腹腔镜全子宫切除术中损伤膀胱1例

患者 5 0岁 ,因下腹隐痛 1年 ,渐进性痛经 6个月入院 ,既往健康。查体 :Ｔ 37℃ ,Ｐ 80次 /ｍｉｎ ,Ｒ 19次 /ｍｉｎ ,ＢＰ 15 /9ｋＰａ。心肺无异常。下腹轻压痛 ,无反跳痛和肌紧张。外阴已婚已产式 ,阴道通畅 ,宫颈光滑 ,子宫孕 2 + 月大 ,质硬 ,有轻压痛 ,活动 ,双附件未及异常。入院诊断为子宫腺肌病。常规术前治疗 ,排除手术禁忌症。在持续硬膜外麻醉下行腹腔镜全子宫切除术。术中处理双附件及子宫动脉顺利 ,因膀胱宫颈间隙不疏松 ,下推膀胱后 ,发现膀胱底部有Ｆｏｌｙ氏尿管球囊 ,尿管引流出血尿 ,诊断膀胱损伤。立即经阴道断主韧带及…     

2017 ACOG《良性疾病全子宫切除术的入路选择》解读

<正>全子宫切除术是妇科最常进行的手术之一,大部分患者因子宫良性疾病而需要行全子宫切除,常见的手术入路包括经阴、腹腔镜、开腹手术等,妇产科医师常需要针对患者自身状况进行综合性分析做出最佳的选择。2017年3月,美国妇产科医师学会(ACOG)颁布第701号委员意见,即《良性疾病全子宫切除术的入路选择》,该指南详述了各个手术入路的利弊,并作出了推荐意见。本文就该指南推荐意见进行简要解读。指南推荐意见总结:(1)首选阴式全子宫切除     

改良式经阴道全子宫切除术与经腹全子宫切除术的临床对比分析

目的:探讨改良式经阴道全子宫切除术(ITVH)与经腹全子宫切除术(TAH)的临床效果.方法:回顾性分析2007年1月至2009年2月我院采用ITVH病例55例(研究组),并与同期TAH 50例(对照组)比较两种术式的手术并发症、手术时间、术中出血量、术后病率、术后排气时间、住院天数.结果:研究组并发症发生率明显低于对照组,并且手术时间短、术中出血少、术后排气时间早.结论:ITVH拓宽了传统全子宫切除的方式和适应证,手术难度不大、并发症少、术后恢复快、手术创伤小,符合微创原则.     

子宫颈锥形切除术后全子宫切除95例临床分析

目的:分析子宫颈锥形切除术(宫颈锥切)后全子宫切除的指征,重点探讨宫颈锥切后腹腔镜子宫切除(LH)的可行性、安全性和手术要点。方法:回顾性分析2005年11月~2007年10月北京协和医院开展的95例宫颈锥切后全子宫切除术的手术指征、手术时间、出血量、残余宫颈病理、术中及术后并发症等。结果:(1)95例宫颈锥切后全子宫切除中,80例为LH,15例为开腹子宫切除(AH)。患者年龄43.2±5.9岁,术前诊断包括宫颈上皮内瘤变(CIN)Ⅲ及以下18例(18.9%)、CINⅢ累腺35例(36.8%)、宫颈原位癌(CIS)23例(24.2%)、宫颈浸润性鳞癌ⅠA1期19例(20.0%);(2)15例AH和25例LH是在宫颈锥切6周后施术,55例LH是在宫颈锥切后72h内。LH组和AH组手术时间分别为60.8±17.1min和88.0±19.8min(P<0.01),术中出血分别为54.3±24.4ml和103.3±48.1ml(P<0.01)。LH组和AH组的术后住院时间为4.5±1.1天和5.8±1.4天(P<0.01);(3)子宫切除标本的阴道断端边缘均未见病变,但残余宫颈中48例(50.5%)存在持续性病变(39例为CINⅡ及以下病变,4例为CINⅢ,3例为CIS,2例为浸润癌);(4)全组无1例需术中/术后输血,无膀胱、输尿管和肠道损伤发生。LH组患者无1例中转开腹,但4例放置专用举宫器困难,其中1例发生子宫穿孔但未引起并发症;(5)宫颈锥切后72h内行LH的55例中,7例(12.7%)术后出现发热(超过38.5℃),宫颈锥切6周后行LH或AH的40例中,仅1例(2.5%)术后发热。LH组1例患者术后发生阴道残端出血。结论:全子宫切除是某些诊断性宫颈锥切患者锥切后再处理措施之一。对于宫颈锥切后全子宫切除,LH具有优势和特点,其手术时间短,术中出血少,术后住院时间短。正确放置LH专用举宫器最大限度地上举子宫、锐性分离子宫膀胱腹膜返折是减少锥切后LH并发症的关键。     

腹腔镜全子宫切除术中膀胱损伤经阴道修补6例

目的:探讨腹腔镜全子宫切除术中经阴道修补损伤膀胱的可行性和手术技巧,寻找微创治疗膀胱损伤的新路径.方法:膀胱破裂6例,均位于后壁.平均年龄40.6岁(35～65岁),6例均有不同程度的盆腔粘连,其中3例既往有剖宫产手术史,粘连严重,1例为子宫峡部肌瘤.术中均经阴道行膀胱修补术.结果:6例手术均获得成功,术后1周拔除尿管后排尿通畅,无尿潴留及尿瘘形成.结论:经阴道修补膀胱破裂创伤小、安全、可行,是治疗妇科手术中膀胱损伤可选择的微创技术.     

非脱垂大子宫经阴道子宫全切除术55例临床分析

目的探讨大子宫经阴道子宫全切除术(TVH)的临床效果.方法回顾性分析比较55例大子宫(子宫体积如孕12～16周)经阴道子宫切除术的临床资料,包括手术时间、术中出血量、术中、术后并发症、术后肛门排气时间、术后病率、下床活动时间和术后住院日.并和同期经腹子宫全切除术57例进行比较.结果55例大子宫经阴道子宫全切除术均成功完成,无中转开腹手术者,较腹式子宫全切除术组手术时间长,术后肛门排气时间早,下床活动时间早,术后住院日短,差异有显著性(P＜0.01),术中出血量,术中、术后并发症和术后病率,两组比较差异无显著性(P＞0.05).结论大子宫经阴道子宫切除虽然较经腹切除手术时间长,但对患者损伤小,术后恢复快,术后住院时间短.子宫体积增大超过12孕周并非TVH的绝对禁忌证.     

腹腔镜子宫全切除术216例临床分析

目的探讨应用腹腔镜行子宫全切除术的安全性及效果。方法对自2002年3月至2004年3月,于腹腔镜下行全子宫切除的216例患者的资料进行回顾性分析。患者平均年龄45.5岁(38～60岁);其中功能失调性子宫出血24例,子宫内膜不典型增生5例,子宫肌瘤139例,子宫腺肌病46例,子宫颈原位癌2例。216例患者中,曾有下腹部手术史36例。腹腔镜下行子宫全切除均由超声刀完成,切除的子宫经阴道取出,并于腹腔镜下缝合阴道断端及膀胱腹膜反折。结果216例患者均于腹腔镜下完成手术,无一例转为开腹手术。216例中,103例行单纯子宫切除术;113例同时行下列手术,即行单侧或双侧附件切除术23例,卵巢囊肿剔除术36例,盆腔粘连松解术54例。手术时间平均为(103±35)min,出血量平均为(83±45)ml(60～300ml)。术后住院时间2～11d,平均为(5.3±1.9)d。术中发生膀胱穿孔1例,经腹腔镜下行缝合修补。术后发生膀胱阴道瘘2例、输尿管阴道瘘1例,均经保守治疗后治愈。结论腹腔镜子宫全切除术是一种安全、有效的术式。为子宫切除提供了一种可选择的方法。     

子宫内膜非典型增生行全子宫切除术159例临床分析

目的：探讨子宫内膜非典型增生（AEH）患者的临床特点及行全子宫切除术后病理升级为子宫内膜癌（EC）的危险因素。方法：回顾性分析2015年1月—2018年12月159例因AEH于首都医科大学附属北京妇产医院妇科微创中心行全子宫切除术患者的临床资料,按照术后病理情况分为非EC组134例（84.3%）、EC组25例（15.7%）,分析其术后病理升级的高危因素。结果：与非EC组相比,EC组肥胖、绝经、异常子宫内膜血流信号及糖尿病的发生率差异具有统计学意义（均P＜0.05）。多因素Logistic回归分析结果显示,肥胖（OR=3.196,95%CI：1.147～8.902,P=0.026）及糖尿病（OR=3.866,95%CI：1.019～14.673,P=0.047）是AEH患者术后病理升级为EC的危险因素。结论：AEH患者并发EC的发生率较高,对于合并肥胖及糖尿病的患者更应引起重视,术前综合评估,制定个体化治疗方案。     

全子宫切除术后尿瘘3例分析

尿瘘是一种极其痛苦的损伤性疾病，为了减少该病的发生，提高医疗手术质量，现将我院诊治的3例全子宫切除术后致输尿管膀胱损伤而引起尿瘘的病例分析如下。     

Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: A meta-analysis

Hysterectomy is a very common gynaecological procedure. The vaginal route is considered preferable for hysterectomy, although the ideal route for women unsuitable for the vaginal approach remains unclear. We performed a meta-analysis of published randomised controlled trials to compare outcomes in total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) for benign disease. Pooled odds ratios (OR) were calculated for categorical variables using random effects models as per Der Simonian and Laird. Continuous variables were compared by means of weighted mean differences (WMD). TLH is associated with reduced overall peri-operative complications (pooled OR 0.19; 95% CI 0.07–0.50) and reduced estimated blood loss (WMD −183 ml; 95% CI −346 ml to −21 ml; p = 0.03). Additionally, there are trends towards shorter hospital stay (WMD −2.5 days; 95% CI −5.1 days to 0.01 days; p = 0.05) and post-operative haematoma formation (pooled OR 0.17; 95% CI 0.03–1.01) compared to TAH. The only trade-off appears to be a longer operating time in the TLH group (WMD 22 min; 95% CI 5–39 min; p = 0.01). Rates of major complication were not statistically different (pooled OR 1.35; 95% CI 0.32–5.73) though this analysis is likely underpowered to detect many major complications. As such, TLH appears to offer benefits to women requiring total hysterectomy for benign indications compared to TAH, particularly regarding minor complications, blood loss and hospital stay. However, larger studies are needed to assess the impact on major intra-operative complications and long-term clinical outcomes, particularly pelvic organ prolapse.     

阴式子宫切除术50例临床分析

目的 探讨阴式子宫切除术（ＴＶＨ）的优点、适应证、手术要点及临床应用价值。方法 自１９９５年１０月至１９９８年１１月,对５０例因多发性子宫肌瘤、子宫腺肌病、宫颈原位癌、功能失调性子宫出血及子宫内膜不典型增生而部垂患者,行ＴＶＨ。术前子宫大小正常者１０例（２０％）,子宫〉１２周者（大子宫）１６例（３２％）,子宫增大但≤１２周者２４例（４８％）。既往有手术史者６例（１２％）。同时行附件功除术者１１例（     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

阴式与腹腔镜子宫全切除术的临床效果比较

目的比较阴式子宫全切除术和腹腔镜子宫全切除术的临床效果。方法收集我院2002年1月至2004年6月接受以上不同途径子宫切除术的病例共301例的临床资料,其中阴式子宫全切除术197例(阴式组),腹腔镜子宫全切除术104例(腹腔镜组),比较两组疾病种类、手术时间、术中出血量、住院时间、医疗费用及术后恢复情况等。结果(1)疾病种类:宫颈非典型增生阴式组19例、腹腔镜组3例;子宫腺肌病、合并附件疾病或盆腔子宫内膜异位症,阴式组分别为58例、9例、8例,腹腔镜组分别为45例、33例、13例;(2)手术时间:阴式组(76±28)min、腹腔镜组(139±52)min;(3)术中出血量:阴式组(170±125)ml、腹腔镜组(206±153)ml;(4)肌瘤或腺肌瘤最大直径:阴式组(49±17)mm、腹腔镜组(57±22)mm;(5)手术费用:阴式组(1073±203)元、腹腔镜组(1526±676)元。以上各指标两组比较,差异均有统计学意义(P<0·05);(6)住院时间:阴式组(5·6±1·2)d、腹腔镜组(5·7±2·4)d;(7)子宫重量:阴式组(235±115)g、腹腔镜组(256±158)g;(8)手术并发症发生率:阴式组为2·54%、腹腔镜组为2·88%。住院时间、切除子宫重量及手术并发症发生率等两组比较,差异均无统计学意义(P>0·05)。结论无明显盆腔粘连和附件疾病的子宫全切除术可选择阴式途径,子宫大小并非选择术式的决定因素。     

Clinical opinion: guidelines for hysterectomy

OBJECTIVE: Abdominal hysterectomy remains the predominant method of uterine removal in the United States, despite evidence that vaginal hysterectomy offers advantages in regard to operative time, complication rates, return to normal activities, and overall cost of treatment. STUDY DESIGN: The predominance of the abdominal approach may be based on factors other than clinical considerations that include resident training, use of obsolete or limited guidelines, a perception rather than a confirmation that pathologic conditions exist that may suggest contraindications to the vaginal approach, misconceptions regarding the cost and safety of vaginal hysterectomy, and increased third-party reimbursement for the abdominal procedure. RESULTS: Evidence-based practice guidelines that were developed by the Society of Pelvic Reconstructive Surgeons and were adopted by the National Guidelines Clearinghouse have demonstrated that, in a number of studies that span several years, a dramatic shift toward the vaginal approach occurred when the guidelines were applied prospectively. CONCLUSION: The guidelines demonstrate that transvaginal hysterectomy is both feasible and optimal for many patients who long have been considered inappropriate candidates for vaginal hysterectomy. This clinical opinion attempts to address the reasons for the predominant use of the abdominal approach.     

子宫全切除术后发生输卵管脱垂的临床分析

目的探讨子宫全切除术后输卵管脱垂的诊断、处理及预防措施。方法收集1983年1月至2005年8月行各类子宫全切除术7949例患者的资料,其中行开腹子宫全切除术6229例,行阴式子宫全切除术780例,行腹腔镜辅助阴式子宫全切除术940例。结果手术后共发生阴道残端输卵管脱垂9例,发生率为0．11％（9／7949）。其中开腹子宫全切除术后发生5例,发生率为0．08％（5／6229）;阴式子宫全切除术后发生4例,发生率为0．51％（4／780）;腹腔镜辅助阴式子宫全切除术后无一例发生输卵管脱垂。9例患者子宫全切除术后均放置了阴道引流管,其中5例子宫切除后未行阴道残端腹膜化处理。9例患者中,3例无任何症状;6例有症状的患者中,1例出现左侧腰背部痛,5例出现阴道排液。妇科检查,3例阴道残端发现输卵管伞端,6例阴道残端可见类似肉芽样组织。9例患者均经阴道切除,局部烧灼脱垂的输卵管,切除组织经病理检查证实均为输卵管组织。之后随诊1-59个月无异常发现。结论输卵管脱垂是子宫全切除术后的一种少见并发症,输卵管脱垂一般发生于子宫全切除术后放置阴道引流管的患者,经正确的诊断和治疗预后良好。行子宫全切除术时,应将附件固定在骨盆侧壁或行输卵管切除。     

Laparoscopic hysterectomy for benign diseases

Despite more than 1000 publications on laparoscopic hysterectomy (LH), its role remains difficult to define. LH is not there to replace vaginal hysterectomy, but may be an alternative for abdominal hysterectomy when there are (relative) contraindications for vaginal hysterectomy, including concomitant oophorectomy, previous pelvic surgery and/or risk for adhesions, the larger uterus and nulliparity, and some oncological indications. Randomized trials have demonstrated that, compared to abdominal hysterectomy, LH shortens hospital stay and induces less postoperative pain and quicker recovery at the expense of a longer operation time. LH carries a higher risk for adjacent organ injury, and may be cost-effective, despite higher direct costs, because of the shorter hospital stay and quicker recovery.     

The effect of total hysterectomy on specific sexual sensations

OBJECTIVE: Assess whether women note a change in aspects of arousal because of removal of the uterus and cervix. STUDY DESIGN: Between 1990 and 1992, 105 women were asked to report on their sexual function before and at 3, 8, and 18 months after undergoing a total hysterectomy. Results were analyzed by chi 2 . RESULTS: Hysterectomies were abdominal or vaginal, and 42% of subjects had ovaries removed and initiated estrogen replacement. Ease of arousal diminished in 24% and improved in 11%. Intensity of orgasms decreased in 15% and increased in 14%. Effects of nipple stimulation were usually preserved. Sexual satisfaction increased significantly. Seven women noted distinctly worse sexual function. CONCLUSION: An indicated total hysterectomy will likely increase sexual satisfaction and not change the effect of breast stimulation. The few women with disturbingly reduced sexual sensation deserve assessment and treatment.