腹腔鏡手術(shù)-電外科與卵巢功能-課件

腹腔鏡手術(shù)

電外科與卵巢功能1ppt課件祝兄弟姐妹們歡聚一堂！2ppt課件提綱止血方法卵巢功能止血與卵巢功能3ppt課件止血設(shè)備激光高頻電凝固超聲刀微波刀氬氣刀射頻刀器械止血4ppt課件激光CO2NdYAGKTP-532HaYAK氬激光較早使用漸被取代5ppt課件高頻電凝固單極電凝雙極電凝PK刀結(jié)扎速血管閉合系統(tǒng)（LigaSure）

應(yīng)用廣泛6ppt課件單極電凝

1926優(yōu)點(diǎn)操作簡單省時(shí)經(jīng)濟(jì)缺點(diǎn)（1）產(chǎn)生大量煙致手術(shù)視野模糊且產(chǎn)生有毒氣體

（2）熱效應(yīng)明顯，產(chǎn)生100～400℃高熱熱損傷大，損傷周圍組織可達(dá)15mm

（3）易發(fā)生電損傷，損傷大血管及輸尿管腸管（4）組織粘連嚴(yán)重，焦痂形成，術(shù)后并發(fā)癥多7ppt課件雙極電凝1950

安全性確切性優(yōu)點(diǎn)（1）止血效果較單極電凝好，可電凝直徑3mm的血管，如子宮、卵巢血管等（2）不易發(fā)生電損傷

缺點(diǎn)（1）產(chǎn)生大量煙霧且含有毒氣體（2）熱效應(yīng)大、熱損較大，但遠(yuǎn)比單極?。?）組織粘連嚴(yán)重，焦痂形成，術(shù)后并發(fā)癥多8ppt課件PK刀

新一代高頻電刀電凝電切優(yōu)點(diǎn)（1）熱效應(yīng)小，作用熱度為40～70℃；熱損傷較小，熱損傷范圍不超過4mm（2）可以閉合7mm以下的血管、能支持300mmHg的持續(xù)壓力（3）具有抓持、電凝、切割、分離和鈍性撥棒5種功能，縮短了手術(shù)時(shí)間，減少了術(shù)中出血（4）蒸汽脈沖凝固可使凝血可靠和完全（5）組織粘連較輕，焦痂形成少，術(shù)后并發(fā)癥少（6）切割準(zhǔn)確快捷、操作簡單缺點(diǎn)產(chǎn)生有毒煙霧，但較電刀少。

9ppt課件結(jié)扎速血管閉合系統(tǒng)（LigaSure）優(yōu)點(diǎn)（1）熱損傷?。▊?cè)向熱傳導(dǎo)距離1～2mm）（2）能完全和永久閉合直徑小于7mm的血管（3）閉合帶持久且?guī)缀跬该?，且比其他所有以能量為基礎(chǔ)的熔合方式都堅(jiān)固，可達(dá)到與縫線結(jié)扎相似的強(qiáng)度，可承受3倍的正常人體動(dòng)脈收縮壓（4）直接閉合組織束，無需切開和剝離（5）沒有或有極少粘連和焦痂形成，體內(nèi)無異物存留缺點(diǎn)（1）價(jià)格較貴（2）雖產(chǎn)生煙霧，但較電刀產(chǎn)生的少（3）不宜用于分離較精細(xì)的組織

10ppt課件超聲刀1993優(yōu)點(diǎn)（1）只產(chǎn)生小水滴而不產(chǎn)生煙霧，手術(shù)視野清晰（2）熱效應(yīng)小，作用熱度為80℃～100℃；熱損傷小，損傷周圍3mm范圍（3）兼有組織切割、凝固和分離的作用，且可精確控制切割和凝固范圍，縮短了手術(shù)時(shí)間，減少了術(shù)中出血（4）無電損傷的可能（5）組織粘連少，焦痂形成少，術(shù)后并發(fā)癥少（6）快速振蕩有自凈作用，不會(huì)發(fā)生刀與組織的粘合（7）適用于妊娠期腹腔鏡手術(shù)（8）可用來處理大網(wǎng)膜廣泛粘連的手術(shù)，網(wǎng)膜脂肪斷離無電凝攣縮現(xiàn)象，切口整齊，網(wǎng)膜血管凝固完全11ppt課件

超聲刀1993缺點(diǎn)（1）操作遲緩（2）價(jià)格昂貴（3）用于凝固直徑＜3mm的血管效果確切，但凝固較大的血管仍需使用其他方法（4）只能切凝與之接觸并有一定張力的組織，且每次不能切割太多組織12ppt課件微波刀優(yōu)點(diǎn)（1）不產(chǎn)生煙霧，術(shù)野清晰（2）無電損傷的可能，安全性高（3）熱效應(yīng)小，作用溫度一般在60℃～80℃（4）不碳化，術(shù)后并發(fā)癥少（5）止血效果可靠，術(shù)中出血少（6）設(shè)備價(jià)格低廉缺點(diǎn)（1）僅能凝固封閉直徑3mm以內(nèi)的血管（2）對(duì)膽管只起暫時(shí)性閉塞作用，不能凝固閉塞。13ppt課件氬氣刀優(yōu)點(diǎn)（1）止血時(shí)不會(huì)產(chǎn)生煙霧，術(shù)野清晰（2）組織損傷小，深度＜3mm（3）不接觸創(chuàng)面、能有效制止大面積出血，連續(xù)性凝固（4）熱效應(yīng)小，創(chuàng)面溫度控制在110℃（5）形成的焦痂致密，止血效果好（6）止血速度快，術(shù)中出血少缺點(diǎn)（1）僅能凝固直徑＜2mm的血管（2）有增加氣腹壓力的危險(xiǎn)，有可能促進(jìn)氣體栓塞和發(fā)生呼吸、循環(huán)功能障礙［25，26］（3）氬氣流量使用不當(dāng)，會(huì)影響止血和凝血效果，且有產(chǎn)生血管氣栓的可能14ppt課件射頻刀優(yōu)點(diǎn)（1）極少產(chǎn)生煙霧，術(shù)野清晰（2）熱效應(yīng)小，在組織下1mm深處的溫度≤55℃（3）熱損傷小，穿透深度僅50μm（4）不易發(fā)生電損傷（5）止血時(shí)不斷有鹽水滴出，止血效果好、止血精確、術(shù)中出血少（6）集組織止血、解剖、管道永久閉合等功能于一體缺點(diǎn)（1）僅能凝固直徑＜2mm的血管，對(duì)超過2mm血管止血時(shí)，不如超聲刀效果好，切割膜狀結(jié)構(gòu)時(shí)不如電刀快（2）需要在液態(tài)環(huán)境下工作，因此需要大量的生理鹽水（3）更換器械時(shí)，需開/關(guān)鹽水通路，相對(duì)不便15ppt課件器械鈦夾自動(dòng)切割吻合器閉合器縫扎內(nèi)套圈結(jié)扎16ppt課件鈦夾優(yōu)點(diǎn)（1）可根據(jù)需要夾閉直徑大小不同的血管，效果可靠（2）對(duì)周圍組織無損傷缺點(diǎn)（1）價(jià)格較貴（2）只用于能游離的血管（3）使用不可吸收的鈦夾使體內(nèi)存留了異物。17ppt課件縫扎優(yōu)點(diǎn)（1）止血可靠，適用于較大的血管或用其他方法無法止血時(shí)

（2）組織有切割傷時(shí)，可選用縫扎缺點(diǎn)（1）操作困難、費(fèi)時(shí)（2）易致誤損傷18ppt課件

卵巢功能評(píng)估19ppt課件AgeingandOvarianReserveAgeInfertilityPrevalenceOverall2.4%>34years11%>40years33%>45years87%>50years100%20ppt課件AgeingandOvarianReserve21ppt課件OvarianReserveTestingBasalTestingDay3FSHDay3EstradiolDay3InhibinDay3AntimüllerianHormoneUltrasoundthechniques

AntralFollicularCount(AFC)OvarainVolumeOvarianbloodflowAntralFollicleCountOvarianVolumeMeasurements22ppt課件OvarianReserveTestingDynamicTestingClomipheneCitrateChallengeTest(CCCT)ExogenousFSHOvarianReserveTest(EFORT)GnRHagoniststimulationtest(GAST)23ppt課件OvarianReserveTestingAnatomicaltest-ovarianbiopsy24ppt課件FollicleStimulatingHormone(FSH)UsuallymeasuredDay2or3ofcycleDifferentlaboratoriesdifferenttechniques/levelsWomenwith>10IU/ldoworseWomen>15mIU/lononetestdoworseonIVFSensitivity7%andPositivePredictiveValue90DateFooter25ppt課件SerumOestradiolE2aloneoflittlevalueSuggestedE2of>80pg/mlday3preIVFcycle-highercancellationrateSomeattemptstocombineE2andFSHlevelsOflittlevalueElevatedday3levelsindicatesubtleFSHincreasesnotdetectedbyassayNormalrange<300pMDateFooter26ppt課件InhibinβHeterodimericprotein32kDasimilartoAMHSelectivelyinhibitsFSH(TGF-βfamily)AssociatedwithelevatedFSHlevelsBUThighfalsepositiverateNOTCURENTLTYUSEFULDateFooter27ppt課件Anti-Mullerianhormone(AMH)AMHisaglycoproteinAppearsinfemalesatpubertyProducedbygranulosacellsofpre-antralandsmallantralfolliclesPhysiologicalfunction-preventexcessivefolliclerecruitmentNotcycledependant-canbemeasuredanydayLesscycletocyclevariationthanFSHNoreffectedbyGnRHagonists-canmeasureduringdownregulationClinicalrolenotdefinitelyestablishedAMH<1.26MorepromisingthanothertestBUTexpensiveDateFooter28ppt課件AntralFollicleCount(AFC)Follicles2to5mmonDay1or2Inter-observervariationSomecorrelationwithovarianresponsebutonlyatlowthresholdIfAFC<5-significantlyworseoutcomeBeforeageof37-AFCmeanyearlydeclineof4.8%Afterageof37-meanyearlydeclineof11.7%DateFooter29ppt課件OvarianvascularityTrans-vaginalpulseDopplercanassessovarianbloodflowHowevermuchheterogeneityoftechniquesDifferentequipmentVariationintechniqueSomesuggestionthathighvascularityinlatefollicularphasegoodprognosticsignNoclinicalvalueatpresen<3CM2DateFooter30ppt課件Clomiphenecitratechallengetest(CCCT)

MeasurebaselineE2,FSHandLH(day2-3)AdministerCC100mg/dayDays5to9MeasureE2,FSHandLHonDay9to11ExaggeratedFSHafterCCbadprognosticsignProbablynobetterthanbasalFSHOftenusedforpredictingInVitroFertilizationoutcomesPregnancyOR0.40-0.58when≥10IU/Loneitherday3or10Sensitivity26%andPositivePredictiveValue90+%DateFooter31ppt課件ExogenousFSHovarianreservetest(EFORT)

BaselineE2andFSHAdminister300IUFSHRecheckE2–24hourslaterOfnoprovenbenefitDateFooter32ppt課件GnRH-agoniststimulationtest(GAST)

Garcia1993PhysiologicalresponsetoGnRHagonistisaflarefollowedbysuppressionLatentimpairmentsofovarianfunctionmaybediagnosedbyabnormalresponseInsufficientdataforclinicaluseatpresentDateFooter33ppt課件OvarianbiopsyReproductivepotentialdependsonthenumberprimordialfolliclesinovariancortexCountingthenumberoffolliclesonovarianbiopsyisanattractiveconceptHoweverbiopsiesstudiedshowedahighvariationinfollicularnumbersOfnoclinicalvalueDateFooter34ppt課件止血與卵巢功能35ppt課件36ppt課件37ppt課件38ppt課件39ppt課件40ppt課件結(jié)論

兩組術(shù)后共發(fā)生卵巢儲(chǔ)備功能下降12例，縫合組4例，電凝組8例腹腔鏡下雙側(cè)卵巢內(nèi)異癥囊腫剝除術(shù)后可能造成卵巢儲(chǔ)備功能下降，對(duì)卵巢創(chuàng)面出血的處理，電凝法較單純縫合法所致卵巢儲(chǔ)備功能下降更加明顯。41ppt課件Theimpactofelectrocoagulationonovarianreserve

afterlaparoscopicexcisionofovariancysts:

aprospectiveclinicalstudyof191patients

Fertil

Steril2009

42ppt課件43ppt課件44ppt課件45ppt課件46ppt課件

Result(s):Whencomparingthebipolargroupandultrasonicscalpelgroupwiththesuturegroup,astatisticallysignificantincreaseofthemeanFSHvaluewasfoundinbilateral-cystpatientsat1-,3-,6-,and12-monthfollow-upevaluationsandinunilateral-cystpatientsatthe1-monthfollow-upevaluation.Statisticallysignificantdecreasesofbasalantralfolliclenumberandmeanovariandiameterwerefoundduringthe3-,6-,12-monthfollow-upevaluationsaswellasstatisticallysignificantdecreasesofpeaksystolicvelocityatallofthefollow-upevaluations.

Conclusion(s):

Electrocoagulationafterlaparoscopicexcisionofovariancystsisassociatedwithastatisticallysignificantreductioninovarianreserve,whichispartlyaconsequenceofthedamagetotheovarianvascularsystem.

47ppt課件48ppt課件49ppt課件50ppt課件51ppt課件52ppt課件53ppt課件54ppt課件Result(s):BipolarelectrocoagulationresultedinsignificantlymoredestructionperburnthantheCO2laserandmonopolar

lectrocoagulation(287.6versus24.0and70.0mm3,respectively).Thedamagefoundperlesionwasmultipliedbytheregularlyappliednumberofpuncturesperprocedureindailypractice(basedontheliterature).A