The development of laparoscopy, like the development of all new technologies in medicine, has taken place over a long period of time. The use of a speculum to peer into the rectum was described as early as BC, when people longed to be able to see the various organs and tissues in the dark body cavity with the aim of making a definitive diagnosis of disease. The laparoscope is a type of endoscope used for direct visualization of organs in the abdominal cavity.
The development of minimally invasive laparoscopic techniques has gone through nearly a century of history, from the use of candlelight illumination for abdominal observation to the current use of laparoscopy to perform various surgeries. With the development of modern electronic information technology and light-guided process technology, laparoscopic minimally invasive techniques are gradually becoming a new paradigm for many surgical treatments. Some even predict that after the first 20 years of the 21st century, the vast majority of gynecological procedures can be performed lumpectively.
Minimally invasive laparoscopic techniques matured in the 1980’s and 1990’s. In 1987, Mouret, France, first reported the televised laparoscopic cholecystectomy, which opened a new chapter of modern minimally invasive surgery, and in February 1991, Xun Zuwu performed the first laparoscopic cholecystectomy in China. The outstanding representative of modern minimally invasive surgical technology – TV laparoscopic technology, known in the medical field as the end of the 20th century photoelectric field of modern high technology and modern surgical science organic combination of a new technological revolution in the field of surgery, is a new milestone in the history of modern surgical development.
First, the history of the development of gynecological laparoscopy
Gynecological laparoscopic technology is constantly developing and progressing, it has gone through three stages.
(A) pelvic laparoscopy
In 1901 the Russian gynecologist D.O. ott also observed the abdominal cavity of a woman by cutting open the posterior vaginal vault and putting in a cystoscope under frontoscopic illumination. This was the first pelvicoscopy.
(ii) Diagnostic laparoscopy
In 1910 Jacobaeus.H.C first applied a trocar puncture needle into the abdominal wall and introduced air into the abdominal cavity through a trocar, which was then placed into the cystoscope for examination. in 1944 Raoul Palmerjiang in France formally applied laparoscopy to the field of gynecology, examined a large number of infertile patients and developed a routine for laparoscopy. In 1963, a monograph was published to systematically introduce some relatively simple operations under laparoscopy, such as: tubal aeration and lavage; simple separation of visceral adhesions; tubal electrocoagulation sterilization; endometriosis electrocoagulation and electrocautery, etc.
(C) Surgical laparoscopy
After entering the 70s due to the invention of cold light source, glass fiber endoscope, and the introduction of Semm’s artificial pneumoperitoneum monitoring device – automatic pneumoperitoneum machine in Germany, laparoscopic surgery has developed with great enthusiasm since then. In 1980, Dr. Nezhat in the United States started to use television laparoscopy to perform surgery. In the late 1980s, Professor Kurt Semm of Germany invented and created many new surgical instruments and techniques. Such as: microscopic suturing instruments, flushing pumps, various clamps, scissors, combination crushers, cutters and so on. In 1988, Reich H performed the first laparoscopic total hysterectomy, and since then, the scope of gynecological surgery has become larger and larger, and almost 90% of gynecological surgery can be done laparoscopically.
Laparoscopic surgery in China started late, and the first case of laparoscopic surgery was started in 1979 under the leadership of Jordan Phillips, the president of American Laparoscopic Association, and has reached the world advanced level since then.
Second, gynecological laparoscopic surgery equipment
Equipment includes: light source, conduction system and endoscope, TV recording system, inflatable device, i.e. CO2 pneumoperitoneum machine, electrosurgical instruments, irrigator and operating parts.
Third, the operation skills of gynecological laparoscopic surgery
(a) basic operating techniques.
1, position Gynecological laparoscopic surgery using head low hip high 15-30 degrees position.
2.Puncture site selection The umbilicus is the most common choice for the entry position of the mirror. It is estimated that for large pelvic masses or surgical scars reaching the umbilical rim, the upper edge of the umbilical foramen should be selected, where the groups of muscles and fascia of the abdominal wall meet and are the thinnest.
3, pneumoperitoneum formation After determining the puncture site, a 6mm pointed scalpel is inserted 2mm and then the skin is picked upward about 1cm, and the abdominal wall is held and lifted with two scarf clamps next to the umbilicus so that the abdominal wall is away from the omentum and intestinal canal. Slowly enter the abdominal cavity and inject gas.
4.Place the microscope to observe and decide the operation style
5.Select the operation hole for puncture
(B) electrosurgery application skills: electrocoagulation is one of the most commonly used methods of hemostasis in laparoscopic surgery. Including: cautery, coagulation, vaporization
(iii) Operating techniques of microscopic suturing and knotting Microscopic suturing is the most complete method of hemostasis and is extremely difficult for beginners. The first suture tying may take 20-30 minutes, but once you have mastered the technique of microscopic suture tying, laparoscopic surgery is at your disposal.
(iv) Suture tying technique The principle of suture tying is that slip knots are usually provided by the manufacturer with ready-made suture coils.
Fourth, the indications for gynecological laparoscopy
1, a variety of unexplained abdominal pain
2, more difficult abortion laparoscopic supervision and the diagnosis and treatment of its complications
3.Etiological examination of infertility
4. Clinical staging of endometriosis
V. Scope of gynecological laparoscopic surgery
1.Ovarian benign tumor resection
2.Uterine fibroid removal
3.Hysterectomy
4.Pelvic adhesion dissection
5.Tubectomy for ectopic pregnancy
6.Tubectomy for ectopic pregnancy
7.Cuneatectomy and laparoscopic perforation of ovaries for polycystic ovary syndrome
8.Fallopian tube sterilization
9.Biopsy and electrocautery of endometriosis lesions
10.Pelvic bruise round ligament shortening
11.Uterine malignant tumor surgery (radical total hysterectomy, pelvic lymph node dissection)
VI. Features of laparoscopic surgery
1, the surgery is to remove the lesion under the observation of the scope, without the need for conventional incision surgery, fine operation with little damage, fast recovery, small incision without sutures, short hospitalization time.
2.The lesion must be clearly observed through the speculum, and the operation of separation, stripping, ligature and excision must be performed with long forceps through the trocar into the body cavity.
3, in order to reveal the surgical field clearly and facilitate the operation, a large amount of CO2 gas must be injected into the abdominopelvic cavity and head-low-hip-high position.
Seven, the specific application of laparoscopy in gynecology
1.Application in the diagnosis of infertility
The main role of laparoscopy in infertility is to diagnose and deal with infertility caused by tubal and abdominal factors, which are mainly inflammation (including tuberculosis) and endometriosis. Diagnostic laparoscopy and tubal lavage can be used to directly visualize the internal genitalia and to be informed about the patency of the fallopian tubes, and are therefore considered the most effective tools to confirm adhesions and endometriosis in the adnexal region.
2. Application in the diagnosis of abdominal pain
Abdominal pain is one of the most commonly encountered symptoms in clinical practice, and in the gynecological category, abdominal pain mainly refers to lower abdominal pain. It is differentiated by time: acute abdominal pain, chronic abdominal pain (cyclic, continuous).
Among acute abdominal pain, the main causes originating from the reproductive system are: 1) pregnancy-related: miscarriage, ectopic pregnancy; 2) tumor-related: ovarian cyst torsion or rupture, uterine fibroid degeneration or torsion; 3) inflammation-related: acute pelvic inflammatory disease; 4) others: ovarian corpus luteum rupture, ovarian hyperstimulation syndrome, dysmenorrhea and menstrual reflux.
Among chronic abdominal pain, it can be divided into two main categories: 1. Periodic chronic abdominal pain whose onset of pain is related to the menstrual cycle. Such as midmenstrual pain and dysmenorrhea; 2. Non-cyclic chronic abdominal pain whose onset of pain is not related to the menstrual cycle. Such as pelvic inflammatory disease, pelvic adhesions, endometriosis.
3.Application in the diagnosis of pelvic masses
From a purely diagnostic point of view, some of the tools currently used clinically such as CT, MRI and ultrasonography are sufficient to meet the general need, i.e., to determine the presence of masses. Therefore, for benign pelvic masses, the role of laparoscopy is not in the diagnosis but in the surgery, i.e. whether the mass can be removed laparoscopically.
For gynecologic malignancies laparoscopy has the following 4 main roles: 1) evaluation of ovarian tumors; 2) diagnosis and staging of ovarian cancer; 3) post-treatment detection; and 4) staging of pelvic or para-aortic lymph nodes.
The above-mentioned diseases can be visualized at a glance in laparoscopy. The vast majority of them can be treated by simultaneous laparoscopic surgery.
VIII. Complications of laparoscopic surgery
Laparoscopic surgery has the same problem of complications as open surgery, so it is important to diagnose them quickly and deal with them appropriately. The main complications are: 1, anesthesia accident; 2, intravenous air embolism; 3, extraperitoneal hyperinflation or emphysema formation; 4, electrothermal injury; 5, vascular injury; 6, organ injury; 7, others: nerve injury, infection, abdominal wall hernia.
IX. Future of laparoscopic surgery
The various advantages of minimally invasive laparoscopic surgery determine its inevitable development. As the surgery causes less damage to patients, less pain, shorter hospital stay, and faster postoperative recovery, it reduces the medical burden on the government, insurance agencies and patients, and promotes and improves the social benefits of the country while reducing medical expenses.