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
GENERAL PRINCIPLES
Definition
Ovarian cysts are common pelvic abnormalities. They may be due to functional causes such as ovulatory follicles or corpora
lutea, though functional cysts should ultimately resolve with observation or central gonadotropin suppression. Pathologic cysts
can be due to collections of endometriosis or neoplasms.
https://t.me/med1917
Differential Diagnosis
Cystic structures in the pelvis that can be mistaken for ovarian masses include hydrosalpinges and pelvic adhesions causing
fluid loculation (pseudocyst formation).
https://t.me/med1917
Nonoperative Management
Ovarian cysts can generally be observed for a period of 4 to 8 weeks, in which time functional cysts should resolve. Urgent
surgical management is necessary in cases involving ovarian torsion or hemorrhagic cysts causing a hemoperitoneum.
https://t.me/med1917
IMAGING AND OTHER DIAGNOSTICS
Transvaginal ultrasonography is the first-line imaging study for ovarian masses. In cases of an unclear origin or inadequate
visualization, an MRI may be beneficial.
https://t.me/med1917
PREOPERATIVE PLANNING
Imaging should be performed to guide expectations of surgical findings. Endometriomas will often be encountered with
implants of pelvic endometriosis and adhesions, often at an advanced stage. In this case, excision of the associated
endometriosis should be planned at the same time.
Patients should be counseled as to the known effect of cystectomy on ovarian reserve. This risk is higher in cases of
endometriomas.
1
https://t.me/med1917
SURGICAL MANAGEMENT
Surgical ovarian cystectomy should be considered in cases of persistent ovarian masses that do not have suspicious features
for malignancy. This procedure often follows a period of conservative management and follow-up imaging.
https://t.me/med1917
Positioning
The patient should be placed in the normal standard dorsal lithotomy position as for other laparoscopic gynecologic
procedures. An intrauterine manipulator may assist in positioning the uterus.
https://t.me/med1917
Approach
Laparoscopy is the preferred route for management of ovarian masses. Robotic assistance may be beneficial in cases of
large masses and associated advanced endometriosis.
In most cases, three laparoscopic ports are needed in addition to a camera port. This is typically using a right and left lower
quadrant port along with a suprapubic port. This allows two instruments to grasp the ovary and a third instrument to provide
traction on the cyst wall.
https://t.me/med1917
Procedures and Techniques (Video 5.1.1)
Lysis of surrounding ovarian adhesions
If the ovary is adhered to the pelvic sidewall, any adhesions should be lysed. Often the ovary can be bluntly separated from
the sidewall. In the case of dense adhesions, specific bands should be cut with scissors.
https://t.me/med1917
Planning entry point into ovary
In the case of endometriomas, these most often occur from endometriosis implants between the ovary and pelvic sidewall,
leading to invagination into the body of the ovary. These cysts are those that rupture upon elevation of the ovary out of the
pelvis. The site of this rupture opening can be extended slightly as needed to facilitate cyst wall excision. The cyst wall will
merge with the ovarian cortex at this opening, and at this point, the wall may not be apparent at this edge.
In other cysts, they are most easily opened where the cyst is most translucent, which will limit damage to normal ovarian
cortex that appears as more dense white tissue.
In cases of vary large cysts that have a large translucent area, opening at the junction of the white cortex and the thin cyst
wall can assist in dissection, as much of the thin translucent cyst wall covering may ultimately be resected with the cyst
wall.
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана