腹腔镜手术治疗输卵管异位妊娠（图文演示）

LAPAROSCOPIC   SURGICAL   TREATMENT   OF   TUBAL   ECTOPIC   PREGNANCY

中文：
腹腔镜手术治疗输卵管异位妊娠（中文图文）

Authors
O Garbin

Abstract
The description of the laparoscopic surgical treatment of tubal ectopic pregnancy covers all aspects of the surgical procedure used for the management of tubal ectopic pregnancy.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, exploration, conservative treatment, specific cases, laparoscopic salpingectomy, Medical treatment.
Consequently, this operating technique is well standardized for the management of this condition.

1. Introduction
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The developments in ultrasonography, as well as accurate and rapidly available measurements of beta-human chorionic gonadotropin (b-hCG) levels, have modified the diagnosis and management of ectopic pregnancy (EP). Until recently considered a potentially life-threatening surgical emergency, it is now detected earlier and can usually be treated laparoscopically.
The management of EP is unique in the history of laparoscopic surgery: it is one of the first laparoscopic procedures (Bruhat et al., 1980) and Manhès, who developed the technique, was the inventor of the Triton, the first laparoscopic multi-function instrument.
The laparoscopic treatment of EP may be either radical or conservative.
At the same time, medical treatment for EP has become increasingly popular.

2. Anatomy
• Topographical anatomy


The uterine tube is made up of 4 segments:
1. Interstitial or intramural junction
2. Isthmus
3. Ampulla
4. Infundibulum

• Vascular supply

1. Medial tubal artery
2. Lateral tubal artery
3. Uterine artery
4. Ovarian artery
5. Infratubal arch
The vascular supply of the uterine tube is dependent on two arteries: the medial tubal artery (terminal branch of the uterine artery), and the lateral tubal artery (terminal branch of the ovarian artery). These 2 arteries anastomose at the level of the infratubal arch.

• Ectopic pregnancy

Ectopic pregnancy (EP) usually occurs (99% of cases) in the uterine tube (Philippe, 1970). It can be found in:
1. the ampulla (64%);
2. the isthmus (25%);
3. the infundibulum (9%);
4. the intramural junction (2%).
The other localizations are less common: ovarian (0.5%); cervical (0.4%); abdominal (0.1%); intraligamental (0.05%).

3. Indications

At the present time, most cases of EP may be treated surgically via laparoscopy.

Absolute contraindications
Absolute contraindications to laparoscopic treatment are as follows:
- ruptured EP with massive hemoperitoneum and hemodynamic instability;
- surgeon’s lack of experience in laparoscopy.

Relative contraindications
Relative contraindications are as follows:
- multiple previous surgery in the pelvic region;
- unruptured interstitial EP;
- morbid obesity.

4. Radical treatment/other
• Conservative surgery
Conservative surgery for EP (salpingostomy) maximizes the preservation of the affected tube for subsequent fertility. However, it is associated with a risk of EP persistence (5%, Pouly, 1991) and of recurrence.
The decision as to whether to preserve the tube or not depends on several factors:
- the patient’s choice: in patients who do not wish to become pregnant anymore, the logical treatment for EP is salpingectomy combined or not with a contralateral tubal ligation;
- the patient’s previous history: the risk of EP recurrence is high in cases of prior history ipsilateral tubal plasty or after previous history of EP;
- the condition of the ipsilateral and contralateral tubes. In cases of a highly impaired tube, salpingectomy is the treatment of choice.

• Scoring system

Pouly et al. (1991) proposed a therapeutic scoring system of EP mainly based on information provided by the patients.

In patients with no previous history of tubal or infertility surgery and with a healthy contralateral tube, fertility is similar after conservative treatment and after radical treatment (Dubuisson et al.,1996).

5. Preop period
The preoperative workup includes:
- complete blood count;
- blood group serological typing including Rhesus and Kell phenotypes;
- search for immune system antibodies;
- coagulation workup;
- a quantitative assay of b-hCG.

Patient preparation
- fasting, unless emergency;
- bowel preparation by enema, unless emergency;
- shaving of the suprapubic hair;
- premedication: 5 mg midazolam intramuscular injection one hour prior to surgery.

Patient information
The patient should be informed of:
- laparoscopic modalities;
- its risks and complications;
- the risk of conversion to laparotomy;
- the risk of salpingectomy.

6. Operating room set-up
• Patient

- general anesthesia;
- low lithotomy position;
- 30° Trendelenburg;
- thighs and legs stretched apart, buttocks at the distal edge of the table;
- left arm alongside the body;
- urinary catheter necessary throughout operation;
- nasogastric tube;
- uterine cannulation.

• Team

1. The surgeon stands on the patient’s left.
2. The first assistant stands on the patient’s right.
3. The second assistant sits between the patient’s legs.
4. The scrub nurse stands on the surgeon’s left.

• Equipment

1. The first monitor is placed opposite the right foot of the patient. It is used by the surgeon and the first assistant.
2. The second monitor is used by the second assistant and the scrub nurse. It is situated at the level of the patient’s right shoulder.

7. Trocar placement
• Trocar placement

Three trocars are generally sufficient.
A: A 12 mm optical trocar is placed at umbilicus level.
B and C: Two 5 mm lateral operative trocars are placed in suprapubic position 3 fingerbreadths above the symphysis pubis within the inferior epigastric pedicles.

• Fourth trocar

The additional use of a fourth 10 to 12 mm trocar is recommended in cases of: EP of large diameter, active bleeding, massive hemoperitoneum, difficult operative conditions (obesity).
Trocar positioning is then as follows:
- one 12 mm optical trocar at umbilicus level;
- two 5 mm trocars at the level of right and left iliac fossae 2 fingerbreadths within the anterior superior iliac spine;
- one 12 mm trocar 3 fingerbreadths above the symphysis pubis.

• Pneumoperitoneum

The Veress needle may be introduced either at umbilicus level or at Palmer’s point (3 cm below the costal margin on the left midclavicular line). The peritoneal cavity is inflated with CO2 to a pressure which does not exceed 14 mm Hg.

8. Instruments
• Optical

The procedure may be performed using a 0° or 30° laparoscope.

• Operating


• Retractors

Uterine cannulation with an asymmetric grasper

9. Exposure
• Principles

Laparoscopic procedures in gynecology are performed in the pelvic cavity. In supine position, the cavity is naturally filled with part of the small intestinal loops and with the sigmoid colon.
Good exposure of the lesser pelvis may be obtained by:
- Trendelenburg position,
- uterine cannulation.
Warning: uterine cannulation should only performed if an intrauterine pregnancy has been ruled out.

• Trendelenburg position

It causes the small intestinal loops and the sigmoid loop to move cephalad, thereby exposing the pelvis. Its angle should not exceed 30°.

• Uterine manipulation
• Principle


The uterus is anteverted in order to expose the rectouterine pouch. It is also displaced towards the side contralateral to the ectopic pregnancy, freeing the adnexa requiring treatment.

• Instruments

The cannulation may be performed using diverse instruments.
1. A Cohen cannula, with which a methylene blue test can be performed. It cannulates only the cervical canal and does not allow for proper mobilization of the uterus;
2. A blunt curette placed in the uterine cavity after dilation, coupled with 2 Pozzi graspers placed on the anterior and posterior labia of the cervix;
3. An asymmetric grasper.

• Exposure

The first assistant holds the laparoscope, pushes the small intestinal loops cephalad and maintains the sigmoid loop cephalad using a flat fenestrated grasping forceps.
The second assistant anteverts the uterus and pushes it to the side contralateral to the EP.