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Middle East Fertility Society Journal
Middle East Fertility Society
ISSN: 1110-5690
Vol. 11, Num. 1, 2006, pp. 53-58

Middle East Fertility Society Journal,Vol. 11, No. 1, 2006, pp.53-58

Transvaginal hydrolaparoscopy: an advance or a gimmick!

Amr El-Shalakany, M.D., F.R.C.O.G.,Abdel-Megeed Ismaeel, M.D.,Mohamed Sayed Ali, M.D.,Hanaa Ahmed ,Mahmoud, M.D.

Department of Obstetrics & Gynecology, AinShamsUniversity, Abbassia, Cairo, Egypt.

Correspondence: Prof. Amr El-Shalakany, M.D., F.R.C.O.G., Professor in Obstetrics and Gynecology, 109 Haroon El-Rasheed Street, Heliopolis, Cairo 11351, Egypt. Tel: + 202 6372189, Fax: +202 6377567, E-mail: amrhasssn@tedata.net.eg

Code Number: mf06009

ABSTRACT

Objective: Transvaginal Hydrolaparoscopy (TVHL) is the recent modification of a well known gynecological procedure culdoscopy used for exploration of the pelvic cavity that takes advantages of micro-endoscopic technology and uses aquafloatation for inspection of the tubo-ovarian structures. This is a case series to evaluate the feasibility, procedure performance and complications of Transvaginal Hydrolaparoscopy.
Materials and Methods: The study was conducted at the AinShamsUniversityMaternityHospital in Cairo. Twenty two women were included in the study being referred for diagnostic fertility investigation or for performing benign hysteroscopic surgery (e.g., myomectomy, septum resection) for infertility or recurrent miscarriage reasons. Transvaginal hydrolaparoscopy was carried out in all participants under general
naesthesia.
Results: Entry into the peritoneal cavity was successful in 21 out of 22 (95.5%) cases. The mean duration of the TVHL procedure was 15.6 ±3.2 minutes with a time range from 12 to 19 minutes. The pelvic inspection was excellent in 10 (45.5%), satisfactory in 3(13.6%), unsatisfactory in 7 (31.8%), and failed in 2 (9.1%). In 3 women traditional laparoscopy was performed in the same setting. There were no difficulties in inspecting the posterior wall of the uterus and the uterine contour in all women with septate or bicornuate uterus (n=7) to guide the procedure of septum resection.  TVHL detected pelvic pathological findings in 12 (54%) women (4 endometriosis, 3 polycystic ovaries, 2 peritubal adhesions, 3 hydrosalpinx). Tubal patency was tested by transcervical dye hydrotubation with methylene blue in 5 (22.7%) cases only (4 of them had normal patent both tubes, 1 case had bilateral tubal obstruction).
Conclusion: Transvaginal hydrolaparoscopy may allow limited detailed exploration of the tubo-ovarian structure in some infertile patients. The procedure can be combined with hysteroscopy and dye hydrotubation. Visualization is restricted to the posterior part of the uterus and can judge the uterine contour effectively. However, the whole pelvic inspection process is inferior to that achieved by conventional laparoscopy.

Key words: Hydrolaparoscopy, vaginal

Transvaginal Hydrolaparoscopy (TVHL) is a recent modification of the previously well known gynecological procedure culdoscopy used for exploration of the pelvic cavity that takes advantages of microendoscopic technology and uses aquafloatation for inspection of the  tubo-ovarian structures. TVHL was reintroduced in 1997 by Gordts et al. (1). In contrast to culdoscopy, the patient is in the dorsal lithotomy position and abdominal distention is obtained by instillation of saline or preferably lactated Ringer's solution. TVHL is likely to be more acceptable by avoiding general anesthesia (1).

To expose the full ovarian surface and fossa ovarica several steps are required; such as Trendlenburg position, distention by CO2 pneumo-peritoneum, insertion of a second trocar and manipulation of bowel and adnexa (2). Additionally, structures such as fimbriae, tubo-ovarian structures, and avascular adhesions are easier to inspect by hydroflotation than with a pneumoperitoneum (3,4). TVHL improves the visualization of the tubo-ovarian structures because the access from the caudal pole with hydroflotation, allows inspection of the organs in their normal position without manipulation (1, 5).

TVHL was used for investigating unexplained primary infertility in women. The procedure can be combined with hysteroscopy and dye hydrotubation and has the potential of offering the patient a complete and early exploration of the reproductive tract in a painless, safe and cost-effective way (1, 5). TVHL has been suggested to be better tolerated than hysterosalpingography, less invasive than standard laparoscopy, and can be used safely as a first line investigation of the female partner in one - stop infertility clinic (5).

TVHL has been used as well to examine the contour of the uterus before hysteroscopic metroplasty for uterine septum (6). Also, ovarian drilling was carried out by Hirano et al., on two clomiphen citrate-resistant infertile women with polycystic ovaries using Nd:YAG laser vaporization through TVHL (7).  Fernandez et al. also reported their experience with bipolar ovarian drill in 13 patients with polycystic ovary syndrome through TVHL (8).

These reports appeared encouraging to adopt this technique in gynecologic practice and evaluate its definitive role, advantages and complications.

MATERIALS AND METHODS

The study was conducted at The Early Cancer Detection Unit of The Ain Shams University Maternity Hospitals, between March 2004 and February 2005. Twenty two patients were included in this study. Patients were referred for diagnostic workup of their fertility or admitted for performing benign hysteroscopic surgery (e.g., myomectomy, septum resection) for fertility or recurrent pregnancy loss reasons. All patients received full information about the procedure and an informed consent was obtained from each patient under study. All patients were subjected to thorough history taking and clinical examination. Patients were excluded if there was evidence of upper or lower genital infection, significant uterovaginal prolapse, expected adhesions in the pouch of Douglas or history of previous pelvic surgery including previous caesarean section.

Operative technique

All TVHL were performed under general anesthesia with the patient in the dorsal lithotomy position. In all patients examination under anaesthesia is performed to exclude any suspected pathology in the pouch of Douglas followed by hysteroscopic inspection of the uterine cavity using a 4 mm hysteroscope and CO2 distention.

The cervix is lifted with a tenaculum placed on the posterior lip. A Veress needle is introduced about 1.5 cm below the cervix.

Approximately 500 mls of saline are instilled in the pouch of Douglas. Then a one cm stab incision is performed in the posterior fornix involving the vaginal skin only and not deeper (to avoid puncturing the formed fluid distension of the pouch of Douglas). A rigid endoscope with an optical angle of 30o and a 4 mm outer diameter diagnostic sheath with a flow channel (Karl Storz GmbH & Co., Tuttlingen, Germany) is introduced (using the unaided force of the forearm) to bluntly puncture the pouch of Douglas. After introduction of the telescope, the posterior wall of the uterus is inspected. Subsequently, by rotation and deeper insertion of the scope, the tubo-ovarian structures on either side are inspected. Saline irrigation is continued during the procedure under gravity to keep the bowel and tubo-ovarian structures afloat. Tilting the patient in an anti-Trendlenburg position is sometimes resorted to in order to float bowel loops out of the pelvis. Tubal patency testing using methylene blue dye is performed if needed using 6-8 Fr catheter introduced into the uterus transcervical. At the end of the TVHL procedure, saline is left in situ, the instruments are removed and the incision in the vaginal skin is repaired.  

If hysteroscopic surgical procedures are indicated they are done after the conclusion of TVHL. The clarity of inspection of genital organs is described by the surgeon as follows:

  • Excellent: when both adnexa and the whole uterine contour are clearly visualized with clear appearance of color tones and surface vascular patterns
  • Satisfactory: when all the structures are seen but color tones and surface vascular patterns are not clear
  • Unsatisfactory: when any one of the structures (tube, ovary, uterus) could not be inspected fully
  • Failed inspection: when none of the structures (tubes, ovaries and uterus) is seen or there is failure of entry.

Prophylactic broad-spectrum antibiotics are given to all patients at the time of induction of anesthesia. All data were collected and analyzed using simple descriptive statistics (mean, SD, range).

RESULTS

A total of 22 women were included whose characteristics and the indications for transvaginal hydrolaparoscopy are shown in table 1, 2. All women received general anesthesia and had diagnostic hysteroscopy prior to TVHL and the findings are presented in table 3. Entry into the peritoneal cavity was successful in 21 out of 22 (95.5%) cases and in one patient there was no successful peritoneal entry because the distension fluid was inserted extraperitoneal. The mean duration of the TVHL procedure was 15.6 ±3.2 minuteswithatimerangefrom12to19minutes and mean postoperative stay was 8 ± 2.4 hours (range 4-24). There was only one operative complication related to the transvaginal hydrolaparoscopy procedure in the form of a limited puncture site bleeding that markedly impaired the inspection process and necessitated standard laparoscopy.

The pelvic inspection was excellent in 10 (45.5%), satisfactory in 3 (13.6%), unsatisfactory in 7 (31.8%) (in 5 at least one of the adnexal structures was not inspected fully and in 2 the dim vision prohibited proper judgment of surface texture  and color tones), and failed in 2 (9.1%)(one due to failure of entry and the other due to dim vision due to blood staining of the distention fluid). In 3 women traditional laparoscopy was performed in the same setting (in two due to the failed inspection and in the third one to perform ovarian drilling for polycystic ovaries).

There were no difficulties in inspecting the posterior wall of the uterus and the uterine contour in all women with septate or bicornuate uterus (n=7) to guide the procedure of septum resection.  TVHL detected pelvic pathological findings in 12 (54%) women (4 endometriosis, 3 polycystic ovaries, 2 peritubal adhesions, 3 hydrosalpinx) (figure 1, 2). Tubal patency was tested by transcervical dye hydrotubation with methylene blue in 5 (22.7%) cases only (4 of them had normal patent both tubes, 1 case had bilateral tubal obstruction) (Figure 3).

DISCUSSION

TVHL could be performed under local anesthesia of the posterior fornix as reported by Gordts et al., and Waterlot et al. (1,9). Performing the procedure under local anesthesia, allows the patient to explain the sensation and the intensity of pain occurring during the procedure and consequently, the procedure was gentler and more atraumatic and was tolerated by all the patients (1,9). Another advantage of local anesthesia described was that the patient can follow the procedure on the video screen, and this allowed it to be explained to her and her partner (10). In the current study TVHL was performed under general anesthesia as the procedure was recently introduced and surgeons felt more comfortable performing it under general anaesthesia in addition to the fact that half the patients required hysteroscopic surgery.

The technique for TVHL procedure we used was a modification of the technique reported by Gordts et al, on which the insertion of the Veress needle was facilitated by a stab incision 1.5 cm below the cervix in the posterior fornix (we introduced the needle without the stab). Our technique is also different from the technique described by Waterlot et al., who used specially designed disposable balloon introducers. One was put in the uterine cavity and the second balloon introducer was inserted in the pouch of Douglas. They suggested that the role of the balloon was very important in maintaining the introducer in the pouch of Douglas during the procedure especially when the scope was pulled back to obtain a wider angle view (9). Instead, we used the same telescope used in hysteroscopy introduced bluntly through a stab involving the vaginal skin into the pouch of Douglas. The blunt introduction of the scope is believed to ensure a safer entry into the pouch of Douglas

Our failure rate was low, 2 out of 22 cases (9.7%), failed due to extraperitoneum distention. This is higher than a failure rate of 3.1% recorded previously by Waterlot et al., who didn't exclude from the study women with retroverted uterus as others have done, and three failures out of 28 cases (10.7%) as was described by Gordts et al., who suggested that the failures mostly occurred at the beginning of their experience (1, 9).

Use of 30° optical angle system allowed detailed inspection of the posterior pelvic compartment including the tuboovarian structures, the uterosacral ligaments and the pouch of Douglas, except for the area of entrance. The anterior pelvic compartment was not accessible for inspection at this procedure. Rudi Campo et al. suggested that this was not a major disadvantage for the diagnosis of endometriosis because the exclusively anterior pelvic endometriosis occurs in less than 4% of cases (11).

Complete evaluation of all pelvic organs was not possible in all cases of this study. It was noted that without manipulation of the adnexa (which can not be satisfactorily achieved), it was difficult in some cases to check the ovarian surfaces from all sides. We also noted that overestimation of the size of lesions encountered because of the magnification of the scope at close distances can be troublesome. Another problem with inspection was that the visualization was not panoramic and was markedly decreased when the distention fluid became turbid or hemorrhagic. However, we suggest that increasing the experience of the surgeon may help to overcome these problems.

Casa et al., differently stated that inspection under fluid improves the visualization of subtle, non-fibrotic lesions of endometriosis by the three dimensional effect of fluid, and allows visualization of the capillary network, which tend to be masked by pneumoperitoneum at standard laparoscopy. They also, concluded that inspection of the tuboovarian structures under fluid makes it easy to identify filmy connecting and non-connecting adhesions (12).

Our study didn't evaluate the pathologies by their number and location, and didn't compare the findings with laparoscopy (1,11,13) or with hysterosalpingography (HSG) (7). However; in more than 40% of the cases the inspection process either was unsatisfactory or failed as the excellent comprehensive evaluation of genital structures was not achieved. These findings suggest that comparison with conventional laparoscopy regarding diagnostic excellence could be difficult to justify.

Previous studies reported the value of TVHL in evaluation of tubal pathology even by performing salpingoscopy (1,9). In our study, the tubal patency was tested by hydrotubation with methylene blue dye in 5 cases, among these patients one had a negative chromopertubation test, and the rest had normal bilateral tubal patency. However, due to strict patient selection criteria, the technique can be difficult to use in patients with suspected adhesive pelvic pathology.

 In all the patients where judging the uterine contour (N=7) was required, TVHL definitely helped the reaching desired diagnosis before attempting hysteroscopic septum resection (N=6). However, continuous guidance during septum resection (or when dissecting intrauterine synechia) may not be achievable in the same way with conventional laparoscopy.

At the end of the procedure fluid was left in situ. Casa et al removed excess fluid because they suggested that fluid is not routinely used at laparoscopy (12). The posterior fornix was sutured to prevent visceral herniation. However, in some studies, the vaginal fornix was left to close spontaneously (1, 14).

Regarding complications, previous studies reported bleeding from the puncture site, inadvertent puncture of the posterior wall of the uterus, parametrium or an ovarian cyst, rectum perforation and peritonitis (1,9,13). In our study, strict exclusion criteria were previous pelvic surgery, obstruction of the pouch of Douglas by the rectum or a prolapsed mass and were routinely excluded by bimanual examination. This preoperative selection kept the rate of complications low in the form of bleeding from the puncture site in one patient.

CONCLUSION

Transvaginal hydrolaparoscopy may allow atraumatic and detailed exploration of the tubo-ovarian structure in selected infertile patients. The procedure can be combined with hysteroscopy and dye hydrotubation. Visualization is restricted to the posterior part of the uterus. So, it can be combined with hysteroscopy to differentiate between septate and bicornuate uterus prior to septum resection. However, the pelvic inspection process is inferior to that achieved by conventional laparoscopy.

REFERENCES

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  2. Jacobi CA, Ordemann J, Bohm B,Zieren HU, Liebenthal C, Volk HD, et al. The influence of laparotomy and laparoscopy on tumour growth in a rat model. Surg Endosc 1997, 11: 618-21
  3. Nezhat C, Nezhat F, Nezhat C.  Operative laparoscopy (minimally invasive surgery): state of the art. J Gynecol Surg. 1992 Fall; 8 (3): 111-41
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  5. Gordts S, Campo R, Puttemans P, et al. Investigation of the infertile couple: a one-stop outpatient endoscopy-based approach. Hum Reprod 2002; 17(7): 1684-7
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  7.  Hirano Y, Shibahara H. Usefulness and prognostic value of Transvaginal Hydrolaparoscopy in infertile women. Fertil Steril 2003; 79(1): 186-9
  8. Fernandez H, Alby JD, Gervaise A, de Tayrac R, Frydman R. Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome: a new minimally invasive surgery. Fertil Steril 2001; 75(3): 607-11
  9. Waterlot A. Dreyfus JM. Andine JP. Evaluation of the performance of fertilioscopy in 160 consecutive infertile patients with no obvious pathology. Hum Reprod 1999; 14: 707-11
  10. Brosens I, Campo R, Gordts S. Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility. Curr Opin Obstet Gynecol 1999; 11(4): 371-7
  11. Campo R, Gordts S, Rombauts L, Brosens I. Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility. Fertil Steril 1999; 6: 1157-60
  12. Casa A, Sesti F, Marziola M, Piccione E. Transvaginal Hydrolaparoscopy vs conventional laparoscopy for evaluating unexplained primary infertility women. J Reprod. Med 2002; 47(8): 617-20
  13. Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal Hydrolaparoscopy compared with laparoscopy for evaluation of infertile women: a prospective comparable blind study. Hum Reprod 2000; 15: 2379-82
  14. Dechaud H, Ali Ahmed SA, Aligier N, Vergnes C, Hedon B. Does Transvaginal Hydrolaparoscopy render standard laparoscopy obsolete for unexplained infertility investigation; Eur J Obstet Gynecol Reprod Biol 2001; 94(1): 97-102

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