腹腔镜盆腔手术致泌尿系脏器损伤的防治

目的总结腹腔镜盆腔手术致泌尿系脏器损伤的原因、处理方法及预防措施。方法回顾性分析26例因腹腔镜盆腔手术致泌尿系脏器损伤的临床资料,包括普外科直肠手术3例、妇科手术23例;输尿管损伤21例、膀胱损伤5例。结果术中及时发现泌尿系损伤者7例,分别经内置双J管、输尿管端端吻合、输尿管或膀胱修补处理,均一期愈合,无并发症发生。术后发现泌尿系损伤者19例,其中膀胱阴道瘘3例,行耻骨上经膀胱修补成功;输尿管损伤16例,2例行逆行插管置双J管、14例行开放输尿管膀胱再植术治愈。结论腹腔镜盆腔手术创伤小、疗效高,提高手术操作技巧、积累经验有利于减少并发症的发生。     

腹腔镜技术在治疗妇科手术致输尿管损伤中的临床应用研究

目的:探讨妇科手术导致输尿管损伤行腹腔镜治疗的安全性及有效性。方法:回顾性分析2014年1月~2016年6月妇科手术发生输尿管损伤并腹腔镜修复的17例患者临床资料。平均年龄42(22~67)岁。术中发现输尿管损伤5例,即刻腹腔镜或膀胱镜置入双J管,腹腔镜下输尿管修补缝合或输尿管断端吻合。术后延迟发现输尿管损伤12例。其中1例为孤立肾患者,输尿管镜检发现输尿管下段局部缺损,予置入双J管并腹腔镜下修补输尿管。其余均在术后7~35天出现阴道残端漏尿。先在膀胱镜或输尿管镜下置双J管,置管失败11例患者行腹腔镜探查。损伤位置低,输尿管与膀胱直接插入吻合。损伤位置高,游离裁剪膀胱壁瓣并缝合成管状与输尿管吻合。结果:1例术后延迟发现输尿管损伤并成功置入双J管者长期漏尿,3个月后再行腹腔镜手术成功。其余患者均一期手术成功。术后住院5~8d,平均6d,保留导尿3~4周,术后4~8周膀胱镜下拔除双J管。全部病例术后3~6个月复查B超提示轻度积水。结论:妇科手术致输尿管损伤行腹腔镜下修复安全性好,成功率高,而且创伤小,瘢痕少,可以提高患者的满意度。     

南山医院妇科近10年腹腔镜手术严重并发症的回顾性分析

目的探讨妇科腹腔镜手术的并发症及处理措施。方法对我院2005年1月~2014年5月9208例妇科腹腔镜手术的临床资料进行回顾性分析。结果发生并发症9例,发生率0.1%(9/9208)。3例大血管破裂术中发现,间断缝合修补,术后生命体征平稳;肠管损伤1例,术后第5天发现,经阴道行直肠阴道瘘修补术;输尿管损伤3例,1例术中发现,即行输尿管移植术,其余2例术后1~2周发现,术后2个月余行开腹输尿管膀胱植入术;膀胱损伤2例,均为术中发现,腹腔镜下行膀胱修补术。9例术后3个月随访恢复好。结论术中应仔细解剖,手术结束前常规查看输尿管蠕动及膀胱情况,检查导尿袋尿是否红色及有无气体,怀疑肠道损伤可肛门直肠充气看盆腔有无水泡产生。大血管损伤应保持镇定,一般可以在腹腔镜下行缝合术。     

机器人辅助腹腔镜手术治疗深部浸润型子宫内膜异位症

目的探讨机器人辅助腹腔镜治疗深部浸润型子宫内膜异位症的安全性及可行性。方法回顾性分析2015年3月～2019年1月行达芬奇机器人辅助腹腔镜手术治疗深部浸润型子宫内膜异位症9例的临床资料,其中输尿管浸润型1例,膀胱浸润型2例,直肠浸润型6例。结果 9例均顺利完成机器人辅助腹腔镜手术,1例行输尿管狭窄段切除+端端吻合+双J管置入,术后12周拔除双J管;2例行部分膀胱切除+膀胱修补;2例行部分直肠切除+端端吻合;4例行部分直肠前壁切除+直肠修补。围手术期均无严重并发症。术后辅助3～6次亮丙瑞林3.6 mg皮下注射。术后随访10～14个月,9例临床症状均消失,无复发。结论机器人辅助腹腔镜手术治疗深部浸润型子宫内膜异位症安全可行。     

腹腔镜子宫切除术后输尿管阴道瘘的原因及处理

目的探讨腹腔镜子宫切除术后输尿管阴道瘘的原因及外科处理方法的选择。方法 2002年3月~2009年6月对22例妇科腹腔镜子宫切除手术导致输尿管阴道瘘施行即时经膀胱镜放置双J管（2例）;膀胱镜置管失败者采用经输尿管镜置入斑马导丝然后再置入双J管（4例）;上述2种方法均失败者采用经腹膜外或腹腔途径输尿管膀胱再吻合术,输尿管内置双J管（16例）。结果通过手术探查和输尿管镜检发现电刀电凝伤7例,血运障碍6例,直接损伤3例,输尿管缝扎2例,解剖变异2例;2例经膀胱镜双J管置入治愈未能了解原因。22例随访6~48个月,平均25.7月,6例经内镜支架管置入中3例术后出现输尿管下段狭窄行输尿管膀胱再吻合术;16例行输尿管膀胱再吻合术,其中15例治愈,1例术后2个月再次出现输尿管阴道瘘,经皮肾穿刺肾造瘘后3个月再行膀胱肌瓣输尿管吻合术治愈。结论输尿管阴道瘘是腹腔镜妇科手术的严重并发症,一经确诊应积极处理,但应根据患者具体病情制定个体化的治疗方案,治疗措施以恢复正常排尿通路及保护患侧肾脏功能为原则。     

腹腔镜辅助阴式子宫切除术泌尿系统损伤5例报告

目的 总结腹腔镜辅助阴式子宫切除术(laparoscopic-assisted vaginal hysterectomy,LAVH)泌尿系统损伤的教训与处理经验.方法 回顾分析我院1995年12月～2006年1月415例LAVH中5例出现泌尿系统损伤的临床资料.结果 术中2例膀胱损伤;术后3例输尿管损伤:2例术后第4天出现腹痛而发现,1例术后30d因无症状阴道大量排液发现.并发症发生率1.2%(5/415).结论 LAVH并发症高危因素有肿瘤直径＞5 cm,肿瘤突向阔韧带及接近宫颈峡部水平,手术修补是主要的治疗方式.     

罗氏穹隆杯在腹腔镜全子宫切除术中的应用价值

目的探讨罗氏穹隆杯在腹腔镜全子宫切除术中的应用价值。方法2004年10月～2005年2月，对7例有手术切除子宫指征者，脐孔置45。腹腔镜，脐耻间一个操作孔置超声刀，切断双侧圆韧带、卵巢固有韧带和输卵管近端、子宫动静脉、部分主韧带、膀胱宫颈韧带和宫骶韧带。术中应用罗氏穹隆杯定位撑开阴道穹隆。超声钩环形切开阴道前穹隆，从阴道取出罗氏穹隆杯，剪开后穹隆，将子宫自阴道取出，缝合阴道残断。结果7例手术均获成功，手术时间90～250min，手术者易于辨认和旋切阴道穹隆顶端，暴露充分，无一例膀胱、输尿管、直肠等重要脏器的损伤。结论罗氏穹隆杯是腹腔镜下全子宫切除术理想的手术辅助器械，有较高的临床应用价值。     

子宫切除术致输尿管或膀胱损伤的手术处理

目的:探讨子宫切除术所致的输尿管、膀胱损伤的手术处理时机。方法:对4例膀胱阴道瘘及5例输尿管阴道瘘中的近期4例,于损伤后2~3周内经腹入路一次修复;先前1例于4个月后修复。3例输尿管离断伤(其中2例为双侧),2例于损伤后第2天直接吻合,1例行输尿管皮肤造瘘。1例输尿管、膀胱并发直肠损伤患者,Ⅰ期尿、粪转流,Ⅱ期行修补、复通术。8例输尿管梗阻、肾积水患者,于伤后3~32个月,5例行输尿管膀胱肌瓣吻合,3例行输尿管膀胱再植术。结果:8例损伤后2~3周、1例于损伤后4个月施行膀胱阴道瘘及输尿管道阴道瘘修补术均获成功。3例输尿管离断伤其中直接吻合成功1例、失败1例。1例输尿管、膀胱并发直肠损伤患者经Ⅰ期尿、粪转流,Ⅱ期修补、复通后1年康复出院。8例输尿管梗阻、肾积水患者行输尿管膀胱再植术或输管膀胱吻合术均获成功。结论:子宫切除术所致输尿管、膀胱损伤的修复手术可提前于损伤后2~3周内施行;输尿管离断伤,应先行输尿管皮肤造瘘,经腹入路手术修复。     

女性盆腔手术后尿瘘诊治分析

目的探讨女性盆腔手术后尿瘘的病因、手术时机及手术方法。方法回顾分析我院2003年1月至2016年3月收治的28例尿瘘患者,年龄39~52岁,平均44.5岁,子宫附件切除术后6d~5月。其中输尿管阴道瘘8例,膀胱阴道瘘18例,输尿管膀胱阴道瘘2例。输尿管阴道瘘行输尿管插入法膀胱再植术,膀胱阴道瘘选择经膀胱三层交叉缝合法修补术,输尿管膀胱阴道瘘行输尿管膀胱再植加膀胱修补术。结果 28例全部一次手术治愈,平均手术时间90(70~150)min。28例患者随访未再出现漏尿,输尿管膀胱再植者1例患侧肾脏轻度积水,7例患侧吻合口无狭窄及反流。结论输尿管插入法膀胱再植术、经膀胱三层交叉缝合法修补术术式简单、成功率高,是最容易掌握的术式。膀胱阴道瘘修补术宜在术后3月进行,输尿管阴道瘘及时通过手术解除梗阻可避免肾功能进一步损害。     

腹腔镜结直肠手术中输尿管及尿道损伤的预防及处理

腹腔镜结直肠手术中输尿管及尿道损伤不容忽视。对于有输尿管扩张、肾盂积水、局部进展期肿瘤、新辅助放化疗、肿瘤复发需再次手术者,术前应放置双J导管。经腹手术中应熟知与输尿管相关的结直肠膜解剖,在正确的筋膜平面游离,保证肾前筋膜的完整,可以有效防止输尿管损伤。术中或术后早期发现的输尿管损伤,应及时修复重建;延迟发现的损伤应行Ⅱ期修复。经会阴手术,寻找直肠尿道肌、Hiatal韧带等解剖标志,遵循“先易后难”的原则,可以避免尿道损伤。术中发现尿道损伤可行尿道修补术或尿道端端吻合术,术后发现者应先膀胱造瘘后期行尿道牵引术。     

医原性输尿管膀胱损伤诊治分析

目的 探讨医原性输尿管膀胱损伤发生原因及防治方法.方法 医原性输尿管膀胱损伤患者47例,男7例,女40例.其中妇产科手术损伤38例、泌尿外科5例、普外科4例. 结果 术中发现输尿管损伤16例,其中断裂14例,输尿管壁部分撕裂伤2例;行输尿管断端吻合术13例,肾盂输尿管吻合术1例,1例输尿管镜手术引起输尿管穿孔者予终止手术并留置双J管,1例被迫切除肾脏;术后3～7 d发现输尿管损伤7例,其中输尿管下段被结扎4例.输尿管阴道瘘3例,均于术后2周内行输尿管下段膀胱再植术.术中发现膀胱损伤19例,膀胱壁不规则撕裂长约1～3 cm;行膀胱修补术17例,由腔镜和TVT手术引起膀胱穿孔2例予留置导尿1周;术后1周～1个月发现膀胱阴道瘘5例,均于3个月后行瘘管切除修补术.术后47例随访5个月～11年,平均47个月,患者均治愈,无并发症. 结论 医原性损伤重在预防,术中及时发现、正确处理可避免二次手术;术后出现尿瘘者选择合理治疗方案可提高治愈率.     

36例直肠、乙状结肠癌腹腔镜手术的临床经验总结

目的：总结腹腔镜直肠、乙状结肠癌手术的临床经验。方法：回顾分析2009年2月至2009年12月为36例患者行腹腔镜直肠、乙状结肠癌手术的临床资料。结果：34例顺利完成腹腔镜手术,2例因肿瘤较大、侵犯周围脏器（膀胱或子宫）而中转开腹行Hartman手术。平均手术时间145min;术中平均出血105ml;术后2~3d胃肠功能恢复;所有标本残端均无癌细胞浸润或残留,清扫淋巴结12~29枚,平均（16.2±4.7）枚;术后发生2例吻合口瘘,1例术后早期炎性肠梗阻,无术后出血、输尿管损伤等并发症发生。术后随访所有患者均恢复良好。结论：腹腔镜结直肠手术安全可行,短期效果理想。     

宫腔镜代替膀胱镜行膀胱内检查及输尿管逆行插管在妇科腹腔镜手术中的应用（附28例分析）

目的探讨在妇科腹腔镜手术中,以宫腔镜代替膀胱镜行膀胱内检查及输尿管逆行插管的临床应用价值。方法对19例盆腔病变复杂的妇科腹腔镜手术,在手术前使用宫腔镜代替膀胱镜行输尿管逆行插管;另有9例腹腔镜术后使用宫腔镜代替膀胱镜观察双侧输尿管开口蠕动（喷尿）及膀胱内情况。结果术前行输尿管逆行插管的19例,术中借助导管的定位辨识,避免了输尿管损伤及相关并发症;9例术后宫腔镜代替膀胱镜检查,发现1例左侧输尿管开口蠕动消失,立即腹腔镜探查并拆除该侧输尿管周围组织缝合线,再次置镜观察,输尿管开口蠕动恢复;1例发现膀胱内菜花状新生物,定位活检病理回报为膀胱移行细胞癌,转泌尿外科诊治。28例术后肉眼血尿时间16～42h,无泌尿系感染及相关并发症发生。结论在妇科困难腹腔镜手术中,以宫腔镜代替膀胱镜进行膀胱内检查及输尿管逆行插管,能够降低和及时发现输尿管损伤,是预防妇科腹腔镜手术中输尿管损伤并发症的有效措施。     

输尿管插管在预防妇科三、四级腹腔镜手术中输尿管损伤的应用价值

目的：探讨输尿管插管在预防妇科三、四级腹腔镜手术中输尿管损伤的应用价值。方法选取2009年1月～2011年11月182例我科三、四级腹腔镜手术182例作为研究组,术前均用膀胱镜放置双侧输尿管导管,然后行腹腔镜手术,术中在输尿管导管指示下手术,术后立即拔除导管。选取同期我科三、四级腹腔镜手术200例作为对照组,术前未行输尿管插管,比较2组患者术后输尿管损伤的发生率。结果研究组双侧输尿管置管成功率98．9％（180/182）,无一例损伤输尿管。对照组术后发现输尿管损伤2例,开腹行输尿管修补术并留置双J管,术后2个月治愈;膀胱损伤2例,术中均及时发现,立即请泌尿外科会诊,在泌尿外科大夫的协助下及时行膀胱修补术,术后留置尿管2周治愈。2组并发症发生率无统计学差异（ P＝0．125）。结论在妇科三、四级腹腔镜手术中应用输尿管导管可减少术中输尿管损伤的发生。     

Postoperative urinary outcomes in catheterized and non-catheterized patients undergoing laparoscopic-assisted vaginal hysterectomy—a randomized controlled trial

The objective of this study is to assess the impact of bladder catheterization on the incidence of postoperative urinary tract infection (UTI) and urinary retention (PUR) following laparoscopic-assisted vaginal hysterectomy (LAVH). One hundred fifty patients undergoing LAVH were randomly assigned to no catheter use, 1-day, and 2-day catheter groups. The relationship between preoperative, intraoperative, and postoperative factors and the rates of UTI and PUR were determined. The incidences of UTI and PUR were 9.3% and 18.7%, respectively. The highest rate of UTI occurred in the 2-day catheter group; the highest rate of PUR occurred in no-catheter-use group. Multivariable logistical regression showed the duration of catheterization was the single predictor of UTI; duration of catheterization and diabetes mellitus were predictors for PUR. While short-term indwelling catheterization resulted in decreased rate of PUR, UTI rate increased among patients undergoing LAVH. Nonetheless, most patients resumed normal urination shortly after surgery.     

Laparoscopic assisted vaginal hysterectomy (LAVH). Overview on 25 case series

The aim of the study is to evaluate the laparoscopically assisted vaginal hysterectomy (LAVH) in terms of indications, uterine size, surgical procedures and their safety, intraoperative complications and blood loss, operative time, concomitant surgical procedures and postoperative period of complications. A total of 25 patients underwent LAVH between 1998 and 1993, in our surgical unit. The mean age of our patients was 44.2 years (range 36-66). The most common indication was fibromyoma. The mean size of the removed uterus was 11.5 cm. The mean weight was about 242 g. The mean estimated blood loss was 155 ml and the mean operative time 150 min. Intraoperative complications included one case of bladder injury due to thick adhesions. Postoperative complications included 2 cases of cystitis, and 3 cases of ileus. The hospital stay was 2 to 7 days.     

电视腹腔镜子宫切除术与阴式、腹式子宫切除术的临床评价

本文对腹腔境辅助阴式子宫切除术、阴式子宫切除术、腹式子宫切除术三组术式进行信床评价。每组10制，对其手术指征、腹腔镜组、腹式组以子宫肌瘤、卵巢肿瘤为主各为90％、100％，而阴式组则以子宫脱垂为主占100％(P值＜O．001)。腹腔镜组还能同时行胆囊切除术占30％。所切除子宫大小阴式组小于正常子宫占90％。而腹腔境组、腹式组均超过正常子宫大小(P＜0．001)。术后肠功能恢复在24h之内．腹腔镜组占100％、阴式组占80％、腹式组占20％(P＜0．001)。腹腔境组术后无需用镇痛剂。术后住院日腹腔镜组平均5天乏与腹式组平均7．3天比较。P＜0．001。得出腹腔镜辅助阴式子宫切除术兼阴式、腹式子宫切除术的优点。虽然出现2例非损伤性并发症．但只要仔细操作，该项手术在妇科手术领域有很大空间。     

Minimizing bladder injury in laparoscopically assisted vaginal hysterectomy among women with previous cesarean sections

Background This study demonstrated a method to prevent bladder injury during laparoscopically assisted vaginal hysterectomy (LAVH) to patients with vesicocervical adhesion after previous cesarean deliveries. Methods Between July 2004 and July 2005, 50 women with vesicocervical adhesion who had given birth by cesarean delivery underwent LAVH. To minimize the chance of bladder injury, transvaginal lateral intervention was used to enter the anterior cul-de-sac during laparoscopic intrafascial hysterectomy. The lateral windows of the vesicocervical space were opened first. Usually, the potential spaces lateral to the adhesions could be developed easily by blunt finger dissection. Once adequate lateral spaces were created, an index finger was swept medially to define the margin of the midline adhesions secondary to the cesarean delivery scar. Under direct vision and finger guidance, the dense adhesions were dissected with more confidence and safety. Subsequently, the bladder was pushed gently aside to avert unexpected tearing or injury along the intrafascial hysterectomy. Because the vesico-uterine fold had been cut open previously under laparoscopy, the anterior cul-de-sac could be entered without much resistance. Results The average age of the patients was 45 ± 7 years, and the extirpated uterine weight was 323 ± 170.8 g (range, 85–730 g). Intraoperatively, the mean operation time was 124.6 ± 28.5 min (range, 80–235 min), and the average blood loss was 79.1 ± 47.8 ml (range, 20–250 ml). The mean intramuscular meperidine requirements were 1.2 ± 0.8 ampules (range, 0–2 ampules) (1 ampule = 50 mg), and the average hospital stay was 3.2 ± 0.9 days (range, 2–5 days). Of these 50 patients, 24 (48%) had one, 22 (44%) had two, and 4 (8%) had three previous cesarean deliveries. No bladder injury occurred among the patients, and there was no other complication. Conclusion Transvaginal lateral intervention may help to minimize bladder injuries during LAVH for patients with previous cesarean deliveries.     

Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse

Objectives:   To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP).
Methods:   Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series.
Results:   Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain.
Conclusions:   Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.