阴式子宫切除分碎术与经腹子宫切除对比分析

目的　评价阴式子宫切除分碎术 (VHM)的优点及手术结局 ,并与腹式子宫切除术 (TAH)作对比分析。方法　回顾分析 1999年 4月～ 2 0 0 3年 3月应用分碎术经阴道切除子宫 5 10例 (研究组 ) ,同期行TAH5 5 6例 (对照组 ) ,对两组患者的年龄、体重指数 (BMI)、产次、手术时间、失血量、子宫重量、手术并发症、住院时间及费用进行比较。结果　研究组均成功经阴道完成手术 ,未使用腹腔镜协助。两组患者年龄、产次、BMI差异无显著性。手术时间研究组明显短于对照组 (85 18± 2 7 6 1)min <(113 5 8± 30 97)min ,术中失血量研究组 (12 0 36± 98 5 3)ml明显少于对照组 (198 78± 12 3 0 2 )ml,(P <0 0 0 1)。平均子宫重量腹式组 (36 8 92± 30 6 0 4 )g大于阴式组 (2 6 0 6 4± 10 7 88)g ,住院费用阴式组 5 2 4 7 6 2元低于腹式组 6 833 87元。两组患者均无膀胱或直肠损伤。结论　本文证实阴式子宫切除术中应用分碎术 ,即使是大子宫 ,也是安全便利的 ,而且费用较经腹切除术低     

Laparoscopic-assisted vaginal hysterectomy with in situ morcellation for large uteri

STUDY OBJECTIVE: To estimate whether laparoscopic in situ morcellation (LISM) can facilitate laparoscopic-assisted vaginal hysterectomy (LAVH) for large uteri. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: In all, 147 women with myoma or adenomyosis weighing more than 500 g from January 2004 through December 2007 were enrolled. The patients were divided into 4 subgroups: patients with uteri weighing 500 to 749 g who had traditional LAVH without LISM (group 1A, n = 69) or with LISM (group 1B, n = 16); and patients with uteri weighing 750 g or more who were treated by traditional LAVH without LISM (group 2A, n = 38) or with LISM (group 2B, n = 24). INTERVENTIONS: Laparoscopic-assisted vaginal hysterectomy with or without LISM. MEASUREMENT AND MAIN RESULTS: No significant differences existed in age, body mass index, preoperative diagnoses, complications, or duration of hospital stay among groups. The mean uterine weights were 608 +/- 75, 597 +/- 66, 989 +/- 179, and 935 +/- 226 g for groups 1A, 1B, 2A, and 2B, respectively. The operative time (120 +/- 16 vs 157 +/- 36 minutes, p <.001; 140 +/- 19 vs 224 +/- 57 minutes, p <.001) were significantly shorter in patients with LISM than without in both groups 1 and 2. The estimated blood loss was highest in group 2A. Six (16%) patients lost more than 500 mL of blood and 3 (8%) of them needed blood transfusions. Conversion to laparotomy occurred in 1 (2.6%) of 38 patients in group 2A. No repeated surgery or surgical mortality occurred. CONCLUSION: Laparoscopic-assisted vaginal hysterectomy with LISM was an efficient and safe procedure for removal of large uteri during LAVH.     

Uterine morcellation during vaginal hysterectomy: apropos of a series of 216 prospective cases

OBJECTIVE: The purpose of this study was to compare the surgical outcomes of women undergoing vaginal hysterectomy with and without morcelation. PATIENTS AND METHOD: Between December 1999 and December 2000, 216 women underwent vaginal hysterectomy without laparoscopic assistance at the Department of Gynecology of H?tel-Dieu hospital in Paris. The patients were divided into two groups: 114 of them underwent vaginal hysterectomies with morcelation whereas 102 underwent vaginal hysterectomies without morcelation. The two groups were compared as to demographic data, total complications, operative time, hospital stay length and peri-operative hemoglobin concentration change. RESULTS: Although women undergoing morcelation were significantly younger (mean 49 versus 52, p = 0.01) and less parous (mean 1.9 versus 2.3, p = 0.03), there were no significant differences in other surgical or anesthetic risks factors, including weight, BMI, nulliparity and preexisting surgical diseases. Mean uterine weight was significantly greater in those undergoing morcelation (331 versus 110 g, p < 0.001); operative time was increased in the group which had undergone morcelation (331 versus 110 g, p < 0.001). There were no significant differences between the two groups with respect to peri-operative hemoglobin concentration change or hospital stay length. Finally, the rate of surgical complication was similar in the two groups (17.5 versus 21.5%). CONCLUSION: Although vaginal hysterectomy requires an increase in operative time, morcelation at the time of vaginal hysterectomy is safe and facilitates the vaginal removal of enlarged uteri without increasing peri-operative morbidity.     

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.     

ESGE survey on tissue power morcellation complications other than leiomyosarcoma

The exact incidence of power morcellation complications (PMC) is unknown and probably underestimated. Medical literature mainly describes case reports and the vast majority of complications after tissue power morcellation are not reported. ESGE has run a survey among its members about complications emerging after laparoscopic electromechanical morcellation including the risk of leiomyosarcoma (LMS). The reported risk of a sarcoma after myoma or uterus morcellation is low and presented in a separate article. The Central office using the ESGE server and website, activating the ‘Survey Monkey’ programme, sent a request to 3422 ESGE members to answer, anonymously, a structured electronic questionnaire with multiple structured answer options, within 3 months. The doctors responding to the call were automatically given a serial number in an EXCEL spreadsheet, enabling statistical analysis using the SPSS v.18. The probabilities were calculated by using the raw data as reported to each individual question, dividing the number of incidence with surgeon’s lifetime experience in laparoscopic surgery. The electronic questionnaire was answered by 216 (6 %) surgeons. The majority of the respondents used the morcellator for 10 years. The overall probability of direct power morcellator injuries to internal organs is more frequent (0.12 %) than that of morcellator injuries to the abdominal and pelvic wall (0.06 %). The risk of parasitic myoma is estimated 0.08 and 0.16 % for the de novo endometriosis after myoma and adenomyoma morcellation. Furthermore, the vast majority of surgeons have never experienced bladder or ureter, aorta and vessel injuries by using the morcellator, proven by the standard deviation being close to zero. Three surgeons with morcellator experience between 1 and 5 years were involved in an injury that caused permanent damage, 1 nerve, 2 bowel and 1 port-site hernia injury due to the morcellator. According to surgeons’ answers, death has never occurred after power morcellation. Morcellator technical problems found also to be of low probability between 0.12 and 0.3 % as estimated for all endoscopic surgeries in lifetime of 188 surgeons. The average number of times per doctor where the morcellator stacked and stopped working is 2.17 with standard deviation equal to 4.4 and sum of incidents equal to 426 times for all 196 doctors. The most frequent technical problem was morcellator transient stacking and the least frequent was the morcellator stopped working and colpotomy needed to evacuate the tissue out of the abdominal cavity 0.12 % operations. The majority of surgeons 136/188 (72 %) are using reusable morcellator devices and 51 (27 %) are using disposable devices. Moreover, 97/188 (51.6 %) of surgeons are using exclusively, only reusable morcellators; 56/188 (29.8 %) are using both disposable and reusable types of morcellators. The incidence of power morcellation complications is very low reputedly. The ESGE board advises that endoscopic operations must be performed only by doctors who have had an adequate training and knowledge. It is compulsory to know the publications about dangers, contraindications and complications before performing these operations. A complete knowledge of techniques and principles of endoscopic surgery is needed to avoid and minimize complications. A training session prior to morcellator first use might decrease further PMC.     

Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation

ObjectivesTo evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation.Material and methodsA retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016.ResultsThe cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively.ConclusionTwo-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.     

Comparison between bisection/morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study

BACKGROUND: Vaginal hysterectomy (VH) is being performed increasingly by gynecologic surgeons. Thus, enlarged uteri are more frequently removed vaginally, requiring reducing techniques to allow vaginal extraction. MATERIAL AND METHODS: We designed a randomized prospective study to compare bisection-morcellation and myometrial coring. Patients scheduled for VH or laparoscopically assisted vaginal hysterectomy (LAVH) were offered entry into the study. Endometrial cancer was an exclusion criterion. Uterine size was not a contraindication for vaginal surgery. We compared data from preoperative workup as well as from the operative and the postoperative course. Data were recorded prospectively. Results were analyzed with nonparametric tests and logistic regression models. RESULTS: Thirty patients were included in the study. Patients were similar in both groups. No severe peroperative complication occurred in this series. Operating time was comparable in both groups. Uteri weighed more than 280 g in more than 70% of patients in both groups. Myometrial coring failed more often than bisection-morcellation (25% vs. 0%, p = 0.06). Patients and uteri characteristics had no influence on the risk of failure, except for narrow uteri, which were associated with an increased risk of failure in the myometrial coring group only (68.3 vs. 83.9 mm, p = 0.01). Postoperative courses were similar for the two techniques, except for an increased rate of fever in the myometrial coring group (28%, p = 0.03). CONCLUSION: Both techniques appeared safe in this trial. Myometrial coring failed more frequently than bisection-morcellation, especially in the case of a narrow uterus. Postoperative fever was significantly more common after myometrial coring. Both techniques should be taught to resident surgeons.     

Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach

Study Objective

To compare the number of days required to return to daily activities after laparoscopic hysterectomy with 2 tissue extraction methods: manual morcellation via colpotomy or minilaparotomy. Secondary outcomes were additional measures of patient recovery, perioperative outcomes, containment bag integrity, and tissue spillage.

Progesterone receptors in human vaginal tissue

Specific progesterone receptors were measured in both cytoplasmic and nuclear fractions of vaginal tissues obtained from 17 women between 33 and 53 years in age. Whereas nuclear receptors could be measured in 11 of 17 tissues examined, cytoplasmic receptors were detected in only four. The distribution of receptor-positive tissues was similar in the follicular and luteal phases and no significant difference was observed in the nuclear receptor concentration in the two phases. The receptor concentration from all tissues examined ranged from 31 to 105 pmol/mg of protein and the apparent dissociation constant was 1 to 2 nmol/L. The presence of progesterone receptors in the nuclear fraction and their absence in the cytoplasm raise questions about the authenticity of the classical two-step model for steroid hormone action.     

Decision-to-delivery interval for instrumental vaginal deliveries: vacuum extraction versus forceps

Objective: The aim of this study was to assess the decision-to-delivery interval for forceps delivery and vacuum extraction. Study design: A retrospective analysis of all instrumental deliveries over a 1-year period in a delivery ward of a university tertiary health care facility was performed. The decision-to-delivery interval was compared between forceps delivery and vacuum extraction. Results: The decision-to-delivery interval was 8.6±5.4 and 13.8±6.2 min for forceps and vacuum deliveries, respectively (P=0.0001). Conclusion: It appears that it is quicker to accomplish forceps delivery than vacuum extraction.     

Operative vaginal delivery: clinical appraisal of a new vacuum extraction device

The efficacy of a new vacuum extraction device, the Kiwi OmniCup, and its effects on mothers and infants were tested in a study of 18 non-rotational and 32 rotational vacuum assisted deliveries. Forty-nine (98%) of the extractions resulted in successful vaginal births. Autorotation of the fetal head when the occiput was transverse or posterior was achieved in 31 (97%) of the 32 vacuum procedures. The high success rates recorded for both vaginal delivery and autorotation of the fetal head were largely attributable to the fact that flexing cup applications were achieved in 90 % of the vacuum attempts. There were no cases of serious maternal trauma or clinically significant neonatal injuries. Two infants had cephalohaematomas and one infant developed a small subgaleal haemorrhage following a difficult delivery, which resolved rapidly without complications. It was concluded that the Kiwi OmniCup is an efficient and safe vacuum device for assisted vaginal delivery, provided it is used correctly and appropriately.     

Actinomyces associated with persistent vaginal granulation tissue

BACKGROUND: We report a case of symptomatic actinomycosis associated with vaginal suture erosion and granulation tissue refractory to conservative management, in an outpatient setting. CASE: Three months after total vaginal hysterectomy and uterosacral ligament vaginal vault suspension, a woman complained of painless, intermittent vaginal discharge and spotting. Despite cauterization of granulation tissue, vaginal spotting persisted for another month. On re-examination, braided polyester suture that was found underlying the granulation tissue was removed. Recurrent symptoms, together with a biopsy revealing actinomycetes, prompted a trial of oral penicillin VK. With persistent symptoms and discomfort during attempts in the outpatient clinic, the woman eventually required suture removal in the operating room. Her symptoms subsequently resolved without recurrence, and no further antibiotic treatment was required. CONCLUSIONS: Actinomyces may be associated with persistent granulation tissue and vault suspension suture material. In rare circumstances, when tissue debridement and suture removal in the clinic is unsatisfactory, surgical intervention in the operating room may be necessary. Ten days of antibiotic therapy alone did not eradicate the granulation tissue, and symptoms resolved only after complete removal of the underlying permanent suture.