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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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Approach
A laparoscopic approach offers an easier recovery to the patient, but may require longer surgical times and a higher level of
laparoscopic surgical skill. The laparoscopic approach may also involve the use of robotic assistance. Mini-laparotomy is
typically done as an outpatient procedure. Both routes are reasonable options and require microsurgical skills, though a
laparoscopic approach requires a more skilled laparoscopic surgeon. Both routes have similar fertility outcomes, though
mini-laparotomy may be more cost effective.
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Procedures and Techniques
Exposure and setup
For mini-laparotomy, a small 6 to 8 cm transverse skin incision is made. Overweight or obese patients may require a slightly
larger incision. A vertical fascia incision is made which may result in less postoperative pain, aiding in the patient discharge
soon after the procedure. A self-retaining wound retractor (Alexis
®
Wound Retractor, Applied Medical, Rancho Santa
Margarita, CA) aids in exposure. The exposure to each side can be made easier by suturing the round ligament of that side
to the midline of the lower incision skin edge, thus retracting the uterus slightly to one side.
For laparoscopy, four ports are typically used (two on each side) in addition to an umbilical camera port. In a robotic-
assistance case, one of these will be used as an assistant port, using an 8-mm trocar to allow easier passage of sutures
(Te ch Fig. 4.4.1).
Te ch Fig ure 4.4.1. Location of the laparoscopic ports on the abdomen. If robotic assistance is used, the right upper quadrant port can be the assist ant port.
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Lysis of adhesions and mobilizati on of tubal ends
Any tubal adhesions should be carefully lysed. The divided tubal ends should be freed up to allow approximation (Te ch Fig.
4.4.2A).
The mesosalpinx should be freed up so that it can be brought together to help approximate the tubal ends. The mesosalpinx
does not need to be dissected away from the tubal end (Tech Fig. 4.4.2B).
Te ch Fig ure 4.4.2. A: Lysis of adhesions near distal t ubal segment. B : Cutting mesosalpinx to free tubal ends.
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Opening of tubal ends
The proximal portion of the tube should be opened first, to verify patency prior to distal end preparation. Attempting to
perform chromotubation at this point will often cause the distal end of the tube to push outwardly as well as stain with the
blue dye (Tech Fig. 4.4.3A).
The end of the tube can be grasped with a forceps, pulled distally, and then the tube is cut (usually requiring 1 to 2 mm to
remove scar tissue and reach the tubal lumen). If the lumen is not reached, subsequent cuts are made until the open lumen
is reached and no scar tissue is visualized. Bleeding usually comes from small vessels in the muscular portion of the tube
and can be cauterized by using micro-bipolar forceps, or pinpoint monopolar cautery, using as low of a setting to achieve
hemostasis (often 10 to 12 W) (Te ch Fig. 4.4.3B).
In many cases, the opening location on the distal end is not clearly defined as with the proximal segment. Gentle passage of
a small catheter (5-F pediatric feeding tube) through the fimbriated end toward the proximal occlusion can serve to
delineate the desired point for tubal opening. The distal opening should be opened just enough to approximate the size of the
proximal tubal opening (Tech Fig. 4.4.3C).
Both tubal ends should be made fully hemostatic in preparation for approximation.
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Te ch Fig ure 4.4.3. A: Opening proximal t ubal end, with free flow of dye. B: Using pinpoint cautery (monopolar) to cauterize subluminal vessel. C : Opening of
distal tubal segment. Initial cut opened serosa, this second cut ent ers lumen.
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Approximation of tubal ends
The mesosalpinx is sutured to fold the edges together to approximate the tubal ends. A small diameter suture such as a 7-0
monofilament suture is well suited (Monocryl
®
or PDS
®
, Ethicon, Inc., Somerville, NJ) (Te ch Fig. 4.4.4A).
This suture should not be over tightened so as to pull the tubal ends past each other. The suture can then be tied, leaving it in
place so that it can be used at the end to reapproximate the serosa/tubal muscularis in a continuous running fashion.
At this point the tubal ends should be near each other, and ready to reattach (Tech Fig. 4.4.4B).
Te ch Fig ure 4.4.4. A: Approximat ion of t ubal ends by placing sut ure in mesosalpinx edges. B: T ubal ends reapproximated, ready t o place lumen sutures.
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Placement of tubal lumen sutures
Sutures for tubal approximation should be small and nonreactive. 8-0 Ethilon
®
nylon or Prolene
®
(Ethicon, Inc., Somerville,
NJ) on a small taper needle (needle length of 6 to 8 mm) is a good choice. The contrast of the black nylon suture aids in
visualization during suture tying.
Each suture should be placed outside-to-inside, then inside-to-outside, allowing the knot to lie away from the lumen. Care
should be taken to tie flat square knots.
For smaller diameter tubes, such as in an isthmic–isthmic reanastomosis, four sutures may suffice. For larger size openings
seen in the distal isthmus/early ampulla, five or six sutures may be required. These should be spaced evenly around the
lumen, using as many as is deemed necessary to fully close the tube.
Sutures should be placed through a small portion of the muscularis and a portion of the lumen. If possible, it is preferable to
not pass completely through the lumen. This is easily accomplished in the isthmic portion where the muscularis and lumen
are more prominent, but may be difficult to do on the distal segment, where the suture may need to pass into the lumen.
Ensure that the tubes are lying in a natural anatomic position and not rotated in respect to each other. The most inferior
suture is usually placed first, on the side of the tube adjacent to the mesosalpinx (Te ch Fig. 4.4.5A). This first suture is
then tied, as it will become difficult to reach after placement of the other sutures. The knot should be tightened just enough
to bring the tube edges together. Such fine sutures only require three to four throws to secure the knot. Ends should be cut
very short.
The remaining sutures are then placed equally spaced around the remaining tube. Ends should be cut to approximately 2 to
3 cm and laid out lengthwise to keep them organized. After the remaining sutures are all placed, the sutures are now ready
to be tied (Tech Fig. 4.4.5B).
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Te ch Fig ure 4.4.5. A: First lumen suture placed at inferior edge of tube, suturing outside to in, then inside to out, leaving knot away from t ube. T his suture is
tied first. B: Placement of three additional sutures t o approximat e the t ubal lumens. T he three sutures were all placed before tying any of t hem.
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Tying lumen sutures/closure of tubal lumen
The remaining sutures are tied sequentially from posterior to anterior around the tube.
After tying the sutures, any openings between sutures can be reinforced with an additional suture. Care should be taken in
placing these additional sutures so that they stay shallow and do not enter the lumen.
After tying all sutures, chromotubation should be performed to demonstrate a freely patent tube. Any significant leakage at
the anastomosis point can be reinforced with an additional suture.
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Reinforcement of tubal muscularis, if needed
After satisfactory closure of the tubal lumen, interrupted sutures are placed in the muscular portion of the tube. These serve
to provide the tube strength, while the lumen sutures were only for luminal approximation (Tech Fig. 4.4.6).
This can be performed with the same 8-0 nylon suture, or a slightly larger 7-0 PDS
®
(Ethicon, Inc., Somerville, NJ) suture.
Generally, three to five sutures may be required to reinforce the tube.
Te ch Fig ure 4.4.6. After lumen is closed, additional sutures are placed in muscularis for reinforcement.
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