00:00hello friends this is a case of diagnostic laparoscopy with hysteroscopy for infertility
00:08this is a person 36 year old and she has primary infertility although all the hormonal and every
00:18all the medical things are fine so we will do diagnostic laparoscopy tubal potency test and
00:24hysteroscopy to see what is the cause of infertility so let us go inside the operation theater first we
00:31will see how to do access you should take two elise forceps which should be applied on either
00:39side of the crease of the umbilicus one small stab wound will be given over the inferior crease of
00:46umbilicus with 11 number of knife then the 14 or 12 centimeter various needle will be taken
00:57and that various needle you should put it over the incision side and lift the abdominal wall
01:03it should be lifted not near the various needle it is near the pubic symphysis and perpendicular to the
01:11abdominal wall you will introduce the various needle so that various needle should go towards the
01:16illness after that this is irrigation test fluid is going freely in then suction test nothing is
01:30coming out and then you will do hanging drop test that is it will be sucked in that hanging drop because
01:37of negative pressure inside the abdominal cavity after that we will attach the tubing of the insufflator
01:45pressure and pneumo plutonium will be started initial preset pressure is 15 slowly we can see actual
01:56pressure is increasing and pneumo plutonium is created you will wait till the actual pressure reach to the
02:05preset pressure right now actual pressure is 9 and flow rate after 1 liter you can increase to 3 also
02:13initially up to 1 liter of pneumo plutonium flow rate should be 1 liter per minute but once the 1 liter of
02:20gas has gone in then flow rate can be increased to 3 liter per minute and now actual pressure is 13
02:28the pressure pressure is already 15 and slowly actual pressure is reaching to the 15 and now the insufflation is
02:36over after that you should take the various needle out and enlarge the incision to 11 mm
02:47this initial 12 millimeter the 2 millimeter incision will be enlarged to 11 mm and this is now trocar will be
02:58introduced keeping it perpendicular to the abdominal wall and slowly it is entered in then we will introduce
03:08the various needle
03:12this is a telescope attach the tubing of the insufflator and then telescope will be introduced
03:20then we will use the second report patient head is going 30 degree down
03:24and head is down 30 degree that is a steep tendon bone position so that all the bobble will move up
03:32and now the secondary port is in the mcbarnie left mcbarnie point that is in between the anterior superior
03:38elic spine and umbilicus so that inferior epigastic vessel will not come in your way and you can easily
03:46introduce it and that's all for diagnostic only you need these two port some people they use suprapubic
03:54here it is according baseball if you will make a shape of a diamond with your hand then thumb is over
04:01them like us index finger over the target and this is the snuff box where you will put the port
04:08now atraumatic grasper will be introduced and diagnostic laparoscopy will start here we can see
04:14it is very nicely looking normal looking uterus and all the bobble will be lifted up lifting the
04:23bobble will show you sacral pulmonary this is the sacral pulmonary is visible here is ureter
04:29this is internal iliac this is sigmoid colon and all the structures are fine peristalsis of ureter can
04:37be appreciated and below the ureter this is internal iliac
04:40and some fluid is in the cul-de-sac which we will collect later
04:45for the histopathology and for the culture and sensitivity so these structures are visualized
04:53after that this is the peristalsis of ureter you will see within few seconds here here it is going to
05:00start and this is the peristalsis of the ureter this is internal iliac
05:06now all the structures are fine tube fimbria is visible this is triangle of doom where iliac vessels
05:13are there this is triangle of doom where the apex is deepening medially round ligament laterally
05:20samsung's artery then this is triangle of pain here you have the gfn and lfcn two nerves are visible
05:28this is gfn and lfcn through the peritoneal transparent peritoneum you can appreciate the nerves here is the
05:36cecum and ilium and there is a retrocecal buried sub serous appendix but it's okay this is the type
05:45of appendix our main concern is here the infertility
05:55so we can see this is the appendix which is visible and it is sub serous and you can find it
06:02out this is cecum this is ascending colon this is gallbladder here is the lever which is visible nicely
06:11so you have to do diagnostic laparoscopy as a clockwise fashion and you should go this is
06:18the right hypochondrium this is falsiform ligament and then you cross and this is the left lobe of the
06:26liver and here is the stomach this is the splenic flexor of colon transverse colon stomach and all
06:34these are normal pulsation of the diaphragm that is transmitted pulsation this is sigma ad colon
06:42fallopian tube ovary iliac vessel and utero sacral ligament and these all structures are visible
06:50so all these structures will be identified in a clockwise fashion and now this is ip
06:55ligament of left side you can lift it up and then you can see the ureter of the left side
07:02that will be nicely visible you can see the peristalsis and you can wait for this peristalsis
07:08this is sigmoid left ureter uterus cul-de-sac here the uterine hump this is little fluid in the cul-de-sac
07:16and this is utero cycle ligament here is the sigmoid and this is the this is the small intestine
07:25and here is the rectum now this fluid in the cul-de-sac if it is present and this is left
07:31tube this is ovary this is right tube this is bulky ovary there is a polycystic appearance of this patient
07:40so we are planning that we will do the ovary and drilling as well although there is a in ultrasound it
07:49was showing so this is ovary and drilling you can just go and you can drill it out
07:57these are the follicles
07:58and it can be punctured four to eight drill is required
08:17fimbria should be taken care of that fimbria should not touch the
08:22this this pc od needle because pc od needle can injure the tube so it is blunt and it is syringe like
08:33that pc od needle tip is blunt and when you will press a button then only needle comes out
08:40so generally four poles should be punctured 40 watt current should be used
08:44four seconds you should keep it and it's a four month for any effect to be visible
08:57so this is punctured now going to the left side again the four pole will be punctured on the left side
09:06so pc od needle has a good thing that it doesn't damage the surrounding structure because by default by a
09:17spring mechanism the needle is always inside the this tube and this is insulated tube once you will press
09:26it then only needle comes out and get activated so it is very safe and this is over
09:33so both the side the puncture of the ovarian cyst was done and now this is little fluid collected from
09:44the cul-de-sac for pcr examination or culture or sensitivity or any other purpose which you are
09:53thinking about that is fnse or any other examination now this is hysteroscopy
09:59as we can see this is entering into the cavity and now you will turn the telescope and you will turn
10:07it to see the ostia here we can see this is the left ostia your right is percent left in hysteroscopy
10:17so this is very good patent left ostia and it is nicely visible and the fluid escape is also visible
10:26after that 30 degree telescope you will turn and this is right ostia so both the ostias are fine that means
10:34there is no any space occupying lesion inside the cavity anterior wall posterior wall everything is okay
10:44good patent ostia looks like normal and you will visualize it and not only that at the same time
10:53you should try to capture the image in the second camera so you can give to the patient also
11:00so you will look for patient obviously should be post menstrual period for the diagnostic laparoscopy and
11:09hysteroscopy so that you will not have a problem of these this proliferative endoth endo material layers
11:21otherwise these proliferative phase endo material flakes will be disturbing you and it will be difficult
11:28to visualize so this ostia is nicely visible then again telescope is withdrawn out and then you will check
11:35the fundus and again you can check the posterior wall this is posterior wall this is again left ostia
11:46few frimsy additions are there near the ostial opening but that is okay you should not try to traumatize it
11:54otherwise adhesion may be more our purpose is you just to examine the endo material cavity and here it
12:02is everything is fine this is the fundus this is the posterior wall there is no any myoma or polyp in the
12:10posterior wall of uterus so you will carefully inspect every centimeter of the uterine cavity
12:17and after that similarly you can go to the fundus and then similarly you can examine the anterior wall
12:25so diagnostic hysteroscopy is always necessary when you are doing the diagnostic laparoscopy for infertility
12:34because if you were you will do both together then you can rule out almost all the uterine and tubal
12:42causes of infertility so now this is the fundus this is anterior wall anterior wall also look nice there is
12:49no any pathology over the anterior wall and here will be the internal loss region and absolutely fine
12:57normal anatomy is there then slowly you can try to withdraw the hysteroscope into the cervix again
13:05and seeing the cervical canal you will come out so this is final inspection in the panoramic view
13:22where right and left both the ostias are together visible at the level of internal loss and now it is
13:28coming out so this is the hysteroscopy is complete after that again we will go for laparoscopic
13:35view and we can see a lot of fluid inside what is this fluid oh this is good news this is the fluid which
13:42was hysteroscopic fluid has leaked from the fimbria and you should suck it immediately and then you
13:49should irrigate and suck again because these hysteroscopic fluid can bring some infection so
13:56better is to clean couple of time the pelvis and after that you will do the tubal potency test
14:03methylene blue test dye test so that is important to rule out the any of the tubal block s so hsg cannula
14:13will be connected to the this cervix and the methylene blue dye will be injected and you will inspect
14:21carefully that this dye should must come out through the fimbria this is anterior cul-de-sac posterior
14:27cul-de-sac everywhere washed out and now we are waiting for this is the movement of uterus which
14:34you can see is due to fixing the hsg cannula and here this is the this is the fimbria and we can see
14:41dye is coming and it is good this is the blue colored methylene blue showing patent tube and after
14:49that again you will inspect the another tube fimbria suction irrigation is a good instrument avoid holding by
14:56the graspers because it can create a structure so now again we will inspect and here again methylene
15:04blue should and it's coming very good so methylene blue is showing that both the tubes are patent
15:10and some methylene blue which has gone into the pelvis you should suck it out you should not leave it in
15:18and little irrigation and again cleaning of that pelvic cavity will be carried out so this way you can
15:26complete the diagnostic laparoscopy and hysteroscopy with the dye test and here in this patient our
15:33finding is that everything was normal except little pcod there was no any pathology and everything was
15:42normal in the this patient so we will do this diagnosis and after that you will come out so thank
15:50you very much for watching this video have a nice day god bless you
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