Application of minimally invasive technique in gynecological tumor therapy

In 1983 England Wickham first proposed the concept of minimally invasive surgery. "Modern minimally invasive" is not just the smallest incision, but should have a new concept, that is, in the process of medical intervention, to maintain the best internal environment of the state of stability, the smallest tissue damage, the lightest inflammatory response, the best Of the scar healing and to achieve the best medical results [1]. Gynecological minimally invasive not only include hysteroscopy, laparoscopy, various interventional therapy and vaginal surgery, but also a variety of small incision surgery. Palace laparoscopic technology to gynecological diagnosis has undergone a revolutionary change, but also the treatment into a new concept and technology. Palace laparoscopic technology to build a gynecological minimally invasive platform, gradually become the mainstream of minimally invasive treatment of gynecological tumors.
 
First, the progress of laparoscopy in the treatment of gynecological tumors
 
1. Progress in laparoscopic treatment of gynecological benign tumors: In 1989, Harry Rein took the lead in laparoscopic total hysterectomy to enter the new era of gynecological endoscopic surgery. Laparoscopy has become the most widely used, the best results, the most promising "minimally invasive gynecological" surgery, almost all of the ovarian tubal benign lesions can be completed under the laparoscopic surgery, a great replacement of open surgery trend. Even if the huge ovarian cysts, but also in the small incision under the eyes of the capsule out of the capsule after the volume of cysts into the abdominal cavity, laparoscopic resection of the capsule, and even directly from the small incision pulled out of the abdominal cavity, Cut back to the abdominal cavity after losing the requirements of minimally invasive. With the use of single-hole laparoscopy and micro-laparoscopy, ovarian cysts are smaller, less, and more. Ovarian cyst laparoscopic surgery is most likely to be controversial before surgery can not determine the benign and malignant ovarian cysts, cyst rupture during surgery and cause pelvic spread of malignant tumor cells. So before surgery, according to imaging and tumor markers to fully assess the nature of the tumor, the surgery as far as possible complete stripping of cysts, intraoperative routine to send rapid pathology, malignant tendencies in a timely manner to expand the operation.
 
Laparoscopic surgery has become the gold standard for the diagnosis of endometriosis, is the treatment of peritoneal and ovarian endometriosis preferred method. But the pelvic severe adhesions and deep endometriosis surgery complicated, but also the operator skilled surgical techniques and postoperative system management.
 
Uterine fibroid surgery has entered a minimally invasive era, the current laparoscopic total hysterectomy (TLH) is more mature and safe surgery. Compared with the vaginal hysterectomy, larger volume of uterine fibroids and pelvic adhesions with hysterectomy using laparoscopic more dominant. Laparoscopic myomectomy (TLM) requires the need for microscopic suture technology and easy bleeding, requiring surgery to have more skilled surgical skills. Malzoni et al [2] proposed TLM contraindications: (1) more fibroids> 10; (2) gestational uterus; (3) uterine fibroids have a tendency to vicious. Special growth sites of fibroids (such as cervical fibroids, submucosal uterine fibroids) and the larger uterine fibroids is relatively taboo.
 
Gynecological malignant tumor laparoscopic treatment progress: early endometrial cancer staging surgery and cervical cancer radical surgery can be performed under the laparoscopic, surgical scope and surgical outcome and laparotomy no significant difference. Even stage Ⅲ endometrial cancer can also be laparoscopic pelvic and abdominal aortic lymph node biopsy in order to facilitate surgical staging, determine the choice of the next treatment. Laparoscopic extensive cervical resection and pelvic lymphadenectomy is a safe and effective surgical method of preserving fertility. Laparoscopic total staging of ovarian cancer is a more difficult operation, but also controversial surgery. Recent studies have shown that the 5-year survival rate of laparoscopic surgery for early, low-risk or low-grade ovarian cancer patients is similar to that of open surgery [3]. For the future laparoscopic ovarian cancer surgery has laid a theoretical foundation for ovarian cancer for many years is not suitable for laparoscopic surgery controversy raised the challenge. Now that can be under the laparoscopic phase III within the implementation of a comprehensive ovarian cancer surgery. Laparoscopic completion of all operations, including the whole uterus, double attachment, large net, appendix and pelvic and abdominal aortic lymph node dissection. Vaginal cancer treatment purposes and methods similar to cervical cancer, generally applicable to stage Ⅰ and Ⅱ a period of local infiltration patients, the lesion is located in the vagina in 1/3 of patients, you can use extensive hysterectomy and total vaginal resection and pelvic Lymph node dissection. At present, laparoscopic total vaginal resection of vaginal cancer reported little, but with its less bleeding, resection of the complete advantages of the organization, will provide another treatment for patients with vaginal cancer.
 
On the complete problem of malignant tumor laparoscopic surgery, gynecologic oncology experts have been the focus of attention. At present, the scope of laparoscopic tumor surgery and evaluation measures are still the same as the standard of open surgery, and laparoscopic surgery itself can not be compared with the advantages of laparotomy: (1) field of vision has a magnifying effect and good light, (2) laparoscopic surgery using ultrasound knife cutting tissue, without leaving the ligation of the organization and removal of tissue more thoroughly, to stop bleeding better. (2) laparoscopic surgery, However, due to laparoscopic surgery more use of energy devices, burning tissue and accidental injury ureter and intestine more open surgery, but with the increase in surgical proficiency, this complication is also gradually reduced.
 
3. Laparoscopic equipment improvement and development: single-hole laparoscopic and 3 mm microporous laparoscopic use of surgical incision smaller, more beautiful surface, so that laparoscopic technology is more invasive, more easily accepted for patients. Due to the limitations of the operating space and the impact of the intensity of the device, at present can only complete a simple attachment surgery and small hysterectomy surgery [4]. Robotic laparoscopic surgery (roboticlaparoscopy) application to improve the dexterity of surgery and high resolution of optical instruments, reducing the operator's labor intensity, can be ovarian cyst myomectomy and hysterectomy surgery, but the robot is not touch, lack of Pressure grip force feedback system, its indications and surgical effects still need further exploration [5]. Laparoscopic energy system experienced a single pole electric knife, bipolar, plasma knife and ultrasonic knife development, ultrasonic knife on the body without electrophysiological effects, cutting precision, can be solidified 3 ~ 4 mm blood vessels, hemostatic, controllable The Ligasur can be closed 7 mm blood vessels, heat conduction only 1.5 ~ 2 mm. PK plasma knife using the principle of steam pulse in the energy intermittent cooling effect, reduce tissue temperature, thermal diffusion <1 mm, can be used to close within 7 mm of blood vessels. The VIO system in the field of high frequency electrosurgery has all the functions required for surgical resection, electrocoagulation, tissue deactivation gasification, macrovascular closure and plasma double ion cutting, which provides the greatest convenience and safety for surgery.
 
Second, the application of hysteroscopy in the treatment of gynecological tumors
 
1. Hysteroscopy treatment of uterine fibroids: hysteroscopic uterine fibroids is the first way to deal with submucosal uterine fibroids, fertility requirements or to retain the best choice for uterine patients. Intraoperative ultrasound monitoring is the best way to prevent perforation of the uterus. The most common complication of uterine fibroid resection is TURP syndrome, which uses plasma bipolar resection (TURis) to use the electrode around the saline-mediated circuit to produce plasma, to achieve the cutting effect, due to the use of saline as the uterine distention medium, Reduced the incidence of hyponatremia. Intrauterine morcellator (IUM) [6] application, so that the removal of tissue fragments easy to remove, surgical field of vision clean, more clear, reducing the mirror repeatedly into the uterine cavity caused by air embolism, due to shorten the operation time Significantly reduced the fluid load, thereby reducing the occurrence of TURP syndrome, the operation becomes more simple and safe. Attractive new cutting equipment has been added to the suction device, while cutting tissue tissue at the same time, to maintain a clear vision, its clinical efficacy is still in the assessment. Japan Lin Baoliang and so on the use of special fibroids can be achieved by sub-mucosal uterine fibroids stripping surgery to ensure tissue integrity, and less bleeding.
 
2. Hysteroscopy diagnosis and treatment of uterine malignancy progress: hysteroscopy plus endometrial biopsy in the diagnosis of endometrial lesions play an important role. Hysteroscopy to obtain specimens to diagnose endometrial cancer than ultrasound plus diagnostic method is more reliable. But its sensitivity is only 80% [7], indicating that only morphological changes in the endometrium is not enough to make a diagnosis. Endometrial narrowband imaging (NBI) technology to make up for the general hysteroscopy can not see the lack of microvascular structure, NBI is the use of xenon light source in the visible spectrum of blue light imaging, you can clearly see the microvascular structure, to help physician identification Accompanied by dense and irregular microvascular suspicious sites to early detection of endometrial lesions, increase the accuracy of microscopic recognition of endometrial cancer and endometrial hyperplasia [8].
 
In recent years, cervical endometrial resection (TCRE) and endometrial ablation (EA) have been involved in the treatment of endometrial precancerous lesions and early endometrial cancer, TCRE supplemented by high-dose radiotherapy treatment contraindications Of patients with endometrial cancer. Skilled hysteroscopic resection may be an alternative to conditional follow-up of atypical hyperplasia in patients with hysterectomy. For endoscopic examination of endometrial cancer cells spread, Obemair et al [9] conducted a multi-center retrospective analysis showed that fluid swelling and perfusion can cause endometrial cancer cells spread, but whether caused by cancer cell metastasis and planting Need further follow-up. Selvaggi et al. [10] suggested that at low dilatation pressure (20 to 50 mm Hg), fluid expansion did not increase the risk of peritoneal transmission of endometrial cancer.
 
Third, vaginal surgery
 
With the concept of minimally invasive surgery was introduced into the gynecological field, in line with minimally invasive principles of vaginal hysterectomy surgery to get the attention of gynecologists at home and abroad, and gradually showing the replacement of some of the classic abdominal hysterectomy and partial laparoscopic hysterectomy Trend, a modern surgical way to add and innovate.
 
1. vaginal uterine total resection (transvaginal supercervical hysterectomy, TVSH): a less traumatic way to replace the previous need to complete the completion of the sub-hysterectomy has become a concept, inspired by this idea, At home and abroad a small number of non-prolapsed uterus vaginal hysterectomy exquisite doctor tried a smaller than the laparoscopic wounds of the transvaginal uterine subtotal resection, and achieved initial results. There are physicians on the basis of this operation, learn from the experience of laparoscopic hysterectomy, the use of special equipment to remove the cervix and its surrounding parts of the organization, to retain the outer sheath of the cervix, called intravaginal hysterectomy (Transvaginal intrafascial supercervical hysterectomy, TISH).
 
2. laparoscope assisted vaginal hysterectomy (LAVH): LAVH is essentially an improvement in vaginal hysterectomy. Through the laparoscopic exploration of pelvic organs, visual ovarian situation, excluding malignant changes, so that more safe vaginal surgery, so that some of the more difficult non-prolapsed uterus by vaginal hysterectomy become easy. LAVH for uterine fibroids, adenomyosis, benign endometrial disease, severe cervical dysplasia or carcinoma in situ. Uterine activity is poor, it is estimated that patients with severe pelvic adhesions and other not suitable for abdominal hysterectomy under the circumstances can be considered to do LAVH.
 
3. Small open abdominal assisted vaginal hysterectomy (minilaparotomically assisted vaginal hysterectomy, MAVH): South Korea Choi and other changes to create a new minimally invasive vaginal hysterectomy, MAVH simple to learn, incision pain is light, less complications, not The need for expensive equipment is a safe and effective alternative to most transabdominal hysterectomy.
 
4. vaginal uterine fibroid resection: located in the lower uterine segment or anterior and posterior wall of the subserosal uterine fibroids is particularly suitable for vaginal myomectomy.
 
Fourth, interventional therapy
 
The use of interventional methods for the treatment of gynecological malignancies began in 1952, with the interventional radiation technology, interventional devices, interventional embolization materials and chemotherapy drugs continue to develop and mature, the method has been widely used in the treatment of various gynecological malignancies, the effect is better than a single Intravenous chemotherapy and intraperitoneal chemotherapy, can significantly improve the 3-year, 5-year survival rate.
 
1. Cervical cancer vascular interventional chemotherapy: mainly used for histological cytology suggest that poorly differentiated or can not direct surgery in patients with advanced cervical cancer, advanced cervical cancer before surgery combined with chemotherapy can effectively reduce the lesion, reverse staging, reduce intraoperative bleeding , To improve the surgical resection rate, reduce the local recurrence rate of tumor, thereby improving the survival rate and the opportunity to patients with advanced surgery palliative treatment [11]. But simply involved in chemotherapy can only achieve better near-term efficacy, but also combined with surgery or radiotherapy in order to improve the overall long-term efficacy.
 
2. Ovarian cancer vascular interventional chemotherapy: Ovarian cancer treatment mostly in the late, often extensive implantation of pelvic metastasis, surgery is difficult to completely removed, after treatment with pelvic recurrence, pelvic arterial interventional chemotherapy can improve the pelvic floor Drug concentration and increase drug maintenance time, can effectively control the pelvic foci, improve the surgical resection rate [12].
 
3. Advanced endometrial cancer interventional chemotherapy: uterine arterial chemoembolization can make advanced endometrial cancer foci shrink, reduce staging, control lymphatic metastasis, conducive to surgical resection, reduce intraoperative postoperative distant metastasis. For young people who want to retain fertility, chemotherapy is one of the options.
 
4. Arterial chemotherapy pump indwelling: In order to avoid each treatment repeated puncture femoral artery, can be placed in the first treatment of arterial chemotherapy pump, chemotherapy pump placement technology is simple, easy to use in the future, worthy of study and application [12].
 
Uterine artery arterial embolization (UAE): uterine artery arteries embolization (UAE): to retain reproductive function or surgical contraindications of uterine fibroids patients provide a minimally invasive conservative treatment, UAE can significantly reduce the size of fibroids , Reduce menstrual flow, low recurrence rate, fewer complications. But the safety of patients with fertility requirements to be further studied. UAE is not a radical treatment, can not replace the traditional gynecological surgery.
 

Five, cold or hot coagulation treatment

1. High intensity focused ultrasound (HIFU): HIFU treatment of uterine fibroids, is the use of ultrasound can be focused and energy through human nature, from low-energy ultrasound in vitro gathered in the body lesions, causing transient high temperature Effect, the target tissue temperature within 0.5 ~ 1.0 s rise to 65 ~ 100 ℃, so that the damaged tissue coagulation necrosis and then gradually dissolved by the body absorption or fibrosis [12]. Transient cavitation effects, mechanical effects and acoustic chemical effects such as non-thermal mechanism can also directly kill tumor cells. HIFU treatment of uterine leiomyoma has a clear effect.
 
2. Microwave ablation therapy: microwave ablation treatment of tumor is the use of microwave biological tissue of the ion heating and dipole heating mechanism, resulting in the role of tissue local temperature rise and coagulation, necrosis. This method is applicable to submucosal submucosal fibroids, pedicled submucosal fibroids and cervical fibroids.
 
3. Radiofrequency ablation: radiofrequency ablation of uterine fibroids began in 2000. Since then, with the birth of radiofrequency ablation, the vagina, the cervix, uterine cavity to the fibroids into the radio frequency self-curing knife treatment of uterine fibroids have been widely used clinical. Radiofrequency ablation can help patients who are unfit for or do not want to undergo treatment and have the greatest possible retention of normal tissue. Radiofrequency ablation can reduce the expression of ER and PR in non-necrotic cells, so radiofrequency is expected to be a new method of minimally invasive treatment of uterine fibroids [13].
 
4. Frozen treatment: frozen treatment of uterine fibroids reported in the literature there are two main methods, one is laparoscopic guided percutaneous puncture, into the tumor into the frozen probe, with a safe minimally invasive, small response, non-toxic side effects, efficacy Accurate and other advantages, with the laparoscopic surgical instruments and surgical techniques continue to improve, argon helium cryotherapy and laparoscopic surgery, clear vision, to avoid damage to adjacent organs, improve the safety of surgery. The other is the vagina, cervical natural cavity into the frozen probe, ablation of fibroids, after treatment, clinical symptoms improved, the volume reduction, but long-term efficacy still need to evaluate. There are also reports of MRI-guided percutaneous treatment of uterine fibroids.
 
In summary, minimally invasive techniques with its trauma, less bleeding, postoperative complications is low, fast recovery, short hospital stay, the role of gynecological disease in the treatment of more and more people's attention in gynecological tumors Diagnosis and treatment gradually play an irreplaceable role. With the continuous development of science and technology, the accumulation of clinical experience, after summing up the improvement, and soon the future minimally invasive technology in the treatment of gynecological diseases will occupy a dominant position.