先天性宫颈阴道闭锁初次手术治疗失败后的再处理：附5例报告

目的探讨先天性宫颈阴道闭锁初次手术失败的影响因素及再次手术的处理。方法对2006年5月。2012年2月5例先天性宫颈阴道闭锁外院初次手术失败均以术后周期性持续性腹痛转入我院。5例初次手术前均仅诊断为阴道闭锁行阴道成形术,术中发现合并宫颈闭锁而行宫颈阴道贯通术,分别于术后4年6个月、3个月、3年4个月、1年4个月、3年2个月（二次术后）来我院治疗。2例不完全闭锁在术前检查后出现严重盆腔感染,抗生素治疗无效先行急诊手术治疗。第1例行宫颈粘连松解修补术＋官腔镜检查＋宫颈修补术,第2例行部分宫颈切除＋宫颈闭锁分离成形＋自体皮瓣阴道成形术,第3例行腹腔镜子宫＋双侧输卵管切除术,第4、5例行开腹宫体切开宫颈造口术＋阴道成形术。4例术后经宫颈在官腔内留置F18～F20Foley’s尿管或剪短的蘑菇头尿管,术后分别放置2周（因阴道放置模具而取出）、6个月（因结婚而取出）、11个月、1年。结果5例术后随访0．5—5年,腹痛未再复发。结论对复杂的阴道闭锁初次手术前做影像学的充分评估,使用不脱落的宫颈管支架和适当的阴道成形是手术成功的关键。对不全闭锁首选影像学检查。     

机器人手术系统在女性梗阻性生殖道畸形中的应用

目的:分析达芬奇机器人手术系统在女性梗阻性生殖道畸形中的临床应用效果.方法:回顾性分析空军军医大学第一附属医院2015年9月～2019年10月使用达芬奇机器人手术系统完成的梗阻性生殖道畸形手术患者7例的临床资料,统计分析不同生殖道畸形的分类、临床表现、手术方法、术后并发症、月经恢复情况和性生活满意度等.结果:7例患者中,宫颈发育异常者6例,阴道完全闭锁者4例,阴道下段闭锁者1例,合并子宫内膜异位症者6例,合并泌尿系统畸形者1例.所有患者均保留了有功能子宫,6例行宫颈成形术,5例行阴道成形术;所有患者均恢复规律月经,2例有性生活者性生活均满意.结论:对于梗阻性生殖道畸形的患者,达芬奇机器人手术系统能更好地重建生殖道解剖结构,保留有功能子宫.     

罗湖三式治疗先天性阴道闭锁合并宫颈闭锁1例报告

2015年3月,采用罗湖三式(闭锁宫颈切除+腹腔镜腹膜阴道成形+子宫人工阴道吻合术)治疗先天性阴道闭锁合并宫颈闭锁1例,手术顺利,术后1个月月经来潮,术后随访7个月,腹痛未再复发。     

腹腔镜与阴式全子宫切除术治疗子宫良性疾病的疗效观察

目的：比较腹腔镜与阴式全子宫切除术治疗子宫良性病变的临床效果。方法：回顾分析2012年1月至2013年1月为105例子宫良性疾病患者行全子宫切除术的临床资料,其中55例行腹腔镜子宫切除术（腹腔镜组）,50例行阴式子宫切除术（阴式组）。对比分析两组患者疾病种类、年龄、手术时间、术中出血、术后康复、并发症等情况。结果：两组患者在疾病种类、年龄、术前血红蛋白、合并内科疾病、子宫重量及术后并发症、术后住院时间等方面差异均无统计学意义（P〉0.05）,盆腔粘连例数及术中失血量腹腔镜组优于阴式组,差异均有统计学意义（P〈0.05）,但手术时间、术后排气时间长于阴式组（P〈0.05）。结论：腹腔镜及阴式子宫切除术各有优缺点,相较阴式手术,腹腔镜全子宫切除术手术视野更清晰,尤其合并子宫内膜异位症、盆腔粘连等疾病的患者。术者应根据手术指征、自身手术经验及盆腔解剖关系选择合适的手术方式。     

罗湖四式治疗合并功能性子宫的阴道闭锁(Ⅰ型)5例报告

目的探讨罗湖四式(腹腔镜下闭锁阴道切开术+游离积血囊壁及腹膜行阴道成形术)治疗先天性阴道闭锁Ⅰ型合并正常子宫患者的可行性及近期效果。方法 2015年7月~2016年1月对5例先天性阴道闭锁Ⅰ型合并正常子宫施行罗湖四式,术中切开闭锁阴道,腹腔镜下游离子宫下方积血囊壁作为人工阴道前壁覆盖物,游离腹膜作为人工阴道后壁覆盖物,覆盖闭锁阴道切开后创面,形成通畅的新阴道。结果 5例顺利完成手术,手术时间140~198 min,平均165 min;术中出血量100~200 ml,平均140 ml。术后1个月月经来潮。5例平均随访7.4月(3~10个月),月经正常,无周期性腹痛。结论罗湖四式治疗先天性阴道闭锁Ⅰ型合并正常子宫是一种可行的微创方法,近期效果满意。使用游离的积血囊肿壁及腹膜作为人工阴道壁覆盖物和术后阴道扩张是手术成功的关键,术后无须长期放置子宫阴道支架。     

女性肥胖患者妇科腹腔镜手术围手术期评估及管理初探

目的:探讨女性肥胖患者妇科腹腔镜手术围手术期的评估及管理。方法:回顾分析2003年1月至2013年1月收治的因不同手术指征拟行腹腔镜手术肥胖患者的临床资料。其中146例行腹腔镜全子宫切除术,188例行子宫次全切除术,88例行子宫肌瘤切除术,120例行卵巢囊肿手术,100例行异位妊娠手术,探讨其术前准备、合并症的治疗、手术结果及术中术后并发症的预防。结果:经术前评估,患者均适宜行腹腔镜手术,2例子宫全切术因术中出血量较多、止血暴露困难中转开腹,余患者均完成腹腔镜手术,手术成功率99.7%。近期共发生并发症57例,占8.9%,无远期并发症发生。结论:肥胖患者常合并肥胖相关疾病,与接受腹腔镜手术的一般患者相比,术前需要更为全面的评估与准备。规范女性肥胖患者腹腔镜手术围手术期的诊疗流程,术前完善各相关科室的会诊评估,制定针对肥胖患者腹腔镜手术的应急措施,可最大限度地保障手术成功,减少术中、术后并发症的发生。     

子宫肌瘤697例的微创手术治疗

目的:评价子宫肌瘤微创手术的价值和手术适应证。方法:宫腔镜下经宫颈行子宫肌瘤切除术(TCRM)115例,完全腹腔镜下行全子宫切除术(TLH)5例,腹腔镜行全子宫切除术(LH)58例,腹腔镜鞘内子宫切除术(CISH)153例,腹腔镜次全子宫切除术(LSH)8例,腹腔镜辅助阴式子宫切除术(LAVH)36例,腹腔镜子宫肌瘤剜除术(LM)156例,阴式全子宫切除术(TVH)166例。结果:子宫肌瘤697例行微创手术治疗均获成功。结论:TCRM主要适于子宫粘膜下肌瘤及部分内突型壁间肌瘤。LM术主要适于保留子宫的肌瘤。CISH术适于年轻患者。但宫颈极度肥大,宫颈重度糜烂,CIN者,应行LAVH、LH、TLH术或TVH。TVH适于宫颈肥大、宫颈重度糜烂、CIN者,尤其是合并子宫脱垂、阴道壁膨出、张力性尿失禁、子宫腺肌病患者。对盆腔粘连尤其需要切除附件者以行LAVH术为宜。     

肾移植术后异常子宫出血的手术治疗

目的探讨肾移植术后异常子宫出血(abnormal uterine bleeding,AUB)的原因及手术治疗效果。方法收集2003年11月至2010年3月在中山大学附属第一医院因肾移植术后AUB接受手术治疗的6例患者资料,进行回顾性分析。所有患者均签署知情同意书,符合医学伦理学规定。6例患者AUB发生在肾移植术后6个月至12年,临床表现以月经量增多、经期延长为主。6例患者的临床诊断分别为子宫肌瘤2例,子宫腺肌病2例,子宫肌瘤合并子宫内膜增殖症1例,子宫内膜息肉合并子宫内膜增殖症1例。3例行子宫切除术,2例行子宫内膜诊断性刮宫(诊刮)术,1例行腹式子宫肌瘤剔除术。结果所有患者手术顺利,AUB得到控制,贫血改善。手术操作对移植肾未造成不良反应,未发生术后并发症。随访至投稿日,复查血红蛋白及肾功能正常。结论肾移植术后AUB发生原因复杂,合并子宫器质性病变为常见原因之一。对于药物保守治疗效果不佳或合并子宫器质性病变者应尽早手术治疗,手术治疗安全有效。     

Ⅱ型先天性阴道、宫颈闭锁1例诊治体会

正先天性宫颈闭锁有多种分类方法~([1~3])。冷金花等~([2])将先天性阴道闭锁分为2型:阴道下段闭锁,阴道上端和宫颈发育正常者为Ⅰ型;阴道完全闭锁为Ⅱ型,多合并宫颈发育不良,宫体正常或子宫虽有畸形但内膜有功能。秦成路等~([3])将先天性宫颈闭锁分为3型:Ⅰ型,有发育正常的子宫体,也具有发育良好的宫颈体及宫颈管,但缺乏宫颈出口;Ⅱ型,宫颈发育程度差,由纤维结缔组织组成的索状或板状     

宫腔镜治疗异常子宫出血106例分析

目的 :探讨宫腔镜电切术治疗异常子宫出血的疗效及安全性。方法 :选择有手术指征的异常子宫出血患者 10 6例 ,行经宫颈子宫内膜切除术、经宫颈子宫肌瘤电切术或内膜并息肉及肌瘤切除术 ,观察术中并发症、术后月经改善情况。结果 :术中无 1例发生严重并发症 ,75例功血患者治愈率达 85 .33% ,满意率96 .0 0 %。 2 4例子宫肌瘤及 7例子宫内膜息肉治愈率为 10 0 %。结论 :宫腔镜电切术对有生育要求或要求保留子宫的患者是最佳选择 ,正确选择手术适应证 ,严格B超监测是提高术后疗效和手术安全的保障。     

The surgical management of infants and children with ambiguous genitalia. Lessons learned from 25 years.

Over a 25-year period, 91 children with ambiguous genitalia have received surgical management. Female sex assignment was made for 79. Of these, 60 patients underwent extensive clitoral reconstruction consonant with the female assignment. Forty-two patients had vaginal reconstruction. Factors relating to success include: (1) prompt and appropriate sex assignment; (2) early and accurate diagnosis; (3) conservative reconstruction of the clitoris at an early age (less than 1 year); and (4) choice of vaginal reconstruction based on the severity of the malformation. Long-term follow-up demonstrates satisfactory anatomic and functional results when clitoral surgery alone was required. Functional results for patients with extensive vaginal reconstruction have been compromised. Physicians caring for children with congenital intersexual anomalies can expect to encounter a wide spectrum of anatomic and physiologic derangements. Cosmetic appearance alone is an inadequate measure of success because endocrinologic, social, psychological, and sexual factors must be blended into comprehensive evaluation of these patients. The management plan must be flexible and individualized, incorporating long-term follow-up to adulthood.     

Vaginoplasty using deepithelialized vulvar transposition flaps: the Grünberger method

BACKGROUND: One of the most important criteria indicative of the longterm success of vaginal enlargement is the absence of postoperative contracture. Numerous procedures have been developed for reconstruction of an inadequate vagina. Some are technically complex techniques (myo- and fasciocutaneous flaps) with few postoperative complications of vaginal contracture, and others implement autografts with a greater tendency of tissue contraction. STUDY DESIGN: We report here a method of vaginoplasty using deepithelialized vulvar transposition flaps to enlarge the width of narrow vaginas found mainly in cases of congenital adrenogenital syndrome-associated vaginal atresia, but also in cases of acquired vaginal atresia (surgery and radiotherapy-induced). We used deepithelialized dermis from the labia majora to construct an enlarged vaginal entrance and cavity, a technique that is easy to learn and perform. RESULTS: The healing phase of this operation is free of tissue rejection, most likely because of the close embryologic relationship of the cornified, paravaginal squamous epithelium of the labia majora and the noncornified squamous epithelial lining of the lower third of the vagina. The epithelium of the graft loses its cornified layer and becomes nonhair-bearing; its cytology and histology mimic normal vaginal epithelium. Postoperative function and sexual contentment were reported to be satisfying.CONCLUSIONS: The followups of 17 patients who underwent this operation in the last 16 years show optimal cosmetic and functional results.     

宫颈缝扎术治疗宫颈机能不全临床分析

目的探讨宫颈缝扎术治疗宫颈机能不全的临床疗效。方法分析2000年1月～2011年6月19例因宫颈机能不全行宫颈缝扎术患者的临床资料。结果 19例宫颈机能不全患者中17例获得活婴,2例失败,手术总成功率为89.5%。其中孕20周前行宫颈缝扎术者15例,手术成功14例;孕20周后手术者4例,成功3例;急诊手术2例,均成功。手术方式分别为U型缝合法、Shirodkar法、McDonald法。结论宫颈缝扎术治疗宫颈机能不全疗效肯定,手术时机宜选择在孕20周前。经阴道行宫颈缝扎术方法简单,术式较多,采用术式应根据病情变化进行合理选择。经临床实践,急诊行宫颈缝扎术是可行的,它可以改善宫颈机能不全患者的妊娠结局。     

先天性食管闭锁的外科治疗

目的 总结32例先天性食管闭锁手术治疗经验。方法 手术均采用食管上盲端前壁肌层U形翻转，即经胸膜外入路充分游离食管上端及瘘管，近气管侧缝扎切断瘘管。用剪刀将远端食管前壁纵行剪开5min，吻合前距吻合口上方10min处行食管上下两端浆肌层缝合3针，然后距吻合口上方15～20min处将食管前壁肌层切开，从切开处向吻合口方向从两侧纵行切开肌层至吻合口约5mm，轻轻分离前壁肌瓣，形成U形向下翻转，缝合在食管远端浆肌层上。结果 32例中17例采用此方法未发生吻合口瘘，1例吻合口狭窄。2例成功行一期胃代食管术。结论 食管上盲端前壁肌瓣U形翻转能有效预防吻合口瘘及狭窄。Ⅰ、Ⅱ型食管闭锁采用一期胃代食管术，可避免二次手术。     

Vaginoplasty

PURPOSE OF REVIEW: This review summarizes the most recent advances in the field of vaginoplasty. New surgical techniques and recent modifications to existing techniques are included as well as up-to-date outcome data when available. RECENT FINDINGS: It is increasingly clear that vaginal dilation treatment is a successful method of vaginal creation and avoids the risks of surgery. When vaginal dilation is unsuitable or unsuccessful, however, vaginal reconstruction surgery is needed. Most of the novel advances in vaginal reconstruction have been related to the advances made in laparoscopic techniques. It is anticipated that as surgeons become more adept at such procedures, maximally invasive procedures such as intestinal neovagina may be necessary only in a small minority of patients. Autologous vaginal tissue transplantation may also transform this field. Long-term sexual function outcome data are essential for full evaluation and comparison of surgical techniques and the recent literature has begun to include this information. SUMMARY: Vaginal dilation treatment should be the first choice of treatment. If unsuccessful, laparoscopic techniques offer good outcomes and quick recovery. Additional research into the long-term outcomes of sexual satisfaction, orgasm and patient body image is essential, however, to allow a comparison of newer and traditional procedures.     

Vaginal reconstruction with sigmoid colon in patients with congenital absence of vagina and menses retention: a report of treatment experience in 22 young women

Introduction and hypothesis

We evaluated the surgical feasibility, sexual satisfaction and complications of vaginal reconstruction with sigmoid colon in patients with congenital absence of vagina and menses retention.

Methods

Retrospective analysis of surgical techniques and long-term postoperative follow-up was performed for 22 patients who underwent vaginal reconstruction with sigmoid colon at a single hospital between 1977 and 2011 to treat congenital absence of vagina with menses retention.

Results

All patients achieved satisfactory sexual function after marriage. No patients experienced enterospastic abdominal pain during sexual intercourse. The neovaginas accommodated two or more fingers and had depths >10 cm. The mucous membranes were soft and flexible, and secretions of the sigmoid mucosa provided adequate and acceptable lubrication. No patient required vaginal stents, and none developed vaginal stenosis or reported pain with vaginal expansion. Fifteen of the 22 patients underwent hysterectomies due to cervical agenesis; seven retained their uterus and had onset of normal menses postoperatively. Two patients became pregnant 1 year after marriage; one achieved 38-week gestation, underwent cesarean section due to premature rupture of membranes, and delivered a healthy boy. The other experienced natural incomplete abortion and underwent curettage at her local hospital.

Conclusion

This study confirms that sigmoid colon vaginal reconstruction is a good choice for treating congenital absence of vagina and menses retention and results in the closest approximation to the physical function of a normal female vagina. Reproductive ability can be retained in many cases for patients with a well-developed uterus and cervix.     

严重外伤性阴道损伤的手术治疗

目的 探讨严重外伤性阴道损伤的手术治疗方法。方法 回顾性分析7例严重外伤性阴道损伤患者的临床资料与治疗结果。结果 根据阴道闭锁段发生的位置及阴道损伤程度的不同,选择经耻骨上入路、会阴或两者联合入路,应用皮片移植、游离皮瓣移植、阴道黏膜推进瓣、断端对端吻合、Z成形术等方法进行修复,除1例发生阴道直肠瘘外,其余病例均取得满意治疗效果。结论 术前对阴道损伤程度及相邻器官解剖关系的准确把握是决定手术入路、手术修复方法及治疗效果的关键因素。     

Atresia of the esophagus. New trends in the management of high-risk neonates

Once the reconstruction of esophageal atresia in infancy was reported, immediate repair became standard practice. High-risk infants carry an operative mortality of 30% to 80%. Staged surgical procedures were introduced to improve survival. "Delayed" reconstruction of esophageal atresia in selected cases has been reported to improve survival and eliminate staged surgical procedures. Between 1982 and 1986, 21 newborns were diagnosed as having esophageal atresia. Eight infants (32%) underwent "immediate" repair. In 13 infants repair was "delayed" for seven to 252 days. Four neonates with "pure" esophageal atresia underwent primary anastomosis, one was awaiting surgery, and another died in the postnatal period. As more high-risk infants survive the perinatal period, surgical reconstruction must be planned to maximize operative survival. The goal of delayed management of esophageal atresia is to restore intrinsic esophageal continuity.     

复杂性阴道畸形的影像学诊断与外科治疗策略

目的探讨复杂性阴道畸形的辅助诊断及手术治疗方法。方法回顾性分析13例复杂性阴道畸形患者的临床资料与治疗结果。结果通过术前骨盆平片、造影、经肛B超及CT等检查可基本明确阴道损伤情况,根据阴道损伤发生的位置及损伤程度的不同,选择经耻骨前路、会阴或两者联合入路,运用游离植皮、皮瓣游离移植、阴道粘膜推进瓣、断端对断吻合、"Z"成形等方法进行修复,除1例发生阴道直肠瘘外,其余病例均取得满意治疗效果。结论术前对阴道损伤程度及相邻器官解剖关系的准确把握是决定手术入路、手术修复方法及治疗效果的关键因素。