From the development of laparoscopy to the maturity of the technology today has experienced a long century, before 1940 was the period of diagnostic laparoscopy, then entered the period of therapeutic laparoscopic exploration, about half a century later laparoscopic surgery was able to develop rapidly, especially the application of monitors in the 1980s opened the door to modern laparoscopic surgery, to 1989 with the successful implementation of hysterectomy and pelvic lymphatic It was only with the successful implementation of hysterectomy and pelvic lymphatic dissection in 1989 that laparoscopic surgery really entered a period of technical maturity, and it was only after the unremitting efforts and bold practice of many endoscopic scholars over the past 10 years that laparoscopic surgery has reached its present glory. Over the past century, people’s understanding of the indications and contraindications for laparoscopic surgery has been changing, closely related to specific historical conditions, contemporaneous scientific and technological development and people’s mindset.
1, the understanding of the indications for laparoscopic surgery
It can be said that laparoscopic surgery is a revolution in traditional surgical techniques, which uses minimally invasive techniques, changes the access to traditional surgery and improves the quality of life of patients. However, there is no essential difference between the treatment methods for the disease and traditional surgery, therefore, the indications and scope of laparoscopic surgery should be consistent with traditional surgery. However, the indications for laparoscopic surgery include at least the following diseases due to the small incision, the need to use a pneumoperitoneum, the need to operate through instruments and apparatus, and the inability to touch by hand, which affects the performance of some procedures.
1.1 Endometriosis
At the beginning, laparoscopy was used only for the diagnosis of ectopic diseases, until the application of CO2 laser in the late 1970s opened a new chapter of laparoscopic treatment of ectopic diseases, and later the widespread use of electrocoagulation and electrodesiccation techniques greatly promoted the pace of laparoscopic surgery for ectopic diseases. Nowadays, laparoscopic surgery has become the recognized best method for surgical treatment of endometriosis, and all stages of endometriosis are suitable for laparoscopic surgery. Some laparoscopic surgery experts abroad can do laparoscopic bowel resection for intestinal endometriosis, so there are almost no contraindications to laparoscopic surgery for endometriosis. Most hospitals in China are not yet skilled enough in laparoscopic techniques, and open surgery is still appropriate for huge ovarian cysts, estimated extensive intestinal adhesions, intestinal resection required or surgery judged to be very complicated.
1.2 Ectopic pregnancy
The conservative laparoscopic treatment of tubal pregnancy was first reported by Bruhat in 1977, and nowadays, linear tubal dissection (windowing) has become the “gold standard” for the surgical treatment of ectopic pregnancy.
The advantages of laparoscopic surgery are The advantages of laparoscopic surgery are accuracy, safety and ease of use, and integration of diagnosis and treatment, which have been adopted as the first choice of surgical treatment for ectopic pregnancy in hospitals where available. Interstitial tubal pregnancy was once considered a contraindication to laparoscopic surgery, but in recent years, due to the improvement of surgical skills and the use of internal loops, there have been many reports of successful laparoscopic surgery at home and abroad, so it should no longer be considered a contraindication for those who are skilled.
Hemorrhagic shock from ruptured ectopic pregnancy was also considered a contraindication to laparoscopic surgery. However, in recent years, many scholars at home and abroad have concluded that with extensive surgical experience and good surgical equipment, patients in shock from internal hemorrhage in ectopic pregnancy can still safely undergo laparoscopic surgery, because the hip-high, head-low position during laparoscopic surgery is beneficial to patients in shock, combined with the ability to rapidly locate the site of bleeding laparoscopically, rapidly stop bleeding, and subsequently perform autologous blood transfusion, thus effectively treating shock.
1.3 Benign ovarian masses
1.3.1 Epithelial tumors of the ovary
The major concern during laparoscopic surgery is whether the ovarian mass is malignant, because the mass may rupture during surgery and the contents may enter the pelvic or even abdominal cavity, which, at least in theory, could lead to the spread of cancer cells if it is malignant. Fortunately, it is not uncommon to encounter malignant tumors during laparoscopic surgery, which is estimated to be only about 1%. From the limited data available, there is a lack of clinical evidence as to whether intraoperative malignant rupture affects patient prognosis and leads to increased mortality, but the small number of cases is not sufficient to draw conclusions. Intraoperative rupture of malignant masses often results in flushing of the peritoneal cavity with large amounts of saline, etc., or intraperitoneal retention of anticancer drugs after surgery, etc., all of which may have reduced the chance of cancer cell implantation.
Because early-stage (non-metastatic) ovarian cancer is not an indication for laparoscopic diagnosis, preoperative routine ultrasonography (especially vaginal ultrasonography) and tumor marker measurement, etc., combined with the patient’s age, should be emphasized to help understand the nature of the mass. A careful and comprehensive examination of the cyst and surrounding area should be performed first during laparoscopy, and if a suspicious tumor nodule is found, a biopsy should be taken immediately and sent for frozen pathological examination to clarify the diagnosis. Adnexal resection on the affected side is recommended for high-risk patients over 40 years old to reduce the possibility of exfoliating malignant tumor.
The suitability of laparoscopic surgery for mucinous cystadenoma of the ovary is still controversial. Because ovarian mucinous cystadenoma is usually large in size and often multi-housed, the surgeon has to do cyst puncture and aspiration either to facilitate surgery or to remove the excised mass. Even if the puncture is done with great care, there is no guarantee that the intracapsular fluid will not escape and contaminate the pelvic and abdominal cavity, which may lead to the possibility of peritoneal pseudomucinous tumor, which is a terrible disease with a low 5-year survival rate. However, in recent years, many scholars believe that ovarian mucinous cystadenoma and peritoneal pseudomucinous tumor are two different diseases, and this concern is superfluous. The clinical experience of Peking Union Medical College Hospital also proves that the efficacy and recurrence rate of laparoscopic surgery and open surgery for ovarian mucinous cystadenoma are similar. We believe that those who are skilled in laparoscopic techniques and have solid knowledge of ovarian tumor diagnosis and management can carry out this type of surgery with caution and minimize the chance of contamination by extravasation of intracapsular fluid during surgery.
Despite careful handling during cyst debridement, many cysts still rupture, and it is difficult to ensure complete debridement of cysts especially when debridement of cysts >10 cm in diameter is performed. Therefore, cyst puncture and aspiration can be performed before debridement of large cysts. To reduce the escape of intracapsular fluid, cyst puncture and aspiration can be considered first, and for multifoveal mucinous cystadenoma, coarse needle puncture is required to try to perform multiple cystic cavities from one puncture hole and aspirate as much intracapsular fluid as possible, followed by closure of the puncture hole by electrocoagulation or suture. Mucinous cystadenoma should be put into a specimen bag after excision, and the specimen should be removed by decisively extending the abdominal wall incision or incising the posterior vaginal fornix if it is difficult to take the specimen from the 10 mm incision.
1.3.2 Teratoma
The suitability of teratoma for laparoscopic surgery was once controversial. Teratomas often rupture during debridement, and their contents are at risk of contaminating the abdominal cavity and causing chemical peritonitis. However, observations over the past decade or so have shown that postoperative chemical peritonitis is rare as long as the peritoneal cavity is flushed with plenty of warm saline. This, together with the possibility of malignancy in teratomas, is only about 2%. Therefore, laparoscopic surgery for ovarian teratoma is now considered safe and feasible.
The surgeon should continuously improve the skills of tumor debridement and cyst removal, master the skills of specimen removal, and avoid contamination of the pelvic and abdominal cavities by rupture of the masses as much as possible. In order to prevent the rupture of the mass from contaminating the pelvic and abdominal cavities during surgery, some authors have performed cyst puncture and aspiration with a coarse needle, and injected hot saline to repeatedly flush and aspirate the cyst before debridement. However, we believe that complete exfoliation should be strived for in teratomas, and this surgical method should be considered only for large teratomas (> 8-10 cm in diameter) that affect the visual field and are estimated to be difficult to be completely exfoliated.
Teratomas that are not ruptured or have a small rupture should be removed in a specimen bag after excision. In our own experience, after excision of teratomas with more hairy and solid components inside the cyst, teeth or large bone fragments, removal of the specimen from a 10 mm incision is usually difficult and requires an extended abdominal wall incision for removal. To reduce abdominal trauma, we prefer to perform posterior vaginal fornix puncture with a 10 mm puncture cannula, through which a large specimen can be removed not only from the cystic wall intact, but also faster.
Since about 1/6 of teratomas involve both ovaries and small teratomas are often located deep inside the ovary in an undetectable appearance, it is generally accepted that patients with teratomas on one side should be routinely dissected and explored even if the opposite ovary is normal in appearance. However, in most cases the tumor is not found, and not only that, the surgery brings trauma to the ovary and can lead to adhesions around the ovary, etc. In recent years, vaginal ultrasound has been widely used clinically and it can show teratomas of about 1 cm in diameter. We believe that routine preoperative vaginal ultrasonography can be performed without dissection and exploration if no abnormal strong echogenicity is found in the contralateral ovary and if the thickness and morphology of the contralateral ovary are normal under careful intraoperative observation, and this aspect deserves further exploration.
1.4 Uterine fibroids
It is suitable for subplasmic fibroids with tissues and interstitial fibroids protruding into the plasma membrane, but the diameter of fibroids should not be too large (<8-10 cm in diameter) and the number of fibroids should not be too large.
However, the diameter of the fibroids should not be too large (diameter < 8-10 cm) and the number should not exceed 2-3; submucosal fibroids are suitable for hysteroscopic surgery. Hysterectomy is feasible for those who do not require fertility.
Laparoscopic surgery for interstitial fibroids is still controversial. Opponents believe that laparoscopic surgery is technically difficult, takes a long time, may have defects in suturing, and may not be clean. In recent years, many scholars have found that compared with open surgery, laparoscopic surgery is longer, less bleeding, faster recovery, better recent results, and similar long-term results. We believe that laparoscopic myomectomy requires high surgical skills, and the operator should act according to his ability and not force himself. In recent years, the use of a small suprapubic abdominal incision (for anterior uterine wall or fundus fibroids) or posterior vaginal fornix incision (for lower posterior uterine wall fibroids) to assist laparoscopic myomectomy has been reported, improving the success rate and safety of the operation and broadening the indications for laparoscopic surgery.
The suitability of laparoscopy for hysterectomy was once highly controversial. However, after more than 10 years of clinical practice and research by many doctors at home and abroad, laparoscopic hysterectomy has now been confirmed and is gradually replacing open surgery in many hospitals. Depending on the operator’s ability and preference, laparoscopic assisted negative hysterectomy or laparoscopic total hysterectomy is feasible for those with uterus size below 14 to 16 weeks of gestation.
1.5 Pelvic inflammatory disease
In the past, acute pelvic inflammatory disease was considered a contraindication to laparoscopic surgery, mainly because of the concern that the hip-high and head-low position during laparoscopic surgery might cause the spread of inflammation. After several years of clinical practice, acute pelvic inflammatory disease is now no longer listed as a contraindication to laparoscopic surgery, but can instead be used as an indication. This is because laparoscopy not only allows for a clear diagnosis in a timely manner, but also allows for surgical treatment, such as separation of adhesions, flushing of the inflammatory site, incision and drainage of abscesses, and the application of antibiotics to speed up the inflammatory regression process, which is more conducive to protecting the patient’s reproductive function. In the acute inflammatory stage, the tissues are congested and edematous, and the adhesions are often loose and easy to separate, but it should be noted that chronic abscesses often form dense adhesions, which increase the difficulty of surgery and the risk of injury and require great care during surgery.
1.6 Infertility
Laparoscopy has always been an indication for laparoscopic surgery. before the 1990s, it was used mainly as a diagnostic procedure, and later it was often performed along with the diagnosis, as most patients had abnormal findings. In recent years, there has been a quiet rise in the use of transvaginal water laparoscopy (THL), which is based on the principle of a posterior trap recess mirror but uses an expanded medium of warm saline rather than gas, similar to hysteroscopy, with an average operative time of only 8 minutes, a success rate of 95%, and a compliance rate of 81.8% with laparoscopic diagnosis. There are more than 10 reports from abroad using this technique to diagnose infertility, and the diagnostic accuracy of whether the fallopian tubes are patent and whether there are adhesions is higher than that of hysterosalpingography. Some authors believe that THL is sufficient to diagnose more than 40% of infertility patients without obvious causes, and it is estimated that THL will gradually replace diagnostic laparoscopy and may also replace part of hysterosalpingography.
1.7 Acute and chronic pelvic pain
In the past, laparoscopy was mainly used as a diagnostic tool for acute abdominal disease, and the problem was detected and treated immediately by opening the abdomen; after the 1990s, treatment can be performed at the same time as the diagnosis, which has greatly improved the efficiency and has become an indispensable tool for the diagnosis and treatment of acute abdominal disease in many hospitals. Chronic pelvic pain is also an indication for laparoscopic surgery. About 1/3 can be found to have endometriosis, 1/3 have other abnormalities such as pelvic adhesions, and the remaining 1/3 have a generally normal pelvis. Laparoscopy is performed at the same time of diagnosis and treatment. Most of the abdominal pain is reduced or disappears after surgery, but some patients do have persistent pain and laparoscopic treatment is ineffective.
1.8 Reproductive tract anomalies
In the past, hysteroscopic surgery was the mainstay of diagnosis and treatment of uterine anomalies; however, the diagnosis may be incomplete or inaccurate, and pelvic anomalies may be easily missed, and there is a risk of uterine perforation and injury to surrounding organs if hysteroscopic surgery is performed. Nowadays, there are data suggesting that combined hysterolaparoscopic treatment of genital tract anomalies is efficient and safe for those with a uterus, which is worth promoting. We have also recently performed laparoscopic-assisted peritoneal vaginoplasty in three cases of congenital anovagina, all of which were successful.
1.9 Monitoring of hysteroscopic uterine surgery
With the further development of hysteroscopic techniques, the indications for hysteroscopic surgery are widening, and the risk of uterine perforation and other risks are increasing. Some foreign scholars prefer to do some difficult hysteroscopic procedures under laparoscopic surveillance and guidance, such as hysterectomy of longitudinal septum and resection of large intermuscular protrusions to submucosal myomas.
1.10 Early malignant tumors of the internal genitalia
In the past, malignant tumors of the genitalia were considered as contraindications to laparoscopic surgery because of the difficulty, high risk of injury, long operation time, and CO2 pneumoperitoneum, which may also lead to the spread of cancer cells. However, with the skill of operators, improvement of surgical methods, and application of new equipment (such as ultrasonic knife), more and more doctors have started to step into the treatment of genital malignant tumors by laparoscopic surgery in recent years. At present, it is estimated that dozens of hospitals in China have started laparoscopic pelvic lymphatic dissection and radical hysterectomy. However, laparoscopic treatment of genital malignancies is still limited to early cases, such as early endometrial cancer, early cervical cancer and early ovarian cancer, and the scope of surgery is the same as that of open surgery. From the limited data available so far, it seems that laparoscopic surgery is longer than open surgery in terms of operative time, but with less bleeding, faster postoperative recovery, lower postoperative morbidity rate, and similar recent efficacy for those who are skilled. However, because of the small number of cases, the exact efficacy remains to be further observed.
2. Awareness of contraindications to laparoscopic surgery
With the continuous improvement of laparoscopic equipment and the increasing proficiency of surgical skills, the contraindications to laparoscopic surgery are becoming less and less. The absolute contraindications listed in Practical gynecological laparoscopic surgery edited by Liu Yan (1999) are: ① cardiovascular diseases and pulmonary disorders that cannot tolerate anesthesia; ② serious arrhythmias, atrioventricular block of degree II or above; ③ hemodynamic changes; ④ sepsis. The relative contraindications are: (1) neurological diseases; (2) blood coagulation disorders; (3) abdominal masses with upper boundary above the umbilical level; (4) pregnancy over 4 months; (5) abdominal wall hernia and diaphragmatic hernia; (6) intestinal obstruction; (7) excessive obesity; (8) history of multiple abdominal surgeries, etc. The book Gynecologic Endoscopy, edited by Xia Enlan and Li Zixin (2001), also includes “inexperienced surgeons” as an absolute contraindication to laparoscopic surgery.
In the draft gynecologic endoscopy protocol published by the editorial board of the Chinese Journal of Obstetrics and Gynecology in 1997, excessive obesity or excessive wasting, limited peritonitis, and age over 60 years were also considered as relative contraindications to laparoscopic surgery. However, Nezhat et al. (2000) concluded that pregnancy, obesity, severe abdominal adhesions, previous history of open surgery, abdominal cancer, ventral hernia, hypovolemic shock, and intestinal perforation with diffuse peritonitis are no longer contraindications to laparoscopic surgery. Indeed, these so-called contraindications, especially relative ones such as midterm pregnancy, excessive obesity, abdominal wall hernia, history of multiple abdominal surgeries and old age, are no longer contraindications to surgery in many hospitals. With the skill of the endoscopist, the improvement of anesthesia techniques and the use of pneumoperitoneum laparoscopy, it is possible for elderly patients to undergo the procedure successfully, and we have successfully performed laparoscopic resection of one adnexa in 3 elderly women (72-78 years old) with good cardiopulmonary function. Of course, these procedures can also be performed safely using pneumoperitoneum laparoscopy.
3. Changing trends in indications for laparoscopic surgery
With the unremitting efforts of endoscopic surgeons, the continuous improvement of laparoscopic equipment, the continuous improvement of surgical skills and the continuous improvement of surgical methods, it is believed that laparoscopy will be able to perform more and more types of surgery, and the indications for surgery will become wider and wider, and the contraindications will become less and less. Diseases that are now considered contraindications to surgery may gradually be included in the category of relative contraindications, while those that are now considered relative contraindications may gradually become indications, thus gradually replacing open surgery, and eventually most pelvic surgeries can be completed by minimally invasive techniques such as endoscopy.
References
1. Zhou Yingfang, Xia Enlan. Current status of gynecologic endoscopy and related issues. Chinese Journal of Obstetrics and Gynecology,2005,40(7):433-434.
2. Zhou YF. Changes in the scope of laparoscopic applications and development trends. Chinese Journal of Practical Gynecology and Obstetrics,2003,19(11):648-650
3. Leng JH, Long JH, Yang JX. Advances in the diagnosis and treatment of endometriosis. Chinese Journal of Obstetrics and Gynecology, 2000, 35:53
4. Zhou YF, Cui H, Qiao J, et al. Standardization of diagnosis and treatment of endometriosis should be emphasized. Chinese Clinical Obstetrics and Gynecology, 2001,2(2):68-71
5. Cui H, Wang Qiu S. Translation. Gynecologic laparoscopic surgery: principles and techniques of treatment (2nd ed.). First edition. Beijing: People’s Health Publishing House, 2002:135
6. Pouly JL. Strategy for treatment of ectopic pregnancy: conservative treatment. in Endoscopic Surgery For Gynecologists, edited by Sutton C,Diamond MP.WS Saunders Company Ltd. second edition, London,1998:150-158
7, Yue XY, Zhou YF. Current status and trends in the treatment of tubal pregnancy. Journal of Practical Obstetrics and Gynecology,2002,18(3):149-151
8, Audebert AJM. Laparoscopic ovarian surgery and ovarian tortion. In Endoscopic Surgery For Gynecologists, edited by Sutton C,Diamond MP.WS Saunders Company Ltd. Second edition, London, 1998:150-158
9, Cui H, Wang Qiusheng, ed. Gynecologic laparoscopic surgery: treatment principles and techniques (2nd edition). First edition. Beijing: People’s Health Publishing House, 2002:103-115
10. Liu Guoli, ed. Modern Minimally Invasive Surgery. Science Press, 2003, First Edition, Beijing, P717-718.
11, Dechaud H, Ali Ahmed SA, Aligier N, et al. Does transvaginal hydrolaparoscopy render standard diagnostic laparoscopy obsolete for unexplained infertility investigation? Eur J Obstet Gynecol Reprod Biol 2001, 94(1):97-102
12, Moore ML, Cohen M, Liu GY. Experience with 109 cases of transvaginal hydrolaparoscopy.J Am Assoc Gynecol Laparosc 2003, 10(2):282-285
13. Duan H, Xia E L, Wang L, et al. Clinical analysis of 235 cases of combined hysteroscopic and laparoscopic surgery. Chinese Journal of Obstetrics and Gynecology,2002,37(6):342-345
14. Li K.Y.,Chen S.L.,Wang G. et al. Clinical analysis of 63 cases of early endometrial cancer treated by laparoscopic surgery and laparotomy. Chinese Journal of Minimally Invasive Surgery,2002,2(2):105-106
15. Liu Yan, Y.. Practical gynecologic laparoscopic surgery. First edition. Beijing: Science and Technology Literature Press, 1999:P126-131
16, Xia Enlan, Li Zixin, eds. Gynecologic endoscopy. First edition. Beijing: People’s Health Publishing House, 2001:308-330
17, Chinese Journal of Obstetrics and Gynecology Editorial Board. Gynecologic endoscopy operation specification (draft). Chinese Journal of Obstetrics and Gynecology,1997,32(5):267-275
18. Zhou YF. Discussion on hot issues of laparoscopy. Modern advances in obstetrics and gynecology,2004,13(3): 81
19.Zhou YF. Current status of clinical diagnosis and treatment of endometriosis (Lecture). Chinese Journal of Obstetrics and Gynecology,2005,40(1):67-70.
20. Wang A-Q, Zhou Y-F. Effectiveness and safety of laparoscopic surgery for ovarian teratoma, Chinese Journal of Endoscopy 2005;11(4):361-363.