A new technique for laparoscopic anterior resection for rectal endometriosis.

BACKGROUND: Anterior rectal resection is sometimes necessary to treat deeply infiltrating rectovaginal endometriosis. We describe a completely laparoscopic approach as a new way of excising rectal endometriosis that can be used without opening any part of the rectum. This avoids opening the abdomen or any risk of fecal spillage. METHODS: The patient received preoperative oral bowel preparation. Ureteric stents (6 F) were inserted cystoscopically. The peritoneum in the ovarian fossae was opened lateral to any disease and the rectum reflected off the back of the cervix, leaving any endometriosis on the front of the rectum. The pelvic peritoneum was reflected medially, below the level of the ureters. The mesorectum was then dissected off a 6-cm length of rectum by using a Harmonic scalpel. A circular end-to-end anastomosis instrument was passed anally until the outline of the anvil was visible, inside the colon, above the diseased rectum. The anvil was detached and held by a soft grasper before the rectum was then divided above and below the disease using a laparoscopic stapling device. The tip of the anvil was pushed through the proximal end of the colon allowing reanastomosis of the rectal stump. CONCLUSION: The patient was discharged after 5 days without complications.     

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection

Background Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed. Methods The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon. Results Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%). Conclusions Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).     

Accuracy of laparoscopic diagnosis of endometriosis.

BACKGROUND AND OBJECTIVE: Laparoscopy is the standard method to visually identify endometriotic lesions under magnification within and outside the minor pelvis. The aim of this study was to analyze the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically. METHOD: Presumed endometriotic sites were observed in 164 patients operated on under the clinical suspicion of endometriosis. Targeted biopsies were performed for histologic corroboration, comparing the laparoscopic findings and diagnosis to the histological results. RESULT: The histological reports of the biopsies confirmed the presence of endometriosis in 138 patients (84.1%), but in 26 patients (15.9%), no evidence of endometriosis was observed. 100% of "red" lesions, 92% of "black" lesions, and 31% of "white" lesions turned out to be endometriosis. Of the 264 various suspected endometriotic sites observed, 142 (53.8%) were confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 9/9 cases (100%); the ovarian fossa, confirmed in 8/12 cases (66.7%); and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 83/138 cases (60.1%). As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesicouterine fold of the peritoneum were 48%, 40%, and 13%, respectively. CONCLUSION: Endometriosis has a multiple appearance, and the lesions may be confused with nonendometriotic lesions. It is clear that a nonhistology-based diagnosis may lead to unnecessary prolonged medical treatment and operations and may delay the proper treatment measures from being applied. Therefore, a meticulous histological confirmation should still be the first step in the laparoscopic diagnosis and treatment of suspected endometriosis.     

腹腔镜子宫内膜异位症粘连分离的临床体会

目的:探讨腹腔镜手术治疗子宫内膜异位症盆腔粘连的优势。方法:为30例患者行开腹手术,54例患者行腹腔镜手术;明确分期后施术,根据患者年龄、分期、有无合并症及生育要求制定个体化手术方案。结果:开腹组术中出血量平均(136.57±83.24)ml,术后平均住院(7.26±0.82)d,术后排气时间平均(31.35±7.27)h,6例复发,复发率20.00%。腹腔镜组术中出血量平均(57.36±33.73)ml,术后平均住院(4.69±0.77)d,术后排气时间平均(21.22±5.45)h,5例复发,复发率9.26%。结论:腹腔镜手术相对开腹手术,患者创伤小、术中出血少、术后康复快,可作为治疗子宫内膜异位症的首选术式。     

对比观察腹腔镜手术治疗子宫内膜异位症的疗效

目的 :评估腹腔镜手术治疗子宫内膜异位症较常规开腹手术的优势与不足。方法 :随机将 99例内膜异位症患者分为A、B两组。A组用腹腔镜手术治疗 ,B组行常规开腹手术。分析对比两组结果。结果 :除Ⅲ期内膜异位症A组的手术时间大于B组外 ,在相同期别内 ,术后发热、胃肠功能恢复时间、开始床边活动时间、住院时间、术后镇痛剂使用率的对比分析显示A组显著优于B组。     

Quality of life and sexual function 1 year after laparoscopic rectosigmoid resection for endometriosis

Aim Endometriosis is relatively common condition in fertile women and may affect the alimentary tract. Laparoscopic rectosigmoid resection for endometriosis has been found to be both feasible and safe. The aim of the present study was to prospectively evaluate the quality of life and sexual function of patients who have undergone rectosigmoid resection for endometriosis. Method All patients undergoing rectal or sigmoid resection for endometriosis in two specialist hospitals were prospectively recruited in the study. Details regarding demography, endometriosis‐related symptoms, procedure and postoperative recovery were collected. One year after the operation patients were sent a postal questionnaire asking about endometriosis‐related symptoms, quality of life and sexual functioning. The 15D Questionnaire and McCoy Female Sexuality Questionnaire were used for this purpose. Results A total of 26 patients responded to the 15D questionnaire. Endometriosis‐related bowel symptoms decreased significantly after the operation. The responses showed improvements in the overall score and scores for five different dimensions (usual activities, P = 0.04; discomfort and symptoms, P < 0.001; distress, P < 0.001; vitality, P < 0.001; sexual activity, P < 0.001). Sexual satisfaction was greater 1 year after the operation (P = 0.01). Sexual problems and partner satisfaction scores had not changed significantly. Conclusion Laparoscopic rectal and sigmoid resection for endometriosis significantly reduce endometriosis‐related symptoms and improve quality of life and sexual well‐being.     

Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement

BACKGROUND: Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement. STUDY DESIGN: All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned. RESULTS: The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n = 26), bowel resection (n = 18), and disc excision (n = 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, 1 to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy, and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms. CONCLUSIONS: Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location.     

直肠阴道隔子宫内膜异位症的腹腔镜手术治疗

目的:探讨腹腔镜手术治疗直肠阴道隔子宫内膜异位症的方法。方法:回顾分析8例直肠阴道隔子宫内膜异位症患者的临床资料。结果:7例行腹腔镜手术,1例行腹腔镜+阴式手术。切除病灶经病理检查证实为直肠阴道隔子宫内膜异位症。随诊最长2年,完整切除病灶者预后良好,未能完整切除病灶者症状、病灶持续存在。结论:直肠阴道隔子宫内膜异位症以痛经、肛门坠痛、性交痛、慢性盆腔痛、腰背部疼痛为主要临床表现,必须进行三合诊和阴道超声检查。手术是主要的治疗手段,腹腔镜或腹腔镜+阴式的手术方法值得应用。     

等离子刀在腹腔镜下治疗子宫内膜异位症165例报告

目的:探讨等离子刀在腹腔镜下治疗子宫内膜异位症的安全性和有效性。方法:应用等离子刀在腹腔镜下治疗子宫内膜异位症患者165例,包括保留生育功能、卵巢功能及根治性手术3种。结果:手术成功162例,中转开腹3例。结论:腹腔镜手术治疗子宫内膜异位症具有患者损伤小,出血少,康复快,住院时间短,术后生活质量高等优点。应用等离子刀可一次完成分离、止血、切割,使手术简单易行,是治疗子宫内膜异位症安全、有效的手术方式。     

Robotic-assisted laparoscopic treatment of bowel, bladder, and ureteral endometriosis

Background:

Endometriosis commonly affects the pelvic organs but can also affect organs outside the pelvis and is then termed extragenital endometriosis.

Cases:

Successful robotically assisted laparoscopic management of extragenital endometriosis, specifically, endometriosis of the bowel, bladder, and ureter in 5 patients.

Conclusion:

A substantial body of evidence supports the laparoscopic approach as the preferred method for many procedures; yet, a majority of procedures today still are performed by laparotomy. This preference for open procedures is likely due to the lack of trained endoscopic surgeons, the difficulty in obtaining proper instruments, and the long learning curve of operative laparoscopy. The recent advent of computer-enhanced technology may provide the bridge necessary for more surgeons to incorporate laparoscopic surgery in the treatment of complex cases.     

腹部无切口经肛门切除标本的腹腔镜低位直肠癌根治套入式吻合手术配合

目的 探讨腹腔镜低位直肠癌根治腹部无切口经肛门切除标本套入式吻合保肛术手术配合方法及配合模式.方法 对30例低位直肠癌经腹腔镜下根治腹部无切口经肛门切除标本行套入式吻合保肛术的手术配合,均采用统一的整体规范管理模式,四做到：术前访视患者、术前与手术医师沟通、术前熟悉解剖与手术程序、术前特殊仪器和器械准备.六配合：手术体位配合、气腹建立配合、上夹切断肠系膜下动静脉配合、游离直肠下段配合、肛门显露与切除标本配合、套入式吻合配合.结果 本组30例低位直肠癌患者,平均手术时间为178 min,腹部手术时间约为132 min,经肛门套入式吻合操作时间46 min,术中无任何意外发生,无中转手术,均顺利完成手术.结论 腹部无切口经肛门切除标本的腹腔镜低位直肠癌根治套入式吻合是一个创新手术,手术配合强调规范化,四做到、六配合模式是有效配合手术医师顺利完成手术的重要保证.     

腹腔镜下低位直肠癌经肛拖出切除吻合术的临床研究

目的：探讨腹腔镜下低位直肠癌经肛拖出切除吻合术在低位直肠癌治疗中的临床应用价值。 方法：回顾性分析12例低位直肠癌应用腹腔镜下经肛拖出切除吻合术的临床资料。12例肿瘤锯齿状线为1~3 cm, 肿瘤局限在肠腔内, 直径均<4 cm, 浸润<肠腔1/2, 均为高-中分化瘤。均行腹腔镜下全直肠系膜切除, 直肠及肿瘤经肛门拖出切除, 用吻合器行结直肠或结肛吻合术。 结果：12例均顺利完成腹腔镜下手术, 无中转开腹手术者。手术时间160~240 min, 平均200 min。术中出血30~80 mL, 平均40 mL。切缘均无癌残留。胃肠功能恢复时间36~60 h, 术后住院时间7~10 d, 无吻合口瘘及吻合口出血发生。12例随访12~18个月, 未发现局部复发。 结论：腹腔镜下低位直肠癌经肛拖出切除吻合术准确、简便、安全, 为瘤体较小、组织学分型好的早、中期的低位直肠癌提供一种较好的术式选择。     

子宫内膜异位症腹腔镜术后复发的相关因素分析

目的：探讨子宫内膜异位症患者腹腔镜手术后复发的危险因素,为临床治疗提供依据。方法：回顾分析2009年5月至2011年5月134例子宫内膜异位症患者（Ⅰ、Ⅱ期62例,Ⅲ期49例,Ⅳ期23例）腹腔镜术后复发情况,并对相关影响因素进行logistic回归风险分析,筛查复发的相关因素。结果：经logistic回归分析显示,纳入分析的患者复发率为16．4％（22／134）,与内异症患者术后复发率相关的因素有r-AFS分期（OR=5．785,CI=1．939—17．261,P=0．002）、手术方式（OR=0．301．CI=0．109-0．830,P=0．020）、术后联合用药（OR=0．062,CI=0．016—0．234,P=0．000）。结论：r—AFS分期、手术方式及术后联合用药是影响子宫内膜异位症患者腹腔镜手术后复发率的相关因素,临床应加强干预,以降低术后复发率。     

Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.

OBJECTIVE: The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. METHODS: The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. RESULTS: The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with shaving only, 92% vs 80%, respectively, P<0.04. The least invasive procedure, shaving, was associated with a significantly lower complication rate, 6%, compared with 23% for disc excision (P<0.007) and 38% for segmental resection (P<0.001), and higher pregnancy rates. The incidence of pregnancy in patients with a history of infertility was 34% during the follow-up period.     

腹腔镜手术联合药物在中重度子宫内膜异位症诊治中的应用

目的:探讨腹腔镜联合药物治疗中重度子宫内膜异位症的效果。方法:选择2003年12月至2006年12月确诊为子宫内膜异位症的患者98例,术前半年内未用过激素治疗,肝、肾功能正常,无心肺疾患。随机分为对照组50例,腹腔镜手术+米非司酮;研究组48例,腹腔镜手术+孕三烯酮。腹腔镜下进行病变分期,术后随访12~36个月,观察各组有效率、术后复发率、术后妊娠率及血CA125水平变化、肝、肾功能变化。结果:对照组有效率60.0%,研究组有效率84.3%,研究组疼痛症状和体征完全缓解率高于对照组,复发率低于对照组,两组比较差异有统计学意义(P<0.05)。对照组术后10个月内复发5例,均为中重度患者,且病情复发程度与血CA125水平升高呈相关性,经服用孕三烯酮后病情得到控制。研究组复发2例,均发生在术后12个月以后,为重度患者,经再次服用孕三烯酮后病情得到控制。研究组于术后服药后出现闭经32例,停药后2~3个月月经恢复,无痛经及性交痛。对照组闭经48例、子宫内膜过度增生1例,停药后半年内恢复月经。结论:孕三烯酮及米非司酮均可作为中重度子宫内膜异位症腹腔镜术后的控制用药,因其服药方便、有效、副作用少可用于广大患者,而孕三烯酮的服药效果明显优于米非司酮且不影响子宫内膜,对复发的子宫内膜异位症治疗仍然有效而备受偏爱。     

腹腔镜手术联合散结镇痛胶囊治疗子宫内膜异位症的疗效观察

目的:探讨腹腔镜联合散结镇痛胶囊治疗子宫内膜异位症的疗效。方法:回顾分析2005年2月至2009年5月为140例子宫内膜异位症患者行腹腔镜手术的临床资料,患者分为散结镇痛胶囊组和孕三烯酮组,比较腹腔镜术后应用散结镇痛胶囊和孕三烯酮治疗内异症的疗效、不良反应及复发情况。结果:2组患者痛经症状均得到不同程度的缓解,缓解率分别为91.7%和94.2%,差异无统计学意义(P0.05),复发率分别为8%和5%,差异无统计学意义(P0.05)。散结镇痛胶囊组月经恢复正常及术后妊娠率明显高于孕三烯酮组,差异有统计学意义(P0.05)。结论:散结镇痛胶囊用于子宫内膜异位症患者腹腔镜术后的巩固治疗有效,可预防和减少复发,调节内分泌,提高妊娠率,且不良反应小,尤其适于有生育要求的患者。     

腹腔镜联合药物治疗中重度子宫内膜异位症合并不孕症的临床分析

目的:探讨腹腔镜联合药物治疗中重度子宫内膜异位症伴不孕的临床价值。方法:对78例Ⅲ~Ⅳ期子宫内膜异位症伴不孕症在腹腔镜下行卵巢子宫内膜异位囊肿剔除术,粘连分离术,异位病灶电凝术,输卵管造口术及输卵管通液术。术后随机分为三组,A组28例未用药物治疗,B组23例内美通治疗三月,C组27例诺雷德治疗三月。比较三组患者术后复发、妊娠结局及用药副作用情况。结果:本组患者术后均病理诊断证实为子宫内膜异位症。至随访时,A、B、C组术后妊娠率分别为17.86%、30.43%、44.44%,复发率分别为32.14%、17.39%、14.81%。B、C组比A组的妊娠率高,而复发率低(P<0.05)。B组患者的副反应以高雄激素症状为主,C组患者的副反应以低雌激素所至围绝经期征候为主,均于停药后恢复。结论:应用腹腔镜可诊断各期内膜异位症及其引起不孕症的盆腔因素;腹腔镜手术治疗可提高内膜异位症患者的妊娠率。在腹腔镜术后加用抑制卵巢功能药物对提高妊娠率、降低复发率有重要作用。     

Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer

Background With advanced stereoscopic vision, lack of tremor, and the ability to rotate the instruments surgeons find that robotic systems are ideal laparoscopic tools. Because of its high operating cost, however, robotic surgery should be reserved to procedures in which the technology can be of maximum benefit, usually when precise dissections in confined spaces are required. Because conventional laparoscopic total mesorectal excision is a challenging procedure, we have sought to assess the utility of the DaVinci robotic system in laparoscopic low anterior resections for cancer of the rectum. Methods Between November 2004 and May 2005 robotic-assisted low anterior resection with total mesorectal excision was performed on six consecutive patients with rectal cancer. These cases were compared with six consecutive low anterior resections performed with conventional laparoscopic techniques by the same surgeon. Results There were no conversions in either group. Operative and pathological data, complications, and hospital stay were similar in the two groups. Robotic operations appeared to cause less strain for the surgeon. Conclusions Robotic-assisted laparoscopic low anterior resection for rectal cancer is feasible in experienced hands. This technique may facilitate minimally invasive radical rectal surgery. Presented, in part, at the 14th International Congress of the Society of Laparoendoscopic Surgeons, September 14–17, 2005 San Diego, California.