 21: 343-347, 1963
14. Del Corral Garces F: Cien culdoscopias contra cien laparoscopias (Estudio comparativo). Rev Col Obstet Ginecol 26:363-368, 1975
490
TheJournal of the American Associationof Gynecologic Laparoscopists
Development of Flexible Culdoscopy John D. Paulson, M.D., Jim W. Ross, Ph.D., M.D., and Samir El-Sahwi, M.D.
Abstract Study Objective. To assess correlation between findings at standard laparoscopy and office flexible culdoscopy. Design. Observational study (Canadian Task Force classification II-1). Setting. University-affiliated hospital. Patients. Eleven women undergoing diagnostic laparoscopy to evaluate infertility. Interventions. Microlaparoscopy and flexible culdoscopy. In the first six cases laparoscopy was performed first followed by culdoscopy; in the last five cases the order was reversed. Measurements and Main Results. The number of endometriotic implants or adhesions was counted for both operative techniques. The flexible 2.2-mm culdoscope provided a view of the pelvis similar to the laparoscope. Correlation between the procedures was 100%. The flexible scope achieved better visualization than the standard rigid posterior cul-de-sac culdoscope. Conclusion. Flexible culdoscopy is a excellent procedure for diagnostic endoscopy. It correlates well with office laparoscopy, requires less anesthesia, and is better tolerated by patients. Several operative procedures are currently being tested through this mode of access. (J Am AssocGynecol Laparosc6(4):487-490, 1999)
Culdoscopy is an endoscopic procedure that permits visualization of the rectovaginal pouch and pelvic organs through a puncture in the posterior vaginal wall. Various terminologies have been used to describe the method over the past 50 years, including douglascopy, transvaginal peritoneoscopy, transvaginal pelviscopy, and transvaginal celioscopy. Von Ott in 1902 was the first to use the vaginal posterior colpotomy route for visualization, with a special table that allowed him to obtain 45-degree Trendelenburg position? With the aid of a mirror and artificial light, he visualized pelvic and abdominal organs for the first time. Use of Trendelenburg position for the next 30 years yielded little
success because of poor visualization. Decker and Cherry were the first to use the knee-chest (genupectoral) position. 2 This position creates an intraperitoneal vacuum of minus 12 to 22 cm H 2 0 that is indirectly transmitted to the vagina, creating ballooning out of the posterior cul-de-sac when the posterior vaginal wall is retracted. When a fiberoptic culdoscope was developed that minimized heat injury and allowed for better field of view, 3 culdoscopy became an important procedure for diagnosing pelvic pathologyY Ovarian biopsy was performed and ectopic pregnancy was diagnosed, ~-9 and the approach was used extensively for tubal ligations and infertility evaluation and treatment. 1~
From the Department of Obstetrics and Gynecology, Fallon Clinic, Institute for Advanced Endoscopic Training, Worcester, Massachusetts (Dr. Paulson); Center for Reproductive Medicine and Laparoscopic Surgery, S alinas, Caifornia (Dr. Ross); and Department of Obstetrics and Gynecology, Alexandria University School of Medicine, Alexandria, Egypt (Dr. El-Sahwi). Address reprint requests to John D. Paulson, M.D., Department of Obstetrics and Gynecology, Fallon Health Clinic, 100 Central Street, Worcester, MA 01608; fax 508 795 0854. Sponsored in part by a nonrestrictive educational grant from Ethicon Endo-Surgery, Cincinnati, Ohio. Special instrumentation was provided by Karl Storz Endoscopy, Culver City, California. Accepted for publication August 26, 1999.
487
Flexible Culdiscopy Paulson et al
In the late 1960s and early 1970s laparoscopy became the procedure of choice because of panoramic pelvic views, as the anterior uterus and inferior cul-desac wall remained hidden from view with culdoscopy. With modem flexible culdoscopes, panoramic pelvic views should be possible.
Results
Of the 11 patients, 8 underwent culdoscopy (Table 1). In three women the indication for surgery was infertility. Two of them had diagnostic laparoscopy first, at which severe cul-de-sac and adhesive disease was found. They did not have the characteristic ballooning of the posterior vaginal fomix when placed in knee-chest position. Because of this negative sign and laparoscopic findings, culdoscopy was not attempted. The third patient had a negative posterior fornix sign, so culdoscopy was not performed. At laparoscopy the Veress needle passed through small bowel adhering to the abdominal wall and it was impossible to place a cannula and sleeve, even at open laparoscopy. Minilaparotomy to examine the bowel revealed extensive bowel adhesions and an obliterated cul-de-sac. Total anterior and posterior pelvic examinations were carried out with culdoscopy. Correlation between culdoscopic and laparoscopic findings was 100%. With the flexible culdoscope, the anterior pelvis was completely visualized in all patients. There was no difficulty examining the ovaries, tubal fimbriae, or tubal os. A panoramic view of the upper abdomen was seen with 180-degree flexion of the culdoscope. Flexion also allowed examination of the inferior lining of the cul-de-sac where the culdoscope entered the pelvis. No gas or liquid was necessary to aid the examination, although warm saline did allow dilatation of the tubal ostia.
Materials and Methods
Eleven consecutive women were selected for culdoscopy in the Infertility Clinic of the Alexandria Medical School in Alexandria, Egypt. Patients with a pelvic mass, history of severe pelvic inflammatory disease, or suspected frozen cul-de-sac were excluded. Laparoscopy was performed in the usual manner using 5-mm laparoscope and midline 5-mm suprapubic port for suction and irrigation or probe placement. The pelvic contents were visualized and all pathology noted. Culdoscopy was performed with the patient in the knee-chest position. A tenaculum grasped the posterior lip of the cervix and a cul-de-sac puncture was made with a small, sharp, 3-mm cannula without a sleeve. This allowed room air to be pulled into the abdominal cavity due to negative pressure achieved, establishing pneumoperitoneum, and allowing viscera to slide down out of the pelvis. A 5.5-mm cannula with sleeve was introduced, the cannula was removed, and a 5-mm 30-degree rigid endoscope was placed through the sleeve. Posterior pelvic structures were visualized and a 2.2-mm flexible cystoscope was introduced. After examining the cul-de-sac, posterior pelvis, tubes including ostia, and ovaries, the flexible scope was flexed 180 degrees. A panoramic evaluation of the pelvis was performed, and the anterior cul-de-sac was inspected by bringing the scope over the anterior broad ligament. The camera head was placed in a position to allow partial reversal of orientation similar to laparoscopy, except the sides were reversed (right was left and left was right). Panoramic evaluation of the pelvis was accomplished and all pathologic sites were recorded. Then correlation between culdoscopic and laparoscopic findings was recorded. After the culdoscopic procedure was completed, air was pushed out of the abdominopelvic cavity by gently pushing down toward the pelvis before removing the culdoscopic sleeve. The first six patients had laparoscopy first and then culdoscopy. This order was reversed with the last five patients.
Discussion
Culdoscopy is simple procedure for the experienced laparoscopic surgeon, and with careful patient selection we believe it can be performed in the office under local anesthesia as shown by others. HIt requires the knee-chest position, but external gas is not necessary. The knee-chest position aids the examination in several ways. First, the bowel falls toward the diaphragm due to posterior attachment and suspension of the bowel mesentery. Bowel falling into the pelvic cul-de-sac is a major problem in office laparoscopy when the patient is in supine lithotomy position. In addition, the knee-chest position causes a negative suction effect when the vagina is opened. Ballooning of the posterior vaginal fomix before entry indicates that culdoscopy should be safe and helps direct placement of the vaginal cannula. No patient had serious
488
November 1999, Vol. 6, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 1. Patient Characteristics and Operative Findings Age (yrs)
Gravida/ Para
Preoperative Diagnosis
24
1/0
Infertility
37
3/3
27
0/0
Infertility, mild dysmenorrhea Infertility, pain, dyspareunia
20 39
0/0 2/2
20 28 31 41
0/0 0/0 1/1 4/4
34
]/1
37
3/3
Infertility Pelvic pain, dyspareunia Infertility Pelvic pain Pelvic pain Infertility, dyspareunia Infertility, pelvic pain Pelvic pain, dyspareunia
Findings LSC
CDS
Cul-de-sac endometriosis stage II Endometriosis stage II
Complications
No attempt, negative cul-de-sac sign
None
Endometriosis stage II
None
Abdominal, pelvic adhesions, unable to visualize Endometriosis stage II Endometriosis stage I
No attempt, negative cul-de-sac sign
None
Endometriosis stage I1 Endometriosis stage I
Uterine perforation None
Endometriosis stage II Endometriosis stage III Endometriosis stage Ill Abdominal wall adhesions
Endometriosis stage II Endometriosis stage III Endometriosis stage III No attempt, negative cul-de-sac sign
Endometriosis stage II
Endometriosis stage 11
None None None Perforation of small bowel with Veress needle None
Endometriomas stage Ill
Endometriomas stage Ill
None
complaints about the position when the indications were fully explained. Any electric proctology table has the connections and pads for the knee-chest position that can be set up in minutes. Local anesthesia is sufficient for culdoscopy, even operative cases, making it an excellent outpatient office procedure, n Women in this study had general anesthesia, but only because we were doing both laparoscopy and culdoscopy to verify that the two procedures were comparable diagnostically. We are in the process of performing outpatient culdoscopy under local anesthesia, which is well tolerated, even by obese patients. Originally, 7-mm cannulas were used in culdoscopy and the initial incision was often enlarged. In the present series a 3-mm sharp cannula was used with direct puncture technique. Since our initial cases, a graduated introducing cannula was developed, which we believe will be safer and easier to place than the sharp 3-mm one. Much has been written about the potential dangers of the vaginal approach with regard to infection. Prophylactic antibiotics, although not administered in our
study, should lessen the problem, as it does for vaginal hysterectomy. The major problem with culdoscopy has always been inadequate visualization. At first, the optics were less than ideal. The rigid culdoscope had a limited field of view and did not allow examination of the anterior pelvis, and the panoramic view of laparoscopy was the death knell for culdoscopy. Now with efforts to develop office procedures under local anesthesia, laparoscopy falls short. Conscious patients will not tolerate the several liters of CO2 necessary to expand the abdomen adequately to view the pelvis, and it is often difficult, if not impossible, to move bowel out of the pelvis without causing patient discomfort. Our results indicate that flexible endoscopes offer the gynecologist an easy, quick, and safe method of evaluating the pelvis. The only flexible endoscope available in this study was 2.2-mm. The entire pelvic cavity was examined, but a larger image would have been helpful. In our second study a larger flexible scope gave images comparable to 5-ram laparoscopes, allowing a much more satisfactory panoramic view. Even with the 2.2-mm
489
Flexible Culdiscopy Paulson et al
4. Fugo NW: Clinical evaluation of adnexal masses. W V Med J 66:35-37, 1970
flexible scope correlation with laparoscopic findings was excellent, suggesting that the diagnostic capabilities of flexible culdoscopy could possibly approach those of laparoscopy and be better than those of office laparoscopy. Patient selection is critical, especially for office procedures. If a positive cul-de-sac sign is not present, culdoscopy should not be done. Other excluding factors are several abdominal or pelvic surgeries, history of severe pelvic adhesions or pelvic inflammatory disease, and history of obliterated cul-de-sac. The potential indications for flexible culdoscopy are numerous. In infertile women the diagnosis of endometriosis, determination of tubal patency, egg retrieval, and simple fimbrioplasty are all possible. Office tubal ligations may be less difficult. Even simple ablation procedures for mild to moderate endometriosis are possible. If pain mapping proves to be helpful, culdoscopy could be simpler than laparoscopy. We are carrying out studies to explore these possibilities.
5. Lane E: Culdoscopy--Useful or useless? Int J Gynaecol Obstet 17:372-374, 1980 6. Karam K, Mroueh A: Ovarian biopsy in the evaluation of amenorrhea. Acta Obstet Gynecol Scand 57:301-311, 1978 7. Marshall JR, Hammond CB: Ovarian biopsy performed under culdoscopic visualization. Am J Obstet Gynecol 96:1022-1026, 1966 8. Paldi E, Timor-Tritsch I, Abramovici H, et al: Operative culdoscopy. Br J Obstet Gynaecol 82:318-320, 1975 9. Timor-Tritsch I, Paldi E: Tubal pregnancy treated by salpingectomy using operative culdoscopy. Acta Obstet Gynecol Scand 54:285-286, 1975 10. Castro OF: Vaginal fimbriectomy with the use of the culdoscope. Adv Plan Parent 12:69-78, 1977 ll. Cheng MC, Khew KS, Chen C, et al: Culdoscopic ligation as an outpatient procedure. Am J Obstet Gynecol 122:109-112, 1975
References
1. Von Ott D: Die Beleuchtung der Bauchhohle (Ventroskopie) als Methode bei Vaginaler Coeliotomie. Abl Gynakol 231:817-823, 1902
12. Diamond E: Diagnostic culdoscopy in infertility: A study of 4,000 outpatient procedures. J Reprod Med 21:23-30, 1978
2. Decker A, Cherry TH: Culdoscopy--A new method in the diagnosis of pelvic disease--Preliminary report. Am J Surg 54:40--44, 1944
13. Moghissi KS, Sim GS: Correlation between hysterosalpingography and pelvic endoscopy for the evaluation of tubal factor. Fertil Steril 26:1178-1181, 1975
3. Clyman M: A new panculdoscope--Diagnostic, photographic, and operative aspects. Obstet Gynecol 21: 343-347, 1963
14. Del Corral Garces F: Cien culdoscopias contra cien laparoscopias (Estudio comparativo). Rev Col Obstet Ginecol 26:363-368, 1975
490