GORDTS and CAMPO Coagulating Suction Tube GYN /2015-E

Transcription

1 GORDTS and CAMPO Coagulating Suction Tube GYN /2015-E

2 GORDTS and CAMPO Coagulating Suction Tube Introduction Although diagnosed in 25-30% of patients with infertility, the causal relation between endometriosis and infertility is still unclear. The visual stigma of endometriosis seen at laparoscopy is only one aspect of a multifactorial disease. As endometriomas don t respond well to medical treatment {1-2-3}, a surgical approach is often indicated. Certainly in those patients with fertility problems, preservation of their future potential for reproduction of the utmost importance. The Bipolar coagulating electrode system is a new bipolar instrument for the laparoscopic treatment of superficial bleeding and facilitates the treatment of the endometriotic cysts. lining of the cyst by cortical or fibro-reactive tissue and the paucity of endometrial tissue in the wall of the cyst. Based on this theory, the endometrioma can be treated by superficial controlled bipolar coagulation. Pathogenesis The most widely accepted theory goes back to the hypothesis of Sampson and Hughesdon {4-5} where the ovarian endo metrioma is the result of the implantation of menstrual regurgitated endometrial cells on the ovarian surface. Consequently invagination of the ovarian cortex occurs at the site of implantation with an inflammatory reaction and the formation of adhesions, and in the presence of bleeding formation of an endometrioma. The presence of active endometrial implants at the site of inversion was also clearly demonstrated by Brosens et al {6}. Even when formation of an endometrioma is considered as being the result of metaplasia of coelomic epithelium, invagination of the ovarian cortex occurs. Therefore the wall of the endometrioma is lined by ovarian cortex. The stigma of inversion or the so-called Sampson s site of perforation is located on the antero-lateral side of the ovary and, in most cases, surrounded by the adhesions {7-9}. The pathogenesis explains the typical features of the endometrioma, such as the frequent location of the cyst and the adhesions on the anterior side of the ovary opposing the posterior side of the parametrium, the presence of adhesions or scarification on the ovarian surface, the frequent spilling by freeing the adhesions, the Fig. 1a Fig. 1b Fig 1a, 1b: Bipolar probe in contact with ovarian surface for coagulation of superficial lesion. 2

3 Fig. 2 Instrument The Instrument consists of a 5 mm bipolar probe with a central irrigation and suction system (Fig. 2). The tip of the probe consists of several electrically isolated currents fixed one next to the other. The incorporation of irrigation and suction possibilities in the same instrument enables a clear identification of bleeding vessels and can be used for hydro-dissection. As a safety measure the KARL STORZ generator is executed in such a way that the current is reduced when the tissue resistance increases, consequently the depth of thermal injury is limited. 3

4 Operative procedure The operative treatment in case of an ovarian endometrioma is performed in three steps: first a complete adhesiolysis of the ovary, secondly creating a wide opening of the site of inversion thirdly superficial coagulation of the endometriotic implants (Fig 3). Fig. 3 Fig. 3: Whitening of tissue after coagulation with bipolar probe. The technique differs from fenestration and coagulation by the first step. During the first step the cyst is dissected and fully mobilised and the site of inversion is identified. The cyst is opened at this site of inversion to minimise ovarian trauma and to maintain patency of the pseudocyst. After aspiration and rinsing the site of retraction or inversion is widely opened. Using this technique there is no collapse of the wall. The fibrotic area at the site of inversion and the visible vascularised endometriotic implants are coagulated. In case of endometrioma larger than 5 cm a two step procedure is performed with adhesiolysis as the second step whenever necessary and the complete coagulation of suspected implants in the reduced pseudocyst. Using this technique the opening of the pseudocyst is in fact not performed by fenestration, but by adhesiolysis and resection of fibrosis at the site of inversion. In a similar way a hydrosalpinx stays open when a salpingostomy, rather than a salpingotomy, is performed. Fenestration and drainage of endometriomas are poor techniques resulting frequently in recurrences {10,11,12}. Coagulation Technique The 5 mm bipolar coagulating electrode probe is inserted through a 5.5 mm suprasymphysary port and connected to the suction-irrigation unit and the KARL STORZ generator. Meticulous dissection of the adhesions is performed using the possibilities of hydro dissection through the central irrigation and suction channel of the Bipolar coagulating electrode probe. Whenever indicated during dissection bipolar coagulation is activated to assure a complete haemostasis. After opening and rinsing of the cyst, close inspection of the cystic wall is performed and visually controlled biopsies are taken. Consequently the internal cystic wall is coagulated using the 5 mm Bipolar coagulation electrode probe starting at an intensity of 30 Watts. The tissue should be moistened and intermittent irrigation assures clear visualisation. The cystic wall is coagulated in a systematic way until there is white decolourisation of the cystic wall and progressive disappearance of electric activity, which are the signs of sufficient coagulation. At the end of the procedure the ovary is left open and the abdomen is abundantly rinsed and checked for complete haemostasis. Discussion Based on the concept that the majority of the endometriomas are extra ovarian pseudocysts formed by invagination of the ovarian cortex, a bipolar coagulation of the cyst wall after adhesiolysis seems to be the logical approach in the treatment of endometriotic cysts {4,6}. The superficial coagulation can be performed without damage to the underlying ovarian cortex, reducing the risk of impairment of ovarian reserve. For this purpose we used the Bipolar coagulating electrode. The Bipolar coagulating electrode system is a special bipolar instrument form where the typical bipolar forceps is replaced by an adapted probe in the tip of which several electrically isolated circuits are fixed one next to the other. In this way adjacent tissue will always be in contact with both poles and the high frequency current will be enabled 4

5 to run through to adjacent tissue so as to obtain the desired effect. Coagulation will provoke atrophy of the tissue which becomes less electrically conductive. The Bipolar coagulating electrode generator, an adapted 50 Watt bipolar generator, is executed in such a way that the current is reduced when tissue resistance increases. Consequently the depth of coagulation is automatically reduced, resulting in a minimal risk of perforation and undesirable deep coagulation. Therefore the risk of damage to the ovarian tissue is minimal. When coagulation is performed on the cyst wall, a white brownish decolourisation will occur, this combined with a decrease in the amount of power is the proof of correct coagulation. In the Bipolar coagulating electrode the electrical energy is localised and thermal damage cannot occur from energy concentrating in a narrow return pathway. Accidentally touching another instrument when the probe is energised will not discharge current to tissue contacting the other instrument and capacitive coupling to cannula is virtually eliminated. Patient plate related injuries are eliminated since no patient plate is used. In addition the Bipolar coagulating electrode probe has a central irrigation and suction channel, through which clear identification of the cystic wall and bleeding vessels can be achieved, without the necessity of an extra port. It also makes the probe suitable for hydro-dissection. Conclusion Formed through invagination of the ovarian cortex, the Bipolar coagulating electrode coagulation technique offers a new way to treat endometriotic cysts. The main advantages are the restricted localised tissue penetration, the minimal or no carbonisation, the continuous irrigation and suction system and the minimal sticking of the probe to the tissue. The use of low power density and the absence of significant probe heating increases the patients safety. In addition it is very cost effective and as our preliminary results show succesfull. We therefore suggest that this technique and instrumentation should be further evaluated as first line treatment for endometriotic cysts. S. GORDTS, M.D., R. CAMPO, M.D., Leuven Institute for Fertility and Embryology (L.I.F.E.), Leuven, Belgium Fig. 4 Fig. 4: Ovarian endometriotic cyst after coagulation with the bipolar probe: note the whitening of the tissue; using the irrigation and suction carbonisation can be avoided. 5

6 References 1. Cook AS, Rock JA.: The role of laparoscopy in the treatment of endometriosis. Fertil Steril 1991; 55: Canis M, Mageg, Manhes H et al.: Laparoscopic treatment of endometriosis. Acta Obstet Gynaecol Scand (suppl) 150: Nisolle M., Donnez J.: Conservative laparoscopic treatment of ovarian endometriosis. In: Endometriosis, current understanding and management, 1995 pp Blackwell Science Ltd. 4. Hughesdon PE.: The structure of endometrial cysts of the ovary. J Obstet Gynaecol Br Emp 1957; 44: Sampson JA.: Perforating hemorrhagic (chocolate) cysts of the ovary. Arch Surg 1921; 3: Brosens IA, Puttemans PJ, Deprest J.: The endoscopic localisation of endometrial implants in the ovarian chocolate cyst. Fertil Steril 1994; 61: Brosens IA.: Ovarian Endometriosis. In: Endometriosis: current understanding and management, 1995 pp Blackwell Science Ltd. 8. Fayez JA, Vogel MF.: Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynaecol 1991;78: Canis M, Mage G, Wattiez A et al.: Second-look laparoscopy after laparoscopic cystectomy of large endometriomas. Fertil Steril 1992; 58: Busacca M, Colombo P, Natale A, Candiani M, Gruft L, Agnoli B.: Recurrence of endometriomas after laparo scopic conservative treatment. Gynaecol Endoscopy 4 suppl.1; Mettler L, Semm K.: Three step medical and surgical treatment of endometriosis. Ir J Med Sci 1983; 152: Donnez J, Anaf V, Nisolle M, Clerckx- Braun P, Gillerot S, Casanas-Roux F.: Ovarian endometrial cysts: the role of gonadotropic-releasing agonist and/or drainage. Fertil Steril 1994; 62:

7 GORDTS and CAMPO Coagulating Suction Tube, bipolar, size 5 mm GC GORDTS and CAMPO Coagulating Suction Tube, bipolar, size 5mm, length 30cm GC Same, length 36 cm GC Same, length 43 cm Recommended suction and irrigation handle: Handle, for suction and irrigation, autoclavable, for use with 5 mm coagulation suction tubes and 3 and 5 mm suction and irrigation tubes Other suction and irrigation handles are available on request. Recommended tubing set: Silicone Tubing Set, autoclavable, for use with Handle alternative Tubing Set, for single use, sterile, package of 10, for use with Handle It is recommended to check the suitability of the product for the intended procedure prior to use. 7

8 KARL STORZ Endoscopy-America, Inc East Grand Avenue El Segundo, CA , USA Phone: Phone toll free: (US only) Fax: Fax toll free: (US only) KARL STORZ GmbH & Co. KG Mittelstraße 8, Tuttlingen, Germany Postbox 230, Tuttlingen, Germany Phone: +49 (0) Fax: +49 (0) EW GYN /2015/EW-E