腹腔镜手术5056例患者盆腹腔粘连情况调查及其相关危险因素分析

目的 调查腹腔镜手术中盆腹腔粘连的情况,并回顾性分析粘连形成的危险因素.方法 回顾性分析南通大学附属医院2016年10月1日至2017年11月30日行腹腔镜手术的5056例患者的手术过程及病史资料,分析其粘连发生率及相关危险因素.结果 单、多因素分析表明,性别、年龄、基础疾病(高血压、糖尿病)、腹部手术史、多次手术史、...     

不同剖宫产术式盆腹腔及腹壁粘连情况的对比分析

随着剖宫产技术的改进，以及麻醉、输血技术的进步和抗生素的不断发展，大大提高了剖宫产的安全性，近10年来剖宫产率呈明显上升趋势，剖宫产术后出现的腹壁、盆腹腔粘连可以引起小肠梗阻、盆腔疼痛、不孕等并发症，对妇女健康危害很大，且给再次手术带来困难。本研究通过对我院再次行剖宫产术的临床资料进行回顾性分析，比较不同剖宫产术式所致腹壁、盆腹腔粘连的情况，现将结果报道如下。     

不同剖宫产术式盆腹腔及腹壁粘连情况的比较分析

剖宫产是解决难产和许多产科难题的重要手段，剖宫产术后出现的腹壁、盆腹腔粘连可以引起小肠梗阻、盆腔疼痛、不孕等并发症，对妇女健康危害很大。本文对96例再次行剖宫产术患者临床资料进行回顾性分析，现将结果报告如下。     

不同术式剖宫产术后二次开腹手术时盆腹腔粘连情况比较

目的 探讨Stark式剖官产术后腹膜及膀胱腹膜反折愈合及粘连发生情况。方法 采用回顾性分析的方法,对剖宫产术后二次开腹手术患者腹膜及膀胱腹膜反折粘连发生情况进行观察。其中,Stark式剖官产术后二次开腹手术89例（A组）,下腹纵切口式剖宫产术后二次开腹手术212例（B组）．Pfannenstiel切口式剖宫产术后二次开腹手术52例（C组）。比较3组患者剖宫产术后腹壁切口愈合情况以及腹直肌、腹膜、大网膜、膀胱腹膜反折愈合及粘连发生情况。结果 （1）腹壁切口愈合良好,瘢痕纤细：A组86．5％（77／89）,B组29．3％（62／212）,C组75．0％（39／52）;（2）腹直肌粘连：A组25．8％（23／89）,B组53．8％（114／212）,C组13．5％（7／52）;（3）大网膜粘连：A组13．5％（12／89）,B组56．1％（119／212）,C组25．0％（13／52）;（4）腹膜粘连：A组15．7％（14／89）,B组46．2％（98／212）,C组11．5％（6／52）;（5）腹膜未愈合：仅C组有1例,A组与B组均为0;（6）膀胱腹膜反折粘连：A组15．7％（14／89）,B组55．2％（117／212）,C组13．5％（7／52）。腹壁切口愈合及腹直肌、大网膜、腹膜、膀胱腹膜反折粘连情况,A组明显优于B组,两组比较,差异有统计学意义（P〈0．05）;A组与C组比较,差异无统计学意义（P〉0．05）。结论 Stark式剖宫产在腹壁切口愈合,减少腹直肌、大网膜、腹膜、膀胱腹膜反折粘连方面明显优于下腹纵切口式剖宫产;虽然与Pfannenstiel切口式剖宫产相比,差异无显著性,但Stark式剖宫产具有诸多公认的优点,值得推广。     

剖宫产术后腹腔粘连的防治

腹腔粘连是腹部手术后的常见并发症 ,腹腔粘连可以引起小肠梗阻、盆腔疼痛、不孕等并发症 ,对妇女健康危害很大。剖宫产术后再次手术发现腹腔粘连者约占 35 8% ,发生与腹腔粘连相关的小肠梗阻者约有 0 5‰ ,妇科手术后有 97%的病人发生腹腔粘连[1] 。1　腹腔粘连的病因和发病机制1.1　腹腔粘连的病因腹腔粘连的病因极少数是腹腔内先天因素所致 ,如发育异常、胎粪性腹膜炎 ;最主要的原因是后天因素 ,常见的有盆腹腔手术、感染、损伤、出血、缺血、异物、腹腔内注射化学药物等。1.2　粘连的形成过程粘连的形成过程很复杂 ,与纤维蛋白溶解系…     

防粘连措施预防术后盆腹腔粘连有效性及安全性的meta分析

目的:系统评价生物可吸收防粘连膜预防术后盆腹腔粘连的有效性及安全性。方法:计算机全面检索Pub Med数据库、Spring数据库、OVID数据库、CBM数据库、CNKI数据库、万方数据库,查找关于生物可吸收防粘连膜(HC-CMC)预防术后盆腹腔粘连的有效性及安全性的随机对照文献,检索时限2000年2月至2015年3月。按纳入和排除标准进行文献筛选、资料提取和质量评价后,采用Rev Man 5.3软件进行Meta分析。结果:最终共纳入7篇RCT文章。Meta分析结果显示,试验组与对照组的术后盆腹腔粘连、粘连严重程度2级和3级、粘连范围2级和3级的发生率比较,差异均有统计学意义;粘连严重程度1级和粘连范围1级的发生率比较,差异均无统计学意义(P=0.82,P=0.1)。试验组与对照组的术中出血量比较,差异有统计学意义(P0.00001);而术后肠梗阻、盆腹腔脓肿、伤口感染、高热的发生率比较,差异均无统计学意义。结论:手术中应用生物可吸收防粘连膜可降低盆腹腔粘连的发生率,减轻粘连严重程度,减少粘连范围,减少术中出血量,然而术后肠梗阻、盆腹腔脓肿、伤口感染及术后高热的发生率相似。     

Stark剖宫产后再次手术腹腔粘连情况分析

目的 :再次手术论证Stark剖宫产术 (新式剖宫产术 )中不缝合腹膜的可行性 ,提高对Stark剖宫产手术的认识。方法 :本文对 6 9例再次剖宫产手术腹腔粘连及粘连程度、粘连部位的观察进行分析比较。结果 :不缝合腹膜与缝合腹膜 ,粘连差异无显著性 ,但粘连发生的部位及粘连程度的差异有显著性。其中大网膜与腹膜粘连的差异无显著性 ,膀胱腹膜反折处粘连的差异有极显著性。结论 :Stark剖宫产术中不缝合脏层腹膜的改良术式值得临床推广应用。     

腹部手术史者行妇科腹腔镜手术168例临床分析

腹腔镜手术以其创伤小、恢复快等优势,受到越来越多妇科医师和患者的青睐,但有腹部手术史者,尤其是有剖宫产手术史的患者,能否进行腹腔镜下的妇科手术,尚有争议.我科从2003年1月至2005年5月,共对168例有腹部手术史者进行了腹腔镜妇科手术,现将结果报道如下.     

疤痕子宫再次剖宫产手术方式对盆腹腔粘连的影响分析

目的：分析疤痕子宫再次剖宫产手术方式对产妇盆腹腔粘连的影响。方法：对我院在2011年6月至2013年6月间收治的196例剖宫产疤痕子宫再次妊娠产妇分娩术式及产妇盆腹腔粘连情况进行分析。结果：斯塔克剖宫产术与子宫下段剖宫产术相比,在2类轻度粘连和4类重度粘连上无统计学差异（P〉0．05）;子宫下段剖宫产术的无粘连发生率多于斯塔克剖宫产术,差异具有统计学意义;在中度粘连的发生率上,子宫下段剖宫产术的无粘连发生率明显少于斯塔克剖宫产术,差异具有统计学意义。结论：通过疤痕子宫再次剖宫产盆腹腔粘连情况分析发现,疤痕子宫再次剖宫产选择子宫下段剖宫产术优于斯塔克剖宫产术。     

异位妊娠术后再次腹腔内大出血2例

一、病例摘要病例1:29岁,因停经50d,阴道少量出血2次,右下腹痛4h,血β-hCG:9443mIu/ml,尿hCG(+),以“异位妊娠”入院。当日在全麻下行腹腔镜手术,术中见盆腔内未凝血及血块200ml,子宫正常大,右输卵管壶腹部膨大3cm×4cm,表面无破口,左输卵管粘连,伞端包埋,子宫后壁与肠管粘连,切开右输卵管壶腹部,取出绒毛。术后给予补液抗炎治疗,术后3d出院,术后10d少量出血,无腹痛,术后43d血β-hCG:627mIu/ml,术后47d血β-hCG:531mIu/ml,术后55d血β-hCG:175mIu/ml,术后69d无明显诱因突感左下腹坠胀痛,较剧烈,渐弥漫至全下腹,伴头晕,肛门下坠感,查尿…     

Vaginal evisceration after trauma unrelated to previous pelvic surgery

Background  Vaginal evisceration is described as extrusion of intraperitoneal contents secondary to the disruption of the vagina. It is an extremely rare emergency condition. Objectives  To describe a very rare case of vaginal evisceration that occurred after blunt trauma in a patient with no prior pelvic surgery. Case report  This report describes vaginal evisceration in a 73-year-old female with no prior pelvic surgery, after blunt trauma. The patient was handled by the cooperation of gynecology and general surgery departments. An immediate surgery was performed after stabilization of the patient and no postoperative complications occurred. Conclusion  Whatever be the treatment approach, emergency management of vaginal evisceration is critical to the preservation of a viable bowel. Repositioning of viable bowels into the abdominal cavity and appropriate surgical repair are cornerstones of the treatment.     

Risk factors and management of vaginal mesh erosion after pelvic organ prolapse surgery

Objective

Mesh erosion is a serious and not uncommon complication in women undergoing vaginal mesh repair. We hypothesized that mesh erosion is associated with the patient’s comorbidities, surgical procedures, and mesh material. The aims of this study were to identify the risk factors and optimal management for mesh erosion.

子宫内膜异位症保守性手术后复发的相关因素分析

目的　确定与子宫内膜异位症 (内异症 )保守性手术后病变复发的相关因素。方法对 2 85例保守性手术治疗并经病理证实的内异症患者观察并随访 36个月 ,观察患者年龄、发病年龄、术前孕次、术前产次、后穹窿痛性结节、子宫活动度、血清CA12 5、既往内异症手术史、腹腔镜手术史、内异症病变侧别、术中和术后美国生育学会修订的内异症分期标准 (r AFS ,1985 )评分、术后孕激素治疗 6个月、术后枸橼酸氯米芬 (其他名称 :克罗米酚 )促排卵治疗、术后孕次、术后产次等 31项指标 ,随访中记录病变复发情况及复发时间。应用SPSS软件行COX回归风险分析筛查复发的相关因素。结果共有 83例 (2 9 1% ,83/2 85 )患者复发 ,每年复发例数、复发率和累积复发率为 ,第 1年 4 1例 ,14 4 % (41/2 85 )和 14 4 % (41/2 85 ) ;第 2年 30例 ,10 5 % (30 /2 85 )和 2 4 9% (71/2 85 ) ;第 3年 12例 ,4 2 % (12 /2 85 )和 2 9 1% (83/2 85 )。经单变量分析 ,危险性相关因素为既往有内异症手术史 (OR值为 13 6 30 ,P <0 0 1)、后穹窿有痛性结节 (OR值 6 133,P <0 0 1)、术后应用枸橼酸氯米芬促排卵治疗 (OR值 5 173,P <0 0 1)、左侧盆腔病变 (OR值 4 5 0 3,P <0 0 1)、双侧盆腔病变 (OR值 3 70 9,P <0 0 5 )和术后r AF     

Transient abdominal ovariopexy for adhesion prevention in patients who underwent surgery for severe pelvic endometriosis

OBJECTIVE: To assess adhesion reformation and subsequent fertility after a transient ovariopexy performed during severe pelvic endometriosis surgery. DESIGN: Retrospective study. SETTING: University hospital. PATIENT(S): Twenty young women who underwent severe pelvic endometriosis surgery. INTERVENTION(S): Unilateral or bilateral transient ovariopexy to the anterior abdominal wall was performed as the last step in the surgical procedure. Median duration of ovariopexy was 4 days. MAIN OUTCOME MEASURE(S): Adhesion reformation and subsequent fertility. RESULT(S): This well-tolerated procedure induced neither specific complication nor prolonged hospital stay. A second-look laparoscopy, performed in eight patients (40%), has shown a reduction of the occurrence, the extent, and the severity of ovarian adhesions. Two thirds of the suspended ovaries had no or smooth adhesions at second-look laparoscopy, even though all ovaries were initially adherent. Fifteen infertile women without male infertility factors tried actively to conceive after surgery. In this group of patients, four conceived spontaneously, and four conceived after IVF (total pregnancy rate = 53.3%). Seven patients delivered, and one pregnancy is ongoing. Median pregnancy delay was 11.5 months (range, 4-24 months). CONCLUSION(S): Transient ovariopexy appears to be a simple, safe, and effective technique in preventing postoperative adhesion reformation in severe pelvic endometriosis.     

避免产科过度手术的对策

随着重症产科及围产医学的发展,分娩方式、手术方式和手术途径等一系列问题正越来越受到重视。本文就如何避免产科过度手术的问题进行探讨,遵循个体化治疗原则,分析过度手术引起的并发症,并提出对策,以提高手术效果和改进产科质量。     

盆腔器官脱垂手术对下尿路症状影响的前瞻性研究

目的 探讨盆腔器官脱垂患者盆底修复手术后下尿路症状的变化情况,以及术中加行经闭孔尿道中段无张力悬吊带术(TVT-O)对漏尿及下尿路症状的影响.方法 2007年1月至2009年12月期间,共193例盆腔器官脱垂患者在北京大学第一医院行盆底修复手术(其中131例加行TVT-O)且术后随访达3个月以上,前瞻性研究患者手术后的下尿路症状变化情况及术后尿失禁症状的影响因素.结果 (1)193例患者中有下尿路症状者术前为85.5%(165/193),术后为54.4%(105/193),术后下尿路症状总体发生率低于术前,手术前后比较,差异有统计学意义(P＜0.01).(2)手术前后下尿路症状及相关症状发生率,尿频分别为57.0%、25.9%,尿急分别为51.8%、28.0%,咳嗽漏尿分别为50.3%、15.0%,点滴漏尿分别为44.6%、14.5%,排尿困难分别为34.7%、23.3%,排尿不尽分别为49.2%、19.7%,手助排尿分别为31.1%、2.6%,术后各症状的发生率均明显低于术前,分别比较,差异均有统计学意义(P＜0.05).(3)对于术前有漏尿症状的患者,盆底修复手术的同时未行TVT-O是术后漏尿症状不改善的高危因素(OR=4.933,95%CI为1.353～17.990,P=0.016).结论 盆底修复手术对盆腔器官脱垂患者的下尿路症状有改善作用.对于术前有漏尿症状的患者,加用TVT-O手术比单纯盆底修复手术能更有效地治疗其漏尿症状.

Abstract：

Objective To investigate effect of urinary conditions and lower urinary tract symptoms (LUTS) in patients before and after the reconstructive pelvic surgery (RPS) for pelvic organ prolapse (POP) as well as effect of urinary conditions and LUTS by tension-free vaginal tape-obturator (TVT-O).Methods From Jan. 2007 to Dec. 2009, 213 patients with POP underwent RPS, the factors on preoperative, postoperative urinary conditions and qualities of life and postoperative urinary incontinence were studied prospectively. Results Totally 193 patients who was followed up for more than 3 months after surgery attend questionnaires, and 165 preoperative patients of 193 (85.5%) had LUTS, 105 postoperative patients of 193 (54.4%) had LUTS, which reached statistical difference (P ＜0. 01 ). The rate of LUTS before and after operation: urinary frequency ( 57.0% and 25.9% ), urinary urgency ( 51.8% and 28.0% ), urinary leakage due to cough ( 50. 3% and 15.0% ), dropping urinary leakage ( 44. 6% and 14. 5% ), dysuria (34. 7% and 23.3% ), vesicaltenesmus (49.2% and 19. 7% ) and hand assist urination (31.1% and 2.6% ). The incidence of LUTS after surgery is much lower than that of pre-operation ( P ＜0. 05 ). POP patients with stress urinary incontinence ( SUI ) before the operation, surgery without TVT-O simultaneously are the risk factors of unimproved symptom ( OR = 4. 933, 95% CI: 1. 353 - 17. 990, P=0. 016). Conclusions RPS have alleviated LUTS in patients with POP. RPS with TVT-O are more effective than traditional RPS in treatment of the urinary incontinence if the POP patient with SUI or occult SUI.     

Symptomatic pelvic hematoma following transvaginal reconstructive pelvic surgery: incidence, clinical presentation, risk factors, and outcome

Objective

To assess the incidence, clinical presentation, risk factors and outcome of symptomatic pelvic hematomas following transvaginal pelvic reconstructive surgery.

Materials and methods

We reviewed the medical records of all women undergoing transvaginal reconstructive pelvic surgery in our institution between January 2006 and July 2009.

Results

462 patients underwent pelvic reconstructive surgery, of whom 28 (6%) presented with symptomatic pelvic hematomas. All cases occurred after transvaginal hysterectomy, 25 (90%) presented with fever, 20 (71%) with pelvic pain and 5 (20%) with urinary retention. All hematomas were diagnosed by ultrasound. They were located at the vaginal cuff in 18 (64%), anterior vaginal wall in six (21%) and posterior vaginal wall in four patients (14%), and had a mean volume of 590 ± 140 cm³. Laboratory data included leukocytosis (71%), thrombocytosis (57%) and elevated liver enzymes (18%). Nine patients (33%) required ultrasound-guided drainage of the hematoma, which resulted in marked clinical improvement. Surgical outcome was not affected by the presence of pelvic hematoma.

Conclusions

A postoperative symptomatic pelvic hematoma is not rare and is closely related to transvaginal hysterectomy. Its clinical presentation includes fever, pelvic pain, leukocytosis, thrombocytosis and occasionally liver dysfunction. Surgical outcome is generally unaffected.     

Clinical outcome and complications of laparoscopic surgery compared with traditional surgery in women with endometrial cancer

Introduction The purpose of this study was to evaluate the feasibility, clinical outcome and complications of laparoscopic surgery in women with endometrial cancer and to compare surgical outcome and postoperative early and late complications with results of traditional laparotomy. Methods Forty women with endometrial cancer underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Each patient operated by laparoscopy was matched by age, preoperative clinical stage and histology of the endometrial cancer with a patient treated by the same operation but using traditional laparotomy. Half of these patients underwent total pelvic lymphadenectomy and half had pelvic lymph node sampling. The groups were compared in clinical characteristics, surgical outcomes, recoveries and early and late postoperative complications. Results The patients in the laparoscopy group had less blood loss, more lymph nodes removed, shorter hospital stay but longer operation time than those treated by laparotomy. Only one (2.5%) laparoscopy was converted to laparotomy due to pelvic adhesions. There were no intraoperative complications in either group. Postoperative complications were more common (55.0%) in the laparotomy than in the laparoscopy group (37.5%). Only one major complication (2.5%) occurred among patients undergoing laparoscopy as compared with three (7.5%) major complications in the laparotomy group. Superficial wound infection was the most common (20%) infection in laparotomy patients while vaginal cuff cellulitis occurred in 10% of laparoscopy patients. Late (>42 days) postoperative complications were almost equally frequent (20.0 and 22.5%) in both groups. Lower extremity lymph edema or pelvic lymph cyst was found in 12.5% of all cases. As a result of surgical staging the disease of 6 women (15%) in both groups was upgraded. Conclusions Laparoscopic surgery is a viable alternative to traditional surgery in the management of endometrial cancer. The surgical outcome is similar in both cases. In laparoscopic procedures the operation time is longer but the postoperative recovery time shorter than in laparotomy. Severe complications were limited in both groups, while wound infections can be avoided using laparoscopy.