妇科内窥镜技术进展-英文

TheProgressofGynecologicalEndoscopeTechnology

1Ⅰ.Overview--Endoscopyanimportantpartofminimallyinvasivetechnologyarevolutionarypioneerinsurgerychangesthethoughtsandideas,thetechnicalrouteandoperationskillsofdoctors2Overview--Laparoscopy

appliedinGYNfieldbyPalmerin1947firsthasbecomeoneofthemostregularoperationtechnologyingynaecologycurrentlymainlyappliedtoexaminationsandsimpleoperationsfrom1950sto1970sin1970s,expansionofvitreoretinalsurgery,ChinaandZhejiangProvincebegantheapplicationoflaparoscopyinOB&GYN3ThelaparoscopichysterectomyandQuerlenlymphaticexcisionbyReichin1989significantadvantagesinOB&GYNandwidelyusedexploreconstantlyfornewareas,inmalignanttumors,pelvicfloorreconstructionandothersurgicalfields4Overview--hysteroscopyAnidealoperationmethoddiagnosisandtreatmentofintrauterinebenignlesionstherangeindicationsincreasinglywidened.5Afterthefirstquarterinthe21stcentury,thevastmajorityoftheGYNoperationscanbedonethroughtheendoscope6Advantagesandapplications

oflaparoscopy7（I）

AcutegynecologicalabdomenDiagnosisandtreatmentintime.Ectopicpregnancy,corpusluteumrupture,acutepelvicinflammation,pelvicabscess,andovariancysttorsion,etc.an

indicatorformeasuringthe

applicationinaunit,thepresentationofthebasicconceptandtheuniversalscaleoflaparoscopy.8Forectopicpregnancytreatment(bytakingembryooftubalpregnancyincisio)

---goldstandardOncefallopianportionpregnancywasconsideredcontraindication,nowlotssuccessfulcasesreported910rupturedectopicpregnancy---onceconsideredascontraindications,nowcanfinishedbyexperienceddoctors

(thoughquicklyfindthebleedingsite)11（II）Gynecologicalbenigntumorsovariansimplecyst,benignmatureteratoma,ovariancyst,etc.laparoscopypreferred.

Somehospitalamountedto90-100%.12（III）Endometriosisgoldstandardfordiagnostic,rAFSinstallmentbasis,thebesttreatmentapproach.abdominaltype,ovarytype

canbeachievedthroughlaparoscopicremovelesionstorelievepain,improvethepurposeoffertility,andreducetherecurrence.difficultinDIE,butsecurityincreasewhencombinedwithvaginalsurgeryNOTusedinuncertainendometriosisandmalignanttumor,especiallyforCa125>200iu/mlorimaging“special”byiconography,whichmaydelaythediseases1314151617EverystageofEMSiscurrentlyfitbylaparoscopy

Someexpertsperformbowelresectioninmicroscopic,andalmostnoobjectionhasoccuredItisbetterbylaparotomyinlargeovariancyst,widelyintestinaladhesion,intestinalresectionorjudgedtobeaverycomplicatedsurgery18（IV）ChronicpelvicpainbestwaytodiagnosecommonsymptomsinducedbymanycausesApproximatelyonethirdisEMs,onethirdpelvicadhesion,onethirdnormalpelvic80%adhesionseparation,thelesionresectioncanbealleviatedmicroscopicallyPelvicpaincausedbyEMscanberemovedbysacralnervetransectionorsacralnerveresection,withsatisfiedrateover70%.19（V）Pelvicinflammatoinrelativelycontraindicated20yearsago;nowacuteorchronicpelvicinflammationtreatedbylap.

topreventinflammation,reducepelvicadhesionandpelvicpainandinfertility.Pelvicabscessincisiondrainage,appendixresection,adhesionseparatingandpelvicflushingwillimprovetheprocessandresults.congestiveandedemawithlooseadhesioninacuteinflammatointissue,buteasytoseparate;chronicabscesswithdenseadhesionoftenmakessurgerydifficult.20大网膜黏连1、腹膜牵拉症状2、胃肠功能紊乱3、部分因横结肠牵拉成角，出现不全性机械性梗阻症状21Ⅲ.SelectionproblemsandnewfieldsofendoscopicsurgeryTheapplicationoflaparoscopyshouldbeprudent.Surgery,patientsanddiseasemustbeentirelyappropriatetoeachother.Aimedtofindandimplementthemostappropriatesurgery,ratherthantopursueandshowofftechnologyandequipment.22Choosetheappropriatesurgery

Choosetheappropriatepatient

inappropriateinappropriate×appropriateappropriatebestchoicesurgerypatientsordiseases×23（I）HysterectomyOneofthemostcommonGYNsurgeriesDiffirentadvantagesandlimitationsviaabdomalandviavagina,orauxiliary,foster

strengthsandcircumventweaknesses.Totallaparoscopichysterectomy(TLH)Laparoscopicassistedvaginalhysterectomy(LAVH)Vaginalassistedlaparoscopichysterectomy(VALH)24(II)myomectomySingle,<5cmofmyomaMultiple,morethanthree,or>7cm,orsingle>15cm(ormuscleintramural>10cm),deepbroadligamentorposition,orclosetothelowpartuterusandcervicalmyomaarenotfitintramuralorsubmucousmyomaincreaselegacyandrecurrence.Skillfulsuture（缝合）techniquerequired.Clinicalvalueofrecedefibroidsbyelectriccoagulation,laser,freezstillneedsevaluation.2526（III）GynecologycancersFullofhopeanddissent（异议）Moreconsensus（意见一致）isonStageIofendometrialcancer.

Pelviclymphnodeclearancerequiredafterhysterectomysimplelyandsafelyunderlap.pre-sentinel(前哨)lymphnodeexcisionincervicalcancerunderlap,aimingatpromptradiationorradicalhysterectomy.Trachelectomy(保留生育功能根治术)inearlycervicalcancer,aimportantstepispelviclymphnodeexcisioninlap.

Thenegativehistologyresultindicatefollowingsurgeryshowouttheadvantageoflap.27fullyusedinovariancancerdiagnosisandpreliminaryclinicalstaging.

Basicofpreviouschemotherapy,andwellacceptforsecondpelvicexplore

foritsminimallyinvasive.FitforStagesIandIIofovariancancerbutNOTforStagesIIIandIV.28（IV）Pelviccavityreconstructionchangetraditionalmodusoperandisofpelviccavityorgansrolapseandstressurinaryincontinence.burch,foldinguterosacralligament,sacro-vaginaimmobilizationcanbefinishedbylap.Micro-injury,fastrecovery,idealeffect,butrichexperienceandgoodtechniquerequired.29（V）ChoicePrinciplesinmedicineandhumanityPrinciplesofmedicine:providebestsurgerytodisease.Principlesofhumanity:moreconsiderationtoeffectsoflifequality,willofpatientsandfamilialities,understandingtorisksandcomplicationsofoperation30LaparoscopyinpregnancyOnceisacontraindication,

nowovariancystsinmiddle-pregnancyisreported.EffectsofpneumoperitoneumandCO2topregnancyshouldbebalancedinadvantagesanddisadvantagesandtotallytoldtopatientsandtheirfamilialitiesfortheiragreement.31IV.ContraindicationsincreasingadvancewithdecreasingcontraindicationAbsolutecontraindications:Cardiovascularandlungdiseasescannottolerateanesthesiaseverearrhythmia,IIdegreeorover

atrioventricularblockhemodynamicchangesSepsis

LiuYan,PracticalGynecologiclaparoscopicoperativesurgery.

32Relativecontraindications:nervoussystemdisordersbloodclottingdisordersmassoftheabdominaaboveumbilicus(脐)levelPregnancymorethan4monthsabdominalwallhernia（腹壁疝）,diaphragmatichernia（膈疝）intestinalobstructionObesitMultipleabdominalsurgeryhistoryinexperiencedoperators(XiaEnlanetal.)33attentiontotheprocedureandtheoperationitselftheirknowledgelinkstolaparoscopicinstrument,includinginstrumentcharacteristics,specificcomplicationsrelatedfactors,andpreventionmeasuresStrictoperationstandardsIntensivetraining,stepbystep34V.ThepreventionsofcomplicationsDeathrateinlaparoscopicsurgeryisatleastfourperhundredthousand.Limitedvisionfield,damagefromequipmentandenergy,effectsofCO2pneumoperitoneumandpositionDevicesdependsurgery,experienceandskillsplayadecisiveroles.

35

Some"low-levelproblems"inprimarystage:subcutaneousemphysema(皮下气肿)Retroperitoneal（腹膜后）vessels,abdominalarteries(0.005-0.01%)andintestinalcanalinjuryduringneedleortracarpunctureelectricburns:intestine,ureter(输尿管)isthemostcommon.uncorrect

vasculartreatmentinducehemorrhageoccurs:electriccoagulation,

knotspecimenlossinabdominalcavity36some“Seniorproblems”inexperiencedendoscopicphysicians:Uretersdamagedwhendissectingtissuesofside-uterus.Hemorrhagewhencleaninglymphnodes.Heavyadhesionofintestineandbladder,damageoccurwhenseparate37

Clinicallaparoscopicstudies

concentrateon:circulatorysystem,respiratorysystem,liver-kidneyfunctionbodystressresponseOxidativestressIschemiaandreperfusion(缺血再灌注)38Comparisonbetweenlaparoscopy

andopenoperationsmainlyrelatedtoimmunity,disseminateion,adhesion39StudiesonCarbondioxidepneumoperitoneumtumorcellproliferationandapoptosistumorspreadandtransferofincisionsitesadhesionandinvasionlackofoxygen,lowPHcausedtoepigeneticschangeseffectsonperitonealmicroenvironmenteffectsonbody’simmunefunctionChangedangiogenesisandsecretionofcytokinescausedbypneumoperitoneum

pressure40VI.ProgressofthelaparoscopicsurgeryMicrolaparoscopy(微型)gaslesspneumoperitoneumtransvaginalwater-laparoscop（经阴道水腹腔镜）Robertremotediagnosis,

surgery,teaching411.GaslesslaparoscopyNocontinuousCO2pressure,minimallyinvasive.(1)Gaslesslaparoscopyusingtheabdominalwalllifting(AWL)(腹壁悬吊式无气腹腔镜)mostcommonlyused42(2)airbaglaparoscopy(气囊腹腔镜)43(3)Magneticattraction:Anderson(USA)

&Power(Canada),usingfourmagneticobjectsbyTrocarintoabdominalcavity,usingmagneticattractioninandoutabdominalwalltomakegaslessspace.experimentalpigsnephrectomy(肾切除)proved

itsfeasibility(byAnderson)

442.Narrowbandimaging(NBI,窄带成像)ImproveaccuracydiagnosisofEMsfilteroutbroadbandspectrumfromendoscopicredbluegreenlight,onlyleavingnarrowbandspectrumfordiagnosis.Agoodreflecttothereconstructbloodcapillary.rangeofapplicationindigestivetract,ear,nose&throat,respiratorytract,gynecologicalendoscopicandlaparoscopicsurgery,etc.easytoidentifythesuperficialEMs,andjudgetheextentoflesion.453.Theprogressofthelaparoscopicoperation-uterinearteryblock(子宫动脉阻断)464.TreatmentsofmalignanttumorinLaparoscopy47(1)preventthecannulatransfer

(预防套管处转移)thecannulafixedwithsutures(缝线)ontheabdominalwallspecimenbagsusedtoavoidpolluteabdominalincisionfirstCO2escapethenpulltracarcasingtoprevent‘chimneyeffect’(烟囱效应)attheend48(2)ReducepneumoperitoneumimpactCO2pneumoperitoneumpromotethegrowthoftumorcells,shortenoperationtimeestablish37℃

CO2pneumoperitoneum,reducethespray(雾化)oftumorcellsset14mmHg

andCO2flowrate<5l/minintraoperative49(3)preventabdominalresidualandinfectionHeatperfusionchemotherapy(热灌注化疗)inabdominalcavityItcollects

heateffect,chemotherapydrugsandmechanicalwashingto

reachmultipleeffectsoncancercells50

(4)HotCO2pneumoperitoneumHotCO2pneumoperitoneuminducesapoptosisoftumorcell

/pubmed?term=%22Peng%20Y%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract,etal.HyperthermicCO2pneumoperitoneuminducesapoptosisinhumancoloncancercellsthroughBax-associatedmitochondrialpathway.2008,19(1):73-951Newconceptofgynecologicallaparoscopy521.Naturalorificetransluminalendoscopicsurgery,NOTES(自然腔道内镜外科)anewkindofultramicrointerdisciplinarysurgery(跨学科的新兴超微创外科手术)Throughnaturalcavitiessuchasoralcavity,anus(肛门),vaginalandurethralintosoftendoscope,respectivelypierceorganssuchasthestomach,therectumandbladder,vaginafornixarrivedinabdominalcavitytoestablishedoperatingchannelsandgaslesslaparoscopicabdominalorwater,doallkindsofbasinceliacsurgeryunderendoscopy53ThegynaecologyNOTESinclude:TransvaginallaparoscopicwaterinjectionThegastricresection,accessoriesandtuballigationJosephA.etal.Peritonealinflammatoryresponseofnaturalorifice

translumenalendoscopicsurgery(NOTES)versuslaparoscopywithcarbondioxi.deandairpneumoperitoneum.(2009)

Zorronetal.NOTES:transvaginalforcancerdiagnosticstaging:preliminaryclinicalapplication.2008Sep;15(3):161-5.542.Laparo-endoscopicsinglesitesurgery(LESS)Integratinglaparoscopicmultimodalintoachannel,toapplyhasthreecomtecasing(triport),throughhumaninherentchannel"bellybutton"intotheabdominalcavity,duetothebellybuttonfoldblockoperationscar,basicbodysurfaceandnoscarcosmeticeffect.Anteriorextremitiesofequipmentsareflexibletooperate.

Becauseofzerodegreeandrestrictedoperationspace,front-endanteriorextremitiesofequipmentsareflexibletooperate.

55Fagotti,etal.Laparo-endoscopicSingle-SiteSurgeryfortheTreatmentofBenignAdnexalDisease:AProspectiveTrial.(2009)563.Roboticlaparoscopy

In2000theUnitedStatesFoodandDrugAdministration(FDA)approvedtheapplicationoftheDaVincirobottechnologyinthefieldofgynecology.

Itimprovestheopticalinstruments,highresolutionand3Dimaging,andtheoperatinginstrumentmovementrangeandoperationflexibility.Robotcontrolcameracanimproveworkefficiency,andreducethefatigueofthesurgery.

57Intelligentandsimulationprogramforgynecologicalendoscopicsurgery（L.Mettler,CampusKiel,Germany）Endoscopicsurgeryinthefuturewillbecombinedwiththeapplicationofadvancedmachineryandequipmentthroughthesensorcontrolsensationandmovement.Thetechniquehashighprecision,minimalinvasion,lessbleeding,andthree-dimensionalvisualareaprecisionoperationindependentontheoperationofsubjectmove.58Operatorscansitinfrontofacomputertooperateinpatient’sbodythroughthejoystickbyDaVinciintelligentsystem,whichshouldbebasedonthefictitiousbodytrainingsystemtraining.Inadditiontoimprovethesenseoftouch,masteringanatomicalknowledgeandsmart,stillneedcarefullyeffectiveapplicationtechnologyandhighprecisioninstruments.59Indications,contraindicationsanddevelopmenttrendofHysteroscopy60(I)DiagnosisandtreatmentofbenignuterinecavitylesionsCheckeuthyphoriaendometrialunderphysiologicalandpathologicalchangesSensitivityandspecificityofdiagnosisofnormalandabnormalendometriumbyhysteroscopyare94.2%and88.8%respectively,andthoseofthediagnosisofpolyparethehighest,95.3%and95.4%respectively.Positionbiopsy,avoidblinddiagnosisofdilationandcurettageofuterus61Examineallkindsofabnormaluterinebleeding,intrauterineplaceholderlesions,infertilityetiologyexamination,identifyabnormaluterineimagingchangesAbsolutecontraindicationsinclude:acutegenitaltractandpelvicinfection,heart,liverandkidneyfailureintolerance.62Hysteroscopycheck3to7daysaftermenstruation:endometrialthinner,noteasytobleed,lessmucussecretion,uterinecavitylesionseasytobeexposed.oftenuse5%GStobulkpalace,on-demandslightlyenlargedornotdilatecervix,handhysteroscopytoexaminecarefullytheuterinewall,tubalopenings,fundus,beforeandafteruterinewalllast,thecervixandcervicalcanal.63（II）Minimallyinvasivesurgeryforthetreatmentofuterinecavitylesions1、DysfunctionaluterinebleedingEndometrialresectionofthedestructionofendometrium(TCRE)byhysteroscopicdamagesfull-thicknessendometriumandthebottompartmusclelayer,andleadstoregenerationoforganizationendometrial,toachieveamenorrheaorreducemenstruationItisnotapplicabletopatientsoffertilityrequirement.64

2、EndometrialpolypsandsubmucousmyomaCuring80%endometrialpolypsPregnancyrateofinfertilitypatientsbymovingsubmucousmyomainhysteroscopicis60.95%.Curing95.2%submucousmyomaofpost-menopausalwomen,polyps,adhesionmicroscopically.Uterinedepthismorethan12cm,whichisnotsuitableforhysteroscopysurgery6566670型黏膜下肌瘤68I型黏膜下肌瘤69II型黏膜下肌瘤70IndicationsofelectrosectionaboutsubmucousmyomaSmallandsingle,submucousmyomawithmicro-pedicel,diameter<1.5~2cm,afterhysteroscopyexaminationswitchtohysteroscopysurgery,willberemovedeuthyphoria.Myomadiameter<5cm,experienced,indicationscanbeextended.Burieddeepwithinthemuscleandmusclelayerinmuscleintramuralmyoma,sometimesmorethantwooperationsarerequired.Intramuralandsubserousmyomaswhichdon‘tcausedeformitiesoftheuterinefibroidsareunfavorableforhysteroscopysurgery713.separationofintrauterineadhesionRecoveuterinenormalanatomicalmorphology,correcttheabnormalmenstruation,restorefertilityPreutthipanreported65separationofintrauterineadhesioncasescuttingafterelectrosectionsurgery,90.9%secondaryamenorrhearecoverynormalmenstruation,periodicabdominalpaindisappearaltogether.Katz,90casesofmergerhistoryofadverseproductioncausedbyintrauterineadhesionsaftertreatment,earlyabortionratefallsto62.4%from17.4%,lateabortionratefallsto16.0%from4.7%,full-termbirthsincreasesfrom18.3%to68.6%.72针状电极分离黏连环状电极切割右侧壁黏连环状电极切割右侧壁黏连后针状电极分离黏连后73TCRA术前宫腔封闭，镜体前方为盲端TCRA术后切割出孔隙74术后宫腔可见左输卵管开口暴露左宫角显露右侧输卵管口75暴露宫腔术后宫腔形态宫腔形成764.CorrecttheuterineabnormalitiesRestoreinfertilitycausedbyintrauterineanatomymorphology,treatment,mediastinumuterusaremostcommon.RenaissanceBeijinghospitaltreated116casesofmediastinumuterus.Theabortionratefallsto72.6%from25.4%,full-termbirthsincreasesfrom9.2%to94.7%.77785.HandlingintrauterineforeignsubstanceAccuratepositioning,withoutdamagingthenormalendometrium.Embryoandplacentatissueresiduesfetusskeletonsresidue,lostorbroken,theintrauterinedeviceandsooncausedbyintrauterineforeignbodyremovalandremove79（II）ApplicationvaluesandcontroversysofthemalignanttumorSomescholarsfound26casesofendometriallesionsandcurettageomissionsnoabnormalhysteroscopyexaminationandpositioningbiopsy,26casesofendometriallesionsandcurettageomissions,among206casesofabnormaluterinebleedingandcurettagefoundnoabnormalhysteroscopyexaminationandpositioningbiopsy,26casesofendometriallesionsandcurettageomissions,70%werefocalchange.80（III）Diagnoseandtreatmentonexterioruterinecavitylesion1、DiagnoseandtreatectopicpregnancyMarpeauperformedhysteroscopyon60casesofsuspectedectopicpregnancy.41casesofthemwerediagnosedasectopicpregnancy,fornopregnancytissuewasfoundunderthescopewhileoviductonsidewasopenandbloodflowedout;18caseswereuterineembryodeaths,and1casewasnotdetermined.81Therewerecasereportonuterinehornpregnancy,interstitialtubalpregnancyinforeigncountrieswhichhadbeensuccessfullyremovedbyapplyinghysteroscopyafterMTX.ThereisasuccessfulcaseofpregnancyinscarpartofCesareansection.822、ResectionofcervicallesionCervicalpolypoidhyperplasiaCervicalpolypusCINI-II3、AuxiliarytreatmentonothersystematicdiseasesNon-organicdiseasesoftheuterus,andthemassmetrorrhagiacausedbyotherdiseasesandmedicine.83Thecorequestionofdisputeis:doesperfusionmediumcauseexpansionoftumorcellsandaffectfutureprognosis?Arikanperformedsimulatedvitrohysteroscopyon24casesofendometrialcancersamplestreatedbyuterus+dualuterineappendagesremovalandfoundthat83%sampleuterineperfusionpenetrateswhenflowingthroughoviduct,andtumorcellsarefoundin71%ofpenetratingliquidwhere42%oftumorisalive.84ButitisfoundamongvariouscentersandbigsampleclinicalresearchesinAustria:thesurvivalratewithouttumor5yearsafterperforminghysteroscopybeforetheoperationonendometrialcancerwhiletherateforthosewithoutperforminghysteroscopyis84.7%.Thereisnostatisticaldifferencebetweenthem.ItisconsideredinMulvanyreportsthatperforminghysteroscopywillnotcauseharmfulinfluenceonprognosis.85

Surgicalcomplicationsanditscountermeasureof

hysteroscopy1．uterineperforation：

Itregularlyhappensunderchargedoperationswhenthehorizonisvague.Onceithappens,thesurgicaloperationshallbestopped,andthepatientshallbekeptinthe