Histerectomia Laparoscópica

Desde 1988, quando Harry Reich fez a primeira histerectomia assistida por laparoscopia, muitos de nós trabalharam para o desenvolvimento desta técnica em nosso meio. No final do século passado, disseminou-se mundialmente a técnica de histerectomia assistida por videolaparoscopia como alternativa à via abdominal convencional. Este procedimento utiliza técnicas cirúrgicas laparoscópicas e instrumentos para remover o útero e / ou trompas e ovários através da vagina. Atualmente, a histerectomia é classificada como histerectomia total videolaparoscópica quando ligamento dos vasos uterinos, dos ligamentos uterossacros e ligamentos cardinais, assim como a colporrafia são realizadas por via laparoscópica.

Dentre as diversas técnicas de histerectomia, sugere-se que a técnica intrafascial, histerectomia realizada por dentro da estrutura facial em torno do colo, apresenta vantagens como: manutenção do posicionamento das estruturas de sustentação da cúpula vaginal, manutenção das medidas da vagina e risco diminuído de trauma às estruturas adjacentes, tais como bexiga e ureteres.

O maior desafio talvez tenha sido estabelecer uma técnica cirúrgica padronizada e reprodutível. Discussões sobre o número e o local das punções auxiliares, tipo de energia a ser utilizada e até mesmo os limites do volume uterino para a realização desta técnica permearam o meio científico nestas quase 3 décadas.

Relacionando as vantagens oferecidas pela técnica intrafascial e pela via vaginal na histerectomia, pareceu pertinente associar estes procedimentos ao recurso tecnológico moderno da videolaparoscopia. A associação dos mesmos mostrou-se menos traumática e apresentou vantagens em relação aos procedimentos tradicionais.

Vantagens da via laparoscópica:

As vantagens da abordagem laparoscópica frente à abdominal consistem na ausência de incisão abdominal ampla, menor sangramento e necessidade de transfusões sanguíneas, menores taxas de complicações, menor tempo de internação hospitalar e retorno mais rápido às atividades habituais. Frente à técnica vaginal, as vantagens da via laparoscópica estão na possibilidade de inspeção da cavidade abdominal e diagnósticode patologias associadas, permite a lise de aderências, mobilização segura e remoção de tumores anexiais benignos e secção mais fácil dos ligamentos uterinos redondo e largo.

Indicações e Contra-indicações:

        Dentre as inúmeras indicações possíveis, as principais são: miomatose uterina, dor pélvica crônica, endometriose, patologia endometrial benigna, sangramento uterino disfuncional, patologias ovarianas benignas.

        Em contrapartida, as contraindicações não são numerosas, sendo elas: situação clínica que não permita a realização do pneumoperitôneo, situação clínica que não permita ventilação adequada durante a anestesia, tamanho uterino que impeça acesso às artérias uterinas, existência de aderências extensas abdominais e pélvicas e prolapso dos órgãos pélvicos tornando mais adequada a via vaginal.

        Hoje, temos a certeza de que a histerectomia laparoscópica tem seu espaço consagrado na prática cirúrgica ginecológica graças aos esforços dos pioneiros em nosso meio, mas, acima de tudo, à padronização da técnica.

        Estes resultados nos encorajam a postular a disseminação do treinamento de sutura laparoscópica como ferramenta deaperfeiçoamento e desenvolvimento técnico em cirurgia laparoscópica. Ressaltamos ainda a importância da padronização da técnica da histerectomia total laparoscópica, seguindo os preceitos de A. Wattiez, para atingir a excelência neste procedimento. A padronização da técnica cirúrgica da histerectomia total laparoscópica (HTL) permite a realização de uma cirurgia eficaz e segura tanto para cirurgiões experientes quanto para jovens cirurgiões em treinamento.

Fonte: Febrasgo

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