Sonographic and Histological Morphometry of the Uterine Cervix-An Assessment of Laparoscopic and Other lntrafascial Hysterectomy Techniques

New abdominal and vaginal hysterectomy techniques, such as classic intrafascial serrated edged macro-morcellator (SEMM) hysterectomy (CISH), by pelviscopy/laparoscopy or laparotomy, and intrafascial vaginal hysterectomy (IVH), are both essentially supravaginal techniques. It has been claimed that they give a prophylaxis against cervical stump carcinoma by coring out the cervix with the SEMM. We set out to answer two questions: 1) How can vaginosonography help to choose an adequate SEMM diameter so that the cervical mucosa and transformation zone are completely removed, and 2) How often do cervical glands remain after the coring out procedure? We were able to show a good correlation between sonographic and histological morphology by giant and serial sections. In 253 CISH operations, resection of both endocervix and transformation zone was complete in 92.9%. Dysplasias were always removed completely; only 18 cervical cores exhibited healthy glands (retention cysts) in the resection margin. Therefore, CISH procedures should be able to prevent most of the cervical stump carcinomata that follow traditional supravaginal hysterectomy, but only long-term follow-up will give the final proof.     

Intrafascial supracervical hysterectomy without colpotomy and transuterine mucosal resection by pelviscopy and laparotomy

Between September 1991 and December 1993, 253 patients were operated on using the Classical Intrafascial SEMM (Serrated Edged Macro Morcellator) Hysterectomy (CISH) technique. One hundred fifty-two patients were assigned to pelviscopic CISH and 101 to laparotomic CISH. Uterine leiomyomas with menstrual disorders and pressure symptoms topped the list of indications with 61%. In all cases, initially transuterine mucosal resection and coring of the cervicouterine cylinder were carried out followed by the intrafascial supracervical dissection of the uterus. The size of the uterus played a decisive role in selecting the cases for CISH technique either by pelviscopy or laparotomy. The cervicouterine mucosal cylinders were cored using the Calibrated Uterine Resection Tool (CURT). Cervical thickness and diameters were measured preoperatively by transvaginal sonography for facilitating the use of a specific-sized CURT. After removal of this cylinder, hemostasis in the area was secured by coagulating with an endocoagulation device. The advantage of this technique is that the pelvic floor integrity remains intact, and because uterine arteries and ureters were not touched, the so called "complication zone" is thus avoided.The histological findings are in agreement with the indications, the leiomyomas and leiomyomas with adenomyosis being the most frequent pathology. The histologic analysis showed that in all cases the squamocolumnar transformation zone was totally removed. There were 11 (4.4%) complications, promptly identified and treated without further problems.The value of the Classical intrafascial supracervical hysterectomy without colpotomy including the resection of transformation zone speaks for itself, because there is less physical stress and recovery is quick. However, it has yet to prove its value as compared with other techniques for hysterectomy for specific indications.     

腹腔镜下子宫切除3种术式的比较

目的 探讨腹腔镜子宫切除3种术式的手术效果、手术适应证及并发症的预防。方法 对该院2001年8月-2006年5月有子宫切除手术指征的763例患者行腹腔镜子宫切除术，其中腹腔镜下子宫次全切除术（LSH）251例，腹腔镜筋膜内子宫切除术（CISH）245例，腹腔镜辅助阴式子宫切除术（LAVH）267例，观察手术时间、出血量、住院时间及并发症发生情况。结果 763例中，中转开腹8例，手术成功率95．37％。LSH组的手术时间、出血量及住院时间与CISH组和LAVH组比较差异均有显著性（P〈0．05），而CISH组与LAVH组比较差异无显著性（P〉0.05）。发生并发症3例，LAVH组中损伤2例，其中1例膀胱损伤，1例直肠损伤；CISH组中1例为宫颈管内积血；LSH组无并发症发生。结论 腹腔镜手术虽然具有创伤小、恢复快等优点，但严格掌握手术适应证，提高操作技术是减少并发症的关键。     

经腹小切口低位筋膜内全子宫切除术与传统子宫切除术比较

目的:探讨小切口低位筋膜内全子宫切除术的可行性。方法:100例子宫良性病变患者随机分为观察组和对照组各50例。观察组采取小切口低位筋膜内全子宫切除术式,切断子宫主、骶韧带,于子宫骶韧带水平剥离宫颈筋膜至宫颈外口;对照组采用传统方法行子宫切除术。结果:观察组切口长度、手术时间、术后排气时间以及术后住院时间与对照组比较均缩短,差异有统计学意义(P<0.01)。结论:小切口低位筋膜内全子宫切除术操作简单、安全,值得临床推广。     

非脱垂子宫经阴道切除术87例的临床研究

目的探讨非脱垂、大子宫阴式切除术的可行性及优越性。方法选择我院2004年1月至2005年12月87例非脱垂子宫有手术治疗指征的患者施行经阴道全子宫切除术(TVH),大子宫采用肌瘤剔除及粉碎术等方法减小子宫体积。对照组90例采用经腹全子宫切除术(TAH),观察手术时间、术中出血量、术后排气时间、术后住院时间、并发症、术后随访满意度。结果87例非脱垂病变子宫经阴道切除全部成功。平均手术时间(65±23)m in,与对照组相似,平均出血量(90±65)m l,术后平均排气时间(16±3)h,术后平均住院时间(4±2)d,均小于对照组;无手术副损伤,术后发生一例输卵管脱垂并发症。结论经过详细的术前检查、正确的评估及充分的准备,经阴道切除≤16孕周大小的非脱垂子宫是安全、有效的。     

腹腔镜鞘膜内子宫切除术的临床研究

目的　探讨腹腔镜鞘膜内子宫切除术 (PCISH )的临床价值。方法　将 198例因子宫良性疾病需行子宫切除的患者随机分成两组 ,研究组 10 8例采用PCISH ;对照组 90例采用传统腹式全子宫切除术 (TAH)。结果　两组手术均成功 ,手术时间比较无显著性差异 (P >0 .0 5 )。两组术中出血量、术后病率及术后恢复等差异有高度显著性 (P <0 .0 1)。两组均无并发症发生。结论　PCISH具有损伤小、出血少、手术时间短、疼痛轻、康复快等优点。经过手术技术改良 ,能顺利进行大子宫的切除。是一种较理想的治疗子宫良性疾病的手术方式。     

腹式筋膜内子宫切除术的临床探讨

目的 探讨腹式筋膜内子宫切除术的优越性。方法 对92例因子宫良性病变要求行子宫切除者行下腹横切口筋膜内子宫切除术，随机选择同期90例类似病人采用传统子宫切除术作为对照。比较两组的手术时间术中出血量及术后恢复情况。结果 两组的手术时间无显著性差异（P〉0．05），术中出血量、术后肛门排气时间和住院天数及术后发热率均有明显减少。结论 下腹横切口筋膜内子宫切除术操作简单，出血少，病人术后恢复快，住院时间短，切口美观。     

Pelviscopic compared to laparotomic and vaginal intrafascial hysterectomy

Between 1993 and 1994, 368 women underwent hysterectomies for benign disorders at the University of Kiel. Of these, 58.7% were performed either by pelviscopic or by laparotomy Classic Intrafascial Supracervical Hysterectomy (CISH). Of the remaining, 14.8% were performed by abdominal hysterectomy, 13.6% by Intrafascial Vaginal Hysterectomy (IVH), 12.2% by Vaginal Hysterectomy (VH), and only 0.05% by Laparoscopic Assisted Vaginal Hysterectomy (LAVH). Comparative data of these six surgical techniques concerning patients characteristics, indications for operation, histological features, blood loss, operating time, hospital stay, uterine weights and postoperatively used analgesics are described.     

A review of 445 cases of laparoscopic hysterectomy: benefits and outcome

Hysterectomy is a major procedure indicated for women with gynaecologic pathologies. After reporting the first laparoscopic hysterectomy (Reich 1989), this technique has recently been considered as a safe and efficient alternative to traditional abdominal hysterectomy in the management of benign uterine pathologies when vaginal route is contraindicated. The laparoscopic approach should not be held to compete with vaginal hysterectomy. From 1995 to 2001 in our institute, the proportion of laparoscopic hysterectomy has increased and laparotomic hysterectomy has decreased. Between January 1999 and January 2001 we carried out 445 total laparoscopic hysterectomies. There were 5 laparotomy conversions for large uterus. The average haemoglobin drop was 1,36 g/dl. Median operative time was 95 +/- 27 min. The mean in postoperative stay was 2.7 +/- 0.8 gg. The postoperative complications were minimal. Laparoscopic approach is less painful, is associated to less blood loss, shorter hospital stay, more rapid recovery and a better assumption by affected women. Some disadvantages are reported too, such as larger operating time, high rate of complication and experience required for performing laparoscopy including a learning curve. A training period is necessary to standardize the operating procedure, to put in place methods of avoiding complication and to reach a plateau of surgical skill. The purpose of this study was to show the role of total laparoscopic hysterectomy and how it can be performed safely with a minimal morbidity after a period of training in which we worked out shrewdness to get a standardized technique with the most effective outcome.     

Vaginal Hysterectomy

1. In this series 150 cases of vaginal hysterectomy performed with or without associated procedures are reviewed. They have been analyzed as to indications and complications.

2. Vaginal hysterectomy and repair is the operation best suited to many women with pelvic relaxation and who have menstrual disturbances. Occasionally, when hysterectomy is needed it is safer to remove per vaginam than per abdomen.

The chief indication for operation in our series was pelvic relaxation. Other indications were dysfunctional uterine bleeding, fibroid uterus and in situ carcinoma of cervix.

The operative complications included excessive bleeding in 20 percent of cases. No bladder or ureteral injuries were encountered. Laparotomy was performed in three cases for uncontrollable bleeding (two percent).

The most common postoperative complication was significant rise in temperature due to non-specific morbidity in 47 cases (31 percent) and recognizable urinary tract infection in 27 cases (18 percent).

     

腹腔镜筋膜内子宫切除术322例临床体会

【目的】探讨腹腔镜筋膜内子宫切除术的临床应用价值与手术操作技巧。【方法】选择本院1998年10月至2008年10月实施的腹腔镜筋膜内子宫切除术322例进行回顾性分析。【结果】322例患者中320例均在腹腔镜下顺利完成手术，手术成功率99．4％，并发症少。【结论】腹腔镜筋膜内子宫切除术是安全可行的，不失为一种较为理想的治疗子宫良性病变的手术方式。     

Lapabot: A compact telesurgical robot system for minimally invasive surgery: Part II. Telesurgery evaluation

This study was undertaken to determine the usefulness of routine intra‐operative cystoscopy in documenting ureteral patency after laparoscopy‐assisted vaginal hysterectomy (LAVH). There were eighty patients who underwent LAVH for benign tumors of the uterus (adenomyosis and myoma), uterine prolapse, persistent intraepithelial neoplasm of the cervix (CIN3) and cervical carcinoma in situ (CIS). Intra‐operative cystoscopy with ureteral stenting was performed at the time of LAVH to evaluate the urinary tract. From among the 80 patients who underwent LAVH, 52 had myoma, 19 had adenomyosis, six patients had uterine prolapse, one had CIS and seven patients were diagnosed to have CIN3. Cystoscopy discovered one unsuspected bladder injury. Hematuria was the immediate complication caused by intraoperative cystoscopy. It was observed in ten patients. Urinary tract evaluation, including cystoscopy and ureteral stenting at the time of complex gynecologic surgery such as LAVH could be incorporated in the whole surgical procedure. It decreases morbidity associated with unrecognized injury.     

新式经阴道全子宫切除术的临床应用

目的研究新式经阴道全子宫切除术(TVH)的临床应用价值。方法选择2008年6月至2010年3月我院收治的60例子宫良性病变行TVH者作为研究组,随机抽取同期同指征行腹式全子宫切除术(TAH)者60例作为对照组,比较两组子宫、肌瘤大小及术中、术后情况,研究TVH的临床疗效。结果 TVH手术时间比TAH缩短20%,术中出血量减少23%,术后病率、杜冷丁使用率明显降低,排气时间缩短8 h。结论 TVH具有手术时间短、术中出血少、术后疼痛少、恢复快、术后病率低及住院时间短等优点,新式经阴道全子宫切除术值得在临床中广泛应用。     

Total abdominal hysterectomy versus laparoscopically-assisted vaginal hysterectomy versus total vaginal hysterectomy

Introduction: While total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) are conventional procedures, we have actively introduced laparoscopically‐assisted vaginal hysterectomy (LAVH) since its advent. This study was the first attempt to retrospectively compare the surgical results, including invasiveness, among the three methods of performing a hysterectomy. Methods: The subjects included 1181 patients who underwent total hysterectomies (TAH, n=465; LAVH, n=629; TVH, n=87) due to uterine fibroids or uterine adenomyosis at our hospital between January 1995 and December 2009. The mean age, parity, weight of the removed uterus, operative time, blood loss, rates of intra‐ and post‐operative complications, length of post‐operative hospital stay, leukocyte count, and CRP and hemoglobin levels were compared. Results: The operative time was significantly longer in the LAVH group than the other two groups. Blood loss was significantly greater in the TAH group than the LAVH and TVA groups. The rates of intra‐ and post‐operative complications were significantly higher in the TAH group than the LAVH group. The CRP level and leukocyte count were significantly lower in the LAVH group than the TAH and TVH groups. Conclusion: LAVH can be applied to nulligravidas or patients with relatively large uteri and it is proved less invasive than TAH and TVH in this study. We recommend active application of LAVH.     

先天性阴道斜隔的超声诊断与鉴别诊断

目的　评价超声诊断阴道斜隔的价值。方法　对 7例阴道斜隔患者的临床表现、声像图特点及术中所见进行分析 ,从中找出声像图特征。结果　进行性加重的痛经是各型阴道斜隔患者均有的症状 ;双子宫双宫颈畸形、宫腔及宫颈下方积液、一侧肾缺如是各型阴道斜隔患者均具有的声像图特点 ;手术可见阴道内隔膜。结论　二维超声检查应为诊断阴道斜隔首选而可靠的方法 ,但应注意提高操作技巧和识别能力。     

腹腔镜筋膜内子宫切除术并发症分析

目的探讨腹腔镜筋膜内子宫切除术（CISH）的并发症及预防措施。方法回顾性分析本院2003年1月至2006年12月共145例行CISH患者的并发症情况。结果发生并发症12例，占8．27％，其中术中并发症4例（2．76％），术后并发症8例（5．52％）。结论阴道少许出血和线圈滑脱是腹腔镜筋膜内子宫切除术的主要并发症，绝大部分并发症是可以预防的。     

腹腔镜筋膜内子宫切除术52例

目的：介绍改良式腹腔镜筋膜内子宫切除术的步骤及经验。方法： 有子宫切除指征的患者共193例，分为腹腔镜组和开腹组，比较手术时间、术中出血量、术后恢复情况及住院时间。结果：腹腔镜组手术时间短于开腹手术组；术中出血量明显减少；术后恢复情况如镇痛药物使用率低，发热不明显，起床活动及肛门排气提早，住院时间缩短，结论：改良式腹腔镜筋膜内子宫切除术是一种损伤小、出血少、恢复快的手术方法。     

腹腔镜筋膜内子宫切除术与剖腹子宫切除术治疗子宫病变的临床研究

目的：比较剖腹子宫全切术、腹腔镜筋膜内子宫切除术两种术式的临床效果。方法：将2003年1月-2005年6月288例良性子宫病变患者分为剖腹子宫全切术组（146例）和腹腔镜筋膜内子宫切除术组（142例），比较术中、术后情况。结果：两组年龄、体重、剖腹手术史、子宫大小、子宫病变等方面比较无统计学意义（P〉0．05），手术时间、术中出血量、术中并发症、术后3d体温、肛门排气时间、对镇痛的需求、术后住院天数、术后随访，腹腔镜筋膜内子宫切除术组明显优于剖腹子宫全切术组（P〈0．05）。结论：腹腔镜筋膜内子宫切除术在保留器官功能，提高患者生存质量方面较剖腹子宫全切术有明显的优势。     

Analysis of factors affecting vaginal hysterectomy

Abstract

The study analyzes factors that affect vaginal hysterectomy to establish the indications of a vaginal approach to benign uterine disease. In a retrospective study, 174 patients underwent vaginal hysterectomy for uterine leiomyomas or adenomyosis by one gynecologist between December 2005 and December 2006. All data were compared and analyzed by X²- test, t-test, and multiple logistic regression. Based on a uterine weight ≥ 500 g, body weight, a history of surgery, concomitant surgery (adenexectomy), penetration of the posterior cul de sac during surgery, uterine descent, and average uterine weight we determined the feasibility of vaginal hysterectomy. Based on an operative time ≥ 33 min, body weight, concomitant surgery (adenexectomy), penetration of the posterior cul de sac, vertical length of the vaginal opening, uterine descent, and the uterine weight had significant effects on the success of vaginal hysterectomy. The range of indications for vaginal hysterectomy may vary greatly depending on the surgeon's experience. If experiences are accumulated gradually, together with the advantages of laparoscopically assisted hysterectomy, most abdominal hysterectomies and laparoscopic hysterectomies can be replaced by vaginal hysterectomy.