大子宫阴式子宫切除术50例分析

目的 探讨大子宫阴式子宫切除术的可行性。方法 双侧子宫血管结扎后，行子宫对半切除术、肿瘤剔除术、子宫分碎术。结果 50例大子宫阴式子宫切除术均成功。结论 大子宫阴式子宫切除术可行。     

大子宫经阴道切除25例临床分析

目的 探讨大子中经阴道切除的安全性和可行性。方法 采用子宫劈开、肌核剜除、碎解等缩小子宫体积的方法,对２５例子宫增大如１２～１７孕周「平均（１４．０±１．７）周」、重２８０～５７０ｇ「平均（３７２±７４）ｇ」的子宫肌瘤患,行经阴道子宫切除术（ＴＶＨ）。对手术方式、时间、出血量、副损伤及术后病率进行分析。结果 ２２例成功经阴道切除,３例改经腹手术。手术成功率８８％。术中膀胱损伤１例,大出血１例,输     

子宫肌瘤手术意外发现的子宫肉瘤临床处理分析

目的探讨腹腔镜下子宫肌瘤手术使用分碎器意外发现子宫肉瘤患者的概率及对患者预后的影响,避免其应用于子宫肉瘤患者。方法通过回顾性分析2011年1月至2016年12月中日友好医院收治的2072例初步诊断为子宫肌瘤拟行子宫肌瘤剔除或子宫次全切除患者的病例资料,分为腹腔镜手术组(1944例)和开腹手术组(128例)。结果 1944例患者接受了腹腔镜手术且术中使用了分碎器,其中5例患者意外发现子宫肉瘤(0.3%),使用子宫肌瘤分碎器意外发现的子宫肉瘤患者的概率为0.3%;128例开腹手术组有2例意外发现子宫肉瘤(1.6%),两组意外发现子宫肉瘤的概率比较差异无统计学意义(P0.05);7例患者随访2~45个月,均存活,腹腔镜组子宫肉瘤患者术后复发3例,开腹手术组患者术后无复发。结论腹腔镜下使用分碎器行子宫肌瘤手术可能导致子宫肉瘤患者预后恶化,分碎器应避免应用于子宫肉瘤患者。     

80例大子宫阴式子宫切除的临床分析

目的 :探讨大子宫阴式切除方法的安全性、可行性及临床价值。方法 :2 0 0 1年 4～ 12月 ,我科对 80例因子宫肌瘤、子宫腺肌瘤而无生殖道脱垂 ,子宫增大如孕 10～ 2 0周者行阴式子宫切除术 (TVH)。结果 :80例全部经阴道切除 ,成功率 10 0 %。无一例膀胱、直肠损伤。子宫重 2 80～ 10 0 0g。手术时间 30～ 180分钟。术中同时采用子宫对半切开、子宫肌瘤剜除术、子宫分碎术其中 1种或多种特殊方法处理大子宫 5 1例 (6 3.75 % )。术中同时行轻度粘连松解术 15例(18.75 % )。同时行附件切除或囊肿剔出术 6例 (7.5 % )。术中出血 30～ 6 0 0ml。住院天数 6～ 8天。结论 :大子宫经阴道切除是安全有效的手术。子宫增大超过孕 12周并非TVH的绝对禁忌证。伴有轻度盆腔粘连亦可行TVH。     

改良式非脱垂大子宫经阴道全切除术67例分析

目的：探讨经阴道非脱垂大子宫切除术的方法和可行性。方法：对67例子宫大于孕12周、活动、无粘连的子宫肌瘤、子宫腺肌瘤患者,行改良式非脱垂阴式全子宫切除术。改良步骤包括直接切断子宫骶韧带、主韧带,无需缝扎；直接切断子宫动静脉主干；钳夹动静脉断端向上撕,推过阔韧带无血管区；紧贴宫颈绕行充分剪开阔韧带后叶；采用子宫颈切开、子宫体粉碎、子宫肌瘤剔除等减小子宫体积的方法联合使用。结果：67例患者成功地经阴道完成手术,平均子宫重量为617±50 g(510～2600 g),平均手术时间为57±12分钟(41～127分钟),平均估计失血量为290±78 ml(150～930 ml)。术后出院时间平均为6．5±2．1天(4～9天)。结论：改良式非脱垂大子宫经阴道行全子宫切除术是可行的,且简便、安全。     

一种经腹全子宫切除术的术式介绍

参阅文献和经过临床实践,我们研究了一种经腹全子宫切除的新术式,临床应用取得良好效果。１　资料与方法１－１　病例选择　１９９８年８月至１９９８年１２月采用新术式行子宫切除２５例,患者年龄４２～５８岁,手术指证为子宫肌瘤、功能失调性子宫出血、子宫腺肌病或（和）附件良性肿瘤需同时行子宫切除者。１－２　手术方法　以下只介绍改进的步骤,余同常规子宫切除术步骤：①沿着下腹部Ｐｆａｎｎｉｅｌ’ｓ皱襞横形切口,长度同子宫的最大横径,以能牵出子宫为原则。切开皮肤,钝性撕开皮下组织,横向剪开腹直肌前鞘,沿中线钝性分…     

子宫动脉栓塞与子宫肌瘤剔除术治疗子宫肌瘤疗效对比分析

目的探讨子宫肌瘤子宫动脉栓塞治疗与子宫肌瘤剔除术治疗疗效.方法回顾分析40例(A组)经子宫动脉栓塞治疗、42例(B组)经腹腔镜子宫肌瘤剔除术、36例(C组)经阴式子宫肌瘤剔除术及30例(D组)经腹式子宫肌瘤剔除术治疗子宫肌瘤病例临床资料及随访情况,分析疗效.结果4组病例均保留子宫,临床症状均明显改善,且未出现明显并发症.术后随访3～24 个月(平均18个月),术后6个月,A组子宫及肌瘤体积缩小平均62%,6例肌瘤消失;B、C、D组子宫体积缩小平均84%.术后18个月,A组子宫及肌瘤体积缩小平均86%,子宫体积恢复正常大小23例,14例肌瘤消失,B、C、D组子宫体积恢复正常大小分别为30例、29例、23例,肌瘤复发分别为3例、2例、2例.结论子宫动脉栓塞治疗与子宫肌瘤剔除术治疗子宫肌瘤均有良好疗效,子宫肌瘤剔除术治疗子宫肌瘤后子宫体积恢复正常大小及肌瘤消失率较子宫动脉栓塞治疗法高,但近期复发率高于子宫动脉栓塞治疗法.     

4例医源性寄生子宫肌瘤病例分析及文献回顾

目的:探讨医源性寄生子宫肌瘤的临床特点、预防和治疗。方法:回顾分析2012年9月至2014年12月北京大学第一医院收治的4例医源性寄生子宫肌瘤病例,总结其临床特点,结合国内外相关文献,分析其病因及防治。结果:4例患者有腹腔镜子宫肌瘤剔除术史或腹腔镜子宫次全切除术史,术中均应用粉碎器,病理均为子宫平滑肌瘤,术后42~69个月复发。1例表现为腹痛、腹胀,1例表现为腹部包块,2例无症状为常规体检发现。再次手术方式为开腹探查术或腹腔镜探查术,切除病灶,其中1例行乙状结肠切除术,术后病理回报为平滑肌瘤及腺肌瘤,结局良好。结论:应用粉碎器的腹腔镜子宫肌瘤剔除手术或子宫切除手术会增加寄生性子宫肌瘤的发病风险。操作中避免组织残留,术后结合其他相关治疗,将最大限度地减少寄生性子宫肌瘤发生。     

经阴道子宫黏膜下肌瘤剔除术36例临床分析

目的:探讨经阴道行子宫黏膜下肌瘤剔除术的可行性、临床效果和安全性.方法:我院2005年3月至2008年5月经宫腔镜联合B超检查诊断为子宫黏膜下肌瘤36例,均位于子宫下段.肌瘤直径30～63mm,其中30～40mm 13例,41～60mm 20例,61～63mm 3例.行宫腔镜子宫肌瘤电切术失败后,改行经阴道子宫肌瘤剔除术.术后随访3～40个月.根据术后月经改善情况、残余肌瘤有无增长、是否再次手术等将疗效分为满意和不满意.结果:36例患者均成功施行手术,手术平均时间64.7±10.4分钟,术中平均出血量200.0±38.4ml,术后平均住院时间4.9±1.2天,术后满意率均达100%,2例要求生育者1例妊娠.结论:对位于子宫下段、肌瘤直径30～63 mm的黏膜下肌瘤,考虑到宫腔镜可能不易切除的,可经阴道行子宫肌瘤剔除术.     

半腹膜外筋膜内子宫切除43例分析

我院１９９６年１月至１９９７年１２月,共施行半腹膜外筋膜内子宫切除术４３例,效果良好,现报道如下。１　资料与方法１．１　一般资料　自１９９６年１月至１９９７年１２月行半腹膜外筋膜内子宫切除术４３例（研究组）,其中功能性子宫出血３例,子宫肌瘤２７例,子宫腺肌病１３例;同期随机选择腹膜内子宫切除术４９例（对照组）,其中功能性子宫出血１０例,子宫肌瘤２９例,子宫腺肌病１０例。两组年龄、病种经统计学处理无明显差异（Ｐ＞０．０５）,两组手术适应证均为子宫增大约妊娠１２周以内,无盆腔粘连。１．２　手术方法１…     

Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams

Objectives: The purpose of this study was to compare the surgical outcomes of women with moderately enlarged uteri undergoing vaginal hysterectomy with those of women with uteri of normal size undergoing vaginal hysterectomy. A secondary objective was to investigate the roles of uterine morcellation and laparoscopically assisted vaginal hysterectomy in the treatment of these women. Study Design: Thirty consecutive women during a 2-year period with uterine enlargement to a weight of between 200 and 700 g underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy limited to lysis of adhesions or adnexectomy. These patients with uterine enlargement (group 1) were compared with 160 women with uteri weighing <200 g who also underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy during the same interval (group 2). The 2 groups were compared for total complications, operative time, hospital stay, perioperative hemoglobin concentration change, and use of vaginal uterine morcellation and laparoscopically assisted vaginal hysterectomy. Results: Operative time for vaginal hysterectomy was significantly longer for women in group 1 than for women in group 2 (66.6 ± 26.2 minutes vs 53.0 ± 25.5 minutes, P = .008). There was a linear relationship between uterine weight and operative time: Operative time = 47.156 + 0.056 × Uterine weight (r = 0.20, F = 7.66, degrees of freedom 1, 188, P = .006). Vaginal morcellation of the uterus was needed in 80.0% of the women in group 1 and in 10.0% of the women in group 2 (P < .001). Two women in group 1 (6.7%) and 9 women (5.6%) in group 2 had laparoscopically assisted procedures for lysis of adhesions, adnexectomy, or both, unrelated to uterine size (P = .69). There were no significant differences between the 2 groups with respect to perioperative hemoglobin concentration change or hospital stay. Finally, the rates of major surgical complications were similar in the 2 groups (3.3% in group 1 vs 4.3% in group 2, P > .99, 95% confidence interval –8.1% to 5.9%). Conclusions: Although vaginal hysterectomy requires a modest increase in operative time, it is as safe and effective for the woman with a moderately enlarged uterus as for the woman with a uterus of normal size. Vaginal uterine morcellation is the key to a successful operation and obviates the need for either abdominal or laparoscopically assisted hysterectomy solely to deal with moderate uterine enlargement. (Am J Obstet Gynecol 1999;180:1337-44.)     

Vaginal hysterectomy for the large uterus

Objective To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.
Design A prospective observational study.
Setting The Royal Free Hospital, London.
Participants Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size.
Interventions Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy.
Main outcome measures Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra-and post-operative complications, duration of hospitalisation.
Results The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (   n = 6  ) and superficial vaginal grazes (   n = 5  ). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days).
Conclusion Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.     

Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation

OBJECTIVE: The purpose of this study was to compare intraoperative and postoperative complications of abdominal hysterectomy for the enlarged, myomatous uterus with vaginal hysterectomy with morcellation. STUDY DESIGN: Medical records of 139 patients who underwent vaginal hysterectomy with morcellation and 244 patients who underwent total abdominal hysterectomy for an enlarged, myomatous uterus between August 1990 and July 2001 were reviewed. Uterine weights of >982 g were excluded because this was the largest uterus removed vaginally, which left 208 evaluable cases of total abdominal hysterectomy. The perioperative and postoperative course of the two groups was compared. The Student t test was used for continuous variables, and the Fisher exact test was used for binary or categoric data. RESULTS: There were no significant differences between the two groups in surgical or anesthetic risk factors (P>.05). Operative time was similar between the groups (P>.05). Length of hospital stay was increased significantly with total abdominal hysterectomy (mean, 3.9 days vs 2.6 days; P<.001). Perioperative complications were increased with the abdominal route (10% vs 25%, P<.001). CONCLUSION: In this large series, uterine morcellation at the time of vaginal hysterectomy is safe and facilitates the removal of moderately enlarged and well-supported uteri and is associated with decreased hospital stay and perioperative morbidity rate compared with the abdominal route.     

中等大良性病变子宫经阴全子宫切除术的探讨

目的：探讨中等大、良性病变的非脱垂子宫经阴道行全子宫切除术的可行性。方法：87例施行此术式,其中子宫中等大（重200～750g）60例作为研究组,小子宫（＜200g）27例作为对照组,部分病例采用子宫分碎术。对两组因手术期情况进行分析。结果：研究组59倒成功地经阴道切除子宫,其中21例（35％）采用子宫分碎术,1例转经腹手术,转经腹手术率为1．7％,对照组则全部经阴道完整切除。研究组和对照组的子宫重量分别为280．18±100．40g、146．48±35．19g,差异有高度显著性（P＜0．001）;研究组的平均手术时间为83．93±26．26min,长于对照组的55．22±20．55min,差异有高度显著性（P＜0．001）;术中平均出血量为164．92±89．83ml,多于对照组的135．56±111．57ml,但差异无显著性（P＞0．05）;术后病率分别为3．33％与3．70％,差异无显著性（P＞0．05）;两组患者均无膀胱、直肠损伤,无阴道残端炎症。结论：对具备经阴道手术经验的术者,中等大、良性病变的子宫经阴道切除是安全可行的。部分病例需施行子宫分碎术,减小子宫体积,缩短手术时间,减少术中出血量和降低术后并发症。     

Subtotal hysterectomy and myomectomy - vaginally

Vaginal subtotal (or supracervical) hysterectomy and vaginal myomectomy are elegant procedures rarely carried out by the average gynaecologist. Both techniques, however, are easily learned, and in view of the proven advantages of vaginal surgery over abdominal or laparoscopic approaches, they are worthy of a wider application. Subtotal hysterectomy may be preferred to excision of the entire uterus in certain circumstances, and may be carried out vaginally. Vaginal myomectomy allows for a more thorough myomectomy and stronger uterine repair than a laparoscopic procedure, as well as avoiding abdominal wounds. It may represent the optimal approach where fibroids are favourably sited. We first set out the case for subtotal hysterectomy and then describe the development of vaginal subtotal hysterectomy and vaginal myomectomy. We discuss the evidence supporting their use and indications, and then describe techniques for both vaginal procedures.     

A comparison of abdominal and vaginal hysterectomy for the large uterus.

OBJECTIVE: To compare the perioperative outcomes of women with an enlarged uterus (>or=250 g) who had abdominal and vaginal hysterectomies. METHOD: Retrospective study of the perioperative outcomes of 288 consecutive women with an enlarged uterus, of whom 200 underwent an abdominal hysterectomy and 88 a vaginal hysterectomy, all for benign gynecological conditions. RESULTS: Among the perioperative complications, only the risk of ileus was significantly higher in the group that underwent abdominal hysterectomy. Although the need for blood transfusions was similar between the groups, mean perioperative hemoglobin change was significantly lower for women who had the abdominal approach. Vaginal hysterectomy shortened the length of hospitalization significantly but did not affect the operative time. All of these differences remained significant after adjusting for uterine weight (P<0.05). Baseline characteristics were similar between the groups, except for uterine weight. CONCLUSIONS: For women with a uterus weighing 250 g or more, vaginal hysterectomy shortens the hospital stay without significantly increasing perioperative morbidity when compared with the abdominal route.     

Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial

OBJECTIVE: The purpose of this study was to compare advantages, disadvantages, and outcomes in patients who undergo vaginal or abdominal hysterectomy for enlarged symptomatic uteri. STUDY DESIGN: In a prospective, randomized study, 60 vaginal hysterectomies (study group) were compared with 59 abdominal hysterectomies (control group); all of the hysterectomies were performed for symptomatic uterine fibroids from January 1997 through December 2000. We excluded from the study the other common causes of hysterectomy such as prolapse, bleeding, adenomyosis, and endometrial or cervical carcinoma. In both groups, uterine weights ranged from 200 g to 1300 g. For enlarged uteri, vaginal hysterectomies were performed with the use of volume reduction techniques: Intramyometrial coring, corporal bisection, and morcellation. The evaluated parameters included patient age, weight, parity, uterine weight, operative time, blood loss, demand for analgesics, eventual surgical complications, length of admission, and hospital charges. The Mann-Whitney U test and chi(2) tests were applied for statistical analysis. Probability values of <.05 were considered statistically significant. RESULTS: There were no major differences in patient age, weight, parity, and uterine weight between the two groups. Operative time was significantly lower for the vaginal route as compared with the abdominal route (86 minutes vs 102 minutes, P <.001). No intraoperative complications were noted both in the study and control groups or the control group. Surgical bleeding (expressed by hemoglobin loss) was not significantly different between the two groups. In the postoperative period, we found a higher incidence of fever (30.5% vs 16.6%, P <.05) and demand for analgesics (86% vs 66%, P <.05) in the abdominal group as compared with the vaginal group. Significant advantages of vaginal hysterectomy were a reduction in the hospital stay (3 days vs 4 days, P <.001) and cost. CONCLUSION: These results should lead to the choice of vaginal hysterectomy as a valid alternative to the abdominal hysterectomy, even for enlarged uteri.     

Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations.

OBJECTIVE: To determine the effectiveness and safety of vaginal hysterectomy for benign nonprolapsed uteri. METHODS: Three hundred consecutive women with nonprolapsed uteri requiring hysterectomy for benign uterine conditions, without suspected adnexal disease, were treated prospectively by vaginal hysterectomy. Twenty-one women (7%) were nulliparous, and 219 (73%) had history of pelvic surgery (150 had previous cesareans). Operating time, estimated blood loss, surgical techniques (Heaney, Pelosi, uterine morcellation), operative complications, conversion to laparoscopy or laparotomy, and length of hospital stay were recorded for each case. RESULTS: Vaginal hysterectomy was successful in 297 women (99%). Morcellation (hemisection, intramyometrial coring, myomectomy, and wedge resection) was done in 170 cases (56.7%). The mean operating time was 51 minutes (range 20-130 minutes), mean estimated blood loss was 180 mL (range 50-1050 mL), and mean length of hospitalization was 22 hours (range 16-72 hours). Four operative complications occurred (three cystotomies, one rectal laceration) and were repaired transvaginally. One woman needed a blood transfusion. Eleven urinary tract infections occurred. Two conversions to laparotomy and one conversion to laparoscopy were necessary. CONCLUSION: Vaginal hysterectomy is an effective and safe procedure for benign nonprolapsed uteri irrespective of nulliparity, previous pelvic surgery, or uterine enlargement. We question the true need for laparoscopy or laparotomy in this setting.     

Vaginal Hysterectomy for the Enlarged Fibroid Uterus: A Report of 85 Cases

ObjectiveTo demonstrate that increased uterine size should not be a deterrent to the vaginal approach for performing hysterectomy.MethodWe performed a retrospective study of the medical records pertaining to 2769 hysterectomies performed by a single surgeon. For this study, we reviewed the surgical details and outcome of 85 women who had a vaginal hysterectomy for a symptomatic fibroid uterus that was estimated to be equivalent in size to a uterus of between 10 and 20 weeks’ gestation.ResultsThe vaginal approach for hysterectomy was successful in all 85 cases and complication rates were low. Sixteen women had additional adnexal surgery besides hysterectomy. In 52 cases, morcellation of the uterus was required. Average operating time was 60 minutes.ConclusionIncreased uterine size should not be an automatic deterrent to the vaginal approach for hysterectomy. Nevertheless, individual surgeons should perform such challenging procedures only if they are properly trained and are comfortable doing so. Some surgeons may choose not to perform hysterectomies using the vaginal approach