OBG518 — Gynaecological Endoscopy: Lecture Note

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This is the complete lecture note for OBG518 Gynaecological Endoscopy. You can read it online below, open it in the full viewer, or download the PDF for offline study. It pairs with the course's video lectures, so you can read and watch together.

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la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Course code: OBG 518 Course title: Gynaecological Endoscopy Course credit load: 2 Units Series 1: Indications for Laparoscopy • Part 1.1: Overview of Diagnostic and Operative Laparoscopy o Sub Part 1.1.1: Principles and equipment of laparoscopy o Sub Part 1.1.2: Diagnostic versus operative laparoscopy o Sub Part 1.1.3: Patient selection and contraindications • Part 1.2: Laparoscopy in Infertility and Pelvic Pain o Sub Part 1.2.1: Laparoscopy in the infertility workup o Sub Part 1.2.2: Laparoscopy in chronic pelvic pain o Sub Part 1.2.3: Laparoscopy in suspected endometriosis • Part 1.3: Laparoscopy in Acute Gynaecological Conditions o Sub Part 1.3.1: Laparoscopy in suspected ectopic pregnancy o Sub Part 1.3.2: Laparoscopy in ovarian cyst accidents o Sub Part 1.3.3: Laparoscopy in suspected pelvic inflammatory disease • Part 1.4: Laparoscopy in Adnexal Mass Evaluation and Sterilisation o Sub Part 1.4.1: Laparoscopy in adnexal mass evaluation o Sub Part 1.4.2: Laparoscopic tubal sterilisation o Sub Part 1.4.3: Second-look laparoscopy and oncological staging Introduction A young woman presents with six months of pelvic pain and difficulty conceiving, and despite a normal pelvic ultrasound, her symptoms persist. Rather than continuing to guess at a diagnosis from the outside, her gynaecologist proposes laparoscopy, a procedure that allows the pelvis to be seen directly, often revealing endometriosis, adhesions, or other pathology invisible to imaging. This ability to look inside the abdomen and pelvis through a small incision, with minimal disruption to the patient, has transformed gynaecological practice over the past several decades.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Gynaecological endoscopy, encompassing laparoscopy, hysteroscopy, and colposcopy, now underpins a very wide range of diagnostic and therapeutic gynaecological care, from the investigation of infertility and chronic pelvic pain to the management of acute abdominal emergencies and gynaecological malignancy. Understanding when each technique is indicated, and the specific value it adds over other investigations, is fundamental to modern gynaecological training. This Series introduces laparoscopy, covering its principles and equipment, the distinction between diagnostic and operative laparoscopy, and its indications across infertility and pelvic pain, acute gynaecological conditions, and adnexal mass evaluation, sterilisation, and oncological staging. Series Learning Outcomes At the end of this Series, you should be able to: • SLO 1.1: describe the principles and equipment used in laparoscopy, • SLO 1.2: distinguish diagnostic from operative laparoscopy, • SLO 1.3: describe patient selection and contraindications for laparoscopy, • SLO 1.4: list the indications for laparoscopy in infertility and chronic pelvic pain, • SLO 1.5: describe the role of laparoscopy in suspected endometriosis, • SLO 1.6: list the indications for laparoscopy in acute gynaecological conditions, • SLO 1.7: describe the role of laparoscopy in adnexal mass evaluation and sterilisation, and • SLO 1.8: describe the role of laparoscopy in oncological staging. Part 1.1: Overview of Diagnostic and Operative Laparoscopy 1.1.1 Principles and equipment of laparoscopy Laparoscopy involves introducing a rigid telescope, or laparoscope, connected to a camera and light source, into the abdominal cavity through a small umbilical incision, after first creating a working space by insufflating the abdomen with carbon dioxide gas using a Veress needle or direct entry technique, allowing direct visualisation of the pelvic and abdominal organs on a monitor. Additional accessory ports, generally two or three, are placed in the lower abdomen under direct vision to introduce instruments such as graspers, scissors, and diathermy or energy devices for

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS dissection and haemostasis, with the number and position of ports tailored to the complexity of the planned procedure and the surgeon's preferred approach. Fill in the blank: Laparoscopy requires insufflation of the abdomen with ________ gas before telescope insertion. A ________ needle or direct entry technique is used to establish the initial working space. 1.1.2 Diagnostic versus operative laparoscopy Diagnostic laparoscopy is performed purely to visualise and assess the pelvic and abdominal organs, confirming or excluding suspected pathology such as endometriosis, adhesions, or tubal disease, without any therapeutic intervention beyond the diagnostic assessment itself, and is often the definitive step when non-invasive investigations have failed to establish a clear diagnosis. Operative laparoscopy extends this same access to perform therapeutic procedures, including adhesiolysis, cystectomy, myomectomy, tubal surgery, and hysterectomy, converting what began as a purely diagnostic procedure into a treatment in the same setting wherever the findings and the patient's prior consent make this appropriate. Fill in the blank: Diagnostic laparoscopy confirms or excludes pathology without any ________ intervention. Operative laparoscopy can extend to procedures such as adhesiolysis, cystectomy, and ________. 1.1.3 Patient selection and contraindications Careful patient selection requires assessment of fitness for general anaesthesia, since laparoscopy is generally performed under general anaesthetic, and consideration of factors that may complicate safe abdominal entry or pneumoperitoneum, including significant obesity, extensive previous abdominal surgery with likely adhesions, and large abdominal masses. Absolute contraindications include haemodynamic instability, severe cardiorespiratory disease unable to tolerate pneumoperitoneum, and bowel obstruction, while relative contraindications, such as advanced pregnancy or extensive prior surgery, require individualised judgement weighing the benefits of laparoscopy against the increased technical risk in each specific case. Fill in the blank: Laparoscopy is generally performed under ________ anaesthesia. Haemodynamic instability and severe cardiorespiratory disease are ________ contraindications to laparoscopy.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Figure 1.1: Basic laparoscopic set-up showing telescope, camera, and port placement. Pilot questions 1.1 1. Describe the equipment and steps involved in establishing laparoscopic access. (Linked to SLO 1.1) 2. Describe the purpose and placement of accessory ports during laparoscopy. (Linked to SLO 1.1) 3. Distinguish diagnostic from operative laparoscopy with examples of each. (Linked to SLO 1.2) 4. Describe the factors considered in patient selection for laparoscopy. (Linked to SLO 1.3) 5. List the absolute and relative contraindications to laparoscopy. (Linked to SLO 1.3) Part 1.2: Laparoscopy in Infertility and Pelvic Pain 1.2.1 Laparoscopy in the infertility workup Laparoscopy, often combined with a dye test through the cervix, allows direct assessment of tubal patency and pelvic anatomy in the infertility workup, identifying tubal occlusion, peritubal adhesions, or endometriosis that may not be visible on hysterosalpingography or

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS pelvic ultrasound, and is generally reserved for women with an abnormal or equivocal initial investigation, or specific risk factors for pelvic pathology. Where pathology is identified during diagnostic laparoscopy for infertility, operative correction, such as adhesiolysis or excision of endometriotic deposits, can often be performed in the same procedure, potentially improving natural conception rates and, in some cases, avoiding or delaying the need for assisted reproductive technology. Fill in the blank: Laparoscopy combined with a ________ test assesses tubal patency during the infertility workup. Operative correction such as adhesiolysis can often be performed in the ________ procedure as diagnosis. 1.2.2 Laparoscopy in chronic pelvic pain Chronic pelvic pain, defined as pain persisting for six months or more, is a common and often frustrating presentation, and laparoscopy is indicated when initial history, examination, and imaging fail to identify a clear cause, or when specific findings, such as suspected endometriosis or pelvic adhesions, are strongly suspected clinically. Laparoscopy in chronic pelvic pain serves both diagnostic and, where appropriate, therapeutic purposes, allowing biopsy or excision of suspected endometriotic lesions, division of adhesions, and, importantly, providing reassurance to the patient where no significant pathology is found, which itself carries genuine value in the overall management of chronic pain. Fill in the blank: Chronic pelvic pain is defined as pain persisting for ________ months or more. Laparoscopy can provide diagnostic ________ to the patient where no significant pathology is found. 1.2.3 Laparoscopy in suspected endometriosis Laparoscopy remains the gold standard for diagnosing endometriosis, allowing direct visualisation of characteristic peritoneal implants, endometriomas, and deep infiltrating disease, with histological confirmation obtained through biopsy of visualised lesions, since the appearance alone, while often characteristic, is not always definitive. Beyond diagnosis, laparoscopy allows staging of endometriosis severity and, in the same setting, excision or ablation of visualised disease, meaning a single procedure frequently combines definitive diagnosis with meaningful therapeutic benefit for women whose symptoms have often been present, and sometimes dismissed, for a considerable period before referral. Fill in the blank: Laparoscopy remains the ________ standard for diagnosing endometriosis. Histological confirmation of endometriosis is obtained through ________ of visualised lesions.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Indication Role Endometriosis Diagnosis, staging, and excision/ablation of lesions to improve fertility and relieve pain Tubal factor infertility Assessment of tubal patency, adhesiolysis, and correction of tubal pathology Pelvic adhesions Identification and adhesiolysis to restore pelvic anatomy and reduce pain Ovarian cysts Cystectomy or drainage to improve ovarian function and relieve pain Unexplained infertility Diagnostic laparoscopy to detect subtle pelvic pathology not seen on imaging Chronic pelvic pain Direct visualization to identify causes (endometriosis, adhesions, PID) and provide therapeutic intervention Suspected pelvic inflammatory disease sequelae Evaluation of tubal damage,

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