在卵巢子宫内膜异位症腹腔镜膀胱切除术期间优化卵巢储备的手术技术
1Department of Obstetrics & Gynecology and Women’s Health,Montefiore Medical Center, 2Albert Einstein College of Medicine, 3Department of OB/GYN, 1400 Pelham Pkwy S,Jacobi Medical Center, 4Division of Minimally Invasive Gynecologic Surgery, Department of OB/GYN,Jacobi Medical Center, 5Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology and Women’s Health,Montefiore Medical Center
Summary
该协议介绍了腹腔镜切除卵巢子宫内膜异位症的技术，在保留电外科手术的情况下进行粘连溶解，以及采用术中色术插管来评估生殖道通畅性。这种系统的方法将促进最佳的子宫内膜异位症管理，指导伴随的附件手术，并增强术后生育结果。
Abstract
对于希望生育能力的患者，卵巢子宫内膜异位症的手术治疗变得复杂，因为需要平衡疾病的最大切除术与努力挽救正常的卵巢皮层。输卵管解剖结构的优化是另一个常见的考虑因素。卵巢子宫内膜异位瘤膀胱切除术时的保留生育力的腹腔镜技术旨在限制对卵巢皮层的医源性手术损伤，并战略性地评估和应对生殖道通畅性。手术候选人经常希望缓解子宫内膜异位症相关的疼痛，同时也寻求优化自发或辅助受孕率。手术获益包括子宫内膜异位症的手术和组织病理学诊断、生殖道通畅性评估以及可视病变的治疗。然而，卵巢子宫内膜异位症的切除术会带来重大风险，包括手术损伤、失血、术后卵巢储备下降和术后炎症伴粘连形成，这两者都可能损害卵泡生成。
我们介绍了一名32岁的女性的病例，她患有已知的子宫内膜异位症，并且持续疼痛对药物管理无效，她选择手术治疗她的疾病，以优化她未来受孕的机会。以这个案例为例，我们描述了诊断性腹腔镜检查，粘连溶解，卵巢膀胱切除术，染色输卵管插管和输卵管切除术的技术和注意事项，重点是保持生育能力保存的方法。
Introduction
子宫内膜异位症是一种慢性炎症性疾病，由异位子宫内膜组织1定义。子宫内膜异位症患者通常表现为与异位着床部位相关的疼痛相关主诉和器官功能障碍，其可能位于身体的任何地方，但通常在骨盆内2，3。卵巢子宫内膜异位症，其中子宫内膜异位症的囊肿在卵巢内形成，通过多种方式导致生育力减退，包括卵巢卵泡池的消耗，促进炎症环境，黄体酮抵抗以及卵巢释放和捕获受损4。受累患者在就诊时经常有卵巢储备减少，手术后卵泡池进一步耗尽5，6。具有异位子宫内膜组织部位的周期性出血导致炎症和明显的粘连，这可能会损害卵子的拾取和运输，受精和胚胎通过7，8，9。异常的炎症环境也可能损害卵泡生成和早期胚胎发育10，11。
在实际手术水平上，由此产生的粘连经常会消除正常缺血的手术平面，使患者面临手术时间延长、失血和手术损伤的风险增加。希望未来生育的患者的手术管理提出了额外的挑战，最显着的是输卵管和卵巢医源性损伤的风险，损害输卵管通畅性或卵巢储备12，13，14。然而，子宫内膜异位症的手术切除也提供了一个独特的机会，可以潜在地诊断，评估和治疗已发现的病变，包括优化生育能力15。
我们详细介绍了我们治疗希望未来生育能力的患者卵巢子宫内膜异位症的方法。与剖腹手术相比，我们强烈支持腹腔镜方法，以增强术后效果，包括减少疼痛，缩短住院时间和更快恢复16。该协议优先考虑卵巢子宫内膜异位瘤的切除而不是引流和消融，因为它在囊肿复发，疼痛复发和自发妊娠方面提供了更有利的结果17，18，19，20。此外，它允许标本检索用于组织学。我们通过剥离技术切除卵巢子宫内膜异位症，并具有有限的电外科能量应用。尽管如此，已经描述了许多用于卵巢子宫内膜异位症管理的专用工具，并且对于希望未来生育的患者存在多种可接受的手术方法。无论采用何种特定技术，本方案中描述的考虑因素和手术原理都适用于所有希望进行生育优化手术的子宫内膜异位症患者。
下面描述的方案用于护理一名32岁的女性，该女性患有慢性盆腔疼痛和组织学证明的子宫内膜异位症，在先前的腹腔镜检查中发现，在此期间子宫内膜异位症被完全切除。她赞同一线药物治疗难治性疼痛，并对未来的生育能力感兴趣，尽管没有积极尝试自发受孕。她被认为是微创手术切除的候选人，并接受了麻醉，诊断性腹腔镜检查，粘连裂解，卵巢膀胱切除术，染色手术插管和输卵管切除术的检查。她的手术和康复并不复杂。
Protocol
所描述的患者为出于教育和科学目的使用和发布医疗数据，手术视频和相关图像提供了书面知情同意书。以下协议符合Montefiore医疗中心和纽约市卫生和医院公司的人类研究伦理委员会指南。 由于可用原始记录的限制，并非该协议中的每个步骤都可以完全记录在该患者的视频中。 1. 术前评估 注意：选择适合进行微创手术切…
Representative Results
表1 显示了我们患者示例的结果。从麻醉诱导到拔管的总手术时间为251分钟，估计失血量为200 mL。恢复期并不复杂。由于她希望将来怀孕远离手术时间，她开始口服避孕药。组织病理学检查显示右输卵管积水伴视管旁囊肿、双侧子宫内膜异位症（4.5 cm 和 3.7 cm）和卵巢组织。 该手术结合了保留生育力和优化生育能力的方法，用于卵巢子宫内膜异位症的腹腔镜膀胱?…
Discussion
被诊断为子宫内膜异位症的患者通常报告疼痛或植入物相关的器官功能障碍，包括不孕症。高达50%的子宫内膜异位症患者符合不孕症标准23。卵巢储备，通过AMH水平，月经周围的FSH水平或窦卵泡计数测量，用于预测患者对促性腺激素刺激的反应。已知子宫内膜异位症的手术治疗会减少卵巢储备23。然而，即使保守治疗，子宫内膜异位症患者的卵巢储备继续下降<su…
Disclosures
The authors have nothing to disclose.
Acknowledgements
没有。
Materials
| Basic laparoscopy | |||
| 1L bag 0.9% NaCl solution | Suction irrigation, hemostasis, lysis of adhesions | ||
| 1-10% povidone-iodine | Sterile prep | ||
| 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin | Sterile prep | ||
| 4% chlorhexidine gluconate | Sterile prep | ||
| 5mm laparoscopic trocar and sleeve x 3 | Covidien | ONB5STF | Diagnostic laparoscopy |
| 12mm laparoscopic trocar and sleeve | Covidien | ONB12STF | Diagnostic laparoscopy and larger size facilitates specimen retrieval bag |
| CO2 insufflator | Stryker | 620-040-504 | Diagnostic laparoscopy |
| CO2 insufflator tubing | Stryker | 620-030-201 | Diagnostic laparoscopy |
| Electrosurgical generator | Covidien | VLFT10GEN | Diagnostic laparoscopy |
| Foley kit and urometer bag | Bard | 153214 | Diagnostic laparoscopy |
| Laparoscopic scope, 5mm 0 degree | Olympus | WA4KL500 | Diagnostic laparoscopy |
| Laparoscopic scope, 5mm 30 degree | Olympus | WA4KL530 | Diagnostic laparoscopy |
| Laparoscopic suction irrigation pool tip | Stryker | 250-070-406 | Suction irrigation, hemostasis, lysis of adhesions |
| StrykeFlow II suction irrigator | Stryker | 250-070-500 | Suction irrigation, hemostasis, lysis of adhesions |
| Suction tubing | Stryker | 250-070-403 | Suction irrigation, hemostasis, lysis of adhesions |
| Suction/vacuum source | Suction irrigation, hemostasis, lysis of adhesions | ||
| Cystectomy and Salpingectomy | |||
| 10mm tissue retrieval bag | Covidien | 173050G | Specimen retrieval bag to be used in 12mm laparoscopic trocar site |
| Atraumatic laparoscopic bowel graspers | Stryker | 250-080-319 | Lysis of adhesions, cystectomy, salpingectomy |
| Bipolar Cord | Stryker | 250-040-016 | Lysis of adhesions, cystectomy, salpingectomy |
| Endopeanut laparoscopic retractor | Covidien | 173019 | Lysis of adhesions, cystectomy, salpingectomy |
| Harmonic ACE +7 ultrasonic shears | Ethicon | HARH23 | Lysis of adhesions, cystectomy, salpingectomy |
| Laparoscopic bipolar grasping forceps | Karl Storz | 38951 MD | Lysis of adhesions, cystectomy, salpingectomy |
| Laparoscopic curved Metzenbaum scissors | Stryker | 250-080-267 | Lysis of adhesions, cystectomy, salpingectomy |
| Ultrasonic generator unit | Ethicon | GEN11 | Lysis of adhesions, cystectomy, salpingectomy |
| Vasopressin solution (20 units in 50 to 100cc of injectable saline) | Cystectomy | ||
| Chromopertubation | |||
| 10mg methylene blue in 150mL 0.9% NaCl solution | Pigmented solution for chromopertubation | ||
| ZUMI uterine manipulator/injector | Cooper Surgical | ZSI1151 | Chromopertubation, diagnostic laparoscopy, lysis of adhesions |
| Hemostatic agents | |||
| Arista absorbable hemostatic particles 3g | Bard Davol | SM0002-USA | Hemostatic agent |
| Floseal gelatin thrombin matrix 5ml | Baxter | ADS201844 | Hemostatic agent |
| 10mm tissue retrieval bag | Covidien | 173050G | |
| Arista absorbable hemostatic particles 3g | Bard Davol | SM0002-USA | Hemostatic agent |
| Atraumatic laparoscopic bowel graspers | Stryker | 250-080-319 | |
| Endopeanut laparoscopic retractor | Covidien | 173019 | |
| Floseal gelatin thrombin matrix 5ml | Baxter | ADS201844 | Hemostatic agent |
| Harmonic ACE +7 ultrasonic shears | Ethicon | HARH23 | |
| Laparoscopic bipolar grasping forceps | Karl Storz | 38951 MD | |
| Laparoscopic curved Metzenbaum scissors | Stryker | 250-080-267 | |
| Methylene blue 10mg in 150mL 0.9% NaCl solution | For chromopertubation | ||
| ZUMI uterine manipulator/injector | Cooper Surgical | ZSI1151 | For uterine manipulation and chromopertubation |
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Cite This Article
Saturnino, K., Obanor, O., Arvizo, C., Gingold, J. A. Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma. J. Vis. Exp. (179), e62742, doi:10.3791/62742 (2022).