Aly M. Amin, MD

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 To study the findings obtained by diagnostic  laparoscopy in gynaecological problems in order to re-assess the role of  laparoscopy in the diagnosis of gynaecological problems during the  study period.

 A retrospective study for cases of  diagnostic laparoscopy that have been carried out in the Department of  Endoscopy and Microsurgery Unit of Al-Azhar University Hospitals, during  the period between January 1993 through December 1994. Laparoscopic  technique employed, in this study was performed under general  endotracheal intubation anaesthesia with controlled ventilation.

  Six hundred cases were included in this study.  The mean age was 28, 56 years ± 5.54 S.D.Of these,383 cases (64.77%) had  normal peritoneal and uterine findings. Pelvic adhesions were seen in  150 cases (25.17%). Uterine pathology were seen in 28 cases (4.69%) in  the form of uterine myoma 22 cases (3.69%) and pelvic tuberculosis was  suspected in 10 (1.68%) of cases. Periovarian adhesion was observed in  120 (20.13%) on right ovary, 142 (23.02%) on left ovary and 104 (17.44%)  on both ovaries. Polycystic ovaries observed in 48 (8.05%) of cases. In  244 (40.93%) of these patients there were normal findings on both  tubes, 352 (59.06%) normal findings were observed in the right tube and  338 (60.06%) normal findings were observed in the left tube. Ectopic  pregnancy was found in 16 patients (80%)     

, normal pelvic findings in one patient (5%) and 3 patients (15%) with pelvic inflammatory disease.

 laparoscopy is a reliable procedure which  improve diagnostic accuracy in pelvic disorders and can reveal  information which may make laparotomy unnecessary.


 
 Laparoscopy is one of the most gynaecological operative procedures  performed today and is being done with increasing frequency and safety 

.
 
 The introduction of a 2 mm laparoscope for diagnostic and minor  procedural work may represent a technologic advance. Before such system  are used widely, their diagnostic accuracy must be validated 

.
 
 In the past 5 years the emphasis shifted to major procedures being  performed laparoscopically with advantages for patient for a decrease in  hospitalization time and post-operative pain, and subsequently a faster  return to normal activity 


 
 	To study the findings obtained by diagnostic laparoscopy in  gynaecological problems in order to re-assess the role of laparoscopy in  the diagnosis of gynaecological problems during the study period.
 
 


 
 	This is a retrospective study for cases of diagnostic laparoscopy that  have been carried out in the Department of Endoscopy and Microsurgery  Unit of Al-Azhar University Hospitals, during the period between January  1993 through December 1994.
 
 Assessment of these patients was carried out carefully before starting  the endoscopic procedures. A full history was taken, this was followed  by thorough general, abdominal and pelvic examination.
 
 All infertile patients, in this study, underwent infertility work-up.  This included evaluation of ovulation, evaluation of tubal patency and evaluation of male factor. In  addition, in some patients, postcoital test was performed to evaluate  cervical factor.
 
 Laparoscopic technique employed, in this study was performed under  general endotracheal intubation anaesthesia with controlled ventilation. The patient was placed in a modified lithotomy position and then 15-20°  trendelenburg position was added. The patient was appropriately prepared  and draped. The bladder was catheterized, and a pelvic examination was  carried out. The uterine cannula was secured to the cervix by means of  single toothed tenaculum. After induction of proper pneumoperitoneum  laparoscopy was performed using an intra-umbilical entry. A multiple  puncture technique was employed. The peritoneal cavity including the  upper abdomen, was inspected, the pelvis then was inspected (fallopian  tubes, ovaries, uterus, peritoneal flimsy adhesions, and other  abnormalities).
 
 For infertile patients methylene blue dye solution was used for  laparoscopic hydrotubation, to the observation of tubal patency with  free spill of methylene blue in the peritoneum, then the instruments  were removed and pneumoperitoneum was deflated, and the umbilical  incision is closed with a 4-0 vicryl sutures opposing deep fascia and  skin dermis.
 
 


 
 Six hundred cases were included in this study. The mean age was 28, 56 years ± 5.54 S.D. (ranged from 18 to 43 years).
 
 

  showed the indications for diagnostic laparoscopy in 600 cases there  were 530 cases of infertility (88.3%), the cases of primary infertility  were 176 (29.3%) and secondary infertility were 354 (59.0%) of cases.  The acute abdomen was the second in Rank in the indications for  diagnostic laparoscopy it formed 32 (5.3%) of these cases, where  suspected ectopic cases were 12 (3.3%) and pelvic inflammatory diseases  cases were 12 (2.0%).
 
 Chronic pelvic pain cases were 18 (3.0%), missed IUD cases were 8  (1.33%) of this cases, primary amenorrhoea cases were 6 (1.0%) and in  this study laparoscopy was indicated for pre-operative evaluation of  patients with previous tubal sterilization were 6 (1.0%). Four cases  excluded because of failed pneumoperitoneum. So, these study really  included 596 cases.
 
 

  showed that 383 cases (64.77%) had normal peritoneal and uterine  findings. Pelvic adhesions were seen in 150 cases (25.17%). Uterine  pathology were seen in 28 cases (4.69%) in the form of uterine myoma 22  cases (3.69%) and pelvic tuberculosis was suspected in 10 (1.68%) of  cases.
 
 

  represents data concerning the ovarian pathology observed at  laparoscopy, in 294 (49.32%) of cases, there were no abnormalities on  both ovaries, in 344 (57.71%) of cases, there were no abnormalities on  right ovary and in 330 (56.71%) of cases, there were no abnormalities on  left ovary.
 
 Periovarian adhesion was observed in 120 (20.13%) on right ovary, 142  (23.02%) on left ovary and 104 (17.44%) on both ovaries. Polycystic  ovaries observed in 48 (8.05%) of cases. In 44 (7.38%) of cases the  right ovary was not seen. In 40 (8.05%) of cases the left ovary was not  seen and in 20 (3.35%) of cases both ovaries were not seen.
 
  	Right tubo-ovarian mass 

  was seen in 18 (3.02%) of cases, left tubo-ovarian mass was seen in  12(2.01%) of cases and bilateral tubo-ovarian masses were seen in 4  (0.67%) of cases. Right ovarian cyst 

 was seen in 16 (2.88%) of cases and left ovarian cyst 

  was seen in 6 (1.01%) of cases. Miliary nodules were seen in (1.01%) of  cases in the right ovary 4 (0.67%) of cases in the left ovary and 4  (0.67%) of cases in the both ovaries. Gonadal dysgenesis was observed in  4 (0.67%) of cases.
 
 

  represented data concerning the tubal pathology diagnosed by  laparoscopy. In 244 (40.93%) of these patients there were normal  findings on both tubes, 352 (59.06%) normal findings were observed in  the right tube and 338 (60.06%) normal findings were observed in the  left tube. In 112 (18.79%) of these patients there were peritubal  adhesions on right side, 120 (20.13%) of these patients there were left  peritubal adhesions and 74 (12.75%) of these patients there were  peritubal adhesions on both side. In 44 (7.38%) of these patients there  were right fimbrial block, 74 (12.41%) of them there were left fimbrial  block and bilateral fimbrial block were observed in 16 (2.68%) of cases.  In 64 (10.37%) of these patients there were right cornual block, 54  (9.06%) of these patients there were left cornual block and 22 (3.69%)  of these patient there were bilateral cornual block. In 32 (5.36%) of  these patients there were right hydrosalpinx, 30 (5.03%) of these  patients there were left hydrosalpinx (

)  and bilateral hydrosalpinx were observed in 10 (1.67%) of cases. In 18  (3.02%) of these patients there were right tubo-ovarian mass, 12 (2.01%)  of these patient there were left tubo-ovarian mass and bilateral  tubo-ovarian masses were observed in 4 (0.67%) of cases.

Picture of tuberculosis was seen in 12 (2.01%) of these patients in  the form of miliary nodules on right tube, 6 (1.01%) of these patients  on left tube and 6 (1.01%) on both tubes. In 10 (1.67%) of these  patients there were right tubal pregnancy and 6 (1.01%) of these  patients there were left tubal pregnancy. In 36 (6.04%) of these  patients there were the right tube not seen and in 26 (4.86%) of these  patients there were the left tube not seen.
 
 Regarding the tubal patency in 526 cases of infertility, examined by  laparoscopy,in 352 (66.92%) of these cases there were positive  hydrotubation test in right tube, 358 (68.06%) of these cases positive  hydrotubation test in left tube and bilateral tubal patency were  observed in 244 (46.38%) of cases.
 
 Regarding the degree of pelvic adhesion in 185 cases with pelvic adhesions 

.In  105 (56.75%) of these cases there were mild pelvic adhesion, 54  (29.10%) with moderate pelvic adhesions and severe pelvic adhesions in  26 (14.05%) of these cases.
 
 In 108 cases with previous laparotomy included in the study,80 (74.07%)  had prior pfannenstiel incisions and 28 (25.93%) had prior midline  incisions.
 
 Adhesions to omentum and bowel were found in 18 women (22.5%) in the  pfannenstiel group, 16 women (57.14%) in the midline incision. Twenty patients with clinical picture compatible with ectopic pregnancy  were examined. Ectopic pregnancy was found in 16 patients (80%) 

,  normal pelvic findings in one patient (5%) and 3 patients (15%) with  pelvic inflammatory disease. adhesions to omentum and bowel were found in 18 women (22.5%) in the  pfannenstiel group, 16 women (57.14%) in the midline incision.


 
 	Since the 1960 when safe techniques for induction of pneumoperitoneum  were developed and fiber-optic system for light transmission become  available, laparoscopy has gained widespread popularity in gynaecologic  practice, it has been used to diagnose unknown problems, to follow the  course of a known disease and to modify therapy. Furthermore, some  surgical procedures such as biopsy, lysis of adhesion, and tubal  sterilization have been performed through laparoscopy. So, the  laparoscopy achieved widespread use as a valuable diagnostic aid in  gynaecology 

.
 
 In this retrospective study, laparoscopy was done in 176 (29.3%) of  patients with primary infertility and 347 (59.0%) of patients with  secondary infertility. On the other hand the indication for laparoscopic  examination given by Chang et al., (1989)

, represents 37.8% of the studied cases for primary  infertility and represents 33.0% of the studied cases for secondary  infertility as the indication for laparoscopy.
 
 Laparoscopy is also discovers unsuspected pelvis pathology especially pelvic adhesions 

. Laparoscopy is superior in evaluation of proximal tubal obstruction, pelvic adhesions and endometriosis 

. In the current study, the pelvic adhesions were found in  35.23% of studied cases. This is noticeably less than the 50% given by  Chang et al., (1987)

, and similar to the results of Musich and Behrman (1982

, who found that 35% of patients had pelvic adhesions.
 
 Laparoscopy is an essential step prior to any tubal surgery as it may  not only preclude the unnecessary operation but may also provide  essential information regarding the nature and extend of future surgery 

.With regarding the tubal patency test done during  laparoscopy, the test was positive in 66.92% of studied cases in the  right tube, 60.06% in the left tube, and 46.06% of studied cases with  bilateral tubal patency.
 
 This is less than the result of Adelusi et al., (1995)

,  who found that, 52% of the patients with both tubes patent, 89.0% of the  patients with right tube patent and 85% of the patients with left tube  patent, and also less than the result given by Saliman et al., (1995)

, who found that tubal patency in 71.0% of his  patients who reported. The magnification offered by the laparoscope may  also aid in the diagnosis of endometriosis use of laparoscope has  dramatically increased over the last couple of decades 

.
 
 Pelvic endometriosis was present in 3.69% of studied cases. This is higher than the results given by Adelusi et a;., (1995)

, who reported, the presence of pelvic  endometriosis in 1.9% of patients, and slightly higher than the result  given by Chang et al., (1987)

, who reported, the presence of pelvic endometriosis in 2.1%. and less than the results given by Peterson and Behrman (1970)

.Most ovarian abnormalities can be managed  laparoscopically and often a laparoscopic examination of the adnexae  will enable the gynaecologist to decide if laparotomy is indicated 

.
 
 In the current study, the incidence of polycystic ovarian disease was  8.05%, which is noticeable slightly higher than the result of Adelusi et  al., in 1995

, they found the incidence of polycystic ovarian  disease as 6.7% in their series. In this study the incidence of ovarian  cyst was 3.89% of the patients. This is less than the result of Adelusi  and co-workers 

, where they found that 7.7% of their patients have had ovarian cyst.
 
 The incidence of post-operative intra-abdominal adhesions has been  examined previously in several studies, in the present study 108  patients with previous laparotomy has been examined for the presence of  intra-abdominal adhesion. The incidence of adhesion to the bowel and  omentum were more likely to occur after a midline incision 57.14% of  patients, in patients with previous pfannenstiel incision we noted 22.5%  of patients with bowel and omentum adhesions.
 
 Brill et al., (1995)

, studied a group of 360 patients for  the presence of intra-abdominal adhesions after abdominal surgery  during a variety of laparoscopic procedures; and found adhesions to  bowel and omentum in 70 women, 27 & in pfannenstiel group, 48 women, 55% in the midline below the  umbilicus group, and 10 women 67% in the midline above the umbilicus  group.
 
 Nezhat and Nezhat (1990)

, stated that at laparoscopy, the  location, the size and the nature of the tubal pregnancy are  ascertained, ruptured tubal pregnancies can be treated successfully  endoscopically if the bleeding has ceased or can be arrested adequately,  laparoscopy is valuable for establishing a definite diagnosis in  clinically suspected ectopic pregnancy and preventing the unnecessary  surgery which carries an increased morbidity.
 
 In this study laparotomy was avoided in 20% of patients with clinically  suspected ectopic pregnancy and in 10% of patients early diagnosis and  treatment of unruptured ectopic pregnancy prevented the catastrophic  bleeding seen after rupture. 
 
 Chang et al., (1987)

, reported the laparotomy was avoided  in 32.4% of patients with clinically suspected ectopic and in 42.6% of  patients early diagnosis and treatment of unruptured ectopic pregnancy  settled down and obviously these results are much higher than the  results of the current study because number of patients were much more  than our patients and the frequency of using the laparoscopy for the  diagnosis of clinically suspected ectopic pregnancy cases are more than  other diagnostic tools.
 
 The pre-operative evaluation to determine the feasibility of reversing  previous tubal sterilization procedures has been gradually increased. In  this study laparoscopy was indicated for pre-operative evaluation of  patients with previous tubal sterilization was done in 1% of patients,  which is less by far than the cases done by Chang et al., (1987) who has  had 30% of his cases underwent pre-operative laparoscopic evaluation  prior to tubal reverse of sterilization.

In conclusion: laparoscopy is a reliable procedure which improve  diagnostic accuracy in pelvic disorders and can reveal information which  may make laparotomy unnecessary .On the other hand will decrease any  diagnostic pitfalls before any decision about surgical therapy.

Articles

Objective: To study the findings obtained by diagnostic laparoscopy in gynaecological problems in order to re-assess the role of laparoscopy in the diagnosis of gynaecological problems during the study period.

Author | Aly M. Amin, MD

Articles

Diagnostic Laparoscopy in Gynaecological Problems: A Retrospective Study