Indications for endoscopic intervention
Laparoscopic access accounts for a significant proportion of all abdominal interventions in gynecology. Elective surgeries are scheduled for the following conditions:
- polycystic ovary syndrome;
- benign ovarian tumors and tumor-like lesions;
- uterine fibroids and genital endometriosis;
- malformations of the internal genital organs;
- pelvic pain of unclear etiology;
- uterine and vaginal prolapse;
- stress urinary incontinence;
- surgical sterilization.
Emergency laparoscopy is indicated for conditions requiring urgent care:
- ectopic pregnancy and ovarian apoplexy;
- acute inflammatory diseases of the uterine appendages;
- suspected ovarian tumor torsion or rupture;
- torsion of a subserosal fibroid;
- the need for differential diagnosis between acute surgical and gynecological pathology.
Contraindications for surgery
The choice of surgical access is strictly regulated. Elective interventions are postponed if the patient has suffered acute infectious or viral illnesses less than 4 weeks prior to surgery.
| Absolute contraindications | Relative contraindications |
|---|---|
| Hemorrhagic shock | Polyvalent allergy |
| Decompensation of the cardiovascular and respiratory systems | Diffuse peritonitis |
| Uncorrected coagulopathy | Severe adhesions following previous surgeries |
| Acute and chronic hepatorenal insufficiency | Late stages of pregnancy (more than 16–18 weeks) |
| Pathologies precluding the Trendelenburg position (brain injuries) | Large uterine fibroids (more than 16 weeks) |
Surgical tactics for ovarian apoplexy
Treatment of ovarian rupture may begin with conservative therapy strictly in an inpatient setting. Antispasmodic agents (drotaverine, papaverine) and vitamins (thiamine, pyridoxine, cyanocobalamin) are used.
Conversion to laparoscopy is necessary if conservative treatment is ineffective within 1–3 days, recurrent pain attacks occur, general condition worsens, hemodynamic instability is observed, or ultrasound shows an increasing volume of free blood. A direct indication for endoscopy is the accumulation of more than 150 ml of blood, provided hemodynamics are stable.
Principles of surgery:
- Maximum gentleness. Priority is given to organ-preserving methods: coagulation of the rupture site or ovarian resection.
- Radicality according to indications. Complete removal of the organ (oophorectomy) is performed exclusively in cases of massive damage when tissue preservation is completely impossible.
Complications and conversion to laparotomy
The frequency and structure of adverse outcomes directly depend on the surgeon's qualification and the nature of the intervention. Complications are divided into anesthesia-related and surgical (injury to major vessels, trauma to gastrointestinal and urinary organs, gas embolism, mediastinal emphysema). Prevention requires careful patient selection considering contraindications and strict alignment of the physician's experience with the complexity of the procedure.
If laparoscopy is impossible due to severe adhesions, increased bleeding from ovarian vessels, or if the patient develops hemorrhagic shock, an emergency conversion to open surgery — laparotomy — is indicated. Surgical access is performed via a lower midline incision or a Pfannenstiel transverse suprapubic incision.
For quick memorization of absolute contraindications to laparoscopy, use the SHOCK rule: S — Shock (hemorrhagic). O — Organs (decompensation of heart, lungs, liver, kidneys). C — Coagulopathy (as well as cerebral pathologies precluding the tilting of the operating table).
Class and exam questions
In which cases is surgery immediately indicated for ovarian apoplexy?
Emergency intervention is required in the presence of more than 150 ml of blood in the abdominal cavity, hemodynamic instability, or worsening condition despite conservative therapy.
Is the ovary always removed during a rupture?
No, surgical treatment should be as conservative as possible. Radical removal (oophorectomy) is performed only for extensive damage incompatible with organ preservation.
What to do if severe bleeding starts during laparoscopy?
If bleeding cannot be stopped endoscopically or if hemorrhagic shock develops, it is necessary to urgently convert to laparotomy.
Is uterine fibroid a contraindication for laparoscopy?
Only large fibroids (more than 16 weeks of pregnancy) are considered a relative contraindication. In other cases, laparoscopy is successfully used for conservative myomectomy.
What else to study on this topic
- Differential diagnosis of the «acute abdomen» syndrome in gynecology.
- Surgical treatment of tubal pregnancy and tubal abortion.
- Organ-preserving surgeries for uterine fibroids (conservative myomectomy).
- Indications for radical uterine removal (hysterectomy).
- Management tactics for patients with nutritional impairment and necrosis of a myomatous node.
Master the entire topic in the "Obstetrics and Gynecology" course
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- Complete study guide on «Ovarian laparoscopy» and 973 more pages of the subject
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Other topics in the "Gynecology" section
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