Laparoscopy in private practice

The technique of laparoscopy is described together with indications and contraindications. A list of operative procedures and illustrative case histories are included. A plea is made for training young gynaecologists in the use of this technique.From 1963 to 1968 it was our practice to do culdoscopic examinations of the pelvis, but since then we have changed over entirely to laparoscopy. This procedure has been popularized in the UK by Steptoe.' The disadvantages of culdoscopy are:(a) The knee-chest position in which the patient is placed and held by a Clover's clutch is not favoured by the anaesthetist, because of the respiratory embarrassment which may occur. Patients often complain of pain along the sites where the shoulder straps are plaoed. When the procedure is prolonged, puffiness of the eyes and echymosis may occasionally result.(b) The view of the pelvis is very limited compared to that possible with the laparoscope, and besides is limited to the posterior surface of the uterus and the accessible ovaries and tubes. During laparoscopy a probe introduced through a second cannula is used to push aside bowel or momentum which may obscure the vision. This cannot be done during culdoscopy.(c) In the presence of 'pelvic adhesions culdoscopy cannot be performed.A small vagina, especially one with a narrow vault, makes culdoscopy difficult, if not impossible. Decker' considers culdoscopy superior to laparoscopy because it gives a better view of the pelvic organs. From 1969 onwards laparoscopy only has been used. The increased safety of this procedure is due to two factors: CO, gas is introduced to effect a pneumoperitoneum (we use a Wolff' air-insufflation instrument which allows a carefully regulated entry of gas at between 10 - 30 mmHg pressure); and a light source from outside the abdomen with the light conducted along fibre-optic guides prevents overheating of the light tip (this is a safeguard against accidents through electrical faults)