Fig 31.1
Trocar 10 mm
Fig. 31.2
Trocar 10 mm, Veress needle
Laparoscopy is performed via three ports of entry after insufflation of the peritoneal cavity by electronic high-flow pneumoperitoneal insufflators with carbon dioxide gas. A 10-mm laparoscope is inserted through 10-mm port in the inferior crease of the umbilicus into the abdominal cavity with two additional 5-mm ports (Fig. 31.3) in the left and right iliac fossae, and a diagnostic laparoscopy with chromotubation for tubal patency is done.
Fig. 31.3
10-mm and 5-mm laparoscope
An atraumatic grasping forceps (Fig. 31.4a, b) is used to hold the ovarian ligament to stabilize the ovary and to perform the ovarian drilling using an insulated unipolar electrocautery needle electrode, on both ovaries.
Fig. 31.4
Plain (a) and toothed (b) grasper (plain grasper should be used as it is atraumatic)
The uninsulated part of the needle is 8 mm long and its diameter is <1 mm (Fig. 31.5a, b). The needle is inserted into the ovarian surface as close to and as perpendicularly as possible. A short duration of a cutting current of 100 W is used to aid the entry of the needle. The whole length of the needle is inserted into the ovary and is activated for 2–3 s with 40 W of coagulating current at each point. A total of 4–5 punctures per ovary are created, depending upon the size of the ovary (Fig. 31.6a–d).
Fig. 31.5
(a, b) Monopolar needle has an open end 8 mm long, which can be inserted in ovaries
Fig. 31.6
(a–d) Laparoscopic ovarian drilling. (a) Bulky ovaries with multiple cysts lying in the ovarian fossa. (b) Ovaries being held with plain grasper. (c) Monopolar cautery brought near the ovaries for ovarian drilling. (d) 4–5 punctures made in ovary with monopolar cautery with a 100-W current
After drilling, the ovary is allowed to cool in a pool of saline to prevent excessive heat trauma. The abdominal cavity is then rinsed with 500–1,000 cc of sterile saline with suction and irrigation cannula (Fig. 31.7) to remove blood and coagulated tissue and minimize postoperative adhesion.
Fig. 31.7
Suction and irrigation cannula, after ovarian drilling to wash the ovaries with normal saline
31.4.3.3 Mechanism of Action
The mechanism of action of LOD is thought to be similar to that of ovarian wedge resection. Both procedures may destroy ovarian androgen-producing tissue and reduce the peripheral conversion of androgens to estrogens (one of the many disturbances of endocrine physiology that occur in women with polycystic ovarian syndrome).
A fall in the serum levels of androgens and luteinizing hormone (LH) and an increase in follicle-stimulating hormone (FSH) levels have been demonstrated after LOD [9, 10]. The endocrine changes following the surgery are thought to convert the adverse androgen-dominant intrafollicular environment to an estrogenic one and to restore the hormonal environment to normal by correcting disturbances of the ovarian–pituitary feedback mechanism. Thus, both local and systemic effects are thought to promote follicular recruitment, maturation, and subsequent ovulation [11].
31.4.3.4 Advantages
With ovarian drilling, studies have shown (Table 31.1) [6, 9, 12–17] that there has been decrease in pregnancy loss, in subsequent ovulation induction ovaries become more responsive, and less ovulation induction drugs or gonadotropins are needed [6, 7, 9].
Table 31.1
Various studies showing the effect of LOD on pregnancies
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