Download - Curs LSK 7. Fibrom
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FIBROMUL UTERIN
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Tumora benigna, reproduce structura uterului - miofibrom - fibromiom
Frecventa: - 20% - mai frecvent la pacientele -de culoare -fara copii
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ANATOMIE PATOLOGICA
• Macroscopic: rotunde, lobulate dure• Microscopic: celule musculare netede, dispuse in
vartejuri tesut fibros
• Marime: de la mici, cat un “ac de gamalie” enorme• Numar: - unice - multiple
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LOCALIZARE
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MODIFICARI ASOCIATE
• Miometru: hiperplazie
hipertrofie• Cavitate uterina: deformata• Endometru: hiperplazie• Trompa: hidrosalpinx
hematosalpinx• Ovar: macro ovar
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Evolutie anatomica: •Menstra•Sarcina •Menopauza
•Degenerescenta: benigna
maligna
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distrofie hialina: - incepe la elementele vasculare, ingrosare, lumen ingustat,
- avanseaza spre tumora chistica: - in fagure de albina grasa: - metaplazia celulelor musculare calcara: sechele de la hialina prost vascularizata grasa teleangiectazica: - femei in varsta
necrobioza aseptica: datorita intreruperii rapide a circulatiei
lente favorizanta de: sarcina, nasterea, menopauza uterotone radioterapia traumatisme locale leziuni vasculare (tromboflebita) necrobioza septica – supuratia: - direct - pe cale limfatica vasculara - anaerobi GANGRENA
Degenerescentabenigna
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Degenerescenta maligna: 0,1%-1%
“carne cruda”
- crestere rapida
-sangerari dupa menopauza
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• HEMORAGIA: - niciodata NU se instaleaza brusc - incepe cu modificari ale menstruatiei - rar apare intermenstrual - poate deveni complicatie a fibromului - mecanisme: - ulceratii ale mucoasei - interferente cu contractilitatea uterina
ASISTOLIE UTERINA - cresterea suprafetei endometrului > 20 cm² - activarea locala a fibrinolizei - compresiunea plexurilor venoase din
endometru miometru
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• DUREREA: in mod normal NU apare durere
daca DA COMPLICAT sub forma de: - “GREUTATE” in pelvis - COLICATIV, SPASMODIC - DISMENOREE PARTICULARA SEVERA - DURERI PAROXISTICE - rupturi intercapsulare - pre / torsiune iritatie peritoneale varsaturi subocluzie - CRAMPE SFASIETOARE - degenerescenta
- TENSIUNE HIPOGASTRICA + creste rapid in menopauza => SARCOM - DURERE IRADIATA IN MEMBRUL INFERIOR =>
INCLAVARE
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EXAMEN CLINIC
• T. V. : - pozitia colului
- aspectul chiste Naboth cervicita leziune – Papanicolaou - secretii – examen bacteriologic - apreciere: marime consistenta situatie contur mobilitate
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EXPLORARI
• HSG - semne directe - semne indirecte
SUBMUCOS - imagine lacunara - defect de umplere
INTRAMURAL semne directe - deformarea cavitatii uterine - imagine lacunara – peretele anterior posterior semne indirecte - cavitate - marita, balonata - deviata, rotata - aspect de uter unicorn
- trompe - impinse - mulate
SUBSEROS -“ pe gol” calcificari - pete alburii - elongatie exogena a trompei - circumscrierea tumorii
LEZIUNI ASOCIATE: - hiperplazia de endometru - polipi endometriali - adenomioza - cancerul de corp uterin - malformatii uterine - hidrosalpinx, hematosalpinx
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• FLEBOGRAFIA PELVINA: - semne directe: plaje avasculare vase comprimate indirecte: marime, forma uter ingrosarea peretelui defecte de umplere• ECHO: - dimensiune - numar, forma, situatia - se exclude sarcina - supraveghere si tratament• LAPAROSCOPIA• HISTEROSCOPIA, HISTEROMETRIA – cavitatea alungita deformata scurtata• UROGRAFIA• CLISMA BARITATA• CHIURETAJ: - BIOPSIC - TERAPEUTIC
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EVOLUTIE
• LENT• CRITIC 40 – 50 ani• DUPA MENOPAUZA - INVOLUEAZA
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COMPLICATII
• COMPRESIUNEA: - pe caile urinare: polakiurie
compresiune retentie urina (rar) - colo – rectale (rar): - tenesme - constipatie - ocluzie - vasculara (exceptional): - edem membru inferior - flebite spontane
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• INCLAVAREA: - dureri violente - tensiune rectala - retentie acuta de urina - imobilizarea tumorii in bazin
• TORSIUNEA TUMORII: ACUTA: - dureri mari - iritatie peritoneala - distensie abdominala - varsaturi - ocluzie
REPETATE: - simptome mai sterse - descoperire intraoperat
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• HEMORAGIA: uterina mare => anemie secundara
- frecvent fibromul submucos interna => prin ruperea traumatica a unui
vas, o vena superficiala a fibromului prin:
- traumatism abdominal - comprimare pe promontoriu - cresterea presiunii intraabdominale - degenerescenta, torsiune, congestie menstruala
• NECROZA: aseptica septica• DEGENERESCENTA: calcara sarcomatoasa• PERITONITA GENERALIZATA: prin fibromiom
necrozat, infectat, perforat in cavitatea peritoneala
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DIAGNOSTIC DIFERENTIAL
• Cu: SARCINA
TUMORI OVARIENE
INFECTII ANEXIALE REZIDUALE
UTER MALFORMAT
RVF
TUMORI PELVIABDOMINALE - anexiale
- extragenitale
CANCER DE CORP SAU COL UTERIN
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FIBROMUL SI SARCINA
• INFLUENTA FIBROMULUI ASUPRA SARCINII/NASTERII: - STERILITATE prin: anovulatie motilitate anormala (trompe, uter) interferenta cu transportul spermei IUD endometru impropriu - TULBURARI DE NIDATIE: sarcina ectopica placenta praevia - AVORT SPONTAN: de 3 ori mai frecvent complicat cu hemoragie - PREZENTATII DISTOCICE - NASTERE PREMATURA - DISTOCIE DE DINAMICA, RUPTURA UTERINA - DEFORMARI FETALE - DPPNI in fibromul retroplacentar
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• INFLUENTA FIBROMULUI ASUPRA LEHUZIEI: - in lehuzie poate duce la: - retentie de placenta - inversiune uterina - hemoragie - boala tromboembolica - tulburari de involutie uterina, infectii• EVOLUTIA FIBROMULUI IN SARCINA (INFLUENTA SARCINII ASUPRA FIBROMULUI): - evolueaza silentios - necrobioza aseptica, gangrena - torsiune - inclavare in micul bazin - hemoragii
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TRATAMENTUL FIBROMULUI UTERIN
• TRATAMENTUL MEDICAL: - ADJUVANT – pana la operatie - TRANZITOR – pana la menopauza ♦ tratamentul hemoragiei – medicamentos
Hemostatice si uterotone - ERGOMET
- adjuvante: - ADRENOSTAZIN - vitamina K, CALCIU - EAC ♦ antianemice: - preparate de Fe.
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♦ progestative de sinteza: - efect antiestrogenic antigonadrotop luteomimetic MEDROXIPROGESTERON 10mg/zi ziua 15 – 24 de ciclu LINESTRENOL = ORGAMETRIL = ENDOMETRIL5mg/zi (1tb/zi) ziua 5-25 de ciclu, 6 luni
♦ agonisti ai GnRH – realizeaza o gonadectomie chimica (“ovarectomie medicala”) reversibila
BUSERELIN intranazal ZOLADEX s.c. 3 – 6 luni DECAPEPTYL i.m.
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TRATAMENTUL CHIRURGICAL:
CHIURETAJ HEMOSTATIC SI BIOPSIC
MIOMECTOMIA SAU MIOMETRECTOMIA
HISTERECTOMIA SUBTOTALA CU SAU FARA ANEXECTOMIE BILATERALA
HISTERECTOMIA TOTALA CU SAU FARA ANEXECTOMIE BILATERALA
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Tratamentul laparoscopic al fibromului uterin
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• Miomectomia
• Este indicata in cazul mioamelor de marime medie (8-10 cm) si putine la numar (unul sau doua).
• Plasarea anterioara a miomului creste dificultatea de tehnica si rata conversiei.
• Abordarea tumorii localizate in ligamentul larg se impune o mare atentie in sensul evitarii lezarii vaselor mari si a ureterului.
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• Tehnica operatorie
Principiile de baza ale tehnicii operatorii laparoscopice sunt:
• Respectarea principiilor microchirurgiei constand in evitarea contaminarii intraperitoneale, utilizarea de instrumente fine si atraumatice, manipularea fina si atraumatica a uterului fara a apuca organele pelvine (cu exceptia miomului).
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•Fiecare miom se extirpa printr-o histerotomie proprie; nu este posibila o incizie pentru mai multe fibroame.
•Respectarea planului de clivaj. Pastrarea miometrului adiacent scade riscul hemoragiei postoperatorii prin nelezarea vaselor perimiomatoase dilatate de compresia miomului si asigura material de sutura.
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• Electrocoagularea trebuie sa fie utilizata cat mai rar posibil, deoarece poate duce la formarea unor zone de necroza care pot determina fistule postoperatorii sau rupturi uterine la sarcini ulterioare.
• Histerorafia cu fire extracorporeale sau intracorporeale trebuie facuta intotdeauna in cazul unor plagi mai adanci in miometru sau cu deschiderea cavitatii uterine; se recomanda suturarea cu fire adanci, cuprinzand tot stratul muscular sau sutura in doua straturi.
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Variante de tehnica
•In cazul mioamelor intramurale se practica o incizie eliptica a miometrului.
•Enucleerea miomului se realizeaza prin disectia pe planul de clivaj.
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• Miomul este prins cu o pensa cu gheare sau un tirbuson de constructie speciala prin care este tractionat.
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• Treptat aderentele si vasele miomului sunt electrocoagulate apoi sectionate. Irigatorul este utilizat pe post de disector bont.
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• Sutura miometrului se poate realiza cu fire izolate in doua straturi.
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• Tehnica fara sutura a miometrului este o alta varianta de tehnica ce se recomanda in cazurile in care parturitia este exclusa.
• Se fac mai multe puncte de hemostaza cu forcepsul bipolar in jurul fibromului.
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In fibroamele pediculate, este posibila aplicarea unei ligaturi, urmata de sectiune si extractie.
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Extractia miomului se realizeaza in mai multe moduri:
•in toto sau fragmentat pe trocare de 10-15-20-24 mm
•prin morselare – cu morselatorul Rotocut Storz •prin colpotomie posterioara, realizata pe cale clasica si laparoscopica, sau in mod clasic vaginal in toto, fragmentat sau dupa morselare.
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Consideratii generale:
Miomectomia este considerata o operatie sangeranda.
Abordarea ei laparoscopica reduce pierderile sanguine datorita compresiunii vasculare exercitate de capnoperitoneu si posibilitatilor de hemostaza, cu identificarea planului de clivaj oferit de imaginea videolaparoscopica.
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Convertirea intraoperatorie clasica variaza intre 0-41%.
Factorii care sunt incriminati in riscul conversiei ar fi:
-dimensiunea fibroamelor-numarul fibroamelor-localizarea intramurala si catre marginile uterului-prezenta adenomiomatozei.
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Histerectomia laparoscopica
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Avantajele histerectomiei laparoscopice:
•incizie minimala abdominala;
•reducerea durerii si simptomelor postoperatorii;
•necesitatea scazuta de analgezice;
•scurtarea perioadei de spitalizare;
•recuperare mai rapida in comparatie cu interventiile efectuate abdominal.
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Clasificarea histerectomiei laparoscopice dupa Gary si Reich:
•Laparoscopie de diagnostic cu histerectomie vaginala (HV);
•Histerectomie vaginala asistata laparoscopic (HVAL);
•Histerectomie laparoscopica (HL);
•Histerectomie laparoscopica totala(HLT);
•Histerectimie supracervicala laparoscopica (HSL);
•Histerectomie clasica laparoscopica intrafasciala supracervicala (HCI).
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Histerectomia supracervicala
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Timpi operatorii
Dupa pozitionarea coresunzatoare si dezinfectia corecta , se introduce un manipulator uterin care va fi manevrat de un ajutor.
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• Inspectia atenta a cavitatii abdominale, liza aderentelor cand acestea exista si vizualizarea traseului ureterelor.
• In cazul pastrarii anexelor se vor coagula si diseca structurile cornuale, ligamentul propriu al ovarului si ligamentul rotund.
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Daca se practica anexectomie se diseca ligamentul infundibulo-pelvic in locul ligamentului propriu al ovarului
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Disectia ligamentului larg pentru evidentierea arterei uerine.Vizualizarea si separarea pliului vezico uterin.
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Vasele uterine se coaguleaza si se diseca la intrarea lor in peretele uterin.
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Separarea corpului uterin la nivelul orificiului cervical intern (cu ajutorul ansei electrice).
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• Uterul se va morsela si se va extrage pe bucati.
• Toaleta cavitatii abdominale , controlul hemostazei si identificarea unor posibile leziuni ale organelor.
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Histerectomia totala
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• Asigurarea si sectionarea parametrelor si a ligamentelor utero-sacrate (se poate face si cu instrumente avansate laparoscopice cum ar fi „LigaSure”).
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• Colpotomia se face pe cale laparoscopica.
• In cazul histerectomiei totale extragerea uterului se face pe cale vaginala.
Inchiderea vaginului se realizeaza cu 3-4 fire izolate.
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Va multumesc!