DİE Cerrahisinde Sinir Koruyucu Yaklaşım
Özet
Giriş
Klasik olarak derin infiltratif endometriozis (DİE), endometrial bezlerin ve stromanın periton yüzeyinden 5 mm ya da daha fazla altına uzanan ektopik büyümesi olarak tanımlanır. DİE eksizyonu esnasında pelvik otonom sinir sistemindeki sinir liflerinde iatrojenik yaralanmaların olduğu ve buna bağlı olarak organ disfonksiyonlarının gelişebildiği görülmüştür. DİE cerrahisinde karşılaşılan bu disfonksiyonlar nedeniyle, cerrahi müdahalenin etkinliğini tehlikeye atmadan, sempatik ve parasempatik cerrahi denervasyonu en aza indirmek suretiyle postoperatif visseral disfonksiyonu engellemeyi amaçlayan sinir koruyucu (SK) cerrahi kavramı önem kazanmıştır.
Tartışma
DİE nedeniyle sinir koruyucu cerrahi yapılan ve yapılmayan hastaları karşılaştıran çalışmalar incelendiğinde; üriner sistem ve gastrointestinal sistem komplikasyonları, cinsel disfonksiyon oranları arasında anlamlı farklılıklar bulunmaktadır. Bu kitap bölümümüzde sinir koruyucu yaklaşımın detayları anlatılmakta ve ilgili farklılar hakkında detaylı bilgi verilmektedir.
Sonuç
Son yıllarda yapılan kapsamlı araştırmalar cerrahi teknikleri iyileştirmiş ve cerrahi nöroanatomi anlayışımızı derinleştirmiştir. Bununla birlikte karmaşık patolojilerde bile SK cerrahinin uygulanabilirliğini ve faydalarını ortaya koymuştur. Ayrıca SK cerrahisi yerleşik cerrahi prensiplerin yerini almaz veya onlardan sapmaz; bunun yerine bu temel ilkeleri vurgular ve geliştirir.
Introduction
Deep infiltrative endometriosis (DİE) has been defined as endometrial glands and stroma growing ectopically deeper than 5 mm under the peritoneum. It has been observed that during the excision of DIE, iatrogenic injuries occur in the nerve fibers in the pelvic autonomic nervous system and organ dysfunctions may develop as a result. Due to these dysfunctions encountered in DIE surgery, the concept of nerve-sparing (NS) surgery, which aims to prevent postoperative visceral dysfunction by minimizing sympathetic and parasympathetic surgical denervation without compromising the effectiveness of the surgical intervention, has gained importance.
Discussion
Studies comparing patients with and without NS surgery due to DIE are examined; There are significant differences between the rates of urinary system and gastrointestinal system complications and sexual dysfunction. In this section of the book, the details of the NS approach are explained and detailed information is given about the relevant differences.
Conclusion
Extensive research in recent years has improved surgical techniques and deepened our understanding of surgical neuroanatomy. However, these studies have also demonstrated the feasibility and benefits of NS surgery even in complex pathologies. Additionally, NS surgery does not replace or deviate from established surgical principles; instead, it emphasizes and develops these basic procedures.
NS surgical techniques are now at the forefront of endometriosis management, raising hope for patients to improve their quality of life in their relentless fight against endometriosis.
Referanslar
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Giudice LC: Clinical practice. Endometriosis. N Engl J Med. 362(25):2389-98, 2010
Nisenblat V. Bossuyt P.M. Farquhar C. Johnson N. Hull M.L.Imaging modalities for the non-invasive diagnosis of endometriosis.Cochrane Database Syst Rev. 2016;
Ata B, Uncu G. Impact of endometriomas and their removal on ovarian reserve. Curr Opin Obstet Gynecol. 2015;27:235–241.
Becker C.M., Bokor A., Heikinheimo O., Horne A., Jansen F., Kiesel L., et. al.: ESHRE guideline: endometriosis. Hum Reprod Open 2022; 2022:
Possover M, Diebolder H, Plaul K, Schneider A.Laparascopically assisted vaginal resection of rectovaginal endometriosis Obstet Gynecol. 2000 Aug;96(2):304-7.
Kondo W, Bourdel N, Tamburro S, Cavoli D, Jardon K, Rabischong B, Botchorishvili R, Pouly J, Mage G, Canis M.Complications after surgery for deeply infiltrating pelvic endometriosis BJOG. 2011 Feb;118(3):292-8.
Berlanda N, Somigliana E, Frattaruolo MP, Buggio L, Dridi D, Vercellini P.Surgery versus hormonal therapy for deep endometriosis: is it a choice of the physician?Eur J Obstet Gynecol Reprod Biol. 2017 Feb;209:67-71.
Dubernard G, Rouzier R, David-Montefiore E, Bazot M, Daraï E. Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gynecol. 2008 Mar-Apr;15(2):235-40.
Possover M.: Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 2014; 101: pp. 754-758.
Lemos N., Possover M.: Laparoscopic approach to intrapelvic nerve entrapments. J Hip Preserv Surg 2015; 2: pp. 92-98.
Butler-Manuel S.: Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative study of nerve types in the uterine supporting ligaments. J Soc Gynecol Invest 2002; 9: pp. 47-56.
Volpi E., Ferrero A., Sismondi P.: Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surgical Endoscopy and Other Interventional Techniques 2004; 18: pp. 1109-1112.
Kavallaris A., Banz C., Chalvatzas N., Hornemann A., Luedders D., Diedrich K., et. al.: Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients' outcome. Arch Gynecol Obstet 2011; 284: pp. 131-135.
Che X., Huang X., Zhang J., Xu H., Zhang X.: Is nerve-sparing surgery suitable for deeply infiltrating endometriosis?. Eur J Obstet Gynecol Reprod Biol 2014; 175: pp. 87-91.
Darwish B., Roman H.: Nerve sparing and surgery for deep infiltrating endometriosis: pessimism of the intellect or optimism of the will. Semin Reprod Med 2017; 35: pp. 72-80.
Fujii S.: Original film of the Okabayashi's radical hysterectomy by Okabayashi himself in 1932, and two films of the precise anatomy necessary for nerve-sparing Okabayashi's radical hysterectomy clarified by Shingo Fujii. Int J Gynecol Cancer 2008; 18: pp. 383-385.
Red Wine D.B.: Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56: pp. 628-634.
Bonneau C., Zilberman S., Ballester M., Thomin A., Thomassin-Naggara I., Bazot M., et. al.: Incidence of pre- and postoperative urinary dysfunction associated with deep infiltrating endometriosis: relevance of urodynamic tests and therapeutic implications (no DOI). Minerva Ginecol 2013; 65:
Fujii S., Takakura K., Matsumura N., Higuchi T., Yura S., Mandai M., et. al.: Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol 2007; 107: pp. 4-13.
Possover M., Stöber S., Plaul K., Schneider A.: Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III. Gynecol Oncol 2000; 79: pp. 154-157.
Possover M., Quakernack J., Chiantera V.: The LANN technique to reduce postoperative functional morbidity in laparoscopic radical pelvic surgery. J Am Coll Surg 2005; 201: pp. 913-917.
Catello M., Donna D., Cucinella G., Sozzi G., Ianieri M.M., Scambia G., et. al.: Surgical neuropelviology: combined sacral plexus neurolysis and laparoscopic laterally extended endopelvic resection in deep lateral pelvic endometriosis. J Minim Invasive Gynecol 2021; 28: pp. 1565.
Chiantera V., Petrillo M., Abesadze E., Sozzi G., Dessole M., Catello Di Donna M., et. al.: Laparoscopic neuronavigation for deep lateral pelvic endometriosis: clinical and surgical implications. J Minim Invasive Gynecol 2018; 25: pp. 1217-1223.
Ceccaroni M., Clarizia R., Bruni F., D'Urso E., Gagliardi M.L., Roviglione G., et. al.: Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the negrar method. A single-center, prospective, clinical trial. Surg Endosc 2012; 26: pp. 2029-2045.
Ceccaroni M., Clarizia R., Roviglione G.: Nerve-sparing surgery for deep infiltrating endometriosis: laparoscopic eradication of deep infiltrating endometriosis with rectal and parametrial resection according to the negrar method - video article. J Minim Invasive Gynecol 2020; 27: pp. 263-264.
Ceccaroni M., Roviglione G., Kapurubandara S., Ruffo G.: Laparoscopic eradication of Deep Endometriosis with segmental recto-sigmoid resection and bilateral posterior parametrectomy with nerve-sparing “touchless” technique according to the “Negrar Method”. J Minim Invasive Gynecol 2023;
Seracchioli R., Mabrouk M., Mastronardi M., Raimondo D., Arena A., Del Forno S., et. al.: Anatomic cartography of the hypogastric nerves and surgical insights for autonomic preservation during radical pelvic procedures. J Minim Invasive Gynecol 2019; 26: pp. 1340-1345.
Kanno K., Andou M., Aiko K., Yoshino Y., Sawada M., Sakate S., et. al.: Fertility- and nerve-sparing laparoscopic eradication of deep endometriosis with total posterior compartment peritonectomy: the kurashiki method. J Minim Invasive Gynecol 2021; 28: pp. 170-171.
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Sayfalar
279-292
Gelecek
21 Ocak 2025
Telif Hakkı (c) 2025 Akademisyen Yayınevi Kitap DOI Portalı
