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Sheath Obturator Cannula

Obturator Canal $70.1 High Quality Content by WIKIPEDIA articles The obturator canal is a passageway formed in the obturator foramen by part of the obturator membrane. It connects the pelvis to the thigh. The obturator artery, obturator vein, and obturator nerve all travel through the canal. The obturator foramen is the hole created by the ischium and pubis bones of the pelvis through which nerves and muscles pass. It is bounded by a thin, uneven margin, to which a strong membrane is attached, and presents, superiorly, a deep groove, the obturator groove, which runs from the pelvis obliquely medialward and downward. Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 82 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.20 inches

Obturator Veins $58.94 High Quality Content by WIKIPEDIA articles The obturator vein begins in the upper portion of the adductor region of the thigh and enters the pelvis through the upper part of the obturator foramen, in the obturator canal. It runs backward and upward on the lateral wall of the pelvis below the obturator artery, and then passes between the ureter and the hypogastric artery, to end in the hypogastric vein. It has an anterior and posterior branch (similar to obturator artery). Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 70 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.17 inches

Obturator Artery $70.1 High Quality Content by WIKIPEDIA articles The obturator artery passes anteroinferiorly (forwards and downwards) on the lateral wall of the pelvis, to the upper part of the obturator foramen, and, escaping from the pelvic cavity through the obturator canal, it divides into both an anterior and a posterior branch. In the pelvic cavity this vessel is in relation, laterally, with the obturator fascia; medially, with the ureter, ductus deferens, and peritoneum; while a little below it is the obturator nerve. Inside the pelvis the obturator artery gives off iliac branches to the iliac fossa, which supply the bone and the Iliacus, and anastomose with the iliolumbar artery; a vesical branch, which runs backward to supply the bladder; and a pubic branch, which is given off from the vessel just before it leaves the pelvic cavity. Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 78 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.19 inches

Obturator Membrane $58.94 High Quality Content by WIKIPEDIA articles The obturator membrane is a thin fibrous sheet, which almost completely closes the obturator foramen. Its fibers are arranged in interlacing bundles mainly transverse in direction; the uppermost bundle is attached to the obturator tubercles and completes the obturator canal for the passage of the obturator vessels and nerve. The membrane is attached to the sharp margin of the obturator foramen except at its lower lateral angle, where it is fixed to the pelvic surface of the inferior ramus of the ischium, i. e., within the margin. Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 74 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.18 inches

Obturator Foramen $58.94 High Quality Content by WIKIPEDIA articles The obturator foramen is the hole created by the ischium and pubis bones of the pelvis through which nerves and muscles pass. It is bounded by a thin, uneven margin, to which a strong membrane is attached, and presents, superiorly, a deep groove, the obturator groove, which runs from the pelvis obliquely medialward and downward. This groove is converted into the obturator canal by a ligamentous band, a specialized part of the obturator membrane, attached to two tubercles: Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 74 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.18 inches

Kendall Monoject Blunt Cannula Needles - Needle, Blunt, 15G X1-1/2, Alum Hub, Ll. 25 EA/BX $54.48 Manufacturer: Kendall. 25 EA/BX. Monoject Blunt Cannula Needles: Latex Free. Stainless steel cannula. Aluminum luer lock hub. Color-coded needle sheath - charcoal gray cap. Autoclavable in rigid pack for use in O.R./procedure packs. Sterile. Blunt Cannula

Shiley Single Cannula Trach Tube, Cuffed, Size 7, 80 mm Long $48.47 Features of the Shiley Single Cannula Trach Tube: Smooth, rounded-tip obturator facilitates insertion. Allows bypass of upper airway obstructions or to provide long term ventilation, support and/or manage tracheal/bronchial secretions. 9.6 mm O.D., 7.0 mm I.D., 80 mm long.

Palatal Obturator $58.94 High Quality Content by WIKIPEDIA articles A palatal obturator is a prosthesis that totally occludes an opening such as an oronasal fistula (in the roof of the mouth). They are similar to dental retainers, but without the front wire. Palatal obturators are typically shortterm prosthetics used to close defects of the hard/soft palate that may affect speech production or cause nasal regurgitation during feeding. Following surgery, there may remain a residual oronasal opening on the palate, alveolar ridge, or labial vestibule. A palatal obturator may be used to compensate for hypernasality and to aid in speech therapy targeting correction of compensatory articulation caused by the cleft palate. In simpler terms, a palatal obturator covers any fistulas (or holes ) in the roof of the mouth that lead to the nasal cavity, providing the wearer with a plastic/acrylic, removable roof of the mouth, which aids in speech, eating, and proper air flow. Author: Surhone, Lambert M./ Tennoe, Mariam T./ Henssonow, Susan F. Binding Type: Paperback Number of Pages: 68 Publication Date: 2010/08/13 Language: English Dimensions: 6.00 x 9.02 x 0.16 inches

Obturator Process $70.1 High Quality Content by WIKIPEDIA articles The obturator process is an anatomical feature on the pelvis of archosaurs. It is a raised area of the ischium bone of the pelvis. It is the origin of muscles that attach to the femur and aid in running. These muscles are called M. puboischiofemoralis externus 1 and 2 in crocodylians. In birds the muscles are called the M. obturatorius lateralis and M. obturatorius medialis. They insert on the greater trochanter of the femur. Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 82 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.20 inches

Sheath $9.49 Sheath

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Obturator Internus Muscle $58.94 High Quality Content by WIKIPEDIA articles The obturator internus muscle originates on the medial surface of the obturator membrane, the ischium near the membrane, and the rim of the pubis. It exits the pelvic cavity through the lesser sciatic foramen. The obturator internus is situated partly within the lesser pelvis, and partly at the back of the hipjoint. It functions to help laterally rotate extended thigh and abduct flexed thigh, as well as to steady the femoral head in the acetabulum. Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 70 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.17 inches

Obturator Externus Muscle $70.1 High Quality Content by WIKIPEDIA articles The obturator externus muscle is a flat, triangular muscle, which covers the outer surface of the anterior wall of the pelvis. It is sometimes considered part of the medial compartment of thigh, and sometimes considered part of the gluteal region. It arises from the margin of bone immediately around the medial side of the obturator foramen, viz., from the rami of the pubis, and the inferior ramus of the ischium; it also arises from the medial twothirds of the outer surface of the obturator membrane, and from the tendinous arch which completes the canal for the passage of the obturator vessels and nerves. Author: Surhone, Lambert M./ Timpledon, Miriam T./ Marseken, Susan F. Binding Type: Paperback Number of Pages: 98 Publication Date: 2010/07/22 Language: English Dimensions: 6.00 x 9.02 x 0.23 inches

Shiley Spare Inner Cannula, Size 10, Each $13.76 Shiley Spare Inner Cannula

Smiths Nasal Cannula, Adult, 10/cs $141.65 Features of the Smiths Nasal Cannula: For use with Capnocheck.

Welch Allyn KleenSpec Disposable Anoscope with Obturator, 100/cs $287.06 Features of the Welch Allyn KleenSpec Disposable Anoscope: A high-performance, disposable anoscope for convenient, safe, and efficient examination. 45 degree bevel at distal end to facilitate instrumentation. Convenient disposable speculum and obturator ready for instant use. 19 mm x 10 cm.

Respironics Nasal Cannula, Small, 25/Pk $152.95 Nasal Cannula, Small, 25 per pk. For use with Stardust.

Shiley Disposable Inner Cannula, Size 10, Each $7.99 Shiley Disposable Inner Cannula, Size 10

Shiley Disposable Inner Cannula, Size 10, 10/bx $51.94 Shiley Disposable Inner Cannula, Size 10, 10/bx

Assesing Tubal Factors in Infertility

Assesing Tubal Factors in Infertility

by Dr. Jyoti Mishra- Gynaec. Endoscopist & Infertility specialist

Having a child of her own is the most intense desire & right of every woman. Inability to conceive can devastate her emotionally, socially & often financially. Tubal pathologies constitute >25% of all causes of infertility.
Various diagnostic techniques have evolved over time. Rubin first described the insufflation technique of testing tubal patency in 1920. As the results of this technique could not be documented, hysterosalingography (HSG) evolved in 1940s. It was since late 1960 that laparoscopy with chromopertubation became a widely used procedure. As ultrasonography made tremendous progress, hystersalpingo contrast sonography (HyCoSy) came into use. The first successful endoscopic evaluation of the lumen of tubes from intramural to fimbrial end was made in 1990, by the introduction of salpingoscopy & falloposcopy.
The evolution of so many techniques itself indicates that no single method is self-sufficient.Most of the time they complement each other.

Rubin’s Tubal Insufflation Test

Done in the postmenstrual phase, this test involves pushing of air via a canulla fitted in the cervix. A stethoscope placed in the suprapubic region auscultates the sound produced by air, escaping through the fimbrial end. Though this is an easy, inexpensive, OPD procedure which needs no special training, the test has several drawbacks. It cannot diagnose unilateral blocks, can be false positive in large hydrosalpinx.
In addition to this there is a definite risk of air embolism and the results are very subjective.

Hysterosalpingography (HSG)

This test precedes Laparoscopy in most of the patients. The test is performed between days 8 & 10 of LMP for the following reasons
• No risk of pregnancy.
• Endometrium is at its thinnest, hence better visibility of ostia.
• Done in secretary phase, thick endometrial fragments may get dislodged & block the ostia.
• No risk of pushing the menstrual blood into the peritoneal cavity.
• No exposure to X-Rays at the time of ovulation.

Media
Oil soluble media whose benefit was better resolution, are obsolete now, as they may cause severe inflammatory reaction and oil embolism..
Now we use water-soluble contrast media like urograffin 76%. Still better are non-ionic media such as echovist, which although expensive, markedly reduce the chance of allergic reaction.

Technique
The technique involves positioning of a screw tipped canulla into the cervical canal. About 3ml of medium is pushed to outline the uterine cavity & tubes & the first film is obtained. After pushing in more dye, a second film is obtained. Usually 2 films are sufficient to make a diagnosis. If spill is not seen, giving head low & taking a delayed film helps in most cases. Postoperatively analgesics & antibiotic cover is given.

Interpretation of results
A normal uterus is seen as a triangular cavity with slightly concave lateral walls. Tubes show slight tortuosity. Rugae which may be seen in a good quality film indicate a good prognosis in terms of achieving pregnancy.

Abnormalities of cornua
Uni/bilateral blocks may be due to true organic lesions or they may be false positive results of conual spasm, mucus plug, debris, or pressure of fibroids. To prevent spasm, a spasmolytic oral tablet may be given 1 hour prior, in addition to explaining the procedure to the patient.

Other Pathologies
There may be evidence of SIN( Salpingitis Isthmica Nodosa), tubercles, intraluminal adhesions (leapordskin appearance) or hydrosalpinx. Adhesions can lead to fimbrial phimosis. Loculation of dye around distal end suggests peritubal adhesions.

This is a cheap OPD procedure which gives adequate information about intraluminal features of tubes. It exactly pinpoints the site of block and is often therapeutic.
The drawbacks include risk of allergy to the medium, flaring up of PID, pain and radiation exposure.The test is contraindicated in presence of active PID.

Laparoscopy :
Diagnostic laparoscopy is indicated in any situation where inspection of pelvic organs will help in further management. Often it will be converted into operative laparoscopy.

Technique:
General anaesthesia with endotracheal intubation
Patient position.
Uterine manipulator, catheterization.
Pneumoperitoneum, confirmation.
Insertion of primary trocar & cannula, laparoscope.
Insertion of secondary trocar & cannula.
Systematic inspection of abdominal & pelvic organs:
• Panormic view
• Uterus
• Anterior cul-de-sac
• Rt. fallopian tube
• Rt. ovary
• Rt. uterosacral ligament & POD
• Lt. side of pelvis
• Upper abdomen

Chromopertubation
Dilute (1:20) methylene blue solution is injected through a cervical cannula. Patency of each tube should be established individually.

Tubal Pathologies seen frequently on Laparoscopy:
Blocks
Peritubal adhesions
Isthmus- tubercles, fusiform swelling-SIN
Hydrosalpinx, Thickened walls
Fimbrial phymosis
Tuboovarian Relation, Fimbria ovarica

Benefits:
A diagnostic procedure can be converted into a therapeutic one.
Other peritoneal, ovarian factors can also be diagnosed.

Complications:
Anaesthesia related
Procedure related
Pneumoperitoneum, Gas embolism
Bladder injury
Bowel injury
Vessel injury
Perforation of uterus
Others; costly, training needed

Sonosalpingography -Sion Test

Normal TVS cannot show tubes, which are isoechoic. Injecting saline through the cervical canal & through the tubes will surround them with fluid & enable them to be visualized. A non-invasive test, which can show tubal patency, any gross pathology & perifimbrial adhesions. By seeing fluid in POD, uni/bilateral patency is not known.

Hysterosalpingo-contrast-sonography (HyCoSy)
Echovist is used. Tubes patent if forward flow of dye, with turbulence at fimbrial end. False positive in large hydrosalpinx.

Selective Salpingography

Under fluoroscopic control, a radio-opaque catheter is passed through the cervical canal & then wedged into the ostium. Medium is injected. Tubal Spasm , flimsy blocks are overcome. If resistance, a guide wire is passed further. Medium is pushed again .In 80% of patients, tubal spasms, & flimsy organic blocks are treated. Complication- false passage.

Hysteroscopic transcervical cannulation

Indicated in Proximal tubal block.
Needs operative sheath, Catheter, Obturator, Guide wire & simultaneous laparoscopy.
Anatomy of intramural part of tube should be known. Perforation common in intramural& ampullary parts. Patency rate-75-80%, Pregnancy rate 40%.

Tuboscopy
Salpingoscopy: Visualization of endosalpinx through the fimbrial end. After a diagnostic laparoscopy is done, fimbria are stabilized by an atraumatic grasper. A 3mm endoscope is advanced along with a continuous flow of saline, which keeps tube distended. This can show upto isthmo-ampullary junction. Normal mucosa is pink, velvety with rugosities.

Falloposcopy: Seeing the endosalpinx through the cornual end. Hysteroscopic tubal catheterization is done. Guide wire is passed beyond the fimbria & catheter over it. Guide wire is withdrawn & a 0.5 mm endoscope is passed. Visualization is done in a retrograde manner.
Tests based on transportation of particles

Ascending: Human albumin particles labeled with technitium99 are placed on cervix. Gamma camera measures radioactivity at fimbria.

Descending: Starch is placed in POD by culdocentesis. If detected in cervical mucus, confirms patency of tubes.
Is a pain free test, but does not tell about uni/bilateral blocks.

Conclusion

Some of these tests have become obsolete & some are still in a nascent stage to get widely accepted. To hold the test of time a preliminary HSG followed later, if needed, by a hystero-laparoscopy with chromopertubation would be the ideal way of assessing tubal factors. Still better would be to add tuboscopy to the armamentarium.

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