Continuing Education Column The Application of Endoscopic Surgery to Gynecologic Conditions Ki Hyun Park, M.D. Department of Obstetrics & Gynecology Y

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1 The Application of Endoscopic Surgery to Gynecologic Conditions Ki Hyun Park, M.D. Department of Obstetrics & Gynecology Yonsei University College of Medicine, Severance Hospital E mail : kh8730@yumc.yonsei.ac.kr Eun Hee Yoo, M.D. Department of Obstetrics & Gynecology Ewha Womans University College of Medicine, Tongdaemun Hospital E mail : helpman@ewha.ac.kr Abstract The advancements in optics, video technologies and endoscopic instrumentations have led to the expansion of endoscopy into the current therapeutic surgical practice of benign and malignant gynecologic conditions. So, minimally invasive and organpreserving surgery can be performed in terms of organ-specific difficulties in the field of gynecology instead of conventional surgical techniques that require laparotomy and uterotomy. Also, the recent introduction of computeraided instruments seems to have the potential to revolutionize endoscopic surgery. Major advantages of an endoscopic surgery include minimization of patient discomfort and analgesics requirements, a short period of hospitalization, rapid recuperation, superior cosmetics, easier intraoperative access to the pelvic floor, culde sac and intrauterine cavity, less blood loss and less postoperative adhesion. Today every gynecologists should have the knowledge and skill of the endoscopic surgery in order to gain great benefits from endoscopic surgery. In this article, recent advancements in the endoscopic surgery of gynecological conditions are reviewed. Keywords : Endoscopic surgery; Laparoscopy; Hysteroscopy 437

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Pre operative assessment Ultrasound CA125 Menopausal status Obvious malignancy Ascites, omental cake Postmenopausal with elevated CA125 or suspicious ultrasound Moderate risk of malignancy Low risk

8 Pre operative assessment Ultrasound CA125 Menopausal status Obvious malignancy Ascites, omental cake Postmenopausal with elevated CA125 or suspicious ultrasound Moderate risk of malignancy Low risk of malignancy Large mass, mostly solid Refer to gynecologic oncologist for laparotomy +/- staging or laparoscopic assessment in selected cases. suspicious Discontinue procedure and reschedule definitive surgery. Continue with surgery only if facilities for frozen section and immediate staging are available. Laparoscopic assessment and washings Not suspicious Laparoscopic assessment and washings Continue laparoscopic cysectomy, oophorectomy etc. 444

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10 Type O Type I Type II Type III Type IV Laparoscopicdirected preparation for vaginal hysterectomy Occlusion and division of at least one ovarian pedicle, but not including uterine artery(ies) Type I plus occlusion and division of the uterine artery, unilateral or bilateral Type II plus a portion of the cardinal-uterosacral ligament complex, unilateral or bilateral Complete detachment of cardinal-uterosacral ligament complex, unilateral or bilateral, with or without entry into the vagina Type LSH Occlusion and division of at least one ovarian artery with or without dissection to, but not including, uterine arteries Type LSH LSH I plus occlusion of uterine artery(ies) Type LSH LSH II plus division of uterine artery(ies) 446

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14 1. Technique Method 2., 10 cm Endometrial ablation Nd: YAG laser 3. hysteroscopic Electrosurgical ball Vaporizing electrode 4. Endometrial ablation Cryoablation 5. nonhysteroscopic, Thermal ballon ablation 6. or global VestaBlate system Hydrothermal ablation Endometrial resection, Transcervical resection hysteroscopic of endometrium Endomyometrial resection 450

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16 10. Vergote I, De Brabanterb J, Fylesc A, Bertelsend K, Einhorne N, Tropea CG, et al. Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. Lancet 2001 ; 357 : VanDam PA, DeCloedt J, Tjalma A, Buytaert P, Becquart D, Vergote I. Trocar implantation metastasis after laparoscopy in patients with advanced ovarian cancer : Can the risk be re- Am J Obstet Gynecol 1999 ; 181 : duced? Hulka JF, Reich H, eds. Textbook of laparoscopy. 2nd ed. Philadelphia : WB Saunders, 1994 : Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989 ; 5 : Baggish MS, Barbot J, et al. eds. Diagnostic and operative hysteroscopy. 2nd ed. St. Louis : Mosby, 1999 : Palter SF, Olive DL. Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Am Assoc Gynec Laparosc 1996 ; 3 : Campo R, Gordts S, Rombauts L, Brosens I. Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility. Fertil Steril 1999 ; 71 : Sueoka K, Asada H, Tsuchiya S, Kobayashi N, Kuroshima M, Yoshimura Y. Falloposcopic tuboplasty for bilateral tubal occlusion. A novel infertility as an alternative for invitro fertilization? Hum Reprod 1998 ; 13 : Wood GP. Laparoscopic examination of the normal infertile woman. Obstet Gynecol 1983 ; 62 : Kresch AJ, Seifer DB, Sachs LB, Barrese I. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 1984 ; 64 : Tulandi T, Sammour A. Evidence based management of ectopic pregnancy. Curr Opin Obstet Gynecol 2000 ; 12 : Fayez JA. An asessment of the role of operative laparoscopy in tuboplasty. Fertil Steril 1983 ; 39 : Yoon TK, Sung HR, Cha SH, Lee CN, Cha KY. Fertility outcome after laparoscopic microsurgical tubal anastomosis. Fertil Steril 1997 ; 67 : Dessolle L, Soriano D, Poncelet C, Benifla JL, Madelenat P, Darai E. Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for infertility. Fertil Steril 2001 ; 76 : Doridot V, Dubuisson JB, Chapron C, Fauconnier A, Babaki- Fard K. Recurrence of leiomyomata after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001 ; 8 : Nezhat C, Nezhat F, Bess O, Nezhat CH, Mashiach R. Laparoscopically assisted myomectomy : a report of a new technique in 57 cases. Int J Fertil Menopausal Stud 1994 ; 39 : Wang CJ, Yen CF, Lee CL, Soong YK. Laparoscopic assisted vaginal myomectomy. J Am Assoc Gynecol Laparosc 2000 ; 7 : Olive DL, Parker WH, Cooper JM, Levine RL. The AAGL classification system for laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 2000 ; 7(1) : Wattiez A, Canis M, Mage G, Pouly JL, Bruhat MA. Promontofixation for the treatment of prolapse. Urol Clin North Am 2001 ; 28 : Esposito C, Garipoli V, Di Matteo G, De Pasquale M. Laparoscopic management of ovarian cysts in newborns. Surg Endosc 1998 ; 12 :

17 21. Fatum M, Rojansky N. Laparoscopic surgery during pregnancy. Obstet Gynecol Surv 2001 ; 56 : Dargent DF. Laparoscopic surgery in gynecologic oncology. Surg Clin Nor Am 2001 ; 81 : Magrina JF. Laparoscopic surgery for gynecologic cancers. Clin Obstet Gynecol 2000 ; 43 : Emanuel MH, Wamsteker K, Hart AA, Metz G, Lammes FB. Longterm results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol 1999 ; 93 : Lewis BV, Magos AL. Endometrial ablation. 1st ed. New York : Churchill livingstone, 1993 : Ballantyne GH. Robotic surgery, telerobotic surgery, telepresence, and telementoring. Surg Endosc 2002 ; 116 :

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황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic