Video Description
Transvaginal hydro-laparoscopy is a minimally invasive technique that allows direct visual examination of the pelvic structures through the vaginal wall of the posterior fornix as opposed to going through the abdominal wall during the traditional laparoscopy.
Insertion of the hydro-laparoscopy trocar is accomplished through a puncture done under sedation passing through the vaginal wall posteriorly and directly into the cul-de-sac. Approximately, 200-300 cc of normal saline are used to facilitate navigation between pelvic structures allowing excellent, close-up visualization of the pelvic organs and peritoneal surfaces including the posterior wall of the uterus, fallopian tubes, ovaries, pelvic sidewalls and the cul-de-sac. Fimbrioscopy is also feasible assessing the mucosal folds of the distal tube.
The operative capabilities of that approach are limited to simple lysis of adhesions, ovarian drilling and ablation of surface endometriosis. There is also promising potential to collect cytology samples from ovarian surfaces and from the distal tubal mucosa which can be of interest to oncologists aiming to offer screening for early diagnosis of epithelial ovarian tumours.
The video illustrates the examination of the reproductive system during TVHL. It captures the appearance and orientation of pelvic structures when entering the pelvis from a direction opposite to what gynecologists are accustomed to during traditional laparoscopy.
Presented By
Affiliations
Astra Fertility Group, William Osler Health System – Etobicoke General Hospital
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Video Transcript: Transvaginal Hydro-Laparoscopy (TVHL). A Simple Minimally Invasive Tool for the Contemporary Gynaecologist
With the patient sedated and after inserting the trocar through the vaginal wall posteriorly into the cul-de-sac, your first landmark is a posterior wall of the uterus which is revealed in the upper half of the screen. Normal saline is used to navigate the thirty-degree 2.9 millimetre hysteroscope through the pelvic structures.
In this case, we started by surveying the right-hand side, looking at the right tube and ovary with special attention to the ovarian fossa, the ovarian surfaces and the fimbriated end of the fallopian tube. During our survey, peritubal and periovarian adhesions were encountered. You can observe the different vascular patterns of the fallopian tube compared to that of the small bowel. One can also perform a fimbrioscopy by going through the distal tube and observing the health of the tubal mucosa.
You can now see the Methylene blue dye coming through when injected transcervically at the same time. You can also see the Methylene blue dye that had come from the left fallopian tube, confirming tubal patency bilaterally. Here you can see the pelvic side wall with the uterine artery and uterocene transperitoneal.
To complete the survey of the pelvis, one has to come down and examine the peritoneal surfaces of the cul-de-sac and perirectal areas. As is evident in the clip, you can see superficial endometriotic implants in the left perirectal area extending to the pelvic side wall.
It is important to note the different orientations are approaching the pelvis from below, in the opposite direction compared to conventional laparoscopy. The examination should always be done in a systematic way, starting at the midline, identifying the posterior surface of the uterus, moving towards the right side, following the right tube and ovary all along, repeating the same on the left-hand side, and looking at the pelvic side walls. And finally, looking at the perirectal area and cul-de-sac.
Limited operative intervention is also possible by dividing adhesions or ablating surface endometriosis. This is not shown in this video. At the end of the procedure, the scope is withdrawn, the pelvic fluid is drained, and the patient is sent to recovery shortly thereafter.