Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
.pdf
Treatment of distal fimbriated end
The fimbriated end should be freed up as much as possible to allow it to drape over the ovary to receive an oocyte.
Care should be taken when lysing fimbrial adhesions as the vascularity in this region can lead to significant bleeding.
Encountered bleeding should be addressed with a bipolar cautery instrument such as a Maryland bipolar or microbipolar. If
unavailable, a monopolar fine-tipped grasper can be used to directly grasp the origin of the bleeding and minimal use of
electrocautery applied to obtain hemostasis.
The fimbrial opening can be identified by chromotubation, and the opening should be gently probed with a Maryland forceps,
as adhesions can also be found within the ampulla and should be lysed.
https://t.me/med1917
Adhesion prevention
Careful dissection with limited trauma and judicious use of electrocautery are key in the prevention of future adhesion
formation. All adhesion barriers have limitations as to their effectiveness, though for this procedure, we prefer to use
Interceed
®
(Ethicon Inc., Somerville, NJ). Use ½ of a standard 3 × 4-in sheet to wrap around the distal portion of the tube
to form a tubal “sock.” The remaining ½ sheet is then used to wrap under the ovary, making an effort to separate the tube
from both the ovary and pelvic sidewalls during the healing process (Tech Fig. 4.1.7).
The patient can attempt to conceive immediately following surgery. However, if Interceed
®
is placed, this can be expected
to persist for 1 month after surgery (per manufacturer’s insert).
If unable to conceive after 6 to 12 months of appropriate timed intercourse, the patient should consider in vitro fertilization
(IVF). Repeat surgical management is unlikely to give added benefit.
Te ch Fig ure 4.1.7. Covering tube and ovary with antiadhesion barrier at end of procedure.
https://t.me/med1917
PEARLS AND PITFALLS
https://t.me/med1917
OUTCOMES
Chance of conceiving postoperatively is related to the severity of tubal damage.
https://t.me/med1917
COMPLICATIONS
Reformation of adhesions, limiting tubo-ovarian interaction and function.
https://t.me/med1917
KEY REFERENCE
1. Swart P, Mol B W, van der Veen F, et al. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a
meta-analysis. Fertil Steril. 1995;64(3):486–491.
https://t.me/med1917
Chapter 4.2
Tuboplasty/Neosalpingostomy
Travis W. M cCoy, Steve n T. Nak ajima
https://t.me/med1917
GENERAL PRINCIPLES
Definition
A damaged fallopian tube in which the fimbriated end of the tube has become occluded due to adhesive disease can result in a
hydrosalpinx. Besides rendering the tube nonfunctional, the presence of a hydrosalpinx reduces pregnancy rates in patients
undergoing in vitro fertilization (IVF).
1
A tuboplasty is a surgical procedure that involves lysing fimbrial adhesions to open a
partially occluded distal end. A tubal neosalpingostomy is a procedure in which a fallopian tube can be reopened as a method
of restoring fertility or less commonly as treatment for pelvic pain occurring due to the presence of the hydrosalpinx.
https://t.me/med1917
Differential Diagnosis
Distal tubal damage in the form of partial or complete fimbrial closure is most commonly due to postinfective adhesions, but
can also result from postoperative adhesions or scarring due to endometriosis. Pelvic adhesive disease can also cause
functional restrictions, limiting the interactions of the tube and ovary without affecting the fimbria.
https://t.me/med1917
IMAGING AND OTHER DIAGNOSTICS
Distal tubal obstruction is most easily demonstrated by hysterosalpingogram (HSG), though this test can have both false
positive and negative results with findings suggestive of a blockage in the setting of a normal tube, or vice-versa. A moderate
to severe hydrosalpinx may also be visualized through standard transvaginal ultrasound, hysterosalpingo-contrast sonography
(HyCoSy),
2
MRI, or pelvic CT, though the latter two are much less sensitive for tubal damage.
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана