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
KEY REFERENCES
1. Perlman S, Kjer J. Ovarian damage due to cyst removal. A comparison of endometriomas and dermoid cysts. Acta Obstet
Gynecol Scand. 2016;95(3):285–290.
2. Fielder EP, Guzick DS, Guido R, et al. Adhesion formation from release of dermoid contents in the peritoneal cavity and
effect of copious lavage: a prospective, randomized, blinded, controlled study in a rabbit model. Fertil Steril.
1996;65(4):852–859.
3. Özgönen H, Erdemoglu E, Günyeli I, et al. Comparison of the effects of laparoscopic bipolar electrocoagulation and
intracorporeal suture application to ovarian reserve in benign ovarian cysts. Arch Gynecol Obstet. 2013;287(4):729–732.
4. Asgari Z, Rouholamin S, Hosseini R, et al. Comparing ovarian reserve after laparoscopic excision of endometriotic cysts
and hemostasis achieved either by bipolar coagulation or suturing: a randomized clinical trial. Arch Gynecol Obstet.
2016;293(5):1015–1022.
5. Pellicano M, Bramante S, Guida M, et al. Ovarian endometrioma: postoperative adhesions following bipolar coagulation
and suture. Fertil Steril. 2008;89(4):796–799.
6. Keckstein J, Ulrich U, Sasse V, et al. Reduction of postoperative adhesion formation after laparoscopic ovarian
cystectomy. Hum Reprod. 1996;11(3):579–582.
https://t.me/med1917
Chapter 5.2
Laparoscopic Ovarian Drilling
Mir iam S. Krause, Steve n T. Nakajima
https://t.me/med1917
GENERAL PRINCIPLES
Definition
Laparoscopic ovarian drilling (LOD), also known as a modified ovarian wedge resection, ovarian diathermy, ovarian cautery,
or “whiffle ball” surgery, is a surgical procedure performed in patients with polycystic ovary syndrome (PCOS) to lower the
level of circulating androgens and to help establish ovulatory cycles. It is usually performed in patients with PCOS who
desire fertility and do not respond to medical treatment options or prefer surgical treatment.
Ovarian drilling replaces the surgical procedure bilateral ovarian wedge resection (BOWR) through a laparotomy incision
originally described in 1935. The traditional BOWR is no longer performed secondary to side effects of postoperative
adhesion formation and loss of functional ovarian tissue.
https://t.me/med1917
Differential Diagnosis
The differential diagnosis for PCOS is broad and includes other endocrinopathies such as thyroid dysfunction,
hyperprolactinemia, androgen-producing tumors of the ovary and adrenal glands, decreased ovarian reserve, unexpected
pregnancy, late-onset congenital adrenal hyperplasia, and Cushing syndrome.
https://t.me/med1917
Anatomic Considerations
It is important to know whether the patient has undergone previous pelvic surgery or has had a previous pelvic infection, as
these can cause adhesions that could make this procedure more difficult.
https://t.me/med1917
Nonoperative Management
Nonoperative management options are preferred and should be utilized prior to LOD. They include ovulation induction using
selective estrogen receptor modulators (SERM) such as clomiphene citrate, aromatase inhibitors such as letrozole, or insulin
sensitizers such as metformin. In many overweight or obese patients, lifestyle modifications including weight loss can also
lead to spontaneous ovulatory cycles.
https://t.me/med1917
IMAGING AND OTHER DIAGNOSTICS
Radiologic studies are not necessary in order to perform the described procedures.
Transvaginal ultrasound is usually performed prior to the procedure to make the diagnosis of polycystic ovaries. Polycystic
ovaries are defined as having at least 12 follicles measuring less than 10 mm in mean diameter, or a volume of greater than
10 cm
3
. This only has to apply to one ovary but can apply to both.
1
PCOS is defined as at least two of the following: Oligo- or amenorrhea, clinical or laboratory evidence of
hyperandrogenemia, and polycystic ovarian morphology.
1
https://t.me/med1917
PREOPERATIVE PLANNING
As with any surgery, informed consent needs to be obtained. This includes discussion of the procedure as well as the
indications, risks, benefits, and alternatives (Table 5.2.1). Besides the general risks of surgery, this procedure specifically
includes the risk for postoperative decreased ovarian reserve and adhesion formation.
Prior to performing the ovarian drilling, an appropriate fertility evaluation needs to be completed. It is important to rule out
any other fertility factors (such as tubal obstruction and semen abnormalities) that would require additional surgery or a
different treatment approaches such as in vitro fertilization (IVF).
Preconception counseling needs to be addressed in order to ensure a healthy pregnancy, including any contraindications for
pregnancy in general.
https://t.me/med1917
SURGICAL MANAGEMENT
Androgens are produced in the ovarian stroma, whereas the ovarian follicles are located in the ovarian cortex. In LOD,
either a laser or needle electrode (mono- or bipolar) is used to cause thermal damage to the ovarian stroma, while
attempting to protect the follicles. This leads to changes in the intraovarian steroid environment (mainly androgens and
inhibin) with restoration of ovulation function by increasing follicle stimulating hormone (FSH).
2
LOD may increase ovarian
blood flow in addition, and potentially improve insulin sensitivity.
3
https://t.me/med1917
Table 5.2.1 Obtaining Informed Consent for Laparoscopic Ovarian Drilling (LOD)
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана