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Minimally Invasive Gynecologic Surgery: Evidence-Based Laparoscopic, Hysteroscopic and Robotic Procedures
Jon Ivar Einarsson, Arnaud Wattiez
CHAPTER 1:
Surgical anatomy of the pelvis
INTRODUCTION
MUSCLES
FASCIAE
PELVIC SPACES
Retropubic (Retzius’) space
Retroinguinal (Bogros’) space
Paravesical space
Pararectal space
Retrorectal space
Iliolumbar space
Vesicovaginal space
Rectovaginal space
THE OVARIES
THE FALLOPIAN TUBES
THE UTERUS
THE PARAMETRIUM
Lateral parametrium
Anterior parametrium
Posterior parametrium
THE URINARY BLADDER
THE URETER
SIGMOID COLON
RECTUM
PELVIC LYMPH NODES
PELVIC VISCERAL NERVES
CHAPTER 2:
Exposure in laparoscopic surgery
INTRODUCTION
PREOPERATIVE EXPOSURE TECHNIQUES
Bowel preparation
INTRAOPERATIVE EXPOSURE TECHNIQUES
Exposure strategy
Abdominal inspection
The Trendelenburg sequence
Uterine manipulation
The detachment of the sigmoid
Ovarian suspension
Bowel suspension
Cervical suspension
Uterine suspension
Peritoneal suspension
NOSE procedures
PERIOPERATIVE INSPECTION
CONCLUSION
CHAPTER 3:
Electrosurgery
HISTORY
BASIC PRINCIPLES
WAVEFORMS
MODERN ADVANCES
ELECTROSURGICAL COMPLICATIONS
MODERN BIPOLAR LAPAROSCOPIC INSTRUMENTS
ELECTROSURGERY DURING HYSTEROSCOPY
PLASMA ENERGY
CHAPTER 4:
Choice of suture materials in minimally invasive gynecologic surgery
INTRODUCTION
WOUND HEALING AND INFLAMMATORY RESPONSES
Phase I: inflammation (onset of injury to days 4–6)
Phase II: proliferation (days 4–14)
Phase III: maturation and remodeling (week 1–year 1)
EFFECTS OF FOREIGN BODIES AND EXCESS INFLAMMATION ON WOUND HEALING
EFFECTS OF TENSION ON WOUND HEALING
EFFECTS OF SURGICAL KNOTS ON WOUND HEALING
CLASSIFICATION AND CHARACTERISTICS OF SUTURE MATERIALS
Suture size
Tensile strength
Absorbable versus nonabsorbable (permanent)
Multifilament versus monofilament
Stiffness and flexibility
Smooth, braided, or barbed
Wound closure strength: knotted suture versus barbed suture
Inflammation and wound healing: knotted suture versus barbed suture
Efficiency: knotted suture versus barbed suture
SPECIAL CONSIDERATIONS FOR MINIMALLY INVASIVE PROCEDURES
Suture length
Knot tying
PRACTICAL TIPS
CONCLUSION
CHAPTER 5:
Hysteroscopy – instrumentation, office and operating room set-up
INTRODUCTION
INSTRUMENTATION FOR OFFICE-BASED DIAGNOSTIC HYSTEROSCOPY
Hysteroscopic inflow or ‘inner’ sheath
Hysteroscopic outer sheath
Light source
‘Combination’ systems – light source, video camera, and monitor
Image capturing system
Uterine distention system
Fluid collection system
Examination table
Ancillary equipment
Ultrasound
Monitoring equipment
Emergency equipment
SET-UP FOR OFFICE-BASED DIAGNOSTIC HYSTEROSCOPY
Designated procedure room
PERSONNEL
INSTRUMENTATION FOR OPERATIVE HYSTEROSCOPY
The gynecologic or continuous flow resectoscope
Continuous flow bridge
Hysteroscopic morcellators
Light source, video camera, and image capturing system
Fluid management system
Fluid collection drapes
Distention media
Operating room table and stirrups
Electrosurgical generator
Instrument table
Ultrasound machine
Operating room set-up for operative hysteroscopy
CONCLUSION
CHAPTER 6:
Laparoscopy – instrumentation and operating room set-up
VERESS NEEDLE
ELECTRONIC CO2 INSUFFLATOR
SUSPENSION SYSTEM OF THE ABDOMINAL WALL
TROCAR
ENDOSCOPES
VIDEO CAMERA
MONITOR
COLD LIGHT SOURCE AND COLD LIGHT CABLE
FORCEPS AND SCISSORS
HIGH-FREQUENCY ELECTROSURGICAL TECHNIQUES
Monopolar electrosurgery electrodes
Bipolar electrosurgery instruments
VESSEL-SEALING TECHNOLOGY
ULTRASONIC DISSECTION AND COAGULATION SYSTEMS
SUCTION/IRRIGATION SYSTEMS
SUTURE AND LIGATURE SYSTEMS
Needle holders
Knot pushers
Clips applicators and surgical staplers
Extraction bags
Morcellators
Uterine manipulators
Operating room set-up
CHAPTER 7:
Avoiding and managing complications of laparoscopic surgery
INTRODUCTION
ENTRY COMPLICATIONS
Techniques comparison
General safety rules
Veress needle safety rules
First trocar safety rules
BOWEL COMPLICATIONS
Safety rules
Diagnosis and treatment
BLADDER COMPLICATIONS
Safety rules and treatment
URETERAL COMPLICATIONS
Safety rules and treatment
VASCULAR COMPLICATIONS
SAFETY RULES AND MANAGEMENT
CHAPTER 8:
Complications of hysteroscopic surgery – how to avoid and manage
INTRODUCTION
METHODS
RESULTS
Complications related to the use of distension media
Use of gas as distension medium
Use of fluid as distension medium
Other complications
Complications related to the patient positioning and anesthesia
Trauma to the uterus and cervix
Air or gas embolism
Bleeding
Infection
Late complications
DISCUSSION
Preoperative phase
Operative phase
Postoperative phase
CHAPTER 9:
Laparoscopy in pregnancy
NONOBSTETRIC SURGERY IN PREGNANCY
ADNEXAL MASSES
PHYSIOLOGIC CHANGES
PREOPERATIVE ASSESSMENT
Anesthesia
Imaging
OPERATIVE TECHNIQUE
VENOUS THROMBOEMBOLIC PROPHYLAXIS
CONCLUSION
CHAPTER 10:
Laparoscopic tissue extraction
INTRODUCTION
EXTENSION OF PORT SITES
SPECIMEN RETRIEVAL BAG
COLPOTOMY AND CULDOTOMY
MINILAPAROTOMY
MORCELLATION
CONCLUSION
CHAPTER 11:
Single-port surgery
INTRODUCTION
PORTS AND GAINING ACCESS
SETUP AND INSTRUMENTATION
KEY STEPS
Step 1: Orientation of the port and camera placement
Step 2: Insert the assistant instrument/grasper
Step 3: Insert the operating electrosurgical instrument
SPECIMEN EXTRACTION
SUTURING
RISKS SPECIFIC TO LESS
CONCLUSION
CHAPTER 12:
Surgical management of a uterine septum
INTRODUCTION
DIAGNOSIS OF UTERINE SEPTUM
SURGICAL TECHNIQUE
OPERATIVE RESULTS
OBSTETRIC COURSE
COMPARISON WITH CURRENT LITERATURE
CONCLUSION
CHAPTER 13:
Endometrial ablation
INTRODUCTION
SET-UP
TRANSCERVICAL ENDOMETRIAL RESECTION
Instrumentation
Key steps of the procedure
SECOND-GENERATION TECHNIQUES
COMPLICATIONS AND POSTOPERATIVE FOLLOW-UP
Complications
Postoperative follow-up
ALTERNATIVES
CONTRAINDICATIONS
SUMMARY OF EVIDENCE
PRACTICAL TIPS
CONCLUSION
CHAPTER 14:
Hysteroscopic management of uterine fibroids and polyps
INTRODUCTION
PRESURGICAL EVALUATION
Presence of polyps
CHARACTERIZATION OF FIBROIDS
CONTRAINDICATIONS
PROCEDURE LOCATION
PREOPERATIVE MEDICATIONS
OFFICE OPERATIVE HYSTEROSCOPY
Set-up
Instrumentation
General technique
Vaginoscopy
Polypectomy
Key steps
Myomectomy
Key steps
OPERATIVE HYSTEROSCOPY IN THE OPERATING ROOM
Set-up
Instrumentation
Polypectomy
Myomectomy
Wire-loop resectoscopic technique (for both bipolar and monopolar resectoscopes)
Type 0
Types I and II
Fibroid vaporization
Intrauterine morcellation
OUTCOMES
ALTERNATIVE TREATMENT APPROACHES
PRACTICAL TIPS
CONCLUSION
CHAPTER 15:
Hysteroscopic and laparoscopic sterilization
INTRODUCTION
HISTORY
TUBAL STERILIZATION PROCEDURES IN THE UNITED STATES
TECHNIQUES
Laparoscopic sterilization
Electrosurgery
Falope ring
Hulka clips
Filshie clips
Salpingectomy
HYSTEROSCOPIC STERILIZATION
History of hysteroscopic sterilization
Contraceptive effectiveness
Laparoscopic versus hysteroscopic sterilization
Cost
COMPLICATIONS
Nickel sensitivity
CHOICE
Patient counseling
CONCLUSION
CHAPTER 16:
Laparoscopic management of pelvic organ prolapse
LAPAROSCOPIC PROMONTOFIXATION: SURGICAL TECHNIQUE
Setup and instrumentation
Key steps
Step 1: Exposing the promontory
Step 2: Pararectal and rectovaginal dissection
Step 3: Start of supracervical hysterectomy
Step 4: Vesicovaginal dissection
Step 5: End of supracervical hysterectomy
Step 6: Installing the prosthesis
Step 7: Peritoneal closure
Step 8: Fixing to the promontory
Step 9: Paravaginal repair and Burch colposuspension
AVAILABLE EVIDENCE ON LAPAROSCOPIC TREATMENT FOR GENITAL PROLAPSE
OUR EXPERIENCE
CONCLUSION
CHAPTER 17:
Laparoscopic hysterectomy
SET-UP AND INSTRUMENTATION
Operative set-up
Patient positioning and preparation
Instrumentation
KEY STEPS OF THE PROCEDURE
Uterine manipulation
Laparoscopic entry
Round ligament transection
Bladder flap development
Securing the cornual pedicles
Uterine vessel skeletonization
Securing the uterine artery
Colpotomy
Vaginal cuff closure
ALTERNATIVES: SURGICAL AND NONSURGICAL OPTIONS
Medical alternatives to hysterectomy
Nonhormonal agents
Hormonal medications
Ablation
Uterine artery embolization (UAE)
Myomectomy
CONTRAINDICATIONS TO A MINIMALLY INVASIVE APPROACH
Practical tips
Alternative techniques for obtaining visualization
Alternative trocar placement
Alternative to uterine artery ligation
Alternative technique for colpotomy
Alternative techniques for developing the bladder flap
CONCLUSION
CHAPTER 18:
Laparoscopic myomectomy
INTRODUCTION
SET-UP AND INSTRUMENTATION
KEY STEPS OF THE PROCEDURE
Set-up: patient positioning and placement of a uterine manipulator
Port placement
Vessel ligation
Vasopressin injection
Hysterotomy
Tumor extraction
Hysterotomy closure
Tissue extraction/morcellation
Procedural alternatives
Hysterectomy
Hysteroscopic myomectomy
Uterine artery embolization
Magnetic resonance-guided focus ultrasound surgery
Laparoscopic volumetric radiofrequency ablation
Laparoscopic uterine artery vessel occlusion
Endometrial ablation
CONTRAINDICATIONS TO A MINIMALLY INVASIVE APPROACH
CONCLUSION
CHAPTER 19:
Ectopic pregnancy
HISTORY
OPERATIVE TECHNIQUES
Conservative treatment
Inspection and aspiration of the hemoperitoneum
Salpingotomy
Tubal aspiration
Verification of tubal emptiness
Hemostasis
Tubal closure
Peritoneal washing
Postoperative check-up
Salpingectomy
Special situations
Fimbrial pregnancy
Interstitial pregnancies
Cervical pregnancies
Cesarean section scar pregnancies
Medical treatment
TREATMENT FAILURES
Fertility
Conservative treatment versus salpingectomy
Conservative treatment versus MTX
TREATMENT INDICATIONS
Contraindications
Indications
CONCLUSION
ACKNOWLEDGMENT
CHAPTER 20:
Cervical incompetence and laparoscopic abdominal cerclage
INTRODUCTION
INDICATIONS OF ABDOMINAL CERCLAGE
Laparotomy versus laparoscopic approach
Robotic-assisted abdominal cerclage
PROCEDURE
Timing
Surgical steps
POTENTIAL INTRAOPERATIVE PROBLEMS
COMPLICATIONS
PREGNANCY OUTCOME
CONTRAINDICATIONS
PATIENT SATISFACTION
CONCLUSION
CHAPTER 21:
Laparoscopic treatment of endometriosis
INTRODUCTION
STRATEGY IN ENDOMETRIOSIS
General strategy
Specific strategy
Endometrioma
Bowel endometriosis
Urinary endometriosis
Bladder endometriosis
Ureteral endometriosis
NEW CHALLENGES
CONCLUSION
CHAPTER 22:
Management of adnexal tumors
INTRODUCTION
BACKGROUND
ETIOLOGY AND DIFFERENTIAL DIAGNOSIS
OVARIAN TUMORS
Functional cysts
Endometrioma
Dermoid cyst
Benign epithelial tumors or cystoadenomas
Other adnexal tumors
DIAGNOSIS
Tumor markers
Ultrasound and malignancy index
MANAGEMENT
General
Goals
Laparoscopy: benefits and harms
Indications and contraindications
Informed consent
Surgical management
Preoperative preparation
General strategy
Specific strategy
Puncture and aspiration
Cystectomy
Oophorectomy/adnexectomy
Mass extraction
ADNEXAL TORSION
Incidence
Etiology
Diagnosis
Management
CONCLUSION
CHAPTER 23:
Laparoscopic management and prevention of pelvic adhesions and postoperative pain
INTRODUCTION
UNWANTED SIDE EFFECTS OF SURGERY
Postoperative pain, recovery, and fatigue
Postoperative adhesions
Economic burden of adhesions (Table 23.1)
PATHOPHYSIOLOGY OF ADHESION FORMATION
Surgical trauma
Peritoneum and acute inflammation of the peritoneal cavity
Peritoneal acute inflammation: main factor in adhesion formation
PREVENTION OF ADHESION FORMATION
Quantitative efficacy of adhesion prevention
Efficacy in animal models
Efficacy in humans
LAPAROSCOPIC MANAGEMENT OF ADHESIONS
ADHESIONS, THE LARGER PICTURE AND CONCLUSIONS
Genetics and fibroblasts
Duration of surgery
Inflammation of the peritoneal cavity as a key mechanism
Prevention of acute inflammation through conditioning
Barriers are important as an additive
Flotation agents
CHAPTER 24:
Laparoscopic appendectomy
INTRODUCTION
PATIENT SET-UP AND INSTRUMENTATION
KEY STEPS OF THE PROCEDURE
Position of trocars
Exploration of the abdomen
Dissection of the appendix and vascular control
Division of the appendix
Extraction of the appendix
Abdominal lavage
APPENDICEAL STAPLING
LAPAROTOMY: MCBURNEY'S INCISION
INTERVENTIONAL RADIOLOGY
MEDICAL TREATMENT
CONTRAINDICATIONS TO THE MINIMALLY INVASIVE APPROACH
SUMMARY OF EVIDENCE
AUTHOR'S EXPERIENCE
CONCLUSION
CHAPTER 25:
Robotic instrumentation and room set-up
INTRODUCTION
OPERATING ROOM SET-UP
The da Vinci robotic system
Surgeon console
Patient cart
Vision cart
The da Vinci instruments
EndoWrist instruments
Single-Site instruments
Cannulae, obturators, and accessories
Cannulae
Obturators
Single-Site port
DRAPING PROCEDURES
Instrument arm draping
Camera arm draping
Camera head draping
PATIENT POSITIONING
PATIENT CART DOCKING
Center docking
Side docking
Single-Site docking
CONCLUSION
ACKNOWLEDGEMNET
CHAPTER 26:
Robotic hysterectomy
INTRODUCTION
THE DA VINCI SURGICAL SYSTEM
Components
Surgeon console
Patient cart
Vision cart
INDICATIONS FOR ROBOTIC HYSTERECTOMY
PATIENT PREPARATION
PATIENT POSITIONING, PORT PLACEMENT, AND DOCKING
HYSTERECTOMY PROCEDURE
SINGLE PORT PLATFORM
EVIDENCE IN ROBOTIC HYSTERECTOMY
ADVANTAGES OF THE ROBOTIC APPROACH
LIMITATIONS OF THE ROBOTIC PLATFORM
CONCLUSION
CHAPTER 27:
A decade of robotassisted laparoscopic myomectomy: reflections on the present and future
INTRODUCTION
ROBOT-ASSISTED LAPAROSCOPIC MYOMECTOMY
History and current techniques
Limitations
Looking ahead
CHAPTER 28:
Robotic management of pelvic organ prolapse and incontinence
INTRODUCTION
INDICATIONS
PERIOPERATIVE CONSIDERATIONS
TROCAR PLACEMENT AND ROBOT DOCKING
SACRAL COLPOPEXY
SACRAL COLPOPERINEOPEXY
VENTRAL RECTOPEXY
UTEROSACRAL LIGAMENT COLPOPEXY
HYSTEROPEXY
RETROPUBIC PROCEDURES
Burch colposuspension
Paravaginal defect repair
ENTEROCELE REPAIR
ADVANTAGES OF ROBOTIC SURGERY
DISADVANTAGES OF ROBOTIC SURGERY
CONCLUSION
CHAPTER 29:
Laparoscopic staging of pelvic malignancies
INTRODUCTION
SET-UP AND INSTRUMENTATION
PROCEDURE
Pelvic lymphadenectomy
Para-aortic lymphadenectomy
CONTRAINDICATIONS TO A MINIMALLY INVASIVE APPROACH
SUMMARY OF EVIDENCE
Endometrial cancer
Cervical cancer
Ovarian cancer
PRACTICAL TIPS
CONCLUSION
CHAPTER 30:
Laparoscopy and endometrial cancer
INTRODUCTION
SURGICAL STAGING
SURGICAL RADICALITY AND ONCOLOGICAL OUTCOME
Radicality of surgical staging
Perioperative outcome, survival, and recurrence data
Cost-effectiveness issues
SPECIFIC ISSUES
High BMI patients
Incomplete staging/restaging surgery
Trocar-site metastases
Robotic surgery
CONCLUSION
CHAPTER 31:
Laparoscopic management of cervical cancer
INTRODUCTION
DIAGNOSIS AND STAGING
CERVICAL CANCER AND SURGICAL MANAGEMENT
LAPAROSCOPIC RADICAL HYSTERECTOMY FOR ECC MANAGEMENT
LAPAROSCOPIC RADICAL HYSTERECTOMY: SETUP AND INSTRUMENTATIONw
KEY STEPS OF THE SURGICAL PROCEDURE
CONCLUSION
CHAPTER 32:
Laparoscopic management of adnexal tumors
INTRODUCTION
LAPAROSCOPIC DIAGNOSIS OF A SUSPICIOUS ORGANIC MASS
LAPAROSCOPY IN EARLY ADNEXAL CARCINOMAS
Laparoscopic staging/restaging
Early ovarian carcinomas (EOC) (ovarian or tubal origin)
Borderline ovarian tumors (BOT)
Nonepithelial tumors
Clinical results of laparoscopic staging procedure for EOC
SOME ISSUES CONCERNING THE USE OF LAPAROSCOPY IN EOC
COMPLETE LAPAROSCOPIC MANAGEMENT OF EARLY ADNEXAL TUMORS
LAPAROSCOPY IN ADVANCED STAGES OF OVARIAN CANCER
CONCLUSION
CHAPTER 33:
Role of laparoscopy in advanced pelvic cancers
INTRODUCTION
TYPES OF EXENTERATION
Anterior exenteration
Procedure
Posterior exenteration
Criteria for laparoscopic posterior exenteration
Procedure
Total pelvic exenteration
Procedure
CONCLUSION
CHAPTER 34:
Robotic procedures for malignant conditions
INTRODUCTION
ENDOMETRIAL CANCER
Robotic hysterectomy and pelvic and aortic lymphadenectomy
Patient position and preparation
Trocar placement and docking
Pelvic lymphadenectomy
Aortic lymphadenectomy
CERVICAL CANCER
Robotic radical hysterectomy
Patient position and preparation
Radical hysterectomy technique
Nerve-sparing technique
Aortic lymphadenectomy
Robotic fertility-sparing radical trachelectomy
Patient position and preparation
Technique
Robotic parametrectomy
Patient position and preparation
Technique
Nerve-sparing technique
OVARIAN CANCER
Resection of diaphragmatic and hepatic metastases
Patient position and preparation
Trocar placement and docking
Technique
CONCLUSION
INDEX
TOC
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