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Laparoscopy
Vol. 21, No. 3, March 1970 Printed in U.S.A .
FERTILITY AND STERILITY
Copyright
© 1970 by The Williams
& Wilkins Co.
LAPAROSCOPY BARRY D. SMITH, M.D.,*
AND
THOMAS F. DILLON, M.D., F.A.C.O.G.
Department of Obstetrics and Gynecology, the New York Hospital-Cornell Medical Center, New York, New York
light sources of high intensity were developed. This led to renewed interest in laparoscopy. Improved lens systems and modern instrumentation have provided better visualization plus the ability to obtain excellent photographic studies. "Peritoneoscopy" has become very popular in the field of gastroenterology. Most of the studies in this field are done with local anesthesia. Edlin5 showed that peritoneoscopy using local anesthesia may be performed safely despite the presence of advanced age, general debility, fever, jaundice, anemia, and portal hypertension. Laparoscopy was introduced into the Department of Obstetrics and Gynecology of the New York Hospital-Cornell Medical Center in October 1966. Two hundred and sixty-nine laparoscopic examinations were performed between October 1966 and May 1968. All but one of these procedures were done utilizing general anesthesia, and the results of the first 134 procedures constituted a report by Fear. 6 It is the purpose of this paper to review our total series with particular emphasis on the value of the procedure in the study of infertility, in the evaluation of pelvic pain, and in the diagnosis of obscure pelvic pathology.
Modern optical systems, high intensity fiber-optic light sources, and convenient and safe means of inducing pneumoperitoneum have made laparoscopy an accepted and safe procedure. The procedure is an old one . The history of laparoscopy is well summarized by several authors. 6 • 15 • 16 In 1901 Georg Kelling, 10 a surgeon of Dresden, Germany, demonstrated that the intraabdominal organs of a dog could be visualized by inserting a cystoscope through a small incision in the animal's anterior abdominal wall. J acobaeus 8 of Sweden, in 1910, was the first to apply this new procedure to patients. It was he who coined the name laparoscopy for the procedure of endoscopic examination of the abdominal organs by the transperitoneal route. The first use of laparoscopy in the United States was by Bernheim2 in 1911. The concepts of using pneumoperitoneum and the Trendelenburg position were added in 1912. In the 1930's Ruddock/ 3 an internist, became the main proponent of the procedure in the United States. He reported a series of 500 cases in 1937. All of his cases were done with local anesthesia, and most of the cases were done with the aim of investigating upper abdominal pathology. In the same year, Hope 7 emphasized the great value of laparoscopy in the differential diagnosis of ectopic pregnancy. For the next 20 years, however, culdoscopy remained the popular form of pelvic endoscopy in the United States while laparoscopy was being used and improved upon in Europe. In the early 1950's remote
TECHNIC
*Present address: U. S. Naval Hospital, Philadelphia, Pa.
The instruments used in this study were manufactured by the Richard Wolf Co. of Knittlingen, West Germany, and by the American Cystoscope Makers, Inc., Pelham Manor, N. Y. The technic that was utilized has been described by Jacobson9 and Fear6 in previous communications. The
193
194
SMITH AND DILLON
principal points in the technic are as follows. The procedure is performed under general anesthesia and is preceded by bimanual pelvic examination after suitable anesthesia has been induced. Endotracheal technics for the administration of anesthesia are extremely desirable in order to prevent the upper gastrointestinal tract from being inadvertently distended with anesthetic gases. An ordinary tenaculum is placed on the anterior lip of the cervix to permit an assistant to maneuver the uterus during the examination. The patient is placed in 5-10° of Trendelenburg. The skin at the lower margin of the umbilicus is grasped with two Adair clamps, the anterior abdominal wall is elevated, and a small skin incision is made for the insertion of the pneumoperitoneum needle and of the main trocar. This incision is located in the midline 2 em. below the umbilicus. Carbon dioxide gas is administered through the Ruddock pneumoperitoneum needle after the appropriate placement within the peritoneal cavity has been ascertained. The laparoscope trocar is inserted through the same midline incision. A secondary probe is inserted in the right lower quadrant to aid in the manipulation of the pelvic organs and through which several diagnostic procedures can be performed. INDICATIONS AND CONTRAINDICATIONS
The indications for laparoscopy in gynecology and obstetrics have fairly wide limits. Principal indications include: 1. Infertility, due to tubal occlusion or peritoneal adhesions. 2. Amenorrhea, primary or secondary, with ovarian biopsy. 3. Suspected ectopic pregnancy. 4. Unexplained chronic pelvic pain mcluding dysmenorrhea. 5. Obscure pelvic masses. 6. Verification of suspected pelvic mflammatory disease.
Vol. 21
7. Acute pelvic pain of uncertain origin. 8. Verification of metastatic liver disease. We, as well as others,5 • 6 • 16 have added several additional indications or possible uses for laparoscopy. These include: 1. The differential diagnosis of ascites. 2. Staging of carcinoma of the cervix, endometrium, and ovary. 3. Accurate measurement of radiation dose. 4. Tubal sterilization by ligation, clips, cauterization, or cryosurgery. 5. Removal of displaced intrauterine contraceptive devices. 6. Evaluation of treatment of endometriosis. 7. Postcoital examination of fluid in the cul-de-sac for sperm. 8. Bacteriologic and cytologic .examination of fluid in the cul-de-sac. 9. Ventrosuspension of the uterus. 10. Aspiration of ovarian cysts. 11. Studies of tubal physiology. 12. Studies of the ovary before and after drug stimulation. In the literature3 • 12• 16 diaphragmatic hernia, marked circulatory failure and previous laparotomy have been quoted as absolute contraindications to laparoscopy. It can now be said that previous laparotomy is, in our experience and that of others, 6 • 9 only a relative contraindication, with each case best judged on its individual merits. In most cases laparoscopy can be carried out with safety. If the previous incision was a low midline one, then the incision may be made in the usual place. If the incision extended to the umbilicus, then an area to the right or left of the midline should be chosen. Acute generalized peritonitis has in the past been listed as an contraindication to laparoscopy, and, certainly, the acute surgical abdomen must be managed in the time-honored fashion. In selected cases such as those possibly representing spread from acute salpingitis, the laparoscope can
r
c s . f , f e e o r
e o re es d n
LAPAROSCOPY
March 1970
be particularly helpful in the differential diagnosis. Absolute Contraindications: 1. Severe cardiac or respiratory disease, except where local anesthesia can be utilized. 2. Diaphragmatic hernia. 3. Abdominal, umbilical, or inguinal hernia. 4. Acute distended surgical abdomen with intestinal distention. Relative contraindications: 1. Previous laparotomy. 2. Ascites. 3. Obesity. 4. Diffuse intra-abdomina}. malignancy with ascites. RESULTS
A total of 269 laparoscopies were performed. These procedures were carried out on 266 patients by 23 residents and 10 attending gynecologists. The series was divided quite equally between private and ward service patients with 134 private patients and 132 ward service patients included in the series. There were 74 patients who had had previous abdominal surgery. In 32 cases the surgery had been an appendectomy via a McBurney incision. In 42 cases the patient had had a pelvic operation, and in all but 3 of these patients the laparotomy had been through a midline incision. The indications for the 269 procedures are summarized in Table 1. The infertility and ovarian dysfunction group is reviewed in Table 2. This group of 86 cases includes all patients with a preoperative diagnosis TABLE 1. Indication
Infertility and ovarian dysfunction Acute pelvic pain Chronic pelvic pain Obscure pelvic mass Miscellaneous
No. of cases
86 73
49 49 12
195
TABLE 2. Patients Studied for Infertility and Suspected Stein-Leventhal Syndrome Total patients Preoperative diagnosis Stein-Leventhal syndrome
86 17
Expected normal findings Unexpected normal findings
13 12
Expected abnormal findings Stein-Leventhal ovaries Peritubal adhesions Pelvic inflammatory disease (old) Cornual obstruction Myomata uteri Endometriosis
14 7 11 2 3 6
Unexpected abnormal findings Pelvic inflammatory disease (old) Peritubal adhesions Stein-Leventhal ovaries
1 5 10
Laparotomies spared Failures Critical to management of patient
5 2 28
of Stein-Leventhal syndrome, as well as those patients being studied for "infertility." It can be seen that 14 of the 17 patients with a preoperative diagnosis of Stein-Leventhal syndrome were confirmed. In 2 cases normal ovaries were found, and the remaining case was a "failure" due to severe obesity. · The pneumoperitoneum needle could not be introduced properly, and the procedure was therefore discontinued. Laparotomy revealed bilateral cortical sclerosis. In addition to these cases, 10 cases of unexpected Stein-Leventhal type ovaries were diagnosed. Two of these were confirmed by wedge resection, and 2 others were successfully treated with clomiphene citrate. Laparoscopy can be used to clarify inconclusive hysterogram findings. Two patients thought to have distal obstruction on hysterogram were shown to have normal tubes on laparoscopic examination. Lapa· rotomy was spared in these 2 patients. Laparoscopy was used to confirm tubal pathology prior to definitive surgery. Lapa-
196
TABLE 3. Patients Studied for Acute Pelvic Pain Total cases Preoperative diagnosis confirmed Obscure diagnosis made Preoperative diagnosis changed Incomplete visualization Laparotomy spared Laparotomy mandated Laparoscopy critical in management
Vol. 21
SMITH AND DILLON
73 24 37 11 4 36 10 48
rotomy was spared in 2 patients judged to have such severe pelvic inflammatory disease that surgery was not indicated. The other failure in the group was a thin woman, but a good pneumoperitoneum could not be established and the procedure was discontinued. The results in the group investigated for acute pelvic pain are summarized in Table 3. In this group the differential diagnosis was usually between tubal pregnancy, ruptured or twisted ovarian cyst, appendicitis, and acute pelvic inflammatory disease. Of the 73 patients in the group, 38 were investigated for suspected ectopic pregnancy. The diagnosis was only confirmed in 7 cases ( 18%) . Various stages of pelvic inflammatory disease were found in 9 patients, while 8 were noted to have a leaking ovarian cyst. One intrauterine pregnancy was diagnosed, and 2 cases of regional ileitis were diagnosed as well. Laparoscopy was felt to have spared 22 laparotomies in this group of 38. Immediate surgery was mandated on 10 occasions. The findings in these cases included ectopic pregnancy, appendicitis, bleeding corpus luteum, and ruptured endometriotic cysts. Also included in this group were 21 patients with a preoperative diagnosis of acute pelvic inflammatory disease. In 16 cases the diagnosis was substantiated. There were 2 women shown to have a bleeding corpus luteum, 1 with a leaking endometriotic cyst, 1 with an infarcted epiploic appendage, and 1 with acute appendicitis. A dermoid cyst was diagnosed
in 1 patient who also had acute pelvic inflammatory disease. There were 4 cases in the group in which visualization was incomplete. In 1 case enough was seen to require laparotomy for a leaking endometriotic cyst. In the second case pelvic adhesions prevented any accurate diagnosis. Laparotomy revealed a tubo-ovarian abscess beneath adherent bowel. The third patient was diagnosed as having pelvic inflammatory disease with periappendicitis. One week later appendectomy was carried out because of perforation. In the fourth case anesthesia difficulties were encountered, and the pneumoperitoneum needle could not be inserted properly. The procedure was discontinued. Two of the 3 women who were examined twice were included in this group. One of the patients twice presented with right lower quadrant pain. In each case acute pelvic inflammatory disease was found. The second patient was referred to above. She presented with right lower quadrant pain which was found to be resulting from an infarcted epiploic appendage. Her second procedure was again for right lower quadrant pain with a mass. In this instance an intrauterine pregnancy plus a simple cyst of the right ovary was found. The third group of patients are those investigated for chronic pelvic pain. The diagnoses made in this group are listed in Table 4. Of special note are the 15 patients with normal findings. Many of these paTABLE 4. Patients Studied for Chronic
Pelvic Pain T~alcasM
Normal findings Pelvic inflammatory disease (old) Endometriosis Adhesions Stein-Leventhal syndrome Myomata uteri Preoperative diagnosis changed Laparotomy spared Laparoscopy critical in management
M 15 13 13 7 1 1 15 8 40
-
March 1970
tients became asymptomatic following laparoscopy. Of 33 women with a preoperative diagnosis of chronic pelvic inflammatory disease, 13 were confirmed. Endometriosis was found in 8 cases. Three young women were laparoscoped for dysmenorrhea. One patient was found to have chronic pelvic inflammatory disease, and 2 had normal findings. In this group laparoscopy was felt to have spared eight laparotomies. Forty-nine women were subjected to laparoscopy for the evaluation of adneJ~:al masses (Table 5). In 20 cases the preoperative diagnosis was confirmed, while the pre-operative impression was wrong in 16 cases. It was felt that 32 of these women would have had laparotomies, if laparoscopy had not been performed. The ages of our patients varied from 13 to 79. The age distribution is shown in Table 6. Of particular interest is the group of 11 who were age 60 and older. Ten of these 11 are included in the group investigated for an obscure mass. Five of these women had asymptomatic masses diagnosed as myomas at laparoscopy. All tolerated the procedure well and were discharged on the day following laparoscopy. In 1 very obese patient, age 62, there was a questionable adnexal mass. There was a feculent odor upon insertion of the pneumoperitoneum needle. The patient underwent immediate exploratory laparotomy; only a small laceration in the omentum was found. The ovaries were normal. TABLE 5. Patients Studied for Obscure Pelvic Masses Total cases Diagnosis made Preoperative diagnosis confirmed Preoperative diagnosis changed Laparotomy spared Laparotomy mandated Laparoscopy critical in management Failures
197
LAPAROSCOPY
49 46 20 16 32 2 36 3
TABLE 6. Age Distribution of Cases Age
No. of cases
yr.
13-19 20-29 30-39 40-49 50-59
60-
13 150 66 25 4 11
The other 5 in this group had adnexal masses noted at the time of dilatation and curettage for postmenopausal bleeding. Three were found to have pedunculated myomas. In 1 case the ovary contained a small cyst, but it could not be fully visualized. It was confirmed as a simple cyst when the patient underwent appendectomy 2 months later. In the remaining case adenocarcinoma of the endometrium was diagnosed on curettage. Laparoscopy because of an enlarged adnexa revealed what was thought to be a metastatic nodule in the ovary. Subsequent surgery revealed the ovary to contain a simple cyst. The last case in the group was the third failure. A 4-cm. firm right adnexal mass was noted. There had been a previous appendectomy. Laparoscopy was unsuccessful due to omental adhesions which obscured the right adnexa. Laparotomy revealed a serous cyst. The miscellaneous group includes 12 patients. One was a patient with a followup examination after treatment for acute pelvic inflammatory disease; there were normal findings. In a second patient an attempt at removing an ectopic intrauterine contraceptive device failed. Four patients with primary amenorrhea were studied; 3 had normal pelvic organs and 1 had testicular feminization. One patient with hirsutism and another with postpartum amenorrhea were noted to have normal findings. Three women with vaginal and uterine agenesis were studied. Two had normal ovaries and distal tubes. The remaining patient in the 60 and
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SMITH AND DILLON
over group was in the miscellaneous category. The patient was a 79-year-old woman with massive ascites and probable ovarian carcinoma. The laparoscope trocar was inserted without attempting pneumoperitoneum. The ascitic fluid was removed by suction. The fluid turned to blood after removal of about 2500 cc. Immediate laparotomy revealed bleeding from the tumor-filled hilum of the spleen. Splenectomy was carried out. The patient recovered from surgery but died 1 month later of carcinomatosis. COMPLICATIONS
In the literature3 • 11 • 16 • 17 the great proportion of complications have occurred in establishing the pneumoperitoneum. These include: 1. Hemorrhage from puncture of abdominal wall vessels. 2. Intestinal perforation. 3. Gas embolism. 4. Subcutaneous emphysema. 5. Injection of gas into omentum or viscus. 6. Aggravation of existing hernias. 7. Mediastinal emphysema. 8. Rupture of the diaphragm. 9. Pneumothorax. 10. Respiratory or circulatory embarrassment. Proper technic and proper selection of cases can avoid most of these complications. An empty bladder is important. We favor the use of carbon dioxide with an escape valve set at less than 36 em. of water to avoid the problems of embolization and overdistention. The technic of testing for proper placement of the insufflation needle with 1 drop of saline has been of great value to us. If it is decided to investigate a patient with ascites, slow withdrawal of the fluid is advisable in view of our experience. Other reported complications include: 1. Perforation of a vessel or viscus with the large trocar.
Vol. 21
2. Herniation of intestines into or through the incision if the patient strains before closure. 3. Bleeding from the tenaculum site on the cervix. 4. Incisional hernia 15 as a late complication. Deaths have been reported, but they have been very rare. Most have resulted from air embolism, bile peritonitis (following a biopsy) , or hemorrhage. A review of the medical literature by Aronson and Parker 1 showed a combined mortality of 0.12% in over 8000 cases. This compares with a mortality of 0.28% for blind liver biopsy. Ruddock14 teported one death in 5000 cases. M ajO'T' Complications:
1. Intraperitoneal bleeding following removal of ascitic fluid. 2. Probable bowel perforation with the pneumoperitoneum needle. 3. Perforation of the stomach. The first 2 cases have been described previously. The third patient was a 26year-old infertility problem. There was some difficulty inserting the pneumoperitoneum needle and several insertions were made. After obtaining pneumoperitoneum, laparoscopic examination revealed some peritubal adhesions. Seven hours later the patient had the onset of hematomesis. Exploration revealed three small perforations of the stomach which were repaired. The patient recovered without further complications. Minor Complications: 1. Ileus following lysis of adhesions with the probe. 2. Protrusion of a knuckle of intestines prior to incision closure. 3. Preperitoneal carbon dioxide. The first case subsequently developed a mechanical bowel obstruction. At laparotomy a congenital band was lysed and recovery was rapid. The second patient
March 1970
199
LAPAROSCOPY
was treated by re-establishing good anesthesia and closure of the wound. The preperitoneal carbon dioxide absorbed rapidly. It should also be noted that postoperative shoulder pain was very uncommon. When it did occur, it was gone within 24 hr.
TABLE 7. Summary of Laparotomies Spared Study group
Infertility Acute pelvic pain Chronic pelvic pain Obscure pelvic masses Miscellaneous
No. of cases
5
36 8 32
1
DISCUSSION .
The recent interest in laparoscopy seems to us to be fully justified. Direct visualization of the pelvic organs in obscure disease has become an accepted and valuable procedure. The technic is basically simple and safe. The high degree of diagnostic accuracy has enabled laparoscopy to spare many patients from exploratory laparotomy. At the same time the procedure has value in avoiding unnecessary delay before needed surgery. The study of infertility has been aided greatly. Hysterogram findings can be disproven or verified; tubal surgery can be planned or rejected; Stein-Leventhal ovaries can be diagnosed; nonpalpable endometriosis may be found and palpable, verified. In our series we were particularly interested in the number of unnecessary laparotomies that were avoided. These are summarized in Table 7. The total of 82 in 269 cases, or 30%, seems quite impressive to us. Of perhaps equal importance are the cases in which a change in the pre-operative diagnosis resulted from the laparoscopy. As can be seen from the tables, this occurred in 59 cases. A review of the clinical records of the 266 patients revealed that the laparoscopic findings were considered to be critical to the management of the patient in 158 cases (59%). The complications that we encountered were not severe. More critical selection of patients might have avoided two of our three major complications. There seems little doubt that with proper care and case selection, laparoscopy can be a very safe procedure.
82
As we have indicated in the study of the culdoscopies performed at our institution, which are reported in a companion paper, 4 comparison with laparoscopy is in order. Certain advantages for the laparoscope can be listed. One of the obvious ones is that it may be done in those cases where contraindication due to disease or abnormal anatomy preclude culdoscopy. Also, a more complete examination can be carried out with the patient under general anesthesia with the laparoscope, which will give the operator a larger field of examination. It is probably correct to state that the ability to visualize the organs in the upper abdomen is important. It would represent our experience to say that laparoscopy can be learned more readily and be mastered by more physicians, without restriction to those subspecializing in endoscopy. SUMMARY
Laparoscopy has been shown to be a precise and acceptable diagnostic tool for the gynecologist. In a series of 269 cases performed under general anesthesia at the New York Hospital-Cornell Medical Center (New York Lying-In Hospital) the procedure has been shown to be safe and reliable. The technique, indications, contraindications, and complications are reviewed. The value of the procedure in the diagnosis and treatment of infertility, in the evaluation of acute and chronic pelvic pain, and in the definition of obscure pelvic masses is discussed. Laparoscopy may frequently obviate exploratory lapa-
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SMITH AND DILLON
rotomy, and it can also help to avoid serious or even disastrous delays in surgery. REFERENCES
9.
10.
1. ARONSON, A. R., AND PARKER, G. W. Perito-
2. 3. 4. 5. 6.
7. 8.
neoscopy: Its value as a diagnostic aid. A mer J Dig Dis 5:931, 1960. BERNHEIM, B. M. Organoscopy: Cystoscopy of the abdominal cavity. Ann Burg 13:764, 1911. CoHEN, M. R. Culdoscopy vs. peritoneoscopy. Obstet Gynec 31:310, 1968. DILLON, T. F., AND SMITH, B. D. Cudoscopy. Unpublished data. EDLIN, P. Peritoneoscopy in private practice. Postgrad Med 43:120, 1968. FEAR, R. E. Laparoscopy: A valuable aid in gynecologic diagnosis. Obstet Gynec 31:297, 1968. HoPE, R. Peritoneoscopy. Burg Gynec Obstet 64:229, 1937. JACOBAEUS, H. E. Ueber die Moglichkeit die Zystoskopie hie Untersuchung seroser Hoh-
11. 12. 13. 14. 15.
16. 17.
Vol. 21
lungen Anzuwenden. Munchen Med Wschr 57:2090,1910. JACOBSON, L. Laparoscopy in the diagnosis of acute salpingitis. Acta Obstet Gynec Scand 43:160, 1964. KELLING, G. Uber Oesophagosckopie, Gastroskopie und Colioskopie. Munchen Med Wschr49:21, 1902. LEVY, M. A late complication of peritoneoscopy. Gastroint Endosc 14:117, 1967. PALMER, E. D. Peritoneoscopic technique. Gastroint Endosc 14:106, 1967. Ruddock, J. C. Peritoneoscopy. Burg Gynec Obstet 65:623, 1937. Ruddock, J. C. Peritoneoscopy: A critical clinical review. Burg Clin N A mer 37:1249, 1957. ScOTT, N. M. Role of peritoneoscopy in diagnosis of intra-abdominal disease. Arch Intern Med (Chicago) 120:207, 1967. Steptoe, P. C. Laparoscopy in Gynaecology. Livingston, London, 1967. VILARDELL, R. Complications of peritoneoscopy. A survey of 1,455 examinations. Gastroint Endosc 14:178, 1968.
FERTILITY AND STERILITY
Copyright
© 1970 by The Williams
& Wilkins Co.
LAPAROSCOPY BARRY D. SMITH, M.D.,*
AND
THOMAS F. DILLON, M.D., F.A.C.O.G.
Department of Obstetrics and Gynecology, the New York Hospital-Cornell Medical Center, New York, New York
light sources of high intensity were developed. This led to renewed interest in laparoscopy. Improved lens systems and modern instrumentation have provided better visualization plus the ability to obtain excellent photographic studies. "Peritoneoscopy" has become very popular in the field of gastroenterology. Most of the studies in this field are done with local anesthesia. Edlin5 showed that peritoneoscopy using local anesthesia may be performed safely despite the presence of advanced age, general debility, fever, jaundice, anemia, and portal hypertension. Laparoscopy was introduced into the Department of Obstetrics and Gynecology of the New York Hospital-Cornell Medical Center in October 1966. Two hundred and sixty-nine laparoscopic examinations were performed between October 1966 and May 1968. All but one of these procedures were done utilizing general anesthesia, and the results of the first 134 procedures constituted a report by Fear. 6 It is the purpose of this paper to review our total series with particular emphasis on the value of the procedure in the study of infertility, in the evaluation of pelvic pain, and in the diagnosis of obscure pelvic pathology.
Modern optical systems, high intensity fiber-optic light sources, and convenient and safe means of inducing pneumoperitoneum have made laparoscopy an accepted and safe procedure. The procedure is an old one . The history of laparoscopy is well summarized by several authors. 6 • 15 • 16 In 1901 Georg Kelling, 10 a surgeon of Dresden, Germany, demonstrated that the intraabdominal organs of a dog could be visualized by inserting a cystoscope through a small incision in the animal's anterior abdominal wall. J acobaeus 8 of Sweden, in 1910, was the first to apply this new procedure to patients. It was he who coined the name laparoscopy for the procedure of endoscopic examination of the abdominal organs by the transperitoneal route. The first use of laparoscopy in the United States was by Bernheim2 in 1911. The concepts of using pneumoperitoneum and the Trendelenburg position were added in 1912. In the 1930's Ruddock/ 3 an internist, became the main proponent of the procedure in the United States. He reported a series of 500 cases in 1937. All of his cases were done with local anesthesia, and most of the cases were done with the aim of investigating upper abdominal pathology. In the same year, Hope 7 emphasized the great value of laparoscopy in the differential diagnosis of ectopic pregnancy. For the next 20 years, however, culdoscopy remained the popular form of pelvic endoscopy in the United States while laparoscopy was being used and improved upon in Europe. In the early 1950's remote
TECHNIC
*Present address: U. S. Naval Hospital, Philadelphia, Pa.
The instruments used in this study were manufactured by the Richard Wolf Co. of Knittlingen, West Germany, and by the American Cystoscope Makers, Inc., Pelham Manor, N. Y. The technic that was utilized has been described by Jacobson9 and Fear6 in previous communications. The
193
194
SMITH AND DILLON
principal points in the technic are as follows. The procedure is performed under general anesthesia and is preceded by bimanual pelvic examination after suitable anesthesia has been induced. Endotracheal technics for the administration of anesthesia are extremely desirable in order to prevent the upper gastrointestinal tract from being inadvertently distended with anesthetic gases. An ordinary tenaculum is placed on the anterior lip of the cervix to permit an assistant to maneuver the uterus during the examination. The patient is placed in 5-10° of Trendelenburg. The skin at the lower margin of the umbilicus is grasped with two Adair clamps, the anterior abdominal wall is elevated, and a small skin incision is made for the insertion of the pneumoperitoneum needle and of the main trocar. This incision is located in the midline 2 em. below the umbilicus. Carbon dioxide gas is administered through the Ruddock pneumoperitoneum needle after the appropriate placement within the peritoneal cavity has been ascertained. The laparoscope trocar is inserted through the same midline incision. A secondary probe is inserted in the right lower quadrant to aid in the manipulation of the pelvic organs and through which several diagnostic procedures can be performed. INDICATIONS AND CONTRAINDICATIONS
The indications for laparoscopy in gynecology and obstetrics have fairly wide limits. Principal indications include: 1. Infertility, due to tubal occlusion or peritoneal adhesions. 2. Amenorrhea, primary or secondary, with ovarian biopsy. 3. Suspected ectopic pregnancy. 4. Unexplained chronic pelvic pain mcluding dysmenorrhea. 5. Obscure pelvic masses. 6. Verification of suspected pelvic mflammatory disease.
Vol. 21
7. Acute pelvic pain of uncertain origin. 8. Verification of metastatic liver disease. We, as well as others,5 • 6 • 16 have added several additional indications or possible uses for laparoscopy. These include: 1. The differential diagnosis of ascites. 2. Staging of carcinoma of the cervix, endometrium, and ovary. 3. Accurate measurement of radiation dose. 4. Tubal sterilization by ligation, clips, cauterization, or cryosurgery. 5. Removal of displaced intrauterine contraceptive devices. 6. Evaluation of treatment of endometriosis. 7. Postcoital examination of fluid in the cul-de-sac for sperm. 8. Bacteriologic and cytologic .examination of fluid in the cul-de-sac. 9. Ventrosuspension of the uterus. 10. Aspiration of ovarian cysts. 11. Studies of tubal physiology. 12. Studies of the ovary before and after drug stimulation. In the literature3 • 12• 16 diaphragmatic hernia, marked circulatory failure and previous laparotomy have been quoted as absolute contraindications to laparoscopy. It can now be said that previous laparotomy is, in our experience and that of others, 6 • 9 only a relative contraindication, with each case best judged on its individual merits. In most cases laparoscopy can be carried out with safety. If the previous incision was a low midline one, then the incision may be made in the usual place. If the incision extended to the umbilicus, then an area to the right or left of the midline should be chosen. Acute generalized peritonitis has in the past been listed as an contraindication to laparoscopy, and, certainly, the acute surgical abdomen must be managed in the time-honored fashion. In selected cases such as those possibly representing spread from acute salpingitis, the laparoscope can
r
c s . f , f e e o r
e o re es d n
LAPAROSCOPY
March 1970
be particularly helpful in the differential diagnosis. Absolute Contraindications: 1. Severe cardiac or respiratory disease, except where local anesthesia can be utilized. 2. Diaphragmatic hernia. 3. Abdominal, umbilical, or inguinal hernia. 4. Acute distended surgical abdomen with intestinal distention. Relative contraindications: 1. Previous laparotomy. 2. Ascites. 3. Obesity. 4. Diffuse intra-abdomina}. malignancy with ascites. RESULTS
A total of 269 laparoscopies were performed. These procedures were carried out on 266 patients by 23 residents and 10 attending gynecologists. The series was divided quite equally between private and ward service patients with 134 private patients and 132 ward service patients included in the series. There were 74 patients who had had previous abdominal surgery. In 32 cases the surgery had been an appendectomy via a McBurney incision. In 42 cases the patient had had a pelvic operation, and in all but 3 of these patients the laparotomy had been through a midline incision. The indications for the 269 procedures are summarized in Table 1. The infertility and ovarian dysfunction group is reviewed in Table 2. This group of 86 cases includes all patients with a preoperative diagnosis TABLE 1. Indication
Infertility and ovarian dysfunction Acute pelvic pain Chronic pelvic pain Obscure pelvic mass Miscellaneous
No. of cases
86 73
49 49 12
195
TABLE 2. Patients Studied for Infertility and Suspected Stein-Leventhal Syndrome Total patients Preoperative diagnosis Stein-Leventhal syndrome
86 17
Expected normal findings Unexpected normal findings
13 12
Expected abnormal findings Stein-Leventhal ovaries Peritubal adhesions Pelvic inflammatory disease (old) Cornual obstruction Myomata uteri Endometriosis
14 7 11 2 3 6
Unexpected abnormal findings Pelvic inflammatory disease (old) Peritubal adhesions Stein-Leventhal ovaries
1 5 10
Laparotomies spared Failures Critical to management of patient
5 2 28
of Stein-Leventhal syndrome, as well as those patients being studied for "infertility." It can be seen that 14 of the 17 patients with a preoperative diagnosis of Stein-Leventhal syndrome were confirmed. In 2 cases normal ovaries were found, and the remaining case was a "failure" due to severe obesity. · The pneumoperitoneum needle could not be introduced properly, and the procedure was therefore discontinued. Laparotomy revealed bilateral cortical sclerosis. In addition to these cases, 10 cases of unexpected Stein-Leventhal type ovaries were diagnosed. Two of these were confirmed by wedge resection, and 2 others were successfully treated with clomiphene citrate. Laparoscopy can be used to clarify inconclusive hysterogram findings. Two patients thought to have distal obstruction on hysterogram were shown to have normal tubes on laparoscopic examination. Lapa· rotomy was spared in these 2 patients. Laparoscopy was used to confirm tubal pathology prior to definitive surgery. Lapa-
196
TABLE 3. Patients Studied for Acute Pelvic Pain Total cases Preoperative diagnosis confirmed Obscure diagnosis made Preoperative diagnosis changed Incomplete visualization Laparotomy spared Laparotomy mandated Laparoscopy critical in management
Vol. 21
SMITH AND DILLON
73 24 37 11 4 36 10 48
rotomy was spared in 2 patients judged to have such severe pelvic inflammatory disease that surgery was not indicated. The other failure in the group was a thin woman, but a good pneumoperitoneum could not be established and the procedure was discontinued. The results in the group investigated for acute pelvic pain are summarized in Table 3. In this group the differential diagnosis was usually between tubal pregnancy, ruptured or twisted ovarian cyst, appendicitis, and acute pelvic inflammatory disease. Of the 73 patients in the group, 38 were investigated for suspected ectopic pregnancy. The diagnosis was only confirmed in 7 cases ( 18%) . Various stages of pelvic inflammatory disease were found in 9 patients, while 8 were noted to have a leaking ovarian cyst. One intrauterine pregnancy was diagnosed, and 2 cases of regional ileitis were diagnosed as well. Laparoscopy was felt to have spared 22 laparotomies in this group of 38. Immediate surgery was mandated on 10 occasions. The findings in these cases included ectopic pregnancy, appendicitis, bleeding corpus luteum, and ruptured endometriotic cysts. Also included in this group were 21 patients with a preoperative diagnosis of acute pelvic inflammatory disease. In 16 cases the diagnosis was substantiated. There were 2 women shown to have a bleeding corpus luteum, 1 with a leaking endometriotic cyst, 1 with an infarcted epiploic appendage, and 1 with acute appendicitis. A dermoid cyst was diagnosed
in 1 patient who also had acute pelvic inflammatory disease. There were 4 cases in the group in which visualization was incomplete. In 1 case enough was seen to require laparotomy for a leaking endometriotic cyst. In the second case pelvic adhesions prevented any accurate diagnosis. Laparotomy revealed a tubo-ovarian abscess beneath adherent bowel. The third patient was diagnosed as having pelvic inflammatory disease with periappendicitis. One week later appendectomy was carried out because of perforation. In the fourth case anesthesia difficulties were encountered, and the pneumoperitoneum needle could not be inserted properly. The procedure was discontinued. Two of the 3 women who were examined twice were included in this group. One of the patients twice presented with right lower quadrant pain. In each case acute pelvic inflammatory disease was found. The second patient was referred to above. She presented with right lower quadrant pain which was found to be resulting from an infarcted epiploic appendage. Her second procedure was again for right lower quadrant pain with a mass. In this instance an intrauterine pregnancy plus a simple cyst of the right ovary was found. The third group of patients are those investigated for chronic pelvic pain. The diagnoses made in this group are listed in Table 4. Of special note are the 15 patients with normal findings. Many of these paTABLE 4. Patients Studied for Chronic
Pelvic Pain T~alcasM
Normal findings Pelvic inflammatory disease (old) Endometriosis Adhesions Stein-Leventhal syndrome Myomata uteri Preoperative diagnosis changed Laparotomy spared Laparoscopy critical in management
M 15 13 13 7 1 1 15 8 40
-
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tients became asymptomatic following laparoscopy. Of 33 women with a preoperative diagnosis of chronic pelvic inflammatory disease, 13 were confirmed. Endometriosis was found in 8 cases. Three young women were laparoscoped for dysmenorrhea. One patient was found to have chronic pelvic inflammatory disease, and 2 had normal findings. In this group laparoscopy was felt to have spared eight laparotomies. Forty-nine women were subjected to laparoscopy for the evaluation of adneJ~:al masses (Table 5). In 20 cases the preoperative diagnosis was confirmed, while the pre-operative impression was wrong in 16 cases. It was felt that 32 of these women would have had laparotomies, if laparoscopy had not been performed. The ages of our patients varied from 13 to 79. The age distribution is shown in Table 6. Of particular interest is the group of 11 who were age 60 and older. Ten of these 11 are included in the group investigated for an obscure mass. Five of these women had asymptomatic masses diagnosed as myomas at laparoscopy. All tolerated the procedure well and were discharged on the day following laparoscopy. In 1 very obese patient, age 62, there was a questionable adnexal mass. There was a feculent odor upon insertion of the pneumoperitoneum needle. The patient underwent immediate exploratory laparotomy; only a small laceration in the omentum was found. The ovaries were normal. TABLE 5. Patients Studied for Obscure Pelvic Masses Total cases Diagnosis made Preoperative diagnosis confirmed Preoperative diagnosis changed Laparotomy spared Laparotomy mandated Laparoscopy critical in management Failures
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49 46 20 16 32 2 36 3
TABLE 6. Age Distribution of Cases Age
No. of cases
yr.
13-19 20-29 30-39 40-49 50-59
60-
13 150 66 25 4 11
The other 5 in this group had adnexal masses noted at the time of dilatation and curettage for postmenopausal bleeding. Three were found to have pedunculated myomas. In 1 case the ovary contained a small cyst, but it could not be fully visualized. It was confirmed as a simple cyst when the patient underwent appendectomy 2 months later. In the remaining case adenocarcinoma of the endometrium was diagnosed on curettage. Laparoscopy because of an enlarged adnexa revealed what was thought to be a metastatic nodule in the ovary. Subsequent surgery revealed the ovary to contain a simple cyst. The last case in the group was the third failure. A 4-cm. firm right adnexal mass was noted. There had been a previous appendectomy. Laparoscopy was unsuccessful due to omental adhesions which obscured the right adnexa. Laparotomy revealed a serous cyst. The miscellaneous group includes 12 patients. One was a patient with a followup examination after treatment for acute pelvic inflammatory disease; there were normal findings. In a second patient an attempt at removing an ectopic intrauterine contraceptive device failed. Four patients with primary amenorrhea were studied; 3 had normal pelvic organs and 1 had testicular feminization. One patient with hirsutism and another with postpartum amenorrhea were noted to have normal findings. Three women with vaginal and uterine agenesis were studied. Two had normal ovaries and distal tubes. The remaining patient in the 60 and
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over group was in the miscellaneous category. The patient was a 79-year-old woman with massive ascites and probable ovarian carcinoma. The laparoscope trocar was inserted without attempting pneumoperitoneum. The ascitic fluid was removed by suction. The fluid turned to blood after removal of about 2500 cc. Immediate laparotomy revealed bleeding from the tumor-filled hilum of the spleen. Splenectomy was carried out. The patient recovered from surgery but died 1 month later of carcinomatosis. COMPLICATIONS
In the literature3 • 11 • 16 • 17 the great proportion of complications have occurred in establishing the pneumoperitoneum. These include: 1. Hemorrhage from puncture of abdominal wall vessels. 2. Intestinal perforation. 3. Gas embolism. 4. Subcutaneous emphysema. 5. Injection of gas into omentum or viscus. 6. Aggravation of existing hernias. 7. Mediastinal emphysema. 8. Rupture of the diaphragm. 9. Pneumothorax. 10. Respiratory or circulatory embarrassment. Proper technic and proper selection of cases can avoid most of these complications. An empty bladder is important. We favor the use of carbon dioxide with an escape valve set at less than 36 em. of water to avoid the problems of embolization and overdistention. The technic of testing for proper placement of the insufflation needle with 1 drop of saline has been of great value to us. If it is decided to investigate a patient with ascites, slow withdrawal of the fluid is advisable in view of our experience. Other reported complications include: 1. Perforation of a vessel or viscus with the large trocar.
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2. Herniation of intestines into or through the incision if the patient strains before closure. 3. Bleeding from the tenaculum site on the cervix. 4. Incisional hernia 15 as a late complication. Deaths have been reported, but they have been very rare. Most have resulted from air embolism, bile peritonitis (following a biopsy) , or hemorrhage. A review of the medical literature by Aronson and Parker 1 showed a combined mortality of 0.12% in over 8000 cases. This compares with a mortality of 0.28% for blind liver biopsy. Ruddock14 teported one death in 5000 cases. M ajO'T' Complications:
1. Intraperitoneal bleeding following removal of ascitic fluid. 2. Probable bowel perforation with the pneumoperitoneum needle. 3. Perforation of the stomach. The first 2 cases have been described previously. The third patient was a 26year-old infertility problem. There was some difficulty inserting the pneumoperitoneum needle and several insertions were made. After obtaining pneumoperitoneum, laparoscopic examination revealed some peritubal adhesions. Seven hours later the patient had the onset of hematomesis. Exploration revealed three small perforations of the stomach which were repaired. The patient recovered without further complications. Minor Complications: 1. Ileus following lysis of adhesions with the probe. 2. Protrusion of a knuckle of intestines prior to incision closure. 3. Preperitoneal carbon dioxide. The first case subsequently developed a mechanical bowel obstruction. At laparotomy a congenital band was lysed and recovery was rapid. The second patient
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LAPAROSCOPY
was treated by re-establishing good anesthesia and closure of the wound. The preperitoneal carbon dioxide absorbed rapidly. It should also be noted that postoperative shoulder pain was very uncommon. When it did occur, it was gone within 24 hr.
TABLE 7. Summary of Laparotomies Spared Study group
Infertility Acute pelvic pain Chronic pelvic pain Obscure pelvic masses Miscellaneous
No. of cases
5
36 8 32
1
DISCUSSION .
The recent interest in laparoscopy seems to us to be fully justified. Direct visualization of the pelvic organs in obscure disease has become an accepted and valuable procedure. The technic is basically simple and safe. The high degree of diagnostic accuracy has enabled laparoscopy to spare many patients from exploratory laparotomy. At the same time the procedure has value in avoiding unnecessary delay before needed surgery. The study of infertility has been aided greatly. Hysterogram findings can be disproven or verified; tubal surgery can be planned or rejected; Stein-Leventhal ovaries can be diagnosed; nonpalpable endometriosis may be found and palpable, verified. In our series we were particularly interested in the number of unnecessary laparotomies that were avoided. These are summarized in Table 7. The total of 82 in 269 cases, or 30%, seems quite impressive to us. Of perhaps equal importance are the cases in which a change in the pre-operative diagnosis resulted from the laparoscopy. As can be seen from the tables, this occurred in 59 cases. A review of the clinical records of the 266 patients revealed that the laparoscopic findings were considered to be critical to the management of the patient in 158 cases (59%). The complications that we encountered were not severe. More critical selection of patients might have avoided two of our three major complications. There seems little doubt that with proper care and case selection, laparoscopy can be a very safe procedure.
82
As we have indicated in the study of the culdoscopies performed at our institution, which are reported in a companion paper, 4 comparison with laparoscopy is in order. Certain advantages for the laparoscope can be listed. One of the obvious ones is that it may be done in those cases where contraindication due to disease or abnormal anatomy preclude culdoscopy. Also, a more complete examination can be carried out with the patient under general anesthesia with the laparoscope, which will give the operator a larger field of examination. It is probably correct to state that the ability to visualize the organs in the upper abdomen is important. It would represent our experience to say that laparoscopy can be learned more readily and be mastered by more physicians, without restriction to those subspecializing in endoscopy. SUMMARY
Laparoscopy has been shown to be a precise and acceptable diagnostic tool for the gynecologist. In a series of 269 cases performed under general anesthesia at the New York Hospital-Cornell Medical Center (New York Lying-In Hospital) the procedure has been shown to be safe and reliable. The technique, indications, contraindications, and complications are reviewed. The value of the procedure in the diagnosis and treatment of infertility, in the evaluation of acute and chronic pelvic pain, and in the definition of obscure pelvic masses is discussed. Laparoscopy may frequently obviate exploratory lapa-
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rotomy, and it can also help to avoid serious or even disastrous delays in surgery. REFERENCES
9.
10.
1. ARONSON, A. R., AND PARKER, G. W. Perito-
2. 3. 4. 5. 6.
7. 8.
neoscopy: Its value as a diagnostic aid. A mer J Dig Dis 5:931, 1960. BERNHEIM, B. M. Organoscopy: Cystoscopy of the abdominal cavity. Ann Burg 13:764, 1911. CoHEN, M. R. Culdoscopy vs. peritoneoscopy. Obstet Gynec 31:310, 1968. DILLON, T. F., AND SMITH, B. D. Cudoscopy. Unpublished data. EDLIN, P. Peritoneoscopy in private practice. Postgrad Med 43:120, 1968. FEAR, R. E. Laparoscopy: A valuable aid in gynecologic diagnosis. Obstet Gynec 31:297, 1968. HoPE, R. Peritoneoscopy. Burg Gynec Obstet 64:229, 1937. JACOBAEUS, H. E. Ueber die Moglichkeit die Zystoskopie hie Untersuchung seroser Hoh-
11. 12. 13. 14. 15.
16. 17.
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lungen Anzuwenden. Munchen Med Wschr 57:2090,1910. JACOBSON, L. Laparoscopy in the diagnosis of acute salpingitis. Acta Obstet Gynec Scand 43:160, 1964. KELLING, G. Uber Oesophagosckopie, Gastroskopie und Colioskopie. Munchen Med Wschr49:21, 1902. LEVY, M. A late complication of peritoneoscopy. Gastroint Endosc 14:117, 1967. PALMER, E. D. Peritoneoscopic technique. Gastroint Endosc 14:106, 1967. Ruddock, J. C. Peritoneoscopy. Burg Gynec Obstet 65:623, 1937. Ruddock, J. C. Peritoneoscopy: A critical clinical review. Burg Clin N A mer 37:1249, 1957. ScOTT, N. M. Role of peritoneoscopy in diagnosis of intra-abdominal disease. Arch Intern Med (Chicago) 120:207, 1967. Steptoe, P. C. Laparoscopy in Gynaecology. Livingston, London, 1967. VILARDELL, R. Complications of peritoneoscopy. A survey of 1,455 examinations. Gastroint Endosc 14:178, 1968.