Abdominal puncture through the posterior fornix. Possible complications of puncture

This operation is used:

To confirm the diagnosis ectopic pregnancy, uterine rupture and others internal organs;
to confirm or exclude the diagnosis of pelvioperitonitis and general peritonitis;
to determine the nature of the exudate of saccular tumors fallopian tubes and ovaries (only if there is no suspicion of their malignant degeneration).

Starting the puncture abdominal cavity through back vault, it should be remembered that this operation is very painful. Before surgery, if possible, you should empty the rectum and be sure to bladder, treat the external genitalia and vagina with 70% ethyl alcohol and 1% alcoholic iodine solution. Having exposed the cervix, you should not grab it with forceps. It is much more convenient to lift the cervix to the pubic symphysis. In this case, the wall of the posterior part of the vaginal vault is stretched between the lift and the speculum. Before puncturing the tissue of the posterior part of the vaginal vault, it is necessary to infiltrate it with a 1-2% lidocaine solution using a thin injection needle. After waiting 3-5 minutes for the novocaine to take effect, with a long injection needle, with a light but sharp push, pierce the back of the vaginal vault strictly along the midline and use a syringe to suck out the liquid present in the rectal-uterine cavity. The position of the needle during puncture should be horizontal or the needle should be directed slightly upward so as not to puncture the rectum.

Puncture of the abdominal cavity through the posterior part of the vaginal vault can be performed for therapeutic purposes to suction the inflammatory exudate and introduce antibacterial drugs, and also how preliminary operation before colpotomy (for posterior parametritis) or before colpoceliotomy (for abscess of the rectal uterine cavity).

In cases of ectopic pregnancy, defibrinated blood is usually aspirated. However, with just begun internal bleeding Blood can be obtained from the abdominal cavity, the fibrin of which has not yet had time to fall out. This blood clots quickly, just like blood obtained from a vessel. In some cases, nothing can be sucked out, although there is blood in the abdominal cavity. This is usually explained by thrombosis of the needle with a blood clot, which can be pushed out of the needle with air using a syringe onto a gauze pad and examined; you can also push the blood clot out of the needle with a mandrel.

Obtaining a blood clot, as well as defibrinated blood, is sufficient to confirm the diagnosis of ectopic pregnancy. Sometimes it is not possible to suck out blood due to the fact that some tissue adheres to the cut of the needle and blocks the lumen of the needle. In such cases, you should take a few milliliters of a sterile solution of novocaine or isotonic sodium chloride solution into a syringe, inject it into the abdominal cavity and immediately suck it out. If there is blood in the abdominal cavity, the sucked liquid will be stained with blood, and small pieces of clots will be detected in it.

A therapeutic puncture of the abdominal cavity is also performed through the posterior part of the vaginal vault. However, if the inflammatory exudate is of a very thick consistency, some sterile solution, for example an isotonic sodium chloride solution, should be injected into the abscess and the now diluted exudate should be sucked out. The exudate is sent for bacterioscopic and bacteriological examination.

A puncture of the abdominal cavity is performed for the purpose of drainage and examination of fluid that may accumulate in the free space between the internal organs or in the pelvic cavity.

The presence of fluid is a symptom of many diseases. To put correct diagnosis, alleviate the patient’s condition and prescribe correct treatment, this medical procedure is prescribed. It can be done in two ways. These include culdocentesis and laparocentesis. Culdocentesis - puncture of the abdominal cavity through posterior arch vagina, performed only on women. The second method, abdominal puncture, is used in both sexes.

Preparation and performance of abdominal puncture

If the patient has been prescribed an abdominal puncture, so that no complications arise during its implementation and all the manipulations performed have a positive outcome, it is necessary to properly prepare.

Approximately 2–3 hours before the minimally invasive intervention, the patient needs to undergo a cleansing enema. Immediately before the puncture itself, you should visit the restroom and empty your bladder.

Drainage of the cavity is usually carried out in the manipulation room, that is, an operating room is not required. All devices used during the procedure must be sterile.

A solution of Promedol or Atropine sulfate is used as an anesthetic drug.

If the patient’s condition is serious, then the process of collecting biological material is carried out in a lying position (on the right side). Under other circumstances, the patient is seated in a chair so that he can lean on the back.

The area where the puncture will be performed is treated disinfectant. To ensure that the entire process takes place under strict medical supervision, it is carried out using an ultrasound machine. Otherwise, there is a risk of damage to internal organs, which can lead to serious bleeding.

Puncture abdominal wall followed by collection of biological material for analysis, as a rule, using a device such as a trocar. As soon as the liquid begins to come out, its first portions are collected in a pre-prepared sterile container and sent to the laboratory. When the puncture is performed not only with diagnostic purpose, but also for pumping out all available liquid, that is, in medicinal purposes, after collecting biological material for research, pumping out the contents of the abdominal cavity continues. It is collected in a special tank. In 1 session, you can pump out up to 6 liters of liquid. To compensate for the loss of salts and proteins, the patient must be administered a solution of Albumin or its analogues.

The final stage of puncture is the removal of all instruments used and the application surgical sutures. The stitched puncture site is covered with a sterile napkin and bandaged.

When all manipulations are completed, the patient remains under medical supervision. Medical staff monitors:

blood pressure indicators;
condition of the skin;
condition of the mucous membranes;
general well-being.

Puncture through the posterior vaginal fornix

In gynecology, puncture is used both as therapy and for diagnosis. It may be prescribed if an ectopic pregnancy is suspected or if there are symptoms of an abscess in the pelvic cavity. The puncture is performed using local anesthesia.

Accumulated biological material in the area where the pelvic organs are located may consist of:

exudate;
blood;
pus.

The collected cavity contents are immediately sent for laboratory analysis.

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 this place that is most convenient for performing a puncture.

After completing the disinfection of the external genitalia, the doctor begins to perform a puncture. Using a speculum, he exposes the vaginal part of the cervix. Special gynecological forceps are used to grasp and bend the posterior lip of the uterus. This is how the posterior arch is stretched.

The puncture needle should enter between the uterosacral ligaments. It is deepened by approximately 2 cm. When the end of the needle is at the required depth, biological material is collected using the syringe plunger.

Although laboratory testing is required, experienced specialist By appearance fluid can make an assumption about what pathological process is developing. Eg, liquid blood, which has a dark color, is characteristic of the termination of an ectopic pregnancy. Small clots can be seen in the biological material.

Puncture through the posterior vaginal fornix should be performed qualified specialist to eliminate the possibility of receiving false positive result and additionally do not harm the patient.

IN Lately puncture through the posterior vaginal fornix is rarely performed, since during recovery period There is big risk addition of a secondary infection. Less traumatic and equally informative is laparoscopic examination. It is preferred because, according to statistics, the risk of complications after this manipulation is minimal.

Vaginal puncture, or culdocentesis, is performed to diagnose various pathological conditions. At its core, this is a minimally invasive examination technique that uses a special needle. Vaginal puncture allows you to accurately diagnose:

. ectopic pregnancy;
Ovarian apoplexy;
Uterine rupture;
Peritonitis;
Malignant neoplasms;
Inflammation of the pelvic organs.

Preparation and carrying out the procedure

Before vaginal puncture, a woman needs to empty her bladder and bowels. These organs must be free of contents. If there is no urge to go to the toilet, an enema and a catheter are used. The patient is then given anesthesia and prepared for puncture. To do this, the entire vagina, as well as the cervix, is generously lubricated with alcohol and iodine solutions to completely eliminate the possibility of infection entering the internal cavities body.

The patient's vagina is dilated using a special speculum with a lifting mechanism. With a narrow vagina, the doctor manipulates only with his fingers to avoid ruptures. The cervix is then secured and pulled back slightly with forceps to release the posterior vaginal vault. The puncture can only be done through the posterior fornix. Otherwise, the needle may damage the bladder or uterus.

The needle is inserted with a sharp push of 3 cm. The piston is manipulated carefully, checking whether the syringe is filled with liquid. If this does not happen, the needle must be slowly removed from the hole, pulling up the piston in case liquid appears.

Puncture results

After such a minimally invasive examination, the resulting liquid is sent to the laboratory. Previously, the doctor can determine the patient’s condition by the appearance of the material received. If the fluid is cloudy and mixed with pus, this indicates the presence of serious inflammation. Blood in the syringe indicates internal hemorrhage, which requires urgent medical attention.

With extensive bleeding in the abdominal cavity, the blood obtained by puncture has a dark purple color and is replete with small clots. If a thrombus or large clot enters the suction needle, it becomes difficult to remove blood from the abdominal cavity. In such a situation, the thrombus/clot is removed from the medical instrument and the manipulation is repeated. If an ectopic pregnancy is confirmed, doctors pump out the defibrated blood.

When examining blood obtained as a result of vaginal puncture, the following factors are important:

. its color;
Presence of signs indicating inflammation;
A large number of small clots.

Possible complications

Despite the fact that culdocentesis is considered a minimally invasive examination operation, it is associated with great risk for the patient's health. It is important to choose the right clinic where the puncture will be performed. Its personnel must be highly qualified and experienced in this type of diagnosis. But even with the highest qualifications of the surgeon, complications sometimes occur.

The first concerns the needle getting into nearby organs: uterus, ureter, etc. An aspiration needle can puncture the vessels of the uterus. In this case, the blood in the syringe will be dark purple and without clots. Maybe profuse bleeding, in which vaginal tamponade is used.

Another danger is infection from the vagina into bloodstream internal organs. Even the most thorough treatment does not protect 100% from the flora that inhabits a woman’s vagina. And yet in front of everyone existing risks it is necessary to do a puncture. This is especially important in the case of ectopic pregnancy, internal hemorrhage in case of organ rupture and risk of cancer.

Puncture of the posterior vaginal fornix- this is the most convenient and closest access to the pelvic area, where fluids such as blood, pus, exudate, etc. accumulate during various pathological and gynecological processes.

Puncture of the posterior vaginal vault is surgical intervention and is carried out in a hospital.

The procedure is carried out in cases of determining the presence or absence of blood, pus, serous fluid in the pelvic cavity. The resulting liquid for diagnostics inflammatory process in the pelvic cavity or early diagnosis ovarian cancer is sent for cytological and bacteriological examination.

Puncture of the posterior vaginal fornix They are also used to confirm or exclude diagnoses of diseases of internal organs, including:

rupture of the uterus or other internal organs;
ectopic pregnancy, pelvioperitonitis or general peritonitis;
to determine the nature of the exudate of saccular tumors of the fallopian tubes and ovaries of non-malignant origin.

The procedure is carried out in therapeutic purposes: for administering antibacterial drugs or suctioning inflammatory exudate; preliminary operation before colpotomy or before colpoceliotomy.

Puncture of the posterior vaginal fornix is a very painful operation. Preoperative preparation is that first of all it is necessary to empty the rectum and bladder.

70% are processed before surgery ethyl alcohol and iodine on the external genitalia and vagina.

Method of manipulation during surgery

Without grasping with forceps, the cervix is exposed and retracted with a lift to the pubic symphysis.

This allows the back of the vaginal vault to stretch between the speculum and the lift. Before the puncture, the puncture site is numbed with lidocaine solution. Some time after the anesthesia has taken effect, using a long injection needle, with a light but decisive push, strictly along the midline, the back part of the vaginal vault is pierced and the liquid present in the rectal uterine cavity is sucked out. The needle is inserted to a depth of up to two centimeters.

During the puncture, the needle should be directed horizontally or slightly upward so as not to damage the rectum. By the reverse movement of the piston, simultaneously with the slow removal of the needle, the liquid is removed, then it is bacteriologically and cytological examination.

To confirm the diagnosis ectopic pregnancy defibrated blood is sucked out. But this does not always work out, since this blood quickly clots and the needle is thrombosed by a blood clot. This clot is pushed out with a syringe onto a gauze pad and tested in the same way as with blood, since this is enough to confirm an ectopic pregnancy. If the blood that gets into the syringe is thick and dark with clots, this is also an indicator of an ectopic pregnancy.

Blood is also detected when the spleen ruptures, ovarian apoplexy, and also after curettage of the uterus.

Puncture of the posterior vaginal vault is also used if an abscess of the uterine appendages is suspected. In this case, when the pus is sucked out, antibiotics are injected into the cavity of the purulent tumor.

Complications after puncture of the posterior vaginal vault

Complications during puncture are extremely rare, although punctures of a vessel or vagina are possible. Uterus, intestinal injury, etc., but that's all special treatment does not require.

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 (to diagnose the inflammatory process in the pelvic cavity or early diagnosis of 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 an 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: if there is a fresh accumulation of blood in the rectal cavity, 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 do not get 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, and also with reflux 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. At inflammatory diseases 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, injuring the intestines (does not require special treatment).