腹腔镜皮样卵巢囊肿切除术【视频+英文讲义】

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Laparoscopic Dermoid Ovarian Cystectomy

Mature cystic teratomas, often referred to as dermoid cysts, would be the most common germ cell tumors with the ovary. Within the recent years, trans vaginal sonographic carried out ovarian dermoid cysts along with laparoscopic approach have greatly improved the treatment of this benign lesion. We retrospectively reviewed the results of laparoscopic surgery for suspected ovarian dermoid cysts. A typical benign tumour that appears by having an ovary is really a dermoid cyst. Dermoid cysts originated from primitive skin tissues which has been within the ovary from birth. The fluid inside is sebaceous material, as with a blackhead, and quite often contains hair. Dermoid cysts are more common in ladies, sometimes in the ovaries. Many questions come to mind regarding by using a laparoscopic procedure. A few of the more frequent will be addressed and answered. It usually is better to consult an accredited healthcare professional immediately in case you experience any of the symptoms which can be regarded as a crisis.

How dermoid cyst form and is it dangerous?

Benign cystic teratoma, or as commonly addressed dermoid cysts, are basically germ cell tumors of the ovary. Pathologically, they are enrolled under group of benign mature teratomatas. They account for about 20 - 25% of all ovarian. The prevalence of malignant transformation in dermoid cysts has been reported as 1- 3 %. Most of dermoid cysts occur without significant clinical symptoms and they are often discovered incidentally during pelvic examination or routine ultrasound.

What are the advantage of laparoscopic dermoid cyst?

The phobia of spillage complications existed for too long time up to now challenged by many laparoscopists. Accordingly, laparoscopic approach is becoming increasingly accepted plus much more commonly adopted since 1989. Since the majority of cases with benign cystic teratoma are of reproductive age and even preserve fertility, a conservative approach is good to minimize post operative adhesions thereby decrease chances to compromise fertility.

Trained endoscopic surgeons became well informed to approach dermoid cysts via endoscopic rout and reported satisfactory results with out complications. Inside our study, we appraise the safety and efficacy of laparoscopic control over benign cystic teratoma and present some guidelines and tricks to improve connection between surgery and avoid possible complications that may derive from cyst spillage. We at World Laparoscopy Hospital demonstrated that the usage of endobag creates satisfactory and easy elimination of content of dermoid cyst.

What is the operative technique of laparoscopic ovarian dermoid cystectomy?

Access is done either by open technique or by veress needle technique It is recommended against steep Trenedelenberg's position to avoid any potential for migration of spilled material of dermoid cyst to upper abdomen during laparoscopic surgery. This could be little awkward during minimal access surgery but we atone for this by proper bowel retraction and positioning of bowels to upper abdomen with all the fan retractor or nathanson retractor. After obtaining clear view for pelvis, surgeon should do lysis of the existing adhesions allowing free mobilization and dissection of the dermoid ovarian cysts. In cases designed for laparoscopic dermoid ovarian cystectomy, according to dissection and electro surgical dissection principle applied the policies recommended by Dr R . K. Mishra.

The gynecologist should add some modifications from side to facilitate surgery and add safety just in case any spillage happen. A grasper forceps or striker mini alligator was utilized to use traction on ovarian ligament and steady the ovary. Combined uterine manipulation plus grasping ovarian ligament allows keeping the cysts on ovaries steady during steps of cystectomy. It was facilitated by squeezing the ovary between body of uterus and lateral pelvic wall to take care of steady and accessible dissection from the cyst. First, cleavage plane is made by diathermy spatula or Maryland's forceps. A ovarian cystic plane is widened between cyst capsule and stroma of the ovary and hydro dissection continue the enucleation steadily. Combined hydro dissection and with blunt pealing of capsule with the help of maryland will complete the job easily. Gynecologists use laparoscopic harmonic scalpel sometime and cutting coagulation forceps occasionally for dissection and hemostats. It possesses a great value for multifunction since its narrow tip allows precise dissection of cyst capsule, also grasping and traction featuring its serrated edge was quite secure.

The blade of harmonic scalpel or with the maryland instrument allows mono polar coagulation from a bleeding points combined with its sharp scissors on its proximal end of the blade which was useful for precise incision of tissues. Actually, it saves time which may be consumed for exchanging instruments as well as preserves the pneumoperitoneum stable throughout surgery. Grasping the perimeters with the cyst and slaw traction apart will undress the cyst capsule and provide the dermoid from its bed. Eventually, the cysts were enucleated easily and haemostasis was performed for any bleeding spots encountered during dissection. Because of thick nature of dermoid cyst capsule, blunt dissection and pealing was rather easy and risk of cyst puncture was seldom occurring if keeping in proper tissue planes. In the event that spillage occurs, we immediately turn to vigorous jet wash suction irrigation using warm ringer's solution. Jet irrigation dislodge and clear any sticky debris from surface of peritoneum and push them towards cul de sac. Gynecologist should use suction irrigation canulae simultaneously from both secondary puncture sites. The evacuated dermoid cyst, together with its contents were shelled out from normal ovarian tissues and removed via trocar sleeve.

You can use Ethicon endobag or nicely prepared gloves endobag to contain the cysts prior to its aspiration or puncture. In this method, the dermoid cyst should be placed in the impermeable bag and only then punctured and aspirated while contained inside the protective good quality endo bag. Any spillage dermoid content material should be securely contained inside the endobag to avoid any risk of spilled material. If spillage occur then copious lavage should done.

What are the complications of dermoid cyst?

The chance of complications like torsion, spontaneous rupture, risk of chemical peritonitis, and malignancy usually makes surgical procedures quite necessary upon diagnosis. Most operative textbooks describe classical treatment for dermoid cysts are already ovarian cystectomy or oophrectomy through laparotomy with utmost choose to avoid spillage of cyst contents. Although laparoscopic surgery has replaced many standard laparotomy techniques, however many skeptical opinions were hesitant about role of laparoscopic surgery for dermoid cyst removal. The opportunity anxiety about spillage of cyst material and possible progression of chemical peritonitis imposed fears of adopting laparoscopic approach.

Conclusion of laparoscopic dermoid ovarian cystectomy?

Using strict adherence to guidelines for preoperative clinical assessment and intra-operative management, laparoscopic management of dermoid cysts appears to be a safe and secure procedure.