Laproscopy

Ans. is C. i.e. CO₂

• CO2 is the gas used to create pneumoperitoneum during laparoscopy.
• Another option is – N₂0: But it is expensive, less soluble in blood, and supports combustion.
• Gases used for pneumoperitoneum include carbon dioxide (CO2), air, oxygen, nitrous oxide (N20), argon, helium, and mixtures of these gases.
• CO2 gas insufflation is preferred by most laparoscopists because it has a high diffusion coefficient and is a normal metabolic end product rapidly cleared from the body.
• Also, CO2 is highly soluble in blood and tissues and does not support combustion.
• The risk of gas embolism is lowest with CO2.
• Cardiac arrhythmias can occur with CO2 pneumoperitoneum.
• Because of possible CO2 induced hypercarbia, N₂0 may be preferred in patients with cardiac disease. With prolonged procedures, CO2 retention is possible as evidenced by tachycardia and acidosis.

Also know :

• The instrument used for creating pneumoperitoneum is veress needle.
• Flow Rate of CO, for creating pneumoperitoneum 200 – 2000 ml/min & pressure between 15 – 25 mm of Hg.

COPD

CO₂

Laproscopy

10 – 15 mm of Hg

Ans. is D. Laparoscopy 

• In the given clinical condition first, it is important to know the status of uterus & ovaries present or absent for which imaging is required.
• Therefore, laparoscopy should be performed first.
• If the uterus is absent, a karyotype and serum testosterone level should be checked to distinguish between such conditions as müllerian agenesis and androgen insensitivity syndrome.
• If the uterus is present and there is no other lower genital anatomic abnormality, an endocrine evaluation should be performed.

Hysteroscopy + Laparoscopy

Laparoscopy

Ans. is d i.e. Fallopian tube

• Laparoscopic visualization of the pelvis is the most accurate method of confirming the diagnosis of an acute PID.
• However, it is not practical to advise diagnostic laparoscopy to all patients of PID,

Indications of Laparoscopy in Acute PID :

• Patients not responding to therapy, to confirm the diagnosis.
• To obtain cultures from a cul-de-sac or fallopian tube.
• To drain pus if necessary.
• Thus, cultures can be obtained from both cul-de-sac and fallopian tubes (commonly from Fallopian Tubes).

Te Linde’s Operative Gynae. 9/e, p 679 further says -“Laparoscopy is an excellent means of obtaining cultures directly from the tubes.” 

Ans. is A. i.e. CO₂

CO₂ is the gas used to create pneumoperitoneum during laparoscopy.

• Another option is N₂0. But it is expensive, less soluble in blood, and supports combustion.
• The ideal gas for pneumoperitoneum should be nontoxic, colorless, readily soluble in blood, easily ventilated through the lungs, nonflammable, and inexpensive.
• Carbon dioxide is the standard gas used for pneumoperitoneum. Nitrous oxide is dangerous because of unpredictable and uncontrollable absorption into the bloodstream.
• Identifying an ideal insufflation gas to replace carbon dioxide attracts the attention of some researchers in the era of laparoscopic surgery.
• Various gases, such as helium, argon, nitrogen, nitrous oxide, and room air, have been introduced as alternatives to carbon dioxide to establish pneumoperitoneum.
• However, their uses are controversial. Helium and argon are inert gases that may offer some advantages over carbon dioxide. Nevertheless, they are less soluble than carbon dioxide, which might increase the risk of venous gas embolism.
• Nitrous oxide, also known as laughing gas, is a mild anesthetic. It may reduce postoperative pain theoretically because of its anesthetic and analgesic properties. However, there have been cases of explosion using electrocautery during laparoscopy, and the risk of explosion when using nitrous oxide insufflation remains controversial.

Also know :

• The instrument used for creating pneumoperitoneum is a veress needle.
• Flow Rate of CO2 for creating pneumoperitoneum 200 — 2000 ml/min and pressure between 15 — 25 mm of Hg.

11-15 mm Hg REF: Maingot’s 10^th ed p. 243

The intrabdominal pressure during laparoscopy is monitored by insufflator and it is set between 12-15 mm Hg.

Diagnostic Laproscopy REF: Novak’s Gynecology 13^th edition Chapter 15

Traditionally, the diagnosis of PID has been based on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal tenderness, and the presence of fever.

More elaborate tests may be used in women with severe symptoms because an incorrect diagnosis may cause unnecessary morbidity. These tests include endometrial biopsy to confirm the presence of endometritis, ultrasound or radiologic tests to characterize a tuboovarian abscess (TOA), and laparoscopy to confirm salpingitis visually.

Laparoscopy currently provides the most accurate way to diagnose salpingitis. It should be used when the diagnosis is unclear, particularly in patients with severe peritonitis, to exclude a ruptured abscess or appendicitis.

Shoulder pain is although a minor complication is exceedingly common and is due to the presence of a significant amount of residual carbon dioxide in the peritoneal cavity, trapped under the diaphragm and causing irritation of the diaphragm and thus referred pain to the shoulder through the phrenic nerve.

Laparoscopy

Cholecystectomy is the definite line of treatment for patients with acute cholecystitis.

Early cholecystectomy performed within 2-3 days of presentation is preferred over interval or delayed cholecystectomy.

Laparoscopic surgery can be performed under local anesthesia, but general anesthesia is preferable. Under local anesthesia, N2O is used as the insufflating agent, and insufflation is stopped after 2 L of gas is insufflated or when a pressure of 10 mmHg is reached.

Laparoscopy is the primary method used for diagnosing endometriosis.

Laparoscopic findings are variable and may include discrete endometriotic lesions, endometrioma, and adhesion formation.

The pelvic organs and pelvic peritoneum are typical locations for endometriosis. Lesions are variable colors, which may include red, white, and black.

Laparoscopic visualization of ovarian endometriomas has a sensitivity and specificity of 97 percent and 95 percent, respectively.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 10. Endometriosis. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.

Ans. is `d’ i.e., Carbon dioxide 

Ans. is ‘c’ i.e., Minimally absorbed 

Ans is ‘d’ i.e. Gaseous embolism through splenic vessels 

• A sudden drop in pO2 immediately during the induction of pneumoperitoneum suggests the possibility of gas embolism as a result of the entry of insufflating gas into circulation through the tear in splenic vessels.
• Gas embolism may also have resulted from inadvertent insertion of the trocar or veress needle into a vessel or abdominal organ.
• Most commonly seen during induction of pneumoperitoneum at the time of insufflation of gas from unintended insufflations of gas directly into an open vein.
• CO2 is preferred for pneumoperitoneum as it is highly soluble in blood and is rapidly eliminated.
• CO2 Embolism: An initial rise in ET-CO2 due to pulmonary excretion of absorbed CO2 is followed by a sudden decrease due to a fall in cardiac output.

Ans. is (b) i.e. 10-15mm of Hg 

The infra-abdominal pressure during laproscopic surgery is monitored by insufflator. The pressure is set between 12­15 mm of Hg. because at higher pressures there is risk of hypercarbia, acidosis and adverse hemodynamic and pulmonary effects.

Ans is b ie CO2 retention 

Shoulder pain is although a minor complication is exceedingly common and is due to the presence of a significant amount of residual carbon dioxide in the peritoneal cavity, trapped under the diaphragm and causing irritation of the diaphragm and thus referred pain to the shoulder through the phrenic nerve.

Ans. B: Laparoscopy

• Physical examination
• Pregnancy test (to rule out anectopic pregnancy)
• White blood cell test (to rule out appendicitis)
• Genital culture (to look for gonorrhea and chlamydia).
• An endometrial biopsy (tissue sample removed from the endometrium)
• Sonogram (if abscesses are suspected)
• Culdocentesis (fluid sample taken from uterine sac)
• Laparoscopy are done.

Laparoscopy is considered the “gold standard” for diagnosis of PID, because it allows visualization of the pelvic organs. The procedure involves inserting a tiny, flexible lighted tube through a small incision just below the navel.

This procedure is recommended when results of the preliminary tests (physical exam, blood tests and cultures) are unclear.

Ans. A i.e. CO₂

Ans. D: Endometriosis

Indications for gynaecological laparoscopy include the following:

• Ovarian cysts and tumours.
• Removal of fibroids (Myomectomy).or destroying them (Myolysis)
• Infertility, lysis of adhesions.
• Infertility, checking the condition and patency of the fallopian tubes.
• Reproductive or tubal surgery
• Endometriosis
• Intraperitonal Haemorrhage
• Polycystic Ovaries
• Pelvic infection (Pelvic Inflammatory disease)
• Egg collection for assisted reproduction
• Sterilization (laparoscopic Sterilization)
• Severe period pain
• Diagnosis and treatment of some uterine anomalies
• Pelvic floor and vaginal prolapse
• Urinary incontinence

Ans. D: Laparoscopy and hysteroscopy

Laparoscopy is combined with hysteroscopy as a comprehensive one-stop infertility work-up, to detect cause of infertility and treat the cause in one go

Ans. Laparoscopy

Ans. b. Diagnostic laparoscopy

• Clinical features of infertility, dyspareunia, and cyclic pain are highly suggestive of endometriosis. Laparoscopy is a gold standard for diagnosis of endometriosis