妇科腹腔镜878例经验总结

目的：总结妇科腹腔镜手术各种操作技术及其应用价值和注意事项。方法：回顾分析８７８例腹腔手术的经验，根据操作难度分为Ｉ级、Ⅱ级、Ⅲ级，比较其手术时间、术后病率及并发症，Ｉ级操作为内凝法，１２４例；Ⅱ级操作为套扎、水分离法，６５３例；Ⅲ级操作为电切电凝，结扎缝合，１０１例。结果：８６６例手术全过程在上完成，无术 发症；１２例因手术困难中转开腹手术。平均手术时间，Ｉ级组４９分、Ⅱ级组７７分、Ⅲ级组１７１     

腹腔镜辅助阴式子宫切除术98例分析

目的通过对９８例患者行腹腔镜辅助阴式子宫切除术（ＬＡＶＨ）分析,进一步探讨ＬＡＶＨ的适应证、手术要点及临床应用价值。方法自１９９５年２月至１９９７年２月,对９８例因各种良性妇科疾病而需行子宫全切除术的患者,采用ＬＡＶＨ术式。患者平均年龄５２岁（３８～６６岁）,术前子宫正常大小者３８例,子宫增大、小于孕１２周４４例,大于孕１２周１６例,其中有下腹手术史者２９例。结果９８例行ＬＡＶＨ中,２例中转开腹手术,中转率２．０％。平均手术时间１０６分钟（６０～２４０分钟）,出血量约５０～１５０ｍｌ。平均住院日为６天。结论ＬＡＶＨ拓宽了阴式子宫切除的适应证,可避免开腹、减少手术创伤     

妇科腹腔镜手术46例报告

目的 比较常见妇科疾病用腹腔镜手术与传统开腹手术的方法和效果。方法 采用腹腔镜手术治疗常见妇科疾病：异位妊娠、卵巢囊肿46例为研究组与传统开腹手术治疗异位妊娠、卵巢囊肿98例作为对照组。采用t检验及χ^2检验，对两组的手术效果进行比较。结果 在手术效果及术后情况方面，研究组显著优于对照组。结论 腹腔镜手术治疗异位妊娠、卵巢囊肿比传统开腹手术具有手术时间短、术中出血少，术后恢复快，住院时间短等优点。     

妇科腹腔镜手术38例报告

妇科腹腔镜手术３８例报告林晓华陈育梅胡爱月（温州市第三人民医院）１９９６年６月至１９９７年５月我们用电视腹腔镜进行各种妇科手术３８例，疗效满意。现报告如下。１资料与方法１．１临床资料３８例年龄２１～４８ｙ，平均３２．５ｙ，已婚３５例，未婚３例，经产３...     

妇科腹腔镜手术94例报告

１９９６年１月至１９９８年３月我们应用德国Ｗｏｆ腹腔镜行子宫切除等手术９４例，效果满意。现报告如下。１资料与方法１．１临床资料９４例患者２６～５４ｙ，平均３８．６ｙ。术前诊断：盆腔包块２６例，宫外孕１５例，卵巢囊肿２１例，子宫肌瘤１８例，腹痛检查３０...     

妇科电视腹腔镜手术82例报告

自１９９４年１月至１９９８年６月我院共开展妇科电视腹腔镜手术（ｔｅｌｅｖｉｓｉｏｎｐｅｒｉｔｏｎｅｏｓｃｏｐｉｃｏｐ－ｅｒａｔｉｏｎ,ＴＶＰＯ）８２例,疗效较为满意,报告如下。１资料与方法１．１临床资料８２例的年龄１９～５４ｙ,平均３０．８±６．４ｙ...     

妇科电视腹腔镜手术200例报告

１９９２年６月至１９９３年１１月，本院在电视腹腔镜下行输卵管切除、格卵管造口、附件切除、卵巢囊肿剔除、子宫肌瘤剜除、子宫次全切除及全宫切除（ＣＡＳＨ）等手术共２００例，占同期妇科腹部手术的５０．４％．２００例中１９１例全部在电视腹腔镜下完成，无术时或术后并发症，手术成功率为９５．５％。９例申途改剖腹术，其中５例因残端或剥离面出血；４例因处理瘤蒂困难。本文提示电视腹腔镜可提高腹腔镜手术效率致手术范围扩大、手术例数增多。满意的气腹和无血的手术野是关键。强调电视腹腔镜整套装备部件和术者操作技巧具同等重要性．要根据手术经验技巧和器械设备来选择病例并采用手术难度分级逐步开展手术以达到“最小侵入性手术”的目的。     

妇科腹腔镜手术454例临床分析

目的:探讨腹腔镜技术在基层医院妇科手术中的应用价值。方法:回顾性分析近5年的454例行妇科腹腔镜手术的临床资料。结果:454例患者中在镜下顺利完成手术450例,其中异位妊娠手术176例,卵巢修补术15例,卵巢肿瘤剔除术61例,子宫肌瘤剥除术55例,子宫次全切除术81例,腹腔镜辅助阴式子宫切除术7例,盆腔粘连松解术55例。术后24h拔除导尿管,1～2d可下床活动,并发症发生率为0.89%。结论:腹腔镜技术在基层医院妇科手术中具有较大的应用价值。     

Results of Selective Use of Operative Laparoscopy in Gynecologic Oncology

Objective.To evaluate the impact of integration of operative laparoscopy on length of stay (LOS) and complication rates on an academic gynecologic oncology service.Methods.Retrospective analysis of all admissions to our gynecologic oncology service was performed for the academic years 1990/1991 and 1993/1994. Primary endpoints were frequency of complications and LOS.Results.In 1990/1991, there were 785 total admissions, of which 287 were surgical and 3% were approached laparoscopically. In 1993/1994, there were 973 admissions of which 436 were surgical and 23% were approached laparoscopically. Operative laparoscopy was applied equally regardless of age and reproductive status; the utilization of laparoscopy was increased by 14-fold for patients with cancer, 4.5-fold for patients with benign disease, and 12-fold for patients with adnexal masses. No change in the mean LOS of nonsurgical admissions was noted, yet overall LOS for all patients decreased from 6.3 to 4.8 days (P< 0.0001). Mean LOS in surgical patients decreased from 9.4 to 6.0 days (P< 0.0001). After correction for complications, decreases in LOS only occurred in procedures for which laparoscopy was significantly integrated. No reductions in LOS were noted with like surgical approaches; i.e., there was no change in the LOS of patients undergoing laparotomy in both years. Surgical complications were not increased by laparoscopy.Conclusions.Aggressive utilization of operative laparoscopy, even only for selected patients, into the surgical practice of a gynecologic oncology service demonstrates significant improvements in LOS without adversely affecting surgical complication rates.     

American Association of Gynecologic Laparoscopists 1988 Membership Survey on Operative Laparoscopy

The American Association of Gynecologic Laparoscopists' (AAGL) 1988 Membership Survey on Operative Laparoscopy had a response rate of 24%. A total of 880 respondents reported performing 36928 operative laparoscopy procedures. A total of 75% of the respondents reported performing 47 or fewer operative laparoscopy procedures. A total of 75% of the respondents reported performing 47 or fewer procedures. The most frequently conditions managed by operative laparoscopy were endometrial implants, extensive adhesions, and ovarian cysts. Most operative laparoscopies were performed because of infertility (40%) or pelvic pain (41%). The overall serious complication rate was 15.4 per 1,000 procedures. Complications which occurred in more than 1 per 1,000 procedures included hospitalization greater than 72 hours, persistent HCG titer elevation after ectopic pregnancy, hospital readmission, and unintended laparotomy to manage bowel injury, urinary tract injury, and hemorrhage. Two deaths (5.4 per 100,000 procedures) were reported.     

Nerve Injuries in Gynecologic Laparoscopy

Nerve injuries during gynecologic endoscopy are an infrequent but distressing complication. In benign gynecologic surgery, most of these injuries are associated with patient positioning, although some are related to port placement. Most are potentially preventable with attention to patient placement on the operating room bed and knowledge of the relative anatomy of the nerves. The highest risk group vulnerable to these injuries includes women who have extreme body mass index and those with longer surgical times in the Trendelenburg position. Upper and lower limb peripheral nerves are the most common nerves injured during gynecologic endoscopy. These injuries can result in transient or permanent sensory and motor disabilities that can interrupt patient recovery in an otherwise successful surgery. Numerous strategies are suggested to reduce the frequency of nerve injuries during gynecologic endoscopies. Proper patient positioning and proper padding of the pressure areas are mandatory to prevent malposition-related nerve injuries. Anatomic knowledge of the course of nerves, especially ilioinguinal and iliohypogastric, nerves can minimize injury.     

Laparoscopy compared with laparotomy for the surgical staging of endometrial carcinoma

AIM: To evaluate and compare laparoscopic-assisted surgical staging with conventional laparotomy for the treatment of endometrial carcinoma. METHODS: From July 2001 to December 2003, a retrospective review of patients with endometrial carcinoma was carried out. The medical records of those patients who had undergone surgical staging with hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy (PLN) were evaluated. Primary outcome measures were operating time (OT), estimated blood loss, total number of lymph nodes yielded, intraoperative complications, postoperative complications, and length of hospital stay. RESULT: A total of 64 cases were identified. Two cases were excluded because of incomplete records. Two cases with para-aortic lymphadenectomy and four cases with Wertheim's hysterectomy were excluded from the study. Thirty-six patients underwent laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy and PLN (laparotomy group). Twenty patients underwent the same surgery by laparoscopy, of which 19 were successfully carried out (laparoscopy group). One case was converted to laparotomy. The mean OT in the laparoscopy group was longer when compared with the laparotomy group (211 min vs 94 min, P < 0.001). The mean estimated blood loss in the laparoscopy group was less (200 mL vs 513 mL, P < 0.001). The post-operative hospital stay was shorter in the laparoscopy group (3.6 days vs 7.7 days, P < 0.001). The mean number of lymph nodes yielded was more in the laparoscopy group (26.1 vs 16.7, P = 0.004). Neither group had intraoperative complications and both had similar postoperative complication rates. CONCLUSION: Laparoscopic-assisted surgical staging for endometrial carcinoma is associated with significantly less blood loss, shorter hospital stay, longer OT time, and more lymph nodes yielded when compared with laparotomy.     

Mini-Laparotomy Versus Laparoscopy for Gynecologic Conditions

Study ObjectiveTo compare conversion rates, operative time, and estimated blood loss in patients undergoing mini-laparotomy (<4 cm vertical or transverse abdominal incision) versus laparoscopy for treatment of benign gynecologic conditions.DesignRetrospective study (Canadian Task Force classification II-2).SettingAcademic medical center.PatientsWomen who underwent laparoscopy or mini-laparotomy for treatment of gynecologic conditions from January 2002 to March 2011. Patients who underwent hysterectomy as part of the surgery, cancer staging procedure, pregnancy-related procedure, or diagnostic surgery alone were excluded.InterventionsMini-laparotomy or laparoscopy.Measurement and Main ResultsPrimary outcomes were operative time and estimated blood loss. Secondary outcomes were hospital readmission, repeat operation, overnight hospital admission, emergency room visits because of surgery-related signs or symptoms, and wound complications. Of 950 medical records examined, 493 patients (52%) met the inclusion criteria, of which 141 (29%) underwent mini-laparotomy and 352 (71%) underwent laparoscopy. The groups had similar indications for surgery and level of surgical assistant. Patients who underwent mini-laparotomy were older than those who underwent laparoscopy. In patients who underwent mini-laparotomy, mean operative time was significantly shorter (49.3 versus 91.5 minutes; p = .003), and estimated blood loss was less (20 versus 32 mL; p = .001). The cumulative secondary outcome rate was not statistically different between the 2 groups (15% versus 16%). When each secondary outcome (conversion, repeat operation, overnight hospital admission, readmission to the hospitalization, emergency department visit, and wound complication) was examined independently, only the wound complication rate was significantly higher in the mini-laparotomy group compared with the laparoscopy group (5 of 141 patients versus 1 of 352 patients; p = .008).ConclusionsMini-laparotomy is a safe alternative to traditional minimally invasive approaches in gynecology and offers the additional benefits of shorter intraoperative time and less blood loss; however, it is associated with a significantly higher rate of major wound complications. Mini-laparotomy is an important surgical approach and should be included in gynecologic surgical training.     

Comparative Studies of Energy Sources in Gynecologic Laparoscopy

Energy sources incorporating “vessel sealing” capabilities are being increasingly used in gynecologic laparoscopic surgery although conventional monopolar and bipolar electrosurgery remain popular. The preference for one device over another is based on a combination of factors, including the surgeon’s subjective experience, availability, and cost. Although comparative clinical studies and meta-analyses of laparoscopic energy sources have reported small but statistically significant differences in volumes of blood loss, the clinical significance of such small volumes is questionable. The overall usefulness of the various energy sources available will depend on a number of factors including vessel burst pressure and seal time, lateral thermal spread, and smoke production. Animal studies and laboratory-based trials are useful in providing a controlled environment to investigate such parameters. At present, there is insufficient evidence to support the use of one energy source over another.     

Unsuspected Primary Tubal Carcinoma during Operative Laparoscopy

Objective.To evaluate the possible risk of dealing with an unsuspected primary carcinoma of the fallopian tube during laparoscopic surgery.Methods.We performed a countrywide survey in Austria concerning laparoscopic procedures in cases of primary carcinoma of the tube. The questionnaire consisted of questions regarding the pre-, intra-, and postoperative management.Results.Of 18,435 laparoscopies in cases of an adnexal mass, 5 cases were reported, when laparoscopy was performed on an unsuspected carcinoma of the tube. Therefore, the risk of detecting this malignancy during laparoscopy after preoperative evaluation is 1 in 3687 cases (0.028%).Conclusion.The risk of encountering an unsuspected primary carcinoma of the fallopian tube during laparoscopy in Austria is an extremely rare situation. In case of a malignancy, a staging or debulking laparotomy should be performed immediately or as soon as possible.     

Laparoscopy and Body Mass Index: Feasibility and Outcome in Obese Patients Treated for Gynecologic Diseases

Study ObjectiveTo compare feasibility and surgical outcome of laparoscopic gynecologic surgery between obese, overweight, normal-weight, and underweight women.DesignRetrospective case control study (Canadian Task Force classification II-3).SettingSurgery Unit of Minimally Invasive Gynaecology.PatientsA total of 503 women who underwent laparoscopic procedures for both benign disease and malignancies.InterventionsFour main categories of gynecologic disease were identified: uterine fibroids, benign adnexal masses, endometriosis, and endometrial cancer (stage I). For each category patients were divided into 4 groups: underweight (BMI <18.5 kg/m²), normal-weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25–29.9 kg/m²), and obese (BMI ≥30 kg/m²).Measurements and Main ResultsSelected outcomes were duration of surgery, rate of laparotomy conversion, intraoperative and postoperative complications, and duration of hospital stay. No statistical difference regarding demographic data, surgical and medical history, and intraoperative findings was present between groups. No laparotomy conversion occurred. Regarding duration of surgery, we found no statistical difference among the BMI groups with regard to benign diseases, whereas pelvic lymphadenectomy in obese patients with endometrial cancer had a statistically significant longer duration than in the control group (122 ± 47min vs 65 ± 21 min, p <.001). The postoperative complication rate was 0.01%: 3 cases of blood transfusion and 1 case of hemoperitoneum among myomectomies; 1 ureteral fistula in surgery for pelvic endometriosis; and 1 case of postoperative lymphocele in endometrial cancer group. No statistically significant difference was found in duration of hospital stay among the BMI groups in any of the categories of disease. For each category we conducted an analysis to identify any possible risk factors other than BMI in the surgical outcomes.ConclusionLaparoscopic approach in the various applications of gynecologic surgery does not appear to be significantly influenced by BMI in terms of surgical outcomes, laparotomy conversion rate, intraoperative and postoperative complications rate, and duration of hospital stay. The technical difficulties can be solved if skilled surgeons and anesthetists are available.