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Diagnostic Laparoscopy
https://t.me/med1917
andDye Test
AmosA.Akinbiyi, JudeEhiabhiOkohue,
andIkechukwuI.Mbachu
1 Introduction
The aim of this chapter is to describe the benets
of diagnostic laparoscopic procedures in relation
to methylene blue dye insufation as an investigative tool for infertile patients. The role of laparoscopy in the evaluation of infertility might be
considered controversial, especially due to availability and local prevalent pelvic causatives of
infertility. Hysterosalpingography (HSG) is still
considered the rst-line diagnostic modality in
the evaluation of tubal factor infertility.
Undoubtedly, laparoscopy is invasive and
expensive, while at the same time local training
skills may be a limiting factor in developing
countries. Rich nations of the developed world
are hampered also by cost to some extent and
thereby do not feel that it is justied for laparos-
A. A. Akinbiyi (*)
Department of Obstetrics and Gynaecology,
Reproductive Endocrinology and Infertility,
University of Saskatchewan, Regina, SK, Canada
e-mail: akinbiyi@sasktel.net
J. E. Okohue
Assisted Reproduction Unit, Department of
Obstetrics and Gynaecology, Gynescope Specialist
Hospital and Madonna University, Port Harcourt,
Rivers State, Nigeria
I. I. Mbachu
Department of Obstetrics and Gynaecology, Nnamdi
Azikiwe University, Awka, Anambra State, Nigeria
copy to be used as an initial investigative tool.
Another argument is that the ndings at laparoscopy usually do not alter the initial treatment of
the infertile couple when the initial infertility
evaluation is normal or when it shows severe
male factor infertility.
A perspective that favours laparoscopy and
dye test as an initial investigative tool especially
in afuent countries is that endometriosis may be
present in up to 50% of women who present with
a complaint of infertility [1]. The clinician must
therefore decide when women who present for
the evaluation of infertility undergo surgical
exploration for endometriosis and other pathology as part of their workup. Since the advent of
articial reproductive technology, it should be
stated that nding endometriosis and treatment
do not usually lead to improved pregnancy outcomes [2–4].
Laparoscopy may be indicated in women in
whom endometriosis or pelvic adhesions/tubal
disease is suspected based on physical examination, HSG or history (e.g. current dysmenorrhea,
pelvic pain, or deep dyspareunia; previous complicated appendicitis, pelvic infection, pelvic surgery or ectopic pregnancy). When we perform
laparoscopy, we also perform methylene blue dye
test to assess tubal patency and sometimes hysteroscopy to evaluate the uterine cavity. For these
reasons, if laparoscopy is already planned, then
HSG can be omitted [4–7].
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_12
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A. A. Akinbiyi et al.
2 Preoperative Procedures
2.1 Informed Consent
Informed consent must be obtained from the
patient after the details of the procedure have
been explained to his/her either in the ofce setting or in the hospital visit, prior to the surgical
procedure. This must include alternative procedures such as a hysterosalpingogram or hysteroscopy if it has not been done prior to the ofce
appointment. In some centres in the developed
world, ofce hysteroscopy is performed under
intravenous conscious sedation with reduced risk
of general anaesthesia which may occur in an
operating room setting.
2.2 COVID-19 Era andTesting
Until the pandemic is brought under control,
patients scheduled for elective surgery should be
screened for exposure to or symptoms of coronavirus disease 2019 (COVID-19). The N95 mask
is mandatory for the anaesthesiologist, but not for
the rest of the staff because of the risk of aerosol
spread of COVID-19. The surgeon must leave the
operating room prior to the intubation procedure
to allow for the settling time which varies from
one room to another.
Protocols for preoperative testing vary by
institution and geographic region, and in areas of
high prevalence, testing prior to non-emergency
surgery is advised [8, 9].
As a routine in our practice, we perform a
pregnancy test prior to gynaecologic surgeries,
including laparoscopy and dye test, in all women
of reproductive age.
2.3 Wrong Person, Site, Procedure
Prevention
Practicing safe, high-quality operating room
care begins with accurately identifying the
patient, surgical site and procedure. We routinely perform a checklist which is done on
three separate occasions to ensure that the team
and the patient understands the nature of the
procedure.
2.4 Piercings andTattoos
Oral and nasal jewellery (e.g. tongue and nose
rings) can interfere with intubation during the
administration of general anaesthesia, and body
piercing at any site can conduct electric current if
electrosurgery is performed [10].
2.5 Preoperative Skin Preparation
Preoperatively, the Centers for Disease Control
and Prevention advises that the entire body be
washed (shower or tub) with either soap (antimicrobial or non-antimicrobial) or an antiseptic
agent on the night prior to surgery. Some practices give patients chlorhexidine gluconate solution at their preoperative evaluation to facilitate
appropriate preoperative skin cleansing [10]. We
do not practise this. In a meta-analysis of seven
trials including over 10,000 participants, preoperative bathing or showering with chlorhexidine
or other products was not associated with reduced
rates of surgical site infection [11]. The patient is
advised to fast for about 8h prior to the operative
procedure and instructed to use her regular medications such as antihypertensive medications
even on the morning of the operation. Patients
who are on anticoagulants are usually told to
avoid its usage based on the advice of the
internist.
Depending on other comorbid factors, an
anaesthetic consult may be necessary. In our centre at the University of Saskatchewan, in Canada,
we do not seek a routine preoperative consult
unless it is indicated by her medical history. We
have our accepted departmental screening criteria such as obesity, previous abdominal surgery
and other medical disorders prior to inclusion on
the operating list.
History of allergies must be obtained because
some patients may be allergic to methylene blue
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129
or other medications that may be used during the
surgical procedure. The patient must be accompanied by someone and avoidance of driving for
24h.
Possible complications which may be early or
delayed related to the procedure must be discussed with the patient and written consent is
mandatory detailing possible complications on
the consent form.
3 Operative Procedure
3.1 Instruments
1. Laparoscope (Fig.1)
2. Trocar: 5/10mm
3. Veress needle
4. Suction/cannula
5. Carbon dioxide
6. Graspers
7. Surgical knife
8. Absorbable suture materials
9. Scissors
10. Foley catheter
11. Tenaculum—double tooth preferred
12. Uterine manipulator
13. Sterile drapes
14. Intravenous uids.
15. Methylene blue dye
3.2 Instruments forSingleIncision Laparoscopy
Flexible and articulating instruments are available in resource-rich countries but do not offer
any substantial advantage in our practice in
almost every centre in Canada.
3.3 Instruments
forMini-Laparoscopy
Mini-laparoscopy, also referred to as needlescopic surgery, utilizes instruments with shaft
diameters ranging from 1.9 to 3.5 mm (trocar
diameters from 2.2 to 4.2mm) and may be advantageous for use in an ofce setting under intravenous conscious sedation.
Despite being a simple procedure, adequate
anatomical knowledge and proper surgical techniques are important to reduce the risk of complications. Some centres advocate for an open
procedure for trocar insertion; however, no signicant differences in overall complication rates
have been documented when open techniques for
primary abdominal insufation were compared
with a blind technique in experienced surgeons
[12].
3.4 Insuation Needle
In our centre, nearly all our laparoscopic
instruments are disposable, but disposable instruments are typically less cost-effective, although
this may not be possible in some developing parts
of the world.
Fig. 1 A laparoscope
It is recommended to be trained on how to use the
Veress needle for initial carbon dioxide insufation, while secondary trocars are inserted under
direct laparoscopic visualization.
3.5 Suction andIrrigation
Suction and irrigation are important for all types
of laparoscopic surgery. Irrigation is used to clear
debris, spilled methylene blue dye or blood when
bleeding is encountered. A variety of laparoscopic suction instruments have been designed to
remove irrigation uid or intraperitoneal air and
smoke but the cheapest and the simplest should
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Fig. 2 Suction and irrigation tube
be chosen. The type used by the corresponding
author is shown in Fig.2.
There are combination suction/irrigation devices
that are available and should be used because of
unforeseen circumstances. The methylene blue dye
should be irrigated and the leftover removed from
the pelvis for it may cause pelvic irritation.
3.6 Grasping Instruments
Grasping forceps may be necessary when the fallopian tubes are deeply buried in pelvic adhesions or endometriosis. Salpingostomy may be
performed at the same time for mbria occlusions/phimosis especially in a low-resource setting. Forceps with pointed ends are used for
salpingostomy and the dye leakage could be evident in such circumstances.
4 Technique ofMethylene Blue
Dye Test
The patient is rst placed in the supine position
for induction of anaesthesia following which he/
she is placed in the dorso-lithotomy position
under general anaesthesia. This could be done
under intravenous conscious sedation because it
is a very short procedure. A small longitudinal
incision is made in the infra-umbilical region and
the Veress needle is inserted and insufation
pressure is preset at 25 mmHg. This usually
requires about 4–5 l of carbon dioxide in an
average- sized patient. Another small incision is
made in the lateral abdominal position and a
5-mm trocar is inserted. The probe would then be
introduced through this incision while another
assistant is introducing methylene blue through
A. A. Akinbiyi et al.
Fig. 3 Methylene blue insufation
Fig. 4 Uterine manipulator
the uterine manipulator via the vaginal route.
Dye spillage from each tube is a conrmation of
tubal patency, as shown in Fig.3. There are different types of uterine manipulators but the one
that we commonly use in our centre is as shown
in Fig.4.
The steps can be summarized as follows [13]:
1. In the supine position, the patient is
anaesthetized.
2. The abdominal wall and perineum are
cleaned and draped separately.
3. The bladder is emptied and an assistant introduces a uterine manipulator vaginally.
4. The surgeon stays on the patient’s left-hand
side (right-hand side if left-handed).
5. The Veress needle is inserted at the appropriate site after making a stab incision. (In the
direct trocar insertion method, this step is
omitted.)
6. Tests are carried out to conrm correct Veress
needle placement. Insufation pressure of
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20–25 mmHg is used at the initial trocar
entry.
7. When the desired abdominal pressure has
been achieved, the incision is increased and a
10-mm trocar and cannula is inserted.
8. The insufation tube is reconnected, and gas
ow restarted with the preset pressure
adjusted appropriately.
9. The laparoscope, connected with the breoptic cable from the light source and the
camera head, is introduced.
10. A panoramic view is carried out: The area
below the primary port and the abdominal
and pelvic organs are inspected.
11. Insert at least one secondary port under direct
vision.
12. In an appropriate Trendelenburg position,
move the bowels away.
13. The assistant injects the methylene blue dye
via the uterine cannula.
14. The fallopian tubes are observed carefully
for any spillage which signies tubal patency.
15. Ensure there is no reux of dye through the
cervical canal especially in the absence of
dye spill.
16. After the procedure, suck out the dye from
the peritoneal and pelvic cavities.
17. Remove the secondary port(s) under direct
vision.
18. Remove the laparoscope and allow for the
escape of gas.
19. Reintroduce the laparoscope via its original
port and remove the laparoscope and cannula
simultaneously to prevent inadvertent herniation of bowel or omentum.
20. Suture port wound and apply a sterile
dressing.
21. Document all ndings.
5 Procedure-Related
Complications
The rate of complications associated specically
with a laparoscopic approach is overall very low,
but the procedure still requires adequate training
and practice before performance. Most of the complications have to do with initial abdominal access.
5.1 Conversion toanOpen
Procedure
This may be required to manage complications of
abdominal access but this is quite uncommon
with laparoscopy and methylene blue dye test.
This should not be seen as a sign of weakness but
strength since challenges are inevitable in any
surgical procedure.
5.2 Bleeding
Partial lacerations of the inferior epigastric artery
may not spontaneously stop bleeding, because
the vessel is tethered and cannot retract and
undergo spasm. Similar to the inferior epigastric
vessels, other abdominal wall vessels can be
injured, particularly if the trocar is not placed
under direct vision and if secondary trocars are
placed without prior transillumination of the
abdominal wall to identify the presence of supercial vessels.
Bleeding due to a vascular injury at a port site
may not be obvious initially and be delayed as a
result of tamponade. This is usually recognized
in the recovery room within about an hour.
Unusual oozing from the trocar site or swelling
should not be ignored. Late or delayed abdominal
wall hematomas can present 2–3days later with
an abdominal wall or ank bruising around the
trocar insertion site [12].
5.3 Bladder Puncture
Bladder injury is rare but reported during abdominal access for laparoscopy. A history of prior
pelvic surgery increases the risk of bladder injury.
Injury to the bladder is more commonly associated with primary or secondary trocar insertion,
rather than related to dissection during the course
of the procedure.
In general, puncture of the bladder results
when a midline, suprapubic trocar is placed in a
patient with an overdistended bladder.
When anticipating port placement below the
level of the umbilicus or in the suprapubic region,
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A. A. Akinbiyi et al.
a Foley catheter should be placed to decompress
the bladder. Although it is commonplace for
patients to void immediately before the procedure, it is safer to drain the bladder with a catheter after the induction of anaesthesia.
The urinary bladder may be distended with
bloody urine as a result of bladder injury which
should be promptly diagnosed and treated.
Instillation of methylene blue dye is advised to
identify the injury [12].
Observation is all that is necessary for 3–5mm injury size, but larger defects will require a
suture closure with absorbable sutures with either
an open or laparoscopic approach, depending on
the skill and experience of the operator. The bladder should then be drained for a few days to
10days depending on the size and location of the
injury.
5.4 Port-Site Hernia
Port-site hernia following laparoscopic surgery is
less common compared with incisional hernia
occurring after open surgery. We always close
any trocar site that is 10mm and above.
6 Conclusion
The high prevalence of tubo-peritoneal factors
and additional pelvic pathology in some parts of
the world have made some authors conclude that
laparoscopy and methylene blue dye should be
the rst investigative tool for tubal patency [14].
In our centre in Canada, a hysterosalpingogram is
considered the rst choice for tubal patency. If
the hysterosalpingogram is nonconclusive/difcult or the ultrasound scan is suspicious of a pelvic pathology, then we proceed to laparoscopy,
hysteroscopy and methylene blue dye test.
Eventually, what dictates the approach is the
prevalence of pelvic pathology, availability of
operative equipment and necessary surgical
skills.
Learning Points
• Diagnostic laparoscopy and dye test is a safe
and useful evaluation for female infertility.
• Good techniques on the part of the gynaecologist are necessary to avoid complications.
• Use entry techniques you are comfortable and
well trained on.
• Ensure dye injection is properly done avoiding leakage at the external cervical os.
• Follow the procedure step by step to minimize
errors.
• Accurate reporting of your ndings is very
important with video recording of the procedure for evidence.
References
1. Meuleman C, Vandenabeele B, Fieues S, Spiessens
C, Timmerman D, D'Hooghe T. High prevalence of
endometriosis in infertile women with normal ovulation and normospermic partners. Fertil Steril 2009;
92(1): 68–74.
2. Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi
S, Zolghadrin J, Alborzi SA, et al. A prospective,
randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril.
2004;82:1633.
3. Tang Y, Chen SL, Chen X, He YX, Ye DS, Guo W,
et al. Ovarian damage after laparoscopic endometrioma excision might be related to the size of cyst.
Fertil Steril. 2013;100:464.
4. Namnoum A, Murphy A. Diagnostic and operative
laparoscopy. In: TeLinde's operative gynecology, 8th
ed. Lippincott-Raven, Philadelphia 1997. p.389.
5. Audebert A, Pouly JL, Bonifacie B, Yazbeck
C. Laparoscopic surgery for distal tubal occlusions:
lessons learned from a historical series of 434 cases.
Fertil Steril. 2014;102:1203.
6. Centres for Disease Control and Prevention, American
Society for Reproductive Medicine, Society for
Assisted Reproductive Technology. 2012 assisted
reproductive technology national summary report.
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Atlanta, GA: US Department of Health and Human
Services; 2014.
7. Saleh WA, Dlugi AM.Pregnancy outcome after laparoscopic mbrioplasty in nonocclusive distal tubal
disease. Fertil Steril. 1997;67:474.
8. Orlando MS, Chang OH, Luna Russo MA, Kho
RM. Institutional protocols for COVID-19 testing
in elective gynecologic surgery across sites for the
society of gynecologic surgeons' surgical outcomes
during the COVID-19 pandemic (SOCOVID) study.
Am J Obstet Gynecol. 2021;224(5):540–2. https://
doi.org/10.1016/j.ajog.2021.01.013. [Epub ahead of
print]
9. Alabi OC, Okohue JE, Adewole AA, Ikechebelu
JI. Association of gynaecological endoscopy surgeons of Nigeria (AGES) advisory on laparoscopic
and hysteroscopic procedures during the COVID-19
pandemic. Nig J Clin Pract. 2020;23(5):747–9.
10. Jacobs VR, Morrison JE Jr, Paepke S, Kiechle
M. Body piercing affecting laparoscopy: perioperative precautions. J Am Assoc Gynecol Laparosc.
2004;11:537.
11. Webster J, Osborne S. Meta-analysis of preoperative
antiseptic bathing in the prevention of surgical site
infection. BJS. 2006;93(11):1335–41.
12. Borgatta L, Gruss L, Barad D, Kaali SG.Direct trocar
insertion vs. Veress needle use for laparoscopic sterilization. J Reprod Med. 1990;35:891.
13. Okohue JE.Diagnostic laparoscopy. In: Umeora OUJ,
Orazulike NC, Igberase GO, Nwagha UI, Galadanci
HS, editors. OBGYN step by step. University of Port
Harcourt Press limited; 2018. p.115–7.
14. Ikechebelu JI, Mbamara SU.Should laparoscopy and
dye test be a rst line evaluation for infertile women in
Southeast Nigeria? Niger J Med. 2011;20(4):462–5.
Laparoscopic Suturing Techniques
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UcheA.Menakaya andHaleemaOlalere
1 Background
Prociency in laparoscopic suturing is an essential component of a surgeon’s competency to perform minimal access surgery. Laparoscopic
suturing was rst introduced by Kurt Semm in
the 1970s [1]. Suturing is a complex area in the
eld of laparoscopic surgery and has a steep
learning curve [2]. In certain instances, this hurdle is sufciently great that laparoscopic procedures are abandoned for laparotomy [3].
However, laparoscopic suturing should be mastered by every surgeon with an interest in developing their minimally invasive surgical approach
[4].
There are two types of laparoscopic suturing:
1. Extracorporeal suturing
2. Intracorporeal suturing
U. A. Menakaya (*)
JUNIC Specialist Imaging and Women’s Centre and
Calvary Hospitals, Canberra, ACT, Australia
e-mail: info@junicimaging.com.au
H. Olalere
Lagos State University College of Medicine,
Ikeja, Nigeria
2 Extracorporeal Suturing
This refers to the technique of developing the
suture knot outside of the body and then slipping
the knot snugly inside the body using a knot pusher.
There are many variants of the extracorporeal knot
including Roeder knot, Duncan loop, Nicky’s knot,
Tennessee slider, SMC knot, Weston knot, Meltzer
knot and Tay side knot (see Fig.1) [5].
These knotting techniques are essentially variations in turn around the axis or the number of
reversed half hitches on alternating post [5, 6].
Each technique has its proponents, and some
have been modied for improvement.
A good extracorporeal knot should be simple,
easy, quick and reliable and be able to secure proper
tissue approximation [5]. The characteristics of a
good extracorporeal knot must also include the ability to be easily tightened to ensure maximum
strength (loop security) and ability to resist slippage
when load is applied (knot security) [7, 8].
The safety of extracorporeal knots depends on
knot conguration, suture material and suture
size [5, 8]. Thus, challenges with extracorporeal
suturing would include choosing the appropriate
size of suture material, the numbers of knots that
can be applied at once and the ease of sliding in
the extracorporeal knot [9].
In gynaecology, extracorporeal suturing may be
simple interrupted sutures or gure-of-eight sutures
and can be useful in solid tissue repair (vagina, uterus),
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_13
135
136
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Fig. 1 Different types of extracorporeal knots [5]. Image reproduced with permission from the Society of Laparoscopic
and Robotic Surgeons, publishers of JSLS
homeostasis (infundibulopelvic ligament, uterine
artery, tubal ectopic pregnancy) and deep surgery.
3 Intracorporeal Suturing
U. A. Menakaya and H. Olalere
2.1 The Roeder Knot
The Roeder knot is one of the basic extracorporeal knots. It was initially used as a slip knot for
tonsillectomies in children and was later modied by Simms who introduced a push rod application system for use in endoscopic surgery [7].
The Roeder knot is now available commercially
as the Endoloop by Ethicon. Other knots like the
Meltzer knot and Mishra knot are modications
of the Roeder knot to improve its security [10].
2.2 Instruments
forExtracorporeal Suturing
• Knot pusher
• Scissors
• Suture material (monolament sutures pre-
ferred for ease of sliding)
This refers to the technique of developing the
suture knot inside the abdominal cavity using
laparoscopic suturing instruments. It can be efciently performed by the systematic manipulation of the relationships between laparoscopic
suturing instruments, needle and anatomic area
of interest [11].
Key factors to address prior to undertaking
laparoscopic suturing would include ensuring
adequate endoscopic visualization, understanding the challenges of laparoscopic depth perception and the limitations imposed by the xed
range of laparoscopic ports [11].
3.1 Instruments forLaparoscopic
(Intracorporeal) Suturing
The laparoscopic instruments required to successfully execute intracorporeal suturing include
the following:
ab
ab
cd
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137
1. Needle holder/driver
2. Needle receiver/assisting instrument
3. Laparoscopic scissors
4. Suture material
3.1.1 Needle Holder/Driver
Needle holders are an important piece of instrument for performing laparoscopic suturing. The
reliability and performance of the needle holder
depend on its jaw strength which helps prevent
the needle from slipping or rotating [11].
Needle holder jaws/tips are available in a vari-
ety of models that include curved and straight
Fig. 2 Type of needle
holder tips: (a) Curved
needle holder tip, (b)
Straight needle holder
tip
needle drivers (see Fig. 2). A straight needle
driver tip can be used from both sides and for
both forehand and backhand suturing [11]. A
curved tip allows for better visualization and aids
in the intricate manoeuvres required for intracorporeal knot tying [11].
Needle holder handles are also important to
reduce hand fatigue during suturing with the
axial handles more ergonomically suited to suturing compared to pistol-grip-type handles (see
Fig.3). The addition of a ratchet system can also
help to reduce hand fatigue during laparoscopic
suturing.
Straight needle holder tipCurved needle holder tip
Fig. 3 Different types
of needle holder
handles: (a) Axial
handle, (b
type handle, (c) Shank
handle, (d) Shank
handle
) Pistol-grip-
Axial handle
Pistol grip type handle
Shank handle
Shank handle
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