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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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PREOPERATIVE PLANNING
Preoperative establishment of the severity of tubal damage, if possible, can allow for discussion with the patient on whether
to attempt repair of the tube or perform a salpingectomy.
Presence of a hydrosalpinx can lower fertility rates due to backflow of fluid into the uterine cavity.
1
For this reason,
hydrosalpinges should be completely excised, or if the tube is unable to be completely removed, at least detached from the
cornua of the uterus. If a salpingectomy is performed for treatment of an ectopic, the entire tube should be removed as any
remaining portion can develop into a functional hydrosalpinx.
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SURGICAL MANAGEMENT
Performance of a salpingectomy has been associated with reports of diminishing ovarian function.
2
This has been theorized
to occur due to damage to mesosalpinx collateral vascular flow. Other studies have reported no effect.
3
Due to this possible
connection, it is prudent to attempt to limit damage to mesosalpinx vessels while performing the procedure. Transection of
the mesosalpinx should be kept as close to the body of the tube as possible.
Instruments used should allow dissection near the tube with use of limited electrocautery. A harmonic scalpel is ideal for this
situation, but a simple monopolar scissor (20 to 25 W setting) can work as well.
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Positioning
The patient should be placed in the normal standard dorsal lithotomy position as for other laparoscopic gynecologic
procedures. An intrauterine manipulator capable of allowing chromotubation is helpful to fill the occluded tubes to delineate
the tubal boundaries when extensive adhesive disease is present. Appropriate intrauterine manipulators include the
ClearView
®
(Clinical Innovations, Murray, UT), HUMI
®
(Cooper Surgical, Trumbull, CT), ZUMI™ (Cooper Surgical,
Trumbull, CT), or Kronner Manipujector
®
(Cooper Surgical, Trumbull, CT). Use of a very dark chromotubation solution
consisting of 10 mL of indigo carmine 0.8% solution (two ampules) mixed in 100 mL of saline is helpful in outlining the
tubes.
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Procedures and Techniques
Determine approach
Salpingectomy may be performed starting at the proximal or distal end. Starting distally and progressing proximally may limit
the likelihood of accidently entering the ovarian blood flow where the mesosalpinx and the infundibulopelvic (IP) ligament
merge.
In cases of significant distal damage or distortion, starting proximally may allow better delineation as the tube is gradually
excised.
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Distal to proximal approach
Grasp the fimbriated or distal end and elevate it toward the anterior abdominal wall. This provides the most separation from
the ovary to delineate the mesosalpinx. Use the Harmonic scalpel or scissor to ligate/cut as close as possible to the tubal
lumen (Tech Fig. 4.3.1).
Continue medially, staying as close to the body of the tube as possible (Te ch Fig. 4.3.2).
Te ch Fig ure 4.3.1. Elevating distal portion of t ube to t ransect mesosalpinx.
Te ch Fig ure 4.3.2. T ransecting mesosalpinx in a proximal direct ion, st aying close t o body of the tube.
Continue all the way to the cornua of the uterus, where the tube is then transected (Tech Fig. 4.3.3).
Te ch Fig ure 4.3.3. T ransecting tube at uterine cornua.
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Proximal to distal approach
In cases where the distal end is significantly damaged or scarred, it may be easier to approach the salpingectomy from
proximal to distal.
Transect the tube near the cornua, then grasp and elevate the transected tube. Care should be taken as the mesosalpinx can
be fragile and tear easily while elevating the tube, leading to bleeding (Tech Fig. 4.3.4).
Te ch Fig ure 4.3.4. T ransecting tube at cornua for a proximal to distal approach.
Dissect laterally along the tube, staying as close to the body of the tube as possible (Te ch Fig. 4.3.5).
As the ampulla is neared, regrasping and elevating at that point can provide more directed traction. Traction on the tube
medially can assist in keeping the area of dissection away from ovarian vessels (Te ch Fig. 4.3.6).
Take care in the last 1 to 2 cm of the tube, as the mesosalpinx can merge with the IP ligament, particularly if the tube is
scarred close to the ovary. Damage of ovarian vessels at this point can result in bleeding that is difficult to control without
sacrificing the ovarian blood flow.
Te ch Fig ure 4.3.5. Elevating tube and transect ing mesosalpinx close along body of tube.
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Te ch Fig ure 4.3.6. T raction medially on t ube helps to clarify dist al mesosalpinx and keep dissection away from ovarian vessels.
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Obtaining mesosalpinx hemostasis
After the tube is removed, the mesosalpinx should be observed for bleeding. This can often be venous oozing, so lowering
the intra-abdominal pressure can help to visualize this.
Use pinpoint cautery either with monopolar or bipolar forceps to obtain full hemostasis.
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Cases of severe adhesions
In some settings, the distal aspect of the tube can be involved in dense adhesions to the ovary, bowel, uterus, or pelvic
sidewall. Clearly finding a plane between the tube and other organs may be difficult to discern.
In these cases, use a medial to lateral approach to remove as much of the tube as possible. Open the remaining distal
portion of the tube lengthwise, exposing the lumen. Excise the majority of the tubal structure that can be identified, leaving a
small portion remaining. This can be a safer approach to prevent damage to surrounding structures, while opening the tubal
lumen, preventing recurrent hydrosalpinx formation.
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PEARLS AND PITFALLS
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