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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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Positioning
3
The patient is in supine position. The thighs are not flexed so that the suprapubic and lateral trocars can be maneuvered.
Nasogastric or an oral gastric tube is placed before the procedure. Proper alignment of head and neck is crucial. The
location of fingers, toes, face, and chest should be observed for any unintentional pressure. The blood pressure cuff is then
placed on the right arm and placed high enough that it is away from the ulnar nerve. The eyes are covered with tape, in
order to avoid any corneal abrasions. When securing the arm, ensure the oxygen saturation probe is free and able to be
moved, should there be a need. The arm is secure and the fingers are visualized. The fingers should always be visible when
positioning the patient on the bed. The buttocks are hanging 2 to 3 inches off the table. A warming device may be placed
just beneath the breast line.
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Procedures and Techniques
2,3
(Video 6.1.1 )
This procedure requires an umbilical incision to accommodate the video camera and/or laser laparoscope, in addition to
three accessory trocars (two lateral 5-mm trocars and one 5-mm suprapubic trocar).
The initial step is exploration of pelvis and abdomen to identify the presence, location, and extent of endometriosis. Lesions
of endometriosis are evaluated for their depth of invasion and are classified as superficial or deep lesions.
We routinely start by inspecting the diaphragm, upper abdominal walls, and liver in supine and reverse steep Trendelenburg
position.
Next while patient is in Trendelenburg position, in a clockwise fashion, the pelvis including all reproductive organs are
thoroughly evaluated. These include the anterior cul-de-sac, round ligaments, the ureter, bowel, uterosacral ligaments,
posterior cul-de-sac, and appendix.
Once the depth of the lesion and nodularity are assessed, the choice of instrument and mode of treatment are determined.
Treatment options include: Excision versus ablation. The decision is often determined by the proximity of the endometriosis
to adjacent structures such as ureter and large vessels.
The small superficial implants found on the surface of ovaries and peritoneal surfaces can be efficiently removed by either
excision with unipolar cutting current or ablation using the CO
2
laser held 1-3 mm from the surface of the lesion.
The superficial endometriosis lesions proximal to vital structures such as ureter, major blood vessels, and superficial bowel
lesions can be safely excised using hydrodissection by making a small opening superficially in the normal peritoneum with
either scissors or CO
2
laser. Fluid is then injected beneath the lesion, which separates and lifts the disease away from the
underlying structures. The tissue is then carefully dissected away from proximal structures and excised.
Since normal-appearing peritoneum may contain nonvisualized lesions up to 27 mm from the lesion, wide excision of
peritoneum is recommended.
4
In contrast to superficial endometriosis, deep endometriosis is difficult to ablate with either electrosurgery or laser, because
the energy cannot reach deeper layers and ablation of the lesion may cause thermal damage to the underlying structures
and organs.
In the case of deep endometriosis that is adjacent vital organ, a complete resection with careful dissection of the lesion off
the underlying structures is preferred.
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PEARLS AND PITFALLS
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OUTCOMES
Excision and vaporization provide the same outcomes for patients. One advantage for excision is the preservation of a tissue
specimen for a histologic diagnosis.
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COMPLICATIONS
Complications may include all those inherent in any surgical procedure under anesthesia.
Use of an electrosurgical device can lead to tissue necrosis and poor tissue healing due to lateral thermal spread inherent in
this technique.
Use of an electrosurgical device can present with delayed necrosis and/or direct injury to adjacent organs such as the
ureter, bladder, and bowel.
These complications can be mitigated with surgical experience, knowledge of anatomy, and a thorough understanding of the
potential thermal spread from specific electrosurgical devices.
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KEY REFERENCES
1. Clement PB. The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic
pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol. 2007;14:241–260.
2. Nezhat C, Nezhat FR. Safe laser endoscopic excision or vaporization of peritoneal endometriosis. Fertil Steril.
1989;52(1):149–151.
3. Nezhat C, Nezhat F, Nezhat C. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy with
DVD. 4th ed. New York, NY: Cambridge University Press; 2013.
4. Demco L. Mapping the source and character of pain due to endometriosis by patient-assisted laparoscopy. J Am Assoc
Gynecol Laparosc. 1998;5:241–245.
5. Sutton PA, Awad S, Perkins AC, et al. Comparison of lateral thermal spread using monopolar and bipolar diathermy, the
Harmonic Scalpel and the Ligasure. Br J Surg. 2010;97:428–433.
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Chapter 6.2
Ovarian Cystectomy of an Endometrioma
Arie l Revel, Azade h Nezhat, Cam ran Ne zhat
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GENERAL PRINCIPLES
Definition
Endometriosis is a condition in which functional endometrial tissue is present outside the uterus. It is often confined to the
pelvis involving the pelvic ligaments, cul-de-sac, and the uterovesical peritoneum. When endometriosis involves the ovary it is
referred to as an endometrioma. Between 17% and 44% of women with endometriosis will have endometrioma.
1
Endometriotic patients have lower BMI than age- and smoking-status–matched controls, independent of confounding
variables.
2
Endometriosis poses significant public health concerns. It not only affects health, well-being, and the quality of life
of patients, but it also has great impacts on daily life, work absenteeism, and healthcare consumption.
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Types (Three Main Phenotypes)
1. Peritoneal surface = superficial peritoneal endometriosis [SUP].
2. Subperitoneal (e.g., rectum) = deep infiltrating endometriosis [DIE].
3. Ovarian cysts = ovarian endometrioma (OMA): Contains thick, old blood that appears as a brown fluid (“chocolate cysts”).
Endometriosis is a disease known to be detrimental to fertility.
3
In a recent large series of patients with histologically proven
endometriosis,
2
significant risk factors for presentation for endometriosis-related infertility were:
Age
Previous surgery for endometriosis
SUP endometriosis phenotype
After multivariate analysis OMA was not selected as a significant risk factor for presentation for infertility.
2
Pathophysiology of OMA related to infertility:
Mechanical stretching of the ovarian cortex distorting tubo-ovarian anatomy.
Inflammatory
4
Oxidative damage
5
resulting in poor oocyte quality.
6
The severity of endometriosis is graded according to the location, the extent, and the depth of penetration of the lesions.
7
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Pathogenesis of an Endometrioma (Three Main Theories)
1. Invagination of ovarian cortex secondary to bleeding of a superficial implant.
8
2. Invagination of ovarian cortex secondary to metaplasia of coelomic epithelium in cortical inclusion cysts
9
3. Endometriotic transformation of functional cysts.
10
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