Abdominal puncture technique through the posterior fornix. Puncture of the abdominal cavity through the posterior fornix of the vagina (culdocentesis). Indications for culdocentesis

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A puncture, or else aspirate sampling from an anatomically inaccessible area of ​​the peritoneum, localized between the uterine wall and the rectum, is most often necessary to determine an ectopic pregnancy. A puncture of the uterus is done to take a slice of tissue, exudate or mucous membrane. To obtain the material, the specialist makes a puncture of the posterior fornix of the vagina. The aspirate is evaluated for consistency, odor, and color and, if appropriate, sent for laboratory testing.

What is uterine puncture?

The hard-to-reach place between the uterus and the wall of the rectum is called the pouch of Douglas. In it, with pathologies of the genital organs, a lot of fluid accumulates, which includes exudate, pus and blood. To obtain material for research, a puncture of the posterior fornix is ​​performed and an aspirate is taken with a syringe. Manipulation is performed during an inpatient examination under general or local anesthesia. The material is sent to the laboratory for histological analysis.

Indications for the operation

Puncture of the posterior fornix is ​​a highly informative manipulation used in disease-causing processes in the pelvic area. In this way, direct access to the Douglas space can be provided, in which pus, blood and exudate most often accumulate. This manipulation is an operative intervention and is carried out in a hospital under general or local anesthesia.

Manipulation allows you to quickly establish the presence of pus, blood and exudate in the small pelvis and examine these materials in the laboratory for cytology and the presence of a bacterial infection. The procedure makes it possible to detect ovarian cancer at an early stage, when it is still curable. In addition, the puncture is used to diagnose other diseases of the pelvic organs:

• ectopic pregnancy;
• rupture of the uterus or appendage;
• inflammation of the peritoneum.

In addition, puncture is used to determine the composition of the exudate of benign neoplasms of the appendages, as well as to suck out the contents of a purulent nature and rinse the cavity with an antibiotic solution. Manipulation is very painful, so anesthesia is necessary.

Preparing for the operation

Before starting the operation, you need to empty the rectum and urinate. The vulva area and the vaginal mucosa are treated with iodine and alcohol. Then the expansion of the vagina is done with gynecological mirrors. After that, the cervix is ​​shifted towards the symphysis with a lift, and the posterior fornix of the vagina is opened with the help of a medical instrument. This stretches the vaginal area between the speculum and the lift.

The order of the manipulation

The tissues of the vagina are preliminarily anesthetized with a 2% solution of lidocaine. Anesthesia begins to work after about 5 minutes. A diagnostic puncture is made with a special injection needle strictly horizontally with a 2-4 cm immersion. The biological fluid that has accumulated in the Douglas space is aspirated.

During the puncture, it is necessary to ensure that the needle is directed along the midline or slightly upward, so as not to injure the rectum. The aspirate is aspirated with a gentle movement of the piston, this occurs in parallel with the gradual withdrawal of the needle. The resulting sample is sent for laboratory testing.

The diagnosis of ectopic pregnancy is confirmed by obtaining a defibrinated blood sample. Sometimes during suctioning, the blood coagulates and the needle becomes clogged with a blood clot. In this case, it is necessary to remove a blood clot on a gauze swab with a syringe. The development of an ectopic pregnancy or other conditions requiring urgent surgical care (rupture of the spleen, ovarian apoplexy) is indicated by dark blood with clots.

If an abscess of the appendages is suspected, a diagnostic puncture is also performed. This condition is characterized by the presence of pus in a fluid sample. After aspiration of the aspirate, antibiotics are injected into the Douglas space.

What can a puncture show?

This manipulation is carried out to determine the composition of the biological fluid in the pelvis in order to establish a diagnosis of certain surgical and gynecological diseases. Puncture during ectopic pregnancy is one of the main diagnostic manipulations. Also, puncture is often used for therapeutic purposes, that is, for the introduction of drugs into the recto-uterine space.

Indications for the appointment of a puncture are many gynecological pathologies:

• uterine hemorrhages of unclear etiology;
• female factor infertility;
• diagnosis of hyperplastic processes in the endometrium;
• diagnosis of benign neoplasms;
• cycle disorders;
• taking tissues to monitor the effectiveness of hormone therapy;
• exclusion of oncological formations;
• in rare cases, to diagnose abnormalities in the structure of the uterus.

When performed correctly, the puncture is not accompanied by complications. Sometimes a violation of the technique of the operation leads to minor injuries to the intestines or uterus, but these injuries do not need treatment and go away on their own.

Cost of the procedure

In the capital, the price of a diagnostic puncture averages 7,503 rubles. Manipulation is carried out at 20 addresses. The lowest cost of manipulation is 612 rubles.

Conclusion

Puncture plays a special role in the diagnosis of ectopic pregnancy, when it allows you to take defibrinated blood. If the tube ruptured recently, then fresh blood will be taken from the peritoneum. Its characteristic feature will be accelerated folding. When forming in the Douglas space, despite its filling, it is not possible to take fluid, this is due to the formation of a soft hematoma. The collection of both a clot and defibrinated blood allows us to conclude that an ectopic pregnancy has been terminated. The diagnostic value of manipulation is undoubted, since the puncture allows you to quickly establish the nature of the pathology and take timely measures to eliminate it.

Abdominal puncture is performed to drain and examine 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 make the correct diagnosis, alleviate the patient's condition and prescribe the 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 the posterior fornix of the vagina, is performed only in women. The second method, the abdominal puncture of the abdomen, is used in both sexes.

Preparing and performing a puncture of the abdominal cavity

If the patient was assigned a puncture of the abdominal cavity, so that in the process of its implementation there would be no complications and all the manipulations carried out would have a positive outcome, it is necessary to properly prepare.

Approximately 2-3 hours before a minimally invasive intervention, the patient is required to do a cleansing enema. Immediately before the start of the puncture itself, you should visit the restroom and empty your bladder.

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

As an anesthetic, a solution of Promedol or Atropine sulfate is used.

If the patient's condition is severe, then the process of taking biological material is carried out in the supine 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 carried out is treated with a disinfectant. In order for the whole process to take 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 the discovery of serious bleeding.

The puncture of the abdominal wall with subsequent sampling of biological material for analysis, as a rule, is carried out 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 a puncture is performed not only for diagnostic purposes, but also for pumping out all the available fluid, that is, for therapeutic purposes, after taking biological material for research, pumping out the contents of the abdominal cavity continues. It is collected in a special tank. For 1 session, you can pump out up to 6 liters of liquid. To compensate for the loss of salts and proteins, the patient must enter a solution of Albumin or its analogues.

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

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

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

Puncture through the posterior fornix of the vagina

In gynecology, puncture is used both as a therapy and for diagnostics. 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.

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

• exudate;
• blood;
• pus.

The contents of the cavity taken are immediately sent for laboratory analysis.

Below the cervix, in the region of the posterior fornix, between the diverging sacro-uterine ligaments, the peritoneum comes very close to the walls of the vagina. It is this place that is most convenient for puncture.

After the end of the disinfection of the external genital organs, the doctor proceeds to perform the puncture. Using a mirror, he exposes the vaginal part of the cervix. Special gynecological forceps are used to capture and bend back the posterior lip of the uterus. This is how the posterior fornix is ​​stretched.

The puncture needle must enter between the sacro-uterine ligaments. It is deepened by approximately 2 cm. When the end of the needle is at the required depth, biological material is taken using the syringe plunger.

Although a laboratory study is required, an experienced specialist in the appearance of the fluid can make an assumption about what the pathological process is developing. For example, liquid blood that has a dark color is typical when an ectopic pregnancy is terminated. Small clots can be seen in the biological material.

Puncture through the posterior vaginal fornix should be performed by a qualified specialist in order to exclude the possibility of obtaining a false positive result and additionally not to harm the patient.

Recently, puncture through the posterior vaginal fornix is ​​rarely performed, since during the recovery period there is a high risk of secondary infection. Less traumatic and just as informative is laparoscopic examination. He is preferred, since, according to statistics, the risk of complications after this manipulation is minimal.

Puncture through the posterior fornix vagina, or as it is also commonly called culdocentesis. The posterior fornix is ​​the space between the vagina and the rectum (Douglas space). It is made mainly of adipose tissue and is a reservoir for the accumulation of exudate (pathological fluid).

Indications and contraindications for the procedure

Indications for this type of puncture are:

. Aborted ectopic pregnancy;

. Apoplexy of the ovary;

Abscess of the ovary;

A collection of pus in the pouch of Douglas;

Peritoneal bleeding with accumulation in the vaginal-rectal space;

Tumor suspected.

Contraindications are:

. severe general condition of the patient,

Heart and kidney failure with symptoms of decompensation.

Puncture through the posterior fornix of the vagina is a very painful procedure, so it needs good anesthesia. Previously, this manipulation was performed under general anesthesia. Currently, if the patient's condition requires it, it can also be performed under general anesthesia if the doctor decides.

However, layer-by-layer conduction anesthesia is often performed. The woman lies on her back with her legs bent at the knee joints, the pubis and vagina are treated with a 70% alcohol solution or an alcohol solution of iodine, and then, retracting the cervix with a special lift, the arch is released and infiltration is performed with a solution of lidocaine. After a few minutes, the vaginal fornix is ​​punctured strictly in the middle with a vertically placed syringe so as not to pierce the rectum. However, before the puncture, the fornix is ​​infiltrated with a solution of lidocaine. Then the contents of the vaginal-rectal space are aspirated using a special syringe, pulling the piston towards itself. The resulting liquid is sent for biochemical, bacteriological and cytological examination. Upon receipt of purulent contents, an antibiotic is immediately administered.

If the resulting fluid contains blood without traces of fibrin, then this indicates an interrupted ectopic pregnancy. There may also be blood clots with ovarian apoplexy, exudate may be present with a burst ovarian cyst. If there are adhesions, then even if there is fluid in the vaginal-rectal space, exudate may not be obtained. For this purpose, a sterile saline solution is injected and the resulting liquid is aspirated with a syringe. The presence of blood clots in this fluid also indicates an interrupted ectopic pregnancy. In the presence of a very thick exudate, a saline solution is also introduced, followed by its extraction and examination. Also, blood can be obtained with the so-called reflux menstruation or if the puncture is performed early after the curettage of the uterine cavity.

After the puncture, the anesthetic is infiltrated again and the instruments are removed. Further tactics depend on the results obtained. If a liquid containing pus was obtained, then in addition to introducing antibiotics into the cavity, the woman is prescribed antibiotic therapy. The presence of blood in the exudate is a poor prognostic sign and requires emergency surgical intervention, as it indicates not only an ectopic pregnancy, but may also be a sign of retroperitoneal bleeding. Complications during this operation may be a puncture of a retroperitoneal vessel or a puncture of the rectum, which does not require additional therapeutic measures. It is in our clinic that qualified specialists perform timely puncture of the posterior vaginal fornix with the interpretation of the results.

Diagnostic methods in gynecology are often associated with invasive intervention in the pelvic area. Bimanual examination and ultrasound do not always provide an idea of ​​the pathology. As an emergency diagnostic method, culdocentesis is often used.

Introduction to the methodology

Culdocentesis is the puncture of the retrouterine cavity in order to obtain the biological fluid accumulated there: blood, pus or exudate.

The possibility of accumulation of fluids is explained by the anatomical structure of the Douglas space. The peritoneum covers the pelvic organs in a special way. It completely covers the sigmoid colon, descends to the middle of the rectum. There, only the front and side parts are covered. Then the peritoneum passes to the posterior fornix of the vagina and uterus.

Semilunar folds form on the sides, which help to fix the uterus and bladder. The uterine-rectal pocket turns out to be the lowest place in the abdominal cavity, where, according to the law of physics, all fluids rush. During the ultrasound, you can see it, but it is impossible to understand what nature of the effusion. And further treatment tactics depend on this.

Emergency gynecological pathology requires immediate diagnosis. It is culdocentesis that allows you to quickly make a differential diagnosis between various diseases, many of which require surgical treatment.

Research objectives

The procedure has one goal - to obtain fluid that has accumulated in the retrouterine space. Its composition allows you to confirm various diseases and pathological conditions.

Indications for culdocentesis is an assumption for the presence of the following diseases:

• interrupted with rupture of the fallopian tube;
• ovarian cancer;
• ovarian apoplexy;
• any obscure clinic of an acute abdomen.

Some of these conditions can be diagnosed on ultrasound, but in the absence of an opportunity to conduct an ultrasound, culdocentesis is performed.

For the study to be carried out, certain conditions are necessary:

1. Protrusion of the posterior fornix into the vagina during examination in the mirrors.
2. The symptom of fluctuation of the uterus is positive.

The study is carried out only in a hospital in a small operating room, subject to the requirements of asepsis and antisepsis.

Contraindications for carrying out are such conditions as vaginal obliteration, severe, unstoppable massive bleeding in the abdominal cavity. During pregnancy, culdocentesis is also not performed. With uterine cancer, there is a high risk of contact metastasis, and with inflammatory diseases of the vagina, infection is introduced during the procedure, so it is not performed for these diseases.

Intervention steps

Preparation for culdocentesis is not long. The woman should urinate and empty her bowels. Otherwise, they put an enema and release urine with a catheter.

Tools needed for the procedure:

• spoon-shaped mirrors;
• bullet tongs;
• puncture needle 10-12 cm;
• disposable syringe 10 ml.

Does it hurt to puncture the retrouterine space?

Painful sensations of varying intensity will disturb in the absence of anesthesia. Anesthesia is selected based on medical tactics and hospital conditions. In some cases, an anesthesiologist is called, who gives a short-term mask or intravenous anesthesia. If general anesthesia is contraindicated or if the woman has recently eaten, a paracervical blockade is performed with a 1% lidocaine solution. To do this, they infiltrate the back of the cervix. Some doctors use lidocaine gel anesthesia. It is applied to a cotton swab and pressed against the overhanging vaginal vault.

The execution technique has remained unchanged for many years. The woman is on the gynecological chair in the dorsal lithotomy position, which is standard for intravaginal interventions. Anesthesia is given if a decision is made on general anesthesia. I treat the perineum and the entrance to the vagina with an antiseptic solution - tincture of iodine, chlorhexidine, alcohol.

Mirrors are carefully inserted into the vagina, the cervix is ​​exposed. It is also treated with an antiseptic. At this stage, local anesthesia is performed if such an intervention tactic is chosen.

On the bullet forceps take the posterior lip of the cervix and pull it forward a little up. The needle on the syringe is inserted in the midline into the space of Douglas until a failure is felt. Usually it is 1-2 cm. Sip on the plunger of the syringe and get the contents of the pocket. The needle is carefully removed, the vagina is treated with an antiseptic, and the instruments are removed. The resulting liquid is sent for research.

Interpretation of results

Further tactics depend on the results of the puncture. If an abscess was suspected in the retrouterine cavity and pus was obtained in the syringe, it is possible to simultaneously drain the Douglas pouch. To do this, an incision is made with a scalpel at the puncture site. The edges of the wound are bred with a Kelly forceps and the pus is released. The cavity of the abscess is washed with an antiseptic. Further treatment involves the appointment of a course of broad-spectrum antibiotics.

Serous exudate may appear with inflammatory diseases of the appendages or ovaries. In such cases, culdocentesis is performed for the purpose of bacteriological examination. The resulting liquid is transferred to the laboratory for seeding and determining the sensitivity of pathogens to antibiotics. Pus with an abscess is also sent for bakposev.

The absence of pus or serous effusion when an infectious-inflammatory disease is suspected does not refute the diagnosis. Sometimes, with chronic diseases in the small pelvis, it develops, which prevents the flow of fluid into the uterine-rectal space.

A common result of culdocentesis is blood in the syringe. Dark, with clots speaks of an interrupted ectopic pregnancy. Sometimes little or no blood is drawn into the syringe. This is possible with adhesions in the pelvis and accumulation of blood in the abdominal cavity. Sometimes the clot blocks the cut of the needle, and it is impossible to draw liquid into it. To restore patency, it is blown with air into a sterile napkin. In some cases, the introduction of 1-2 ml of saline or novocaine into the retrouterine cavity helps. They dilute the contents of the pocket, which must be quickly aspirated.

If serous fluid with hemorrhagic impurities is obtained, this does not exclude tubal pregnancy. A false-positive result in case of suspected ectopic pregnancy appears with ovarian apoplexy, blood loss after rupture of the spleen. Carrying out manipulation after, during menstruation, can also give blood impurities in the syringe.

Culdocentesis is accompanied by the appearance of a serous effusion - the contents of a burst cyst. This helps to differentiate cyst rupture from ectopic pregnancy and apoplexy.

Serous effusion may appear with tumors of the pelvic organs. Analysis of the resulting fluid will determine the degree of cellular atypia.

Possible Complications

Complications during the procedure are rare. It can be:

• wound of the uterus with a needle;
• getting into the parametrial vessel;
• bowel injury.

After a parametrial vessel is punctured, liquid blood will appear in the needle, which will soon clot. Bleeding after culdocentesis is uncommon. If bleeding occurs, you should consult a doctor. They can be a consequence of the underlying pathology (ectopic pregnancy) or injury to the vessel.

The long-term consequences of frequently performed manipulations can manifest themselves in the form of an adhesive process in the pelvic area. But do not forget that the diseases that serve as indications for intervention themselves become the cause of the formation of adhesions. Therefore, the root cause of this complication is in the underlying pathology.

Special rehabilitation after. The recovery period corresponds to the diagnosed disease. In most cases, sexual rest, antibiotic therapy, basic hygiene, and at least a year are required. A month later, an examination by a gynecologist is needed to determine the general condition after treatment.

Indications: the need to determine the nature of the contents of the recto-uterine cavity. Evacuation of exudate, pus, introduction of liquid or gas into the abdominal cavity.

Rice. 20. Puncture of the utero-rectal cavity through the posterior fornix of the vagina

Technique. Puncture of the vault during fixation of the cervix. Mirrors are inserted into the vagina. The posterior lip of the cervix is ​​fixed with bullet forceps and pulled to the pubic symphysis. The posterior fornix is ​​exposed.

A long needle is used to puncture the posterior fornix at the cervix. The needle is advanced 10-20 mm parallel to the axis of the pelvis. The contents are sucked out with the plunger of the syringe. The needle is displaced depending on the presence and volume of contents in the pelvic cavity.

Puncture of the posterior fornix on the mirrors

B. D. Ivanova, A.V. Kolsanov, S.S. Chaplygin, P.P. Yunusov, A.A. Dubinin, I.A. Bardovsky, S. N. Larionova