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 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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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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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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