PERITONEOSKOPIYA (grech, peritonaion a peritoneum + skopeo to consider, investigate; synonym: laparoscopy, ventroskopiya, abdominoskopiya, tselioskopiya) — a way of diagnosis of diseases of abdominal organs by means of the special optical tool which is entered through a puncture of a front abdominal wall or a back vault of the vagina. Most widely in a wedge, practice the term «is distributedlaparoscopy».
In 1901 the Russian obstetrician-gynecologist D. O. Ott reported about a possibility of survey of an abdominal cavity by means of a frontal mirror and a round mirror (ventroskopiya) at a vulval chrevosecheniye. Further development of a method is connected with names of Kellinga (G. Kelling, 1902), Yakobeusa (H. Ch. Jacobaeus, 1910), Korbsha (R. Korbsch, 1922), the Tracing-paper (H. Kalk, 1943), Raddoka (J. Page of Ruddock, 1957), A. M. Amineva, 1948], G. A. Orlova (1947). In 60 — the 70th thanks to A.S. Loginov's works, Yu. E. Berezova, P. X. Vasilyeva, J. Wittman, V. S. Savelyev a peritoneoskopiya was created as an independent diagnostic method.
Except survey of abdominal organs of P. includes a tool palpation, receiving material for bacterial., tsitol., gistol, and other researches. Along with transillumination (see), cholecystographies (see), holangiografiya (see), splenoportografiya (see) during P. can be executed various to lay down. manipulations: drainage of an abdominal cavity, removal of foreign bodys, imposing holetsito-, gastro-, ileo-and colostomy, electrothermic coagulation and bandaging of uterine tubes, catheterization and drainage of bilious ways, a puncture of cysts, including ovarian, a biopsy and a resection of ovaries, coagulation of a bleeding point, a perezhiganiye of commissures, a front metropexy, and also some other to lay down. manipulations and operations.
Results of survey of an abdominal cavity can be fixed on photo, a film.
The item allows to see and estimate the sizes, interposition of bodies, their color and a peristaltics, to find patol, changes: signs of an inflammation, growth of connecting fabric, existence of metastasises of a tumor, etc. Accuracy of laparoscopic diagnosis reaches 90 — 95%. It is known apprx. 200 various diseases at which the Item can be applied. It has the greatest value in diagnosis of diseases of a liver, malignant and benign tumors, in differential diagnosis of jaundices and ascites, and also at acute diseases of abdominal organs (acute pancreatitis, acute cholecystitis, peritonitis, etc.).
P. make at an ambiguity a wedge, the diagnosis; for the purpose of establishment of a form or a stage of a disease, and also carrying out differential diagnosis of diseases; in need of performance of medical actions with use of laparoscopic access.
Planned P. is made after preliminary clinical, laboratory and X-ray inspection and is the completing link of diagnosis. The patient is trained for a research in advance, carry out necessary correction of functions cardiovascular, respiratory and other systems. The possibility of complications and risk of intervention at planned P. are, as a rule, minimized.
The emergency P. is carried out at sharply developed pathology of abdominal organs, frequent at night when the doctor is limited in diagnostic aids, and laboratory researches not always help the differential diagnosis.
the General contraindications are a circulatory unefficiency in a stage of a decompensation: the expressed respiratory insufficiency; an idiopathic hypertensia of the III stage with hypertensive crises; decrease in coagulability of blood and hemophilia. Multiple hems and fistulas of a front abdominal wall, ventral hernias with tendency to infringement, the expressed abdominal distention, existence rykhlo the delimited abscesses of an abdominal cavity belong to local contraindications.
use special devices (laparoskop) with a fiber optics To P.'s carrying out. Diagnostic! laparoskop allows to examine only bodies. In the presence of the second trocar and tool kit through an additional puncture it is possible to make a palpation, a biopsy and other manipulations. Handling laparoskop represents an optical tube in which there is an additional special channel for introduction of the corresponding devices. Combined laparoskop it is completed with several internal plugs which change allows to make a biopsy, coagulation and other diagnostic and to lay down. manipulations. Enter laparoscopic set: a needle or a thin trocar for imposing of a pneumoperitoneum; a trocar for introduction of an optical tube; one or several optical tubes with a viewing angle 90 °, 135 °, 165 °, 180 °; a light source, it is possible to connect an electrode for performance of electrothermic coagulation to Krom; flexible light guides; manipulators; Janet's syringe and devices for filtering and administration of air; spare parts; devices for photofilming (special lighter of a photo and movie camera, adapters). The most important part of a laparoskop — the optical tube demanding especially care.
The equipment will be sterilized in vapors of formaldehyde or a paraform (dry formalin). Light guides of sterilization are not subject. During the research put on sterile covers made of cloth them.
Preparation for a research
Prior to a research of the patient it has to be examined by the endoscopist who estimates his general condition, and also a condition of a front abdominal wall, specifies the purpose and P.'s problems, carries out psychological training of the patient. Before P. the patient needs to shave an abdominal wall, to empty a bladder. On the eve of planned P. resolve an easy dinner or tea is better, do a cleansing enema, appoint sedative drugs.
A considerable part of planned and emergency P. can be made under local anesthesia. When plan performance of diagnostic or to lay down. manipulations, usually apply the general anesthesia, especially at children and excitable persons. The issue of a type of anesthesia is resolved together with the anesthesiologist, considering the volume of manipulations, and also probability of the subsequent operative measure, especially at acute surgical diseases of abdominal organs.
Technique of a research
P. carry out in the general or special laparoscopic operating room with observance of all rules of an asepsis and antiseptics. The research is carried out by the crew consisting of the endoscopist, the doctor assistant, the nurse helping at turning on of the device, administration of gas, manipulations, a postural change of the patient, and also instrument nurse and nurse. The endoscopist is located to the left of the patient who is stacked in situation on spin.
The first stage P. — imposing pneumoperitoneum (see). For this purpose the front abdominal wall is punktirut a special needle in the left ileal area or in a circle of a navel. Prevention of perforation by a needle of bodies is promoted by a pripodnimaniye of an abdominal wall for the ends of the purse-string stitch put around a navel at distance of 2 — 3 cm. After control of provision of a needle in an abdominal cavity (the movement by the end of a needle diversely, a nasasyvaniye into the syringe of contents, introduction of small amounts of novocaine or air) through a needle in an abdominal cavity from 2000 to 5000 cm enter 3 carbon dioxide gas, nitrous oxide, oxygen or air. Quality and safety of a research depend on the volume of the gas entered into an abdominal cavity. The sufficient pneumoperitoneum increases the sector of the review, does by safer manipulations. Excessive administration of gas reduces the vital capacity of lungs, causes disturbance funkts, conditions of cardiovascular system.
The second stage P. — a puncture of an abdominal wall a trocar (see. Laparocentesis ) and introduction of an optical tube. Depending on research problems the trocar is entered in one of points the Tracing-paper (fig). For survey of the upper floor of an abdominal cavity it is necessary to use a verkhnelevy point. At introduction of a trocar to a verkhnepravy point it is possible to injure a round ligament of a liver. It is more convenient to conduct a research of lower parts of an abdominal cavity from foots. In that case when typical points the Tracing-paper cannot be used, the trocar is entered, proceeding from research problems, taking into account a projection of large vessels of an abdominal wall and estimated unions.
In some models of a trocar there is a channel for additional administration of gas during the research. In that case it is optional to use a needle since the pneumoperitoneum can be imposed via this channel after introduction of a trocar.
The third stage P. — survey of an abdominal cavity. To examine an abdominal cavity, the tube of a laparoskop is advanced along a gleam of a trocar, then rotate optical system around a longitudinal axis. For the shift of an epiploon, a gut, removal of liquid, etc. during the research change position of the patient, use special manipulators.
Success of a research in many respects depends on methodicalness of survey of an abdominal cavity. Vittman recommends such sequence: 1) the right upper quadrant — survey of the right dome of a diaphragm, right hepatic lobe, a gall bladder, round and crescent sheaves; 2) the left upper quadrant — survey of round and crescent sheaves, the left dome of a diaphragm and left hepatic lobe, front wall of a stomach and spleen; 3) survey of a peritoneum of the left half of an abdominal cavity; 4) survey of a small pelvis and its bodies (uterus, appendages, bladder, sigmoid gut); 5) survey of a peritoneum of the right half of an abdominal cavity; 6) survey of a big epiploon, small and large intestine, worm-shaped shoot. Other order of a research can be accepted: in the beginning examine a verkhnepravy quadrant of a stomach, a liver, the right half of an abdominal cavity and small pelvis. Then verkhnelevy quadrant and left half of an abdominal cavity and small pelvis. In position of the patient on the right side there is more informative a survey of a spleen and the left half of an abdominal cavity; in situation on the left side the field of the review of a liver and the right half of an abdominal cavity increases. Fowler's position (sublime position of an upper body) improves survey of a phrenic surface of a liver, in the provision of Trendelenburga (see. Trendelenburga situation ) bodies of a small pelvis are visible.
P.'s informational content the palpation of bodies or educations by special manipulators increases, capture of liquid from an abdominal cavity for various researches, a biopsy of a liver, and also educations, suspicious by a tumor, tuberculosis etc. At acute diseases of abdominal organs great diagnostic value Has a research of peritoneal exudate on amylase, mikrobiol, and tsitol, its research, determination of quantity of leukocytes in it and erythrocytes. According to special indications can be osushchestvlen! laparoscopic holetsistokho l angiography, splenoportografiya. After these researches the abdominal cavity should be drained for control of completeness of a stop a zhelcheisteche-niya and bleedings. Upon termination of diagnostic or medical manipulations make control survey of an abdominal cavity, paying special attention to those departments where manipulations were made. Laparoskop delete, remove air through a trocar. After extraction of a trocar on a skin wound put one-two stitches. The drainages entered into an abdominal cavity surely fix seams to skin in order to avoid shift them. After the termination P. to the patient within a day appoint a bed rest, anesthetics, cold to a stomach.
Diagnosis at a peritoneoskopiya is based on knowledge of a normal picture of the examined bodies. The normal liver has brownish and chocolate coloring. A phrenic surface its smooth, brilliant, the edge is slightly rounded or acute (tsvetn. fig. 2, 3). The lower surface of a liver is examined, using the manipulator. The round ligament of a liver is presented in the form of the wide tyazh leaving an interlobar crack. The crescent sheaf has an appearance of light or slightly yellowish membrane with a small amount of small vessels. The gall bladder is visible only in the field of a bottom. The wall it depending on a degree of admission has white or bluish coloring. The spleen is visible only at uvelicheniichy the sizes; it has brownish and cherry color. Big curvature of a stomach and a part of its front wall are usually well visible (tsvetn. fig. 4). The wall of a stomach usually has whitish-pink coloring; small vessels are accurately visible, on big curvature there pass vessels of bigger diameter. A considerable part of a stomach and its small curvature in bigger or, smaller degree are closed by a liver. Loops of a small bowel are often covered with a big epiploon. That to examine them, it is necessary to shift an epiploon the manipulator (tsvetn. fig. 5). The small bowel normal has grayish coloring, sometimes it is possible to see its peristaltics. It is possible to see a large intestine in the ascending and descending departments; the wall has it grayish color (tsvetn. fig. 6); gaustra, teniya, fatty suspension brackets are well visible. The worm-shaped shoot is seldom visible completely. Only its basis is visible to a thicket. Survey of an intraperitoneal part of a rectum is in rare instances possible. The parietal peritoneum is presented in the form of a smooth clear film, through to-ruyu the network of pink capillaries is well visible.
In the analysis of a laparoscopic picture it is necessary to pay attention to the nature of changes of a parietal and visceral peritoneum (tsvetn. fig. 7, 8), quantity and type of ascitic liquid. For diagnosis of diseases of a liver its color («a big red liver», «a white liver», «a motley liver», «a green liver»), character of a surface, existence of hems («a hilly liver»), growths of connecting fabric matter (tsvetn. fig. 9). At metastasises of a malignant tumor in a liver the whitish nodes sprouting its capsule are visible. The laparoscopic diagnosis is confirmed by these biopsies (tsvetn. fig. 10). Point increase or its wrinkling, cicatricial changes of a wall, existence of unions, a tumoral conglomerate to pathology of a gall bladder. The diagnosis of portal hypertensia is based on identification of vasodilatation of an epiploon, round and crescent ligaments of a liver, stomach, gall bladder.
About pathology of a spleen judge by increase in its sizes, discoloration, existence of unions. At a carcinoma of the stomach it is possible to see the invaded zone of a wall a tumor, rigidity of a wall of a stomach at a tool palpation comes to light. At a peptic ulcer are visible deformation piloroantralny department of a stomach, an union with an epiploon and the next bodies. Pathology of intestines comes to light on infiltration by a tumor of a wall of a gut, to availability of inflammatory infiltrate at a disease Krone, to detection of small knots of a metastatic carcinoma or tubercular hillocks. The differential diagnosis of these diseases is quite often possible only at a biopeiya.
Acute inflammatory diseases of abdominal organs are shown by a hyperemia of a visceral and parietal peritoneum, availability of the inflammatory exudate having various color is frequent with impurity of bile and pus. Often there are fibrinous plaques on a peritoneum, fresh friable unions of an epiploon with bodies, with an abdominal wall. Dark color of a wall of hollow bodies demonstrates heavy disturbance of blood circulation in it. Detection of spots of a fatty necrosis allows to diagnose a pancreatonecrosis, and existence to a subsa different, hematomas or the streamed blood confirms the diagnosis of injury of abdominal organs.
P. — rather safe method of a research. Nevertheless, according to V. S. Savelyev (1977) with sotr., in 2 — 5% of researches various complications are observed. At the emergency P. made concerning acute pathology of a stomach including the combined injury, complications meet more often that is substantially connected with lack of time for adequate training of the patient. A considerable part of complications of P. arises during imposing of a pneumoperitoneum or introduction of a trocar. Among them various specific complications are emphysema of a big epiploon and hypodermic cellulose at hit in them a needle, mediastinal emphysema at an excessive pneumoperitoneum, bleeding from the damaged vessels of an abdominal wall and bodies, perforation of hollow bodies and peritonitis, an air embolism. Are possible also torsion of an epiploon around a laparoskop, infringement of fatty podvesk in an opening of a trocar, introduction of an optical tube to a parenchyma of a liver, loss of an epiploon after extraction of a trocar. The heaviest complications arise during the performance of laparoscopic manipulations. So, bleedings arise at a biopsy of a liver, a splenoportografiya, drainage of bilious ways. Development of these complications is promoted by existence of jaundice or portal hypertensia.
Emphysema of a big epiploon or hypodermic cellulose passes independently or after a symptomatic treatment. At damage of hollow or parenchymatous bodies the emergency operative measure is required. According to aggregated data of Berchi (G. Berci, 1976), the frequency of complications of P. which demanded a laparotomy makes 0,1 — 0,8%; the lethality at P. fluctuates from 0,029 to 0,18%.
Prevention of complications of P. consists in the correct accounting of indications and contraindications, objective assessment of risk of laparoscopic manipulations, accurate observance of rules of a research.
Peritoneoskopiya in gynecology
is made by Peritoneoskopiya in gynecology at introduction of the endoscope through a front abdominal wall or through a back vault of the vagina (Kuldoskopiya, a duglasoskopiya). Kuldoskopiya is technically simpler, it is reasonable to carry out it at a gross obesity and commissural process in an abdominal cavity. The laparoscopy gives more complete overview of bodies of a small pelvis, allows to carry out a biopsy and some other manipulations.
Indications: an illegibility of the female generative organs given to a palpation at suspicion of a tumor; need of specification of the diagnosis of sclerocystic ovaries, tube and ovarian infertility; not clear nature of anomalies of development of genitalias (lack of a uterus, a double or two-horned uterus), suspicion on an extrauterine pregnancy when by other methods to make the diagnosis it is impossible; need of clarification of the reason of pains in the field of a basin of not clear etiology. Contraindications the general for the Item.
Anesthesia can be as local, and the general. The local anesthesia, especially paracervical anesthesia, is more reasonable at a kuldoskopiya since the patient allows to keep necessary situation actively.
The item at ginekol, diseases it is the best of all to carry out when the patient is in situation Tren-delenburga that allows, using a special uterine tip, to displace a uterus or to enter into it colorant for definition of passability of uterine tubes. Serve as an injection site of a laparoskop a top and bottom Tracing-paper of a point. At a kuldoskopiya the patient shall be in genucubital situation. The endoscope enter into an abdominal cavity after preliminary back a colpotomy the Laparoscopy provides creation pneumoperitoneum (see), Kuldoskopiya of it does not demand since at genucubital situation the pneumoperitoneum is created spontaneously after a puncture of a wall of a vagina.
At a kuldoskopiya the back surface of a uterus and ovary is well visible, it is less accurate — uterine tubes; it is easy to find existence patol, an exudate. For the best orientation in an arrangement of generative organs of I. M. Gryaznov (1972) recommends to displace a uterus by means of the bullet nippers imposed on a back lip of a neck of uterus. At a laparoscopy survey is begun with bodies of a small pelvis. Examine a body of the womb, voronkotazovy and wide ligaments, isthmic departments of uterine tubes, upper parts of ovaries. Using the probe manipulator entered via the channel of a laparoskop examine uterine pryamokishechnoye space, sacrouterine sheaves, a medial pole of ovaries, uterine tubes.
Data of visual survey supplement with capture of smears from an abdominal cavity for mikrobiol, and tsitol, researches, and also a puncture or shchiptsovy biopsy.
At an extrauterine pregnancy one of departments of a pipe of cyanotic-crimson color, is thickened; at the interrupted pregnancy clots or dark liquid blood in a small basin are visible. At an apoplexy of an ovary dribble of blood from defect of a cover of an ovary is found.
The hydrosalpinx represents thin-walled formation of bluish color with moderately expressed vascular drawing. The pyosalpinx looks as retortoobrazno an expanded pipe of usual color or hyperemic with sub-serous hemorrhages; the ampullar end of a pipe is soldered.
At a salpingitis and a pelviperitonitis the uterus and uterine tubes are edematous, thickened, izvita, are hyperemic; from their fimbrialny ends muddy putreform contents arrive. The peritoneum of a small pelvis is hyperemic, with multiple petechias. In a small basin and lateral channels the exudate is defined. At a rupture of a tubo-ovarian tumor, pyosalpinx in a small basin dense slivkoobrazny pus, edematous infiltrirovanny fabrics without sharp separation of borders of a uterine tube and an ovary, imposing of fibrin on an epiploon, loops of intestines, a parietal peritoneum is visible.
At sclerocystic ovaries the dense white capsule, with a smoothed relief is found, follicles through the capsule do not appear through. At a tool palpation a consistence of ovaries cartilaginous. Tumors of ovaries have an appearance one - or multichamber thin-walled elastic educations with transparent contents and not expressed vascular drawing — cysts, serous cystomas (tsvetn. fig. 11) or look thick-walled with the whitish or bluish dense capsule (endometrioid cysts).
The hysteromyoma represents tumorous formation of bright pink color with more expressed vascularization, than not changed body of the womb. The hysteromyoma with disturbance of blood circulation has cyanotic-crimson color, multiple subserous hemorrhages (tsvetn. fig. 12).
The cancer tumor in a small basin presents a conglomerate in the form of a cauliflower of various color — from whitish to dark cherry — with sites of hemorrhages and involvement in process of nearby fabrics. Quite often there are papillary growths on a parietal peritoneum, an epiploon, a liver.
See also Endoscopy .
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B. P. Strekalovsky, Yu. P. Atanov; G. M. Savelyeva (gin.).