CULDOSCOPY AND LAPAROSCOPY: COMPETITIVE OR COMPLEMENTARY TECHNICS?

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1 FERTILITY AND STERILITY Copyright 1970 by The Williams & Wilkins Co. Vol. 21, No.4, April1970 Printed in U.S.A. CULDOSCOPY AND LAPAROSCOPY: COMPETITIVE OR COMPLEMENTARY TECHNICS? MAXWELL ROLAND, M.D., F.A.C.O.G. The New York Fertilit.y Research Foundation, New York, New York Until recently, among gynecologic endoscopic technics, culdoscopy was preferred in the United States, whereas laparoscopy was the method of choice in Europe. Substantial interest in the latter procedure has developed in the United States during the last several years, and reports have been published declaring that the one or the other endoscopic method is superior In this paper experience with both technics is presented, and an attempt is made to assess the merits of each. ENDOSCOPIC TECHNICS Endoscopy has become an important adjunct in the diagnosis of pelvic pathology, both in gynecology and infertility. According to Steptoe, Kelling, in Germany, first visualized the peritoneal cavity in dogs with a modified cystoscope, and J a cobaeous, also in Germany, initiated the use of the laparoscope clinically in Bernheim, in 1911, was the first to employ a laparoscope in the United States. Tubal sterilization through the laparoscope was performed for the first time by Anderson in the United States in The augmented recent interest in gynecologic endoscopy in large part stems from substantial improvements in methods. When such examinations were first attempted, an electric light source had to be introduced into the patient for visualization of the pelvic viscera. This converted only about 3% of the electrical energy into light.10 The remainder was transformed into heat. Hazards of endoscopic examination thus included burning of the peritoneum or viscera, either through direct contact with the bulb or by prolonged exposure. In addition, in patients undergoing culdoscopy with local anesthesia, discomfort was at a fairly high level. With the application of the fiberoptic principle to endoscope design, these objections have largely been overcome. In the fiberoptic system, the light source can remain outside the body. The effects of heat have thus been eliminated almost entirely. The light transmitted through the fiberoptic system is brighter than that provided by the older system. Examination by means of a fiberoptic endoscope can be continued over a longer period of time without incurring the risks that accompanied procedures performed with the older equipment. Culdoscopy. The procedure of culdoscopy, primarily developed by Decker,4 is summarized here. 1. In the office, with the patient in the knee-chest position, a 20-gauge needle is attached to the barrel of a syringe and the wet plunger is withdrawn 1-2 em. from the syringe. The needle is then passed through the dimple of the posterior fornix. If the plunger is sucked into the barrel, indicating negative pressure in the cul-desac, the patient may be considered a candidate for culdoscopy. If the plunger is not sucked into the barrel, culdoscopy is contraindicated, as the cul-de-sac may be occupied by a mass. 2. After Day 20 of the cycle, the patient is admitted to the hospital. She is given the standard soap suds enema the evening before surgery. 3. At operation, the standard puboperi- 361

362 ROLAND Vol. 21 neal prep is given and anesthesia is induced. Caudal anesthesia of the "single shot" type is preferred-i.e., about 30 cc. of Xylocaine or Carbocaine in 1% concentration.

With the patient in the knee-chest position and the abdominal wall completely clear of the operating table, an antiseptic is applied to the perineal and vaginal areas, including the cervix. 5.

2 362 ROLAND Vol. 21 neal prep is given and anesthesia is induced. Caudal anesthesia of the "single shot" type is preferred-i.e., about 30 cc. of Xylocaine or Carbocaine in 1% concentration. The anesthesia is considered adequate when insensitivity to stimuli to the level of T10 has been achieved. 4. With the patient in the knee-chest position and the abdominal wall completely clear of the operating table, an antiseptic is applied to the perineal and vaginal areas, including the cervix. 5. The cervix is exposed with a Sims retractor, grasped with a tenaculum, and drawn down toward the abdomen. The concave ballooning sign of the posterior fornix is again elicited. 6. A 14-gauge needle attached to the barrel of a syringe is used to puncture the dimple of the posterior fornix (Fig. 1). If there is no obstruction in the cul-de-sac, the sound of air being sucked m can be heard. The needle is removed, and the trochar and cannula of the culdoscope are passed downward through the puncture at a 45 angle to the horizontal, so as to avoid the rectum (Fig. 2). The trochar is removed, the culdoscope is inserted, and the examination is begun (Figs. 3 and 4). After inspection of the pelvic contents, dilute indigo carmine solution is introduced through a threaded cone cervical cannula for tubal perfusion with visual confirmation of tubal patency or obstruction. Endometrial curettage is then performed. Upon removal of the culdoscope, the patient is placed in the prone position and the abdomen is compressed to expel air from the abdominal cavity. The cannula is then withdrawn. Usually, the puncture wound requires no particular attention. Fw. 1. A 14-gauge needle being used to puncture dimple of posterior fornix in preparation for culdoscopy (from Roland,8 courtesy of Thomas).

3 FIG. 2. Trochar and cannula of culdoscope being passed through cul-de-sac (from Roland, a courtesy of Thomas). FIG. 3. Culdoscope in place (from Roland,8 courtesy of Thomas) 363

The patient is discharged the following day with instructions to take a broadspectrum antibiotic for 5 days.

4 364 ROLAND Vol. 21 FIG. 4. Photograph of culdoscope in place (culdoscope by American Cystoscope Makers, Pelham, N.Y.). Occasionally, to control excessive oozing from the edges of the wound, a figure chromic suture is taken. The patient is discharged the following day with instructions to take a broadspectrum antibiotic for 5 days. The antibiotic is given routinely because of inability to obtain complete asepsis in the vagma. Laparoscopy. Laparoscopy is more formidable than culdoscopy, since general anesthesia is required. Local anesthesia can be employed in a small percentage of patients with a high threshold for pain. The following is an abridged account of this method The patient is placed supine in a modified lithotomy position and the head of the table is lowered about A self-retaining vacuum cannula is attached to the cervix (Fig. 5). 3. The inferior fold of the umbilicus is penetrated with a Verres needle (described by Semm). After cc. of C02 have been insufflated, a syringe to which a long thin needle has been attached is filled with 5 cc. of sterile saline solution and passed through the abdominal wall one inch below the umbilical fold. The plunger is then withdrawn (Fig. 6). The appearance of bubbles in the syringe shows that the C02 is being aspirated from the peritoneal cavity, and confirms the correctness of the insufflation. 4. A total of approximately 3000 cc. of C0 2 is insufflated to a pressure of 12 mm. Hg, displacing the intestines toward the epigastrium (Fig. 6). Semm's equipment includes a regulating system which automatically introduces additional C02 to compensate for losses due to resorption or leaks in the equipment; the system also

5 FIG. 5. Self-retaining vacuum cannula in cervix and vacuum pump for laparoscopy (developed by Semm; made by Wisap, Munich, Germany). FIG. 6. Verres needle in situ, for C0 2 insufflation. Separate needle and syringe being used to establish that C02 has been insufflated into peritoneal cavity. 365

366 ROLAND Vol. 21 FIG. 7. Trochar and cannula of laparoscope being inserted through incision in inferior fold of umbilicus while abdominal wall is elevated manually.

The trochar and cannula of the laparoscope, which have a 6-mm. diameter, are inserted through the skin (Figs. 7 and 8), then laterally 1-2 em.

6 366 ROLAND Vol. 21 FIG. 7. Trochar and cannula of laparoscope being inserted through incision in inferior fold of umbilicus while abdominal wall is elevated manually. indicates failure of smooth insufflation of the gas due to adhesions or subperitoneal puncture. 5. A 1-cm. incision in the inferior umbilical fold is made with a scalpel. The trochar and cannula of the laparoscope, which have a 6-mm. diameter, are inserted through the skin (Figs. 7 and 8), then laterally 1-2 em., and then downward through the rectus muscle, in this way avoiding the umbilical fascia, which might be the site of herniation. 6. The trochar is withdrawn, and the 4-mm. Hopkins laparoscope (Figs. 9 and 10) is then introduced through the cannula. Following steps in the procedure include examination of all pelvic organs, tubal perfusion with dilute indigo carmine solution, and minor surgical procedures, if indicated. With traction on the self-retaining vacuum cannula, the uterine corpus can be moved to facilitate the examination and bring the adnexa into view. In cases in which the adnexa cannot be visualized in the usual manner, or for minor operative procedures (Fig. 11), the flank is punctured about 2 inches inferior and lateral to the umbilicus with another 4 mm. trochar and cannula under endoscopic visualization. Electrocauterization can be performed through this opening in endometriosis and for tubal ligation, as can lysis of some adhesions, ovarian biopsy, and the like. For termination of the endoscopic examination, the laparoscope is withdrawn, the C0 2 is slowly expelled through the automatically regulated valve, and the wound is dressed with topical antibiotic powder and gauze. The cervical cannula and sound are then removed and curettage is performed. The patient is discharged the following day and is instructed to take

7 FIG. 8. Laparoscope being inserted through cannula ----~~ ~ -~ ~ ~ ~~~ FIG. 9. Hopkins laparoscopes for examination and photography (made by Karl Storz, Germany) 367

MATERIALS Five hundred patients 19 to 40 years of age underwent culdoscopy during the last 8 years, and 60 patients 22 to 35 years

8 368 ROLAND Vol. 21 FIG. 10. Light source for laparoscopy. Unit has attachments for cauterization and photography (made by Karl Storz). a broad spectrum antibiotic for 5 days for prophylaxis. MATERIALS Five hundred patients 19 to 40 years of age underwent culdoscopy during the last 8 years, and 60 patients 22 to 35 years of age underwent laparoscopy during the last 2 years. In most instances, the indication for endoscopic examination was unexplained infertility. In a few cases, the procedure was performed for diagnosis of

April1970 CULDOSCOPY AND LAPAROSCOPY 369 FIG. 11. Instruments used for improved visualization, biopsy or minor surgical procedures at laparoscopy (made by Karl Storz).

9 April1970 CULDOSCOPY AND LAPAROSCOPY 369 FIG. 11. Instruments used for improved visualization, biopsy or minor surgical procedures at laparoscopy (made by Karl Storz). other pelvic pathologic changes, e.g., ectopic pregnancy, endometriosis, or ovarian disease. OBSERVATIONS Representative observations which can be made to best advantage during culdoscopy are shown in Figs Views best afforded by laparoscopic examination are illustrated in Figs Certain observations can be made equally well by either technic (Figs. 19 and 20). COMMENT In this series, the experience with laparoscopy was more limited than that with culdoscopy, but certain impressions appear fairly definite. At culdoscopy, visualization of the ovaries and fimbriated ends of the tubes is accomplished more easily and with a better view than at laparoscopy. Moreover, laparoscopy is technically more difficult in the very obese patient, and, in general, the procedure should be attempted in such patients only by the expert. Culdoscopy is contrainidicated in the presence of masses in the cul-de-sac. Other factors causing the procedure to be ruled out include a history of pelvic inflammatory disease and chronic cervicitis. In addition, it may be unrewarding if there are pelvic adhesions in various locations, as well as large subserous myomas of the posterior lower uterine segment. In general, laparoscopy provides a more extensive view of the uterus, bladder, and tubes than does culdoscopy and, in addition, permits visualization of the inferior surface of the liver, the gallbladder, and other abdominal viscera. The procedure is likely to be uninformative if there are too many adhesions between the parietal peritoneum and the abdominal wall. Contraindications are peritonitis, intestinal obstruction, and conditions precluding the use of general anesthesia. Both endoscopic methods are of great utility in the diagnosis and occasionally the treatment of conditions such as endometriosis which cannot be palpated on bimanual examination. Either method is invaluable in the assessment of tubal abnormalities. Both the quality and quantity of informa-

10 FIG. 12. Culdoscopy. Tubal occlusion with sacculation of fimbria FIG. 13. Culdoscopy. Ovarian endometriosis 370

11 FIG. 14. Culdoscopy. Adhesions between tube and lateral wall of pelvis FIG. 15. Culdoscopy. Dermoid cyst of ovary 371

12 Fra. 16. Laparoscopy. Wide angle view of corpus and adnexa Fra. 17. Laparoscopy. Fibroid growths on anterior uterine fundus 372

13 Fro. 18. Laparoscopy. Multiple pelvic adhesions due to endometriosis Fro. 19. Laparoscopy. Corpus luteum 373

374 ROLAND Vol. 21 Fw. 20. Culdoscopy. Adhesions between ovary and lateral wall of pelvis tion surpass that provided by any other diagnostic modality short of laparotomy.

Endoscopy, in addition to permitting positive assessment of tubal patency, allows virtually definitive evaluation of the operability of a tubal disorder.

14 374 ROLAND Vol. 21 Fw. 20. Culdoscopy. Adhesions between ovary and lateral wall of pelvis tion surpass that provided by any other diagnostic modality short of laparotomy. Hysterosalpingography, the most informative of the lesser diagnostic technics, gives no information regarding the tubes beyond the site of obstruction or the endosalpinx. Endoscopy, in addition to permitting positive assessment of tubal patency, allows virtually definitive evaluation of the operability of a tubal disorder. Minor surgical procedures are performed more readily at laparoscopy than at culdoscopy, except in the hands of the expert culdoscopist. Clyman 2 has described an operative culdoscope and has reported its use for a variety of procedures, including electrocauterization, excision of an ectopic gestation, lysis of adhesions, ovarian biopsy, and fimbrioplasty. Surgical lysis of adhesions at endoscopy, particularly those near or in association with the fimbria, is of dubious value. In my experience, such adhesions are likely to reform eventually. In a personal series of nearly 100 tuboplasties substantial data have been obtained indicating that splinting with Teflon or polyethylene tubing for about 8-12 weeks after operation is necessary for lasting benefit to be obtained. In the present series, there were two instances of rectal perforation at culdoscopy. In each, the procedure was abandoned. Closure of the bowel was unnecessary, since the punctures were extra peritoneal. The routine broad spectrum antibiotics were given and there were no lasting sequelae. No other complications were seen in patients subjected to culdoscopy. Difficulties reported by others include perforation of the rectum and puncture of viscera. The first is unlikely to occur if the trochar and cannula are inserted downward at an angle of 45 and not too close to the uterus. The second type of complica-

15 April1970 CULDOSCOPY AND LAPAROSCOPY 375 tion can occur if culdoscopy is performed in spite of a questionable or absent ballooning sign. If the potential hazard of rupture of a viscus is present, it will be difficult or impossible to insert the culdoscope to its full extent through the cannula. If the operator fails after a second attempt to visualize the pelvic organs, for example, because of adhesions in the culde-sac, the procedure should be abandoned. With increased experience, the endoscopist may become more successful in directing the culdoscope beyond the obstructing tissues. If the method is applied with careful technic, and if the procedure is abandoned after two unsuccessful attempts to insert the culdoscope, no untoward occurrences need be expected. In the laparoscopic cases performed to date, complications have not occurred, except for one instance of extraperitoneal gas insufflation early in the series. The only step which occasionally is difficult to execute is the introduction of gas into the peritoneal cavity proper, avoiding subperitoneal insufflation; this difficulty is more likely to occur in obese patients. In instances in which the adnexa are bound to adjoining structures by adhesions, the use of special grasping forceps inserted through a secondary flank puncture may be helpful. The adnexa, particularly the fimbria, can then be raised and brought within the field of view of the laparoscope. Among the complications described by others are puncture of a: viscus and passage of the trochar above the peritoneum, as a result of which the insufflation may dissect the peritoneum from the abdominal wall, producing an emphysema. Since the C02 is quickly absorbed, there are no lasting consequences. The latter complication does not occur with the Semm equipment, since the C02 insufflation is automatically regulated. The Hopkins laparoscope, with its 4-mm. diameter and wide angle field of view, was found superior to other instruments, whose diameters are nearly twice as great. The ability to pass the instrument through the inferior umbilical fold avoids both visible scarring and the need for sutures. In summary, it is suggested that the following criteria be observed in gynecologic endoscopy. CRITERIA FOR PELVIC ENDOSCOPY WITH FIBEROPTIC INSTRUMENTS 1. Contraindications to be heeded. 2. Proper analgesia and anesthesia to be used. 3. Strict observance of technic. 4. Use of smallest caliber endoscope. 5. Minimal scarring of abdominal wall. 6. Prevention of postoperative infection. 7. Prompt recognition and management of complications. CONCLUSION Experience with 500 culdoscopic and 60 laparoscopic examinations was reviewed. Both procedures were found to be of substantial value in infertility diagnosis. Culdoscopy was particularly suited to observation of the ovaries and fimbriated ends of the uterine tubes. This method was also better suited to obese patients. Laparoscopy provided a more extensive view of the pelvic contents, including the superior and anterior aspects of the uterus, and also the bladder, as well as upper abdominal structures. The more formidable of the two endoscopic methods, laparoscopy, appeared better suited in cases in which the site of abnormality could not be localized by prior diagnostic measures to the ovaries and fimbria. Thus, in diagnosis the procedures were complementary rather than competitive. Although biopsy could sometimes be performed to advantage, surgical procedures at the time of the endoscopic examination such as lysis of peritubal or periovarian adhesions or any type of fimbrioplasty were not found to provide lasting benefit.

16 376 ROLAND Vol. 21 Other minor surgical procedures could be performed during either procedure by an experienced operator. The technics for performing each procedure were reviewed, typical observations at each examination were presented, and complications were discussed. Acknowledgments. The author had the good fortune to observe the method of laparoscopy as employed by Drs. Kurt Semm at the II University Frauenklinik in Munich and Raoul Palmer in Paris. REFERENCES 1. BALIN, H., WAN, L. S., AND IsRAEL, S. L. Recent advances in pelvic endoscopy. Obstet Gynec 27:30, CLYMAN, M. N. A new panculdoscope-diagnostic, photographic, and operative aspects. Obstet Gynec 21 :343, CoHEN, M. R. Culdoscopy vs. peritoneoscopy. Obstet Gynec 31 :310, DECKER, A. Culdoscopy. Davis, Philadelphia, FEAR, R. E. Laparoscopy: A valuable aid in gynecologic diagnosis. Obstet Gynec 31:297, HALL, H. Culdoscupy in infertility investigation. F ertil Steril18 :4, PALMER, R. Instrumentation et technique de Ia culdoscopie gynecologique. Gynec Obstet (Paris) 46:422, RoLAND, M. Management of the Infertile Couple. Thomas, Springfield, Ill., SEMM, K. Die Laparoskopie in der Gynakologie. Geburtsh Frauenheilk, SE)!M, K. Technique of gynaecological pelviscopy. M ed Gynaec Social 4:62, 1969.

ANESTHESIA FOR DIAGNOSTIC AND OPERATIVE LAPAROSCOPY

FERTILITY AND STERILITY Copyright @ 1971 by The Williams & Wilkins Co. Vol. 22, No. 10, October 1971 Printed in U.S.A. ANESTHESIA FOR DIAGNOSTIC AND OPERATIVE LAPAROSCOPY CLIFFORD R. WHEELESS, JR., M.D.