1、腹腔镜在微创妇科手术中 的应用,北大医院 周应芳,20101126,您是 ？医生,会开腹手术 外科医生会做阴式手术 妇科医生会做内镜手术 现代妇科医生会做机器人辅助手术 时髦医术家,腹腔镜手术的适应证,子宫内膜异位症 异位妊娠 子宫肌瘤 卵巢肿物 盆腔炎 不孕症 急、慢性盆腔痛 生殖道畸形 生殖道恶性肿瘤,子宫内膜异位症,子宫内膜异位症,腹腔镜： 诊断的“金标准”手术治疗的最佳方法几乎无禁忌证20世纪70年代末期CO2激光的应用开辟了腹腔镜治疗异位症的新篇章，电凝及电切技术的广泛应用极大地推动了治疗异位症的步伐,深部结节-单极电凝-单极汽化,手术方法,打开囊腔 找到囊壁 完整剥除 妥善止血,剥
2、除囊壁 （直接剥除法）,Small ECO,Small ECO (Type-1),只剥巧囊是不够的！,越来越多的证据表明内异症患者的深部性交痛和直肠部位疼痛症状与深部浸润型内异症（DIE）有密切关系（Porpora MG，et al. 1999）多因素分析表明，直肠内异症和R-AFS 评分是和痛经严重程度唯一相关的因素（Chopin N，et al. 2006 ) 切除DIE病灶显著改善疼痛症状（Chopin，et al 2005）内异症复发与DIE密切相关因此，只做巧囊剥除不是彻底治疗,Associated ovarian endometrioma is a marker for great
3、er severity of deeply infiltrating endometriosis,500 patients with histologically assessed DIE In patients with associated ovarian endometrioma, the number of single isolated DIE lesions was statistically significantly lower (41.9% vs. 61.1%) The mean number of DIE lesions was statistically signific
4、antly higher in patients presenting with an associated ovarian endometrioma (2.51 +/- 1.72 vs. 1.64 +/- 1.0) For patients with associated ovarian endometrioma DIE lesions were more severe with an increased rate of vaginal, intestinal, and ureteral lesionsChapron C, et al. Fertil Steril. 2009 Aug;92(
5、2):453-7.,深部浸润型内异症 （deep infiltrating endometriosis，DIE）,名词来源 上个世纪初，子宫内膜深部浸润的概念首先被提出来，上世纪90年代，才有明确的定义 定义 病灶浸润后腹膜深度5mm 确切发病率尚不清楚 有学者曾经研究了经手术治疗的连续的132例子宫内膜异位症患者，发现有深部病变的比例高达33% The prevalence of bowel endometriosis varied from 14% to 73.3% （ a systematic review and meta-analysis Hudelist G, Ultrasound
6、 Obstet Gynecol. 2010 Oct 15. Epub ahead of print）,深部浸润型内异症 （deep infiltrating endometriosis，DIE）,常见发病部位(Continuous series of 426 patients of DIE ) 宫骶韧带 52.7% 阴道 16.2% 肠道 22.7% 膀胱 6.3% 输尿管 2.1%,Chapron C,et al. Hum Reprod. 2006 Jul;21(7):1839-45,深部浸润型内异症 （deep infiltrating endometriosis，DIE）,Endomet
7、riosis of the sciatic nerve was on the right side in 41 patients, on the left in 20, and bilateral in two (32 reports including 63 subjects were selected . Vercellini P, et al. Obstet Gynecol. 2003 Aug;102(2):383-7 )Lymph node involvement by endometriosis was observed in 11 of the 26 patients (42.3%
8、) and correlated with the size of the lesions, the number of lymph nodes retrieved, and the presence of lymphovascular invasions, which were observed in 36.3% of cases (Nol JC, Chapron C, Fertil Steril. 2008 May;89(5):1069-72 ),后陷凹开放技巧,子宫内膜异位症的治疗,DIE 的手术切除 后穹窿内异症病灶 切除术(1-3),DIE 的手术切除 后穹窿内异症病灶 切除术(4-
9、6),Ureter EM RVEM,Ureter EM,Ureter EM,DIE-RVEM,DIE Excising via. Harmonic Scalpel,异位妊娠,异位妊娠,腹腔镜： 诊断的“金标准”手术治疗的最佳方法异位妊娠破裂大出血休克 曾被认为是腹腔镜手术的禁忌证 近年认为，在有丰富的手术经验及良好手术设备的前提下，仍可安全地接受腹腔镜手术,输卵管间质部妊娠 套圈术,子宫肌瘤,腹腔镜子宫肌瘤剔除术,临床应用： 远期疗效？ 尚有争议适应证： 浆膜下肌瘤、突向腹腔的肌壁间肌瘤； 肌瘤直径=8-10cm; 肌瘤数量=3个,切开包膜,剔除肌瘤,缝合切口,创面粘连预防,前壁肌瘤剔除术,前
10、壁肌瘤剔除术,水分离,切开包膜,分层缝合切口,剔除肌瘤 (注意内膜),前壁肌瘤剔除术,后壁肌瘤剔除术,水分离,切开包膜,剔除肌瘤,缝合切口,取出肌瘤,冲洗止血,后壁肌瘤剔除术,水分离,切开包膜,剔除肌瘤,探查,阔韧带肌瘤剔除术,瘤蒂处理,输尿管走行,创面粘连预防,阔韧带肌瘤剔除术,Predictors of leiomyoma recurrence after laparoscopic myomectomy,Five university hospitals （ Seoul ） 512 （1995 2004）with a follow-up for a median 13 months The
11、 cumulative probability of leiomyoma recurrence increased steadily during the follow-up period 11.7% after 1 year 36.1% after 3 years 52.9% at 5 years 84.4% at 8 years The cumulative probability of reoperation for recurrent leiomyoma was much lower: 6.7% at 5 years 16% at 8 years Yoo EH, J Minim Inv
12、asive Gynecol. 2007 ,14(6):690-7.,LM术后妊娠子宫破裂,LM后妊娠子宫破裂 一直是关注的焦点（新技术） 发生率约为0.5%-1%，与开腹手术相似（约为0-5% ） 均为个案报道 均为临产前破裂 预防 少用电凝 分层缝合,Risk factors for uterine rupture after LM,19 cases of uterine rupture after laparoscopic myomectomy were identified The myomas ringed 1 11 cm (mean 4.5 cm)Only 3 used multil
13、ayered closure Electrosurgery used for hemostasis in 17No plausible contributing factor could be found Parker WH, J Minim Invasive Gynecol. 2010, USA,Risk factors for uterine rupture after LM,It seems reasonable for surgeons to adhere to techniques developed for abdominal myomectomy including limite
14、d use of electrosurgery multilayered closure of the myometrium individual wound healing characteristics may predispose to uterine rupture Parker WH, J Minim Invasive Gynecol. 2010, USA,Adenomyomectomy(30g),Adenomyomectomy(30g),Adenomyomectomy,腹腔镜子宫切除术,曾有很大争议 现在腹腔镜子宫切除术已得到肯定 适用于子宫大小在孕14周16周以下者,1.切断圆韧
15、带,处理附件,3.处理子宫血管,2.下推膀胱,4.切断主、骶韧带,5.环行切开阴道穹窿,6.取出子宫,7.缝合阴道断端,8.盆腔冲洗、止血,LSH,LSH,附件肿物,卵巢上皮性肿物,腹腔镜手术的良好适应证： 担心：肿物为恶性？ 害怕：术中肿物可能破裂，导致癌细胞扩散 腹腔镜手术遇到恶性肿瘤并不多见。从目前有限的资料来看，术中恶性肿瘤破裂是否影响患者预后，导致死亡率上升尚缺乏临床证据，但因病例数较少，不足以下结论 恶性肿物术中破裂时往往会用大量生理盐水等冲洗腹腔，或术毕腹腔内留置抗癌药物等，均可能减少了癌细胞种植的机会,Teratoma,输卵管系膜囊肿切除术,不孕症,输卵管伞端闭锁成型术,输卵管
16、伞端闭锁成型术,输卵管美兰通液术,盆腔炎,急、慢性盆腔脓肿： 常形成致密粘连 手术难度和损伤的风险增加,内生殖器管恶性肿瘤,过去：腹腔镜手术的禁忌证 腹腔镜手术难度大 损伤风险高 手术时间长 CO2气腹还可能导致癌细胞扩散、生长,内生殖器管恶性肿瘤,现在：开始成为腹腔镜手术的适应证早期子宫内膜癌 早期宫颈癌 早期卵巢癌？对技术熟练者来说，腹腔镜手术与开腹手术相比手术时间虽稍长，但出血量少、术后恢复快，术后病率低，近期疗效相似。,Borderline Ovarian Tumors,穿刺孔肿瘤转移,妇科恶性肿瘤腹腔镜手术特有 1978年首次报道卵巢癌诊断性腹腔镜术后发生穿刺孔转移 推测病因 术前、术中均未注意肿瘤为恶性，未采取严密的防范措施，使较多的肿瘤细胞遗漏在穿刺套管上 染有肿瘤细胞的器械与套管接触时，细胞直接接触到穿刺孔 气腹的压力也可将肿瘤细胞压至穿刺孔创面 卵巢肿瘤腹腔镜手术后穿刺孔转移率27.3,腹腔镜手术适应证的变化趋势,越来越宽,腹腔镜手术的禁忌证（1）,越来越少,腹腔镜手术-双刃剑,腹腔镜手术适应证的变化趋势 （奋斗目标）,腹腔镜手术替代大多数开腹手术,努力方向,完善设备 改进术式 提高技巧 与时俱进,Thank You For Your Attention!,祝会议圆满成功 愿同道虎年大吉！,
