Practical Manual for Laparoscopic and Hysteroscopic Gynecological Surgery Liselotte Mettler, Ibrahim Alkatout
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table
A
Abdomen 156
computed tomography of 468
rinsing of 569f
upper 488f
Abdominal access 271, 763
complications 125
Abdominal binders 186
Abdominal cavity 181, 186, 236, 244f, 281
expander 31
inspection of 120f
inventory of 321
Abdominal compliance 199, 209
Abdominal entry
safety steps 119
technique 207
Abdominal hysterectomy 124, 346, 456, 466, 493, 498, 507, 509, 509t, 559, 572
Abdominal incision 9
Abdominal lymphadenopathy 313
Abdominal muscles, rupture of 313
Abdominal myomectomy 450, 458
Abdominal operations 45
Abdominal organs 312
Abdominal pain
acute lower 313
chronic lower 192
lower 238, 313, 430
severe lower 313
Abdominal procedures 85
Abdominal protrusion 221
Abdominal segment 18
Abdominal skin 222
Abdominal surgery 45t
Abdominal tenderness 237
Abdominal vessels 312
Abdominal wall 15, 126f, 181183, 186, 186f, 190, 230f, 271f, 318, 332, 525, 669, 724
endometriosis of 321, 332
layers 272f
lifting 210
Abdominopelvic distension 120f
Abdominopelvic examination 221
Abdominopelvic vascular tree 164f
Abducted legs 432
Ablative chemical technique 646
Ablative fractionated laser 636
Ablative laser resurfacing 643
Ablative surgery 224
Abnormal genital bleeding 346, 430, 431, 507
Abnormal peristalsis 311
Abnormal uterine bleeding 238
disorders 448
Abortions
habitual 720, 721, 749
intrauterine 242
recurrent 744
Abscess 273
formation 191, 196
port position 609f
Accidental injury 609
Acetonitrile 208
Acetylene 208
Acidosis 199, 200
Acne 642
Acral lentiginous malignant melanoma 268f
Acrolein 208
Acrylonitrile 208
Additional trocars, placement of 15
Adenectomy 498
Adenocarcinoma 342, 571
Adenoma 273, 406, 409, 410
bleeds 407
hysteroscopic sight of 408f
mapping, preoperative 406
posterior wall 410f
resection 413
aim of 407
with posterior adhesions 409f
Adenomyoma 338, 406
resection
in infertility 406
technique of 407
Adenomyomectomy 412f
Adenomyosis 336339, 342, 343f, 344, 380, 381, 410, 455, 728, 744
causal treatment of 341, 731
diagnosis of 732
of uterus
surgical treatment of 344
typical of 512f
principal symptoms of 338
prone, sign of 341f
severe 340f
treatment of 336, 382, 732
uteri 507
Adenomyotic lesion 409f
Adenosine triphosphate 648
Adherent bowel, blunt dissection of 186
Adhesiolysis 117, 482, 777
Adhesion 190, 229, 278, 311, 710
barrier-coated polypropylene mesh 184f
formation 204206
reduce 211
lysis of 717
severe 223f
umbilicus, primary 182f
Adiana 297, 305, 306
device 304, 307
Adipose derived 653
Adipose tissue 623, 635
Adnectomy 668
bilateral 666
Adnexa 15, 489
dissection of 489f
from uterus, separation of 497
pelvic
sidewall, separation of 497
wall, separation of 494
preservation of 497
Adnexal mass 257
Adnexal surgery 578
Adnexectomy 222, 226f
Adrenocorticotropin hormone 201
Adson forceps 632
Advanced glycated end products 617
Advancing minimally invasive gynecology worldwide 11
Air embolism 753
Alcock's canal 623
Alkyl benzenes 208
Alpha-fetoprotein 221
Alternative closure technique emphasizing prolapse prevention 533
Alternative entry technique 46
Alternative treatment methods 448
Amenorrhea 721, 749
American Association of Gynecologic Laparoscopists 11, 178, 771
American Association of Gynecological Laparoscopy 11
American College of Surgeons 10
American Society for Gynecologic Endoscopy 10
American Society for Reproductive Medicine 415
Ampulla 236
Ampullo-ampullary anastomosis 289
Analgesia 728
Analgesics 708
Anamnesis 721, 750
Anastomosis 684
types of 288, 291
Anastrozole 344
Ancillary trocar 127f, 354, 528, 725, 757
Anesthesia 319
circuit, integrity of 210
general 432
types of 98, 319
Anesthetic complication 146
Anesthetic consultation 145
Animal models 738
Anococcygeal raphe 623
Anterior abdominal wall 280f, 478f, 683
back side of 16f
Anterior compartment 595, 596
defect, combining repair of 594
model 88
Anterior exenteration 679
Anterior myoma 436f
Anterior myometrium, asymmetrical thickening of 339
Anterior superior iliac spine 609
Anterior vaginal wall 16, 590f
Anteverted uteri 709
Anti-incontinence procedures 88
Antimicrobial peptides 639
Antithrombosis agent 608
Aorta 312
bifurcation 21f, 160f, 164f
test, palpation of 119, 119f
Apocrine sweat glands 621
Appendectomy 192
procedure 191
scar 273f
Appendiceal stump after stapling 191f
Appendicectomy 668
Appendicitis 258
acute 242, 312
Appendix 191
endometriosis of 327f
Applying clips like
Filshie 297
Hulka 297
Applying silastic falope ring 297
Arbeitsgemeinschaft Gynäkologische Endoskopie 78
Arcus tendinous
fascia pelvis 623
levator ani 623
Argon laser and potassium-titanium-phosphate 36
Argon plasma coagulation 34, 59
systems 693
Asherman's syndrome 101, 777
Asian Society of Gynecological Endoscopy 10
Aspiration 245
test 46, 119, 120f, 351, 525, 724
Assisted reproductive techniques 237, 319
development of 477
Atraumatic forceps 324f
types of 28
Atraumatic needle 6f
Augmentation labia majora plasty 628
Autologous cell 653
based therapies 653
Autologous fat 651
Automatic flap valves, simple 27
Autonomic dysfunction 311
Autonomy 106
Auxiliary ports 321
position of 321f
B
Balloon tamponade 776
Basal cell 652
carcinoma 267f
papillomas 266f
Baseball suture 173f
Basic fibroblast growth factors 649
Basic surgical skills 78
Beck depression inventory 386
Benevolence 106
Benign adnexal
cysts 222
mass, laparoscopic management of 259
Benign gynecological diseases 718
Benign labial lentigo 268
Benign mesothelial cyst 280f
Benign ovarian
cysts 225
tumors 221
Benzene 208
Betadine solution 631
Bi-clamp for
open surgery 34
vaginal surgery 34
Bicornuate uterus 478f
Bilateral ilio-obturator lymph nodal dissection 688
Bi-manual coordination 92
Bioactive scaffold 653
Biologic grafts 185
Biologic surgical procedure, dynamics of 199
Biomaterial absorbable mesh plug 189f
Biopsy 669
cup 710
Bipolar coagulation 297, 302f, 303
and cutting tube 297
electrode 752f
Bipolar current 60f
Bipolar diathermy 286, 286f, 303
Bipolar forceps 348
Bipolar hysteroscopy 752
Bipolar instruments 688
Bipolar myoma resection 753f
Bipolar radiofrequency ablation 305
Bipolar resection 753
Bipolar resectoscopes 61f
Bipolar surgical techniques 753t
Bipolar technique 60, 462
Bipolar vessel sealing 34
Bladder 60, 386, 479f, 594
anterior wall of 325f
catheter, placement of 320
deep infiltration of 395
die of 395
dysfunction 390
endometriosis of 325
from uterus, separation of 494, 531
infections 637
injury 146, 678, 766
risk of 222
lesion 326f
peritoneum 487, 540f, 564f
dissection of 364f, 494, 499, 537f
opening of 363f, 500f
wall, endometriosis of 396f
Bleeding 398, 458, 669, 776
disorders 721, 747, 750
recurrent 721
symptoms, treatment of 720
Bloating 336
Blocking tube 297
Blood
loss 490
vessels 60
Blunt trocar sheath, insertion of 115
Body mass index 266, 449, 490, 619, 757
Body posture 105
Bone marrow derived 653
Borderline ovarian tumors 227
Borderline tumor, early stage 667
Bowa metraloop 74f
Bowel 60, 312
disturbances 221
endometriosis of 321, 327
diagnosis of 415
grasping mesentery of 194f
injury 146, 193, 439, 678
lesions 763
perforation of 312, 670
preparation 319, 608
prevent incarceration of 190
resection 196
segmental 386
small 192
symptoms 430
wall injuries, repair 194
Bowen's disease 267f
Box trainers 86, 738
Bradykinin 639
Breast cancer 421
Breisky vaginal speculum 610
Broad ligament 16, 236, 318
dissection of 356, 494, 498, 530
division of 499f
fenestration of 488f
Bulk-related symptoms 448
Bulky pelvic lymph node 159f
Bupivacaine 633
Burning 637
Butadiene 208
C
Cesarean sections 118
Calcium hydroxylapatite 649, 650
large particle 651
Cannula
diameter 437
penetrates peritoneum 116f
retraction of 117f
Cannulaton of fallopian tube ostia 717
Capsular vessels 450
Carbon dioxide 6, 199, 207, 632, 772
administration of 200
Carbon monoxide 208
peritoneal absorption of 208
Carcinoembryonic antigen 221
Cardiac output 200
Cardinal ligament 344, 537, 731
of Mackenroth 16
Cardiopulmonary complications 228
Cardiovascular effects 207
Castroviejo needle holder 177f
Catgut and polydioxanone loops 169
Caudal septum, dissection of 748f
Cautery devices 208
Cave of Retzius 685
Cavity, distension of 705, 718
C-cone 122f, 123f
Cecum 273
Cefoxitin 431
Cell
adhesion molecules 208
based tissue engineering 653
cell contact 205
desquamation, superficial 621
Central compartment 595, 596
defect, repair of 594
Central perineal tendon 624
Cervical
block 708f
canal 710
bipolar coagulation of 565f
cancer 421, 423, 698
early stage 699
prognosis of 699
robot-assisted operations in 698
stage 674
treatment 159f, 423
carcinoma 710
fibroid 479f
gravidity 236
intraepithelial neoplasia 347, 518
laceration 771
polyps 710
pregnancy 251
ripening, dynamic microvascularization of 161
stenosis 342, 710
stump 533, 610, 611f
cancer, risk of 571
peritonealization of 567f
preparation 610
remaining 376f, 549f
symptoms after subtotal hysterectomy 569
trauma 771
Cervicocorporal transition 763f
Cervicosacropexy procedures 696
Cervix 236, 507
laceration of 775
removal of 511
stump 566
Cesarean scar 318
Cesarean section 269
lesion 332f
percentage of 161
Changeover technique 466470
Charged-coupled device cameras 27
Chemical granule, insertion of 297
Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonographie 9
Chlorhexidine 319
Chocolate fluid 408f
Cholecystectomy 258
Cholelithiasis, asymptomatic 273, 275f
Chromopertubation 51
Chromophores 635, 647
Chronic constipation 619
Chronic obstructive pulmonary disease 619
Circular stapler, plug of 330f
Clamping large vessels, instruments for 30
Clark knot pusher 173f
Classic intrafascial
hysterectomy 355, 530
transformation of 555
supracervical hysterectomy 32, 348, 494, 519
Classical box trainers 86
Clickline scissors 64f
Clickline set 64f
Clinical pregnancy rate 478
Clitoral area 626
Clitoral crura 624
Clitoral hood reduction 630
Clitoral reduction 631
Clitoral unhooding 630
Clitoris 621, 622
dorsal nerve of 623
Clitoropexy 630
Clitoroplasty 630
Closed laparoscopic abdominal entry 124
Closed vaginal cuff 503f
Closure technique emphasizing prolapse prevention 361
CO2 for pneumoperitoneum 199t
CO2 insufflation 115
CO2 laser 36
Coagulation, adequacy of 302f
Coccygeus muscle 601
Coelioscopy 118
Coexisting pathologies 406
Coils, insertion of 297
Cold light fountain xenon 300 56f
Collagen 617, 639, 649, 650
metabolic turnover of 619
metabolism 618
synthesis 619
types of 617, 653
Colles’ fascia 628
superficial 624
Colon 190, 273
and rectal tissue donuts 197f
injury 196
Colorectal cancer 421
Colostomy 197, 439
Colporrhaphy
anterior 591
posterior 594
Colposuspension 590, 609, 613
burch 594
Colpotomy 580, 677f, 683, 685, 688
completed 677f
Common esthetic surgical corrections 625
Common iliac
artery, crossing bifurcation of 322f
lymph nodes 22
vessels, right 162f
Compartment, posterior 16, 595, 596
Complete blood count 448
Complete uterovaginal prolapse 598f
Completed ureterosigmoid anastomosis 683f
Compressive suture, first layer of 590f
Computed tomography 332, 417
scan 121
Concrete hysteroscopic procedures 720
Congenital anatomical uterine malformations 733
Congenital obstructive Müllerian malformations 342
Connective tissue
complications of 617
stimulation of 638
Consecutive stimulation 731
Constipation 318, 336
Contact dermatitis 642
Continuous purse-string suture 566f
Contralateral uterine wall, exposure of 464
Conventional open technique 491
Conventional sentinel node marker 422
Conventional single-port technique 694
Conventional trocar and cannula insertion systems 117
Conventional vaginal entry 121
Cook needle holder 178f
Cooper's ligament 16, 188
Corner stitch 502
Corner sutures 368, 503f, 536
Cornual openings 297
Cornual pregnancy 250, 251
Corpus luteum cyst 249f
Corpus polyps, therapeutic management of 751
Corpus uteri, transection of 565f
Counseling 298
and informed consent 449
Counter needle holder 434
Creosols 208
Crew management methods 143
Crocodile forceps 36, 434f
Crohn's disease 193
Cryocoagulation 305
Crystalloids 773
Current laparoscopic training models 78
Current teaching methods 493
Curriculum-based training, essentials of 93
Curve handheld instruments 40f
Cutting instruments 28, 29f
Cyclic dysuria 318
Cyclic vaginal bleeding 512
Cyclical bowel 728
Cyst
contents, spillage of 223f
ovary after removal of 228f
pseudocapsule 223
resection of 227
rupture 669
wall
ablation of 224
during excision, tearing of 225f
extraction of 230f
Cystectomy 225
for small endometriotic nodule 480f
means of 222
ovarian tissue 223
technique of 224
with stripping technique 223f
Cystitis 242, 312, 439
Cystoscope 4f
Cystoscopic examination 601
Cystoscopy 4, 325, 349, 395, 605
Cytotoxic drugs 700
D
da Vinci surgical system 25, 37, 37f, 38f, 118, 119, 691
Death, crown of 19
Decidual stroma 235f
Deep dyspareunia 728
Deep endometriosis 321
laparoscopic treatment 163f
Deep endometriotic lesions 322
Deep external pudendal arteries 622
Deep infiltrating endometriosis 161, 386, 388, 403
Deep lesion, resection of 322f
Deep pelvic endometriosis 161
treatment of 157
Deep perineal muscles 623
Deep peritoneal endometriosis lesion 322f, 323f
Deep retroperitoneal nerves 391
Deep septal resection 777
Deep uterine veins 679
Deep vein thrombosis 146
Deeper retroperitoneal structures 386
De-epithelialization technique 626, 627
Degenerative fibrotic disease 617
Delivery catheter 306
Delphi consensus methodology 93
Dementia 108
Denon Villers’ fascia, layers of 676f
Dermabrasion technique 646
Dermal collagen remodelling, effective for 641
Dermal fibroblasts 639
Dermal fillers 649
Dermal substrates, loss of 639
Dermatitis, chronic 616
Dermoid cysts 224
Descended uterine parts 612
Descended vaginal parts 612
Descensus model 88
Designer laser vaginoplasty 630
Detachable instruments 119
Devices, classification of 636
Diagnostic hysteroscopy 101, 709, 721, 771
training model for 99f
Diagnostic laparoscopy 243
Diaphragm 386, 399, 400, 402
die of 399
endometriosis of 331, 401f
lesion 331f
Diarrhea 336
Diessen bench station 79
Different operative simulator systems 90
Dilatation instruments 28, 28f
Diligent hemostasis 462
Disc following resection 329f
Distal sigmoid colon, primary repair of 195f
Distension fluid, absorption of 450
Distension media, types of 772
Diverticulitis sigmoid colon 190f
Diverticulum 312
Dorsal lithotomy position 609
Double-J-stent 393
Double-layered sutures 465
Douglas drainage 465
Drainage, instruments for 30
Drybox 93, 94
Dyschezia 336
Dysmenorrhea 161, 332, 337f, 338, 339, 409, 430, 448, 513f, 720, 721, 728, 749
and dyspareunia, severe 512f
causes of secondary 339, 342t
Dyspareunia 161, 338, 347, 512, 595, 621, 626
Dysplastic nevus syndrome 268f
Dysuria 430
E
Ectopic pregnancy 235, 236b, 236f, 237, 237b, 238240, 242t, 243, 243t, 254, 257, 258f, 272b, 304, 312, 577, 578fc
diagnosis of 240, 241, 243
early suspicion of 241fc
general operative steps after removal of 252
high incidence of 241
incidence of 237
left sided 577f
localization of 236
treatment 241, 254
Edema 645
Elastic loop 305
Elasticity and tone, loss of 637
Elastin 617, 639
combination of 623
fibers in human vagina 618
Elective supracervical hysterectomy 516
Electrocautery 307
Electrocoagulation 59, 302, 305
system 34
Electrolyte-rich medium 705
Electromagnetically tracking system 84
Electromechanical morcellator 434
Electron
microscopy image of TachoSil's 75f
transport 648
Electronic CO2 insufflation equipment 8f
Electrosurgery 33
uses of 58
Electrosurgical complications 776
Electrosurgical injuries 147
Electrosurgical unit 243, 272
Electrotomy 60
Elevated intra-abdominal pressure 619
Elliptical strip excision technique 407
Empathy 104
Endo GIAtm ultra universal stapler 30f, 31f
Endocameleonâ laparoscope 27f
Endocoagulation 36
Endoderm 224
Endoeye video laparoscope 33f
Endoligature 169
Endoloop 228
Endometrial ablation 101, 720, 747, 752, 752f, 752t, 777
and resection 754
advantages of 751t
disadvantages of 751t
in pig heart 99f
Endometrial biopsy 710
by scraping technique 710f
Endometrial cancer 421, 423, 674, 698
robot-assisted operations in 697
Endometrial cavity 480
Endometrial glands, presence of 728
Endometrial hyperplasia 342
Endometrial injury 482
Endometrial nodules 162
Endometrial polyps 338, 710
Endometrial resection 720, 747
Endometrial scratching 484
Endometrial tissue 337
Endometrioma 223f, 737f
laparoscopic drainage of 223
radical treatment for 224
small 230
Endometriosis 117, 156, 195, 196, 222, 272, 295, 318, 323, 324f, 336, 338, 342, 344, 346, 382, 387, 390, 391, 415, 419, 480, 507, 728, 731
clinical symptoms of 344
diaphragmatic 321
extragenitalis in umbilicus 268f
general 339
treatment of 342, 731
lesion of 328f
nodule of 326f, 396f
pathogenesis of 336, 342
resection of 355, 528, 732
robotic surgical treatment of 700
severe 349, 553
superficial 321
Endometriotic cysts 223
Endometriotic implants 318
Endometriotic lesion 325f, 332, 392f, 396
site of 392f
Endometriotic mass 417f
Endometriotic nodule, small 522f
Endometritis 342, 777
Endometrium 339, 507, 777
functional 447
ovary after removal of 76f
structure 750
transcervical resection of 774
Endopelvic fascia 537
Endorectal sonogram, normal 416f
Endorectal ultrasound 415, 416, 417
Endoscope 32, 32f, 52
insertion of 609
Endoscopic descensus surgery 88
Endoscopic entry, single-port 40
Endoscopic instruments 671
Endoscopic pelvic floor defect corrections 587
Endoscopic procedure 163, 707
safely 156
Endoscopic screening sufficient 415
Endoscopic stack 707, 709
Endoscopic surgery 140, 145, 346, 511
Endoscopic threaded imaging port 115
Endoscopy 417
safe 142
techniques 297
trolleys, routine 25
Endosonography 349
Endosuture 169, 171
technique of 408
Endotip 116f
cannula and telescope stopper 115f
removal 116, 117f
Endowristâ instruments 38f, 119
End-to-end anastomosis 271, 393
Energy
based devices
based skin-tightening devices, classification of 646t
mishap 146
role of 634
technological advancements of 635
subdermal delivery of 646
ultrafast pulses of 645
Enlarged uterus 339f
Enseal sealing instrument 36f
with flexible tip 74f
Entry technique, types of 767
Enucleation 435
Enzymes, family of 617
Epidermis 621
Epigastric artery 30
inferior 669, 759f
superficial 48
Epigastric vessels, inferior 15
Epinephrine 631, 633
Episiotomy 318
Epithelial cilia 237
Epithelial layers 621
Erbe electrosurgical unit 34
Erbium 632
Ergonomics 712
Erythema 645
Essure 297, 303, 305, 305f, 306f
device 305
Estrogen
in collagen metabolism in pop, role of 652
receptor 618
modulator, selective 428
Estrone, higher doses of 652
Ethane 208
Ethicon
endo-surgery 36f
needle holder 177f
Ethos surgical platformtm 42f
Ethylene 208
European Academy of Gynaecological Surgery 178
European Society of Gynecological Endoscopy 10, 101
Evacuation 245
Excess collagen deposits 649
Excessive thermal energy, application of 60
Exemestane 344
Expectant management 447
External genital 639
endometriosis 340f
scarring 645
External genitalia 621
neurovascular supply of 622
External iliac
artery 54f, 157f, 380f
lymph nodes 21
vein 157f, 684
External incisions
number of 124
size of 124
External obliquus abdominis 121
Extra-abdominal relevant anatomy 266
Extracellular matrix, components of 616
Extracellular panproteinase inhibitor 617
Extracorporeal knot 169, 170f, 171, 228
peritoneum 378f
technique 503f
Extracorporeal sutures 348, 519
Extragenital endometriosis 321, 331
Extraluminal ectopic pregnancy 248
Extra-peritoneal insufflation 115
Extra-peritoneal spaces, laparoscopy in 156
Extrauterine gravidity 252
Eyepiece 52
F
Facial expression 105
Factors influencing myoma morcellation 437
Failed procedure 146
Fairness 106
Fallopian tubal torsion
extrinsic causes of 311t
intrinsic causes of 311t
Fallopian tube 236, 242, 297299, 303f, 304, 346, 456, 507, 518, 537f, 562f
bipolar coagulation of right 302f
die of 402
isolated torsion of 311
left 314f
prophylactic removal of 456
reconstruction of 402
torsion of 311
Falope ring 299, 299f, 303
application 297
tubal ligation 286f
Faraday effect 58
Fascia 121f, 621, 623
closure of 438
superficial 268
Fascial edges making 182
Fat
atrophy of 628
cells 616
emboli 651
Fatty tissue 613
Female genital
cosmetic surgery 616
organs, lymphatic drainage of 21f
surgery 653
tract 720
benign tumors of 445
Female genitalia
energy-based devices on 637
esthetic surgery of 624
Female inner genital organ 236f
Female pelvic
cavity 15, 17f
nerves 156
nervous system 161
organs 15, 19
viscera, autonomic nerve supply of 20f
Female pelvis 19f
anatomy 156
autonomic innervation of 20
innervation 156
vascularization of 19
Female tubal sterilization methods 303t
Femoral canal structures 188
Femoral hernia 188
Fertility
enhancing endoscopic surgeries 477
exploration 576
Fever 439
Fiber glass serves 56
Fiberoptic laser energy, subdermal delivery of 646
Fiberoptic light cords 52f
Fibrin 208
matrix 208
Fibrinous adhesions 194f
Fibroblast 619, 653
growth factor 646
Fibroblastic proliferation 649
Fibrofatty lymphovascular tissue 684
Fibroids 342, 427, 446, 447, 455, 711
costs of 447
genetics of 446
mapping of 479
surgical treatment of 447
tissue 479
tumor 427
type 707
uterine preserving surgical treatment of 448
uterus, large 269
Fibrotic metabolism, important regulator of 617
Fibrous adhesion, dissection of 225f
Fibrous collagen, loss of strength of 617
Filshie clip 286, 287f, 297, 301f, 303
applicator 301f
Fimbrial folds 293
Final abdominal situs 569f
Final situs 589f
First portable endoscope 4f
First stich right pectineal ligament 611f
First-generation needle holders 176
Fistulas 678
Fitz-Hugh-Curtis syndrome 278f
Flexible hysteroscope 719
Fluence 635
Fluid
bag 709
in flow 724
media 772
Focal adenomyosis, enucleation of 345f
Focal nodular hyperplasia 273, 275f
Foley's catheter 326f, 355, 432, 487, 679, 776
Follicle-stimulating hormone 285
Food and Drug Administration 118, 431, 572, 587, 593, 608
Footswitches, hand instruments, 34
Forcesense technology 80f
Forgarty catheter 402
Formaldehyde 208
based fixation techniques 85
Fractional ablative lasers, mechanism of 642
Fractional deep dermal ablation 647
Fractional erbium 641
Fractional laser treatment 637
Fractional technology operates 645
Fractionated lasers 636
Framing and sunk cost 211
Free radicals 208
Frictional forces 625
Fulcrum effect 204
Full thickness bowel wall injuries 195
Functional residual capacity 200
Functioning endometrium glands, heterotypic presence of 406
Fundal
pathologies 707
septum, dissection of 748f
Fungal infections 642
G
Gallbladder
disease 258
perforation of 312
solitary adenoma of liver next to 276f
Gas
chemistry 201
chromatography 208b
dryness of 200
embolism 210
quality, physiological effect of 200fc
throttling-down-pressure device 200
velocity 202
Gastric
cancer 421
contents, reflux of 228
Gastroenterologists prefer endoluminal ultrasound 416
Gastrointestinal
complications 228
endosonography 416
stromal tumor 192, 193f
Gelpoint 579f
Generous skin incision 115
Genital
area, appearance of 630
hypertrophy 625
pathophysiology 652
Genitofemoral nerve 18
Genome-wide scan for fibroid genes 446
Genotype, genetics of 446
German Society for Gynecologic Endoscopy 10, 12
German Society for Gynecology and Obstetrics 78, 572
Gestational material 235f
Gestures 105
Giessen bench station 79
Giessen School of Endoscopic Surgery 79
Global application of da Vinci® systems 695
Gluteal veins 19
Glycoproteins 617
Glycosaminoglycans 208
Government Regulatory Agencies 199
Granulocyte-macrophage colony-stimulating factor 208
Granuloma formation, risk of 630
Granulomatous reactions 650
Grasping forceps 433, 434
Greater myometrial heterogeneity 339
Greater vestibular glands 622
Growth factor, transforming 617, 649
G-spot
alteration 651
amplification 651
Guts, injury of 87
Gynecologic cancer, evaluation of 663
Gynecologic endoscopy 139, 146t
programs 143
serious complication of 147
Gynecologic laparoscopic curricula 93
Gynecologic malignancy 222
Gynecological and general laparoscopic surgery, essential equipment for 25
Gynecological cancers 423
Gynecological consultation 313
Gynecological endoscopy 25, 51f
equipment cart for 8f
risk management in 139, 152
Gynecological examination 721, 750
Gynecological indications 257
Gynecological laparoscopic surgery, clinical anatomy for 15
Gynecological laparoscopy 57f, 118, 266
extragenital in 265
preoperative assessment 265
Gynecological malignancies, laparoscopic surgery of 663
Gynecological real simulator system 88, 88f
Gynecological sonography 720
Gynecological surgery 73, 583
Gynecology 4
robot-assisted surgery in 691
H
Hand-eye coordination 92
Handlin's uterine manipulator 286f
Hands-on training models 98
Hanging drop test 724
and fluid in flow 46, 352, 525
Hans Frangenheim 7f
Harmonic ACE
control unit 36f
forceps 36f
Harmonic scalpel 36
Harmonic ultrasound scalpel 74f
Hasson technique 44
Heat
in laser resurfacing 641
loss during surgery 203
shock protein 642
activation of 638
Hegar number 50
Hemangioma 273
Hematomas 439
Hematosalpinx 311
Hematuria 336
Hemoglobin 647
after surgery 440, 441
before surgery 440, 441
Hemoperitoneum
evacuation of 243
severe 243f
Hemorrhage 439, 473, 678
acute 455
into gestational sac 250f
Hemostasis 169, 171, 245, 463
adequate 44
and extended operation 252, 278
endoscopic suture for 721
instruments for 30, 30f
Hepatocellular carcinoma 276f
Hernia 181
defects 185
large 181
repair 186
mesh placement sites 183f
treatment of 181
Herpes simplex virus 643
Heterogeneous comparison groups 698
Heterogeneous structure 418
Heteronomy 106
Heterotopic endometrial glands and stroma, presence of 336
Heterotopic pregnancy 257
High intensity focused ultrasound 448
High-definition three-dimensional vision system 25
High-energy pulsed CO2 laser 641
High-fidelity operating room simulation 93
High-frequency
energy 8
generator 58
surgery, physics of 58
units 26
High-intensity focused ultrasound 637
High-resolution transvaginal ultrasonography 236
Hiss phenomenon 119
Histamine 639
Hohl manipulator 496, 501
application of 496f, 498
Holding and grasping instruments and screws 28
Hollow organ
obstruction of 312
perforation of 312
Home-made models 99
Hooked scissors 434
Hormonal changes during puberty 625
Hormonal fluctuation 618
Hormonal therapy 728
Huge multichambered liver cyst 276f
Hulka clip 286, 297, 303
Hulka-Clemens clip 303
Human anatomy 15
Human cadavers 85
Human camouflage techniques of biases 211
Human chorionic gonadotropin 236, 578
Human epididymis 221
Human tissue combustion 208b
Hyalobarrier, uses of 76f
Hyaluronan 208
injections 651
protection, remove 208
Hyaluronic acid 649, 650f, 711
based gel 76f
filling agents 650
Hydrogel polymers 649
Hydrogen cyanide 208
Hydrosalpinges 481
Hydrosalpinx 295, 311, 481
salpingectomy for 481f
Hymenoplasty 625, 630
local injection, technique for 633
Hypercarbia during laparoscopy 210b
Hyperechoic second layer 418
Hyperechoic submucosa 416f
Hypermenorrhea 448
Hyperpolymenorrhea 430
Hyperreactio luteinalis 228
Hypersensitivity 652
Hypertrophic scars 649
attenuate formation of 649
Hypoechoic mucosa 416f
Hypogastric artery
division of 161f
left 165f
Hypogastric nerve
fibers 161f
plexus 391f, 679f, 680f
Hypogastric plexus
inferior 20, 161f, 162f
upper 162
Hypogastric vein 161f
Hypoglycemia, mild 313
Hypomenorrhea 721, 749
Hypothermia 201, 203, 204
reduce 211
Hypotonic fluids, excessive absorption of 774
Hypoxia 199, 201t
Hysterectomy 85, 88, 118, 336, 344, 349, 382, 447, 448, 455, 458, 471, 506, 507, 507t, 518, 520, 533, 559, 579, 666
classical teaching of 493
complete 610
laparoscopy assisted combined 466
model 88
procedures, types of 124t
specimen, histological examination of 338
types of 124, 582t
Hysteropexy 388, 588, 588f
Hysteroresectoscope 720
Hysterosalpingogram 285
Hysterosalpingography 577
Hysteroscope 51, 305
Hysteroscopic
biopsies 100
chip removal 61f
gynecological surgery 712
myoma resection 751
myomectomy 449, 454, 483
procedures 98, 101, 718
classification of 101t
pump 705, 706f, 719
sterilization 100, 304, 712
surgery 482, 753t, 771
techniques 555
training models 734
tubal cannulation 284
technique of 284
Hysteroscopy 49, 61, 78, 79, 100, 483, 717, 718, 720
adenoma on 406
complications of 771
current training models in 98
instruments for 44
remains complementary 744
surgery 771
anesthesia 772
distension media 772
incidence 771
mechanical complications 775
patient position 772
traumatic complications 775
training 98
simulation-based 98
Hystsimtm simulator 100f
I
Ileocecal valve 328f
Ileum 273
endometriosis of 321, 327
tumor of 274f
Ileus 271
Iliac arteries 760
Iliac circumflex artery, superficial 48
Iliac fossa trocar, left 322
Iliac superficial artery 269f
Iliococcygeus originates 623
Ilio-obturator lymph node dissection, left 678f
Iliopectineal ligament
preparation of 609
right 610
Immunohistochemistry 637
In utero diethylstilbestrol exposure 237
In vitro fertilization 295, 315, 341, 730, 731
cycles 319
embryo transfer 298
Incision 245, 435
fatty, superficial 610f
Incisional hernia 182
defect 182, 185f
repair of 185
laparoscopic bridge repair of 186
primary repair of 182
repairs 181, 185
Indemnity 151
Indiana pouch 683
Indocyanine green 422, 692
Infection 342
Infertility 318, 339, 728, 751
clinical symptoms of 344
history of 237
hysteroscopy in 719
primary 448, 720, 721, 749
secondary 448, 720, 721, 749
Inflammation 204
regulation of 205
Inflammatory bowel disease 266, 342
Inflammatory mediators 639, 648
Information technology risk 149
management 149
Inframesenteric lymph nodes 22
Infundibulopelvic ligament 226f, 677
division of 530
Inguinal hernia 187189
congenital 279f
defect, left 187f
laparoscopic repair of 188
repairs 181
symptoms of 187
Inguinal ligament 267, 268
Inhibits apoptosis 649
Injection solution 633
Inorganic trainers 86, 88
Instruments 632, 705, 706
distribution of 463
single-curved 123f
sterilization mishap 146
Insufflation 57
Insulation failure 147
Integrated fluorescence 693f
Integrated Robotic system 37f
Integrated table motion function 692
Integumentary system 205
Intense pulsed light 637
Intercellular adhesion molecule-1 208
Internal epithelial lining 728
Internal hernia 189
defect 190
right pelvic side wall 190f
Internal iliac
artery, branches of 19f
lymph nodes 22
Internal obliquus abdominis 121, 266
Internal obturator muscle 16
Internal OS 705, 709, 710
International Society for Gynecologic Endoscopy 10, 178
International Society of Minimal Invasive Gynecology 11
Interstitial edema 774
Interval salpingectomy 306
Interval sterilization 303
Interval tubal excision 303
Intestinal injury, incidence of 272
Intestinal polyps 313
Intestinal wall, seromuscular tear of 194f
Intra-abdominal
bleeding, severe 237
drainage 611, 678
fluid collection 775
inflammation 312
insufflation with pump, filter and manometer, apparatus for 5f
mesh, border of 187f
pressure 46, 199, 200, 201, 202fc, 209, 609
physics of 202
tumors 269
Intracervical injection 774
Intracorporeal knot 171f, 228
tying 174f
technique for 174f
Intracorporeal slip-knot technique 408
Intracorporeal vault closure 678f
Intracytoplasmic sperm injection 341, 730
Intraepidermal squamous cell carcinoma 267
Intrafascial hysterectomy 348, 349, 494, 497f, 519, 522
Intrafollicular pattern 247
Intraligamental gravidity 236, 251
Intramural myoma 434, 436
mapping of 479f
Intramyometrial cysts 339
Intraomental blood vessel, accidental needle puncture of 126f
Intraoperative bowel lesions 271
Intraoperative ultrasound guidance 442f
Intratubal adhesions 293
Intrauterine adhesiolysis 721, 747, 749, 754
Intrauterine adhesions 342, 483, 750f, 777
additional 721
minor 101
prognosis of 721t, 750
suspected 750
Intrauterine adnomyosis 413f
Intrauterine contraceptive device, uses of 342
Intrauterine device 428, 710
removal of 101
Intrauterine electrosurgical adhesiolysis 750
Intrauterine gestational sac plus 239
Intrauterine gravidity 252
Intrauterine intervention 750
Intrauterine manipulation 31, 32f
Intrauterine manipulator, visualization of 366f
Intrauterine pathology 720
treatment of minor 705
Introitus ultrasound 593
Invasive cancer
accidental detection of 670
early stage 664
Invasive epithelial tumors 666
Invasive tumors
advanced stage 667
early stage 666
Irrigation
device 58
instruments 29
Irritable bowel syndrome 342
Isobutene 208
Isolated fallopian tube torsion 316
Isthmoampullary anastomosis 289
Isthmoampullary junction 301f, 302f
Isthmo-isthmic anastomosis 288
Italian Robotic system 38
Itching 637
J
Janos veress 6f
Jet grasper 464f
Jet streaming 202
Jordan M Philipps 11f
Joule effect 639
K
Keloids 649
Keratin formation 652
Keratinocytes 621
synthesize insoluble 621
Keratinocytic intraepidermal neoplasia 266
Kidney, rupture of 312
Kiel School of Gynaecological Endoscopy 722
Knot pusher 434
Kocher's clamp 388
Kocher's forceps 115
Koh macro needle holder 63f
Kurt Semm 7f
L
Labia majora 616, 621, 622, 647f
augmentation 629f, 650f
labiaplasty of 630
hypertrophy, primary 628
labiaplasty of 630
reduction of 628
skin tightening 648f
technique for 633
Labia minora 622, 625, 633
hypertrophy of 616, 625
labiaplasty of 630
plasty 626f
reduction of 625, 630f
technique for 633
Labial edge 627
Labial procedures 634
Labiaplasty 621, 625
surgery 627
Lach surgical procedure 467
Lactobacilli 621
vaginalis 637
Lamina propria fibroblasts 638
Laparoendoscopic single-site surgery 688
Laparoscope 609
Laparoscopic
adhesiolysis 295
appendectomy, stages for 259f
camera navigation 92
combined hysterectomy 466
technique 473
cystectomy 223
entry lesions 126
classification of 759
fenestration 224
fimbrioplasty 293
gynecological surgery, learning curve for 93
hysterectomy 32, 124, 455, 494, 506, 509, 509t, 530f, 555, 572, 582, 744
advantages of 559
basic concept of 506
category of 509t
techniques and instruments, development of 348, 519
traditional technique of 539
hysteropexy 594
inguinal hernia repair, technique for 188
instruments 39
development of 29, 760
interventions 44
intrafascial hysterectomy 348
lithotomy 487
mesh, placement of 183
microsurgery 285
myoma
enucleation 66f68f, 451f454f, 507f510f, 727, 728f731f
therapy 462
myomectomy 427, 428, 432f, 440, 442, 450, 454, 462, 470, 727, 728, 744
nerve-sparing radical hysterectomy 678
ovarian drilling 477
pectopexy 608, 612
perineo-colpo-hystero-sacropexy 598
peritoneal access injury, causes of 114
pneumoperitoneum 199
procedure 85, 265, 271, 668
in pregnancy, benefits of 260
in pregnancy, complication of 260
psychomotor skills 92
radical hysterectomy 663, 674, 679
anesthesia 674
contraindications 674
indications 674
port positions 674
preoperative 674
procedure 675
single-incision 688
rectosigmoidectomy 329
repair 587
resection 398
robotic surgery 118
route 297
sacrocolpopexy 157, 598
sacropexy 594
salpingo-ovariolysis 293
situs 511f
skills
evaluation of 79
testing and training 79
training and evaluation of 79
sterilization 297, 303, 304
subtotal hysterectomy 169, 368, 538, 559, 570f
supracervical hysterectomy 347, 458, 466, 493, 507, 516, 531, 538, 582
surgery 45, 83, 93, 104, 207, 222, 228, 257, 698, 744
difficulties of 664
during pregnancy, indications for 257
equipment for 25
establishment of 760
for ovarian cancer, advantages of 227
growing popularity of 118
instruments for 25
newer versions of 118
single-incision 576
suturing 332, 458
techniques 222, 297, 380, 555
total hysterectomy 346, 355, 369f374f, 472, 510, 528, 543f548f
tubal microsurgery 285
advantages 285
equipment and instruments 285
intraoperative evaluation 287
preoperative workup 285
selection of cases 286
surgical steps 288
surgical technique 288
sutures, needles and energy 286
uterosacral ligament 601
Laparoscopy 44, 51, 61, 79, 118, 159, 221, 312, 315, 319, 331, 402, 717, 718, 768f
adenoma on 406
basic concept of 717
beginning of 51f
complications of 228, 759
conventional 62, 418t
diagnostic use of 663
fundamentals of 92
hysterectomy, single entry 124
scar 324
single-entry 122
vascularization in 156
Laparotomy 251, 303, 315, 668
conventional 418t
Lapmentor 95f
LapSim 95f
Laser 35, 305, 632
choice of 640
resurfacing, success of 644
skin resurfacing and rejuvenation 640
vaginal rejuvenation 630
Lash, surgical procedure of 469
Lavage 465
Lee Huang point 47, 353, 528, 725
Left adnexa, aplasia of 281f
Leiomyoma 337, 338, 427
Leiomyomatosis peritonealis disseminata 439
Leiomyosarcoma 427, 429
Lens 32
endoscopic 27
system 53
train 52
Lentigo malignant melanoma 268f
Lesions
bipolar coagulation of superficial 322f
superficial 331
Letrozole 344
Leukocytosis 227
Levator ani
fascia, thickening of 623
muscle 623
Levator fascia 623
Levator plate 623
Lichen sclerosus 637, 640
Lidocaine 633, 648
gel 632
Ligament 610f
preparation of 609
push 613
Ligamentum ovarium proprium, left 281f
Ligation, methods of 286
Light fibers 52
Light-emitting diode lamp system 56
Lina loop 32f
Linear technique 633
Lipoproteins, surface-active 204
Liquid
crystal display 306
diet 674
silicone, hysteroscopic injection of 297
Lithotomy 432
Liver
appendicular abscess of 276f
asymptomatic abscess of 276f
cirrhosis of 278f
cyst 276f
diaphragm 281f
dullness, loss of 352, 525, 725
hemangioma of 276f
lobe, left 276f
metastasis 277f
with superficial ulcer 277f
right lobe of 278f
rupture of 312
Local anesthesia 633
injection
solution 633
technique 633
Loop and roller ball 771
Loop ligatures 169
Low level light therapy 648
Low potency glycolic acid 645
Lower abdominal pain, recurrent 721, 749
Lower segment cesarean scar defects 710
Lumbago 430
Luteomas 228
Lymph node 21f, 160, 609
dissection 678
Lymphadenectomy 21
right-sided 161f
types of 160
Lymphatic imaging, technique of 422f
Lymphatic system 159
Lymphatic trunk, dissection of 610f
Lymphatic vessels, coagulation of 609
Lysyl oxidase 617
M
Macro-tissue level 649
Magnetic resonance 415
guided focused ultrasound 448
Magnetic resonance imaging 121, 332, 417, 601
guided focused ultrasound 428
scans 392
Malignant disease 346, 507
Malignant melanoma 268f
Malignant ovarian tumors 221, 227, 228
Mangeshikar manipulator 496
Mangeshikar mist 94f
Mangeshikar uterine mobilizer 496
Manipulator lesions 439
Manual dexterity training 83
Marcaine 631
Maryland grasper and dissector 39
Mass abutting rectal wall 418
Mast cells 616
Matrix metalloproteinases 617
Mature cystic teratoma 224
McCall-culdoplasty 489
McGill inanimate system 79, 94
Meckel's diverticulum 192, 192f
Medial superficial peritoneal dissection 610f
Medial umbilical ligament 609
Medical therapy 447, 448
Medically assisted reproduction 390
Melanin 635, 647
Melanoma 421
Menopause, genitourinary syndrome of 637
Menorrhagia 338, 448
myomectomy for 777
Menstrual cycle 618
proliferative phase of 618
Menstrual flow alterations 161
Menstrual irregularities 254
Menstrual loss 409
Mentor, role of 93
Mesenteric artery, inferior 685
Mesenteric multi-chambered cyst 280f
Mesenterium 312
Mesentery, vessels of 760
Mesh arm 588f
placement of 589f
Mesh fixation 610
Mesh patch intra-abdominal for repair 186f
Mesh, evaluation of 595
Mesh-supported vaginal and endoscopic pelvic floor surgery, critical evaluation of 593
Mesoappendix 191
Mesogastrium, right-hand 565f
Mesometrial lymph nodes 17, 22
Mesometrium 17
ligamentous 17
Mesothelium repairs 205
Metalloproteinase 208
tissue inhibitor of 208
Methane 208
Methotrexate 252, 253, 578
selective use of 252
therapy 253fc
Methylene blue 671
Metroplasty, lateral 482, 483f
Metrorrhagia 448
Metzenbaum scissors 467, 487, 563
endoscopic 561
Microendoscopy 37
Microepidermal necrotic debris 642
Microlaparoscopy 115
Microprocessor-controlled insufflations system 243, 272
Microthermal zones 636
Midclavicular line 270
Middle trocar 433f
Mifepristone 428
Milia formation 642
Mimic gynecologic pathologies 190
Mini-hysteroscope 705
Mini-hysteroscopy 710, 712
Minilaparoscope 62, 115
Minilaparoscopy set 65f
Minimal access surgeries 688
Minimal invasive
hysterectomy 471
interventions 695
Minimal labia minora tissue 625
Minimally invasive surgery 44, 79, 139, 431
accreditation 79t
advantages of 45t
Minora 621
Miscarriage 242, 458
Modern surgical techniques, advent of 164
Molecules 635
Mono surgical techniques 753t
Monocryl sutures 627
Monocyte chemotactic protein-1 208
Monofilament
mesh 610
suture 611, 629f
Monopolar current 60f
Monopolar diathermy 286
Monopolar electricity 519
Monopolar hook 434
Monopolar hysteroscopic loop 740f
Monopolar resection 753
Monopolar technique 60
Mons pubis 616, 621, 622, 630
liposuction of 631
Monsplasty 631
Monstrous uterus myomatosus 468
Morbidity, laparoscopic-associated 201
Morcellation 437, 727
instruments 29
retrieval of 495
Mozambique 624
Mucinous cystadenoma 225
Mucinous tumor types 668
Mucosa, infiltration of 418
Mucosal strips, lateral removal of 629
Multicolored nevi 268
Multiple fibroids 455
Muscles 621, 623
Muscularis propria 416f, 418
architecture of 620
Myolysis 448
Myoma 427
causes of 427
coagulation 448
enucleation 76f, 406f
fixation with myoma drill 463f
intraligamentous 438
resection 101, 720, 721, 747, 750, 777
screw 36, 434
size 440
treatment for 455
vasculature 429
volume 437, 438f
with tenaculum, traction on 435f
Myomata, enucleation of 36
Myomatous uterus 447t
morcellation of 378f, 552f
Myomectomy 322f, 447449, 462, 464, 479, 482, 555, 700, 726
basic set for 434b
laparoscopic-assisted 440
specific features of 445
using jet grasper 464f
Myometrium 336, 337f, 381, 462, 777
asymmetrical thickening of posterior 339
normal 429
posterior 339
N
Native tissue repair 590
Natural orifice transluminal endoscopic surgery 121, 576, 688
Nausea 227
Necrotic myoma 242, 312
Needle 173
and thread, insertion of 465f
curved 176f
electrode 59
flow test 119, 119f
holder 176, 434
second-generation 176
Neodymium:yttrium-aluminum-garnet laser 36, 307
Neoplasm 311
Nephrolithiasis 242, 312
Nerve 386
injury 146
Neurohormonal vasoactivity 200
Neuroma-like hypersensitivity 626
Neurovascular tissue 623
Nickel allergy 307
Nitric oxide release 648
Nodal dissection 687f
Nodular superficial spreading melanoma, secondary 268
Nodule 331
on rectum 329f
Nonablative fractionated lasers 636
Nonabsorbable suture 603f
after appendectomy 278f
Nonsmall cell lung cancer 421
Nonsteroidal anti-inflammatory drugs 428
Nontubal ectopic pregnancy 247
Normal pregnancy, early stage of 242
North American Obstetrics and Gynecology 140
O
Obesity 349, 520, 608, 722
Objective lens system 52
Obliquus abdominis 266
Obliterated artery 157f
Obliterated hypogastric artery 676
Obliterated umbilical arteries 15
Obliterated urachus 15
Obstructive endometrial polyps 342
Obturator artery 18
Obturator fascia ventral 623
Obturator lymph nodes 21, 160, 161f
Obturator muscle 161f
Obturator nerve 18, 157f, 684
right 391f
Obturator veins 19
Ocular ischemia 651
Ocular lens 52
Office hysteroscope, use of 776
Office hysteroscopy 705, 717719
Office setting 705
Ohm's law 33
Oligosymptomatic 319
Omega-3 fatty acid 182
Omentectomy 663, 666, 668, 669
Omentum 760
Oophorectomy 222, 225, 506, 663
Open abdominal
laparotomy 121
operations 698
Open access 115
Open hysterectomy 124
Open laparoscopy 116
Open laparotomy surgery 199
Open radical hysterectomy 699
Operating team and general instruments 57
Operation, conclusion of 495, 503
Operative armamentarium 164
Operative hysteroscopy 717, 719722, 747, 771
diagnostics and therapeutic management 750
general complications of 753
indications 747
instrumentation and technical equipment 747
postoperative management 750
procedure of 720
staff requirements 747
surgical interventions 748
technique and procedure 747
Operative indications 428
Operative laparoscopy 248
energy systems for 33
Operative learning 83
Operative set-up 432b
Operative sponge counts 143
Operative technique 433
Operative treatment 447
primary 447
Optic trocar 115, 269, 350, 352, 433f, 523, 527, 722, 725
insertion of 244f
Optical cannula 115
Optical veress needle 28, 115
Optimal laparoscopic bowel suturing 176
Optimal positioning, automated endoscopic system for 25, 118
Optimal therapeutic management 319
Optimizing esthetic results 649
Optoelectronic transducer 10
Oral contraceptive 313
Organ injury 146
Organic trainers 85, 88
Orgasm problems 386
Orthotropic ileal neobladders 683
Osada's triple-flap technique 344
Ovarian arteries 21
Ovarian borderline tumors, prognosis of 666
Ovarian cancer 663
advanced 667
laparoscopic management of 227
robot-assisted operations in 699
Ovarian cortex
dissection of 225f
incision on 225f
suturing of 229f
Ovarian cyst 89, 242, 312, 313, 342
aspiration of 226f
large 269
model 88
putting 230f
removed 229f
Ovarian dermoid cyst 224f
Ovarian endometrioma 323, 324f
bilateral 223f
Ovarian endometriosis 321, 323
Ovarian fossa 669
left 323f
Ovarian hormone deficiency 620
Ovarian hyperstimulation syndrome 228, 257
Ovarian ligament 362f, 537f, 562f, 669
Ovarian malignancy 664, 668
laparoscopy for 664
prophylactic operations, laparoscopy for 664
Ovarian mass 257
Ovarian neoplastic lesions 224
Ovarian parenchyma 324
coagulation of 324f
Ovarian pregnancy 247
laparoscopic management of 248f
Ovarian serous cyst adenoma, right 225f
Ovarian surgery 88
suturing in 228
Ovarian tissue, thin layer of 173f
Ovarian torsion 226
right 227f
Ovarian tumor, large 228
in pregnancy 227
suspicious 667
Ovariopexy 388
Ovary 236, 455, 507
oncologic surgery on 663
serous borderline tumor of 664f
torsion of 242, 312
Ovum pickup 478
Oxygen species, reactive 648
Oxyhemoglobin 635
P
Pain 303
during sexual intercourse 386
score after gynecological laparoscopy conic trocars 125f
Painful intercourse 637
Painful nodules 318
Palmer's point 47, 269, 270, 353, 528, 725
use of 759
Palpable abdominal mass 430
Palpable adnexal masses 254
Pap smear 347
Papillary layer 621
Para-aortic lymph node 22
compartments 21
Para-aortic lymphadenectomy 663, 666, 668
Paralytic ileus 204
Parametria, dissection of 489
Parametrial lymph nodes 22
Parametrial tissue 17f
Parametritis 777
Parametrium 22
Para-ovarian peritubal adhesions 293
Pararectal space
dissection of 676, 686f
left 676f
right 686f
transversely 676
Parasympathetic nerves 20
Paravesical fossa 380f
Paravesical space anterior 684
Parenchymatous organs, rupture of 312
Parotid area sign 774, 774f
Partial bowel resection 353f, 525f
Partial cystectomy 386
Partial salpingectomy 246, 303
types of 303
Pectineal ligament 589f
left 612f
Pectopexy 612
Pedunculated myoma 281f, 434
Peeling agents 645
Pelvic
adhesions 342, 478
anatomy 98
arteries 17f
endometriosis 417t
fascia 161f
iliac bone 161f
infection 346
lymph node compartments 21
lymphadenectomy 158f, 159f
models 88
nodes, number of 666
peritoneum of Douglas 162
plexus 391f
retroperitoneal spaces, small 157f
segment 18
support disorders 616
surgery 618
vascular tree 165f
Pelvic autonomic nerve 17f
plexus 20f
Pelvic congestion 311
syndrome 342
Pelvic floor 616, 623
connective tissue 616, 619
defects, surgery for 598
disorders 157
muscles 618
repair 616, 625
objectives of 624
support, reassessment of 605
training 594
Pelvic inflammatory disease 237, 242, 293, 312, 346, 507
chronic 272, 342
Pelvic mass 418
origins of 221
Pelvic nerves 679f
schematic diagram 679f
Pelvic organ 311
prolapse 156, 346, 507, 518, 593, 598, 600, 601
pathogenesis of 616
quantification 600
surgery 599
symptoms of 593f
recovery of 617
support, functional dynamic anatomy of 599
Pelvic pain 192, 237, 254, 346
chronic 161, 338, 728
Pelvic sentinel lymphadenectomy
left 422f
right 423f
Pelvic side wall 190
opening of 487
Pelvic ureters
exposure of 601
identification of 601
Pelvic wall 181
anatomy of right 531f
lateral 161f, 162f
pectineal ligament 609
ureter in 65f, 530f
Pelvis
computed tomographic imaging of 415
evaluation of 222
mesh position in 608f
MRI evaluation of 314f
muscles of 623
surgical endoscopic anatomy of 156
Pelviscopy 40
Penile carcinoma 421
Perforation, instruments for 27
Performing hysterectomy, indications for 346b
Pericardium 386, 400
die of 399
Pericervical ring, restoration of 599
Perineal body 621, 624
Perineal membrane 621, 623, 624
Perineal nerve 622
Perineoplasty 631, 631f, 632, 634
local injection, technique for 633
Periodic stress 617
Peripheral vascular resistance 200
Peritoneal absorption variability 203
Peritoneal access 114
Peritoneal carcinosis, diagnosis of 663
Peritoneal cavity 208
Peritoneal drying, amount of 206
Peritoneal endometriosis 321, 322
Peritoneal endometriotic lesion, superficial 322f
Peritoneal fluid 204, 208b
contains cells 208
Peritoneal hypothermia, local 204
Peritoneal injury 205
Peritoneal insertion methods, classification of 115t
Peritoneal irritation 227
Peritoneal pelvic space 164
Peritoneal space 201
Peritoneal surface 182
Peritoneal thickness 205
Peritoneal wall, opening of 360f
Peritoneal washings 666, 668, 669
Peritoneum 17f, 205, 312, 386, 503, 610, 675
closure of 612f
deep infiltrating endometriosis of 386
malignant mesothelioma of 279f
retraction of 326f
Peritonitis 266
Periurethral pseudocyst formation 652
Perivisceral spaces 156
Persistent adnexal masses 258
Persistent ductus omphaloentericus 126
Persistent pyrexia 271
Phenol 208
Phenotype, genetics of 446
Philtrum-mastoid prominence 774
Phospholipids 208
Photobiomodulation 648
Photoendoscope 4, 4f
Photothermolysis, selective 636
Physiological ovarian hormones variation 618
Pitressin 411f
Pivers type III radical hysterectomy 678
Planned surgery, omission of 146
Plasmin 208
Plasminogen activator inhibitor 208
Plastic uterus reconstruction 462, 463f
Platelet-rich plasma 653
Plug repairs 189
Pneumomediastinum 208
Pneumoperitoneum 6, 124, 199, 200t, 205207, 209t, 210, 281
control of 321
creation of 320
low-pressure 259
Pneumothorax 208
Polycystic ovarian
disorder 477
syndrome 477
Polycystic ovaries 477f
Polydioxanone 502
Polyester mesh 185
Polyfilamental suture 611
Poly-l-lactic acid 649, 651
Polymethylmethacrylate microspheres 649
Polyp 342, 710
removal 100
resection 101, 720, 721, 747, 751
Polypropylene 184
mesh 183f, 188
Polytetrafluorethylene 184
Polyvinylidene fluoride 610
Pomeroy's method 286
Pomeroy-type ligation, modified 303
Porcine bladder 86f
Port placement 350, 523, 722
complications in 759
Port position 288f, 675f, 687f
Port robotic system, single 695f
Positive pregnancy test 237
Post-adenomyotic pregnancy 413f
Post-cystectomy ovarian 223
Posterofundic myoma 436f
Posthysterectomy 604
inspection 373, 542
Postinflammatory hyperpigmentation 642
Postmenopausal status 430
Postpartum
salpingectomy 306
tubal excision 303
Potential ectopic pregnancy 242fc
Pouch of Douglas 243f, 312, 314f, 439, 576, 675
after hysterectomy 278f
infiltrating endometriosis 195f
puncture of 240
Precapillary arteriolar sphincters 639
Pregnancy 304, 311, 342
after sterilization 304
and birth rate, postoperative 750
cumulative risk of 306t
interstitial 251
intramural 251
loss, recurrent 448
of unknown location 577
rate 410, 750
test 237
Prelooped intracorporeal knots 176
Premalignant disease 346, 507
Preperitoneal mesh placement right inguinal hernia 188f
Preperitoneal space 116
Presacral lymph nodes 22
Pressure bag 706f
Pressure symptoms 430
Prevertebral peritoneum, opening of 157
Primary trocar 27, 320
insertion of 760
Procollagen
process 619
production of 649
Progesterone serum level 240
Progestin-only contraceptives 237
Prolapse
awareness of 595
quantification of 593
repeat surgery for 595
tissue 619
treatment of 594
Propene 208
Prophylactic adhesion 711
Prophylactic antibiotics, preoperative 222
Prophylactic antiembolic medication, uses of 144
Prophylactic operations 664
Propylene 208
Prostaglandin synthetase inhibitors 428
Prostrate syndrome, transurethral resection of 44
Proteoglycans 617
Pruritus 642
Pseudocapsule, extraction of 324f
Psoas 610f
Psychogenic disorders 342
Pubic bone 623
Pubic enhancement 631
Pubic lifting 631
Pubic liposuction 631
Pubocervical fascia 604, 605f
exposure of 602, 604f
Pubocervical ligament 16, 17
Puborectalis originates 623
Pudendal block 631
Pudendal nerve 619
Pudendal veins 19
Pulling umbilical ligament 610f
Pulmonary disease 618
Pulmonary vascular resistance 200
Pulsatility index 222, 441
Pulse duration 635
Pulsed lasers 636
Punctual hemostasis, bipolar forceps for 464, 464f
Puncture trocar 320
Pune technique 674
Pur technique, basic rules of 462
Pyelonephritis 242, 312
Pyometra 777
Pyridine 208
Pyrrole 208
Q
Q-tip instructions 634
Quadro test 26, 120, 120f
Questionable staple line 197
Quinacrine 305, 307
R
Radially expanding trocars 115, 125, 125f
Radical surgery 403
Radical treatment 222
Radiofrequency 33, 635
device 632
skin tightening 647
Raloxifene 428
Rectal bleeding 336
Rectal endometriosis 415
management of 418
Rectal plexus 20
Rectal wall 418
infiltration 418
over lesion 329f
Rectopexy 588f
Rectoscopy 349
Rectosigmoid
endometriosis of 321, 328
sectioning of 330f
stapling of 330f
Rectosigmoidectomy 319
Rectovaginal endometriosis 398
Rectovaginal examination 221
Rectovaginal septum 16, 328, 398, 604, 605f
exposure of 602
Rectovaginal space 386
die of 398, 398f
dissection of 675
Rectovaginal vagina, die of 398
Rectum 17f, 20f, 594, 671
Rectus abdominis 121
muscle 15
Rectus fascia 115
anterior 116
posterior 116
Rectus muscle 116
Recurrence, ruture fertility and risk of 254
Recurrent anterior compartment prolapse 595
Redo surgeries 439
Refractory neurogenic bladder 390
Regenerative medicine, role of 653
Regional ischemia 204
Renal failure, postoperative 439
Repairs, types of 185
Reproductive function, preservation of 470
Reproductive tract, endometriosis of 321, 323
Resectoscopy, perforation at 776f
Residual ovarian function 222
Residual placenta, resection of 720, 747
Resistance index 441
Retention 652
Retinoids 645
Retroperitoneal
connective tissue 488
grasper 589f
lipoma 280f
lymphangioma 280f
myoma of cervix 281f
operations 117
pelvic fossa, right 157f
space 156
structures 323f
vessels, small 159
Retroperitoneum 386
Retropubic urethropexy 618
Retrospective analysis 114
Right tube
and right round ligament, stepwise bipolar coagulation of 532f
and round ligament, stepwise dissection of 532f
Right ureter, transperitoneal exposure of 602f
Rigid and flexible hysteroscopes
advantages of 719t
disadvantages of 719t
Rigid endoscope, structure of 52
Rigid hysteroscope 719
Ringer's lactate 373, 773
solution 229
Risk severity index 144
Robi Kelly handgrip 64f
Robinson drainage 30, 31f
Robot-assisted
interventions 696f
laparoscopic
hysterectomy 509t
myomectomy 455
operations in gynecology 700
operations, technique of 695
surgery in urogynecological diseases 699
laparoscopy, use of 700
operations 697, 698, 700
sacrocolpopexy 158
Robotic assistance 458
Robotic cart 687
Robotic endoscopic surgery 37
Robotic hysterectomy 473, 582
Robotic myomectomy 455
Robotic radical hysterectomy 686
Robotic setup 686f
Robotic system, technical innovations of 700
Robotic total vaginal NOTES hysterectomy 579, 582
Robotic vaginally-assisted NOTES hysterectomy 582
Round ligament 318, 530
and tube, left 363f, 537f
transection of 497
Rudimental uterine horn 236, 250
Running suture 395f, 590f
Ruptured corpus luteum cyst 242, 312
Ruptured tubal pregnancy 244f
S
Sacral colpopexy 608
Sacral fixation 587, 588
Sacral promontory, level of 675f
Sacral roots originating 163
Sacrocolpopexy 595, 598
Sacrospinous
fixation 587, 598
ligament 601
Sacrotuberous ligament 623
Sacrouterine ligament 344, 377f, 386, 390, 489, 508, 537, 550f, 731, 735f
conjunction of 377f
die of 390
left 546f
radical resection of 390
right 71f
Saline infusion sonography 707
equipment for 708f
Salpingectomy 246, 297, 316, 506, 663
bilateral 482f
Salpingitis 242, 312
isthmica nodosa 285, 286
Salpingo-oophorectomy 668
bilateral 489
Salpingoscopy 287, 287f, 288f
Salpingostomy 244
incision, suturing of 245
Sarcomas 439
Saw-toothed scissors 28
Scars 608
anesthesia for small 645
vulval skin resurfacing for 637
Scattered nodules, excision of 480f
Scissors, curved 28
Sclerotherapy 222
Scopes 123
Scrotum 209
Sealing instrument 694f
Sealing instruments, uses of 497
Sebaceous
glands 621
materials with bone 224
Seborrheic keratoses 266f
SEL instruments 122
Semi-Trendelenburg position 298
Semm needle holder 174
Senile warts 266f
Sentinel lymph node 421
biopsy 421
detection 421
Sentinel node
biopsy, relevance of 424
concept of 421f
Septa retained tissue 710
Septum 712
resection 482
with fibrotic tissue 712f
Septum dissection 720, 747, 748, 749f, 754
diagnostics and therapeutic management of 748
indications 748
technique of 720, 748
Seroma
formation 184
postoperative 185f
Serosal mucosa, closure of 466f
Serosal tear intestinal wall 195f
Serous cystadenoma 225
Serum tumor markers 221
Sex development, disorders of 631
Sex steroids 652
Sexual activity 634, 732
Sexual function, assessment of 625
Sexual functioning scale, short 386
Sexual intercourse 627
Sexual satisfaction 347, 512
Sexual stimulation 630
Sexually transmitted disease 237
Shaving technique 328
Shoulder pain 399
Sigma colon, chronic diverticulosis of 274f
Sigmoid colon 190, 280f
anteriorly 681f
Silastic band 299
Silastic ring 303
Silicone band application 297
SILS port 122f
Simbionix lap-mentor 80f
Simultaneous hysteroscopy 743f
Single-port
entry 122
laparoscopic system 122
laparoscopy 62
Skin
changes with aging 639
closure 633
necrosis 651
optics 635
rejuvenation, low-level light therapy for 648
Ski-shaped needle 174, 176f, 178f
Slip-knot technique 410f
Smoke plume evacuator 34
Smooth muscles cells 447
Snap test 119, 120f
Sodium bicarbonate 632
Soft tissue 609
Solid organ resection 259
Solitary nodule, vaginal ultrasound of 350f, 522f
Sounding test 120, 120f
Spigelian hernia 181
Spill after hysteroscopic tubal cannulation 284f
Spillage 228
Spiral course 311
Splanchnic blood flow 200
Spleen, rupture of 312
Splenic injury after myomectomy 278f
Spot size 635
Spotting 237
Spray coagulation 59
Stabilize ovary with grasper 477
Standard curved needle 175
Standard trocars disposition 432f
Steatosis hepatitis 277f
Stem cells 653
Stereoscopes 56
Sterile saline 705
Sterilization procedure 298
Stimulating muscles 73
Stimulating nerves 73
Stomach, perforation of 312
Stratum corneum 621
Stress urinary incontinence 595, 600, 616, 639
Styrene 208
Subcostal insufflation technique 47, 269, 353, 528, 725
Subcutaneous emphysema 208, 210b
incidence of 209
Subcutaneous fat tissue 121f
Subcutaneous tissue 184, 621
Subcuticular closure 633
Subendometrial adenoma 407f
Subendometrium 777
Submersion leak testing 197
Submucosa, infiltration of 417
Submucosal fibroids 449, 717
Submucosal myoma 342, 751, 751f
classification of 750f
Subserosal myomas 434, 436
Subtotal hysterectomy 32, 32f, 346, 457, 511
Subtotal laparoscopic hysterectomy 445, 457
Subumbilical insufflation 759
Subumbilical region, palpation in 723f
Suction and irrigation
instruments 29f
system 29f, 694f
tube 64f
Suction device 58
Suction instruments 29
Supracervical hysterectomy 347, 457, 539, 613
laparoscopic-assisted 32, 468
Supramesenteric lymph nodes 22
Suprapubic trocar 322
Supraumbilical trocar 433
Surgeon laparoscopic pneumoperitoneum 199
Surgeon's console 118
Surgeon's knot 175f
Surgery
procedure of 721
role of 477
scheduling of 720
technique of 227
types of 98
Surgical microscope 26
Surgical procedure 222
Surgical specimen mishap 146
Surgical techniques, improvement of 757
Surgical therapy 399
Suture
characteristics 175
hydrolysis 634
ligation 192
Suturing ovarian cortex 224f
Suturing right uterosacral ligament 604f
Suturing technique 169, 436f
Suturing vagina 490f
Sympathetic fibers, resection of 163
Sympathetic nerve fibers 20
Symphysis pubis inferiorly 181
Synechiae 342, 710, 711
T
TachoSil 74f, 75f
uses of 76f
Tachycardia 271
Taenia coli 683
Target biopsies 101
Te Linde, suturing technique of 361, 365, 533, 534
Technical equipment 720
Temporary dysmobility syndrome 204
Temporary ileostomy 271
Temporary transverse colostomy 685
Tenaculum 433, 434f
Tenesmus 318
Tension-free position 611
Terumo guidewire 284f
Terumo Kymerax system 38, 39f
Theoretical curriculum 98
Thermal effect 58
Thermal reperfusion, phenomenon of 639
Thermal techniques 33
Thermofusion 33
Thick anteroposterior adhesion band 484f
Thoralf Schollmeyer 12f
Thorax after breast cancer, skin metastasis of 269f
Three D vision system 119
Three-dimensional imaging 56
Thromboprophylaxis 732
Thyroid malignancies 421
Tightening technique 176f
Tissue
ablation, amount of 640
absorptive capacity 203
desiccation 201, 204
disruption 199
handling 631
operative procedure marking 631
preparation 631
hydration 205
integrity, loss of 617
laxity, skin rejuvenation for 646
plasminogen activator 208
remodeling manipulation 634
resistance 437
Topical antibiotic ointment 634
Topical corticosteroids 650
Topical hydroquinone cream 645
Topography, anatomic 18
Torsion 257
early detection of 227
stress 437
Total abdominal hysterectomy 582
Total atraumatic intrafascial laparoscopic hysterectomy 494, 555
Total hysterectomy 511, 512, 539, 732
Total laparoscopic hysterectomy 348, 445, 457, 458, 361f, 466, 493, 506, 507, 518, 518f, 559, 582, 663
in Kiel school, concept of 494
operative steps of 349, 522
preparation for 494, 495
Total mesometrial resection 17
in cervical cancer 693
Total pelvic exenteration 685
Total salpingectomy 303
Total vaginal notes hysterectomy 576, 579, 582
Traditional laparoscopic operation 697
Traditional laparoscopy 698
Training in minimally invasive gynecological surgery 92
Training systems 85
Transabdominal laparoscopy 577
Transanal discoid resection using circular stapler 329
Transcervical route 297
Transcervical sterilization 304
Transcriptase real-time polymerase chain reaction, reverse 637
Transected corpus 565f
Transepidermal energy delivery 646
Transepidermal fractional
CO2 resurfacing 646
energy delivery 646
Transesophageal echocardiography 210
Transfix right ureter 681f
Transfixation suture 682f
Transient postinflammatory hyperpigmentation 643
Transmyometrial myoma 339f
Transperitoneal ureteral dissection 601
Transsected pig heart 99f
Transuterine route 297
Transvaginal hydrolaparoscopy 576, 578
technique of 576
Transvaginal natural orifice transluminal endoscopic surgery 576
Transvaginal ultrasonography 239, 406
scan 312
Transvaginal ultrasound 236, 313, 316, 593
scan 707
Transverse abdominis muscle 15
Transverse cervical ligament 16
Transverse perineal muscles, superficial 624
Transversus abdominis 121, 266
Traumatic forceps, types of 28
Traumatic surgery 227
Trendelenburg position 48, 528
Tretinoin 644
Trocar 48
correct placement of 528
insertion
places for 269, 271
right direction of 125f
placement 15, 259, 259f, 432, 463, 463f, 494, 497, 561f
and changing sides 467f
preconditions of 757
secondary 50f, 357f, 529f, 726f, 727f, 758f
positioning of 432
Trophoblast 235f
tissue, persistence of 254
Trophoblastic giant cells 235f
Tubal abnormality 237
Tubal cannulation 101
Tubal damage, length of 286
Tubal endometriosis 321, 324
Tubal ligation, previous 237
Tubal occlusion, proximal 284
Tubal patency 577
establishment of 294
Tubal pregnancy 244f
complication of 252
extirpation of 246
surgical treatment of 244
Tubal preservation 316
Tubal rupture 252
Tubal screw 305
Tubal sterilization 101, 146, 297
procedure, reversal of 285
Tubal surgery 284
types of 284
Tubal torsion 311, 312t
management of 315
Tube
coagulation of 36
detorsion of 314
division of 498f
excessive length of 311
interstitial part of 292f
reperfusion of 314
separation of 497
Tuberculosis 295
Tubo-cornual anastomosis 289
Tubo-ovarian abscess 242, 312
Tumescent anesthesia, local 633
Tumor
lymphogenic metastasis of 421
markers 221
necrosis factor-A 208
resemble leiomyomas 193
TUR syndrome 748, 753
Two slicing techniques 711f
Two-cavities-phenomenon 720
U
Ultrasonic energy 36, 435f
Ultrasonography 332
Ultrasound
examinations 221
imaging 238
scissors 392
Umbilical fold, lateral 16f
Umbilical hernia 181, 181, 269
primary 182
Umbilicus 386, 399
piercing of 6
Unifocal cancers, macroscopic 424
Unipolar coagulation 303
Unipolar diathermy 303
Unsuspected malignancy 572
Ureter 17f, 60, 386, 579, 580
anatomical relationships of 18f
anatomy of 382f, 555f
autonomic innervation of 19
cross-section of 18f
die of 393
endometriosis of 325
endometriotic involvement of 393
excess tip of 683f
identification of 322f
injury 146, 601, 766
innervation of 18
movement 373
partial resection of 393
three stented 396f
vascularization of 18, 18f
Ureteral endometriosis 326
Ureteral lesions 767
Ureteral orifices 395
Ureteral stricture, recurrence of 394
Ureteric injury 678
localization of common 18f
Ureteric lesions 670
Ureteric tunnel
dissection 677
left 677f
Ureterosigmoid 683
anastomosis 682f
right edges of 682f
Urethra 594
being cut 680f
Urethral irritation 652
Urethrovaginal
fistulas 652
septum 16
Urinary bladder 17f, 496f, 500
dissection 499, 500
endometriosis of 395
Urinary catheter 379, 544, 732
Urinary disturbances 221
Urinary diversion plays, types of 683
Urinary dysfunctions, postoperative 613
Urinary frequency 430
Urinary incontinence 616, 637
Urinary infections 394, 613, 652
Urinary tract
endometriosis of 321, 325
infection 398
chronic 637
lower 473
injuries 766
Urinoma 394, 398
Urogenital diaphragm 623
Urokinase-like plasminogen activator 208
U-sutures 368, 537
Uterine
adnexa 17f
anatomy 98
cancer, treatment of 674
diagnostic curettage 240
dissection 53f, 543f
growth, rapid 430
horn resection 251
incision 450
leiomyomas 346, 457, 507
ligaments 16, 17f
malignancies 674
pathology 98, 379f, 553f
pedicles, separation of 531f
polyps 717
preserving surgical strategies 731
round ligament 16
rupture 439, 440
size 430
sparing surgery 336
weight 490f
Uterine artery 18, 21, 157f, 161f, 252, 379f, 381f, 488f, 496f, 676, 684
ascending 536f
branch of 361f, 531
clipped, left 687f
coagulation of 488f, 499f
cutting of 500f
dissection of 494, 500
embolization 428, 447, 448
from ureters 498
functions 538f
ligation, primary 528
Uterine bleeding 717
abnormalities 744
Uterine cavity 482f, 728
distension pressure 774
Uterine corpus 70f
resection of 376f, 538
Uterine fibroids 445, 447t, 479
treatment options for 448, 448t
Uterine manipulation 688
instruments for 31
Uterine manipulator 432, 434, 487
placement of 320
Uterine myoma 471
large 470f
Uterine perforation 771
suspect 775
Uterine septum 482, 717
treatment of 101
Uterine vessels
dissection of 487, 488
left 538f
separation of 365f
skeletonization of 563
Uterine wall 61f, 464, 537f
exposure of 463, 464f
lower anterior 359f
reconstruction 728
Uteropelvic junction obstruction 342
Uterosacral ligament 16, 318, 598, 679
left 323f, 325f
proximal 604f
suspension 604
Uterotomy 463
with monopolar needle 463f
Uterovaginal complex 16
Uterus 15, 17f, 20f, 21f, 322f, 479f, 489, 495, 519, 532, 684
adenomyosis of 336, 339f, 342, 342b, 344, 346, 728, 731, 734f
adherent, fundus of 478f
after suture completion 437f
asymmetrical 513f, 734f
cystic enlargement of 336
duplex unicollis 281f
excision of 495, 501
intracervical instrument for mobilization of 228
large 495
ligament of 609
malformation, suspected 748
manipulator 487f
middle-sized 495
mobilization of 561
morcellation of 501, 502
normal-sized 506, 561f
oncologic surgery on 674
palpation of 358f
preliminary inspection of 65f
removal of 489
retrieval of 495, 501
septus/bicornis 748
severe adenomyosis of 53f, 379f, 553f
small 495
specimen, histological examination of 381
through vagina, retraction of 368f, 543f
transvaginal ultrasound of 732f
with adenomyosis 511f
withdrawal of 502f
V
Vacuum intracervical probes 31
Vagal reflex 227
Vagina 15, 236, 487, 594, 600, 616
acidic pH of 621
from cervix 367f
resection of 532
introitus of 576
opening of 501f
subsequent back-stitching of 536
wall of 589f
with monopolar hook, opening of 501f
Vaginal apex 611
fixation 612
Vaginal atrophy 637
Vaginal bleeding 237
Vaginal closure 361, 368, 495, 502, 533, 537
Vaginal cuff closure 503f
Vaginal dryness 637
Vaginal edge, cautious coagulation of 465, 534
Vaginal enterocele 602f
Vaginal examination 349, 522, 722
Vaginal fibroblasts, capacity of 619
Vaginal folds, loss of 652
Vaginal fornices 629
Vaginal fornix 489
Vaginal gravidity 236
Vaginal hysterectomies 346
Vaginal hysterectomy 124, 346, 456, 466, 493, 507, 509, 509t, 582
laparoscopic
assistance for 455
assisted 348, 466, 493, 518, 582
laparoscopically assisted 124, 507, 519
Vaginal incision 124
Vaginal mucosa 710
application on 638
Vaginal muscularis 619
Vaginal native tissue repair 587
Vaginal natural orifice surgery 118
Vaginal opening 621
Vaginal pain 637
Vaginal pregnancy 251
Vaginal probe with oil 648
Vaginal probes 602f
Vaginal rejuvenation procedures 621, 648
Vaginal relaxation syndrome 637
Vaginal sacrospinous fixation 594
Vaginal sonography 719f, 721, 750
Vaginal stump 613
preparation of 610
stable fixation of 533
Vaginal subepithelium 616
Vaginal surgery 45, 45t
Vaginal tightening, single-thread 629
Vaginal tissue 638f
structure 652
Vaginal ultrasonography 407f
Vaginal ultrasound 345f, 381
Vaginal vault
hematoma 473
prolapse, treatment of 494
Vaginal wall 71f, 616
posterior 71f
Vaginal washing 709
Vaginally assisted NOTES hysterectomy 576, 579, 582
Vaginoplasty 621, 628, 632
surgical technique 629
Vaginoscopic approach 709, 709f
Vague lower abdominal symptoms 117
ValtchevTM uterine manipulator 432f
Vascular adhesion molecule-1 208
Vascular clamps 31f
Vascular endothelial growth factor 208
Vascular epithelial growth factor 667
Vascular grafts, manufacture of 185
Vascular hemorrhagic disease 242, 312
Vascular injuries 569
minor 126f, 127f
Vascular ischemic disease 242, 312
Vascular lesions 126, 763
Vascular mesometrium 22
Vascular occlusion 651
Vascularization 18, 159
Vasoconstrictive agents
infiltration of 435
injection 434f
Vasopressin 244
Vasovagal reactions 712
Venous return 200
Veress needle 15, 27, 44, 46, 48, 115, 121f, 243, 273, 299, 350, 351, 352, 467, 523, 525, 527f, 528, 559, 724f, 760
entry 121f
insertion of 119
normal introduction of 126f
technique 45, 350, 523, 722
Vermiform appendix 273
endometriosis of 321, 327
Vesical artery
superior 18
upper 161f
Vesical plexus 390
Vesical tamponade 398
Vesical veins 679
Vesicouterine 537
ligament 679
reflection 322f
Vesicovaginal ligament 742f
Vesicovaginal septum 16
Vessel
injuries 146, 697, 760
sealing 63
Vestibular bulbs with glands 621
Vestibulodynia 640
Villous stroma 235f
Virtual reality
simulators 9294, 100, 744
systems 86, 87f
trainers 79, 86, 87
Visceral lesions 761
Visceral pathologies 190
Visceral peritoneum 205
Visual access systems 265
vNOTES hysterectomy, discussion of 581
Voice-controlled camera-holding arm 25
Voiding dysfunction 398
Voluntas aegroti 106
Vomiting 227, 313
von Leffern knot 68f, 370f, 401, 453f, 510f, 545f
Vulva
liposuction of 630
pain 637
Vulval laxity, laser tightening for 647
Vulvar cancer 421, 424
Vulvar melanoma 268f
Vulvodynia 640
W
Wait-and-see attitude 243
Warmed irrigation fluid prevents 58
Washing-suction device 434
Wertheim's technique of radical hysterectomy 674
Wet warm tissue 200
White cells 208
Wi-Fi system 87
World Health Organization 297
World Society for Gynecologic Surgery 10
Wound healing, inflammatory phase of 639
Wound infection 196, 398, 670
Wrapping technique 174f, 175f
X
Xenon cold light source 243
Xylene 208
Xylocaine 633
Y
Yolk sac 239
Yoon band 297, 299, 299f
Yoon ring 303
Z
Z-insertion technique 115
Z-puncture technique 27
Z-sutures 368, 503, 537
Z-technique 47, 352, 527, 725
Zygote, implantation of 235
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Chapter Notes

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1Basics and Anatomical Aspects of Endoscopic Surgery
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Historical PerspectivesChapter 1

Liselotte Mettler,
Manfred Schollmeyer
Since ancient times, medical men desired to inspect human body cavities and passages to understand their complexity and to treat their diseases. Easily accessible body cavities like mouth, rectum, or even vagina were already inspected in ancient times with the help of speculums.
Accounts of catheters and rectal speculums are handed down from Hippocrates II. The Greek, born on the island of Kos and known for the Hippocratic oath, inserted in vagina tampons with threads using hollowed kalabass. However, the Greeks did not dare to use a speculum to view rectum or inspect vagina.
Erasistos, born in 320 bc in Keos, was first to describe anatomically correct curved catheters. Oreibasis, born in 325 bc in Pergamon, invented an indwelling catheter at Rome in the times of Julius Caesar. He also dilated urethra with a goose quill swathed in swollen parchment.
The origin of endoscopy can be traced back to a reference in Babylonian Talmud. The treatise describes a lead funnel with curved mouth, furnished with wooden outlet (Mechul). Both the parts were inserted into vagina to show, by retraction for the first time to human eyes, cervical os as an internal organ to diagnose uterine bleeding and differentiate it from vaginal bleeding.
A triple-armed vaginal mirror and a rectal speculum were excavated in Pompei. The Syrian gynecologist, Archigenes from Apameia, who practiced in Rome from 95 to 117 bc, wrote a thesis on uterine bleedings. He used a cervical mirror for inspection and commented on various forms of gynecologic palpatory examinations as well as external and internal inspection.
Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, an Arab, is regarded as Middle Ages’ most eminent surgeon. Also known as Alsaha-Ravius or Albucasis of Cordoba (936–1009), he used a glass mirror to reflect light to view the inside of vagina. He described his speculum as “two rods, one lying on the top of the other, which is introduced in the cervix (probably meant vagina) to expand it with the help of screws.”1
The first endoscopic light source can be traced back to Gulio Cesare Aranzi (1530–1589). This Venezuelan used camera obscura (1587) to focus a ray of light to view nasal cavity. He held water-filled spherical glass bottle in front of a hole in a shutter in a darkened room and projected that focused light to view nasal cavity. He recommended an artificial light source on rainy days.
French gynecologist and surgeon, George Arnaud de Rosil (1698–1774), gave new significance to vaginal speculum, which was developed over a century. Arnaud2 was the first to use endoscopic examination lamp making use of a covered lantern. The light source was a night lamp that was placed in a box painted silver from inside. Similar to camera obscura, light focused through a convex lens could be used to illuminate vagina, which was opened with a speculum.
Philipp Bozzini (1773–1809), who marks the turning point from the old to new medicine, must unquestionably be mentioned for his contributions to development of modern endoscopy. Bozzini studied in Mainz and Jena where he became acquainted with Christoph Wilhelm Hufeland who published the Journal of Practical Pharmaceutics and Art of Wound Healing. In 1804 he published first description of his instruments in a small Frankfurt newspaper.4
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Fig. 1.1: First portable endoscope by Desormeaux.
The equipment had optical part with illumination device and mechanical part that adapted itself to the anatomy of body orifice. In 1806 he published a detailed account of his light guide.3
In 1807 the national industrial Comptoir, Weimar, published the monograph, The Light Guide or the Account of a Simple Device to Illuminate Internal Cavities and Passages of Living Animals. Bozzini himself made sketches and even engraved them in copper.4
Bozzini constructed an instrument for vagina, rectum and oral cavity, including throat. One could see and even operate on a modest scale with it. Even though light source was too weak and visual field too small, all further attempts at cystoscopy in the next 70 years were exclusively based on Bozzini's illumination principle using extracorporeal light source to reflect light. His principle of using artificial light source, reflection of light toward the object to be examined as well as the light conduction and directing the reflection and re-reflection to the observing eye, substantially influenced international discussions on the development of endoscopes.
Antonin Jean Desormeaux (1815–1894) constructed the first portable endoscope5 (Fig. 1.1) and presented this historic development on November 29, 1843, for which received a part of Argenteuil prize from Academie Imperiale de Medicine. Desormeaux was first to clinically use Bozzini's light guide for which many regard him the “father of endoscopy.” His instrument was a system of mirrors and lenses with an open flame as a light source. Skin burns were a most frequent complication. The light guide was essentially used in patients with urological illnesses.
The most important development of endoscopic abdominal surgery is connected with photography and television. Theodor S. Stein (1868) started it in Frankfurt. In 1874 he introduced his “photo endoscope” (Fig. 1.2).6
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Fig. 1.2: Photoendoscope by Stein.
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Fig. 1.3: Cystoscope, developed by Nitze and Leiter.
Gynecology was the so to say initiator of the development of operative endoscopy. Apart from Desormeaux,7 Aubinais,8 and Pantaleoni9 must be also mentioned for their attempts to inspect uterine cavity, which is today's hysteroscopy. The technical development of endoscopy to perfection was left to cystoscopy. The plausible cause is that Mignon filament (Edison) at the tip of the cystoscope by Nitze and Leiter10,11 posed no danger of burns because urine in the urinary bladder ensured appropriate cooling (Fig. 1.3).
In 1881 Johann Mikulicz (1850–1905) and Leiter adopted the principle of rigid optic system developed by Max Nitze and successfully constructed first clinically usable gastroscope.12 Mikulicz carried out several clinical examinations at Billroth's surgical clinic in Vienna.5
Between 1890 and 1900 George Kelling (1866–1945) of Dresden worked on anatomy and physiology of stomach “to determine the size of the stomach.”1315 He gained experience in oral air insufflation14,15 and worked on pressure ratio of gastrointestinal tract and abdominal cavity. Simultaneously he worked on improving the techniques of examination of gastrointestinal tract, which resulted in application for a patent.16
Kelling's know-how of gastric and esophageal endoscopy and his knowledge of air insufflation were foundation for future attempts to carry out thera- peutic and diagnostic examinations in closed body cavities. The brilliant idea of connecting his air insufflation apparatus to Fiedler trocar and Nitze cystoscope led to the birth of laparoscopy.
On September 23, 1901, George Kelling gave the historic lecture on “Tour of the Oesophagus and Stomach by Flexible Instruments” to natural history scientists and doctors’ 73rd meeting in Hamburg. He also introduced his new procedure that he called “coelioscopy.”17 Kelling had used his oral air insufflation apparatus for intra-abdominal insufflation (Fig. 1.4) together with a Nitze cystoscope for illumination to see abdomen of a dog, in animal experiment for the time.
I question myself, how the organs will react to the air introduced inside? To find out, I have developed a method to introduce the endoscope in the closed abdominal cavity (Coelioscopy) (Kelling 1901).
After an interval of a century and considering the status of endoscopy today, one can evaluate Kelling's endoscopic work as follows:
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Fig. 1.4: Apparatus for the intra-abdominal insufflation with pump, filter and manometer.
  • Contradicting the spirit of times, Kelling had favored endoscopic procedure to exploratory laparotomy.18
  • With far sight Kelling challenged stagewise treatment of malignancy and for this purpose sent repeated reminders for the primary use of endoscopic procedure.19
  • Kelling was first to assemble all basic instruments for laparoscopy with insufflation needle (Fiedler trocar), insufflation apparatus (air pump by Politser), optic trocar and telescope (Nitze's cystoscope) and described the method.20,21
  • Kelling, for the first time in 1901, formulated indications and contraindications of coelioscopy/laparoscopy.
  • Kelling demonstrated for first time the possibility of intraabdominal diagnostics by endoscopic inspection and palpation.21
  • In 1901, Kelling advised, clearly foreseeing the problems in training young doctors, to practice endoscopic procedures on cadavers. A hundred years ago, dummies were not available to the pioneer of endoscopy.
  • Kelling, a visionary, had predicted use of endoscopic interventions, particularly laparoscopy as daycare procedures (1901).22
  • Ahead of his time, Kelling had recognized profitable economical aspects of endoscopic surgery.23
In 1911 internist Hans Christian Jacobaeus (1879–1937), from Stockholm, introduced the term “laparothoracoscopy.”24 He was first to view thorax and abdominal cavity by endoscopy and recommended endoscopic technique to view other body cavities. In contrast to Kelling, he inserted the trocar directly without creating pneumoperitoneum. Jacobaeus began like Kelling by breaking down adhesions under thoracoscopic vision.
Bertram M. Bernheim (1880–1958) of Johns Hopkins Hospital introduced endoscopic surgery in the United States in 1911. He called the procedure “organoscopy.”25 His instrument consisted of half-inch proctoscope and a simple light.
Heinz Kalk (1895–1973), a gastroenterologist from Berlin, known as founder of German school for laparoscopy, developed a 135° lens system and double trocar.26 He used laparoscopy as a diagnostic method in diseases of liver and gallbladder. In the publication of his experiences in 1939, he reported over 2000 liver punctures under local anesthesia with no fatalities. He broke down adhesions by laparoscopy.6
Constant improvements in laparoscopic methodology smoothened the way for its wider operative use. The important steps in the process were use of harmless carbon dioxide (CO2) for pneumoperitoneum by Zollikofer in Switzerland (1924), coagulation of adhesions by Fervers in Germany (1933)27 and intra-abdominal use of monopolar current by Ruddock in the United States (1934).
Boesch, from Swiss Aarau, reported in his paper on laparoscopy about “wonderful perspective of the feminine, not deformed genitals of woman and about the exposure of hidden organs, e.g., the ovaries with an elevator (palpation probe).”28 He noted further: “with the laparoscope we have obtained a way to carry out the tubal sterilization for the given indication without laparotomy. With a suitably insulated coagulation clamp, the tubes can be coagulated at multiple places in 3–5 minutes under endoscopic vision.” Frank H. Power and Allen C. Barnes developed in 1941 the same technique in the United States; however, they used a peritoneoscope for tubal sterilization.29
The insufflation of abdominal cavity by instruments was problematic for a long time. Kelling carried it out with Fiedler trocar, which had a blunt “mandrin” to avoid injuries; Otto Goetze (1886–1957), who coined the term “pneumoperitoneum” in 1918, produced a similar instrument with spring mechanism (Fig. 1.5) for air insufflation for contrast radiograms.30
In 1938, the Hungarian Janos Veress (1903–1979) (Figs. 1.6 and 1.7) developed a special canula with spring mechanism aiming to create pneumothorax and consequently to treat tuberculosis, which was prevalent at that time.31 With little modifications Veress needle is used still today to create pneumoperitoneum for laparoscopy. Its special mechanism prevents injury to internal organs during needle insertion through anterior abdominal wall.
In 1960, gynecologists first began small operative interventions. However, French gynecologist Raoul Palmer had already carried out laparoscopy in Trendelenburg position in 1944. In this position intestines were displaced out of pelvis and consequently could be better assessed during operation. Additionally, he required continuous gas insufflation, which was controlled automatically. Palmer also carried out the first laparoscopic sterilization in Paris.
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Fig. 1.5: Atraumatic needle by Goetze.
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Fig. 1.6: Janos Veress (1903–1979).
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Fig. 1.7: Publication by J. Veress about the Veress needle developed by him.Source: German Med Sci. 1938; 41:1480.)
Piercing of umbilicus for laparoscope by Raoul Palmer in 1946 was a groundbreaking procedure in gynecology. Like Kelling, he called endoscopic diagnostic procedure “coelioscopy” and developed several methods to insert the endoscope. The abdominal access involved many technical difficulties because of mainly blind insertion technique through anterior abdominal wall.32
Decker, an American, introduced laparoscope transvaginally through vaginal fornix.33 He called this procedure Douglasscopy or culdoscopy (Figs. 1.8A and B). From a diagnostic perspective, Douglasscopy was insufficient. This technique that was initially prevalent in America later lost its importance. In 1998 it was team of Brosens et al34 that brought about a renaissance of this procedure as transvaginal hydrolaparoscopy for diagnosis of sterility.7
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Figs. 1.8A and B: Douglasscopy in the (A) knee-elbow position and in (B) extreme head-low position.
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Fig. 1.9: Hans Frangenheim (1920–2001).
Hans Frangenheim (1920–2001) and Kurt Semm (1927–2003) helped in a special way to develop laparoscopy in Germany after the Second World War.
In 1950, Hans Frangenheim (Fig. 1.9) began his training in gynecology at Anselmino and in 1951 came in contact with laparoscopy for first time. He was called to medical clinic in Cologne where a lower abdominal tumor was diagnosed during hepatoscopy and further line of treatment had to be decided. Looking back he wrote:
I sensed there, that a new aid had presented itself for the field of gynecology and so began to look into literature. A remark made by Kalk in a textbook had impressed me the most, which said, it is certain that gynecology would open a big field of indications for laparoscopy.
After his appointment in October 1955 to the post of assistant medical director of the National Gynecological Hospital at Wuppertal, Frangenheim attended lectures by Palmer in Paris and realized that laparoscopy was clearly superior to culdoscopy, which was still practiced in Germany. Then he concentrated on regulating uncontrolled gas insufflation, developing new instruments and photographic documentation of endoscopic findings. He had difficult time with German endoscopy firms. Finally, with modified anesthesia equipment from Draeger, he succeeded in reducing gas pressure from customary 50 to 15 mmHg. and restricting CO2 gas flow to maximum of 5 L/min. Frangenheim even defined indications for diagnostic laparoscopy in extrauterine pregnancy, chronic lower abdominal pain, sterility and ovarian tumors.
His monographs, Laparoscopy and Culdoscopy in Gynecology,35 Laparoscopy in Gynecology, Surgery and Paediatrics,36 Diagnostic and Operative Laparoscopy in Gynecology—Atlas with Colour Illustrations37 as well as countless publications and lectures contributed to further spread of the method.
In 1966 he was medical superintendent of gynecological clinic at Konstanz and European Congress for Endoscopy was held under his presidency in Konstanz and from that event laparoscopy received further impetus. In 1982 Frangenheim received First Order of Merit of the Federal Republic of Germany for his outstanding work. On the occasion of his 80th birthday Semm praised Frangenheim for his contribution with these words: “Today the name, Frangenheim is inseparably associated with the gynecologic laparoscopic methods. His achievements for Germany and for the world are epoch making and will go down in the annals of history.”38
The Kiel University clinic for women under Semm (1927–2003) (Fig. 1.10) is regarded as birthplace of modern endoscopic surgery. Semm, collaborating with Richard Fikentscher (1903–1993), developed a new universal insufflation equipment39,40 for the diagnosis of tubal patency, i.e., blowing through fallopian tubes by Rubin.41
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Fig. 1.10: Kurt Semm (1927–2003).
8Befitting his knowledge of tubal insufflation, Semm developed an apparatus called “CO2 Pneumo” for insufflating CO2 gas during laparoscopy to minimize operative risks of endoscopy.42 The instrument was in use from 1964 onward at the second university clinic for women in Munich and created pneumoperitoneum automatically.42 The cold light (extracorporeal light that shone across a bundle of fiber glass) was simultaneously developed. Together, they eliminated intestinal burns and gas embolus, which were main dangers of gynecological laparoscopy. In spite of all progress world over, gynecological diagnostic laparoscopy was universally rejected. So, Semm selected the word “pelviscopy” to project that a new technique was developed. Starting from 1965, within three years, this new method spread quickly within Germany as a diagnostic procedure of female infertility. In 1976, Semm developed an electronic version of CO2-Pneumo with the quadrotest for operative pelviscopy43 (Figs. 1.11 and 1.12).
After Semm demonstrated “CO2-Pneumo” at the Congress of American Fertility Association in Washington in 1969, Cohen published a book on this procedure in 1970. In the United States, acceptance of this new method of pelviscopic procedures in gynecology was phenomenal. Even though the method was used a million times, it was employed in 95% of the cases only for tubal sterilization, unlike in Europe,44 where Boesch already accomplished this 35 years before.28 The ignorance about the laws of physics while using the high-frequency (HF) energy in closed body cavities was the cause of many grave accidents causing burns to the internal organs like intestines and ureter. Such incidents once more deeply incriminated this method.
Fascinated by the idea that pelviscopy can be used not only for sterilization but also for other operative purposes,45 Semm introduced it in his new regimen for hemostasis in New Orleans in 1974 (Figs. 1.12A to I). The use of HF current for creating destructive heat was not required in endocoagulation. The human body did not come in contact with the electrical energy. Optimally controlled hemostasis takes place at 110°C. Between 1970 and 1980, the HF current in the monopolar and bipolar techniques using inadequately covered apparatus led to uncontrollable burns; today, in clinical endoscopic practice also, it is ensured that the electrical energy used under supervision does not lead to burns. The modern coagulation and cutting equipment, which work on mono- and bipolar current, have control mechanisms that minimize risk of unintentional burns. Bipolar and monopolar instruments have a controlled, restricted coagulation zone.46
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Fig. 1.11: Electronic CO2 insufflation equipment (Therme-Pneu Electronic, WISAP Gmbh).
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Figs. 1.12A to I: Equipment cart for gynecological endoscopy: (A) Video camera system, monitor, digital video camera; (B) Cold light source; (C) CO2 insufflation equipment—thermoflator®; (D) Hysteroflator for hysteroscopy; (E) Video recorder and video printer; (F) Suction irrigation equipment; (G) Coagulation equipment for monopolar and bipolar coagulation—endocoagulator; (H) Equipment for CO2 pertubation; (I) NaCl bottles, warmed up to 37°C.
Semm, who produced his own instruments, as he was a skilled instrument maker himself, built an automatic CO2 insufflator in 1963, introduced thermocoagulation in 1973, and used for first time Roeder loop to stop arterial bleeding. For laparoscopy he developed special suction irrigation equipment and an electronic insufflator. Difficult interventions were possible because of methods of hemostasis (endosuture with intra- and extracorporeal knots) developed by Semm and his range of instruments. However, many physicians, gynecologists as well as surgeons criticized Semm for his vehement use of so-called keyhole surgery. They were of the opinion that due to the modern anesthetic techniques, big operations by laparotomy posed no problems and Semm had exaggerated the problems with subsequent adhesions. 9Some treated news of the new spectrum of operations (oophorectomy or the removal of complete uterine appendages, treatment of tubal pregnancy) with disbelief and concluded that Semm has started his operation as laparoscopy and then ended it as conventional operation by laparotomy.
Semm was exposed to most intense hostility of the German gynecologists (and endoscopic surgeons) when he carried out first laparoscopic appendectomy in 1983.47 The surgeons especially saw no need to abandon established operative method and to replace it with technically more difficult one. Semm's first attempt at publishing his method therefore met with rejection. The fact that a gynecologist wanted to show the surgeons how an operation should be carried out was simply unthinkable at that time. Semm had crossed the limit that was till then considered as sacrosanct. But he knew that endoscopic surgery had enormous potential not only in gynecology but especially in surgery and therefore continued with his endeavors in laparoscopy, unperturbed toward the goal, of reducing the surgical trauma to the patients. Two German surgeons, Friedrich Gotz and Arnold Pier, followed Semms's intent and provided a wider base to laparoscopic appendectomy.48 In the early 1990s they had already carried out hundreds of appendectomies in this way and perfected the technique, which they could now use even in acute appendicitis.49
In 1977 a 10-mm morcellator (Semm) was produced for pelviscopy purposes. However, in today's operative pelviscopy where even fist-sized myomata is removed from uterus with little blood loss, this instrument is not very effective. So in 1988, manually operated serrated edged macro morcellator (Semm) of 15–20 mm diameter was introduced. The instrument could reduce a myoma of about 5 cm size to small pieces within a few minutes. The posterior colpotomy for removal of myoma or even a small abdominal incision was not required any more.50 Since the introduction of horizontal morcellation, the morcellators are motorized and are available in 10 to 24 mm diameters.
Just like laparotomy, intra-abdominal irrigation equipment are necessary in laparoscopy also to guarantee good view. The acquapurator of 1974 gave way to CO2 aquapurator in 1990. Today the aquapurator biotherm has removed many problems of hypothermia, even in operations of longer duration. In 1994, insufflation of preheated CO2 was introduced to preserve isothermia.
In September 1985 a surgeon from Böblingen, Erich Mühe (1938–2005), performed laparoscopic cholecystectomy for the first time in the world using Semm's instruments.51 In 1986, Mühe reported 97 successful laparoscopic operations.52 In 1989, Reich et al. described the first laparoscopic-assisted vaginal hysterectomy.53 In 1991 Mouret carried out the first cholecystectomy by video laparoscopy.
In the 1970s and 1980s most surgeons simply ignored the development of laparoscopic operations because of introduction of new medicines, impressive results of intensive care and innovations in anesthesia that facilitated extensive surgeries. The basic concept, that a big problem (disease) requires a big solution (abdominal incision), was so deeply rooted in surgeon's thinking that there was no place for “keyhole surgery.” This is why surgical fraternity refused to accept and modify gynecological instruments for their use.
However, contrary to general development some surgeons accepted the challenge and accelerated introduction of laparoscopic techniques in surgery. A group of German surgeons was particularly active in this process and in December 1976 started Chirurgische Arbeitsgmeinschaft für Endoskopie und Sonographie (CAES) in Hamburg. In the United States, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) was set up five years later. In the following years both organizations laid foundation for the introduction of endoscopy in clinical practice.
Prompted by Dr. Bernd Manegold, a surgeon from Manheim and one of the founders of the CAES, the first edition of scientific journal Surgical Endoscopy was published in 1987 under the direction of many leading endoscopists. Just the following year the first World Congress for Surgical Endoscopy was held in Berlin, which was a great success where 500 experts from all over the world participated. This finally led to acceptance of endoscopy in surgery.
In 1983, British urologist John E. A. Wickham (born in 1927) used the concept of “minimally invasive surgery” for the first time. The concept attracted attention in 1987 after Wickham published his vision of extensive endoscopic treatment in the famous British Medical Journal.54 In spite of the strong criticism it mirrored the general trend of the 1980s as minimally invasive techniques had greatly fascinated doctors and their patients.
This development was further accelerated by crucial technological innovations. The introduction of new light sources (Palmer 1953), Hopkins-optics (1960) and cold light source had already improved illumination in endoscopic operations in 1960.21 The video technique was also important. The new video 10camera was much smaller and therefore easier to manage than its predecessor and the videocassettes also were simpler for everyday use than the 8 or 16 mm film. In 1980s more surgeons used video cameras, but even the latest and smallest of the camera together with endoscope proved unwieldy because it altered the balance and made precision work difficult. Electronic minicamera brought the breakthrough: a 4-mm optoelectronic transducer (CCD) converted the view from inside body cavity to electronic impulses and transferred them to a monitor. The combination of optic trocar and video camera opened new possibilities for surgeons because now with both hands free, they could operate ambidextrously and simultaneously follow on the monitor what was happening along with the entire team.
The years that followed were molded by a lively exchange and reciprocal stimulation. Video laparoscopy of cholecystectomy in 1987 in Lyon by Philipe Mouret (born in 1937) and his presentation of the procedure in the SAGES meeting in Louisville triggered a downright boom in France and also encouraged surgeons across the world to tread this path further.
Another milestone was realization of appendectomy by laparoscopy, which Kurt Semm started in patients that showed besides their gynecological problems subacute appendicitis. Although we performed laparoscopic appendectomies since 1981 and numerous German general surgeons had visited Kiel for that purpose, only when Semm presented his laparoscopic appendectomy in Baltimore in 1988, JB Mckernan and W. B. Saye took it up and in June 1988 they reported first laparoscopic cholecystectomy in the United States using Semm's instruments and combining the procedure with laser technology. As a result many successful endoscopists visited both protagonists in Nashville to learn the new technique. At the same time, Sung Tao Ko from Chicago upheld the laparoscopic appendectomy by Semm and brought his instruments to America. A paper on laparoscopic appendectomy that Kurt Semm and I submitted to the American Journal of General Surgery was rejected by declaring this as an unethical surgical technique. We also had the same experience in Germany when a lecture of Kurt Semm to the College of General Surgeons on Laparoscopic Appendectomy was rejected as an unacceptable technology. The news about these sensational methods reached even the media in the United States. During a TV talk show it was made public with the help of gallbladder operation. After that the Nashville surgeons received hundreds of calls not only from the patients but also from doctors.
In October 1989, when Douglas O Olsen and Eddie Joe Reddick announced their courses casually at the congress of American College of Surgeons (ACS) for laparoscopic cholecystectomy, they were booked in shortest time and new courses had to be planned. Many American observers felt that laparoscopy has pervaded the entire surgical fraternity in the United States. In the following weeks, a wave of enthusiasm about this new technique passed through the nation and training courses sprung like mushrooms. The industry was confronted with an abundance of orders so that waiting period rose up to six months. In the beginning leading endoscopists tried to canalize the development and to warn about the risks of injudicious use but soon they realized that it was not possible. No one had thought before 1989 that one of the most established operative method in surgery, cholecystectomy, would change so radically within just a few months. Even surgeons who had substantially contributed to this development were surprised by the speed. Literally thousands of surgeons had to restrain themselves. The courses were booked for months and the shortage of instruments was an unheard of phenomenon in the Western medicine. In the following years with the spread of laparoscopy, as the experiences increased, new operative methods quickly developed in many operative specialties.
The production of endoscopic instruments in the industry showed an upswing and the interaction and interest of the various medical specialties—surgery, urology, and gynecology—increased. Today the interest of the industry, doctors and patients worldwide is reflected in a common endeavor—betterment of surgery in many aspects through modern technology. That is reflected in further developments in the use of digital picture control, robotic instruments, computers, and telesurgery. Numerous specialities that have emerged and which deal increasingly with oncological fields also reflect these efforts. That is why in 1965 the German Society for Gynecologic Endoscopy and in 1971 the American Society for Gynecologic Endoscopy were founded. The World Society for Gynecologic Surgery (1986), the European Society for Gynecologic Endoscopy (ESGE, 1990), the Asian Society of Gynecological Endoscopy, the International Society for Gynecologic Endoscopy and the International Society of Gynecological Endoscopy (ISGE, 1991) came into being with yearly or two-yearly meetings.
The development of hysteroscopy and fallopioscopy must be mentioned here. After Lindemann 11(1971) and Semm (1974) established the CO2 hysterectomy, the real breakthrough in the operative hysteroscopy came after 1980 basically as fluid hysteroscopy. Today hysteroscopy is a routine procedure and one cannot imagine diagnostic and therapeutic interventions without it.
From today's point of view, the ideal entry for viewing the tubal lumen is by hysteroscopy through a transcervical and transuterine catheter with 0.8– 0.3 mm thick telescope or flexible falloposcopes.
When one compares the gynecologic endoscopic surgical work of the 1980s, primarily the sterilization, conservative operations on the adnexa and the enucleation of myoma were described. As against that, from 1989 the publications on adhesiolysis, appendectomy, lymphadenectomy and laparoscopy-assisted vaginal hysterectomy in different variations frequently appeared. In surgery, besides gallbladder resection, fundoplication, and hernia operations, extensive splenectomies, bowel resections, and great advances in surgical oncology and neurosurgery are described. In orthopedics, the operations on knee are improved further. In urology, there are reports on nephrectomies and the first robotic prostatic resection. In gynecology, robotic optic holders and instruments are employed.
The worldwide evolution for improvement of endoscopic surgery has begun; its end is still not in sight.55 The aim of this surgery is to achieve at least the same, if not better results as with conventional operative techniques. On the wider international level mention should be made of Jordan M. Philipps under whose organization Kurt Semm, Liselotte Mettler, and various other team members of the Kiel School of Gynecological Endoscopy, which we really founded in the year 1990 only, but it existed under Kurt Semm's driving patronage since 1970, were able to teach endoscopy courses all over the United States in 1985 and our endoscopic surgery worldwide between 1985 and 2005. In 2005 numerous centers around the world had started to teach their own courses, which they continue to do. Single-port entries and particularly robotics have moved in with high demands and striking results. Contained in bag morcellation has substituted controlled electronic morcellation. Let us see what the future brings.
Jordan M. Philipps (1923–2008) (Fig. 1.13) founded the American Association of Gynecological Laparoscopy (AAGL), now the International Society of Minimal Invasive Gynecology, in 1971 The AAGL is the leading association promoting minimally invasive gynecologic surgery among surgeons worldwide. When established in 1971 it was known as the American Association of Gynecologic Laparoscopists. As the field of minimally invasive gynecologic surgery grew, the membership of the AAGL quickly expanded around the globe and came to encompass more than laparoscopy alone.
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Fig. 1.13: Jordan M. Philipps (1923–2008).
Although the organization had outgrown its American roots, its name and acronym AAGL had become highly recognized worldwide. To best portray its expanding mission and international constituency, while still preserving its heritage and brand recognition, the organization eventually dropped its full name, “American Association of Gynecologic Laparoscopists” and became known simply as the AAGL, along with the phrase “Advancing Minimally Invasive Gynecology Worldwide.”
Today with a membership extending to over 110 countries, the AAGL is an internationally recognized authority in minimally invasive gynecology. With over 7,000 members worldwide, the association counts among its membership the foremost authorities in gynecology and pioneers in technique and procedures and continues besides renowned and as active other previously mentioned international and national societies in our field.56
As extremely active colleagues on the American continent in the United States since 30 years, let me also mention the three Iranian pioneers in endoscopic gynecologic surgery who influenced our field like none others by their intuition, love and dedication to their work, the laparoscopic surgery, totally dedicated to their new country, the United States, the Nezhat brothers: Camran, Farr and Ceana Nezhat.57
Our late German colleague Thoralf Schollmeyer (1964–2014) was from 2007 onward the director of the Kiel School of Gynecological Endoscopy and the president of the German Society of Gynecological Endoscopy (AGE) when he died in 2014.12
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Fig. 1.14: Thoralf Schollmeyer (1964–2014).
He deserves to be especially mentioned in an historical outline as his professional life was fully dedicated to the education in endoscopic gynecological surgery. He was the first editor of our second edition of this book and a truly believing endoscopic surgeon till the end of his early death by the age of 50 years in 2014 (Fig. 1.14). Being a patient himself over eight years he showed us how dedication to the profession and family moves rocks. The development of gynecological endoscopy in clinic, research and science and the support of young researchers characterized his life. He followed his own way, which was marked by extreme passion, audacity and endurance of pain with high ethical and medical values.
In conclusion, it must be stressed that the history of laparoscopy and hysteroscopy and its introduction in the surgical practice is a story of many researchers, who for years battled against prevalent general thinking and partly against rejection of their brainchild of performing “gentle operations.” Many of the pioneers were ignored, called dreamers or regarded as crazy. It is only through their persistence, tenacity, strong personalities and intense dedication to life and love that they could stand firm in the face of adversities.58
The history of laparoscopy is a unique mixture of various trends in different fields, spurred by the activities of established societies as well as opportunities of their publication and influenced by the world's progress, recession, war, peace and the love of the individuals for life. The influence of industry, which has kept pace and actively supported this development for years, is the driving force besides the heroes of doctors and engineers that bring up new ideas. Without suitable technology, this dissemination would not have been possible. Endoscopic development and its future does depend on new inventions, on the audacity of leading heroes, their input into this field but also on their management of life to continue to survive and on a healthy and successful cooperation with the medical technical industry and the governments of our countries, which grant us the freedom of research and development for the best care of all our patients.
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