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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Positioning
The patient is positioned in the dorsal lithotomy position. To prevent any positioning injuries, the arms should be tucked along
the patient’s side, with the arms adducted and pronated, and the feet slightly flexed with thighs parallel to the abdomen.
Foam or egg-crate cushions can be used to protect fingers, hands, knees, and ankles.
Sequential compression devices (SCDs) should be placed on the lower extremities to avoid any thromboembolic events.
Ensure that the patient will not slide back on the table once she is placed in Trendelenburg during the case. Placing the
patient on an egg-crate foam or a surgical gel pad that is taped to the operating room table can assist in preventing the
patient from sliding backward. Fixing the patient on the bed with a safety strap or tape across surgical towels can also be
utilized. Patients can also be placed in a Bean Bag Positioner (AliMed Inc., Dedham, MA) that is initially fixed to the
operating room table. The patient is then positioned in the bean bag and the bag conforms to the shape of the patient’s upper
body and shoulders when desufflated with suction. Equally, undue pressure on the sacrum should be avoided as well.
A Foley catheter should be placed to ensure bladder decompression during the suprapubic port placement.
The patient should be supine for initial trocar placement to avoid injury to blood vessels upon entry into the abdomen.
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Approach
The standard approach is via laparoscopy. Two types of equipment can be used, which include a diathermy probe (monopolar
or bipolar needle electrode, with the bipolar needle being potentially safer) or the CO
2
laser. Different power settings are
described in various studies noted in the Procedures and Techniques section.
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Procedures and Techniques
Laparoscopic entry
The abdomen is entered laparoscopically in the usual standard fashion. If the CO
2
laser is used, a 10-mm umbilical incision
(for the laparoscope and CO
2
laser) as well as a 5-mm suprapubic incision (for the suction irrigator) are necessary. If a
diathermy needle is used, a 5-mm umbilical incision suffices for the camera, but one additional incision for the diathermy
needle (usually in the right or left lower quadrant) will be necessary.
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Exploration of the pelvis
The pelvis is inspected, any adhesions or other abnormalities (such as endometriosis) removed and a chromopertubation
performed, if indicated.
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Ovarian drilli ng
Daniell and Miller
4
report using the CO
2
laser (Tech Fig. 5.2.1A). 25 to 40 punctures are placed on each ovary by applying
25 W continuous pulse for 5 to 10 seconds, leading to drainage of all visible follicles (Te ch Fig. 5.2.1B).
Muenstermann and Kleinstein
5
used the CO
2
laser with a power density of 10
5
W/cm
3
. All visible small follicles were
disrupted until a fluid spurt was noted from the follicle, with 10 to 30 follicles evaporated on each ovary.
Te ch Fig ure 5.2.1. A: Illustrat ion of t he laparoscopic ovarian drilling (LOD) procedure. B: Ovarian surface of a pat ient who had the LOD procedure
performed.
Gjønnaess in 1984 utilized a unipolar biopsy or sterilization forceps, in combination with a Siemens Radiotom electrosurgical
unit, frequency setting of 1.75 MHz and thereby generating 200 to 300 W. The forceps was pushed against the ovary for 2
to 4 seconds, creating cautery areas measuring 3 × 3 mm, with 3 to 8 cautery points per ovary.
6
Liu et al. report using a monopolar electrosurgical needle (Kirgen Co., Shanghai, China). After the ovary was stabilized
laparoscopically, four to six punctures were placed in each ovary, by applying 4 seconds of 40 W monopolar energy. The
monopolar needle was placed into the ovary to a depth of 7 to 8 mm, and the diameter of the cautery area measured 3 to 5
mm.
7
If a diathermy needle is used, the ovary is usually cooled off using irrigation with 200 to 500 mL of sterile saline
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Inspection of the pelvis
The pelvis is irrigated and inspected to ensure good hemostasis and document no damage to adjacent structures.
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Laparoscopic closure
Abdominal incisions are closed in the usual standard fashion.
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ALTERNATIVE PROCEDURES AND TECHNIQUES
Office Microlaparoscopic Ovarian Drilling (OMLOD)
This technique described by Salah and colleagues
8
is performed in the office under local anesthesia and was found to have
the same effects as regular LOD.
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PEARLS AND PITFALLS
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POSTOPERATIVE CARE
Postoperative care should be performed in the standard fashion for a laparoscopic procedure.
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