Women's Corner
Women's Corner
1. Bilateral wedge resection :
- Indications : Failure of induction of ovulation
- Mechanism of action :
a. Removal of androgen producing cells in the ovarian stroma
b. Removal of the thickened tunica albuginea which acts as a mechanical barrier
c. Ovarian surgical trauma may correcr the error
- Amount removed : either
a. Enough to the leave an ovary with a normal size
b. 50% of the ovarian substance should be removed within the wedge (Te Linde)
- Principle :
· Incision : 2-3 cm in the ovarian convexity so as to create a small V-shaped segement of the ovarian tissue .
· Care is taken to avoid the hilum of the ovary to avoid heavy bleeding
· Types of wedge removed:
1. Classical : The base is toward the surface
2. Inverted : The apex is at the surface . It has the advantage of removal of much stroma with less cortical tissue .
· Closure : In 2 layers . The first layer with purse string suture of no. 5-0 polydiaxone (non-reactive) . The second layer is the same suture material in figure of 8 which approximates the ovarian stroma . A running suture of no. 7-0 polydiaxone is used to approximate the surface of the cortex .
- Route :
a. Laparotomy : with the principles as microsurgery (out of date)
b. Laparoscopic
- Complications :
1. Peritubal and periovarian adhesions .
2. Relapses are common .
2. Laparoscopic electrocautery (ovarian drilling) :
- Triple puncture and if neede a 4th puncture for irrigation can be done
- The ovarian ligament is grasped by Semm forceps
- Instruments : A special monopolar needle (Corson) is ideal as it is insulated except at its tip or Semm unipolar diathermy ferceps are used .
- Number of punctures and results :
· 5-8 cautery sites each is 2-4 mm in diameter and depth . The Current used is 300-400 (Novak) (25-30 [Sutton]) watts for 5-6 seconds . A pregnancy rate (90%) and a conception rate is 70% resulted .
· Later studies indicated that by decreasing the number of punctures to 4 ,. is similar to the original method with less adhesions and abortion rate (14%) .
- Immediate irrigation of the cauterized tissues is essential to avoid thermal effect on adjacent tissues .
- It essential to turn off the diathermy source at all times except when cautery is done .
- Complications :
1. Those of laparoscopy
2. Adhesions
3. Electrosurgical :
a. Direct electrode injury :
b. Current diversion
- The diversion can occur when the electrons find a path out of the patient’s body via grounded sites other than the dispersive electrode .
- Insulation defect affecting the shaft of the electrosurgical electrode may allow current diversion to adjacent tissue . Inspection of the instruments prior to the procedure can prevent this complication.
- Direct coupling occurs when the activated electrode touches and energizes another metal conductor . This can be prevented by removal of the electrode when not in use and visual confirmation of no contact.
- Capicitative coupling : All activated monopolar electrodes emit a surrounding charge , proportional to the voltage of the current . This makes the electrode a potential capacitator . Generally as the charge is allowed to disperse through the abdominal wall no ill-effects occur but if the return to the dispersive electrode is blocked by insulation e.g. plastic anchor, the current can directly couple to a conductive cannula or directly to the bowel . This can be prevented by all-plastic or all-metal cannula systems .
c. Dispersive electrode burns
If the dispersive electrode becomes partially detached reducing the surface area , the current may increase resulting in a skin burn .
dr. Hisham Al-Inany Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt Dr. Amr Hussein Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt