As human civilization is moving into the 21st century, medical development has also entered a new era. With the improvement of science and technology and medical level, medical treatment has not only been limited to cure diseases, but also how to reduce complications during treatment, how to make gynecological surgery truly remove only lesions without damaging normal tissues, and how to prevent diseases from occurring fundamentally, which has become a higher pursuit of medical quality today. Minimally invasive means to achieve the purpose of curing the disease with the least trauma and the best treatment. In the past 10 to 20 years, the indications for cervical surgery in line with the concept of minimally invasive have been broadened and surgical skills have been improved, and the application of technologies such as cervical LEEP knife and cervical cold knife conization for cervical lesions has realized the desire of patients to “cure big diseases without knife or small knife”. “surgery has gradually reduced. In some developed countries and some hospitals in China, more than 80% of open surgeries have been replaced by minimally invasive surgical methods.
Minimally invasive”, as the name implies, means minimizing the damage to normal tissues and minimizing the impact of surgery on the function of all systems. Minimally invasive gynecological surgery relies on the increasing popularity of laparoscopic technology and the continuous improvement of negative gynecological surgery technology. Experts from Guangzhou Renai Hospital provide professional answers to help you fully understand the considerations of minimally invasive gynecological surgery.
In most people’s impression, gynecological surgery is associated with a horizontal or vertical incision in the lower abdomen. Nowadays, with the continuous improvement of gynecological operation technology and the application of new instruments in clinical practice, gynecological surgery is developing in the direction of minimally invasive surgery. Minimally invasive”, as the name implies, means minimizing the damage to normal tissues and minimizing the impact of surgery on the function of all systems. Minimally invasive gynecological surgery relies on the increasing popularity of hysterolaparoscopic technology and the continuous improvement of negative gynecological surgery techniques.
Types of minimally invasive surgery:
1. minimally invasive laparoscopy
Laparoscopic surgery Laparoscopic surgery is an operation performed by a doctor using special laparoscopic instruments that integrate optical, computer, ultrasound and mechanical technologies. The basic procedure of the surgery is: after the patient is anesthetized, the doctor punches 3 to 4 small holes of 0.5 to 1 cm in diameter in the patient’s abdominal wall, and a mirror is placed in one of the holes. The mirror is connected to the TV screen through a miniature camera, making the lesion in the patient’s abdominal cavity reflected on the TV screen at a glance. While several other small holes in the abdominal wall are placed scissors, forceps and other surgical instruments, the doctor looks at the screen to perform the surgery. The surgical procedure is basically the same as open surgery, because the mirror has the role of magnification 8 to 10 times, and can even do more fine than open surgery, the doctor looked at the screen to the lesion of the tissue for a series of operations such as clamping, cutting, suturing. At the same time, the application of advanced technologies such as electric knife, argon knife, laser and microwave in the operation makes the operation more perfect. Finally, the excised mass is placed in a plastic bag and shredded and removed, or removed directly from the vagina.
Laparoscopic surgery can treat the following gynecological diseases: uterine fibroids, uterine fibroids, ovarian tumors, ovarian teratomas, endometriosis, endometrial cancer, ectopic pregnancy, infertility, etc.
2.Minimally invasive hysteroscopy
In the treatment of uterine fibroids, patients with subplasmic fibroids or interstitial fibroids should opt for myomectomy, and patients with multiple fibroids and combined cervical lesions should opt for hysterectomy. In our previous laparoscopic hysterectomy, the largest uterus removed weighed 1700 grams, which is approximately the size of a 6-month pregnant uterus. In contrast, in laparoscopic myomectomy, up to 15 large and small fibroids were peeled off, achieving the goal of open surgery.
Hysteroscopy Hysteroscopy works basically the same as laparoscopy, and the procedure is as follows: after the patient is anesthetized, the doctor puts the hysteroscope through the patient’s vagina and cervical canal, which is connected to the TV screen through a miniature camera; and then the doctor looks at the screen and performs the surgical operation through the cutting instruments of the hysteroscope; finally, the removed mass or lesion is removed from the vagina through the cervical opening with forceps, leaving no surgical scar on the abdomen.
Diseases suitable for hysteroscopic surgery: submucosal fibroids (type 0, type 1, type 2), functional uterine bleeding, longitudinal uterine septum, endometrial polyps, decomposition of uterine adhesions, etc., infertility caused by blocked fallopian tubes, removal of broken and displaced birth control rings, etc. These types of surgeries in our hospital are basically done under the hysteroscope.
3.Vaginal surgery
It has the advantages of less trauma, less intestinal interference, less postoperative pain, faster recovery, and no surgical scar on the abdomen, and can be performed simultaneously with adnexal resection, anterior and posterior vaginal wall repair, urethroplasty, and vaginal tightening. In clinical application, most hospitals are limited to performing yin hysterectomy for uterine prolapse, mainly because of narrow surgical field, difficult to grasp indications and contraindications; lack of deep operating skills and applicable surgical instruments by doctors; and lack of knowledge of patients about the choice of surgical methods. With the development of laparoscopy, which opens up the surgeon’s field of vision and enables direct understanding of the intra-abdominal cavity, the scope of cathartic hysterectomy with the assistance of laparoscopy continues to expand.
Negative surgery can treat the following gynecological diseases: uterus with no obvious adhesions to the pelvis, good uterine mobility, diseased uterus that needs to be removed, such as uterine fibroids, uterine myomas, uterine adenopathy, endometrial lesions and tension incontinence.
Benefits of minimally invasive gynecological surgical treatment:
There are many types of minimally invasive gynecological surgery and the benefits are obvious, so it has now become the first treatment method for many women. These include the advantages of less trauma, faster recovery, and smaller post-operative scars.
Minimally invasive laparoscopic gynecologic surgery is the gold standard for the diagnosis of some gynecologic diseases. Such as pelvic inflammatory disease, ectopic pregnancy, endometriosis, etc.
This minimally invasive gynecological surgery takes into account both diagnosis and treatment. For example, in early tubal pregnancy (ectopic pregnancy) without rupture and bleeding, the symptoms are not typical for early diagnosis, but the lesion can be detected laparoscopically, while conservative surgery is performed to preserve the fallopian tube and function on the side of the lesion.
Quick recovery after surgery. Minimally invasive gynecological surgery is performed through perforated holes (5mm-10mm in diameter, 3-4 in total) in the abdominal wall, with surgical instruments inserted outside the abdominal cavity, which causes little disturbance to the pelvic and abdominal environment. Postoperative discomfort is light. There is no long incision in the abdominal wall, so the pain after minimally invasive gynecological surgery is light, and you can eat normally after surgery and keep the catheter for a short time. The first day after surgery can be appropriate activities, and the time for infusion of fluids and medication are shorter than that of open surgery.
The method of minimally invasive gynecological surgery is clinically applicable to acute abdominal pain and uterine perforation. (non-emergency) chronic pelvic pain, infertility. Indications for therapeutic minimally invasive gynecological surgery: tubal ligation, ectopic pregnancy, endometriosis, ovarian endometriotic cysts, benign ovarian teratoma, ovarian cysts, myomectomy, hysterectomy, some malignant tumors in gynecology, etc.
Decrease in medical costs for hospitalization days. Minimally invasive gynecological surgery can be discharged in 3 to 4 days without special circumstances. No obvious scars after abdominal wall surgery to achieve cosmetic effect, less pelvic and abdominal adhesions after surgery, and light impact on fertility. These are the benefits of minimally invasive gynecological surgery treatment. It should be reminded that the surgery must be performed in a large hospital with qualifications and good conditions.
Avoid misunderstandings and choose minimally invasive gynecological surgery correctly
1.The premise of minimally invasive
Minimally invasive, is a concept, not a specific type of surgery. It generally refers to the advantages of such surgery such as less trauma, less bleeding, less pain and faster recovery. In this regard, it is itself the basic concept and abiding principle of surgery. If minimally invasive surgery is to be achieved, the key is to choose the right surgical route and surgical modality. For example, gynecological surgery has 3 kinds of trails: open, transvaginal and lumpectomy. For a certain disease, all 3 kinds of trails may be available, while for the treatment of some other diseases it may not be suitable or difficult to use a certain route, so the choice of surgical entry trails and modalities is particularly important.
2. Selecting the access path: In addition to decision making, the access path is the first step of surgery and best reflects the concept of minimally invasive surgery. The impact on the body can usually be considered to be transvaginal – endoscopic – open from the smallest to the largest. For example, a hysterectomy that is not very large, if it can be done vaginally, does not need to be open and can even be done without laparoscopic assistance. For slightly more difficult adnexal problems, laparoscopic-assisted hysterectomy can be performed. Open hysterectomy is preferred for very large uteri. Of course, the surgical approach should be individualized, considering first transvaginal, then endoscopic, and finally open.
Choice of procedure – Surgery is aimed at removing the lesion, but it is not better to have a larger and more extensive resection. A typical example is surgery for vulvar cancer. The traditional extensive vulvectomy and double inguinal lymph node dissection form a “big butterfly” incision and trauma, which causes great damage and delayed healing is very common. Later, it was modified to “three incisions” and focused mainly on the superficial femoral triangle when performing inguinal lymph node dissection. If the anterior lymph nodes are negative, the operation will not be expanded and pelvic lymph node dissection will not be performed to reduce the damage and achieve better results.
The concept of minimally invasive is always present in the surgery, which is reflected in the cut and sewing, one move after another. When we perform microsurgery or endoscopic surgery, we often mention several technical principles, such as keeping it moist, keeping it bloodless, keeping it clear, keeping it gentle, and keeping it fast, which are fundamentally aimed at keeping it minimally invasive. Therefore, these technical principles are also suitable for any surgical procedure
3.The scope of minimally invasive
Since minimally invasive is a concept and a principle, it is difficult to define what is minimally invasive and what is massively invasive, but some categories can still be broadly classified.
Transvaginal surgery – Except for vaginal surgery, any pelvic surgery that can be performed vaginally is considered to be minimally invasive. Today, the following procedures can be performed transvaginally
(1) Hysterectomy, preferably less than 10 weeks of gestation; it is not appropriate in cases of combined adnexal masses or where malignancy cannot be excluded.
(2) Uterine fibroid removal, preferably with a single fibroid in the anterior and posterior walls.
(3) Tubal sterilization, which is convenient.
(4) Surgery for pelvic organ prolapse and stress urinary incontinence.
(5) Gynecologic oncologic surgery, with cervical cancer surgery being the most challenging. More than a hundred years have passed since the extensive transvaginal hysterectomy. Due to the updated concept and the application of laparoscopy, in recent years, there are radical cervical hysterectomy with preservation of uterus and extensive transvaginal hysterectomy and pelvic lymph node dissection assisted by laparoscopy, so that a brand-new idea and operation style of cervical cancer surgery has appeared.
Endoscopic surgery – Endoscopic surgery is gradually becoming the basic mode of gynecological surgery.
4.Application of laparoscopic surgery.
(1) Laparoscopy is a surgery with clear superiority, including diagnosis and treatment of gynecological emergency abdomen, pelvic masses or benign ovarian cysts, and laparoscopic examination and surgery for endometriosis.
(2) Optional laparoscopic surgeries, mainly hysterectomy, uterine fibroid removal, tubal anastomosis and peritoneal method artificial vaginoplasty, benign ovarian tumor in pregnancy, endometrial cancer surgery, radical cervical cancer surgery, pelvic floor reconstruction, etc. Applications of hysteroscopic surgery: transcervical endometrial resection (for abnormal uterine bleeding), polypectomy, etc. Now there are new energy systems for endometrial removal such as microscopic official cavity imaging and thermal ball, as well as tubal microscopy and operation developed by transcervical cavity. In addition, there are minimally invasive techniques such as ultrasound intervention, radiological intervention and high-energy ultrasound focused therapy. Some new energy systems have also been used in gynecological surgery, complementing traditional knives, scissors and forceps. Conventional weapons” complement each other, such as radiofrequency ablation, hydrogen helium knife, ultrasonic knife, vascular closure system, etc.
5.Indications for minimally invasive surgery
Since minimally invasive is a concept and a principle, it is applicable to any surgery. However, what is emphasized here is the selection of the target and the operator of the surgery, in order to truly achieve the purpose of minimally invasive. The selection of indications is actually a matter of 4 elements, i.e., the patient and his disease, the operator and his surgical procedure, which must fit perfectly to be a good choice, otherwise the choice should be changed or adjusted. For example, if the management of a disease is not suitable for this procedure, or even for this operator, the procedure should be changed, or a more suitable operator should be invited to perform the procedure, not forcibly. No surgical technique or surgeon should use surgery as a showcase for technique or equipment.
Complications can arise from any surgery, and minimally invasive surgery is all the more important to avoid and reduce complications from gynecological disease. It is important to note that the minimally invasive procedures that we currently perform have “risk” factors for complications.
(1) Small space for vaginal surgery, difficult exposure, limited operation, urethra, bladder, rectum adjacent to the front and back, high pelvic cavity or oversized masses add to the difficulty.
(2) The endoscopic observation is a two-dimensional space with a limited field of view, and the operation is done by a “robot”. Robotic” to complete the operation, the lack of touch feeling.
(3) The operation of various systems of energy is actually a source of injury.
(4) Injuries that occur during vaginal or endoscopic surgery, such as bleeding or organ damage, are more difficult to handle, and there is a risk that they will not be detected in time during the operation, making them a passive and difficult problem.
(5) Particular complications, such as air embolism, fluid overload and dilutional hyponatremia (e.g., TURP syndrome), are sometimes fatal.
Therefore, the implementation of these procedures should be no worse or comparable to open surgery, and should be better. Otherwise, “minimally invasive” can become “massively invasive”. A mature gynecologist should have a good command of all surgical modalities and be adept at developing his or her own specialties.
Precautions before and after minimally invasive gynecological surgery
Before surgery, pay attention to personal hygiene, wash the umbilicus with warm water, and preferably remove the dirt from the umbilicus with a cotton swab dipped in soapy water or vegetable oil. In terms of diet, light and easily digestible food should be the mainstay of the day before surgery, avoid large fish and meat to prevent postoperative intestinal distension. At the same time, you should prepare yourself mentally, adjust your psychological state and ensure sufficient sleep. If necessary, take oral sedative drugs as prescribed by the doctor.
After surgery, pay attention to consolidate the effect of surgery and recover strength as soon as possible, for this purpose, we should do the following.
(a) Within 6 hours after surgery, adopt a decubitus position with the head turned sideways to prevent vomit aspiration into the trachea.
Second, because most patients do not feel pain after surgery, do not neglect to massage the patient’s waist and legs, and turn the patient once every half hour to promote blood circulation and prevent decubitus ulcers.
(3) Remove the urinary catheter after the fluid infusion on the same day, and encourage the patient to get out of bed.
Four, 6 hours after surgery, the patient can enter a small amount of liquid diet, such as thin rice soup, noodle soup, etc.. Do not give the patient sweet milk, soy milk powder and other sugary drinks.
Fifth, the laparoscopic incision is only 1cm, so the abdominal dressing can be removed after a week, and you can take a shower, and then you can gradually resume normal activities. Before a week still need to pay attention to appropriate, light activities, so that the body early recovery.