Salpingectomy method

Abstract

The invention relates to surgical gynaecology. A pre-operative step is performed which includes 3D transvaginal ultrasound imaging of a fallopian tube and an ovary using colour and power Doppler flow mapping modes, and contrast magnetic resonance imaging of the pelvic organs, and a 3D model of the uterine appendages is generated, in which characteristic features of the blood supply to the fallopian tube and the ovary are identified. In an intraoperative step, a laparoscopic visual inspection of the uterine appendages is performed. An intraoperative visual image of the uterine appendages is transferred to the 3D model of the uterine appendages. The 3D model and the intraoperative data regarding the uterine appendages are combined and navigation markers are created, taking into account the characteristic features of the blood supply to the fallopian tube and the ovary. A salpingectomy is performed using the intraoperative navigation, thereby preserving the perivascular system and the ovarian reserve. The method makes it possible to identify characteristic features of the blood supply to a fallopian tube and an ovary and to perform a salpingectomy without damaging the perivascular system of the fallopian tube and the ovary or diminishing the ovarian reserve.

Description

[0001] Method of salpingectomy

[0002] The invention relates to medicine, namely to operative gynecology, and can be used to treat infertility in pathological conditions of the uterine appendages during the reproductive period. The method includes salpingectomy by laparoscopic access, which was performed using surgical navigation taking into account the data obtained during the preoperative 3D model, in order to prepare for assisted reproductive technology protocols. This invention helps preserve the ovarian reserve.

[0003] The prior art discloses a method for preparing and performing a surgical operation on the pelvic organs [RU2736800C1, 20.11.2020], which uses a hardware and software complex that includes the stages of creating a preoperative personalized three-dimensional mathematical and graphical model of organs and neoplasms in them, planning - simulating an organ-preserving surgical operation, surgical intervention with the import of a preoperative three-dimensional model, creating an intraoperative model. Moreover, at the stage of planning the operation, the patient undergoes an ultrasound examination or computed or magnetic resonance imaging and forms a preoperative three-dimensional model of organs and neoplasms in them and an operation plan with surgical navigation. Further, the preoperative model during surgery is adapted to the intraoperative parameters of organs and neoplasms and an intraoperative model with surgical navigation is formed.At the stage of constructing a preoperative model of organs and neoplasms in them, modeling of neoplasms in organs is carried out, which is of interest to the surgeon in the planned operation. Then a preliminary plan of the operation is formed with the designation of navigation marks for making an incision and removing the neoplasm with minimal trauma to the healthy tissue of the organ. After that, an organ-preserving laparoscopic intervention is carried out, which begins with an assessment of the topography and size of organs and neoplasms in them and the adaptation of the preoperative three-dimensional model to the intraoperative parameters of organs and neoplasms, after which, using a software and hardware complex on the monitors of the video endoscopic complex, it is possible to evaluate the volume of the neoplasm in the organ in the dialogue mode, with visualization of invisible subtissue structures and vessels.After that, navigation marks appear on the adapted three-dimensional model, with the help of which the place of the incision is positioned, after which the neoplasm is removed from the organ, during the surgical intervention, with spatial displacement of organs or a change in their geometry due to the removal of neoplasms, the repeated binding of the model occurs automatically at fixed moments in time, or manually using the computer control system. The invention provides the possibility of removing neoplasms of the pelvic organs with minimal trauma to healthy tissue of the organ, not requiring or requiring minimal use of coagulation techniques to stop bleeding. In operations on the ovaries, the technical result is also the preservation of healthy ovarian tissue and ovarian reserve.

[0004] The claimed invention differs from the one described in that the invention is used for mapping the circulatory system of an organ that is not subject to oncological changes.

[0005] Also known from the state of the art is a method for performing surgical intervention for the treatment of ectopic pregnancy [Laparoscopy in Gynecology / Ed. G.M. Savelyeva, Academician of the Russian Academy of Medical Sciences. - M.: GEOTAR Medicine, 2000. - 324 p.], in which laparoscopic intervention is performed under ultrasound control, during which the mesosalpinx area of ​​the anterior and posterior leaflets is coagulated simultaneously, parallel to the longitudinal axis of the fallopian tube with a bipolar coagulator without identifying vascular zones, followed by intersection at the site of coagulation with scissors.

[0006] The present invention differs from the known one in that the surgical intervention maximally preserves the blood supply system of the ovarian region.

[0007] The present invention includes preoperative modeling and surgical navigation, as well as transvaginal 3D echography in color and power Doppler mapping modes in order to determine the size, localization and features of the blood supply of the tubo-ovarian formation. Then, surgical interventions were performed using surgical navigation intraoperatively, in the dialogue mode the main vascular structures of the mesosalpinx were visualized, including the upper, paratubal zone of anastomoses, segmental vessels of the midsalpinx and the lower, paraovarian blood supply zone. As a result, a personalized polygonal 3D model of the tubo-ovarian formation was formed, allowing visualization of the topography of the vascular zones of the mesosalpinx.

[0008] Example 1. Patient A., 32 years old, was admitted to the gynecological department No. 2 of the Yudin City Clinical Hospital for planned surgical treatment with the diagnosis: Infertility 1. Chronic salpingo-oophoritis with the formation of bilateral hydrosalpinx.

[0009] History: complaints of failure to conceive despite regular sexual intercourse for 2 years. One unsuccessful attempt at IVF and ET. According to the reproductive specialist, a second attempt at ART is possible after removal of the fallopian tubes. According to the ultrasound examination of the pelvic organs, bilateral hydrosalpinxes with diameters of 3 cm on the right and 3.5 cm on the left (ORADS 1) were detected. The somatic history is not burdened. The patient underwent planned surgical treatment in the form of salpingectomy using the author's technique, which includes preoperative and intraoperative stages: Preoperative - first stage:

[0010] 1. Transvaginal 3D echography in color and power Doppler mapping modes to determine the size, location and blood supply characteristics of the fallopian tube and ovary: Body of the uterus 45x40x44 mm. The structure of the myometrium is homogeneous. M-ECHO 5 mm, homogeneous, three-layer. The right ovary is 23x18x20 mm in size, follicular apparatus - 3 follicles with a diameter of 3 to 5 mm are visualized in the section. An enlarged fallopian tube with a diameter of up to 3 cm with anechoic contents and 0 blood flow at PDC is visualized next to the ovary. The left ovary is 25x17x22 mm in size, follicular apparatus, 3 follicles with a diameter of 4 to 6 mm are visualized in the section. An enlarged fallopian tube up to 3.5 cm in diameter with anechoic contents and 0 blood flow is visualized near the ovary during color Doppler imaging. Free fluid is not visualized in the small pelvis. Conclusion: Echo signs of hydrosalpinx on the right, hydrosalpinx on the left. (ORADS 1).

[0011] 2. Conclusion of MRI with contrast of the pelvic organs: signs of bilateral hydrosalpinx.

[0012] 3. Based on the author's software and ultrasound and MRI data, a 3D model of the uterine appendages is developed, determining the characteristics of the blood supply to the fallopian tube and ovary.

[0013] Intraoperative second stage:

[0014] 1. Application of pneumoperitoneum with control of insufflated gas at a pressure of at least 12-13 mm Hg.

[0015] 2. Installation of port #1. Port #1 (10 mm) for the laparoscope is installed 2 cm above and 2 cm to the left of the navel along the left medial clavicular line. The patient is placed in the Trendelenburg position. Port #2 (5 mm) is installed at the Mac Burnea points on the left, port #3 (5 mm) on the right, and an additional port #4 is installed 3 cm above the line drawn between the Mac Burnea points and 3 cm to the right of the line between the navel and the line connecting the Mac Burnea point. 3. Insertion of the laparoscope (30 degree optics) - laparoscopic visual assessment of the uterine appendages: the body of the uterus is pink, not enlarged, located along the midline. The right ovary is not enlarged, in periovarian adhesions with the right fallopian tube. The right fallopian tube is dilated along its entire length to 3 cm, in peritubal adhesions with the right ovary, the fimbrial section is sealed. The left ovary is not enlarged, in periovarian adhesions with the left fallopian tube. The left fallopian tube is dilated to 3.5 cm, in peritubal adhesions with the left ovary, the fimbrial section is sealed.The anterior and posterior uterine spaces are unremarkable.

[0016] 4. Transfer of the visual intraoperative picture of the uterine appendages into the author’s program.

[0017] 5. Comparison of the 3D model with intraoperative data of the uterine appendages and creation of navigation marks taking into account the features of the blood supply to the fallopian tube and ovary

[0018] 6. Salpingectomy technique with proprietary navigation technology without damaging the perivascular complex:

[0019] 6.1 The surgeon works through ports No. 2 and 4, and the assistant works through ports No. 1 and 3.

[0020] 6.2 Atraumatic clamps are inserted into ports No. 2 and No. 3. Depending on the stages of the operation, a coagulation instrument (biopolar, argon, laser coagulation) or endoscopic scissors are inserted into port No. 4.

[0021] 6.3 Removal of the left fallopian tube: separation of adhesions, salpingo-ophariolysis on the left, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #3, mobilization of the left tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #2. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex with the anterior leaf from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0022] 6.4 Removal of the right tube: separation of adhesions, salpingo-ovariolysis on the right, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #2, mobilization of the right tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #3. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0023] The ovarian reserve indicators in patient A before and 6 months after salpingectomy are shown in Table 1.

[0024] Example 2. Patient B., 39 years old, was admitted to the gynecological department No. 2 of the Yudin City Clinical Hospital with the diagnosis: Infertility 2. Chronic salpingo-oophoritis with the formation of bilateral hydrosalpinxes.

[0025] History: complaints of failure to conceive with regular sexual activity without contraception for 5 years. Male factor infertility. The patient is planned to undergo ICSI. Two unsuccessful attempts at IVF and ET. According to the reproductive specialist, a subsequent attempt at ART is possible after removal of the fallopian tubes. During the examination, according to the ultrasound of the pelvic organs in December 2022, bilateral hydrosalpinx was revealed. The reproductive specialist referred her for salpingectomy. Menstruation from the age of 12 for 5 days, the cycle is 28 days apart, regular, painless, moderate. The gynecological history is burdened: in 2012, laparoscopy was performed, cystectomy on the right. Histological examination: endometrioid cyst. There were two pregnancies in total: the first was a spontaneous, timely birth at 39 weeks in 2008, the second pregnancy ended in a miscarriage at 6 weeks in 2017. The patient's somatic history is not complicated.The patient underwent planned surgical treatment using the author's salpingectomy technique.

[0026] Preoperative - first stage:

[0027] 1. Transvaginal 3D echography in color and power Doppler mapping modes to determine the size, location and blood supply characteristics of the fallopian tube and ovary: Body of the uterus 54x42x48 mm. The structure of the myometrium is diffusely heterogeneous. M-ECHO 6 mm, homogeneous, three-layer. The right ovary is 23x22x27 mm in size, follicular apparatus - 2 follicles with a diameter of 3 to 5 mm are visualized in the section. An enlarged fallopian tube with a diameter of up to 3.5 cm with anechoic contents and 0 blood flow at PIC is visualized next to the ovary. The left ovary is 34x21x30 mm in size, follicular apparatus, 5 follicles with a diameter of 3 to 5 mm are visualized in the section. Near the ovary, an enlarged fallopian tube with a diameter of up to 2.5 cm with anechoic contents and 0 blood flow is visualized during color Doppler scanning. Free fluid in the small pelvis is not visualized. Conclusion: Echo signs of bilateral hydrosalpinx. (ORADS 1). Adenomyosis.

[0028] 2. Conclusion of MRI with contrast of the pelvic organs: signs of bilateral hygrosalpinx, diffuse changes in the myometrium. 3. Based on the author's software and ultrasound and MRI data, a 3D model of the uterine appendages is developed with the definition of the features of the blood supply to the fallopian tube and ovary.

[0029] Intraoperative second stage:

[0030] 1. Application of pneumoperitoneum with control of insufflated gas at a pressure of at least 12-13 mm Hg.

[0031] 2. Installation of port #1. Port #1 (10 mm) for the laparoscope is installed 2 cm above and 2 cm to the left of the navel along the left medial clavicular line. The patient is placed in the Trendelenburg position. Port #2 (5 mm) is installed at the Mac Burnea points on the left, port #3 (5 mm) on the right, and an additional port #4 is installed 3 cm above the line drawn between the Mac Burnea points and 3 cm to the right of the line between the navel and the line connecting the Mac Burnea point.

[0032] 3. Introduction of the laparoscope (30 degree optics) - laparoscopic visual assessment of the uterine appendages: the body of the uterus is pink, not enlarged, located in the midline. The right ovary is not enlarged, in periovarian adhesions with the right fallopian tube. The right fallopian tube is dilated along its entire length to 3.5 cm, in peritubal adhesions with the right ovary, the posterior leaflet of the broad ligament of the uterus, the fimbrial section is sealed. The left ovary is not enlarged, in periovarian adhesions with the left fallopian tube. The left fallopian tube is dilated to 2.5 cm, in peritubal adhesions with the left ovary, the fimbrial section is sealed. The anterior uterine space is normal. The retrouterine space is in multiple planar adhesions.

[0033] 4. Transfer of the visual intraoperative picture of the uterine appendages into the author’s program.

[0034] 5. Comparison of the 3D model with intraoperative data of the uterine appendages and creation of navigation marks taking into account the features of the blood supply to the fallopian tube and ovary

[0035] 6. Salpingectomy technique with the author's navigation technology without damaging the perivascular complex: 6.1 The surgeon works through ports No. 2 and 4, and the assistant works through ports No. 1 and No. 3.

[0036] 6.2 Atraumatic clamps are inserted into ports No. 2 and No. 3. Depending on the stages of the operation, a coagulation instrument (biopolar, argon, laser coagulation) or endoscopic scissors are inserted into port No. 4.

[0037] 6.3 Removal of the left fallopian tube: separation of adhesions, salpingo-ophariolysis on the left, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #3, mobilization of the left tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #2. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex with the anterior leaf from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0038] 6.4 Removal of the right tube: separation of adhesions, salpingo-ovariolysis on the right, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #2, mobilization of the right tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #3. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0039] The ovarian reserve indices in patient A before and 6 months after salpingectomy are shown in Table 2.

[0040] Example 3. Patient O., 40 years old, was admitted to the gynecological department No. 2 of the Yudin City Clinical Hospital with the diagnosis: Chronic salpingo-oophoritis with the formation of bilateral hydrosalpinx.

[0041] History: complaints of nagging pain in the lower abdomen over the past year. In July 2023, she consulted a gynecologist at the antenatal clinic, where a pelvic ultrasound revealed bilateral hydrosalpinx. One unsuccessful attempt at IVF and PE. According to the reproductologist, a second attempt at ART is possible after removal of the fallopian tubes. Menstruation from the age of 13 for 7 days, cycle every 28-30 days, regular, painless, moderate. Gynecological history: in 2015, laparoscopy, tuboplasty due to infertility. In total, there was one pregnancy: - 1st spontaneous delivery on time at 38 weeks in 2016. The patient's somatic history is not burdened. The patient underwent planned surgical treatment using the author's salpingectomy technique.

[0042] Preoperative - first stage:

[0043] 1. Transvaginal 3D echography in color and power Doppler mapping modes to determine the size, location and blood supply characteristics of the fallopian tube and ovary: Body of the uterus 50x32x45 mm. The structure of the myometrium is diffusely heterogeneous. M-ECHO 5 mm, homogeneous, three-layer. The right ovary is 25x18x20 mm in size, follicular apparatus - 3 follicles with a diameter of 3 to 6 mm are visualized in the section. An enlarged fallopian tube with a diameter of up to 4 cm with anechoic contents and 0 blood flow during color Doppler mapping is visualized next to the ovary. The left ovary is 33x20x28 mm in size, follicular apparatus, 5 follicles with a diameter of 2 to 5 mm are visualized in the section. Near the ovary, an enlarged fallopian tube with a diameter of up to 3.2 cm with anechoic contents and 0 blood flow is visualized during color Doppler imaging. Free fluid is not visualized in the small pelvis. Conclusion: Echo signs of bilateral hydrosalpinx. (ORADS 1). Adenomyosis.

[0044] 2. Conclusion of MRI with contrast of the pelvic organs: signs of bilateral hydrosalpinx, diffuse changes in the myometrium.

[0045] 3. Based on the author's software and ultrasound and MRI data, a 3D model of the uterine appendages is developed, determining the characteristics of the blood supply to the fallopian tube and ovary.

[0046] Intraoperative second stage:

[0047] 1. Application of pneumoperitoneum with control of insufflated gas at a pressure of at least 12-13 mm Hg.

[0048] 2. Installation of port #1. Port #1 (10 mm) for the laparoscope is installed 2 cm above and 2 cm to the left of the navel along the left medial clavicular line. The patient is placed in the Trendelenburg position. Port #2 (5 mm) is installed at the Mac Burnea points on the left, port #3 (5 mm) on the right, and an additional port #4 is installed 3 cm above the line drawn between the Mac Burnea points and 3 cm to the right of the line between the navel and the line connecting the Mac Burnea point.

[0049] 3. Introduction of the laparoscope (30 degree optics) - laparoscopic visual assessment of the uterine appendages: the body of the uterus is pink, not enlarged, located in the midline. The right ovary is not enlarged, in periovarian adhesions with the right fallopian tube. The right fallopian tube is dilated along its entire length to 4 cm, in peritubal adhesions with the right ovary, the posterior leaflet of the broad ligament of the uterus, the fimbrial section is sealed. The left ovary is not enlarged, in periovarian adhesions with the left fallopian tube. The left fallopian tube is dilated to 3.2 cm, in peritubal adhesions with the left ovary, the fimbrial section is sealed. The anterior and uterine space are normal. The retrouterine space is in multiple planar adhesions.

[0050] 4. Transfer of the visual intraoperative picture of the uterine appendages into the author’s program.

[0051] 5. Comparison of the 3D model with intraoperative data of the uterine appendages and creation of navigation marks taking into account the features of the blood supply to the fallopian tube and ovary

[0052] 6. Salpingectomy technique with proprietary navigation technology without damaging the perivascular complex:

[0053] 6.1 The surgeon works through ports No. 2 and 4, and the assistant works through ports No. 1 and 3.

[0054] 6.2 Atraumatic clamps are inserted into ports No. 2 and No. 3. Depending on the stages of the operation, a coagulation instrument (biopolar, argon, laser coagulation) or endoscopic scissors are inserted into port No. 4.

[0055] 6.3 Removal of the left fallopian tube: separation of adhesions, salpingo-ophariolysis on the left, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #3, mobilization of the left tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #2. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex with the anterior leaf from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag. 6.4 Removal of the right tube: separation of adhesions, salpingo-ovariolysis on the right, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #2, mobilization of the right tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #3. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated with sharp and blunt dissection using the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex from the fallopian tube area towards the ovary is performed. Dissection of the posterior leaf of the mesosalpinx as close as possible to the fallopian tube is performed. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0056] The ovarian reserve indices in patient A before and 6 months after salpingectomy are shown in Table 3.

[0057] Example 4. Patient G., 36 years old, was admitted to the gynecological department No. 2 of the Yudin City Clinical Hospital with the diagnosis: Chronic salpingo-oophoritis with the formation of bilateral hydrosalpinx.

[0058] History: no pregnancy with regular sexual activity without contraception. In March 2023, pelvic ultrasound revealed bilateral hydrosalpinx. Two unsuccessful attempts at IVF and PE. According to the reproductive specialist, a subsequent attempt at ART is possible after removal of the fallopian tubes. Menstruation from the age of 10 for 4 days, cycle every 26 days, regular, painless, moderate. Gynecological history: laparotomy, appendectomy in 2003. A total of one pregnancy - spontaneous labor in 2015. The patient's somatic history is not burdened. The patient underwent elective surgery using the author's technique of surgical salpingectomy.

[0059] Preoperative - first stage: 1. Transvaginal 3D echography in color and power Doppler mapping modes to determine the size, location and characteristics of the blood supply to the fallopian tube and ovary: Body of the uterus 52x43x45 mm. The structure of the myometrium is diffusely heterogeneous. M-ECHO 7 mm, homogeneous, three-layer. The right ovary is 35x25x30 mm in size, follicular apparatus - 4 follicles with a diameter of 3 to 5 mm are visualized in the section. Next to the ovary, an enlarged fallopian tube with a diameter of up to 3.6 cm with anechoic contents and 0 blood flow during color Doppler mapping is visualized. The left ovary is 26x20x25 mm in size, follicular apparatus, 2 follicles with a diameter of 3 to 6 mm are visualized in the section. Near the ovary, an enlarged fallopian tube with a diameter of up to 3.4 cm with anechoic contents and 0 blood flow during CCC is visualized. Free fluid in the small pelvis is not visualized. Conclusion: Echo signs of bilateral hydrosalpinx. (ORADS 1). Adenomyosis.

[0060] 2. Conclusion of MRI with contrast of the pelvic organs: signs of bilateral hydrosalpinx, diffuse changes in the myometrium.

[0061] 3. Based on the author's software and ultrasound and MRI data, a 3D model of the uterine appendages is developed, determining the characteristics of the blood supply to the fallopian tube and ovary.

[0062] Intraoperative second stage:

[0063] 1. Application of pneumoperitoneum with control of insufflated gas at a pressure of at least 12-13 mm Hg.

[0064] 2. Installation of port #1. Port #1 (10 mm) for the laparoscope is installed 2 cm above and 2 cm to the left of the navel along the left medial clavicular line. The patient is placed in the Trendelenburg position. Port #2 (5 mm) is installed at the Mac Burnea points on the left, port #3 (5 mm) on the right, and an additional port #4 is installed 3 cm above the line drawn between the Mac Burnea points and 3 cm to the right of the line between the navel and the line connecting the Mac Burnea point. 3. Insertion of the laparoscope (30 degree optics) - laparoscopic visual assessment of the uterine appendages: the layers of the greater omentum are soldered in the right iliac region, the body of the uterus is pink, not enlarged, and located along the midline. The right ovary is not enlarged, in periovarian adhesions with the right fallopian tube. The right fallopian tube is dilated along its entire length to 3.6 cm, in peritubal adhesions with the right ovary, the posterior leaflet of the broad ligament of the uterus, the fimbrial section is sealed. The left ovary is not enlarged, in periovarian adhesions with the left fallopian tube.The left fallopian tube is dilated to 3.4 cm, in peritubal adhesions with the left ovary, the posterior leaflet of the broad ligament of the uterus, the fimbrial section is sealed. The anterior uterine space is normal. The retrouterine space is in multiple planar adhesions.

[0065] 4. Transfer of the visual intraoperative picture of the uterine appendages into the author’s program.

[0066] 5. Comparison of the 3D model with intraoperative data of the uterine appendages and creation of navigation marks taking into account the features of the blood supply to the fallopian tube and ovary

[0067] 6. Salpingectomy technique with proprietary navigation technology without damaging the perivascular complex:

[0068] 6.1 The surgeon works through ports No. 2 and 4, and the assistant works through ports No. 1 and 3.

[0069] 6.2 Atraumatic clamps are inserted into ports No. 2 and No. 3. Depending on the stages of the operation, a coagulation instrument (biopolar, argon, laser coagulation) or endoscopic scissors are inserted into port No. 4.

[0070] 6.3 Removal of the left fallopian tube: separation of adhesions, salpingo-ophariolysis on the left, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #3, mobilization of the left tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #2. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex with the anterior leaf from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0071] 6.4 Removal of the right tube: separation of adhesions, salpingo-ovariolysis on the right, mobilization of the tube in the proximal section at a distance of 1 cm from the uterus using an atraumatic clamp from port #2, mobilization of the right tube at a distance of 2 cm from the fimbrial section using a similar clamp from port #3. Simultaneously, the surgeon and assistant pull up the fallopian tube to tension the mesosalpinx. The anterior and posterior leaves of the mesosalpinx in the avascular zone as close as possible to the fallopian tube are separated using sharp and blunt methods with the branches of endoscopic scissors under intraoperative navigation. Blunt displacement of the perivascular complex from the fallopian tube area towards the ovary is performed. The posterior leaf of the mesosalpinx is dissected as close as possible to the fallopian tube. Coagulation and intersection of the uterine angle of the fallopian tube. The tube is removed from the abdominal cavity in an endobag.

[0072] The ovarian reserve indicators in patient A before and 6 months after salpingectomy are shown in Table 4.

[0073] Example 5. Comparative characteristics of ovarian reserve markers after laparoscopic salpingectomy using the author's and routine technologies. In the first group (50 patients), the surgical intervention was performed using intraoperative surgical navigation taking into account the data obtained during preoperative 3D modeling using the author's technology. In the second group (50 patients), salpingectomy was performed using the standard technique. The control group consisted of 30 fertile patients (have 1-2 children) of reproductive age, with a regular menstrual cycle, with spontaneous ovulation and who have not used hormonal drugs for 12 months, who sought out dispensary observation. Summary data are presented in Table 5.

[0074] In the presented results:

[0075] 1. Ovarian reserve in infertile women with tubo-ovarian formations (bilateral hydrosalpinx) does not differ significantly from the control group.

[0076] 2. The known method of salpingectomy leads to a reliable decrease in the parameters of the ovarian reserve after the operation compared to the parameters before the operation.

[0077] 3. The claimed method of salpingectomy includes preoperative and intraoperative stages, which allows identifying the features of the blood supply to the fallopian tube and ovary and performing salpingectomy without damaging the perivascular complex of the fallopian tube and ovary. Innovative modeling and navigation technologies allow performing salpingectomy without reducing the ovarian reserve (p>0.05).

[0078] Table 1

[0079] Table 2

[0080] Table 3 Table 4

[0081] Table 5

Claims

Invention formula A salpingectomy method that includes a preoperative stage that includes: transvaginal 3D echography in color and power Doppler mapping modes to determine the size, location, and blood supply features of the fallopian tube and ovary; magnetic resonance imaging with contrast of the pelvic organs; creation of a 3D model of the uterine appendages to determine the blood supply features of the fallopian tube and ovary; an intraoperative stage that includes laparoscopic visual assessment of the uterine appendages; transfer of the visual intraoperative picture of the uterine appendages to a 3D model of the uterine appendages; comparison of the 3D model with the intraoperative data of the uterine appendages and creation of navigation marks taking into account the blood supply features of the fallopian tube and ovary; performance of salpingectomy with intraoperative navigation without damaging the perivascular complex while preserving the ovarian reserve.

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