Laparoscopic management of bleeding after laparoscopic or vaginal hysterectomy.

OBJECTIVE: To assess the results and contributions of laparoscopy in the management of postoperative bleeding following laparoscopic (LH) or vaginal hysterectomy (VH). METHODS: A retrospective study of a 5-year period was carried out on 1167 women who underwent laparoscopic or vaginal hysterectomy. Ten women with postoperative bleeding following laparoscopic or vaginal hysterectomy were identified. RESULTS: The overall incidence of bleeding after laparoscopic or vaginal hysterectomy was 0.85% (10 of 1167). Over the 5-year study period, the incidence fluctuated between 1.1% and 0.4%. Surgical revision was primarily vaginal in 1 woman, followed by laparoscopic control. In 6 patients, laparoscopy was performed immediately. The patients profited from the prompt laparoscopic treatment, because intraabdominal hemorrhage was found and stopped. Of 6 cases of intraperitoneal bleeding, 1 resulted from a blood disorder. The collagen-fibrin agent TachoComb was applied locally, and the patient was postoperatively treated with blood products and coagulation factors. Only bipolar coagulation, TachoComb, and Foley catheter were used to achieve local hemostasis during laparoscopy. The remaining 3 cases where the vaginal cuff was bleeding were managed by vaginal repair and packing without laparoscopy. CONCLUSION: The laparoscopic approach to postoperative bleeding following laparoscopic or vaginal hysterectomy is an attractive alternative to the abdominal surgical approach. Bleeding following laparoscopic or vaginal hysterectomy can be managed by laparoscopy in the majority of patients. Because the abdominal incision is avoided, the recovery time is reduced.     

Multi-institute survey on actual conditions of urologic management for severe bladder dysfunction after hysterectomy

We conducted a multi-institute survey on the conditions related to urologic management of severe voiding dysfunction after hysterectomy for uterine cancer with or without postoperative irradiation. Our first study population was a group of adult female patients currently managed by urologists, using clean intermittent catheterization (CIC). Of the 287 patients in this group, 99 (34%) had suffered from uterine cancer. Of these patients, 94 underwent hysterectomy for this disease; 44 and 30 were treated with or without postoperative radiation, respectively, while postoperative irradiation status was unknown for 20. Median follow-up after surgery was 21 (0.2-52) years and median interval from operation to the introduction of CIC was 4.0 (0-49) years. CIC tended to be introduced later for patients with postoperative radiation than those without it. Seventy-four patients, who required invasive urologic interventions other than CIC for voiding dysfunction after hysterectomy, are the second study population. Most of these (82%) had received postoperative irradiation. Continuous Foley catheter placement was the most frequent procedure. Long-term follow-up and urologic management for voiding dysfunction is required for patients undergoing hysterectomy.     

腹腔镜子宫切除术输尿管损伤的预防

目的:探讨腹腔镜子宫切除术输尿管损伤的原因及预防措施。方法:回顾分析2009年1月至2010年12月6例患者行腹腔镜子宫切除术发生输尿管损伤的临床资料。结果:为337例患者行腹腔镜子宫切除术,包括腹腔镜全子宫切除术及腹腔镜辅助阴式子宫切除术,6例发生输尿管损伤,发生率1.78%。6例均有盆腔粘连,发生于右侧;其中2例为输尿管切断,4例为热损伤导致输尿管漏。手术器械使用不当及处理子宫血管时大块钳夹电凝是腹腔镜手术输尿管损伤的主要原因。结论:盆腔严重粘连患者行腹腔镜子宫切除术应慎重。熟悉器械性能并正确使用,处理子宫血管时避免大块钳夹电凝是预防输尿管损伤的主要措施。     

Hysterectomy for Treatment of CIN

The objective of this investigation was to determine the percentage of microinvasive and invasive cancers found when CIN 3 was treated by hysterectomy. The postoperative histologic findings of all patients with CIN 3 treated by conization or hysterectomy were analyzed. In 295 patients treated by conization, 14 (4.75%) microinvasive and 11 (3.73%) invasive cancers were found. Histologic analysis of 106 hysterectomy specimens revealed microinvasive carcinoma in 11 (10.38%) and invasive carcinoma in 17 (16.04%) cases. The finding of unexpected invasive cervical cancer in hysterectomy specimens seems significantly higher compared with conization. One must be cautious to avoid hysterectomy as the primary mode of treatment for women with coincident uterine pathology, postmenopausal women, or those who do not desire further reproduction. Hysterectomy as a mode of treatment for CIN 3 should be performed only if the existence of invasive cancer was excluded with certainty.     

Hepatic Surgery Using the Ligasure Vessel Sealing System

Blood loss, a well-known risk factor for morbidity and mortality during liver resection, occurs during parenchymal transection, so many approaches and devices have been developed to limit bleeding. Surgical technique is an important factor in preventing intraoperative and postoperative complications. The aim of the present study was to determine whether the bipolar vessel sealing device allows a safe and careful liver transection, achieving a satisfactory hemostasis thus reducing blood loss and related complications.A total of 30 consecutive patients (18 male, 12 female with a mean age of 63 years) underwent major and minor hepatic resection in which the bipolar vessel sealing device was used without routine inflow occlusion. A crush technique followed by energy application was used to perform the parenchymal transection. No other devices were applied to achieve hemostasis. The bipolar vessel sealing device was effective in 27 cases of hepatic resection. It failed to achieve hemostasis in three patients, all of whom had a cirrhotic liver. Median blood loss was 250 ml (range: 100-1600 ml), and intraoperative blood transfusions were required in five patients (17%). Mean operative time was 200 minutes (range: 140-360 minutes). There was no clinical evidence of postoperative hemorrhage, bile leak, or intraabdorninal abscess.The postoperative complication rate was 17%. The bipolar vessel sealing device is a useful tool in standard liver resection in patients with a normal liver parenchyma, but its use should be avoided in cirrhotic livers.     

Changes in surgical strategies for peptic ulcers before and after the introduction of H2-receptor antagonists and endoscopic hemostasis

A total of 902 surgical patients with peptic ulcer disease were evaluated to clarify the effects of H₂-receptor antagonists and endoscopic hemostasis on surgical treatment. Following the introduction of these treatments to our institute in 1982, the number of operations performed annually decreased by 40%, or 36 cases per year. However, a remarkable increase in the frequency of surgical emergency intervention since 1982 was concurrently observed, with the ratio of emergency procedures to the total number of operated cases increasing to 72.5% in the last 5 years of the study. Moreover, intractability as an indication for surgery decreased to 34.1%, compared with an increase in the number of patients with bleeding and perforated ulcers requiring operation. There were 13 postoperative deaths recorded (1.4%). All of the deaths were in patients who had undergone emergency surgery in poor health. Of these 13 patients, 10 had bleeding ulcers. A study of bleeding ulcers for which endoscopic hemostasis had been unsuccessful revealed that shock on admission and a concomitant medical condition had been evident in all the patients who died, and in 52.2% and 30.4% of the survivors, respectively. The current study suggests that the frequency of high-risk patients requiring surgery is increasing since the introduction of H₂-receptor antagonists and endoscopic hemostasis, and thus, prompt surgical treatment and intensive management for such patients is essential.     

The efficacy and mid-term results with use of gelatin resorcin formalin (GRF) glue for aortic surgery.

Twenty-six patients were treated by surgical procedure for aortic diseases with use of Gelatin Resorcin Formalin (GRF) glue. They consisted of 25 cases of emergency surgery for type A acute aortic dissection (AAD) and one elective case of distal arch aneurysm. Fifteen patients had moderate to massive aortic regurgitation (AR). We applied GRF glue to adhere the false lumen. It was further applied to anastomosed stitches from the outer side of the aorta. We evaluated the intraoperative effects of it in terms of adhesion and hemostasis and postoperative aortic regurgitation. Furthermore, the mid-term survival rate was investigated. In all cases, the 2 layers were able to be adhered successfully. Furthermore, it was very easy for suturing to pass through the aortic wall, even though the aortic stump was very hard. However, in the distal arch aneurysm case, additional sutures were needed to control the bleeding from the anastomosis. In postoperative aortography, residual AR was found in only one case. Operative deaths were indicated in 3 cases (11.5%). One patient died of hepatic failure on the 9th postoperative day. The other patients died of multiple organ failure. There were 3 cases of late death. The actuarial survival rate at 35 months was 76. 9%. According to these results, we recommend that GRF glue is very effective to reinforce the diseased aortic wall and will improve long-term survival. However, it is considered that the hemostasis effect of GRF glue is not sufficient to be used on anastomosed stitches from the outer side of the aorta.     

经腹、经阴道及腹腔镜辅助经阴道全子宫切除术临床比较

目的比较经腹全子宫切除术（transabdominal hysterectomy,TAH）、非脱垂子宫经阴道全子宫切除术（non-prolapsed transvaginal hysterectomy,TVH）及腹腔镜辅助经阴道全子宫切除术（laparoscopical-ly assisted vaginal hysterectomy,LAVH）的临床特点及应用价值。方法回顾性分析我院因子宫良性疾病行全子宫切除术的365例患者临床资料,按手术方式分为：TAH组（138例）、TVH组（110例）及LAVH组（117例）。比较三组手术时间、术中出血量、术后镇痛率、肛门排气时间、术后病率、术后住院时间以及医疗费用。结果三组术中出血量、术后病率比较无统计学差异（P〉0.05）,TVH组及LAVH组术后镇痛率、术后肛门排气时间及住院时间均少于TAH组（P〈0.05） TAH组及TVH组的手术时间和医疗费用明显低于LAVH组（P〈0.05）。结论TVH术式手术时间短、术后镇痛率低、住院时间短、医疗费用低,兼有TAH及LAVH的优点 临床应根据不同情况选择不同的子宫切除术式以达到最佳治疗效果。     

Influence of hydroxyethyl starch on coagulation in patients during the perioperative period.

The perioperative use of hydroxyethyl starch (HES) has been implicated as a possible cause of intracranial bleeding. The purpose of this study was to compare the influence on blood coagulation of the isovolemic replacement of 1-L blood loss with either 6% HES (molecular weight [MW] average: 450,000) or 5% human albumin during neurosurgery or lower abdominal surgery. Twenty patients scheduled for brain tumor surgery and 20 patients undergoing transabdominal hysterectomy were studied. The activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor VIII coagulant, von Willebrand factor antigen, platelet count, and the activated clotting time were compared after induction of anesthesia, after administration of 500 and 1000 mL of colloid solution, and 24 and 48 h postoperatively. All measured coagulation variables remained within physiologic range. Changes in coagulation indices were identical in neurosurgical and hysterectomy patients, except for a larger increase in fibrinogen concentration 24 and 48 h after hysterectomy. The acute phase reaction of factor VIII coagulant and von Willebrand factor, which plays a role in postoperative hypercoagulability, was attenuated by the use of HES. We conclude that isovolemic replacement of 1-L blood loss with either 6% HES (MW average: 450,000) or 5% human albumin does not interfere with normal hemostasis during and after neurosurgery or lower abdominal surgery.     

腹腔镜辅助阴式子宫切除术与开腹全子宫切除术的对比研究

目的：比较腹腔镜辅助阴式子宫切除术（laparoscopic assisted vaginal hysterectomy,LAVH）与传统开腹全子宫切除术（total abdominal hysterectomy,TAH）的临床价值。方法：回顾分析为良性子宫病变、无生育要求的102例患者施行全子宫切除术的临床资料。其中LAVH组54例,TAH组48例。结果：LAVH组2例中转开腹,成功率96.3%。两组手术时间及术中出血差异无统计学意义（P〉0.05）,LAVH组术后排气时间、住院时间及最高体温均优于TAH组,差异有统计学意义（P〈0.05）。结论：LAVH能达到传统开腹手术的疗效,具有患者损伤小,术中出血少,疼痛轻,肠功能恢复快,术后体温恢复时间短,住院时间短,美观等优点。     

非脱垂大子宫阴式切除术后腹腔内大出血6例临床分析

目的:探讨非脱垂大子宫阴式切除术(TVH)术后腹腔内大出血的原因、处理及预防措施.方法:回顾性分析我院自1995年8月-2010年10月行非脱垂大子宫TVH 960例患者中6例术后早期腹腔内大出血并成功止血患者的临床资料.结果:腹腔内大出血共6例,发生率0.62%,其中子宫肌瘤4例,子宫肌腺症2例.子宫平均如孕10周大...     

The application of gastro-duodeno-fibroscopy in the diagnosis and treatment of ulcers complicated by gastroduodenal hemorrhage

The results of gastrofibroscopic investigation were analyzed in 1491 patients with gastroduodenal ulcer, complicated by hemorrhage. Comparative analysis of the endoscopic hemostasis efficacy was conducted in 327 patients with persisting hemorrhage and for prophylactic hemostasis--in 158 patients with stopped hemorrhage and unstable hemostasis. The most effective method of coagulation, mechanical hemostasis is that, using the clips and combined methods. Performance of endoscopic hemostasis manipulations had promoted the lowering of general lethality down to 3.6%, and the postoperative one--to 1.8%.     

腹腔镜与腹式全子宫切除术术后疲劳综合征的对比研究

目的:对比分析腹腔镜与腹式全子宫切除术术后疲劳综合征的特点。方法:126例患者根据手术方式分为腹腔镜组(58例)与开腹组(68例),分别于术前(T0),术后第1天(T1)、第3天(T2)、第5天(T3)进行Christensen疲劳评分、利势手握力测试,并抽取空腹静脉血化验白蛋白、转铁蛋白、前白蛋白、维A结合蛋白、C反应蛋白、IL-6、TNF-α和白细胞计数,将两组结果进行对比。结果:术前两组患者各项目差异均无统计学意义(P>0.05)。术后腹腔镜组各测试时间点疲劳评分较低,利势手握力较高,前白蛋白和维A结合蛋白较高,炎症指标水平较低,但两组血浆白蛋白和转铁蛋白差异无统计学意义(P>0.05)。结论:腹腔镜全子宫切除术可减轻术后炎症水平,减少对机体营养状态的影响,有效降低了患者术后疲劳综合征的严重程度,利于术后康复。     

Hysterectomy for benign lesions: peroperative and early postoperative complications

OBJECTIVE: Although hysterectomy for benign disorders is a routine and usually well-tolerated procedure, complications do occur, and the resulting morbidity rates are not negligible. The aim of this prospective study was to report perioperative and early postoperative complications observed after hysterectomy, regardless of the route or the operator. PATIENTS AND METHODS: Between March 31, 1991 and December 14, 1998, 1,604 patients (mean age: 46.5 +/- 8.1 years) underwent an hysterectomy for benign disorders. Perioperative and early postoperative complications, in the 1,248 vaginal hysterectomies (77.9%), 190 laparoscopically-assisted vaginal hysterectomies (11.9%) and 166 abdominal hysterectomies (10.2%) were noticed in each group and compared. RESULTS: None of the patients died in this series. Lesions on the urinary tract included 15 bladder injuries (0.9%) and 1 ureter injury (0.06%) without significant difference between routes. There were 9 (0.6%) intestinal injuries, with a significant increase when laparotomy was performed (2.4%). In 45 patients (2.8%), bleeding exceeded 500 mL: and vaginal hysterectomy caused significantly fewer cases of heavy bleeding (2%, p < 0.001) than either laparotomy (6.7%) or laparoscopy (5.3%). The overall reoperating rate was 0.8% and this does not differ with the type of the procedure. CONCLUSION: Peri- and early postoperative complications after hysterectomy for benign disorders are not a rare event. In order to control complications and decrease the morbidity, a high-risk population should be defined based on the patients' history of pelvic surgery and endometriosis, on their parity and the size of their uterus. For these patients, the most appropriate route should be preferred and complications should be assessed using different tests and subsequently treated during the same procedure.     

Longterm followup of posthysterectomy vaginal vault prolapse abdominal repair: a report of 85 cases

BACKGROUND: There are many surgical procedures to treat posthysterectomy vaginal vault prolapse. Abdominal sacral colpopexy is one of these procedures. The aim of this study was to review the cases of 85 consecutive patients treated by this technique since 1978 by the same surgical team using the same procedure. Our surgical procedure will be explained. STUDY DESIGN: Eighty-five patients were treated in our department between 1978 and 1998 for posthysterectomy vaginal vault prolapse. The mean age was 55.42 years. The mean weight was 63.37 kg. Their parity ranged from 0 to 5 (mean, 2.54). The interval of time between hysterectomy and vaginal vault prolapse repair ranged from 1 to 37 years (mean, 17.92 years). The main indication for hysterectomy was uterine leiomyomas. Of these patients, 67.05% had stress urinary incontinence, and mean urethral closure pressure was 48.7 cm H2O. All patients had abdominal sacral colpopexy associated with a Burch procedure and a posterior perineal repair. RESULTS: Seventeen patients had postoperative fever. Twenty-two had urinary tract infections. Two patients had to undergo blood transfusion. Three patients had postoperative urinary retention. The median longterm followup was 10.5 years; 27.05% of patients had relapsing stress urinary incontinence. Two patients had a relapse of the vaginal vault prolapse. CONCLUSIONS: The abdominal sacral colpopexy is a safe operation with low morbidity and long-standing good results. It can be recommended for sexually active women. Nevertheless, the Burch procedure performed with this operation failed to prevent recurrence of urinary incontinence.     

腹腔镜肝切除术治疗肝内胆管结石中转开腹的原因分析及预防

目的 探讨腹腔镜肝切除术治疗肝内胆管结石中转开腹的原因以及预防措施.方法 回顾性分析2015年1月至2020年8月浙江省人民医院收治的165例因肝内胆管结石行腹腔镜肝切除术,其中15例中转开腹患者的临床资料.结果 本组资料中转开腹率为9.1％(15/165),其中男6例,女9例,年龄34～75岁,中位年龄57岁;肝功能...     

59例难治性宫缩乏力产后出血首次手术干预分析

目的探讨首次选择5种干预性手术在抢救难治性宫缩乏力性产后出血的应用价值。方法回顾性分析2006年3月至2013年2月间,首次采用宫腔填塞(塞纱)、B-Lynch缝合、CHO缝合、子宫动脉栓塞术、子宫切除5种干预性手术的59例难治性宫缩乏力性产后出血病人的临床资料。结果首次止血成功50例,成功率84.75%,其中17例宫腔填塞(塞纱)成功14例,22例B-Lynch缝合成功17例,9例CHO缝合成功8例,9例经导管动脉栓塞术(TAE)及2例子宫切除术均抢救成功,各组间止血成功率比较,差异均无统计学意义(P>0.05)。结论 5种止血手术对于难治性宫缩乏力性产后出血均有良好的止血效果,具体处理方案需根据当时具体情况制定。     

腹腔镜下系统保留盆腔自主神经广泛性子宫切除术的临床观察

目的初步研究腹腔镜下系统保留盆腔自主神经的广泛性子宫切除术（SNSRH）治疗早期宫颈癌的可行性及临床价值。方法选取2011年8月～2013年8月,郑州市第一人民医院对28例Ⅰa～Ⅱa期宫颈癌患者行SNSRH与同期传统的腹腔镜下非保留神的广泛性全子宫切除术对比,分析两组手术时间、术中出血量、手术并发症、术后住院天数及术后膀胱、直肠功能情况。结果（1）保留组与非保留组严格按照Ⅲ型子宫切除标准,手术切除范围差异无统计学意义;（2）成功保留神经24例,失败4例,成功率为86％;（3）两组手术范围、术中出血量差异无统计学意义（P〉0．05）;平均留置尿管天数、术后残余尿量、排气排便时间差异有统计学意义（P〈0．05）。结论腹腔镜下SNSRH具有可行性,有助于术后膀胱、直肠功能的恢复。     

腹腔镜与开腹全子宫切除术对术后深静脉血栓形成影响的对照研究

目的：探讨腹腔镜与开腹子宫切除术对患者凝血、纤溶系统及术后深静脉血栓形成（deep vein thrombosis,DVT）的影响。方法：将65例良性疾病行子宫切除术的患者非随机分为两组,32例行腹腔镜子宫切除术（腹腔镜组）,33例行开腹子宫切除术（开腹组）,分别于术前、术后即刻、术后24 h及术后48 h抽取静脉血检测凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、凝血酶时间（TT）、纤维蛋白原（FG）及D二聚体（D-D）等指标,观察各指标的变化及术后深静脉血栓发生率。结果：术后即刻及术后24 h两组患者APTT较术前明显降低,差异有统计学意义（P〈0.05）;各时点PT、TT较术前无明显变化（P〉0.05）。两组患者术后即刻D-D值明显升高,与术前相比差异有统计学意义（P〈0.05）;术后24 h、48 h进一步升高,与术后即刻相比差异有统计学意义（P〈0.05）。术后即刻、术后24 h两组患者FG均升高,与术前相比差异有统计学意义（P〈0.05）。两组间各指标相比差异无统计学意义（P〉0.05）。两组术后DVT发生率无明显差异（P〉0.05）。结论：腹腔镜与开腹子宫切除术均可使患者血液呈高凝状态,增加了术后血栓的发生风险;对于血栓高危因素的患者术后需常规采取预防措施。因腹腔镜手术住院时间短,术后应密切随访与指导。