腹腔镜全子宫切除两种术式的临床比较

目的比较腹腔镜辅助阴式子宫切除术(laparoscopic-assisted vaginal hysterectomy,LAVH)及全腹腔镜子宫切除术(total laparoscopic hysterectomy,TLH)的临床价值. 方法 2004年1月～2006年8月,因子宫良性疾病行LAVH 128例和TLH 42例,从手术时间、术中出血量、术后住院时间、术后并发症发生率等方面进行对比分析. 结果所有病例均在镜下完成,无一例中转开腹.2组肛门恢复排气时间、术后住院时间、术后并发症发生率差异均无显著性(P＞0.05).手术时间LAVH组短于TLH组[(95.6±18.2)min对(112.9±24.5)min,t=-4.883, P=0.000],但术中出血量以LAVH组为多[(73.8±50.8)ml对(49.8±26.9)ml, t=2.926, P=0.004]. 结论应用腹腔镜行全子宫切除是安全可行的,LAVH和TLH各有优势,但对经验丰富的术者而言,TLH更为合适.     

腹腔镜下全子宫切除与腹腔镜辅助阴式子宫切除的比较

目的对比分析腹腔镜全子宫切除术（total laparoscopic hysterectomy,TLH）和腹腔镜辅助阴式子宫切除术（1aparoscopic-assisted vaginal hysterectomy,LAVH）的临床价值。方法回顾性比较2007年1月-2012年1月1034例TLH和LAVH的手术时间、出血量、排气时间、住院时间、子宫重量及术后病率、泌尿系损伤、肠管损伤、血管损伤等并发症。结果1034例手术均顺利完成,无中转开腹。TLH组手术时间（80．4±19．2）min与LAVH组（80．2±17．8）min无显著性差异（t=0．166,P=0．868）;LAVH组出血量（53．4±14．3）ml显著多于TLH组（49．84-16．8）ml（t=-3．596,P=0．000）;LAVH组排气时间（27．1±5．5）h显著长于TLH组（24．6±5．1）h（t=-7．059,P=0．000）;LAVH组住院时间（5．4±1．2）d显著长于TLH组（5．1±1．4）d（t=-3．581,P=0．000）。LAVH组切除的子宫重量（286．1±28．2）g,与TLH组（279．6±27．4）g有显著性差异（t=-3．528,P=0．000）。术后病率TLH组1．4％和LAVH组1．7％无显著性差异（∥=0．122,P=0．727）。术后泌尿系统损伤1例（LAVH组）、肠管损伤1例（TLH组）、血管损伤2例（2组各1例）,2组并发症发生率无统计学差异[0．6％（2／345）vs．0．3％（2／689）,X2=0．031,P=0．861]。术后随访0．5～5年,平均3．9年,无切口感染、切口疝、出血等并发症发生。结论TLH和LAVH均是安全可行的。     

3种不同术式子宫切除的比较

目的探讨经腹子宫全切术(transabdom inal hysterectomy,TAH)、阴式子宫全切术(transvaginal hysterectomy,TVH)、腹腔镜辅助下阴式子宫全切术(laparoscop ic assisted vaginal hysterectomy,LAVH)的特点。方法回顾性分析2003年7月~2004年7月TAH 48例、TVH 38例、LAVH 31例的临床资料。结果TAH组的手术时间(73.7±5.9)m in显著短于TVH组(80.9±7.0)m in和LAVH组(129.3±9.1)m in(F=612.04,P=0.000);术中出血量LAVH组(142.8±17.1)m l显著多于TAH组(128.1±9.6)m l和TVH(129.7±10.2)m l(F=15.18,P=0.000);术后镇痛率TAH组(75.4%,36例)显著高于TVH组(30.2%,11例)和LAVH组(38.4%,12例)(2χ=20.310,P=0.000);术后住院时间TAH组(7.3±1.6)d显著长于TVH组(4.8±1.0)d和LAVH组(5.1±1.1)d(F=47.07,P=0.000);术后病率TAH组(8.4%,4例),TVH组(7.4%,3例),LAVH组(8.2%,3例)无显著性差异(2χ=0.074,P=0.964)。结论TVH和LAVH创伤小、病人痛苦少,术后恢复快。     

三种途径子宫切除术治疗良性子宫疾病的比较

目的：比较阴式子宫切除（ vaginal hysterectomy ,VH）、腹腔镜辅助阴式子宫切除（ laparoscopically assisted vaginal hysterectomy,LAVH）以及腹腔镜子宫切除（total laparoscopic hysterectomy ,TLH）治疗子宫良性疾病的特点。方法回顾性分析我院2011年3月～2013年11月因子宫良性病变行全子宫切除155例资料,由患者选择手术方式,VH组60例,LAVH组50例,TLH组45例。比较3组手术时间、出血量、止痛药的使用以及住院时间的差异。结果手术时间VH组[中位数65（40～85） min]＜LAVH组[90（45～150） min]＜TLH组[120（80～180） min]（χ2＝89．105, P＝0．000）;术中出血量VH组[208（155～241） ml]和TLH组[183（159～220） ml]＜LAVH组[359（316～413） ml]（χ2＝72．609, P＝0．000）;术后应用止痛药LAVH组[2（1～5）支]＜VH组[4（1～8）支]和TLH组[5（3～8）支]（χ2＝59．243, P＝0．000）。术后住院时间3组间差异无显著性（P＞0．05）。结论对于子宫良性病变,VH及LAVH是比较好的子宫切除术式。     

腹腔镜辅助下阴式子宫切除与阴式子宫切除在非脱垂子宫切除中的应用价值

目的探讨腹腔镜辅助下阴式子宫全切与阴式子宫全切在非脱垂子宫切除中的临床效果。方法回顾性分析2006年12月～2010年3月171例采用以上2种方式子宫切除的临床资料,其中腹腔镜辅助阴式子宫切除术93例（腹腔镜组）,腹腔镜监视下断离子宫圆韧带及附件后,经阴道切除子宫;阴式子宫切除78例（阴式组）,经阴道切开宫颈筋膜,打开前后腹膜,断离骶、主韧带及子宫血管,断离双侧附件,取出子宫。结果阴式组4例子宫周围粘连转腹腔镜辅助下手术。腹腔镜组手术时间（123±34）min,阴式组（80±30）min;腹腔镜组术中出血量（125±35）ml,阴式组（85±30）ml;术后住院时间腹腔镜组（6.2±1.3）d,阴式组（6.7±2.1）d;腹腔镜组住院费用（4635±980）元,阴式组（3320±305）元。腹腔镜组手术并发症发生率3.2%（3/93）,阴式组5.4%（4/74）。阴式组随访6～48个月,平均36个月,1例术后1个月检查发现阴道上段部分粘连,经粘连松解痊愈。腹腔镜组随访6～50个月,平均37个月,未发现并发症。结论腹腔镜辅助下子宫切除与阴式子宫切除两者各有其优势,但腹腔镜辅助下子宫切除较阴式子宫切除适应证广,手术较安全。     

腹腔镜下大子宫切除术86例报告

目的 探讨腹腔镜下巨大子宫切除术的手术技巧. 方法 回顾性分析1998年2月～2005年12月86例子宫超过12孕周行腹腔镜子宫切除手术的临床资料,其中12例腹腔镜下全子宫切除术（total laparoscopic hysterectomy,TLH））,59例腹腔镜子宫次全切除术（laparoscopic supracervical hysterectomy, LSH）和15例腹腔镜辅助阴式子宫全切除术（laparoscopic-assisted vaginal hysterectomy, LAVH）.手术中置镜位置采取在宫底上至少3～5 cm.手术关键步骤是处理附件及子宫血管,其中TLH和LAVH在阻断子宫血管后先旋切大部分宫体. 结果 86例全部在腹腔镜下完成手术,无一例中转开腹.1例术中出现皮下气肿,余无严重并发症发生.手术时间（92.3±33.5） min,术中出血量（113±31） ml,术后住院时间（4.1±0.3） d.86例随访6个月,无一例出现术后并发症. 结论 选择合适的置镜孔,处理好附件及子宫血管,腹腔镜下巨大子宫切除术安全、可行,不会增加手术危险性和手术并发症.     

腹腔镜辅助阴式大子宫切除术与开腹全子宫切除术临床效果的比较

目的探讨对大子宫行腹腔镜辅助阴式子宫切除术(laparoscopic-assisted vaginal hysterectomy,LAVH)的临床应用价值. 方法 2004年9月～2007年9月,根据患者对手术方式的自愿选择,对60例因子宫良性病变致子宫增大超过12孕周的患者行LAVH,将同期的开腹全子宫切除(total abdominal hysterectomy,TAH)患者随意选取60例作为对照组进行回顾性对比研究.2组年龄、子宫大小、病种、腹部手术史、合并卵巢囊肿情况无统计学差异. 结果 2组手术均顺利完成.与TAH组相比,LAVH组术中出血量少[(125.7±46.1) ml vs (148.5±56.0) ml, t=-2.435,P=0.016],术后住院时间短[(3 5±1.2) d vs (6.3±1.2) d, t=-12.324,P=0.000],需术后镇痛者少(5 vs 23, χ2=15.093,P=0.000),2组手术时间无统计学差异[(111.9±26.5) min vs (104.4±21.3) min, t=1.375,P=0.172]. 结论对超过12孕周的子宫行LAVH是安全可行的,但必须熟练地掌握手术技巧.     

腹腔镜下4种子宫切除术的比较

目的探讨腹腔镜子宫切除术4种术式的临床价值. 方法对腹腔镜筋膜内子宫切除术(classical intrafascial supracervical hysterectomy, CISH) 11例,腹腔镜辅助阴式子宫切除术(laparoscopic assisted vaginal hysterectomy, LAVH)9例,腹腔镜下次全子宫切除术(subtotal laparoscopic hysterectomy, SLH) 10例及腹腔镜下全子宫切除术(total laparoscopic hysterectomy, TLH)11例进行回顾性分析. 结果 CISH、LAVH、SLH及TLH 4组的手术时间、术中出血量、术后排气时间及术后住院时间均无统计学差异(P>0.05).4组术后病率均为0,均无严重并发症. 结论 4种术式安全可行,但应根据病人的具体情况选择.     

腹腔镜子宫切除术式的评价

1989年Reich施行首例腹腔镜辅助阴式子宫切除术（laparoscopic assisted vaginal hysterectomy，LAVH）。1991年Semm完成腹腔镜下筋膜内子宫切除术（classic intrafascial Semm hysterectomy，CISH）。经过10多年的发展，腹腔镜子宫切除已具有多种术式，技术趋于成熟，但选用何种术式更能达到预期效果有待进一步探讨，现就相关问题综述如下。     

腹腔镜全子宫切除术的应用

由于女性生殖道的结构特点，有多种方法可用来将病变的子宫切除。传统的手术方法是经腹或经阴道将子宫切除。腹腔镜下全子宫切除术指经过腹腔镜将子宫周围的韧带、血管、阴道壁切断，将子宫切除后自阴道取出，然后经腹腔镜下再次缝合阴道断端。腹腔镜子宫切除术除子宫全切除术外，还有几种不同的术式，包括腹腔镜辅助阴式子宫切除术（laparoscopic assisted vaginal hysterectomy, LAVH）、腹腔镜次全子宫切除术、腹腔镜下筋膜内子宫切除术。     

A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy

apd: 12 December 2000     

Outpatient laparoscopic hysterectomy: evaluation of pain

Background and Objectives:

The purpose of this study was to assess the differences in patient pain postoperatively, comparing 2 types of outpatient hysterectomy procedures.

Methods:

This is a nonblind, nonrandomized, prospective study of surgeries performed at 1 ambulatory surgery center by 1 surgeon over 14 months. Patient pain was assessed using a visual analog scale before and after laparoscopically assisted vaginal hysterectomy and total laparoscopic hysterectomy. Patients were followed through a 2-week postoperative period.

Results:

Nineteen laparoscopically assisted vaginal hysterectomies and 17 total laparoscopic hysterectomies were performed. The 2 groups were similar in age, BMI, uterine weight, and surgical time. Comparing the 2 groups, there were no statistically significant differences in pain throughout any time points of the study.

Conclusion:

There were no statistically significant differences in pain during the postoperative period between the 2 groups. Outpatient hysterectomy is a safe procedure that may improve patient satisfaction surgically and financially, and either approach is well tolerated by patients.     

Total laparoscopic hysterectomy and laparoscopy-assisted vaginal hysterectomy

Background and Objectives:

To compare the feasibility of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted vaginal hysterectomy (LAVH) in the treatment of benign gynecologic diseases and to determine the selection criteria for each technique.

Methods:

This was a retrospective medical records review of 168 patients who underwent TLH or LAVH performed by one surgeon. A chi-square test was used to compare the difference between the TLH and LAVH groups. Pearson''s correlation coefficient was calculated for the relationship between the clinico-demographic factors of the patients.

Results:

There were no differences between the 2 groups with respect to age, parity, history of abdominal delivery, body mass index, and indication for hysterectomy. The operative time was similar between the 2 groups (P>.99). The uterine weight was greater in the LAVH group compared to the TLH group (P<.01). Ten patients were converted from TLH to LAVH, because of a large uterus and/or a lower segmental mass on the uterus, making it difficult to expose the Koh cup rim contour.

Conclusions:

TLH and LAVH are safe, feasible methods by which to perform a hysterectomy. LAVH is preferred in patients with a mass involving the lower segment or a relatively large uterus.     

腹腔镜辅助阴式子宫全切术与阴式子宫切除术的临床应用体会

目的:比较腹腔镜辅助阴式子宫全切术(LAVH)与阴式子宫切除术(VH)的手术效果,探讨子宫切除术患者最佳术式的选择。方法:回顾分析2001年2月至2005年12月LAVH与VH手术病例268例,比较两种手术的手术时间、出血量、术后住院天数、术中、术后并发症的发生率。结果:两组手术的术中出血、手术并发症等差异无统计学意义。结论:VH与LAVH均为患者创伤小、康复快的微创手术,但VH适于子宫小、无粘连并伴下垂者,而LAVH扩大了VH的适应证,即使盆腔内有粘连或合并附件囊肿、子宫较大等也能顺利完成手术,是值得推广的手术方式。     

Introduction of a laparoscopic gynecological program in a general hospital in Taiwan.

BACKGROUND AND OBJECTIVES: We reviewed the records for 571 gynecologic laparoscopies performed at a privately owned general hospital in Kaosiung Taiwan in 1998 and 1999 and discuss here the major obstacles we encountered while introducing these procedures at our institution. METHODS: Included in this series are 293 procedures performed in 1998 (149 hysterectomies, 144 adnexal procedures), and 278 procedures performed in 1999 (131 hysterectomies, 147 adnexal procedures). Thirty-nine of these patients also underwent laparoscopic appendectomy. Mean patient age was 62 years (range 28 to 82). All procedures were performed by 1 of 6 board-certified gynecologic surgeons, or by 1 of 4 residents under the direct supervision of a board-certified surgeon. RESULTS: We experienced 0% mortality and 7.2% morbidity in this series. In comparing cases from 1998 and 1999, we observed a decrease in both mean surgery time (135.4 to 123.0, P=0.032) and mean length of hospital stay (5.52 to 4.62, P=0.046) for hysterectomies and adnexal procedures combined. CONCLUSIONS: These data support ongoing efforts to incorporate gynecologic laparoscopy as an alternative to open procedures at our institution. Introduction of these procedures in privately owned hospitals in Taiwan has been limited because of the large initial investment for equipment, patient education issues, and difficulties obtaining reimbursement.     

257 incidental appendectomies during total laparoscopic hysterectomy

OBJECTIVE: This retrospective observational report analyzes the demographics, blood loss, length of surgical duration, number of days in the hospital, and complications for 821 consecutive patients undergoing total laparoscopic hysterectomy over a 11-year period stratified by incidental appendectomy. METHODS: A retrospective chart abstraction was performed. ANOVA and chi-square tests were performed with significance preset at P<0.05. RESULTS: Of 821 consecutive patients undergoing total laparoscopic hysterectomy, 257 underwent elective appendectomy with the ultrasonic scalpel, either as part of their staging, treatment for pelvic pain, or prophylaxis against appendicitis. Comparing the 2 groups, no difference existed in mean age of 50+/-10 years or mean BMI of 27.6+/-6.7. Both groups had a similar mean blood loss of 130 mL. Surgery took less time (137 vs 118 minutes, P<0.0012) and the hospital stay was shorter in the appendectomy group (1.5 vs 1.2, P<0.0001) possibly because it was performed incidentally in most cases. No complications were attributable to the appendectomy, and complication types and rates in both groups were similar. Though all appendicies appeared normal, pathology was documented in 9%, including 3 carcinoid tumors. CONCLUSIONS: Incidental appendectomy during total laparoscopic hysterectomy is not associated with significant risk and can be routinely offered to patients planning elective gynecologic laparoscopic procedures, as is standard for open procedures.     

腹腔镜辅助与阴式子宫切除术的对比研究

目的:探讨腹腔镜辅助阴式子宫切除术的临床疗效.方法:回顾分析2010年2月至2012年2月为125例患者行腹腔镜辅助阴式子宫切除术(laparoscopic assisted vaginal hysterectomy,LAVH)的临床资料,并与同期117例阴式子宫切除术(transvaginal hysterectomy,TVH)进行对比分析.结果:两组患者手术时间、术中出血量差异有统计学意义(P＜0.05);术后3天平均体温、术后肛门排气时间、术中严重并发症及术后住院时间两组相比差异无统计学意义(P＞0.05).结论:两种术式均符合微创医学理念,各有优缺点.LAVH视野清晰,可发现并处理盆腔内其他病变;TVH利用阴道自然腔道施术,无需复杂、昂贵的仪器,术者只需具备熟练的手术技巧.根据患者自身情况、盆腔有无粘连及粘连程度、是否涉及附件手术,并结合术者手术技巧选择最适宜的手术方式,可最大限度地减少术中并发症.     

腹腔镜下子宫切除术740例临床分析

目的探讨腹腔镜下4种子宫切除术的临床价值。方法回顾性分析1999年1月~2004年12月,我院740例腹腔镜子宫切除术的手术时间、术中出血量、术中切除子宫重量、术后恢复情况、术后性生活恢复时间、性生活满意度、术后并发症发生率等。结果4组740例均在腹腔镜下完成手术。LSH、C ISH、TLH、LAVH组手术时间分别为(95.3±32.4)m in、(84.5±31.7)m in、(105.3±34.5)m in、(169.4±37.4)m in;术后性生活恢复时间分别为(30±5)d、(50±9)d、(35±7)d、(54±11)d;手术并发症发生率分别为1.7%(2/120)、1.3%(4/310)、2.8%(7/250)、1.7%(1/60)。结论应用腹腔镜行子宫切除术是安全可行的,4种手术方式各有利弊,应根据病人的具体情况选择具体的手术方式。     

Laparoscopic supracervical hysterectomy compared with abdominal, vaginal, and laparoscopic vaginal hysterectomy in a primary care hospital setting.

OBJECTIVE: This study compares the operative parameters of laparoscopic supracervical hysterectomy, laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, and total abdominal hysterectomy in patients in a small suburban medical center. METHODS: This investigation is a Canadian Classification II-2. It was performed in a 238 bed not-for-profit community general hospital. Charts of 117 patients were reviewed. These patients had undergone the following procedures: laparoscopic supracervical hysterectomy, laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, total abdominal hysterectomy; questionnaires completed by the patients were reviewed. All patients had hysterectomies performed by members of the Ob/Gyn department of Alamance Regional Medical Center. Comparisons of intraoperative and postoperative events were made in those patients who consented to the study and who returned their questionnaires. Parameters compared were patient age, weight, preoperative diagnosis, operative time, operative complications, blood loss, uterine weight, length of stay, postoperative complications, return to hospital, return to work, resumption of intercourse, dyspareunia, and bowel or bladder problems. RESULTS: Patient demographics and outcomes are similar. Laparoscopic supracervical hysterectomy showed lower morbidity and quicker return to normal function, but most findings did not reach statistical significance. CONCLUSION: The results support the conclusion that the patients in each arm of the study are similar. The operative parameters show a longer operating time for the laparoscopic procedures than for total abdominal hysterectomy and total vaginal hysterectomy, respectively. The other indicators of morbidity show slight advantages of laparoscopic supracervical hysterectomy in blood loss, length of stay, and resumption of normal activities.     

Needlescopic hysterectomy: incorporation of 3-mm instruments in total laparoscopic hysterectomy

Background  Progression to needlescopic techniques for advanced gynecologic procedures currently performed with conventional laparoscopy still is in its infancy, and published series are currently lacking in the gynecologic literature. This study aimed to report initial experience with incorporating needlescopic instruments in the performance of total laparoscopic hysterectomy (TLH). Methods  The study group consisted of 32 consecutive women undergoing needlescopic hysterectomy. The control group included 54 women who underwent conventional TLH over the preceding 12-month period and met the same inclusion criteria as the study group. Conventional TLH was performed using 5-mm working ports and a 10-mm laparoscope. The needlescopic hysterectomy differed from the conventional laparoscopic procedure in that 3-mm working ports were used as well as a 3- or 5-mm laparoscope at the umbilicus. Otherwise, the trocar layout and surgical technique were identical. Parameters of technical feasibility (operating time, estimated blood loss, perioperative complications) were considered major statistical end points. Results  In the study group, all but one procedure were performed successfully using the needlescopic approach. One patient in the needlescopic group required conversion to standard TLH because of uncontrollable bleeding from the uterine artery. The operative time and estimated blood loss of needlescopic hysterectomy were comparable with those of standard TLH. No significant complication occurred in either group. Conclusions  For properly selected patients, the needlescopic technique can be applied to TLH safely and effectively.