1. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT & K.S.A

5. Chronic Pelvic Pain  Chronic pelvic pain is defined as the intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.  Living with any chronic pain carries a heavy economic and social price.  Chronic pelvic pain is defined as the intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.  Living with any chronic pain carries a heavy economic and social price. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

6. Microlaparoscopy is a laparoscopy using instruments less than 5 mm in diameter. Major benefits associated with the use of microlaparoscopy: plays a valuable role in pelvic pain mapping safer than the traditional laparoscopy in patients with multiple abdominal scars scars are more cosmetic can be done under local anesthesia MICROLAPAROSCOPE

7. MICROLAPAROSCOPE INSTRUMENTS Laparoscope less than 5 mm in diameter Less than 1 mm semi rigid fiber optic scope Less than 2 mm scope in diameter 2 and 3 mm rigid fiber optic or glass lens scopes DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

8. Microlaparoscopy Instruments DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA A laparoscopy using instruments less than 5 - mm in diameter A 3 mm microlaparoscopy

9. Conscious Pain Mapping Conscious pelvic pain mapping has added an innovative diagnostic dimension previously absent in gynecology. Because the patient is awake for the entire microlaparoscopic procedure, she can provide crucial information as an active member of the surgical team. The patient is able to help the surgeon locate the source of pain. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

10. The areas of concern are examined laparoscopically in a lightly sedated patient. The patient then directs the physician to the area of concern. Careful in vivo examination often reveals pathologic conditions that are not recognized by other means. When the source of pain has been identified, subsequent treatment steps are often clear. Conscious Pain Mapping DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

12. To evaluate the use of microlaparoscopy in conscious pain mapping in cases with pelvic pain. This is a new modality in Tanta University Hospital. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

14. This study was conducted over a period of 2 years involving one hundred patients who were admitted in the gynaecology department at Tanta University Hospital, Egypt. Patients were divided into 3 groups according to their complaints: First group: patients with dysmenorrhea (n. =16) Second group: patients with dyspareunia (n. =23) Third group: patients with chronic pelvic pain (n. =61) DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

15. Selection Criteria Age: 19 – 40 years old Average body weight Exclusion Criteria Contraindication to conscious sedation techniques Very obese patients Virginity DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

16. Methods DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA All patients were subjected to the following: A complete history taking Thorough general and gynaecological examinations Routine laboratory investigations High vaginal swab Transvaginal ultrasound Microlaparscopy

17. Timing DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA All patients were operated upon post menstrual except for the first group, which was timed during menstruation. Conscious sedation: Intravenous, anxiolytic (Diazepam) & Opioid (Fentanyl citrate) Local anesthetics: Lidocaine & Bupivacaine

19. The nerves conducting the pain pass next to the cervix. Blocking nerve conduction at this point blocks pain. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA Paracervical block

20. Injected a total of 20 cc of 1% Lidocaine into the lateral vaginal fornices, with injection sites of 10, 8, 2, and 4 o'clock. (5 cc in each site) DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

21. Iowa Trumpet (top), Needle (middle), and plastic needle spacer to limit depth of penetration of the needle to 5 mm. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

22. Pain Mapping Procedure DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA The major structures were grasped or propped in standardized fashion i.e. (internal inguinal ring, round ligaments, fallopian tubes, ovaries, pelvic side walls posterior cul - de - sac, uterus and appendix) any visible areas of pathology e.g. endometriosis adhesions, or scarring were also probed the patient was asked to rate the pain of this probing according to a weighted 0 to 10 point scale.

23. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

25. Pain Mapping Procedure DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA The procedure was repeated again for a 2nd and 3rd time for comparison. If the degree of pain sensation at any point was more or less the same, this point was considered as source of pain. Probing of tender points was performed for the fourth time after injection of local anesthesia in the tender places.

26. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

27. Positive mapping cases were defined as those in which one or more lesions were found that correlated with some or all patients pain.CPM procedure was defined as successful if the patient tolerated the procedure and consistently identified the source(s) of pain or stated that no sources could be identified. Patient follow up: After 3 months of suitable treatment, (medical or surgical), each patient was given a questionnaire and asked to respond to their treatment and to evaluate the result of the technique.

29. Clinical and Demographic Data of each group under going conscious pain mapping on admission Group I ( n=23) patients with dyspareunia Group I ( n=61) patients with chronic pelvic pain Mean age in years ± SD Range 29.1±4.35 19-39 29.5±4.56 19-40 29.6±4.39 19-40 Mean body weight in “kg” ± SD Range 66.27±3.87 60-73 66.14±3.45 59-74 66.3±3.38 60-73 Mean pariety ± SD Range 3.4±1.3 0-5 3.5±1.5 0-5 3.2±1.1 0-5 Mean duration of preoperative pain in months ± SD Range 31.63±3.5 10-60 32.1±3.7 10-62 32.6±3.8 11-61 Mean Preoperative verbal analog scale pain levels ± SD Range 8.95±0.96 6-10 8.9±0.90 6-10 8.98±0.93 6-10 Variable Group I ( n=16) patients with dysmenorrhea

32. Results of successful conscious pain mapping in 96 patients Outcome Number of patients Group 1 (n = 15) % to group I Group II (n = 21) % to group II Group III (n = 60) % to group III % to all (pa.n.96) 99- - 2 3311----1--99- - 2 3311----1-- 12 2 7 1 - 38 34 4 1 5 18 16 2 1 - 1 Endometriosis diagnosed visually Positively mapped endometriosis Successfully mapped but not tender visually diagnosed endometriosis Non tender confirmed histologically endometriosis. Total number of confirmed histologically endometriosis under local anesthesia Visually diagnosed adhesions. Positively mapped adhesions. Symptomatic ovarian cysts. Pelvic inflammatory disease Uterine fibroid Residual ovary Chronic appendicitis. Pelvic congestion. Hypoplastic uterus. Generalized visceral hypersensitivity Free-microlaparoscopy. 60% 13.03% 20% 6.6% 6.6% 57.1% 9.5% 33.3% 4.7% 63.3% 56.6% 6.6% 1.6% 8.3% 30% 26.6% 3.3% 1.6% 61.4% 57.29% 4.16% 1.04% 9.37% 29.16% 27.08% 4.16% 3.16% 1.04% DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

33. Endometriosis DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

36. Dose of diazepam and fentanyl used in conscious pain mapping. DrugRangeMean ± SD - Diazepam - Fentanyl 3.3--8mg 770-180ug 55.5±0.6 1125±12.2 DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

37. Mean of mean arterial blood pressure (mm/Hg) during CPM

39. Number of cases Time taken during conscious pain mapping Range in minutes Mean ± SD -All cases -First 16 cases Next 80 cases 24-35 min 16 to 22 min 16-35 min 21.3 ± 2.4 19.5 ± 2.1 19.3 ± 23 DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

40. Postoperative sequelae after conscious pain mapping and operative procedures under local anesthesia Variable Mean ± SD -Time to discharge (in minutes) -Time to return to normal activity (in days) --Time to return to work (in days ) -Time to resume intercourse (in days) 63.5 ± 2.9 1.9 ± 0.3 2.8 ± 2.8 5.6 ± 1.12 DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

41. Variable Clinical data 3 months after CPM and appropriate treatment Number of patients % N=96 22.9 6.25 Mean V. A. S. pain level < 3 [range 2-3 ] -Totally pain free Mean V. A. S. pain level < 5 [range 4-5 ] Mean V. A. S. pain level >8 [range 8-10 ] 62 22 6 6 6.25 DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA

42. Results of 2nd look microlaparoscopy and CPM in 6 patients, 3 months after primary procedure

44. DR ASHRAF ATIA DEWIDAR MD MRCOG EGYPT KSA 1.The microlaparoscope offers a new effective and useful modality in the management of chronic pelvic pain. 2.CPM can be done with reasonable success in women with or without prior surgical valuation and for treatment of chronic pelvic pain. 3.In appropriate cases, pelvic pain mapping during microlaparoscopy under conscious sedation can provide information that may influence surgical decisions, as well as general clinical management. 4.In selected women, several microlaparoscopic procedures, in addition to CPM, can be safely done within a reasonable time frame under local anesthesia and conscious sedation. And it is tolerated well by the patients. 5.This technique is recommended for evaluating selected women with chronic pelvic pain, not responding to medical treatment.