gynecology / al_nahrain college of med 2018

1. ADVANCES IN MINIMAL ACCESS
SURGERY IN GYNECOLOGY
Haneen Ayad
Rawnaq Faris

2. INTRODUCTION
The final quarter of the last century witnessed a
revolution in gynecological surgery when the
traditional approach by laparotomy was replaced by
minimal access surgery. Minimally invasive surgery
(MIS) can be considered as the greatest surgical
innovation over the past 30 years. It revolutionized
surgical practice with well-proven advantages over
traditional open surgery: reduced surgical trauma
and incision-related complications, such as
surgical-site infections, postoperative pain and
hernia, reduced hospital stay, and improved
cosmetic outcome

3. Minimally invasive surgery(MIS)is characteristically
performed through a small incision or no incision, and
visualization is pro- vided by endoscopes. Both
laparoscopy and hysteroscopy are considered in this
category. With laparoscopy, small abdominal incisions
provide access to introduce an endoscope and surgical
instruments into the abdomen. increase operative
space, a pneumoperitoneum is created. As such,
laparoscopy provides a minimally invasive option or
women undergoing intraabdominal gynecologic surgery.
And, with its technology improvements, almost all major
intraabdominal gynecologic procedures can now be
performed with MIS.

4. Hysteroscopy uses an endoscope and uterine
cavity distending medium to provide an internal
view o the endometrial cavity .this tool permits both
the diagnosis and operative treatment of
intrauterine pathology

5. LAPAROSCOPY

6. laparoscopic surgery differs from laparotomy only
by its mode of access to the operative field.
replacement of normal 3-dimensional (3-D) vision by
2-dimensional (2-D) video images

7. ADVANTAGE
*reduce postoperative morbidity (pain wound
complication ,chest)
*accelerated recovery
*lesser adhesion formation
*better cosmetic
*reduce contact with body fluid and disease
transmission
*reduce incidence of ventral hernia

8. LAPROSCOPY INSTRUMENT

9. MANIPULATORS
Atraumatic Manipulators
During laparoscopic surgery, abdomino-pelvic organs
may be elevated, retracted, or placed on tension
Most current instrument designs have incorporated
safety considerations to minimize organ trauma yet
allow elective manipulation. One these, the blunt
probe has an end that is modified to decrease the
perforation risk to retracted tissues.

10. BLUNT PROBE

11. TRAUMATIC GRASPERS
Graspers with tips that are serrated or toothed are
used in procedures that involve resection and
tissue approximation

13. UTERINE MANIPULATORS
devices were originally designed to offer
manipulation o the uterus to create tension, expand
operating space, or improve access to specific
parts o the pelvis. Hulka and the Sargis uterine
manipulators are reusable stainless steel
instruments that contain the following : a stiff blunt
tip for insertion into the endo-cervical canal, a
toothed tip that affixes to the cervical lip or
stabilization, and a handle or vaginal placement

15. SCISSORS
Are integral to most laparoscopic procedures and are
available in reusable and disposable models.
Scissor tips vary depending on the type of
dissection or resection needed
curved blades may be smooth or slightly serrated. A
serrated edge tends to hold tissue and minimize
slippage prior to cutting. A smooth blade is
preferred for sharp dissection ,such as with
adhesiolysis.

16. Straight scissors also come with smooth or serrated
blades. they are used more for cutting and are less
desired for dissection. Many straight scissors are
designed with a single-action jaw, and some
surgeons feel this offers better control.

17. Hooked scissors have a rounded, blunt tip and
hooked blades. When initially approximated, the
blades close around the tissue without cutting and
then cut from the tip toward the hinge . it is offers
acontrolled transection and is useful for partial
transection of tissues. Moreover, its design allows a
surgeon to confirm optimum placement before
cutting. It is type of scissors is commonly used for
suture cutting.

19. TISSUE EXTRACTION MORCELLATORS
tools cut excised tissues into smaller pieces, which
can then be extracted. Available morcellators use
either thin cutting blades or pulsatile kinetic energy

23. LASER ENERGY
Lasers were widely used in laparoscopy in the
1980 through 1990s
are generally used through an operative channel on
the laparoscope or via aseparate port.laser scan
cut , coagulate,and vaporize tissues and are
employed for lysis of adhesions, tubal surgery, and
endometriosis ulguration or resection. In the hands
of skilled surgeons, lasers offer precision and
control with minimal effect on surrounding
tissue.thus laser is able to work near or over
sensitive structures such as bowel, bladder, ureters,
and vessels. Disadvantages are its learning curve,
expense, lack of portability, and smoke production.

24. ROBOTIC SURGERY
One modern approach to MIS uses robotic
assistance, and most abdominal gynecologic
procedures can be completed with this technique.
Similar to laparoscopy, robotic surgery uses
abdominal ports to introduce instruments and a
pneumoperitoneum to expand the operative Field.

25. One positive difference is the miniaturized and wristed
articulating instrument tips that allow successful
completion of complex procedures in tight operating
spaces. the instrument tips mimic those used in open
surgery and in laparoscopy and include graspers,
needle drivers, and cutting instruments. Advanced video
technology within an 8-mm laparoscope provides a high-
definition and magnifed view. disadvantages, tactile
feedback is lost with robotic surgery and forces a
surgeon to use visual cues. this is a learned skill that
carries asignificant learning curve . However ,surgeons
experienced in advanced laparoscopic techniques adapt
more quickly. Other disadvantages include extended
initial set-up time needed during each case, physician
training costs, and robot and instrument expenses.

27. HYSTEROSCOPY

28. Hysteroscopy is the inspection of the uterine cavity
by endoscopy with access through the cervix. It
allows for the diagnosis of intrauterine pathology
and serves as a method for surgical intervention.

30. HYSTEROSCOPY COMPLICATION
_uterine perforation
_ gas emblolization
_ hemorrhage

33. BETTOCHI HYSTROSCOP
is small, 4-mm-diameter rigid operative
hysteroscope has a 5F (1.67 mm) operating
channel that provides diagnostic and operative
capability.

35. RESECTOSCOPE
If resection intra uterine tissues is planned , a
Resectoscope may be used
contains an electrosurgical resection loop and allows
fluid egress from the uterus through aseries of
small holes near the sheath’s distal end.

37. HYSTROSCOPIC MORCELLATOR
For resection of polyps, submucosal leiomyomas,
septa, or synechiae, a hysteroscopic morcellator
may be chosen. Hysteroscopic morcellators offer
different tips depending on tissue type. For polyp
resection, a rake like tip is used. For resection of
thirmer tissue, a cutting tip is selected.
Both tips contain a mechanized blade that
fragments tissue. T ese tips are attached to a
hollow cannula that evacuates the tissue
fragments by suction to a collection receptacle. T e
morcellator fits through the working channel of a
9mm or greater operative hysteroscopic cannula.

39. RESOURCES

_ william gynecology edition
_medscape
_google

40. VEDIO
laparoscopy
https://www.youtube.com/watch?v=AeGzWF46aNc
Hysteroscopy
https://www.youtube.com/watch?v=EFFTnwxnCG0