腹腔镜手术-电外科与卵巢功能.ppt

腹腔镜手术 电外科与卵巢功能,武警上海总队医院妇科 陆晓兰 2010.04,祝兄弟姐妹们欢聚一堂！,提 纲,止血方法卵巢功能止血与卵巢功能,止血设备,激光高频电凝固超声刀微波刀氩气刀射频刀器械止血,激光,CO2NdYAGKTP-532HaYAK氩激光 较早使用 渐被取代,高频电凝固,单极电凝双极电凝PK刀结扎速血管闭合系统（LigaSure）应用广泛,单极电凝 1926,优点 操作简单 省时 经济缺点（1）产生大量烟致手术视野模糊且产生有 毒气体（2）热效应明显，产生100400高热 热损伤大，损伤周围组织可达15mm（3）易发生电损伤，损伤大血管及输尿管肠管（4）组织粘连严重，焦痂形成，术后并发症多,双极电凝 1950,安全性 确切性 优点（1）止血效果较单极电凝好，可电凝直径3mm的血 管，如子宫、卵巢血管等（2）不易发生电损伤 缺点（1）产生大量烟雾且含有毒气体（2）热效应大、热损较大，但远比单极小（3）组织粘连严重，焦痂形成，术后并发症多,PK刀,新一代高频电刀 电凝 电切优点（1）热效应小，作用热度为4070；热损伤较小，热损伤 范围不超过4mm（2）可以闭合7mm以下的血管、能支持300mm Hg的持续压力（3）具有抓持、电凝、切割、分离和钝性拨棒5种功能，缩短 了手术时间，减少了术中出血（4）蒸汽脉冲凝固可使凝血可靠和完全（5）组织粘连较轻，焦痂形成少，术后并发症少（6）切割准确快捷、操作简单缺点 产生有毒烟雾，但较电刀少。,结扎速血管闭合系统（LigaSure）,优点（1）热损伤小（侧向热传导距离12mm）（2）能完全和永久闭合直径小于7mm的血管（3）闭合带持久且几乎透明，且比其他所有以能量为基础的 熔合方式都坚固，可达到与缝线结扎相似的强度，可承受 3倍的正常人体动脉收缩压（4）直接闭合组织束，无需切开和剥离（5）没有或有极少粘连和焦痂形成，体内无异物存留缺点（1）价格较贵（2）虽产生烟雾，但较电刀产生的少（3）不宜用于分离较精细的组织,超声刀 1993,优点（1）只产生小水滴而不产生烟雾，手术视野清晰（2）热效应小，作用热度为80100；热损伤小，损伤周围 3mm范围（3）兼有组织切割、凝固和分离的作用，且可精确控制切割和凝固 范围，缩短了手术时间，减少了术中出血（4）无电损伤的可能（5）组织粘连少，焦痂形成少，术后并发症少（6）快速振荡有自净作用，不会发生刀与组织的粘合（7）适用于妊娠期腹腔镜手术（8）可用来处理大网膜广泛粘连的手术，网膜脂肪断离无电凝挛缩 现象，切口整齐，网膜血管凝固完全,超声刀 1993,缺点（1）操作迟缓（2）价格昂贵（3）用于凝固直径3mm的血管效果确切，但凝固较大的血 管仍需使用其他方法（4）只能切凝与之接触并有一定张力的组织，且每次不能切 割太多组织,微波刀,优点（1）不产生烟雾，术野清晰（2）无电损伤的可能，安全性高（3）热效应小，作用温度一般在6080（4）不碳化，术后并发症少（5）止血效果可靠，术中出血少（6）设备价格低廉缺点（1）仅能凝固封闭直径3mm以内的血管（2）对胆管只起暂时性闭塞作用，不能凝固闭塞。,氩气刀,优点（1）止血时不会产生烟雾，术野清晰（2）组织损伤小，深度3mm（3）不接触创面、能有效制止大面积出血，连续性凝固（4）热效应小，创面温度控制在110（5）形成的焦痂致密，止血效果好（6）止血速度快，术中出血少缺点（1）仅能凝固直径2mm的血管（2）有增加气腹压力的危险，有可能促进气体栓塞和发生呼 吸、循环功能障碍25，26（3）氩气流量使用不当，会影响止血和凝血效果，且有产生 血管气栓的可能,射频刀,优点（1）极少产生烟雾，术野清晰（2）热效应小，在组织下1mm深处的温度55（3）热损伤小，穿透深度仅50m（4）不易发生电损伤（5）止血时不断有盐水滴出，止血效果好、止血精确、术中 出血少（6）集组织止血、解剖、管道永久闭合等功能于一体缺点（1）仅能凝固直径2mm的血管，对超过2mm血管止血时，不如超声刀效果好，切割膜状结构时不如电刀快（2）需要在液态环境下工作，因此需要大量的生理盐水（3）更换器械时，需开/关盐水通路，相对不便,器械,钛夹自动切割吻合器闭合器缝扎内套圈结扎,钛夹,优点（1）可根据需要夹闭直径大小不同的血管，效果可靠（2）对周围组织无损伤缺点（1）价格较贵（2）只用于能游离的血管（3）使用不可吸收的钛夹使体内存留了异物。,缝扎,优点（1）止血可靠，适用于较大的血管或用其他方法无法止血 时（2）组织有切割伤时，可选用缝扎缺点（1）操作困难、费时（2）易致误损伤,卵巢功能评估,Ageing and Ovarian Reserve,Ageing and Ovarian Reserve,Ovarian Reserve Testing,Basal Testing,Day 3 FSHDay 3 EstradiolDay 3 InhibinDay 3 Antimllerian HormoneUltrasound thechniques Antral Follicular Count(AFC)Ovarain VolumeOvarian blood flowAntral Follicle CountOvarian Volume Measurements,Ovarian Reserve Testing,Dynamic Testing,Clomiphene Citrate Challenge Test(CCCT)Exogenous FSH Ovarian Reserve Test(EFORT)GnRH agonist stimulation test(GAST),Ovarian Reserve Testing,Anatomical test-ovarian biopsy,Follicle Stimulating Hormone(FSH),Usually measured Day 2 or 3 of cycleDifferent laboratories different techniques/levelsWomen with 10 IU/l do worseWomen 15 mIU/l on one test do worse on IVFSensitivity 7%and Positive Predictive Value 90,Date,Footer,Serum Oestradiol,E2 alone of little valueSuggested E2 of 80 pg/ml day 3 pre IVF cycle-higher cancellation rateSome attempts to combine E2and FSH levelsOf little valueElevated day 3 levels indicate subtle FSH increases not detected by assayNormal range 300 pM,Date,Footer,Inhibin,Heterodimeric protein 32 kDa similar to AMHSelectively inhibits FSH(TGF-family)Associated with elevated FSH levelsBUT high false positive rateNOT CURENTLTY USEFUL,Date,Footer,Anti-Mullerian hormone(AMH),AMH is a glycoprotein Appears in females at pubertyProduced by granulosa cells of pre-antral and small antral folliclesPhysiological function-prevent excessive follicle recruitmentNot cycle dependant-can be measured any dayLess cycle to cycle variation than FSHNor effected by GnRH agonists-can measure during downregulationClinical role not definitely establishedAMH1.26More promising than other testBUT expensive,Date,Footer,Antral Follicle Count(AFC),Follicles 2 to 5mm on Day 1 or 2Inter-observer variationSome correlation with ovarian response but only at low thresholdIf AFC 5-significantly worse outcomeBefore age of 37-AFC mean yearly decline of 4.8%After age of 37-mean yearly decline of11.7%,Date,Footer,Ovarian vascularity,Trans-vaginal pulse Doppler can assess ovarian blood flowHowever much heterogeneity of techniquesDifferent equipmentVariation in techniqueSome suggestion that high vascularity in late follicular phase good prognostic signNo clinical value at presen3CM2,Date,Footer,Clomiphene citrate challenge test(CCCT),Measure baseline E2,FSH and LH(day 2-3)Administer CC 100mg/day Days 5 to 9Measure E2,FSH and LH on Day 9 to 11Exaggerated FSH after CC bad prognostic signProbably no better than basal FSHOften used for predicting In Vitro Fertilization outcomesPregnancy OR 0.40-0.58 when 10 IU/L on either day 3 or 10Sensitivity 26%and Positive Predictive Value 90+%,Date,Footer,Exogenous FSH ovarian reserve test(EFORT),Baseline E2 and FSHAdminister 300 IU FSHRecheck E 2 24 hours laterOf no proven benefit,Date,Footer,GnRH-agonist stimulation test(GAST)Garcia 1993,Physiological response to GnRH agonist is a flare followed by suppressionLatent impairments of ovarian function may be diagnosed by abnormal responseInsufficient data for clinical use at present,Date,Footer,Ovarian biopsy,Reproductive potential depends on the number primordial follicles in ovarian cortexCounting the number of follicles on ovarian biopsy is an attractive conceptHowever biopsies studied showed a high variation in follicular numbersOf no clinical value,Date,Footer,止血与卵巢功能,结论,两组术后共发生卵巢储备功能下降12例，缝合组4例，电凝组8例 腹腔镜下双侧卵巢内异症囊肿剥除术后可能造成卵巢储备功能下降，对卵巢创面出血的处理，电凝法较单纯缝合法所致卵巢储备功能下降更加明显。,The impact of electrocoagulation on ovarian reserveafter laparoscopic excision of ovarian cysts:a prospective clinical study of 191 patients,Fertil Steril 2009,Result(s):When comparing the bipolar group and ultrasonic scalpel group with the suture group,a statisticallysignificant increase of the mean FSH value was found in bilateral-cyst patients at 1-,3-,6-,and 12-month follow-up evaluations and in unilateral-cyst patients at the 1-month follow-up evaluation.Statistically significant decreases of basal antral follicle number and mean ovarian diameter were found during the 3-,6-,12-month follow-up evaluations as well as statistically significant decreases of peak systolic velocity at all of the follow-up evaluations.Conclusion(s):Electrocoagulation after laparoscopic excision of ovarian cysts is associated with a statistically significant reduction in ovarian reserve,which is partly a consequence of the damage to the ovarian vascular system.,Result(s):Bipolar electrocoagulation resulted in significantly more destruction per burn than the CO2 laser and monopolar lectrocoagulation(287.6 versus 24.0 and 70.0 mm3,respectively).The damage found per lesion was multiplied by the regularly applied number of punctures per procedure in daily practice(based on the literature).Again,the bipolar electrocoagulation resulted in significantly more tissue damage than the CO2 laser and monopolar coagulation(2,876 versus 599 and 700 mm3,respectively).Conclusion(s):Ovarian drilling,especially bipolar electrocoagulation,causes extensive destruction of the ovary.Given the same clinical effectiveness of the various procedures,it is essential to use the lowest possible dose that works;thus,the first choice should be CO2 laser or monopolar electrocoagulation.(Fertil Steril 2010;93:96975.2010 by American Society for Reproductive Medicine.),卵巢打孔术,电针或激光功率 30w每侧打孔：建议4个，可根据患者卵巢大小作个体化处理，但打孔数不宜过多时间：5秒/孔避开卵巢门打孔仅限于进行一次治疗,卵巢功能保护的策略,尽量保留和保护正常的卵巢组织 不要图缝合方便剪除囊壁外看似多余的正常组织 剥离卵巢门部位囊肿壁的要谨慎仔细止血处理尽量避开卵巢门血管尽量减少热损失术前必要的假绝经治疗,值得探讨的问题,手术方式的影响手术时卵巢周期的影响单侧或双侧卵巢内异囊肿的不同基因的研究疾病本身对卵巢功能的影响,衷心感谢！敬请批评指正！,