continued 

Microlaparoscopy made easy by Culdolaparoscopy

This is a technique for the female patient wherein the vagina is used as a visual or operative port. Either a 10-mm or 12-mm port is placed in the posterior fornix or a 33-mm port is placed in the vaginal vault. This enables the reduction of the quantity and size of necessary operative ports placed in the abdomen. 

The operating room assembled for the purpose of performing culdolaparoscopy should be equipped with two monitors. It is important that each monitor not be stationary, and have an articulate arm stand that facilitates mobility. When a surgeon is required to operate in front of the vaginal port, between the legs of the patient, one of the monitors is positioned in an area of the right shoulder and used to provide a view of the cephalad part. The other monitor should remain by the side of the left leg. 

All patients receive pre-operative and post-operative prophylactic antibiotics. General anesthesia is used. The patient is placed in the lithotomy position in Allen type of telescopic stirrups. A pelvic examination is performed to assure the emptiness of the posterior cul-de-sac. If obliteration or tumors are suspected to occupy the space of Douglas this patient is not a candidate for Culdolaparoscopy. Vaginal cleansing is done with a solution of povidone-iodine 10%. A Foley catheter is place in the bladder to keep it empty. The uterine manipulator is then placed.

Microlaparoscopy is done with one umbilical port used for the placement of the scope. Two extra 2 mm or 3 mm ports are placed in each of the lower quadrants. The surgeon will then change position and operate between the legs of the patient. While in this position, the uterine manipulator is pushed cephalad and anterior thereby exposing the cul-de-sac to a microlaparoscopy view.

The posterior fornix is then exposed and a 10mm or 12 mm trocar is pushed gently into de posterior cul-de-sac under laparoscopic surveillance. This decreases the chances of bowel perforation. While in the stirrups, the patient's thighs are brought to the horizontal position and the knees remained flexed. 

The functionality of each of the ports will vary as the surgeon deems necessary depending on the nature or stage of the procedure. For extraction, a small telescope is placed in one of the abdominal ports while the vaginal port is used to place an extracting bag. The abdominal ports are used for visualization and to bring the specimen inside the endobag. In other cases the specimen is delivered vaginally by graspers or morcellated for extraction (for more information visit http://www.culdoscopy.com).  

When culdolaparoscopy is performed during a vaginal hysterectomy, the sleeve of a trocar is secured with a purse-string type of suture. The vagina
is packed with soaked gauze or a 33-mm sleeve. The insufflation is done via the vaginal port until pneumoperitoneum is achieved. Then a 10 mm laparoscope or a culdolaparoscope (a longer 30 degree angled scope) is placed for visualization. Operations like oophorectomies and cholecystectomies could be done in this manner.

Culdolaparoscopy was used successfully in several gynecological procedures including oophorectomies, myomectomies and hysterectomies as well as in appendectomies and cholecystectomies. Many patients will benefits from operative microlaparoscopy when the concepts of this technique become better known. For more information visit http://www.culdoscopy.com. 

Suggested reading:
Tsin D.A..Culdolaparoscopy: A Preliminary Report Journal of The Society of Laparoendoscopic Surgeons. 2001; 5 : 69-71

(Editorial note: The efficacy of a technique depends on several factors including the surgeon's preference. The author prefers this technique. I favor not to do any vaginal procedure and perform all laparoscopic procedures including removing of large myoma, uterus etc. via a secondary trocar. TT)