TheProgressofGynecologicalEndoscopeTechnology

1Ⅰ.Overview--Endoscopyanimportantpartofminimallyinvasivetechnologyarevolutionarypioneerinsurgerychangesthethoughtsandideas,thetechnicalrouteandoperationskillsofdoctors2Overview--Laparoscopy

appliedinGYNfieldbyPalmerin1947firsthasbecomeoneofthemostregularoperationtechnologyingynaecologycurrentlymainlyappliedtoexaminationsandsimpleoperationsfrom1950sto1970sin1970s,expansionofvitreoretinalsurgery,ChinaandZhejiangProvincebegantheapplicationoflaparoscopyinOB&GYN3ThelaparoscopichysterectomyandQuerlenlymphaticexcisionbyReichin1989significantadvantagesinOB&GYNandwidelyusedexploreconstantlyfornewareas,inmalignanttumors,pelvicfloorreconstructionandothersurgicalfields4Overview--hysteroscopyAnidealoperationmethoddiagnosisandtreatmentofintrauterinebenignlesionstherangeindicationsincreasinglywidened.5Afterthefirstquarterinthe21stcentury,thevastmajorityoftheGYNoperationscanbedonethroughtheendoscope6Advantagesandapplications

oflaparoscopy7（I）

AcutegynecologicalabdomenDiagnosisandtreatmentintime.Ectopicpregnancy,corpusluteumrupture,acutepelvicinflammation,pelvicabscess,andovariancysttorsion,etc.an

indicatorformeasuringthe

applicationinaunit,thepresentationofthebasicconceptandtheuniversalscaleoflaparoscopy.8Forectopicpregnancytreatment(bytakingembryooftubalpregnancyincisio)

---goldstandardOncefallopianportionpregnancywasconsideredcontraindication,nowlotssuccessfulcasesreported910rupturedectopicpregnancy---onceconsideredascontraindications,nowcanfinishedbyexperienceddoctors

(thoughquicklyfindthebleedingsite)11（II）Gynecologicalbenigntumorsovariansimplecyst,benignmatureteratoma,ovariancyst,etc.laparoscopypreferred.

Somehospitalamountedto90-100%.12（III）Endometriosisgoldstandardfordiagnostic,rAFSinstallmentbasis,thebesttreatmentapproach.abdominaltype,ovarytype

canbeachievedthroughlaparoscopicremovelesionstorelievepain,improvethepurposeoffertility,andreducetherecurrence.difficultinDIE,butsecurityincreasewhencombinedwithvaginalsurgeryNOTusedinuncertainendometriosisandmalignanttumor,especiallyforCa125>200iu/mlorimaging“special”byiconography,whichmaydelaythediseases1314151617EverystageofEMSiscurrentlyfitbylaparoscopy

Someexpertsperformbowelresectioninmicroscopic,andalmostnoobjectionhasoccuredItisbetterbylaparotomyinlargeovariancyst,widelyintestinaladhesion,intestinalresectionorjudgedtobeaverycomplicatedsurgery18（IV）ChronicpelvicpainbestwaytodiagnosecommonsymptomsinducedbymanycausesApproximatelyonethirdisEMs,onethirdpelvicadhesion,onethirdnormalpelvic80%adhesionseparation,thelesionresectioncanbealleviatedmicroscopicallyPelvicpaincausedbyEMscanberemovedbysacralnervetransectionorsacralnerveresection,withsatisfiedrateover70%.19（V）Pelvicinflammatoinrelativelycontraindicated20yearsago;nowacuteorchronicpelvicinflammationtreatedbylap.

topreventinflammation,reducepelvicadhesionandpelvicpainandinfertility.Pelvicabscessincisiondrainage,appendixresection,adhesionseparatingandpelvicflushingwillimprovetheprocessandresults.congestiveandedemawithlooseadhesioninacuteinflammatointissue,buteasytoseparate;chronicabscesswithdenseadhesionoftenmakessurgerydifficult.20大網(wǎng)膜黏連1、腹膜牽拉癥狀2、胃腸功能紊亂3、部分因橫結(jié)腸牽拉成角，出現(xiàn)不全性機(jī)械性梗阻癥狀21Ⅲ.SelectionproblemsandnewfieldsofendoscopicsurgeryTheapplicationoflaparoscopyshouldbeprudent.Surgery,patientsanddiseasemustbeentirelyappropriatetoeachother.Aimedtofindandimplementthemostappropriatesurgery,ratherthantopursueandshowofftechnologyandequipment.22Choosetheappropriatesurgery

Choosetheappropriatepatient

inappropriateinappropriate×appropriateappropriatebestchoicesurgerypatientsordiseases×23（I）HysterectomyOneofthemostcommonGYNsurgeriesDiffirentadvantagesandlimitationsviaabdomalandviavagina,orauxiliary,foster

strengthsandcircumventweaknesses.Totallaparoscopichysterectomy(TLH)Laparoscopicassistedvaginalhysterectomy(LAVH)Vaginalassistedlaparoscopichysterectomy(VALH)24(II)myomectomySingle,<5cmofmyomaMultiple,morethanthree,or>7cm,orsingle>15cm(ormuscleintramural>10cm),deepbroadligamentorposition,orclosetothelowpartuterusandcervicalmyomaarenotfitintramuralorsubmucousmyomaincreaselegacyandrecurrence.Skillfulsuture（縫合）techniquerequired.Clinicalvalueofrecedefibroidsbyelectriccoagulation,laser,freezstillneedsevaluation.2526（III）GynecologycancersFullofhopeanddissent（異議）Moreconsensus（意見一致）isonStageIofendometrialcancer.

Pelviclymphnodeclearancerequiredafterhysterectomysimplelyandsafelyunderlap.pre-sentinel(前哨)lymphnodeexcisionincervicalcancerunderlap,aimingatpromptradiationorradicalhysterectomy.Trachelectomy(保留生育功能根治術(shù))inearlycervicalcancer,aimportantstepispelviclymphnodeexcisioninlap.

Thenegativehistologyresultindicatefollowingsurgeryshowouttheadvantageoflap.27fullyusedinovariancancerdiagnosisandpreliminaryclinicalstaging.

Basicofpreviouschemotherapy,andwellacceptforsecondpelvicexplore

foritsminimallyinvasive.FitforStagesIandIIofovariancancerbutNOTforStagesIIIandIV.28（IV）Pelviccavityreconstructionchangetraditionalmodusoperandisofpelviccavityorgansrolapseandstressurinaryincontinence.burch,foldinguterosacralligament,sacro-vaginaimmobilizationcanbefinishedbylap.Micro-injury,fastrecovery,idealeffect,butrichexperienceandgoodtechniquerequired.29（V）ChoicePrinciplesinmedicineandhumanityPrinciplesofmedicine:providebestsurgerytodisease.Principlesofhumanity:moreconsiderationtoeffectsoflifequality,willofpatientsandfamilialities,understandingtorisksandcomplicationsofoperation30LaparoscopyinpregnancyOnceisacontraindication,

nowovariancystsinmiddle-pregnancyisreported.EffectsofpneumoperitoneumandCO2topregnancyshouldbebalancedinadvantagesanddisadvantagesandtotallytoldtopatientsandtheirfamilialitiesfortheiragreement.31IV.ContraindicationsincreasingadvancewithdecreasingcontraindicationAbsolutecontraindications:Cardiovascularandlungdiseasescannottolerateanesthesiaseverearrhythmia,IIdegreeorover

atrioventricularblockhemodynamicchangesSepsis

LiuYan,PracticalGynecologiclaparoscopicoperativesurgery.

32Relativecontraindications:nervoussystemdisordersbloodclottingdisordersmassoftheabdominaaboveumbilicus(臍)levelPregnancymorethan4monthsabdominalwallhernia（腹壁疝）,diaphragmatichernia（膈疝）intestinalobstructionObesitMultipleabdominalsurgeryhistoryinexperiencedoperators(XiaEnlanetal.)33attentiontotheprocedureandtheoperationitselftheirknowledgelinkstolaparoscopicinstrument,includinginstrumentcharacteristics,specificcomplicationsrelatedfactors,andpreventionmeasuresStrictoperationstandardsIntensivetraining,stepbystep34V.ThepreventionsofcomplicationsDeathrateinlaparoscopicsurgeryisatleastfourperhundredthousand.Limitedvisionfield,damagefromequipmentandenergy,effectsofCO2pneumoperitoneumandpositionDevicesdependsurgery,experienceandskillsplayadecisiveroles.

35

Some"low-levelproblems"inprimarystage:subcutaneousemphysema(皮下氣腫)Retroperitoneal（腹膜后）vessels,abdominalarteries(0.005-0.01%)andintestinalcanalinjuryduringneedleortracarpunctureelectricburns:intestine,ureter(輸尿管)isthemostcommon.uncorrect

vasculartreatmentinducehemorrhageoccurs:electriccoagulation,

knotspecimenlossinabdominalcavity36some“Seniorproblems”inexperiencedendoscopicphysicians:Uretersdamagedwhendissectingtissuesofside-uterus.Hemorrhagewhencleaninglymphnodes.Heavyadhesionofintestineandbladder,damageoccurwhenseparate37

Clinicallaparoscopicstudies

concentrateon:circulatorysystem,respiratorysystem,liver-kidneyfunctionbodystressresponseOxidativestressIschemiaandreperfusion(缺血再灌注)38Comparisonbetweenlaparoscopy

andopenoperationsmainlyrelatedtoimmunity,disseminateion,adhesion39StudiesonCarbondioxidepneumoperitoneumtumorcellproliferationandapoptosistumorspreadandtransferofincisionsitesadhesionandinvasionlackofoxygen,lowPHcausedtoepigeneticschangeseffectsonperitonealmicroenvironmenteffectsonbody’simmunefunctionChangedangiogenesisandsecretionofcytokinescausedbypneumoperitoneum

pressure40VI.ProgressofthelaparoscopicsurgeryMicrolaparoscopy(微型)gaslesspneumoperitoneumtransvaginalwater-laparoscop（經(jīng)陰道水腹腔鏡）Robertremotediagnosis,

surgery,teaching411.GaslesslaparoscopyNocontinuousCO2pressure,minimallyinvasive.(1)Gaslesslaparoscopyusingtheabdominalwalllifting(AWL)(腹壁懸吊式無氣腹腔鏡)mostcommonlyused42(2)airbaglaparoscopy(氣囊腹腔鏡)43(3)Magneticattraction:Anderson(USA)

&Power(Canada),usingfourmagneticobjectsbyTrocarintoabdominalcavity,usingmagneticattractioninandoutabdominalwalltomakegaslessspace.experimentalpigsnephrectomy(腎切除)proved

itsfeasibility(byAnderson)

442.Narrowbandimaging(NBI,窄帶成像)ImproveaccuracydiagnosisofEMsfilteroutbroadbandspectrumfromendoscopicredbluegreenlight,onlyleavingnarrowbandspectrumfordiagnosis.Agoodreflecttothereconstructbloodcapillary.rangeofapplicationindigestivetract,ear,nose&throat,respiratorytract,gynecologicalendoscopicandlaparoscopicsurgery,etc.easytoidentifythesuperficialEMs,andjudgetheextentoflesion.453.Theprogressofthelaparoscopicoperation-uterinearteryblock(子宮動(dòng)脈阻斷)464.TreatmentsofmalignanttumorinLaparoscopy47(1)preventthecannulatransfer

(預(yù)防套管處轉(zhuǎn)移)thecannulafixedwithsutures(縫線)ontheabdominalwallspecimenbagsusedtoavoidpolluteabdominalincisionfirstCO2escapethenpulltracarcasingtoprevent‘chimneyeffect’(煙囪效應(yīng))attheend48(2)ReducepneumoperitoneumimpactCO2pneumoperitoneumpromotethegrowthoftumorcells,shortenoperationtimeestablish37℃

CO2pneumoperitoneum,reducethespray(霧化)oftumorcellsset14mmHg

andCO2flowrate<5l/minintraoperative49(3)preventabdominalresidualandinfectionHeatperfusionchemotherapy(熱灌注化療)inabdominalcavityItcollects

heateffect,chemotherapydrugsandmechanicalwashingto

reachmultipleeffectsoncancercells50

(4)HotCO2pneumoperitoneumHotCO2pneumoperitoneuminducesapoptosisoftumorcell

/pubmed?term=%22Peng%20Y%22[Author]&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract,etal.HyperthermicCO2pneumoperitoneuminducesapoptosisinhumancoloncancercellsthroughBax-associatedmitochondrialpathway.2008,19(1):73-951Newconceptofgynecologicallaparoscopy521.Naturalorificetransluminalendoscopicsurgery,NOTES(自然腔道內(nèi)鏡外科)anewkindofultramicrointerdisciplinarysurgery(跨學(xué)科的新興超微創(chuàng)外科手術(shù))Throughnaturalcavitiessuchasoralcavity,anus(肛門),vaginalandurethralintosoftendoscope,respectivelypierceorganssuchasthestomach,therectumandbladder,vaginafornixarrivedinabdominalcavitytoestablishedoperatingchannelsandgaslesslaparoscopicabdominalorwater,doallkindsofbasinceliacsurgeryunderendoscopy53ThegynaecologyNOTESinclude:TransvaginallaparoscopicwaterinjectionThegastricresection,accessoriesandtuballigationJosephA.etal.Peritonealin?ammatoryresponseofnaturalori?ce

translumenalendoscopicsurgery(NOTES)versuslaparoscopywithcarbondioxi.deandairpneumoperitoneum.(2009)

Zorronetal.NOTES:transvaginalforcancerdiagnosticstaging:preliminaryclinicalapplication.2008Sep;15(3):161-5.542.Laparo-endoscopicsinglesitesurgery(LESS)Integratinglaparoscopicmultimodalintoachannel,toapplyhasthreecomtecasing(triport),throughhumaninherentchannel"bellybutton"intotheabdominalcavity,duetothebellybuttonfoldblockoperationscar,basicbodysurfaceandnoscarcosmeticeffect.Anteriorextremitiesofequipmentsareflexibletooperate.

Becauseofzerodegreeandrestrictedoperationspace,front-endanteriorextremitiesofequipmentsareflexibletooperate.

55Fagotti,etal.Laparo-endoscopicSingle-SiteSurgeryfortheTreatmentofBenignAdnexalDisease:AProspectiveTrial.(2009)563.Roboticlaparoscopy

In2000theUnitedStatesFoodandDrugAdministration(FDA)approvedtheapplicationoftheDaVincirobottechnologyinthefieldofgynecology.

Itimprovestheopticalinstruments,highresolutionand3Dimaging,andtheoperatinginstrumentmovementrangeandoperationflexibility.Robotcontrolcameracanimproveworkefficiency,andreducethefatigueofthesurgery.

57Intelligentandsimulationprogramforgynecologicalendoscopicsurgery（L.Mettler,CampusKiel,Germany）Endoscopicsurgeryinthefuturewillbecombinedwiththeapplicationofadvancedmachineryandequipmentthroughthesensorcontrolsensationandmovement.Thetechniquehashighprecision,minimalinvasion,lessbleeding,andthree-dimensionalvisualareaprecisionoperationindependentontheoperationofsubjectmove.58Operatorscansitinfrontofacomputertooperateinpatient’sbodythroughthejoystickbyDaVinciintelligentsystem,whichshouldbebasedonthefictitiousbodytrainingsystemtraining.Inadditiontoimprovethesenseoftouch,masteringanatomicalknowledgeandsmart,stillneedcarefullyeffectiveapplicationtechnologyandhighprecisioninstruments.59Indications,contraindicationsanddevelopmenttrendofHysteroscopy60(I)DiagnosisandtreatmentofbenignuterinecavitylesionsCheckeuthyphoriaendometrialunderphysiologicalandpathologicalchangesSensitivityandspecificityofdiagnosisofnormalandabnormalendometriumbyhysteroscopyare94.2%and88.8%respectively,andthoseofthediagnosisofpolyparethehighest,95.3%and95.4%respectively.Positionbiopsy,avoidblinddiagnosisofdilationandcurettageofuterus61Examineallkindsofabnormaluterinebleeding,intrauterineplaceholderlesions,infertilityetiologyexamination,identifyabnormaluterineimagingchangesAbsolutecontraindicationsinclude:acutegenitaltractandpelvicinfection,heart,liverandkidneyfailureintolerance.62Hysteroscopycheck3to7daysaftermenstruation:endometrialthinner,noteasytobleed,lessmucussecretion,uterinecavitylesionseasytobeexposed.oftenuse5%GStobulkpalace,on-demandslightlyenlargedornotdilatecervix,handhysteroscopytoexaminecarefullytheuterinewall,tubalopenings,fundus,beforeandafteruterinewalllast,thecervixandcervicalcanal.63（II）Minimallyinvasivesurgeryforthetreatmentofuterinecavitylesions1、DysfunctionaluterinebleedingEndometrialresectionofthedestructionofendometrium(TCRE)byhysteroscopicdamagesfull-thicknessendometriumandthebottompartmusclelayer,andleadstoregenerationoforganizationendometrial,toachieveamenorrheaorreducemenstruationItisnotapplicabletopatientsoffertilityrequirement.64

2、EndometrialpolypsandsubmucousmyomaCuring80%endometrialpolypsPregnancyrateofinfertilitypatientsbymovingsubmucousmyomainhysteroscopicis60.95%.Curing95.2%submucousmyomaofpost-menopausalwomen,polyps,adhesionmicroscopically.Uterinedepthismorethan12cm,whichisnotsuitableforhysteroscopysurgery6566670型黏膜下肌瘤68I型黏膜下肌瘤69II型黏膜下肌瘤70IndicationsofelectrosectionaboutsubmucousmyomaSmallandsingle,submucousmyomawithmicro-pedicel,diameter<1.5~2cm,afterhysteroscopyexaminationswitchtohysteroscopysurgery,willberemovedeuthyphoria.Myomadiameter<5cm,experienced,indicationscanbeextended.Burieddeepwithinthemuscleandmusclelayerinmuscleintramuralmyoma,sometimesmorethantwooperationsarerequired.Intramuralandsubserousmyomaswhichdon‘tcausedeformitiesoftheuterinefibroidsareunfavorableforhysteroscopysurgery713.separationofintrauterineadhesionRecoveuterinenormalanatomicalmorphology,correcttheabnormalmenstruation,restorefertilityPreutthipanreported65separationofintrauterineadhesioncasescuttingafterelectrosectionsurgery,90.9%secondaryamenorrhearecoverynormalmenstruation,periodicabdominalpaindisappearaltogether.Katz,90casesofmergerhistoryofadverseproductioncausedbyintrauterineadhesionsaftertreatment,earlyabortionratefallsto62.4%from17.4%,lateabortionratefallsto16.0%from4.7%,full-termbirthsincreasesfrom18.3%to68.6%.72針狀電極分離黏連環(huán)狀電極切割右側(cè)壁黏連環(huán)狀電極切割右側(cè)壁黏連后針狀電極分離黏連后73TCRA術(shù)前宮腔封閉，鏡體前方為盲端TCRA術(shù)后切割出孔隙74術(shù)后宮腔可見左輸卵管開口暴露左宮角顯露右側(cè)輸卵管口75暴露宮腔術(shù)后宮腔形態(tài)宮腔形成764.CorrecttheuterineabnormalitiesRestoreinfertilitycausedbyintrauterineanatomymorphology,treatment,mediastinumuterusaremostcommon.RenaissanceBeijinghospitaltreated116casesofmediastinumuterus.Theabortionratefallsto72.6%from25.4%,full-termbirthsincreasesfrom9.2%to94.7%.77785.HandlingintrauterineforeignsubstanceAccuratepositioning,withoutdamagingthenormalendometrium.Embryoandplacentatissueresiduesfetusskeletonsresidue,lostorbroken,theintrauterinedeviceandsooncausedbyintrauterineforeignbodyremovalandremove79（II）ApplicationvaluesandcontroversysofthemalignanttumorSomescholarsfound26casesofendometriallesionsandcurettageomissionsnoabnormalhysteroscopyexaminationandpositioningbiopsy,26casesofendometriallesionsandcurettageomissions,among206casesofabnormaluterinebleedingandcurettagefoundnoabnormalhysteroscopyexaminationandpositioningbiopsy,26casesofendometriallesionsandcurettageomissions,70%werefocalchange.80（III）Diagnoseandtreatmentonexterioruterinecavitylesion1、DiagnoseandtreatectopicpregnancyMarpeauperformedhysteroscopyon60casesofsuspectedectopicpregnancy.41casesofthemwerediagnosedasectopicpregnancy,fornopregnancytissuewasfoundunderthescopewhileoviductonsidewasopenandbloodflowedout;18caseswereuterineembryodeaths,and1casewasnotdetermined.81Therewerecasereportonuterinehornpregnancy,interstitialtubalpregnancyinforeigncountrieswhichhadbeensuccessfullyremovedbyapplyinghysteroscopyafterMTX.ThereisasuccessfulcaseofpregnancyinscarpartofCesareansection.822、ResectionofcervicallesionCervicalpolypoidhyperplasiaCervicalpolypusCINI-II3、AuxiliarytreatmentonothersystematicdiseasesNon-organicdiseasesoftheuterus,andthemassmetrorrhagiacausedbyotherdiseasesandmedicine.83Thecorequestionofdisputeis:doesperfusionmediumcauseexpansionoftumorcellsandaffectfutureprognosis?Arikanperformedsimulatedvitrohysteroscopyon24casesofendometrialcancersamplestreatedbyuterus+dualuterineappendagesremovalandfoundthat83%sampleuterineperfusionpenetrateswhenflowingthroughoviduct,andtumorcellsarefoundin71%ofpenetratingliquidwhere42%oftumorisalive.84ButitisfoundamongvariouscentersandbigsampleclinicalresearchesinAustria:thesurvivalratewithouttumor5yearsafterperforminghysteroscopybeforetheoperationonendometrialcancerwhiletherateforthosewithoutperforminghysteroscopyis84.7%.Thereisnostatisticaldifferencebetweenthem.ItisconsideredinMulvanyreportsthatperforminghysteroscopywillnotcauseharmfulinfluenceonprognosis.85

Surgicalcomplicationsanditscountermeasureof

hysteroscopy1．uterineperforation：

Itregularlyhappensunderchargedoperationswhenthehorizonisvague.Onceithappens,thesurgicaloperationshallbestopped,andthepatientshallbekeptinthe