La laparoscopia diagnostica

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  • 1. La LaparoscopiaLudovico MuziiClinica Ginecologica e Ostetrica,Università Campus Bio-Medico,Roma
  • 2. Laparoscopia Diagnostica - Operativa• Sterilità• Dolore pelvico cronico, acuto• Gravidanza ectopica• Aderenze, endometriosi• Masse annessiali• Isterectomia (LAVH, TLH, LSH)• Miomi uterini• Patologia del pavimento pelvico• Oncologia ginecologica
  • 3. Laparoscopia: accesso• Inserimento ago di Veres• Inserimento trocar secondo tecnica classica• Inserimento trocar secondo tecnica diretta• Open laparoscopy• Trocar ottico• Introduzione trocar accessori
  • 4. Complicanze maggiori dovute all’accesso Garry R. Gynaecol Endosc 8:315-326, 1999Numero Numero Lesioni x 1000 Lesioni x1000di studi di procedure intestinali vascolariTecnica classica 6 357.257 103 0,4/1000 69 0,2/1000Tecnica “open” 7 20.410 99 5,0/1000 0 // 6* 12.410 7 0,6/1000 0 //Tecnica diretta 3 6.833 7 1,1/1000 0 //*escludendo lo studio AAGL (8000 casi, 92 lesioni, 12/1000)
  • 5. “L’approccio ‘open’ secondoHasson dovrebbe esserequello preferito in ogni caso.”Thomas WEG: Basic surgical skills: A participants’hanbook. Royal College of Surgeons 1996
  • 6. Per evitare lesioni vascolari maggiori:MAI DEVIARE DALLA LINEAMEDIANA CON UN ANGOLO DI40-45° VERSO IL BASSO (in pazientiobese angolo maggiore)
  • 7. Presenza di aderenze in relazione a pregressachirurgiaAudebert AJM. Gynaecol Endosc 8:363-7, 1999 Pregressa chirurgia Aderenze n / 1000 Nessuna 4 / 519 ( 8 / 1000) Laparoscopia 2 / 140 (14/ 1000) Pfannenstiel 31 / 145 (214/ 1000) Longitudinale 51 / 96 (531/ 1000)
  • 8. Tecnica classica
  • 9. Tecnica diretta
  • 10. Tecnica open
  • 11. Inserimento trocar accessori
  • 12. Diagnosi di Fattore tubarico di Sterilita’ Quale metodica?Quando?
  • 13. Medicina basata sulla EVIDENZA• Two million articles per year in the biomedical literature• A physician should read 19 articles per day, 365 days per year, to keep up with her/his specialty Sackett DL, BMJ 1995
  • 14. NICE guidelines www.nice.org.uk
  • 15. NICE guidelinesMeta-analysis based on three studies with judgement oflaparoscopy without knowledge of HSG results gave pooledestimates of sensitivity and specificity for HSG as a test fortubal obstruction of 0.65 and 0.83 respectively. When HSGsuggests the presence of tubal obstruction this will beconfirmed by laparoscopy in only 38% of women.Thus, HSG isnot a reliable indicator of tubal occlusion. However, when HSGsuggests that the tubes are patent, this will be confirmed atlaparoscopy in 94% of women. Thus HSG is a reliableindicator of tubal patency.
  • 16. NICE guidelines
  • 17. NICE guidelinesAltre metodiche?
  • 18. NICE guidelinesIn conclusione: Se non ci sono fattori di rischionoti, ISTEROSALPINGOGRAFIA Se ci sono fattori di rischio noti,LAPAROSCOPIA
  • 19. Fertil Steril 2004; www.asrm.org
  • 20. Diagnosi di Fattore tubarico di Sterilita’ Quale metodica?A postal survey was conducted among gynecologistsand radiologists to find out the current practice inthe UK regarding the methods employed to assesstubal patency. In the responses from radiologists, aHSG was the investigation of choice for both lowrisk (61%) and high risk women (50%). In theresponses from gynecologists, in low risk themajority perfomred a HSG (58%) or HyCoSo(15ì4%), whereas in high risk most (84%) performeda laparoscopy Vvjayanthi S, Hum Fertil (Camb) 2004
  • 21. Quando?
  • 22. Quando? ? ? The specific definition of infertility is inability of a couple to conceive after 1 year of sexual intercourse without contraception. The initial diagnostic test for infertility should include a midulteal progesteron assay, a semen analysis and a test for tubal patency such as HSG. The ESHRE Capri Workshop Group: “Optimal use of infertility diagnostic tests and treatments”. Human Reproduction 15:723, 2000
  • 23. Diagnosi di Fattore tubarico di Sterilita’ E’ necessaria la laparoscopia dopo HSG normale?When tubal patency has been demonstrated by HSG,laparoscopy is traditionally suggested as a mandatorystep to preclude the existence of peritubal adhesions andendometriosis. In women without a hystory suggestive oftubal disease and a normal HSG, we demonstrate thatthe probability of clinicallly relevant disease is very lowand laparosocpy does not seem to be justified or cost-effective. In these cases surgery has not been proven toimprove fecundity, and we suggest 3-6 cycles ofCOH/IUI, and if unsuccesful, IVF Fatum M, Hum Reprod 2002
  • 24. STERILITA’ DA FATTORE TUBARICO La sterilità da fattore tubo-peritoneale (aderenze pelviche, occlusioni tubariche prossimali e distali, endometriosi) rappresenta il fattore eziologico nel 40% dei casi di sterilità femminile
  • 25. Fattore Tubo-Peritoneale di Sterilita’ Aderenze Occlusione tubarica distale – Idrosalpinge Occlusione tubarica prossimale Endometriosi
  • 26. Aderenze
  • 27. ADERENZE POST-CHIRURGICHELe aderenze, causate da PID,pregressi interventi, endometriosi,possono essere a loro volta causa disterilità, dolore pelvico cronico,occlusione intestinale, gravidanzaextra-uterina, re-interventi
  • 28. COME SI FORMANO LE ADERENZE: Fenomeni a livello peritoneale (5-7 giorni) Peritoneum Trauma Peritoneal Defect Increased Vessel Permeab Inflammatory Exudate Fibrin Matrix PA Plasminogen Fibrinolysis Ischemia PAI Normal fibrinolytic activity Suppressed fibrinolytic activity Persistence of fibrin Resolution of fibrin Fibroblast Proliferation Mesothelium Organisation of fibrin matrix Repair Adhesion Formation
  • 29. Classificazione delle Aderenze • Incidenza • Estensione • Severità • Localizzazione
  • 30. Fertil Steril 1988
  • 31. Incidenza• Aderenze De Novo• Riformazione delle Aderenze
  • 32. Incidence of De Novo Adhesions• 55% - 100% Incidence of Adhesions after Laparotomy Time from Total Total no. Inital no. of With % with Procedures Patients Adhesions Adhesions Diamomd et al 1 wk -12 wk 106 91 86 DeCherney and Mezer 4 wk - 16wk 20 15 75 1 yr - 3 yr 41 31 76 Surrey and 6 wk – 8 wk 31 22 71 Friedman > 6 mo 6 5 83 Pittaway et al 4 wk – 6 wk 23 23 100 Trimbos-Kemper et al 8 days 188 104 55 Daniell and Pittaway 4 wk – 6 wk 25 24 96Adapted from Diamond MP, Surgical Aspects in Fertility. In Gynaecology and Obstetrics, 1988
  • 33. Adhesion Formation & Laparoscopy Sites of adhesion formation following laparoscopy Number of Reformed De Novo Patients Adhesions Adhesions Diamond 62 67% tube 23% pelvic et al, 1991 80% ovary Canis et al, 42 82% adnexa 21% adnexa 1992 Lundorff et 31 60% tube 17% tube al, 1991
  • 34. Aderenze post-miomectomia laparoscopicaAutore, anno n.pz 2Look (%) % aderenzeMais, 1996a 25 100% 40%Mais, 1996b 25 100% 88%Bulletti, 1996 16 88% 29%Dubuisson, 1998 45 100% 36%Takeuchi, 2002 115 44% 29%Di Gregorio, 2002 635 19% 2%Malzoni, 2003 144 12% 33%Total 1005 289 (29%) 25% (41%)
  • 35. ...THE TWO ENDS OF THE SPECTRUM: • Do not undertreat, or mismanage, the unexpected ovarian cancer • Do not overtreat the functional cyst • (Do not operate on the incidental myoma) Muzii and Benedetti Panici, JAAGL 2004
  • 36. FUNCTIONAL CYSTS EXCISED AT OPERATIVE LAPAROSCOPY n. of patients Functional cysts % Nezhat, 1992 1011 358 36 Mecke, 1992 678 207 31 Canis, 1994 757 149 18 Van Her. 1995 121 17 14 Sadik, 1999 220 74 34Rasmussen, 1999 275 23 8 Mettler, 2001 493 144 29Benedetti Panici, 282 12 4 2002 Marana, 2004 658 29 4 4495 4495 1013 1013 22.5% 22.5% Muzii and Benedetti Panici, JAAGL 2004
  • 37. LAPAROSCOPIC EXCISION OF FUNCTIONAL CYSTS•COST OF THE PROCEDURE•ADHESIONS•HARMFUL OF THE OVARY•MEDICO-LEGAL IMPLICATIONS
  • 38. From Luciano AA et al, Fertil Steril, 1991From Luciano AA et al, Fertil Steril, 1991
  • 39. “...to avoid adhesionsyou must avoid surgery.” L Mettler, Ann N Y Acad Sci, 2003
  • 40. ADERENZE POST-CHIRURGICHELe aderenze possono essere causadi dolore pelvico cronico, sterilità,occlusione intestinale, gravidanzaextra-uterina, re-interventi
  • 41. Pelvic Pain and Adhesions• 15% - 45% of patients with chronic pelvic pain (CPP) have pelvic adhesions• Fix internal genital organs to adjacent structures• Compress/construct ovaries and fallopian tubes
  • 42. Laparoscopy for Chronic Pelvic Pain 80 70 60 50 Liston et al 40 Lundberg et al Renaer 30 Kresch et al 20 Rapkin 10 0 no pathology adhesions endometriosis
  • 43. Pain relief after laparoscopic adhesiolysis No. of Pain Better Pain Not BetterStudy Patients (%) (%)Sutton & Macdonald, 1990 65 53 (82%) 10 (15%)Goldstein et al., 1980 18 16 (89%) 2 (11%)Steege & Stout, 1991 30 19 (63%) 11 (37%)Onders and Mittendorf, 2003 70 50 (71%) 20 (29%)Totals 183 138 (75%) 43 (23%)
  • 44. Pain & Adhesions Controversy• Some patients have pelvic pain and no adhesions• Some patients have adhesions and no pelvic pain• After adhesiolysis, pain but later it could return or• No RCTs
  • 45. Adesiolisi?
  • 46. “The best single source of reliable evidenceabout the effects of health care” www.cochrane.org
  • 47. DJ Swank, Lancet 2003
  • 48. DJ Swank, Lancet 2003
  • 49. “This finding suggest that the value of laparoscopic adhesiolysisdoes not lie in the adhesiolysis itself.Adhesions do not cause pain unless they are causing anobstruction.Diagnostic laparoscopy could be of benefit to patients byrevealing other causes of their pain.We recommend that clinicians consider abandoning laparoscopicadhesiolysis as a treatment” DJ Swank, Lancet 2003
  • 50. L Demco, JAAGL 2004
  • 51. “Filmy adhesions between amoveable structure, such as anovary, and the peritoneum hadthe highest pain scores. Fixed ordense adhesions, no matterwhere they were located, hadthe lowest pain scores.” L Demco, JAAGL 2004
  • 52. Do not lyse the dense,fixed, difficult adhesions.If in doubt, lyse only theeasy adhesions
  • 53. ADERENZE POST-CHIRURGICHE Le aderenze possono essere causa di dolore pelvico cronico, sterilità, occlusione intestinale, gravidanza extra-uterina, re-interventi
  • 54. Role of Adhesions in Infertility• Interference with ovum escape• Impairment of tubal function• Tubal occlusionButtram VC Jr., Reiter RC. Surgical Treatment of the Infertile Female. Baltimore, MD: Williams & Wilkins; 70, 1985Gordji M. Pelvic Adhesions and Sterility. Acta Eur Fertil 6:279, 1975
  • 55. Adhesions & Infertility• Impair fertility severely• Surgical correction only partly effective… - Due to mucosal damage - Due to adhesion reformation
  • 56. Infertility Cumulative Pregnancy Rates of Untreated Tubal/Pelvic Damage vs Surgery 100Percent Couples 90 Normal 80 70 Grade I - Surgery 60 50 Grade II - Surgery 40 30 Grade I - Untreated 20 10 Grade II - Untreated 0 12 24 36 Months
  • 57. Seppure in assenza di studi controllatirandomizzati, l’adesiolisi in caso disterilita’ e’ sicuramente indicata
  • 58. Occlusione tubaricadistale (DTO)
  • 59. OCCLUSIONE TUBARICA DISTALE
  • 60. Fertil Steril 1988
  • 61. Salpingoneostomia: creazione della neostomia con elettrodomonopolare o con laser a CO2 ad elevata densità di potenza (spotpiccolo, potenza alta)
  • 62. Eversione delle fimbrie; tale manovra viene eseguita inlaparoscopia con il laser defocalizzato o con il bipolare abassa potenza
  • 63. Stabilizzazione della neostomia con punti. In laparoscopiatale procedura non è necessaria
  • 64. SALPINGONEOSTOMIA: CONFRONTO TRA LAPAROTOMIA E LAPAROSCOPIA n. pazienti % grav. EP totaliLaparotomia 1011 34% 2-38%Laparoscopia 370 30% 0-18%
  • 65. …We recommend intraoperative salpingoscopy tovisualize the whole length of the ampullary lumen.Whereas the status of the ampullary endosalpinx is alsoan important prognostic parameter, we elected not toinclude it in the scoring system at this time, sincesalpingoscopy is not being practiced universally… The American Fertility Society, 1988
  • 66. SALPINGOSCOPY -classification of lesions-Grade 1: normal fold patternGrade 2: separation and flattening of foldsGrade3: focal lesion, e. g. small adhesionsGrade 4: extensive adhesions and/or disseminated flat areasGrade 5: complete loss of folds Brosens, 1987
  • 67. GRADE 1-2
  • 68. GRADE 3
  • 69. GRADE 4
  • 70. GRADE 5
  • 71. CUMULATIVE TABLE OF PREGNANCIES -According to the salpingoscopic grade of the better tube- Salpingoscopic grade I II III IV VSALPINGO-OVARIOLYSISNumber of patients 16 1 3 3 1Intrauterine 11 1 0 0 0Extrauterine 0 0 1 0 0SALPINGONEOSTOMYNumber of patients 10 1 2 11 3Intrauterine 6 1 0 0 0Extrauterine 0 0 0 2 0 Marana 1999
  • 72. PERCENTAGE OF PATIENTS WITH NORMAL TUBAL MUCOSA: ADNEXAL ADHESIONS Marana (1995) 76% Brosens (1996) 80%Expected intrauterine pregnancy rate: 70%
  • 73. PERCENTAGE OF PATIENTS WITH NORMAL TUBAL MUCOSA: HYDROSALPINGES Marana (1995) 42% Brosens (1996) 34%Expected intrauterine pregnancy rate: 60%
  • 74. Occlusione tubaricaprossimale (PTO)
  • 75. Anastomosi tubo-tubarica (in caso di “reversal”): apposizionedi un punto sul mesosalpinge e del primo punto a ore 6
  • 76. Completamento del primo strato con punti a ore 3, 9 e 12
  • 77. Louise Brown, born July 25, 1978JP Toner, Fertil Steril 2002
  • 78. Al di la’ di ogni discussione di tipoetico, medico, economico, vasalvaguardata la discussione sulleINDICAZIONI !
  • 79. DIAGNOSI ISTEROSALPINGOGRAFICAPREOPERATORIA DI OCCLUSIONETUBARICA: QUANTI FALSI POSITIVIRIVELATI POI ALLA CHIRURGIA?Occlusione prossimale 41-61%Occlusione distale 12%
  • 80. CONCLUSIONI• Appropriata selezione dellepazienti e rispetto delle indicazioni• Conoscere i vantaggi ed i limiti dellachirurgia della sterilità• Corretta informazione alla paziente
  • 81. video
  • 82. Come prevenire le aderenze incorso di chirurgia annessiale?
  • 83. In letteratura è disponibile un’ampiaserie di dati, sia sperimentali che clinici,ma a tutt’oggi non esiste un metodouniversalmente accettato per laprevenzione delle aderenze
  • 84. For laparoscopy, the perceived postoperative de novo adhesion formation rate was 0%-25%, whereas the adhesion reformation rate was 26%-75%; for laparotomy, the rates were 26%- 75% and >75%, respectively.Sixty-five percent of the respondents were using at least onemethod for postoperative adhesion prevention duringlaparoscopy, and 68% during laparotomy.The most frequentlyused method during laparoscopy was Ringers lactate (77% ofthe respondents), followed by ferric hyaluronate gel (46% ofthe respondents), and 4% icodextrin (39% of respondents).During laparotomy, the most frequently used methods wereRingers lactate (28%), normal saline (20%), and 4%icodextrin (20%). Antibiotic prophylaxis was used by 87.5% ofrespondents. Muzii, JAAGL 2004
  • 85. Crystalloid Solutions• Continuous irrigation is positive because: – prevents fibrin deposition and wash away fibrinous exudates – it can keep the tissues moist• Intraperitoneal solutions at the end of surgery: – active on all peritoneal surfaces, possibly preventing de novo – easy to use, reduced costs• However, doubts on the efficacy: – rate of absorption is 35 ml/hour – 300 ml are absorbed in 8.5 hours – the process of peritoneal healing and adhesion formation takes place during the first 5-7 days
  • 86. INTRAPERITONEAL RESIDENCE OF RINGER’S LACTATE: LONGER THAN EXPECTED Results from a randomized, double-blind, clinical trial Kurt Semm Award, AAGL 2003PRELIMINARY STUDY ESTIMATED IP VOLUME (mL) = -4x10-8 V 4 + 4x10-5 V 3 – 1.32x10-2 V2 + 2,45V + 3,4217V = D1 x D2 x D3
  • 87. RESULTS 96 24 0 48TIME (hrs) RINGER mL CONTROL mL P0 289 (+ 38) 18 (+12) p<0.0524 185 (+72) 3 (+2) p<0.0548 55 (+28) 7 (+3) p<0.0596 18 (+6) 6 (+4) N.S.
  • 88. Mechanical Separation of Raw Surfaces• Liquid Instillates – Cystalloid solutions (i.e. Lactated Ringer’s) – Hyskon (32% dextran 70) – Intergel – Adept – Spraygel – Hyalobarrier – Sepracoat• Mechanical Separation via barriers – Interceed – Preclude (Gore-tex) – Seprafilm
  • 89. www.cochrane.org
  • 90. Cochrane menstrual disorders and subfertility groupReviews:• Barrier agents for preventingadhesions after surgery for subfertility• Liquid and fluid agents forpreventing adhesions after surgery forsubfertility
  • 91. AGENTI DI BARRIERA• 15 RCTs• LPTM = 9, LPS = 6• Aderenze pelviche 6, Miomectomia 5, Chirurgiaovarica 4, Endometriosi 2, Indicazioni varie 1• 13 studi: Interceed vs. controllo, 2 studi: Interceed vs.Gore-Tex, 1 studio: Gore-Tex vs. controllo, 1 studio:Seprafilm vs. controllo• In nessuno studio sono state valutate Gravidanze eRiduzione del dolore
  • 92. AGENTI DI BARRIERA• L’uso dell’Interceed e’ associato ad una minore incidenzadi formazione di aderenze (sia ri-formazione cheformazione de novo) dopo chirugia laparoscopica elaparotomica• Il Gore-Tex e’ piu’ efficace di nessun trattamento o diInterceed• Evidenze limitate sull’efficacia del Seprafilm per laprevenzione di aderenze dopo miomectomia• Interceed efficace nel ridurre le aderenze, ma datiinsufficienti per raccomandarne l’uso per migliorare lepercentuali di gravidanza
  • 93. AGENTI LIQUIDI / FLUIDI• Nessuno degli agenti liquidi o fluidi studiati hadeterminato un aumento delle percentuali di gravidanza.• Alcune evidenze sull’efficacia degli steroidi nel ridurrel’incidenza e la severita’ della formazione di aderenze.Destrano inefficace.• L’uso di routine di questi agenti non puo’ essereraccomandato sulla base delle evidenze disponibili.• L’evidenza sugli steroidi e’ ben lontana dall’essereperfetta, ma suggerisce l’efficacia. Dovrebbero esserecondotti studi addizionali.
  • 94. IntergelAdept
  • 95. DB Johns, Fertil Steril 2001
  • 96. “You shouldimmediatelydiscontinue useof the device”March 2003
  • 97. Hum Reprod. 2002 Apr;17(4):1031-8.A randomized, controlled pilot study of the safety and efficacy of4% icodextrin solution in the reduction of adhesions followinglaparoscopic gynaecological surgery.diZerega GS, Verco SJ, Young P, Kettel M, Kobak W, Martin D, Sanfilippo J, Peers EM,Scrimgeour A, Brown CB.University of Southern California Keck School of Medicine, Los Angeles, CA, IGO MedicalGroup, San Diego Fertility Center, Private Practice, Memphis TN, and ML Laboratories PLC,Leicester, UK. DiZerega, 2002P = n.s.
  • 98. CONCLUSIONI - AderenzeNonostante l’enorme mole di dati presenti inletteratura, non esiste oggi un approcciouniversalmente accettato. L’Interceed è ilmetodo sul quale oggi esistono più studi. Nuovimetodi di barriera in studio. L’approcciolaparoscopico, probabilmente, determina unariduzione delle aderenze “de novo”. Lariformazione delle aderenze dopo adesiolisisembra invece essere la norma più chel’eccezione, anche in laparoscopia.
  • 99. CONCLUSIONILa corretta indicazione all’intervento chirurgicoè probabilmente il mezzo più efficace perprevenire le aderenze postoperatorie.L’accurata selezione delle pazienti e il rispettodelle indicazioni sono i punti-chiave per ottenerei migliori risultati in chirurgia laparoscopica delfattore tubo-peritoneale di sterilitàL’utilizzo di tecniche chirurgiche nel rispetto deitessuti è l’altro punto fondamentale.
  • 100. Grazie per l’attenzione!