Carrying out culdocentesis in gynecology: rationale, technique, complications of the intervention. How to perform a puncture of the abdominal cavity through the posterior fornix
A biopsy and histological examination of the obtained tissue make it possible to clarify the nature of the pathological process of the cervix, vagina and external genitalia. Preparation for surgery is the same as for diagnostic curettage. Compliance with asepsis and antiseptics is mandatory.
Kit necessary tools: spoon-shaped mirrors, forceps, tweezers, bullet forceps (2), scalpel, scissors, needle with needle holder, catgut. Sterile material, alcohol, and tincture of iodine are also needed.
The resulting piece of tissue is placed in a formalin solution and sent for histological examination with the appropriate direction.
If cervical cancer is suspected, in addition to excision of a piece of tissue, the mucous membrane of the cervical canal is scraped.
Aspiration biopsy can be used to obtain material from the uterine cavity. For this purpose, a special Brown syringe is used, equipped with a long tip with a smooth rounded end. In addition to the Brown syringe, glass slides are required, onto which the aspirate is applied, air dried, and transported to the laboratory.
Puncture abdominal cavity. Abdominal puncture is performed through posterior arch vagina and anterior abdominal wall. A puncture is performed through the posterior fornix if a tubal pregnancy is suspected, sometimes in acute inflammatory processes of the uterine appendages and pelvic peritoneum in order to detect blood, serous or purulent effusion in the abdominal cavity.
Puncture through the anterior abdominal wall is performed in the presence of ascites. Ascitic fluid is examined for the content of atypical cells to exclude malignant tumor. The absence of atypical cells in ascitic fluid may indicate a connection between ascites and some kind of heart disease, cirrhosis of the liver.
A set of necessary instruments for puncture through the posterior vaginal fornix: spoon-shaped mirrors, forceps (2), bullet forceps, syringe with a long needle (12-15 cm) with side holes. Sterile material, alcohol, and tincture of iodine are also needed.
Preparing the patient, as for diagnostic curettage. Asepsis is mandatory. At tubal pregnancy dark blood with small clots is obtained. When receiving a serous or purulent effusion, it is necessary to carry out a bacteriological examination (the punctate for culture is collected in a sterile tube with a stopper).
After the operation, the patient is transported to the ward on a gurney.
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This topic belongs to the section:
Gynecology. Complaints: leucorrhoea, pain, bleeding, dysfunction of adjacent organs, sexual dysfunction, itching of the external genitalia
Any gynecological pathology has very similar symptoms, so no matter what pathology a woman comes with, her complaints are... complaints of leucorrhoea, pain, bleeding, dysfunction of adjacent organs.. there are many other complaints, but these complaints are the main ones..
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Research methods
1. Anamnesis collection. Great attention is paid to it, since, for example, errors in ectopic pregnancy often associated with a poorly collected medical history. During collection, the main functions are clarified
Additional research methods
To clarify the diagnosis, resort to additional methods research. Of these methods, it is necessary to highlight those that are currently used by all gynecological patients, as well as healthy women.
Bacterial research
It is used to diagnose inflammatory processes and allows you to determine the type of microbial factor. Bacterioscopy vaginal discharge helps determine the degree of vaginal cleanliness, which
Research using bullet forceps.
This study helps clarify the connection of the tumor with the genital organs. It is used when it is unclear whether the tumor comes from the uterus, appendages or intestines.
A set of necessary tools
Diagnostic curettage of the mucous membrane of the cervix and uterine body Curettage of the uterine mucosa and histological examination of the scraping have diagnostic value and give an idea about cyclical changes
endometrium, the presence of pathological p
X-ray methods.
Hysterosalpinography is performed to determine the patency of the fallopian tubes and is most often used in women suffering from infertility.
The most widely used endoscopic methods in gynecological practice are hysteroscopy, culdoscopy and laparoscopy. Devices are used for all endoscopic methods
Study of the functions of the fallopian tubes.
To check the patency and functional capacity of the fallopian tubes, the method of introducing air (perturbation) or liquid (gendrotubation) into the tubes is used. Indications: infertility
Study of ovarian function.
Ovarian function is judged by tests functional diagnostics(cytological picture of a vaginal smear, pupil phenomenon, arborization phenomenon cervical mucus(fern symptom), rectal (basal
In modern medicine there are many different ways diagnostics that can quickly and accurately confirm or refute the suspected diagnosis. Some techniques are simple and do not require any special preparation from patients. Moreover, the procedures themselves are carried out quickly, without any effort. Other methods can cause discomfort, but it is impossible to do without them. One of these manipulations is puncture of the posterior vaginal fornix.
Features of the procedure
Puncture of the posterior vaginal vault has its own characteristics. It is carried out for diagnostic purposes to identify the contents of the rectouterine cavity. Less commonly, this procedure is performed as an auxiliary procedure.
Puncture of the posterior vaginal fornix requires anesthesia. Patients are given short-term anesthesia or local conduction anesthesia.
For diagnosis to be effective, the patient must lie down so that her pelvis is downward. This position helps to drain even a small amount of fluid located in the rectal-uterine area. This greatly increases the effectiveness of the manipulation.
Indications
Puncture of the posterior vaginal vault is used if there is a suspicion of other internal organs, and:
- if you suspect the presence of any type of fluid in the pelvis;
- administer medications if necessary;
- if you suspect ovarian cancer;
- upon breakthrough purulent pathologies into the abdominal cavity.
Puncture through the posterior vaginal fornix allows you to accurately determine the presence of fluid and its type without surgical intervention.
Where is the procedure performed?
The manipulation is carried out only in a hospital, since it is surgical appearance interventions. During the procedure, all rules of antiseptics and asepsis are observed. Before the puncture is performed, the patient must empty bladder and intestines. For these purposes, a cleansing enema may be prescribed.
Most often, nitrous oxide or any other mask anesthesia is used for anesthesia. General intravenous anesthesia and local anesthesia in the form of a solution of novocaine.
How is it carried out?
Puncture of the abdominal cavity through the posterior vaginal fornix is performed with a long, thick needle. Its size is more than ten centimeters. The needle is placed on a 10- or 20-gram syringe.
The patient is positioned in After placement, doctors treat the woman’s external genitalia. Typically, a solution of iodonate is used for this. A speculum and a lift are then inserted into the vagina to help determine the location of the cervix. The doctor grabs the organ by back lip with tongs. After this, the lift is removed and the mirror is handed over to the assistant.
The doctor makes a puncture under the cervix with a needle. It is performed by stepping back a few centimeters from the junction of the vagina and the cervix. At the selected location, the needle is inserted into the abdominal cavity. During the puncture, the specialist feels how the instrument for puncture of the posterior vaginal vault has entered the void. Then the doctor pulls the piston towards himself. If there is liquid in the recess, it begins to flow into the syringe.
Liquid and its meaning
The item is examined to determine its character. As a result of the procedure, blood and pus may be detected. According to indications, a bacteriological, cytological or other type of analysis of the resulting fluid is performed.
If purulent contents appear, the doctor may suspect rupture of the abscess, peritonitis. The presence of pathological contents may indicate an abscess of the uterine appendages.
If there is blood in the depression, this indicates bleeding. It can be caused by a rupture of the fallopian tube during an ectopic pregnancy. In this case, the blood has a dark color mixed with clots. It can also fall into the recess due to a rupture of the internal vessel. In this case, it quickly collapses.
There are times when the doctor is unable to get the fluid, although it is present in the cavity. This version of the procedure is due to the fact that the needle becomes clogged with a blood clot. In order for the doctor to get a result, he must remove the needle and push the clot out of it with air. This is usually done on a napkin so that the presence of blood can be determined. If a clot is obtained and there is no blood in the syringe barrel, then even this will be enough to suggest an ectopic pregnancy.
It happens that it is not possible to suck out the liquid from the cavity because the density is too high. In this situation, a sterile sodium chloride solution is injected into the cavity to dilute the fluid. In this more liquid state, the solution is easily collected and transferred to the laboratory for analysis.
After manipulation
At the end of the procedure, the set used for puncture of the posterior vaginal vault is disinfected. If a disposable instrument was used, it should be disposed of.
After surgery, patients can go home. Complications after puncture occur extremely rarely.
Blood can be detected not only during ectopic pregnancy, but also during other pathological conditions. For example, it appears with ovarian apoplexy, rupture of the spleen, menstrual blood entering the fornix and other types of pathologies.
If purulent contents are revealed during the puncture, the doctor will suck it out and inject an antibiotic into the cavity.
Puncture is an informative procedure performed not only for diagnostic, but also for therapeutic purposes. Through a puncture, the doctor can quickly inject medicine exactly to the affected area.
Rationale for the culdocentesis method
Abdominal puncture through the posterior vaginal fornix (culdocentesis)- the closest and most convenient access to the pelvic cavity (rectumuterine recess, pouch of Douglas), where fluid (blood, pus, exudate) accumulates under various pathological processes, most often of gynecological origin.
Puncture of the abdominal cavity through the posterior vaginal fornix is performed in a hospital in cases where it is necessary to determine the presence or absence free liquid(blood, pus, serous fluid) in the pelvic cavity. The resulting serous fluid is sent for bacteriological and cytological examination(for diagnostics inflammatory process in the pelvic cavity or early diagnosis ovarian cancer).
PURPOSE OF THE STUDY
Detection of blood or other fluid accumulation in the abdominal cavity. Differential diagnosis various diseases(ectopic pregnancy, rupture of ovarian cyst, ovarian apoplexy, inflammatory diseases, ovarian tumors, suspicion of malignancy, etc.) based on the nature of the fluid obtained from the abdominal cavity during aspiration.
INDICATIONS FOR CULDOCENTESIS
In the past, the most common indications were suspected ectopic pregnancy and ovarian apoplexy (currently laparoscopy is replacing this method of examination). Rare indications for puncture include PID and suspected malignancy.
PREPARATION FOR THE STUDY
Necessary tools (Fig. 7–47): spoon-shaped mirrors, bullet forceps, forceps, a 10 ml syringe, a puncture needle 10–12 cm long with a wide lumen and an obliquely cut end.
Rice. 7-47. Instruments for puncture of the abdominal cavity through the posterior vaginal fornix.
PUNCTION METHOD
Below the cervix in the area of the posterior fornix between the divergent uterosacral ligaments, the peritoneum comes very close to the walls of the vagina. It is in this place that a puncture of the abdominal cavity is performed through the posterior vaginal fornix. After treating the external genitalia and vagina with alcohol and a 2% iodine solution, the vaginal part of the cervix is exposed using mirrors, the posterior lip of the uterus is grabbed with bullet forceps and pulled anteriorly down. A thick long needle, put on a syringe, is inserted into the thus stretched posterior vaginal vault strictly along the midline (between the uterosacral ligaments) to a depth of 1–2 cm (Fig. 7–48). The liquid is removed by the reverse movement of the piston or simultaneously with the slow removal of the needle, then it is subjected to bacteriological and/or cytological examination.
Rice. 7-48. Abdominal puncture through the posterior vaginal fornix.
INTERPRETATION OF RESULTS AND FACTORS AFFECTING THE RESULT
Puncture as a diagnostic method is most often used when a terminated ectopic pregnancy is suspected: with fresh accumulation of blood in the rectal sac, blood enters the syringe immediately after the puncture thin wall posterior fornix. If the needle passes a certain distance after the puncture and the blood entering the syringe is thick, dark with clots (from a hematocele), then this indicates an ectopic pregnancy. The results of a puncture of the abdominal cavity can be either false positive (if the needle enters a vessel of the parametrium, vagina or uterus) or false negative (defect in the lumen of the needle, accumulation of a small amount of blood in the abdominal cavity or severe adhesive process in the area of the uterine appendages). Sometimes during puncture they receive not dark blood, but serous fluid with a hemorrhagic component, which does not exclude a disturbed ectopic pregnancy. Blood can be detected with ovarian apoplexy, splenic rupture, as well as with reflux of menstrual blood and after curettage of the uterus. In this regard, laparoscopy is more preferable.
In some cases, puncture is used if an abscess of the uterine appendages (pyovar, pyosalpinx) is suspected, if its lower pole is close to the posterior vaginal vault. When pus is extracted, antibiotics are injected into the cavity of the purulent tumor. In case of inflammatory diseases of the genital organs that occur with the formation of exudate in the rectal uterine cavity, a puncture is performed to determine the nature of the exudate (purulent, serous) and laboratory research punctate for inoculation on the medium, microscopy of sediment.
COMPLICATIONS OF ABDOMINAL PUNCTURE
Rare. The needle may enter the vessel of the parametrium, vagina or uterus, causing intestinal injury ( special treatment does not require).
Posterior fornix puncture The vagina allows access to the pelvic cavity. At various pathologies fluid accumulates in the abdominal cavity (exudate, blood and pus), puncture helps to eliminate this fluid or take it for research, that is, this procedure serves not only as a diagnostic, but also medicinal purposes. A puncture for diagnostic purposes is carried out in inpatient conditions. With its help it is revealed excess liquid in the pelvic cavity. The resulting sample is sent for full examination to the laboratory. There it is studied by bacteriologists and cytologists. Based on the results of this diagnosis, treatment is prescribed. But let's talk about everything in order.
Indications for puncture
More recently this procedure was carried out exclusively in cases of suspected ovarian apoplexy or ectopic pregnancy. But modern medicine laparoscopy is increasingly used for these purposes, although even today puncture is often performed to diagnose ectopic pregnancy. But the main indications for its implementation are suspicion of malignancy and inflammatory diseases in the pelvic organs.
Contraindications for puncture
Contraindications include severe heart failure. There are no more direct contraindications. But after full examination the doctor can identify factors that make this type of puncture undesirable.
How to prepare for research?
Basically, no preparation is required, but if there are any peculiarities of the body, the doctor may prescribe certain preparatory measures, naturally, after a full examination. Before the procedure, you need to empty your bladder and carry out basic hygiene measures.
Puncture technique
The first step is to carry out local anesthesia. The external genitalia are treated with iodine solution or alcohol. Then it is carried out puncture of the posterior fornix vagina, that is, a needle attached to a syringe is inserted into it under the control of ultrasonic equipment. It is inserted 2 cm deep, and with its help the amount of liquid required for the study is extracted. When performing a therapeutic puncture, fluid is pumped out from internal cavity. Upon completion of the procedure, the needle is slowly and carefully removed. The resulting sample is sent for cytological and bacteriological examination.
Although seemingly simple, such a puncture is actually a very complex procedure. All actions must be carried out very carefully so as not to damage the tissue next to the organ being examined. During the puncture, an inexperienced doctor may well hit some artery, so the puncture should only be performed by an experienced specialist. Come to our center, we will perform the puncture without complications.
Possible complications of puncture
As we wrote above, most complications after this type of puncture occur due to the inexperience of the doctor. Their appearance is also possible if the patient does not comply with the specialist’s recommendations. But this is more of an exception, which is why complications rarely occur. Main complications:
. The needle enters the parametrium vessel;Infection;
Injury to a vessel of the uterus or vagina;
Intestinal injury. All these complications are very dangerous and can lead to serious consequences, so immediate treatment is required to eliminate them.
Where to perform the puncture?
This procedure is best carried out in our center in Moscow, under the close supervision of experienced specialists. To monitor the puncture, our center uses the most modern ultrasound equipment, thanks to which the risk of complications is reduced to zero. By contacting our center, you will receive quality treatment and the most accurate diagnosis.
Drainage of the cellular spaces of the pelvis can be done:
1) through the anterior abdominal wall;
2) through the vagina;
3) through the rectum;
4) through the perineum;
5) through the obturator foramen.
The opening of the prevesical phlegmon is made by a suprapubic incision along the white line or through one of the rectus abdominis muscles (along the Rhine). However, the first of these methods of opening phlegmon is fraught with the danger of a postoperative hernia due to the low plastic properties of the aponeuroses that form the white line, which is a consequence of insufficient blood supply.
To open deep abscesses localized around the base of the bladder, anterior access is not anatomically justified. For this purpose, an incision is made in the perineum or through the obturator foramen (according to Buyalsky - McWhorter).
As for drainage with parametritis, in these cases two approaches can be used: either through an incision in the anterior abdominal wall or through the vaginal vault.
As is known, with parametritis, the purulent process can spread from the side wall of the cervix and body of the uterus, from the vaginal vault towards the pelvic wall between the folds of the broad ligament of the uterus.
Depending on the prevalence of clinical symptoms, one or another incision is made.
If there is an infiltrate on the anterior wall of the abdomen, an incision is made above the inguinal ligament and thus penetrates into the preperitoneal cellular space of the abdomen and pelvis. If purulent inflammation of the periuterine tissue develops towards the vaginal vault, then the abscess is opened using the vaginal method, cutting the vaginal vault. In cases of lateral location of the abscess (lateral parametritis), one should remember the danger of damage to the uterine artery and ureter.
Puncture of the posterior vaginal fornix
A prerequisite for the operation is preliminary emptying of the rectum and bladder.
Before puncture of the posterior part of the vaginal vault, the patient is placed on the operating table so that her legs are bent at the hip and knee joints, were widely separated, raised high and secured on leg holders. The buttocks should be moved towards the edge of the table so that it is convenient to insert the vaginal speculum. The patient's arms, bent at the elbow joints, are placed on the chest.
Before puncturing the posterior vaginal fornix with a thin needle, tissue infiltration is performed with a 1% novocaine solution (approximately 10 ml is injected).
The position of a long needle with a diameter of no more than 2 mm before puncture of the posterior vaginal vault must be strictly defined:
1) the needle should be located strictly along the midline;
2) the needle axis should be oriented horizontally. The end of the needle can be directed slightly upward to avoid puncture of the rectum.
Puncture of the posterior vaginal vault is performed with a light but sharp push. With a stretched vault, the pelvic peritoneum is in close proximity to the vaginal wall. Therefore, to obtain a punctate, it is usually enough to advance the needle 1-1.5 cm. As the needle advances, a subtle feeling of “overcoming an obstacle” should appear. If the advancement of the needle is accompanied by strong resistance, you should change the direction of the needle or abandon the puncture. Most often, the cause of this complication is the end of the needle getting into the wall of the uterus.
After puncture of the posterior vaginal fornix, the liquid present in the rectouterine cavity is removed using a syringe. With an interrupted ectopic pregnancy, dark blood with small clots appears from a needle inserted into the rectouterine cavity through the posterior vaginal fornix. Blood in the abdominal cavity (rectumuterine cavity) can be detected with ovarian apoplexy or cyst rupture. It can also enter the peritoneal cavity through the fallopian tubes during menstruation and during uterine curettage.
When intraperitoneal bleeding has just begun, the resulting blood quickly clots. In most cases, with prolonged bleeding, the syringe contains defibrinated, non-clotting blood.
Sometimes blood from the rectal uterine cavity cannot be obtained during puncture due to tissue suction to the needle section. In these cases, a few milliliters of novocaine or saline solution and insert into the peritoneal cavity. After this, the liquid is immediately evacuated. If there is blood in the abdominal cavity, the sucked fluid will contain blood. Pus, slough or exudate is differentiated by consistency.
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