Laparoscopy is a well known minimal invasive surgery.  This procedure places ports, which vary in size from 5 mm (less than 1/4 of an inch) to 12 mm (less than 1/2 an inch),  throughout the abdomen.  The abdomen is then distended with gas (CO2).  A small telescope is introduced into the abdominal area for visual examination.  This telescope is  connected to a dedicated camera, a common feature in the performance of minimal invasive surgery, that can provide both a magnified or panoramic view using a video monitor.  Additonal ports are typically required to place special instruments to operate (operative laparoscopy).  Laser can also be used in a technique call video laser laparoscopy.  Many surgeries are done utilizing this technique with good results in gynecology, general, pediatric, chest, orthopedic, urology and vascular surgery.  These are  hospital procedures usually done under general anesthesia.  (Major contributions by Drs. R.Palmer- K. Seems .-T.F. Dillon-F. Nezhat- H. Reich- J.M. Phillips.)

Port: a point of entrance established with a trocar.

Trocar: a surgical instrument used to enter cavities consisting of a tube, either metalic or plastic, into which fits an obturator.  Subsequently, the obturator is removed and the tube is used to place either a telescope or surgical instruments.

Minilaparoscopy: A procedure similar to laparoscopy that uses smaller ports placed in the abdomen.  The size of these ports placed in the abdomen are less than 5 mm ( or 1/4 of an inch). This provide enough light for some procedure with less panoramic view than laparoscopy.  other limitations are limited light. heavy suction, irrigation and extraction of surgical specimens. Advantages, better cosmetic results. less chances of complications associated with the use of larger ports. These procedure could be done under local or general anesthesia. This surgery is performed in office surgical suites or in hospital procedure.

Microlaparoscopy: A procedure similar to Minilaparoscopy.  The size of the ports placed in the abdomen is less than 2mm.

Hysteroscopy:  is a telescopic view  of the uterine cavity. rigid or flexible instruments are used for diagnostic and treatment of severe  vaginal bleeding (metrorrhagia)., uterine polyps, uterine myomas ( fibroids)infertility, uterine septum, uterine deformities, uterine scars and post menopausal bleeding..
major contributions by Drs. R. Quinones- R.S. Neurewith, R.F. Valle, H.A. Goldfarb.  This could be an office or hospital procedure . Could be done with either local or general anesthesia..  Could be done in a office or hospital  depending the extent of the procedure.

Culdoscopy: A delicate surgical technique that places a port 5 mm to 12 mm in size in the vagina and into the pelvic cavity to visualize and operate. " One of the advantages of culdoscopy is that is a less traumatic procedure" than laparoscopy.  Major contributions by  Drs. A. Decker-E. Klaften-M. Cohen. Culdoscopy uses a rigid type of telescope for visualization. The visual angle of the  telescopes vary form 0 to 90 degrees. A patient  could be place  lying down ( lithotomy) or in her knees ( knee -chest posture)  for this operation. Distention may not be  required in the knee-chest posture. most cases  required gas distention  for visualization. It is use for diagnostic in infertility , pelvic pain and surgeries like tubal ligation, ovarian cyst, lysis of adhesions, biopsy of  endometriosis. This could be done with local, regional or general anesthesia.. Mostly is an Hospital procedure. was done occasional as an office procedure.

Flexible Culdoscopy:  Uses  5 mm or smaller ports than in Culdoscopy. A flexible type of telescope allows a retroview by curving the flexible scope from 0 to 180 degree angles. Contribution by J.D. Paulson, J.W. Ross, S. El-Shawi. This is a new procedure  the indications are similar than Culdoscopy. The advantage , no blind spots as in Culdoscopy ( the bottom of the cul-de-sac and the anterior face of the uterus).

Transvaginal Hydrolaparoscopy:  related with Culdoscopy  uses liquid for distention ( Normal saline at body temperature) using small  diameter optics this procedure offers a less panoramic view than Laparoscopy, Microlaparoscopy or Culdoscopy.  I use for diagnostic procedures  mostly in infertility and minor operations in tubes, lysis of adhesions, ovarian cystectomies, ovarian drilling and vaporization of endometrials implants. Contributions by S. Gordts, R.Campo, L. Rombauts, I Bronsen. and also by A. Watrelot, D.J. Turner, J.M. Dreyfus, J.P. Andine, M. Cohen. Advantage is a well tolerated procedure could be done as an office procedure. without general anesthesia.

Culdoscopy Assisted Laparoscopy:  Uses Culdoscopy to assist Laparoscopy or Microlaparoscopy. Takes the advantages of both techniques. From the less traumatic Culdoscopy , by placing the larger need port  via the vaginal route.  this port is use as visual and extracting. This allows the use of smallest abdominal ports for operative or place small telescopes like in Microlaparoscopy. The Culdoscopy entrance of the trocar is done under Laparoscopy surveillance. Contribution D.A. Tsin. New procedure for indications see Culdolaparoscopy. Use for major surgical operations in hospital procedures.

Culdolaparoscopy: Similar than Culdoscopy assisted laparoscopy surgery. Combines Laparoscopy  and Microlaparoscopy with Culdoscopy. The functions of all ports can change from visual to an operative aid depending on the nature of the procedure or stage of the operation. Contribution by D.A. Tsin. new procedure was use successfully in  Appendectomy, Cholecystecomy, Hysterectomy, Myomectomy, Oophorectomy Salpingoophorectomy

Appendectomy Appendix
Cholecystectomy Gallbladder
Hysterectomy Uterus
Myomectomy Fibroid
Oophorectomy Ovary
Salpingoophorectomy Tube and ovary

The advantage of Culdoscopy Assisted Laparoscopy Surgery and Culdolaparoscopy is to reduce the number as well as the size of the abdominal ports. This technique is cosmetically better, while at the same time reduces the risk of complications such hernias or injuries associated with bigger abdominal ports.

Surgeries Without Scars
Paris, France.

Many surgical procedures for women could be done in a manner that results in no visible scars thanks to an innovative approach call Culdolaparoscopy. The approach was presented by Dr. Daniel A. Tsin, Associated Chief of Gynecology of The Mount Sinai Hospital of Queens, Astoria, New York, U.S.A. at the 2nd World Congress on Controversies in Obstetrics and Gynecology held in Paris, France from September 6-9, 2001.

The technique requires the use of 3-millimeter (approximately one-eighth of an inch) instruments that are placed through the abdominal skin. Given the smaller size of the instruments, as compared to those typically used in laparoscopy, no stitches are required for closure of the skin. A scab formed in the area of the surgery falls several days later usually leaving no marks on the abdomen.

Some surgeons currently use these smaller instruments, however their use is in conjunction with an additional and larger abdominal incision either for the placement of a larger instrument or for extraction during the performance of the surgery. Because of the size of the larger incision, these types of surgeries tend to produce more visible scarring. In contrast, Culdolaparoscopy uses a non-visible incision in the vaginal fornix (the roof of the vaginal wall) instead of the larger abdominal incision.

Culdolaparoscopy, although still in the early stages of implementation, has been used approximately 100 selected cases. Although scar formation can be difficult to predict, in most of the aforementioned cases the surgery resulted in no permanent marks. In a few cases, there was a slight change in skin pigmentation covering an area of less than 3 millimeters. This approach has been used in the removal of the appendix, gall bladder, fibroids, ovaries and uterus.

Culdolaparoscopy is a new contribution to the ever-evolving field of surgery. The movement from large scars to no scars is an attractive way to go.

Literature on Culdolaparoscopy:

1. Culdolaparoscopy a preliminary report
Tsin D.A. J Soc. Laparoendosc Surg 2001;5:69-71

2. Operative Culdolaparoscopy: A novel approach combining operative culdoscopy
with minilaparoscopy, Tsin DA, Colombero LT, Mahmood D, Padouvas J, Manolas P. J Am Assoc Gynecol Laparoscopists. 2001;8:438-441

3. Development of flexible culdoscopy (letter). Tsin DA, J Am Assoc Gynecol
Laparoscopists 2000;7:440

4. Culdolaparoscopic Oophorectomy with Vaginal Hysterectomy: An Optional
Minimal-Access Surgical Technique. Tsin DA, Bumaschny E, Helman M, Colombero LT. J Laparoscopic & Advanced Surgical Techniques 2002;12:269-271

5. Vaginal extraction of the intact specimen following laparoscopic radical
Nephrectomy (letter). Tsin DA, J Urol 2002;188:1110

6. Culdolaparoscopic cholecystectomy during vaginal hysterectomy. Tsin DA,
Sequeira RJ, Giannikas G. J Soc Laparoendoscop Surg. 2003;7:171-172

7. Evolucion de la Culdoscopia : Un siglo de evolucion en Ventroscopia.
Cirugia Laparoscopica y Videoasistida en Ginecologia. Pag 394-398.
Editor: Dr. Pablo Rebon. Published by CiLap, Buenos Aires, Argentina. 2004

Evolution

Colpotomy is a well known method to extact cysts, ovaries and fibromas it was also used by surgeons to extract appendix and gallbladder during laparoscopy. Historically a more resourceful use of colpotomy was presented by Dr. Dmitri Ott at the Meeting of The Gynecology and Obstetrical Society of Saint Petersburg in Russia held on April 19, 1901; that was the introduction of Ventroscopy. Dr Ott adapted an operating table able to provide Trendelenburg positions. He performed a colpotomy. A cotton filter was placed in the vagina, with the patient on the table head downward and pelvis upward , the abdomen vacuumed the filtered air into the abdominal cavity. In this position, a combination of a vaginal retractor and tube were placed for the exposure of the abdomen and the illumination was provided with a peanut-size lamp and a spoon-shaped shield to protect the patient from burn, while reflecting the light into the cavity.

In the meeting of the Medical Society of Wien in 1937, Dr. Emanuel Klaften presented the technique of Colpolaparoscopy. Dr Klaften designed an optical instrument with a light source and a 90-degree angle lens. The lens had shutters that covered the optic and light sources, which kept it clean during its introduction from the posterior vaginal fornix into the cul-de-sac. With the patient in the lithotomy position, Dr. Klaften used this technique for diagnostic and small surgical procedures.


Decker culdoscope (Circa 1950 )


Decker culdoscope (Circa 1950 )

Drs. A. Decker and T. Cherry described Culdoscopy in 1944. The patients were in the knee-chest posture, which allowed for even better visualization. Most of the studies were performed at Knickerbocker Hospital located in Uptown Manhattan, New York. Culdoscopy was the preferred method used by gynecologists for more than 25 years, with thousands of cases performed worldwide. Diagnostic and operative procedures were done with either local or general anesthesia. Patients were prepared with vaginal antiseptics and prophylactic antibiotics. Complications were rare, and mostly related to extraperitoneal bowel perforation, which required a prolonged antibiotic treatment.

During the 1960’s, with the development of safer techniques to build a pneumoperitoneoum, gynecologists became impressed with the wider visual field provided by laparoscopy vs. culdoscopy, and the advantages were obvious. Culdoscopy became abandoned in favor of laparoscopy. I had the opportunity to serve as the Director of the Gynecology Endocrine Clinic at Knickerbocker Hospital, in 1975. By then, culdoscopy was no longer practiced, having been replaced by laparoscopy. While ventroscopy, colpolaparoscopy and culdoscopy appeared forgotten, the utilization of laparoscopy was growing, and along with it benefits of the new technology; among them were fiber optics, hundreds of new instruments, and robotics. Eventually the new technology was used in the aforementioned forgotten techniques.

Transvaginal Hydrolaproscopy, a related technique to culdoscopy, was introduced in 1998 utilizing new technology. Placing a 3mm in diameter culdoscope, and using normal saline as a distention media, this office-based procedure is performed with the patient in the lithotomy position, and anesthesia is not required. The procedure is used as a diagnostic tool for infertility, pelvic pain, and endometriosis. Other minor operative procedures could also be done. This technique could save some laparoscopic procedures and more surgical procedures in the near future.

A Flexible Culdoscopy, flexible instrument technology is used for the visualization of the pelvic. This device is used in the knee-chest posture. The flexible culdoscope gives a range from a 0 degree to 180 degrees angle to view. This permits the view of the blind spots of rigid instruments like the bladder, anterior uterine surface, and depth into the posterior cul-de-sac.

I began utilizing a vaginal port, also in 1998, specifically to assist with minilaparoscopy. The project began utilizing a 12 mm trocar inserted into de cul-de-sac under minilaparoscopic surveillance. This is a new concept where the function of the ports change, depending on the nature or stage of the procedure. The surgeon has the opportunity to utilize different size scopes, and the team has the ability to operate from different angles, triangulations, and at times, against the optics. We use two monitors most of the time; one is at the caudal point and the other cephalad. The monitors have to be mobile, so as to allow a view for both the surgeon and the assistant when operating lateral to the patient, or between the patient’s legs. I used this technique for gynecological procedures, appendectomies and cholecystectomies. I presented the preliminary findings at The Global Congress of Gynecological Endoscopy , Sponsored by The American Association of Gynecologic Laparoscopist in Las Vegas Nevada , November 1999 and at The 8th International Meeting of The Society of Laparoendoscopic Surgeons , New York , New York, December 1999.

During 1999 I began another usage from this approach in the visualization and operation during vaginal hysterectomy. This time the resemblance to ventroscopy was obvious. I was able to insufflate, visualize the abdomen, and perform simultaneous cholecystecomies, difficult oophorectomies, and salpingoophorectomies. Later, I used the posterior colpotomy for the same task.

Culdolaparoscopy: the technique which included the association of culdoscopy with laparoscopy and minilaparoscopy, was officially presented at the XVI FIGO World Congress of Gynecology and Obstetrics on September 8, 2000 in Washington , D.C.

Drs. Taniguchi E, Ohashi S., Ionue Y., Mizuhima T., Itou T. and Matsuda H. presented the same approach for gastric submucosal tumors and large bowel resections at The 10th Annual Meeting of The Society of Laparoendoscopic Surgeons , New York, New York, December 2001.