Justification of the method of culdocentesis
Puncture of the abdominal cavity through the posterior vaginal fornix (cultivated center) is the closest and most convenient access to the pelvic cavity (recto-oral cavity, Douglas space), where fluid (blood, pus, exudate) accumulates during various pathological processes, often gynecological origin.
Puncture of the abdominal cavity through the posterior fornix of the vagina is performed in a hospital in cases when it is necessary to determine the presence or absence of free fluid (blood, pus, serous fluid) in the pelvic cavity. The resulting serous fluid is sent for bacteriological and cytological examination (for the diagnosis of the inflammatory process in the pelvic cavity or early diagnosis of ovarian cancer).
PURPOSE OF THE STUDY
Detection of blood or accumulation of other fluid in the abdominal cavity. Differential diagnosis of various diseases (ectopic pregnancy, rupture of an ovarian cyst, ovarian apoplexy, inflammatory diseases, ovarian tumors, suspected malignancy, etc.) based on the nature of the fluid obtained from the abdominal cavity during aspiration.
INDICATIONS FOR CULDOCENTESIS
In the past, the most frequent indications were suspected ectopic pregnancy and ovarian apoplexy (currently, laparoscopy replaces this research method). The rare indications for puncture include PID and suspected malignancy.
PREPARATION FOR RESEARCH
Necessary tools (fig. 7–47): spoon-shaped mirrors, bullet forceps, forceps, 10 ml syringe, puncture needle 10–12 cm long with a wide lumen and obliquely cut end.
Fig. 7-47. Instruments for puncture the abdominal cavity through the posterior vaginal fornix.
METHOD OF PUNKING
Below the cervix in the posterior fornix between the diverging sacral ligaments, the peritoneum is very close to the vaginal walls. It is in this place and conduct puncture of the abdominal cavity through the posterior fornix of the vagina. After treatment of the external genital organs and the vagina with alcohol and 2% iodine solution using mirrors expose the vaginal part of the cervix, the uterus posterior lip is captured with bullet forceps and pulled down anteriorly. A thick, long needle, worn on a syringe, to a depth of 1–2 cm (Fig. 7–48) is inserted into the posterior vaginal arch, stretched so strictly along the midline (between the sacral chords). The fluid is removed by the reverse movement of the piston or simultaneously with the slow removal of the needle, then it is bacteriologically and / or performed by cytology.
Fig. 7-48. Abdominal puncture through the posterior fornix of the vagina.
INTERPRETATION OF RESULTS AND FACTORS AFFECTING THE RESULT
Puncture as a diagnostic method is most often used in cases of suspected aborted ectopic pregnancy: if there is a fresh accumulation of blood in a rectal cavity, blood enters the syringe immediately after puncture of the thin wall of the posterior fornix. If the needle goes some distance after a puncture and the blood that enters the syringe is thick, dark with clots (from the hematocele), then this indicates ectopic pregnancy. The results of abdominal puncture may be either false-positive (when the needle enters the parametrium vessel, vagina or uterus) or false-negative (defect in the needle lumen, accumulation of a small amount of blood in the abdominal cavity or pronounced adhesions in the uterine appendages). Sometimes during a puncture not dark blood is obtained, but a serous fluid with a hemorrhagic component, which does not exclude impaired ectopic pregnancy. Blood can be detected by ovarian apoplexy, spleen rupture, as well as menstrual blood reflux and after curettage of the uterus. Therefore, laparoscopy is preferred.
In some cases, puncture is used when an uterine appendage abscess is suspected (pyovar, pyosalpinx), if its lower pole is closely adjacent to the posterior vaginal fornix. When removing the pus in the cavity of a purulent tumor injected antibiotics. In inflammatory diseases of the genital organs, occurring with the formation of exudate in the rectangular cavity, puncture is performed to determine the nature of the exudate (purulent, serous) and laboratory examination of punctate for culture on the medium, sediment microscopy.
COMPLICATIONS OF THE ABDOMINAL CASTLE
Rare. A needle may enter the parametrium vessel, the vagina or the uterus, or a wound to the intestine (does not require special treatment).