Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_232_библиотеки_им_акад_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

13.10.2026

Размер:

2 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 89 / 159 10 11 12 13 14 15 > Следующая >>>

8. Laparoscopic Surger

1. Chapron C, Querleu D, Bruhat MA, et al. Sur

ical complications of dia

nostic and

perative

naeco

ica

aparoscop

: a series o

29,966 cases.

um Re

1998;13:867–872.

2. Har

i-Siren P. T

e inci

ence o

entry re

ate

aparoscopic injuries in Fin

naeco

osc.

5–

338.

3. Garry R. Laparoscopic surgery.

est

ract

in O

stet G

naeco

20:89–104.

4. Garry R. Towards evidence based laparoscopic entry techniques: clinical problems

as.

Gynaecol Endosc

1999;8:315–32

5. Hashizume M, Su

imachi K. Needle and trocar in

durin

laparoscopic sur

in Japan.

Endosc.

997;11:1198–1201.

6. Chapron CM, Pierre F, Lacroix S, et al. Ma

or vascular in

uries durin

necolo

aparoscop

Am Co

Sur

. 1997;185:461–465.

7. Ba

MS. Ana

sis o

31 cases o

or vesse

associate

wit

neco

aparoscopy operations.

neco

Surg. 2003

;

19:

3–

8. Yuzpe AA. Pneumoperitoneum nee

e an

trocar injuries in

aparoscopy. A survey

n possi

e contri

uting

actors an

prevention. J Repro

5:4

5–4

9. Nezhat C, Childers J, Nezhat F, et al. Major retroperitoneal vascular injury during

laparoscopic surgery. Hum Reprod. 1997

;

12:480–483.

30. Champault G, Cazacu F, Tafﬁ

nder N. Serious trocar accidents in laparoscopic

sur

: a French surve

of 103,852 operations.

arosc Endosc.

996

;

6:367–370

1. Crist DW, Ga

acz TR. Comp

ications o

aparoscopic sur

. Sur

in Nort

Am.

1993

;

73:2

5–289.

2. Kre

s HB. Intestina

injury in gyneco

ogic surgery: a ten year experience.

m J

stet G

neco

198

155:509–514

3. Audebert AJM. The role of microlaparoscopy for safer wall entry: incidence o

umbilical adhesions according to past surgical history.

ynaecol Endosc.

1999;8:3

3–3

34. Hasson HM. A modiﬁ

ed instrument and method for laparoscopy.

Obstet

necol

1971;110:886–887

35. Hasson HM. Open laparoscop

as a method of access in laparoscopic sur

. G

aeco

osc. 1999;8:353–362.

36. Penﬁ

eld AJ. How to prevent complications of open laparoscopy.

J Re

1985

;

30:

0–

37. Bonjer HJ, Haze

roe

EJ, Kazemier G, et a

. Open versus c

ose

esta

ment o

neumoperitoneum in

aparoscopic surgery. Br J

urg.

997

;

84:599–

38. Australian Safety and Efﬁ

cacy Register of New Interventional Procedures—Surgical

(ASERNIP-S).

Systematic Review of the Methods Used to Establish Laparoscopic

neumoperitoneum

Adelaide

South Australia: ASERNIP-S

;

2001. ASERNIP-S

ort No. 13

39. Garr

R. A consensus document concernin

laparoscopic entr

techniques: Mid-

lesbrou

h, March 19–20 1999.

naecol Endosc. 1999;8:403–406.

https://t.me/med1917

4 J.A. O

0. Reich H, Riberio SC, Rasmussen C, et al. Hi

h-pressure trocar insertion technique.

J Soc La

aroen

osc Sur

1999

;

:45–4

1. Tsa

tas J, Pearce S, Lawrence A, et a

. Sa

aparoscopic trocar entr

: it’s a

out

ressure. Aust N Z J O

stet G

naeco

200

;

44:

–

2. McGurgan, P, O’Donovan P. Optica

Verres as an entry tec

nique.

naeco

osc.

–

382.

3. Garry R. Complications of laparoscopic entry. Gynaecol Endosc. 1997

:319–329.

https://t.me/med1917

9. Urinar

Tract Complications

oseph A. Ogah

Urinar

tract in

is a common cause of liti

ation in

necolo

, accountin

for about 10% of claims [1]. There is a 91-fold increase in liti

ation when the

urinar

tract is in

ure

in comparison to ot

er comp

ications

rom a

ster-

ectomy [2]. It is a signiﬁ

cant cause of morbidity, especially when diagnosis is

delayed. Its occurrence and the sequelae can lead to signiﬁ

cant

ersona

fering, anxiety, depression, loss of employment, difﬁ

ties in inter

ersona

ations

ips, an

poor qua

e [2]

e c

ose proximit

ower urinar

tract to t

ema

enita

tract

puts it at risk of in

durin

necolo

ical sur

. Urinar

tract in

uries

complicate between 0.3% and 1% of all

necolo

ical operations and cesarean

ections [2–6]. Sevent

our percent o

ese in

uries occur

urin

sur

eni

isease.

ret

atrogenic injury to t

e uret

uring vagina

or uterine surgery is

unusua

. It most common

y occurs in association wit

injury to t

e sp

incter

active area o

e uret

ra at t

e time o

uret

iverticu

ectomy. It occurs in

up to 5% o

cases o

simp

iverticu

ectomy

reters

er injuries occur in 1%-5% cases o

enign gyneco

ogica

operations

[2,4,6,7]. Most o

ese injuries are recognize

intraoperative

y [5,8–11]. More

recent studies show rates as high as 3.6%, with vesicovaginal ﬁ

stula occurring

more common

y w

en t

e injury is misse

[10]

ynecological surgery is the second commonest cause after primary uro

ogica

surgery as cause o

iatrogenic ureteric injury [12]. Ureteric injuries

occur in 0.02%–2.5% o

enign pe

vic operations,

ut un

er injuries,

in w

most cases are recognize

intraoperative

y, ureteric injuries are o

ten

misse

intraoperative

y [2,4–7,10,13–15]. T

e true inci

ence o

uretera

injury

is likely to be higher with increasing use of electrosurgery and laser surgery,

primaril

from unreco

nized devascularization; hi

her incidences also occur

in sur

for invasive cancer and in some uro

necolo

ical sur

https://t.me/med1917

6 J.A. O

auses, S

tes, and Types of In

The bladder is typically injured at the trigone between the ureteric oriﬁ

ces

r on t

e posterior

er wa

ust a

ove t

e tri

one. T

e in

ten occurs

hile the sur

eon is attemptin

to mobilize the base of the bladder off the

ervix or t

e upper va

ina or w

e c

osin

e va

ina

vau

t an

ina

vertent

atc

e posterior wa

er wit

a suture. O

ten pro

use

makes recognition of surgical planes difﬁ

cult. Bladder injury also occurs

urin

issection o

e retropu

ic space an

wit

acement o

suspension

sutu

es.

hou

h the ureter can be in

ured an

where alon

its pelvic course, most

uries durin

necolo

ical sur

occur in the distal 3 cm of the ureter

12,16–19] (Fi

ure 9.1). Common sites for in

include the level of the infun-

ibulopelvic li

ament, the cardinal li

ament at the level of the internal cervical

s as the uterine arter

crosses over the ureter, and the anterolateral fornix o

he va

ina as the ureter passes mediall

to enter the bladder

he ureter ma

be in

ured in man

s: li

ated (suture), crushed (clamp),

ransected, kinked, stretched, lacerated, or devascularized b

the effects o

erma

, e

ectrica

, or

aser ener

[20]

isk F

itions t

at put t

ower urinary tract at ris

injury

uring gyne-

cological procedures include pelvic masses (e.g., large uterine ﬁ

broids, large

varian masses, tu

o-ovarian a

scess, pe

vic tumor), pregnancy, previous

pelvic surgery, endometriosis, pelvic inﬂ

ammatory disease, pelvic irradiation,

omp

ete procci

entia, ovarian remnant,

ing, an

ematoma. Less

ommon ris

actors are congenita

norma

ities suc

as mega-ureter,

reteric

ication, an

ectopic ureter or

ney.

Goodno et al. and Liapis et al. in their reviews identiﬁ

some o

ese ris

actors,

ut it is important to note t

at in more t

an 50% o

cases no ris

actor

was identiﬁ

ed [21,22].

revent

wareness of the anatomical relations of the urinary tract is of paramount

mportance, as is knowledge of the risk factors for injury, as outlined previ-

usly (Figure 9.2). To avoid injury to the bladder, preoperative bladder drain

ge with a urethral catheter should be the norm

har

dissection with countertraction on the bladder to se

arate it from

he lower uterine se

ment and cervix is less likel

to cause in

than blunt

issection. Retropubic dissection in the face of previous pelvic surgery is

https://t.me/med1917

9. Urinar

Tract Complications 7

azar

ous. It ma

etter to open t

ome (w

ere it is most easi

repaira

e a

ter

issection) to ai

issection

rom t

e s

sis. Avoi

ampin

in or

er to ac

ieve

emostasis w

en t

ere’s excessive

se o

preoperative intravenous p

ram (IVP) or contrast-en

ance

compute

tomograp

y (CT) w

istortion o

anatomy is suspecte

may

use

ut Piscite

i et a

. [23] reviewe

493 cases o

sterectom

eni

isease an

oun

at 60% receive

preoperative IVP. Twent

-seven percent

of those who received preoperative IVP had abnormal IVP ﬁ

ndings, and the

actors s

own to

e most c

ose

associate

wit

norma

IVP were uterine

12 w

eeks

abo

ass

r m

statistically signiﬁ

cant difference in the incidence of ureteric injury between

A. At the pelvic brim over bifurcation of common iliac artery

1. Oophorectomy

2. Lymphadenectomy

3. Hypogastric artery ligation

B. In the cardinal ligament, lateral to the cervix and lower uterine segment

1. Abdominal hysterectomy

2. Vaginal hysterectomy

3. Intraligamentary myomectomy

C. At vaginal fornices just before entry of ureter into the trigone

1. Retropubic bladder neck suspension

2. Anterior colporrhaphy

3. Paravaginal defect repair

D. At the level of the uterosacral ligaments

1. Excision of pelvic mass

2. Culdoplasty

3. LUNA procedure

4. Ablation of endometriosis

5. Excision of ovarian remnant

Common location o

ureteric injury and procedures most commonly associated

wit

injury [18]

https://t.me/med1917

8 J.A. O

e IVP an

non-IVP

roups. A

so, a norma

preoperative IVP

oes not ne

ate

e responsi

e sur

eon to pa

pate, i

enti

, an

/or

issect t

e ureter

urin

neco

ica

operations. T

ere are

ﬁ

nite

cost issues wit

preop

rative IVP. No doubt clinical examination would be a less expensive wa

dentif

the risk factors mentioned above that were most closel

associated

with abnormal IVP ﬁ

ndings.

se of preoperative ureteric stenting is controversial and not substantiated

y evidence. There is no clear-cut advantage; it is costly and not without

Ligation of Gonadal Vesels:

Injury at pelvic brim during division of

ovarian vessels or resection of pelvic

mass adherent to ureters

Ligation of Uterine Vessels:

Injury as the ureter crosses

under the uterine artery during

hysterectomy

Dissection of Bladder/Vagina:

Injury at anterolateral fornix of

vagina near the insertion of the ureter

into the trigone

Pelvic Dissection:

Injury during lymph node

dissection as the ureter

traverses over the iliac vessels

near the apex of obturator fossa

ure 9.2

Anatomic relations of the ureters and common sites of injur

[16].

https://t.me/med1917

9. Urinar

Tract Complications 7

otentia

com

ications. A retros

ective review o

3071 cases wit

in a 24

month period found no statistically signiﬁ

cant difference between prophylac-

tica

lly

stente

nonstente

roups wit

to ureteric in

[24].

Comp

ications

urin

stentin

inc

e ureteric spasm,

irect ureteric in

ux anuria, urinary tract infection, and hematuria.

hted ureteric stents allow visualization of the ureters durin

advanced lapa

rosco

ic o

erations

ut are o

imite

ue in t

resence o

vic masses

ense a

esions

[

]

Adequate exposure and identiﬁ

cation of the ureters before clamping in

areas w

ere t

are most at ris

are vita

in prevention an

, in some cases,

issection o

e ureter a

its course

ore c

ampin

is require

. In va

ina

urgery, e.g.,

ysterectomy,

ownwar

traction o

e cervix wit

upwar

countertraction

eneat

ps to i

enti

y an

separate t

e utero

vesica

space in or

er to protect t

e ureter

rom in

uries

ue to app

ication o

s an

sutures. Paracervica

arametria

tissues near t

e uterus

e c

ampe

, cut, an

ate

itt

its at a time.

ntraoperat

ve D

agnos

s of Ur

nar

Tract In

urin

pelvic sur

when there is a suspicion of urinar

tract in

, all

attempts should be made to conﬁ

rm and ascertain the extent of the injury

(Fi

ure 9.3). For the ureters, this will entail openin

the posterior aspect of the

broad li

ament and identif

the ureter alon

its course. Durin

inal

operations it is usuall

more useful to carr

out a c

stoscop

and inspect the

bladder and both ureteric oriﬁ

ces.

Failure to conﬁ

rm or refute the suspicion of injury by the above methods

hould lead to use of indi

o carmine or meth

lene blue mixed with saline

intravesicall

to look for leaka

e as evidence of bladder in

. To aid dia

no-

sis of ureteric injury, use intravenous indigo carmine (5 mL) and ﬁ

adde

with 200–300 mL of normal saline or the denser 10% dextrose

[

]

via a ure-

thral catheter, and c

stoscope the bladder to visualize the blue d

e comin

out

of the ureteric oriﬁ

ces at the same rate. Extravasation of the dye into tissues

will su

est bladder in

. Meth

lene blue is cleared less readil

than indi

carmine, but intravenous fast-actin

diuretics ma

speed up this process. If

despite usin

the above steps the dia

nosis in not made, it is important to carr

out a retro

rade p

elo

raph

intraoperativel

Some injuries are missed intraoperatively with signiﬁ

cant long-term impli-

cations for patients. This has led to the su

estion that c

stoscop

should be

carried out routinel

at the end of all ma

necolo

ical sur

. A s

stem-

atic review of studies in the literature of urinar

tract in

durin

beni

necolo

ical sur

showed a 5-fold increase in the detection rates of in

ries when c

stoscop

is used routinel

[6]. These hi

her detection rates were

also evident from the ﬁ

ndings of a recent prospective multicenter study involv-

479 patients [10], with a trend to much hi

her detection rates when there

is concurrent prolapse and incontinence sur

. Missed in

uries ma

lead to

increased morbidit

; some minor in

uries, thou

h, ma

remain as

mptomatic,

https://t.me/med1917

0 J.A. O

with uncertain clinical signiﬁ

cance. Opponents to routine cystoscopy at gyne-

olo

ical operations hi

hli

ht the uncertaint

of clinical importance, the

mplications when in

is minor, the extra cost and inherent risks of an

dditional

rocedure, and the fact that the evidence for its routine use is not

obust. Pro

onents cite the fact that it makes intuitive sense: The

otential for

signiﬁ

cant morbidity and complications from unrecognized injuries and the

etter outcomes for in

uries found and mana

ed at the time of the primar

favor its routine use

ostoperat

ve D

agnos

s of Ur

nary Tract In

ury

wo thirds of ureteric in

uries are dia

nosed postoperativel

. IVP is o

aramount importance in their dia

nosis postoperativel

. There is a need in

he postoperative period to maintain a hi

h index of suspicion. Features to

look out for are often nonspeciﬁ

c complaints such as loin pain and pyrexia.

ers to watc

or are

eatures su

estive o

a urinoma, w

e suspect

hen abdominal distension, swin

fever, and urinar

ascites with ileus or

eritonitis occur. A continuous water

inal dischar

e postoperativel

suspicious of vesicovaginal ﬁ

stula.

ther features are a raised white cell count

nd a sli

ht rise in serum creatinine

VP ma

show h

droureter or h

dronephrosis, dela

ed function, or

xtravasations. USS or CT scan ma

show h

dronephrosis, a urinoma, or

ascites. Biochemical analysis of ﬂ

uid draining from either the wound, drain,

r va

ina will show a creatinine level hi

her than the serum level. Fistulo

ram

Clinical Management of

Ureteral Injury

Postoperative periodIntraoperative period

Minor Injury

Upper Middle Distal

Diagnostic Workup

Location?

Findings:

• Obvious injury

• Leakage of indigo carmine

Findings:

• Transient elevation of creatinine

• Symptoms of costovertebral

angle tenderness, fever, ileus

• Intravenous pyelogram

• Cystoscopy with fluoroscopy

• Ureteral stent if minor injury

• If major injury, may require

additional surgical treatment

(see flowchart on left)

• Ureteral stent

placement via

cystotomy/cystoscopy

• Follow-up intravenous

pyelogram at 6 weeks;

remove stent if normal

• Ureteroilio-

neocystotomy

• End-to-end

anastomosis

± psoas hitch

• Ureteral

reimplantation

gure 9.3. Clinical management o

ureteric injury [16]

https://t.me/med1917

9. Urinar

Tract Complications 8

e test to

erentiate

etween ureterova

ina

vesicova

ina

stulae may be useful [19].

Tre

tment

ost gyneco

ogists wi

e a

e to repair injuries to t

er, an

some

e a

e to repair some ureteric an

uret

injuries,

ut w

ere t

e injur

is comp

ex or expertise is

ing, t

e assistance o

a uro

ogist is a necessity

Urethra

rior catheterization of the urethra before dissection is essential. Re

air

of urethral dama

e is with 3/0 or 4/0 absorbable sutures, which should be

interrupted, and placed horizontall

. A second la

er should be inserted if pos-

ible to separate the primar

repair from the va

inal suture line. A martius fat

pad harvested from the labia ma

ora ma

be needed to reinforce the repair.

Bladd

ayere

repair o

er wit

aye

sor

e suture (2/0 or

/0) s

e carrie

out. T

e cystostomy is

est c

ose

wit

a continuous

-t

ness suture, wit

e secon

ayer, eit

er continuous or interrupte

ace

in an inverte

manner

injury is c

ose to t

e trigone, t

ere is a

anger o

e repair

ing t

intramura

portion o

e ureter. As a precaution, ureteric stents s

inserte

ore carrying out t

er repair. Continuous

rainage

to prevent

istension (w

compromises

ing) is nee

or 7–10

ays.

Ureter

air of the ureter should be tension free, with care to

reserve the

ureters’ vascular and neurological supply, and limited suturing to decrease

tissue necrosis. Ureteric stentin

and retroperitoneal suction draina

e are

important in enhancin

the healin

process and to prevent stenosis of the

ther techniques emplo

ed include spatulated end-to-end anastomosis

with stentin

, ureteroneoc

stostom

, ureteral reimplantation, ureteroureter-

ostom

, and end-to-end anastomosis.

https://t.me/med1917

2 J.A. O

ummar

ere is a

s a potentia

or in

to t

e urinar

tract

urin

neco-

ica

proce

ures, even wit

suppose

dly

simp

e proce

ures. Appreciatin

act with proper preoperative anticipation and plannin

, familiarit

with the

natomica

ations invo

, care

issection, an

meticu

ous

emo-

tasis wi

p to prevent in

. W

en in

is suspecte

, a

orts s

e ma

e to

nose t

e in

intraoperative

, usin

investi

ative tests

ertise avai

e w

e t

atient is sti

er anest

esia. Pro

er o

ative documentation including any difﬁ

cou

ade.

ostoperativel

a hi

h index of suspicion should be maintained, and earl

nvesti

ation should be undertaken where suspicion of in

exists

erences

1. James CA. Risk mana

ement in obstetrics and

naecolo

. J Med De

Union

1991;2:36–37

2. Gi

mour DT, Bas

ett TF. Disa

iti

ation

rom urinar

tract in

uries at

enign gyneco

ogic surgery in Cana

a. O

stet G

neco

200

109

–

3. American Co

ege o

stetricians an

Gyneco

ogists (ACOG).

ower Ur

nar

Trac

Operativ

Injuries

Was

ington, DC: ACOG; 1997. Tec

nica

etin No. 238.

4. Har

i-Siren P, Sjo

erg J, Tiitinen A. Urinary tract injuries a

ter

ysterectomy.

stet Gyneco

1998;92

113

–

118

5. Dorairajan G, Reddi Rani P, Abdullah S, Dorairajan LN. Urological injuries during

hysterectomies: a 6-year review. J Obstet Gynaecol Res

2004

;

30:430–435.

6. Gilmour DT, Das S, Flowerdew G. Rates of urinar

tract in

from

naecolo

and the role of intraoperative c

stoscop

bstet Gynecol.

006;107:1366

–

7. Ma

inen J, Jo

ansson J, Tomas C, et a

. Mor

10 110

sterectomies

approac

. Hum Repro

. 2001;16:1473–1478

8. Lee RA, Symonds RE, Williams TJ. Current status of genitourinary ﬁ

stu

ste

Gyneco

313

–

319.

9. Gra

er EA, O’Rour

e JJ, McE

rat

T. Iatrogenic

er injury

uring

ysterectomy.

stet Gyneco

;

23:2

7–273.

10. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during

hysterectomy: a prospective analysis based on universal cystoscopy. Am

Obste

Gynecol

2005;192:1599–1604.

11. Mathevet P, Valencia P, Cousin C, Mellier G, Dar

ent D. Operative in

uries durin

ina

sterectom

ur J O

stet G

neco

Repro

Bio

001;97:71–75

12. Montz FJ, Bristow RE, De

Carmen MG. Operative in

uries to t

e ureter. In: Roc

ones HW, e

s. TeLin

e’s Operative G

neco

. 9t

. P

ia: Lippincott

iams & Wi

ins

;

2003:1081–1097

https://t.me/med1917

<<< < Предыдущая 1 2 3 4 5 6 7 89 / 159 10 11 12 13 14 15 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
13.10.2026516 Кб0Книга_2315_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026514 Кб0Книга_2316_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026504 Кб0Книга_2317_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026503 Кб0Книга_2318_Библиотеки_им_академика_М_И_Перельмана.epub
#
13.10.2026496 Кб0Книга_2319_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.20262 Мб0Книга_232_библиотеки_им_акад_М_И_Перельмана.pdf
#
13.10.2026489 Кб0Книга_2320_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026480 Кб0Книга_2321_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026477 Кб0Книга_2322_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026467 Кб0Книга_2323_Библиотеки_им_академика_М_И_Перельмана.pdf
#
13.10.2026466 Кб0Книга_2324_Библиотеки_им_академика_М_И_Перельмана.pdf