Laparoskopik Doku Çıkarma Teknikleri
Özet
Jinekolojik cerrahide minimal invaziv yöntemlerin başında gelen laparoskopi; daha az kan kaybı, kısa yatış süresi ve az ağrı gibi avantajlarıyla öne çıkmaktadır. Operasyon sırasında eksize edilen büyük dokuların küçük insizyonlardan çıkarılması amacıyla direkt trokarlardan çıkarma, endobag yardımıyla çıkarma, morselatör kullanımı, kolpotomi ve insizyonu büyütme gibi çeşitli teknikler geliştirilmiştir. Küçük materyaller 5-10 mm'lik trokarlardan doğrudan veya laparoskopik aletlerle yönlendirilerek çıkarılabilirken, daha büyük veya malignite şüphesi taşıyan kitlelerin batın içini kontamine etmemesi için yırtılmaya dayanıklı endobag'ler önerilmektedir. Büyük ve sert miyomlar veya uterus dokuları için 1993'ten beri elektromekanik (power) morselatörler kullanılmaktadır; ancak bu cihazların dönme kuvveti, şüphelenilmeyen malign hücrelerin veya benign dokuların periton boşluğuna iyatrojenik olarak yayılmasına ve patolojik değerlendirmenin zorlaşmasına yol açabilmektedir. Bu riskleri azaltmak adına endobag içinde manuel morselasyon veya vajen posterior forniksten yapılan kolpotomi gibi alternatifler popülerlik kazanmıştır. Sonuç olarak, doku çıkarma yöntemi materyalin boyutuna, karakterine ve cerrahın deneyimine göre seçilmeli, özellikle preoperatif olarak malignite dışlanamıyorsa morselatör kullanımından kaçınılmalı ve hastadan mutlaka yazılı onam alınmalıdır.
Laparoscopy, a leading minimally invasive method in gynecological surgery, stands out for its advantages such as less blood loss, shorter hospital stay, and reduced postoperative pain. Various techniques have been developed to remove excised large tissues through small incisions, including direct removal from trocars, removal with an endobag, morcellation, colpotomy, and enlarging the incision. While small materials can be removed directly through 5-10 mm trocars or guided with laparoscopic instruments, tear-resistant endobags are recommended for larger masses or those with suspected malignancy to prevent intra-abdominal contamination. Electromechanical (power) morcellators have been used since 1993 for large and firm myomas or uterine tissues; however, the rotational force of these devices can cause iatrogenic dissemination of unsuspected malignant cells or benign tissues into the peritoneal cavity and complicate pathological evaluation. To mitigate these risks, alternatives like manual morcellation within an endobag or colpotomy through the posterior vaginal fornix have gained popularity. Consequently, the tissue removal method must be selected based on the size and character of the material and the surgeon's experience, avoiding morcellation if malignancy cannot be ruled out preoperatively, and written informed consent must always be obtained from the patient.
Referanslar
Yıldırım G. “Jinekolojide Robotik Cerrahi”, Ist Tıp Fak Derg 2009;72(4):143-149
Schlaerth AC, Abu-Rustum NR. Role of minimally invasive surgery in gynecologic cancers. Oncologist 2006;11:895-901.
Medeiros LR, Stein AT, Fachel J, et al. Laparoscopy versus laparotomy for benign ovarian tumor: a systematic review and meta-analysis. Int J Gynecol Cancer 2008; 18:387.
Yıldırım G, Fıçıcıoğlu C, “Laparoskopik Teknik- ler Serisi -2: Doku Çıkarma Teknikleri”, 6. Ulusal Jinekoloji ve Obstetrik Kongresi, Belek, Antalya, 14- 19 Mayıs 2008 (Poster sunumu).
Martínez-Zamora MA, Castelo-Branco C, Ba- lasch J, Carmona F. Comparison of a new reusable gynecologic laparoscopic electric morcellator with a disposable morcellator: a preliminary trial. J Mi- nim Invasive Gynecol. 2009 Sep-Oct;16(5):595-8.
4. Kho KA, Nezhat CH. Evaluating the risks of electric ute- rine morcellation. JAMA 2014;311:905-906
Larraín D, Rabischong B, Khoo CK, et al. “Iatrogenic” parasitic myomas: Unusual late complication of laparos- copic morcellation procedures. J Minim Invasive Gynecol 2010;17:719-724.
510(k) premarket notification. Device name: KSE Steiner electromechanic morcellator. Available at http://www. accessdata.fda.gov/scripts/cdrh/ cfdocs/cfPMN/pmn. cfm?ID5K946147. Accessed January 29, 2015.
Milad MP, Milad EA. Laparoscopic morcellatorrelated complications. J Minim Invasive Gynecol 2014;21:486– 491.
FDA executive summary: Laparoscopic power morcellation during uterine surgery for fibroids. Available at: https://wayback.archive-it.org/7993/20170113091521/http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM404148.pdf (Accessed on November 24, 2014).
Mahnert N,Morgan D,Campbel D, et al. Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications.ObstetGynecol 2015;125:397
Seidman MA, Oduyebo T, Muto MG et al. Peritoneal dissemination complicating morcellation of uterine me- senchymal neoplasms. PLoS One 2012; 7:e50058.
GO position statement: Morcellation. Avail- able at https://www.sgo.org/newsroom/position- statements-2/ morcellation/. Accessed January 29, 2015.
ACOG statement: FDA issues safety communi- cation on laparoscopic uterine power morcellation in hysterec- tomy and myomectomy. Available at http:// www.acog. org/About-ACOG/Announcements/FDA- Issues-Safety- Communication-on-Laparoscopic-Uterine- Power-Mor-cellation. Accessed January 30, 2015
AAGL statement to the FDA on power morcellation. Available at http://www.aagl.org/ aaglnews/aagl-statement- to-the-fda-on-power- morcellation/. Accessed January 30, 2015
Updated: Laparoscopic uterine power morcel- lation in hysterectomy and myomectomy: FDA safety communi- cation. Available at http://www. fda.gov/MedicalDevices/ Safety/AlertsandNotices/ ucm424443.htm. Accessed Ja- nuary 30, 2015.
Van den Bosch, T., Dueholm, M., Leone, F.P., et al., 2015. Terms and definitions for describing myometrial patho- logy using ultrasonography. Ultrasound Obstet. Gynecol. (February)
Zullo, Fulvio; Venturella, Roberta; Raffone, Antonio; Saccone, Gabriele (2020). In-bag manual versus uncontained power morcellation for laparoscopic myomectomy. Cochrane Database of Systematic Reviews
