NEW HORIZONS FOR THE APPLICATION OF LAPAROSCOPIC TECHNOLOGIES IN GYNECOLOGICAL SURGERY

ISSN: 2582-4686 SJIF 2021-3.261,SJIF 20222.889, 2024-6.875 ResearchBib IF: 9.948 / 2024 VOLUME-5, ISSUE-12 1235 UDC: 618.14 NEW HORIZONS FOR THE APPLICATION OF LAPAROSCOPIC TECHNOLOGIES IN GYNECOLOGICAL SURGERY Agababyan Larisa Rubenovna https://orcid.org/0000-0003-3011-6998 Isaeva Soxiba Choriyevna https://orcid.org/0009-0000-4615-4986 Samarkand State Medical University, Uzbekistan Abstract. More and more surgeries will be replaced by endoscopic surgeries, which will allow patients to receive high-quality care, but without unnecessary consequences such as postoperative pain, long recovery, and large scars. The modern stage of development of surgical gynecology is characterized by increased requirements not only to the quality of equipment and technical equipment of the operating room. In addition, optical magnification allows more thoroughly stop bleeding, less traumatizing the surrounding tissue. Due to this, laparoscopic access is actively implemented in almost all areas of medicine, and in the performance of some operations acquires the status of “gold standard”. Key words: Surgery, gynecology, laparoscopy, uterine myoma, cyst, optics INTRODUCTION. The current stage of development in surgical gynecology is characterized by increased demands not only on the quality of equipment and the technical equipment of the operating room. Furthermore, optical magnification allows for more thorough bleeding control and less trauma to surrounding tissue. Due to this, the laparoscopic approach is being actively implemented in virtually all areas of medicine, and for some operations, it has become the "gold standard." However, despite the advantages of laparoscopic surgery, there are also some disadvantages. One of the disadvantages of minimally invasive procedures is the time required for the procedure. Such procedures are quite lengthy [3,4,5]. They require specialized qualifications and experience, significantly reducing the pool of potential candidates for this type of surgery. Nevertheless, despite some disadvantages (contraindications), laparoscopy holds great promise for development, in which the surgeon's desire to satisfy the aesthetic needs of patients will be the determining factor. Therefore, the development and refinement of new approaches and methods are relevant, especially in laparoscopic gynecology [3,4,6,8]. Despite the large number of studies conducted, conflicting data regarding the efficacy and safety of minimally invasive approaches for conservative myomectomy have appeared in the international literature in recent years, despite the fact that most leading global centers currently use the laparoscopic approach most frequently in the surgical treatment of patients with uterine fibroids [2,3,5]. Before the advent of the laparoscopic approach, gynecological surgeries were performed using the laparotomy approach. Currently, laparoscopic surgery is becoming more widespread. Indications for laparoscopic access are: diagnosis and surgical treatment of infertility, including restoration of fallopian tube patency, separation of adhesions, some forms of ovarian dysfunction, preparation for ISSN: 2582-4686 SJIF 2021-3.261,SJIF 20222.889, 2024-6.875 ResearchBib IF: 9.948 / 2024 VOLUME-5, ISSUE-12 1236 IVF, benign tumors of the uterus and ovaries, diagnosis and treatment of endometriosis, pelvic pain, sterilization, progressive ectopic pregnancy, surgical correction of prolapse and prolapse of the genitals, conservative myomectomy, hysterectomy [1,8]. In recent years, a large number of studies have been devoted to the use of laparoscopic surgeries in the treatment of oncological diseases of the uterus and ovaries [15]. The systematization of laparoscopic surgeries includes the purpose and timing of the surgical intervention. According to the purpose, laparoscopy is divided into diagnostic, operative and control. Diagnostic laparoscopy and hysteroscopy are a visual examination of the abdominal organs and uterine cavity [4]. In certain cases, diagnostic laparoscopic surgery turns into operative. Almost the entire range of gynecological surgeries, including hysterectomy, is performed using laparoscopic laparoscopy. Operative endoscopic gynecology is an independent section of endoscopic surgery, which includes surgeries on a woman’s pelvic organs, performed using laparoscopic and hysteroscopic approaches. Currently, the development of endoscopic treatment methods in gynecology has allowed for an expansion of indications and improvement of surgical treatment outcomes. In recent years, the rapid development of operative laparoscopy has contributed to the development of new, rational reconstructive, plastic, and organ-preserving surgeries. Control laparoscopy is performed to monitor the effectiveness of previous surgical treatment. Depending on the time of performance, laparoscopy is divided into planned and emergency. Planned laparoscopic gynecological interventions include: diagnostic laparoscopy with biopsy; sterilization; surgeries for tubal and peritoneal infertility; surgeries for ovarian tumors and cysts, polycystic ovary syndrome; tubectomy in case of progressive tubal pregnancy; surgical treatment of endometriosis; enucleation of uterine myomatous nodes; hysterectomy; extirpation of the uterus with lymphadenectomy; reconstructive surgery for malformations of the internal genital organs; colpopexy. Laparoscopic surgeries are performed for emergency indications in the following cases: tubal pregnancy, ovarian apoplexy; ovarian cyst rupture; uterine appendage torsion; subserosal myomatous torsion; acute inflammatory diseases of the uterus (purulent salpingitis, pyosalpinx, purulent tuboovarian formations); the need for differential diagnosis between acute surgical and gynecological pathology. Laparoscopy can be performed as a standalone procedure or in combination with hysteroscopy or vaginal surgeries. In recent years, the use of simultaneous surgeries has made it possible to simultaneously perform surgical interventions on various organs [3]. The capabilities of laparoscopic surgeries are currently expanding, and the frequency of laparoscopic surgeries after previous laparotomies is increasing [2]. In addition to indications, there are also contraindications to laparoscopic intervention. Authors distinguish between absolute and relative contraindications [2]. Absolute contraindications to laparoscopic surgery include acute myocardial infarction, acute cerebrovascular accident, uncorrectable coagulopathy, and hypovolemic shock. According to the authors, absolute contraindications to operative laparoscopy are identical to those for the laparotomic approach, i.e., these patient conditions are contraindications to any surgical intervention [3]. However, relative contraindications to laparoscopic surgery are not contraindications to the laparotomic approach. Relative contraindications to operative laparoscopy include intolerance to general anesthesia, diffuse peritonitis, previous surgeries in the area of the intervention, a tendency to bleeding, late pregnancy, and grade III-IV obesity. The effectiveness of endoscopic intervention, in particular laparoscopy in gynecology, depends on the nature of the pathology and varies from 15 to 70%. Relative contraindications to laparoscopy in gynecology are determined during a doctor's appointment and ISSN: 2582-4686 SJIF 2021-3.261,SJIF 20222.889, 2024-6.875 ResearchBib IF: 9.948 / 2024 VOLUME-5, ISSUE-12 1237 depend primarily on the surgeon's qualifications and the clinic's equipment. Below, we describe the types of laparoscopic procedures. Laparoscopy in gynecology is a standard examination for infertility due to its high information content, which impacts gynecological parameters, low invasiveness, and rapid patient recovery [12]. It is often advisable to combine laparoscopy with hysteroscopy, which allows for a comprehensive diagnosis and correction of the female reproductive system [2,6]. Endoscopic techniques are also used as a preparatory stage for IVF to create the best conditions for pregnancy [9]. Laparoscopic microsurgical interventions are indicated for infertility caused by: adhesions in the pelvic cavity; sactosalpinx; phimosis of the fimbrial sections of the fallopian tubes; and endometriosis [3]. Laparoscopic surgery is ineffective or even contraindicated in cases of tuberculosis of the pelvic organs; hydrosalpinx with a diameter of more than 30 mm; severe adhesions in the pelvic cavity, the presence of dense adhesions around the fallopian tubes and ovaries with the involvement of intestinal loops; active inflammatory process in the appendages [7]. It has been shown that with long-term and ineffective treatment of infertility in women over 35 years of age, the effectiveness of laparoscopic interventions is significantly reduced [8]. The decision on surgical treatment of a patient suffering from infertility is made after a thorough examination of the woman herself and her partner for final verification of the cause of infertility. Functional diagnostic tests are mandatory, the content of gonadotropic and sex hormones is determined, a postcoital test, a spermogram, an ultrasound of the pelvic organs, hysterosalpingography, and a bacteriological examination of vaginal discharge are performed. If necessary, anti-inflammatory therapy is carried out before laparoscopic surgery [2]. In case of tubal infertility, the following laparoscopic microsurgical operations are performed: salpingovariolysis; fimbriolysis and fimbrioplasty; salpingostomy; salpingoneostomy; creation of tubo-tubal anastomoses. Performing any surgery for tubal or peritoneal infertility requires the use of intraoperative ascending chromohydrotubation [8]. For this purpose, the external genitalia and vagina are carefully prepared before the surgery. The cervix is grasped with bullet forceps. A uterine cannula is inserted through the external os of the uterus. The bullet forceps and cannula are fixed to each other. Chromohydrotubation is performed at the beginning of the surgery to determine the level of fallopian tube obstruction. After completion of laparoscopic tubal intervention, chromohydrotubation confirms the effectiveness of the surgery. The level of fallopian tube obstruction can be determined by its filling with fluid. The absence of filling of the fallopian tube with injected fluid indicates its obstruction in the isthmic part. For chromohydrotubation, isotonic sodium chloride solution stained with methylene blue is used. The choice of surgical technique depends on the level of obstruction and the severity of adhesions in the pelvis. Salpingovariolysis involves dissection of adhesions around the fallopian tubes and ovaries, resulting in normal anatomical relationships between the ovaries and fallopian tubes. The effectiveness of salpingovariolysis is 60-65% [3]. Phimosis of the fimbrial portion of the fallopian tubes is a common cause of tubal infertility, and laparoscopic surgery (fimbriolysis) is quite effective in treating this condition. Salpingostomy involves incising the ampullary portion of the fallopian tube, everting the fimbriae, and coagulating the incision edge or applying laparoscopic sutures. According to most gynecologists, the effectiveness of salpingostomy ranges from 20 to 37% [5]. The use of laparoscopy for the diagnosis of external genital endometriosis has led to an increase in its detection rate, especially in its minor forms. In patients with stages I-II of genital endometriosis, thermal destruction of the lesions is performed, while in patients with stage III, cyst ISSN: 2582-4686 SJIF 2021-3.261,SJIF 20222.889, 2024-6.875 ResearchBib IF: 9.948 / 2024 VOLUME-5, ISSUE-12 1238 removal, adhesion separation, and resection of the endometrioid infiltrate are performed [2,9]. Surgical invasive treatment of endometriosis is a rather complex manipulation that requires coagulation or excision of areas of the peritoneum. To perform these manipulations, the surgeon must be well versed in the localization of retroperitoneal pelvic formations: the ureters, the rectosigmoid colon, and large vessels. Laparoscopic treatment of ovarian endometriosis is performed in cases where the diameter of the cystic formation does not exceed 3 cm. Preoperative treatment with danazol is indicated to reduce the size of ovarian endometriomas [2,9]. The cystic mass is punctured, its contents are ablastically aspirated, and the cavity is washed with an irrigant. The upper oval of the cyst is excised for histological examination, and the entire internal surface of the endometrioma is superficially vaporized with a 20-watt carbon dioxide laser beam. The endometrioma bed is either left open or sutured with a double-row suture: the first row with individual sutures, the second (capsule) with a continuous suture. For large endometrioid cysts, their contents are first ablastically removed, and the internal surface is photocoagulated; in the presence of large defects, it is sutured. Laparoscopic surgery using lasers is an alternative to hormonal therapy, especially in the presence of contraindications to its use or significant side effects. A comparative evaluation of the treatment results for external endometriosis using laparoscopic treatment, laparotomy, and drug therapy has shown that endoscopic therapy using lasers is the best method [1]. The use of laser technology in the surgical treatment of stage IV ovarian endometriosis has reduced the duration of the intervention, decreased operative blood loss, and contributed to a more favorable course of the postoperative period [10]. The advantages of laparoscopic surgical treatment of endometriosis are: the ability to perform diagnosis and treatment during a single intervention, the ability to perform the operation on an outpatient basis, reduced costs of the operation compared to laparotomy, a shorter recovery period, effective pain relief, and a higher percentage of fertility restoration [3]. However, since it is possible to determine the actual spread of the process and the extent of organ damage only during surgery, patients with combined forms of endometriosis require a thorough preoperative examination [1,4]. In case of extensive endometrioid lesions of the pelvic organs with involvement of the intestine, it leads to anatomical changes in the pelvic organs and determines the atypical nature of the operation and an increased frequency of intraoperative complications [2]. With involvement of the intestine and an adhesive process, characteristic of severe forms. A laparoscopic-vaginal technique can be used to treat endometriosis [11, 13]. There are studies in the literature on the use of robotic assistance in laparoscopic surgery in patients with stage IV endometriosis [2,7]. In cases of extensive pelvic organ damage by endometriosis, a laparotomy approach should be preferred [2]. The effectiveness of laparoscopic interventions in the treatment of endometriosis in terms of subsequent pregnancy is variable and depends on the initial severity of the endometriotic lesion [24]. The pregnancy rate after hormone therapy with releasing factor agonists and surgical laparoscopy is approximately the same, but increases with a combination of the two [35]. The pregnancy rate after repeat laparoscopic laser treatment in women with recurrent endometriosis decreases [3,7]. 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