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Laparoscopic technique for the diagnosis and treatment of pelvic congestion syndrome


pelvic congestion syndrome (Pelvic congestion syndrome; PCS) is the cause of chronic pelvic pain of gynecological one of the important reasons.
Taylor in 1949 to & ldquo vascular congestion and congestion as the issue of pelvic congestion syndrome, pathophysiology, clinical manifestations, etiology, pathology and prevention and treatment carried out more systematically and comprehensively summarized, and pelvic congestion comprehensive
sign is a unique disease.
After 80 years of the 20th century and laparoscopic application of venography, found that people with unexplained chronic pelvic pain patients, 91 had significant pelvic venous congestion, congestion caused by local tissue and organs begin edema is a temporary, reversible,
After years of repeated exacerbations, or, if lasting changes.
But because the symptoms of pelvic congestion syndrome, involving a wide range, resulting in symptoms of patients and objective findings were not consistent, and easy on the signs of some diseases (such as chronic pelvic inflammatory disease, etc.) to be confused, and the current lack of simple clinical
and easy method for the diagnosis, to bring some of the difficulties of clinical diagnosis; addition, some gynecologists who skeptical attitude toward the disease, but also increased the difficulty of diagnosis.
Cause one female anatomical factors of venous anatomy of the pelvic veins larger number of plexiform distribution was supported by transport connections.
Vein wall is thin and most of the inflexible structure of non-venous blood flow is relatively slow, running in the connective tissue in the pelvic veins vulnerable to the impact of certain factors, the formation of venous blood stasis, venous plexus expansion.
Damage after tubal ligation, uterine compression, frequent pregnancy, pelvic tumors, long term standing, sedentary, constipation and other pelvic pressure caused by increased venous flow obstruction, can cause expansion and tortuous venous plexus form of the disease.
In addition, between the pelvic organs, namely the bladder, genitals and rectum veins from each other the same, among the three can be any one cycle disorders affect the pelvic veins.
Therefore, the above-mentioned female pelvic anatomy to promote recycling PCS formation.
Venous pressure increased in all the pelvic factors, such as ovary and uterus posterior uterus with the uterine blood vessels decreased from buckling in the sacral concave on both sides, early use of abdominal pressure during childbirth frequent sexual intercourse and childbirth class, habitual constipation and rectal venous return are easily
cause the uterus to the vagina plexus congestion, resulting in PCS.
<! - Picture in Picture PIP start --><!-- end -> Second, the endocrine factors in the peritoneal fluid of estrogen and progesterone than from the peripheral circulation, but also directly from the follicular fluid, the level of its
on the expansion and contraction of the pelvic blood vessels with a significant regulatory role.
Expansion of the role of estrogen, estrogen and progesterone can fight to improve the tone of blood vessels, causing pelvic vascular smooth muscle contraction [4].
Then tie a small number of patients with fallopian tube then tie the defective parts or means, of the ovarian blood supply, causing ovarian dysfunction, resulting in imbalance of estrogen and progesterone, to a certain extent, can cause PCS [6].
Third, psychological factors, and other female genital mutilation is a mental factor in the nervous system response is extremely sensitive.
Long-term depression, chronic illness, insomnia and emotional instability are more common in patients with PCS.
Irritation of suggests stimulation, PCS increased pelvic blood flow [8].
Department of membrane rich in oviduct uterus, ovarian vein distal anastomosis, fallopian tube, then tie mesangial vascular surgery often tubal damage, which affects the uterus, ovarian vein reflux, resulting in tubal access difficult to handle pelvic venous congestion levy.
Diagnosis of a medical history of patients, mostly women of childbearing age, menopausal or postmenopausal women were rare.
Most patients are married, their symptoms and the emergence of multi-abortion, childbirth, tubal access bar and other factors.
Usually, following a meeting (usually the last time) occurred shortly after the production or abortion.
Second, the clinical features of PCS for the & ldquo three clinical pain in more than two of a small & rdquo.
Pelvic or abdominal pain, fall, low back pain, deep pain during intercourse; menstrual volume, increased vaginal discharge; gynecological examination less positive signs.
Sometimes the pain may radiate to the lower extremities, perineum machine lumbosacral, and with severe premenstrual tension and breast tenderness.
After the gynecological examination the uterus often has bits, the symmetry increases, softening, congestion and pelvic tenderness has some tips, but not specific.
Congestion was the basket color cervical hypertrophy, vaginal fornix or vaginal wall showed blue purple, genital and lower extremity varicose veins directly prompted the existence of venous congestion, but the low incidence of these manifestations.
Third, the auxiliary examination 1.
B-abdominal or transvaginal ultrasound features of the PCS showed: enlarged uterus, cervical hypertrophy, in some cases increased ovarian volume, uterine, cervical vein, expansion of bilateral ovarian vein tortuosity; performance was beaded & ldquo & rdquo
or & ldquo & rdquo echo-free zone honeycomb.
CDFI showed abnormal echo-free zone for the red, blue and white color flow signals, flow rate slower than the dark color to the traffic branch connected to form irregular lakes & ldquo & rdquo like color spots.
Pulsed Doppler showed a continuous, low-speed, non-volatile main vein spectrum.
Combined with color Doppler ultrasonography of the pelvic veins greatly improve the reliability of diagnosis, no trauma, but also simple and reliable diagnosis of pelvic varicose veins can be used as the preferred method of disease, but negative results do not rule out the PCS
diagnosis.
2.
Laparoscopic laparoscopic pelvic congestion syndrome is a typical image: uterus backward lacunae in the uterus rectum, soft, surface of purple blue, to house the end of the posterior wall of the uterus to the round ligaments stretching, tension,
Bilateral ligament attachment areas in particular showed a violet blue funnel congestion state, the expansion of its vein bent worm-like, generally no adhesion.
Call bar raised tens of seconds after the uterus, uterine and accessories color change, purple blue shallow, red.
This is because the uterus from the posterior into anterior, ovary and uterus area vein pressure to reduce blood flow acceleration, thus improving the congestion state.
Therefore, the lower pelvic venous pressure is the main reason to improve pelvic congestion, which causes the uterus posterior pelvic venous hypertension is an important factor in long-standing and other factors can aggravate the increased venous pressure, thus changing the position of the uterus is the treatment of pelvic congestion syndrome
lies.
PCS has been reported in patients with laparoscopic pelvic veins can be seen enlarged, convoluted, varicose, or into a group [3], but some cases of PCS elevation can not see because of pelvic varicose veins, diagnosis still needs to venography.
3.
Pelvic venography pelvic venography is the uterine vein, ovarian vein and part of the vaginal veins, internal iliac vein development, understanding pelvic blood (mainly uterine vein and ovarian vein) out of the pelvis time as a method of diagnosis of PCS.
The typical performance of PCS as follows: ovarian venous plexus congestion, expansion of uterine vein filling, the largest ovarian vein diameter of more than 10mm, contrast agent clearance time required in the pelvis over 20s [1,3].
Treatment of a general therapy for their respective causes, to give health guidance to patients on the formation and prevention of this disease have a full understanding, foster the confidence to overcome the disease, and actively cooperate with the treatment.
Attention to rest and postural adjustment, to avoid long-term standing and sleep supine position.
Appropriate physical exercise to promote pelvic muscle tension and improve pelvic blood circulation.

Second, PCS drug treatment drug treatment is often temporary, in almost all patients have relapsed after treatment, it can only expedient for further treatment or for control of acute exacerbation.
Xu Chunlin, etc. [] confirmed by injection, suppository indomethacin and methyl testosterone 3 drug combination has a good effect on the PCS, this method can be used as treatment of choice for PCS measures.
Specific methods are: (1) compound Danshen injection 12 ~ 16mL 500mL of a 10 glucose intravenous drip, day 1, 10 ~ 12d as a course of treatment interval of 7 ~ 10d.
(2) drug indomethacin rectal suppository 25mg 2 times a day, non-menstrual period is a continuous 20d course of treatment, treatment interval of 10d.
(3) methyl testosterone 10mg sublingual day 1, once a 20d to a course of treatment, treatment interval of 10d.
Third, the intervention of transcatheter interventional therapy of ovarian vein embolization [2].
This treatment has some effect on the disease, side effects, fewer complications, but the equipment, technology requirements and higher costs in China is still not universal.
Fourth, surgical treatment 1. Fascia transverse broad ligament repair for young, fertility requirements, uterus patients, this method can make the uterus return to normal position, to relieve symptoms.
But again the line of pregnancy Caesarean section is required, or can repair failure.
2. Ovarian vein ligation or resection was first reported in 1995, foreign scholars ovarian vein ligation PCS, two days after the symptoms eliminated within 3 months of follow-up without recurrence [7].
In recent years, laparoscopic ovarian vein ligation for the efficacy of traditional abdominal ovarian vein ligation similar to [15,16].
3.
Assisted laparoscopic surgery pliers with mouse teeth were small incision into the abdominal cavity on both sides of the lower abdomen, lift the side of the middle of the round ligament, release of CO2 gas to reduce the abdominal cavity to the abdominal wall from the round ligament, round ligament of the discount on to mention, respectively, in the second
made or a third puncture the abdominal wall incision serosa, 10 silk tie round ligament of 2, so that self-serous wound bar under the adhesion to the uterus to shorten the length of the correction is appropriate for the former position, no seepage investigation
blood, and then into the abdominal cavity, opposite the same treatment.
Intraperitoneal CO2 gas filled again in order to shorten the round ligaments observed after laparoscopic uterine and accessories: correct for the anterior uterus, improving the earthworm-like vein, the surface colors are purple and blue to red.
Release of CO2 gas, remove the laparoscope, a small umbilical incision a needle, a small incision in the lower abdomen on both sides of band-aid paste, end of surgery.
4.
Total abdominal hysterectomy and oophorectomy for nearly 40 years of age or menopausal women, when other treatment fails and the impact of pain symptoms and quality of life, consider abdominal hysterectomy and oophorectomy.
Uterine surgery should varicose veins and ovarian vein resection as possible, supplemented by hormone replacement after surgery most patients can achieve sustained efficacy [10], but, PCS often occurs in women of reproductive age, so the operation
Indications are subject to certain restrictions.
Discussion with the social development, while women work in sitting or standing position, while early marriage, early childbearing and motherhood frequent, extensive application of tubal ligation, pelvic congestion syndrome caused by a gynecologist should be highly valued.
Complex range of causes of PCS, the clinical symptoms alone is sometimes difficult to determine the cause, so that treatment with blindness, so treatment is poor, recurrent symptoms, longer duration and delay, bring patients physical, psychological and pain of life, seriously affecting the life
quality.
Although there are sterilization by laparotomy after finding the cause of abdominal pain reported [12], but patients do not easily accept Moreover, lesions sometimes found but that led to complications.
The clinical application of laparoscopic techniques to find the cause and treatment of PCS has opened a new way.
China Wang Zhenhai reported laparoscopic techniques such as sterilization and treatment of pelvic pain after surgery [3].
Laparoscopy is also information on foreign countries is a cause of chronic pelvic pain to find effective and practical way to avoid unnecessary laparotomy [45].
Laparoscopic technology not only to correct diagnosis, timely diagnosis, but also simultaneously adhesiolysis lesions coagulation, windows clear cysts, removal of lesions such as tubal surgery, thereby improving efficacy.
The clinical value of laparoscopic diagnosis and treatment of CPP: CPP causes the complexity of the lack of positive signs in some patients, relying solely on history and physical examination is often difficult to diagnose, making the diagnosis and treatment of blindness with poor efficacy.
Laparoscopy has been accepted diagnosis of unexplained CPP is the gold standard [5].
In summary for patients with pelvic congestion syndrome minimally invasive laparoscopic and endoscopic surgery can clear etiology, and treatment to take reasonable measures to obtain good results.
Conventional laparotomy round ligament shortening the line, so that the uterus is anterior posterior correction is a better way to treat the disease, but the surgeries, the patient suffering heavy, a series of surgical complications that most patients be daunting.
Laparoscopic down round ligament shortening reduces the drawbacks of conventional surgery, its advantages: ① laparoscopic abdominal Full careful to various organs; ② minimally invasive surgery, do not open the abdominal cavity, the operation is simple, only small holes in the lower abdomen will
abdominal suture can be made round ligament, surgery without pain; ③ sutureless abdominal wall incision, leaving a large scar, the abdominal wall and beautiful; ④ patients after healing, no hospital; ⑤ higher survival rate.