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1 原著 The Present State of Laparoscopic Operations for Ovarian Tumors and Uterine Myomas at Fukushima Red Cross Hospital : A Study Concerning the Indications for and Limitations of Laparoscopy SUMIKO ENDO, SYOUTARO HAYASHI and HIROYUKI YAZAWA Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima, , Japan : minimally invasive surgery , % % % % % port - site metastasis : E - mail : ikyoku12@fukushima - med - jrc.jp GACT
2 : Abstract : In gynecologic surgery, endoscopic operations are becoming increasingly popular as minimally invasive procedures. In our department, the number of endoscopic surgeries has increased each year ; out of 1,007 operations from January 2002 to December 2009, there were % laparoscopic excisions of ovarian tumors, % laparoscopically assisted vaginal hysterectomies, and % laparoscopic myomectomies. Of the 189 endoscopic operations performed in 2009, there were 100 procedures for ovarian tumor, 25 hysterectomies and 18 laparoscopic myomectomies. These three procedures comprised over 70% of all endoscopic operations. We investigated the indications for and limitations of laparoscopic surgeries in our department to assess whether it is feasible to expand the use of laparoscopy for ovarian tumors and uterine myomas. In operations for ovarian tumors, laparotomy used to be selected for malignant or strongly suspicious tumors in our department. To expand the indication of laparoscopy for ovarian tumors, more precise preoperative diagnosis to distinguish malignant from benign tumors and preparations for intraoperative pathological examination frozen section of suspicious tumors are needed. Laparoscopic techniques to prevent tumor rupture and port - site metastasis also seem to be needed to expand the indication. The introduction of laparoscopic operations for early stage malignant gynecologic tumors or borderline malignant ovarian tumors should also be considered in the future. In the operations for uterine myomas, the size of the tumor or the uterus is the limiting factor for the laparoscopic approach. In the present state of our department, improving the surgeons laparoscopic skill set and selecting the appropriate surgical approach for each patient seem to be the most important matters to address when attempting to expand the indication for laparoscopic vaginal hysterectomy or myomectomy. Laparoscopic surgeries, being less invasive than laparotomies, potentially have fewer complications, but departmental assessment should be conducted before expanding the incidations for laparoscopy. It is important to understand the present state of the department and take measures to expand the indications thereof. Key words : laparoscopic surgery, ovarian tumor, laparoscopic myomectomy, laparoscopically assisted vaginal hysterectomy, malignant tumor minimally invasive surgery 2001 : 1
3 2 : 3 2 open 12 mm first trocar CO mm 12 mm trocar MRI cm Sand - baloon catheter port site cystectomy 1 Endocatch 2 port site port site LapDisk mini 3 2 a 600 g A Sand - baloon catheter B port site C D
4 福 島 医 学 雑 誌 61 巻 1 号 図 2. 体腔内法による右付属器摘出術 可動性良好な右卵巣腫瘍であり A 卵管 卵巣固有 帯 骨盤漏斗 帯を切断 Harmonic Ace 使用 して付属器を摘出 B,C Endocatch 内に収容して内容液を 刺吸引後 D,E port site よ り回収した F 図 3. LapDisk mini を用いた体腔外法による左卵巣腫瘍摘出術 悪性腫瘍 境界悪性腫瘍も否定できない症例に対する手術 腹水貯留を認める場合にはネラトンカテーテル挿入してこれを採取し細胞診へ提出する A Port site にはあらかじめ LapDisk mini を装着し 核出時に腫瘍と port site の接触を回避する D,E 本 症例では迅速病理検査にて境界悪性卵巣腫瘍の診断となり引き続き開腹のうえ根治手術を行った う腹腔鏡補助下腟式子宮全摘術 LAVH : laparoscopically assisted vaginal hysterectomy 2 子宮 動脈の結紮切断までを行う腹腔鏡下子宮全摘術 LH : laparoscopic hysterectomy 3 摘 出 子 宮 の経腟的体外回収以外の全ての操作を腹腔鏡下で 行う全腹腔鏡下子宮全摘術 TLH : total laparoscopic hysterectomy これらの術式のうち当院 では当初は LAVH を主に行っていたが 現在で は腹腔鏡下に子宮動脈を結紮することによって出 血量を減少できる利点があるため主に LH を標準 術式として採用している また最近では適応の拡 大に向けて症例により TLH も行っている b 子宮筋腫核出術 米 国 産 婦 人 科 学 会 ACOG : The American College of Obstetricians and Gynecologists の勧告 では 5 8 cm を越える筋腫 多発性の筋腫 深 い筋層内筋腫では開腹または腹腔鏡補助による筋 腫核出術を推奨している6 現在当院では 単発 性筋腫であれば 7 8 cm 以下 多発性であれば 5 個以下を概ね腹腔鏡下子宮筋腫核出術の適応とし ている 術式には 腹腔鏡補助下に小切開を加え て核出を行う腹腔鏡補助下子宮筋腫核出術 -
5 遠藤他 2 名 : 福島赤十字病院産婦人科における卵巣腫瘍 子宮筋腫に対する腹腔鏡下手術の現状 図 4. 腹腔鏡下腟式子宮全摘術の実際 子宮上部 帯の切断を行う LAVH A 後腹膜腔を展開し子宮動脈と尿管の走行を確認し 子宮動 脈の切断を行う LH B,C 基 帯を結紮切断後 腟管を腹腔鏡下に切断し D 摘出子宮を径腟的 に回収後腟断端を腹腔鏡下に縫合閉鎖する TLH E 腹腔鏡下腟式子宮全摘術施行し後腹膜縫合を 終了したところ F 図 5. 腹腔鏡下子宮筋腫核出術 LM の実際 子宮体部後壁の筋層内筋腫であり A 筋腫核上の筋層を切開して B 筋腫を核出し C 核出 の縫合を行った D LM では これら全ての操作を腹腔鏡下で行い 筋腫核は電動モルセレー ターを用いて腹腔内で細切して体外へ回収した E 5 LAM : laparoscopically assisted myomectomy と 結 果 腹腔鏡下に核出 縫合等全ての操作を行う腹腔鏡 下子宮筋腫核出術 LM : laparoscopic myomecto内視鏡下手術件数の推移 my があり 図 5 現在当院では LM を標準術 図 6 には当院での年次毎の内視鏡下手術件数 式としている 腹腔鏡 子宮鏡 を示しているが 内視鏡下手 腹腔鏡下腟式子宮全摘術 LAVH+LH や腹腔 術件数は年々増加する傾向にある 2002 年から 鏡下の子宮筋腫核出術 LAM LM における 2009 年までの 8 年間における内視鏡下での総手 手術成績 摘出物重量 術中出血量 手術時間 術件数は開腹手術へ移行した症例も含めて 1,007 件 で あ り こ の う ち 卵 巣 腫 瘍 手 術 が 473 件 をそれぞれ開腹での子宮筋腫核出術 腹式子宮全 摘術 ATH : abdominal total hysterectomy の成 47.0% 子宮全摘術が 215 件 21.4% 子宮筋 腫核出術が 49 件 4.9% であった 2009 年 1 年 績と比較検討した
6 : : : % % % % % 22 1 ATH LAVH/LH myomectomy LAM/LM 1 8
7 2 : 7 1. g ml min. ATH LAVH+LH (myomectomy) LAM+LM myomectomy LAM+LM 7 8 MRI ,12 12 cm 7 MRI MRI 93%
8 福 島 医 学 雑 誌 61 巻 1 号 図 9. 術前には悪性腫瘍が疑われたが良性腫瘍であった症例 悪性腫瘍を疑い開腹手術を行ったが 術中迅速病理検査 術後診断で良性甲状腺腫 struma ovarii であった 図 10. 術前には良性腫瘍と思われたが悪性腫瘍であった症例 良性腫瘍の診断で腹腔鏡下付属器摘出術を行ったが 術中の迅速病理検査は施行していない 術後 の診断で漿液性腺癌の診断となり 後日に開腹のうえ卵巣癌根治手術を行った 件の迅速病理検査のうち 46 件 68% は良性腫 瘍であったことも踏まえて 表 2 不必要な開腹 手術を避けるために 悪性を否定できない腫瘍で あっても悪性を強く疑うものでなければ可能な限 り腹腔鏡下での手術を選択するようにしている 子宮筋腫手術について 子宮全摘術 子宮筋腫核出術のいずれの手術に おいても 開腹と腹腔鏡下手術では摘出物の重量 には大きな差が認められた 表 1 腹腔鏡下で の子宮筋腫手術は 子宮上部靭帯の処理 子宮動 脈の同定 結紮 切断 尿管の同定 剥離 ある いは筋腫核出 核出創の縫合など 卵巣腫瘍手術 に比べてより高度なテクニックを必要とする手術 である そのため 手術可能な大きさには制限が ある 術前に内視鏡下手術にするかどうかを決め る際にある程度より大きな筋腫の場合には腹腔鏡 下手術の適応外としている のが現状であり 子
9 2 : : : % : ; 46 68% ; 6 ; 16 : 44 ; ; 25 57% ; 5 ; 14 : 24 ; ; 21 88% ; 1 ; % LM 400 g LM 8 TLH staging up stage port site port site LapDisk mini 3 2 up stage port - site metastasis 10% I 90% III IV 5 96% 77% 2.4%/ Ia 2010 staging laparotomy comprehensive staging peritoneal implant noninvasive or invasive 19 Morice ATH+BSO 2.1% adnectomy cystectomy 7.1% 36.3% 20 Zanetta radical surgery 4.7% fertility sparing surgery 18.5% 21 Suh - Burgmann cystectomy 23% adnectomy 7% 22 Yinon cystectomy 22.7% adnectomy 27.5% 23 I 20
10 Ia 29 Satoh 211 I Ia favorable histology serous, mucinous, endometrioid, or mixed histology and grade 1 or 2 Ia clear cell histology Ic favorable histology staging surgery I NCCN National comprehensive cancer network Nezhat CT, Siegler AM, Nezhat FR, Alvin M, et al. Complications, In : Nezhat CR, ed, Operative gynecologic laparoscopy, 2nd ed, MacGraw - Hill Professional Publishing, New York, p , med - jrc.jp/. 3. Meikle SF, Nugent EW, Orleans M. Complications and recovery from laparoscopy assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol, 89 : , : 55-60, : 63-74, Clinical management Guidline for the obstetrics and gynecologist. Surgical alternatives to hysterectomy in the management of leiomyomas. American College of Obstetricians and Gynecologists ACOG. Number 16, May In : 2004 Compedendium of Selected Publications. Washington, DC : ACOG ,
11 2 : : , Sassone AM, Timor - Tritsch IE, ArtnerA, Westhoff C, et al. Transvaginal sonographic characterization of ovarian disease : Evaluation of a new scoring system to predict ovarian malignancy. Obstet Gynecol, 78 : 70-76, Hricak H, Chen M, Caukley FV, Kinkel K, et al. Complex adnexal masses : Detection and characterization with MR imaging Multivariate analysis. Radiology, 214 : 39-46, Kidron D, Bernheim J, Aviram R, Cohen I, et al. Resistance to blood flow in ovarian tumors : correlation between resistance index and histological pattern of vascularization. Ultrasound Obstet Gynecol, 13 : , p 549, Jeoung HY, Choi HS, Lim YS, Lee MY, et al. The efficacy of sonographic morphology indexing and serum CA for preoperative differentiation of malignant from benign ovarian tumors in patients after operation with ovarian tumors. J Gynecol Oncol, 19 : , : 63-66, : 67-72, Lecuru F, Desfeux P, Camate S, Bissery A, et al. Stage I ovarian cancer : comparison of laparoscpy and laparotomy of staging and survival. Eur J Gynecol Oncol, 25 : , Bostwick DG, Tazelaar HD, Ballon SC, Hendrickson MR, et al. Ovarian epithelial tumors of borderline malignancy. A clinical and pathlogic study of 109 cases. Cancer, 58 : , Yokoyama Y, Moriya T, Takano T, Shoji T, et al. Clinical outcome and risk factors for recurrence in borderline ovarian tumors. Br J Cancer, 94 : , Heintz QP, Odicvino F, Maisonneuve P, Beller U, et al. Carcinoma of the ovary. Int J Gynecol Obstet, 83 supple 1 : , p 40-41, Morice P, Camatta S, Hassan J, Pautier P, et al. Clinical outcomes and fertility after conservative treatment of ovarian borderline tumors. Fertil Steril, 75 : 92-96, Zanetta G, Rota S, Bonazzi C, Bratina G, et al. Behavior of borderline tumors with particular interest to persistence, recurrence and progression to invasive carcinoma : a prospective study. J Clin Oncol, 19 : , Suh - Burgmann, E. Long - term outcomes following conservative surgery for borderline tumor of the ovary : A large population - based study. Gynecol Oncol, 103 : , Yinon Y, Beiner ME, Gotlieb WH, Korach Y, et al. Clinical outcome of cystectomy compaired with unilateral salpingo - oophorectomy as fertility - sparing treatment of borderline ovarian tumor. Fertil Steril, 88 : , Desfeux P, Camatte S, Chatellier G, Blanc B, et al. Inpact of surgical approach on the management of macroscopic early ovarian borderline tumors. Gynecol Oncol, 98 : , Fauvet R, Boccara J, Dufournet C, Poncelet C, et al. Laparoscopic management of borderline ovarian tumors : results of a Fernch multicenter study. Ann Oncol, 16 : , Maneo A, Vignali M, Chiari S, Colombo A, et al. Are borderline tumors of the ovary safely treated by laparoscopy?. Gynecol Oncol, 94 : , Camatte S, Morice P, Atallah D, Thoury A, et al. Clinical outcome after laparoscopic pure management of borderline ovarian tumors : results of a series of 34 patients. Ann Oncol, 15 : , Tinelli R, Malzoni M, Cosentino F, Perone C, et al. Feasibility, safety, and efficacy of conservative laparoscopic treatment of borderline ovarian tumors. Fertil Steril, 92 : , p 33-35, Satoh T, Hatae M, Yaegashi W, Ishiko O, et al. Outcomes of fertility - sparing surgery for stage I epithelial ovarian cancer : A proposal for patient selection. J Clinc Oncol, 28 : , Ovarian cancer guideline (version 1, National comprehensive cancer network. guidelines.asp
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