经阴道自然腔道内镜全子宫双附件切除术临床分析

目的探讨经阴道自然腔道内镜(transvaginal natural orifice transluminal endoscopic surgery，V-NOTES)全子宫双侧附件切除术的临床效果。 方法收集沈阳市第四人民医院妇科2018年1月至2019年1月间实施的V-NOTES全子宫双侧附件切除术20例，手术的所有操作均在V-NOTES下完成，采用传统直杆腹腔镜器械及普通10 mm 30°电子镜，电凝及切割组织采用能量器械(双极、超声刀)。经阴道切下全子宫后，置入PORT，在腹腔镜下离断切除双侧附件。 结果20例患者切除的平均子宫质量(794±115)g，平均手术时间(125±22)min，平均术中出血量(150＋58)ml，平均术后疼痛视觉模拟评分(2.7±0.7 )分，平均术后肠道功能恢复时间(24±1.92)h，平均术后住院时间(3.85±0.42)d。20例患者均未发生并发症，平均术后随访时间(45±22)d。术后随诊，所有患者均无明显自觉症状，尿便正常，阴道分泌物正常，阴道残端切口均愈合良好。 结论V-NOTES全子宫双侧附件切除术安全可行，腹部无切口，术中可同时探查盆腹腔。     

经阴道NOTES辅助腹腔镜下肾切除术

目的 探讨经阴道NOTES辅助腹腔镜下肾切除术的安全性和可行性.方法 应用经阴道NOTES辅助腹腔镜技术行肾切除术5例.均为女性,中位年龄41(36～63)岁.其中输尿管结石并肾重度积水无功能肾4例,结核肾1例;左侧2例,右侧3例.全麻,截石位,患侧垫高约60.,于左右脐缘置入5 mm和10 mm套管;自阴道后穹窿置入10 mm套管,并由此置入腹腔镜,充分游离患肾后完整切除,装入标本袋自阴道后穹窿切口取出.结果 5例手术均成功完成.术中术后未发生并发症.中位手术时间190(150～260)min,术中中位失血量185(150～210)ml.5例术后第1天下床活动,第2天排气并进饮食.腹腔及盆腔引流管引流液少,术后第3天B超检查腹腔及盆腔无积液,先后拔除引流管.术后第7天脐部切口拆线痊愈出院,经窥阴器检查阴道后穹窿切口愈合良好.结论 经阴道NOTES辅助腹腔镜下肾切除术安全可行,较普通腹腔镜和单孔腹腔镜手术创伤更小,美容效果更佳.     

经阴道单孔腹腔镜手术在卵巢良性肿瘤中的应用

目的:探讨经阴道单孔腹腔镜手术(V-NOTES)治疗卵巢良性肿瘤的可行性与安全性。方法:回顾分析2017年12月至2019年10月收治的40例卵巢良性肿瘤患者的临床资料,根据手术方式分为V-NOTES组(n=20)与经脐单孔腹腔镜手术(TU-LESS)组(n=20),对比分析两组手术时间、术中出血量、血红蛋白变化值、术后48 h最高体温、术后首次肛门排气时间、术后住院时间、治疗费用、疼痛视觉模拟评分及美容评分。结果:两组手术均顺利完成。两组手术时间、术中出血量、血红蛋白变化值、术后48 h最高体温、术后住院时间及住院费用差异无统计学意义,但V-NOTES组首次肛门排气时间、疼痛评分、美容评分优于TU-LESS组。结论:与TU-LESS相比,V-NOTES治疗卵巢良性肿瘤疼痛轻、术后康复快、美容效果好。     

剖宫产术后切口瘢痕妊娠的诊断与治疗

目的探讨剖宫产切口瘢痕妊娠的早期诊断、治疗方法及预后情况。方法对2008年1月～2011年8月笔者所在医院妇科收治的9例剖宫产术后切口瘢痕妊娠患者进行回顾性总结分析。结果既往有人工流产史者6例,主要表现为停经（88%）及不规则阴道流血（100%）,血β-hCG介于1899～35276mIU/mL之间。B超均提示剖宫产切口瘢痕妊娠可能。7例患者采用保守治疗成功,1例患者经腹式手术切除妊娠组织成功,1例患者经阴式手术切除妊娠组织成功。结论血β-hCG水平和B超对剖宫产切口瘢痕妊娠诊断帮助较大,多数可保守治疗获得成功,但需充分备血及做好手术切除子宫的准备。     

尼曼匹克病肝移植术后成功妊娠分娩1例并文献复习

目的总结尼曼匹克病肝移植患者术后妊娠的临床经验。方法回顾性分析1例尼曼匹克病B型患者接受肝移植后成功妊娠分娩的临床资料。结果该例患者于2011年7月8日行肝移植术,同时行脾动脉结扎,手术及术后恢复顺利,术后常规抗排斥治疗,后逐渐改为单用他克莫司,剂量2.5 mg/d,血药浓度维持在2 ng/m L。2015年9月该患者成功妊娠,于2016年6月2日行剖宫产分娩一男婴。分娩后短期内少量母乳喂养,产妇及新生儿随访至投稿日,母亲正常,婴儿生长发育正常。结论尼曼匹克病患者肝移植术后妊娠分娩可取得良好结局。     

经阴道超声诊断输卵管妊娠108例分析

目的:探讨经阴道超声在诊断早期输卵管妊娠的价值,提高输卵管超声符合率,给临床早期治疗提供可靠的参考价值.方法:对108例术后诊断为输卵管妊娠的声像图特征进行回顾分析.结果:108例经阴道超声下均探及包块,包块大小约2.4cm,经手术病理证实均为输卵管妊娠,随着阴道彩色多普勒超声检查技术的广泛应用.结论:经阴道超声对盆腔包块的检出极为敏感,再辅以血流显示阴道起声在输卵管妊娠的诊断中成为可靠的首选的方法有着极其重要的价值,给临床治疗提供准确的信息.     

剖宫产术后再次妊娠分娩方式150例分析

目的探讨剖宫产术后再次妊娠的分娩方式,分析经阴道分娩的可能性。方法回顾性分析2009年3月～2012年9月我院收治的既往有剖宫产史的150例孕妇的分娩方式。结果 150例孕妇中,126例选择再次择期剖宫产,24例选择经阴道试产,17例阴道试产成功,阴道试产成功率70.8%,7例试产失败转行剖宫产。再次剖宫产率88.7%（133/150）。结论对于符合条件的剖宫产术后再次妊娠分娩的孕妇可以在严密监护下阴道试产。     

结扎术后输卵管二次吻合术六例临床分析

目的总结分析结扎术后输卵管二次吻合术注意事项。方法1997年3月-2004年3月，对6例患者行结扎术后输卵管二次吻合术。年龄31～38岁。首次吻合术距二次吻合术时间为1～6年。术后随访输卵管复通及复孕情况。结果患者获随访1～7年。术后1个月，输卵管通液检查5例通畅；术后6个月，输卵管通液检查3例通畅，1例已宫内妊娠；术后1年，宫内妊娠2例，足月分娩；术后2年输卵管妊娠1例。结论结扎术后输卵管二次吻合术成功率尚不高，术中应用显微外科技术和保留足够长度输卵管是手术成功的关键。     

经阴道内镜手术在子宫切除术中的应用效果探析

目的 探讨经阴道自然腔道内镜手术在临床子宫切除术中的效果。方法 回顾性分析2019年1月至2022年6月64例行子宫切除术患者临床资料，其中行传统腹腔镜手术者为对照组，32例；采用经阴道自然腔道内镜手术者为观察组，32例。比较两组患者平均手术时间和术中出血量、术后情况（术后排气时间、住院时间、切口疼痛程度、并发症、切口愈合）。比较两组患者术前术后血红蛋白值变化。结果观察组患者平均手术时间为（78.67±12.65） min，较对照组平均手术时间（87.85±18.74） min长，P<0.05。观察组患者术中平均出血量为（7.04±1.23） m L，明显少于对照组（9.86±1.82） mL,P<0.05。观察组患者术后平均排气时间为（9.17±1.63） h较对照组术后排气时间（15.86±3.21） h明显缩短，P<0.05。观察组患者术后切口疼痛程度评分（3.01±0.35）分，较对照组（4.17±0.48）分明显下降，P<0.05。两组患者术后并发症发生率和住院时间无明显差异，P>0.05。两组患者术后切口愈合良好，均未形成明显瘢痕。结论 经阴道...     

胚胎移植术后21例输卵管间质部妊娠临床分析

目的探讨胚胎移植术后输卵管间质部妊娠的发生率、发病影响因素、治疗、妊娠结局等,以加强临床医生对输卵管间质部妊娠的认识。方法回顾性分析我中心2014年1月1日至2016年12月31日胚胎移植术后输卵管间质部妊娠的21例病例的临床资料。结果我中心2014年1月1日至2016年12月31日胚胎移植术后临床妊娠病例共6 487例,输卵管间质部妊娠21例,发病率为0.32%(21/6 487),其中14例(66.67%)有输卵管手术史;20例行腹腔镜治疗,1例保守治疗成功;输卵管间质部合并宫内妊娠8例,经腹腔镜治疗后3例成功抱婴,1例术后宫内胎儿存活(目前妊娠至28周),2例术后宫内妊娠难免流产行清宫术,2例因胚胎停育行清宫术。结论输卵管手术史是导致输卵管间质部妊娠的重要因素;腹腔镜是治疗输卵管间质部妊娠的有效方法;腹腔镜治疗输卵管间质部合并宫内妊娠,有利于宫内妊娠获得良好的妊娠结局。现有的输卵管切除和阻断方式需改进,以减少输卵管间质部妊娠的发生。     

经阴道纯NOTES肾切除术2例报告并文献复习

目的：评价经阴道纯自然腔道内镜手术（NOTES）肾切除术的临床可行性和有效性。方法：对1例右肾无功能和1例左。肾结石并左肾萎缩、左肾无功能的女性患者行经阴道纯NOTES肾切除术。患者取全麻,截石位。切开阴道后穹窿,置入Triport及操作器械。所有操作均经此Triport完成,按照普通腹腔镜肾切除方法游离并切除患肾,装入自制标本袋,自阴道后穹窿切口取出。留置盆腔引流管,缝合阴道后穹窿切口。结果：手术均顺利完成,术中未出现肠管、实质性器官和大血管损伤等并发症。手术时间分别为330min、300min,术中失血量分别为300ml、250ml。例1、2分别于术后第2、1天下床活动,第3、2天肛门通气并进饮食。2例均于术后第6天痊愈出院,患者体表均无切口或穿刺孔。结论：经阴道纯NOTES肾切除术临床应用可行,美容优势明显,可在临床选用。但仍需进一步研发、完善相关器械。     

经阴道纯NOTES肾囊肿去顶术1例报告并文献复习

目的：报告1例经阴道纯自然腔道内镜手术（NOTES）肾囊肿去顶术的临床经验和体会。方法：采用经阴道纯NOTES肾囊肿去顶术治疗右肾囊肿患者l例。患者取截石位,患侧垫高约30°,头低脚高约25°。剪开阴道后穹窿黏膜约3cm,在5mm无损伤分离钳的引导下置人5mmTrocar,插入5mmO°远端可弯曲（四方向）腹腔镜,证实无肠管损伤。扩大阴道后穹窿切口至3cm,置入Triport。改头高脚低约25°,患侧抬高约60°。游离右肾囊肿,切除外露囊壁并取出,彻底止血后留置盆腔引流管,关闭切口。结果：手术顺利完成。手术时间75min,术中失血量约为20m1。患者于术后第1天拔除尿管和盆腔引流管并下床活动,第2天肛门通气并进饮食。术后第4天出院。结论：经阴道纯NOTES肾囊肿去顶术临床应用可行,其美容优势明显。该手术的成功实施,为经阴道纯NOTES其它术式的探索提供了借鉴。     

A Simple Approach to Specimen Retrieval via Posterior Colpotomy Incision

Introduction:

Posterior colpotomy incision for specimen retrieval is infrequently used in gynecologic laparoscopic surgery unless a concomitant hysterectomy is performed. We aim to describe a simple and unique technique for creating the colpotomy incision and to describe intraoperative and postoperative outcomes.

Methods:

Fifty patients underwent adnexal specimen retrieval through a posterior colpotomy incision. After devascularization and detachment of the adnexal specimen, the posterior cul-de-sac was visualized. The colpotomy incision was created by introducing a 12- or 15-mm laparoscopic trocar through the vagina into the posterior vaginal fornix under direct visualization. Specimens were placed into laparoscopic bags and removed through the vagina. The colpotomy incision was closed vaginally. Charts were reviewed for intraoperative and postoperative outcomes.

Results:

Twenty-nine women underwent adnexal surgery for an adnexal mass, 14 women underwent surgery for pelvic pain, and 7 women underwent adnexal surgery for primary prevention of malignancy. The specimens removed ranged in size from 2 to 16 cm (mean 5.7). The mean time patients were under anesthesia was 103 minutes (SD 57.3). There were no operative complications related to the colpotomy incision and no cases of postoperative vaginal cellulitis or pelvic infection were reported. Only 1 woman with a prior vaginal delivery reported dyspareunia postoperatively.

Conclusion:

This simple technique for posterior colpotomy incision can easily be added to the gynecologic surgeon''s armamentarium and can be safely used for most women.     

Effectiveness of the McCall culdeplasty in maintaining support after vaginal hysterectomy

The aim of this study was to evaluate the effectiveness of a McCall culdeplasty in maintaining support of the post-hysterectomy vaginal cuff in women undergoing surgery for uterine prolapse. A retrospective chart review was performed on all patients who had a vaginal hysterectomy and McCall culdeplasty for uterine prolapse without prolapse of the posterior vaginal fornix. Patients were examined pre- and postoperatively using the International Continence Society (ICS) staging system. Data were analyzed using repeated measures analysis of variance (ANOVA) for correlation between preoperative point D and the two postoperative point C measurements. Of the 43 patients studied, 39 (90%) had stage 0 prolapse and 3 (7%) had stage I prolapse of the vaginal cuff 1 year postoperatively. In patients who have hysterectomies for uterine prolapse with good support of the posterior vaginal fornix, the McCall culdeplasty is a highly successful procedure in maintaining proper anatomic support of the vaginal cuff.     

Pure transvaginal laparoscopic appendectomy

Background

Natural orifice transluminal endoscopic surgery has been at the forefront of minimally invasive surgery. Benefits include no visible scars, less pain, and shorter recovery time. We describe a video of a 37-year-old female who underwent a pure transvaginal appendectomy (TVA) for acute appendicitis. This is 1 of 18 successfully performed TVAs at Yale-New Haven Hospital. Appropriate Institutional Review Board was obtained preoperatively.

Methods

The patient was positioned in steep Trendelenburg and then a weighted speculum was introduced into the vagina allowing exposure of the posterior vaginal fornix. The cervix was grasped with a single-toothed tenaculum on the posterior cervical lip and the posterior vaginal fornix was visualized. Access to the peritoneum was achieved by electrocautery and then sharp dissection. A SILS? port (Covidien, Mansfield, MA, USA) was introduced and pneumoperitoneum up to 15?mmHg was achieved. Two 5-mm trocars and one 12-mm trocar were used. A 5-mm 30° angled endoscope, a flexible reticulating endograsper, and straight standard instruments were used. The identified appendix was dissected and a stapler was used to divide the mesoappendix from the appendix. Following confirmation of good hemostasis and no spillage of bowel contents, the appendix was removed from the abdomen within a retrieval bag and the culdotomy was closed with a running absorbable suture. The patient tolerated the 27?min procedure well and was discharged home in good condition on postoperative day 1.     

腹腔镜下经腹膜外阴道旁修补术治疗阴道前壁脱垂9例报告

目的探讨腹腔镜经腹膜外阴道旁修补术治疗阴道旁缺陷所致的阴道前壁脱垂的可行性及疗效。方法2010年7月～2011年10月行腹腔镜经腹膜外阴道旁修补术治疗阴道旁缺陷所致的阴道前壁脱垂9例（Ⅲ度4例,Ⅱ度1例,Ⅰ度4例;4例合并阴道后壁脱垂Ⅰ度）,腹腔镜下腹膜外暴露双侧盆侧壁盆筋膜腱弓（白线）及坐骨棘,阴道穹隆角缝合于同侧坐骨棘,将阴道侧壁缝合于同侧白线。需行子宫全切及阴道壁修补术的患者同时行相应手术,但行阴道壁修补时不去除阴道壁。结果同时行阴式全子宫切除及阴道前后壁修补术4例,阴式全子宫切除1例,阴道前壁修补1例。手术时间75～310 min,平均177 min。除1例术中出血500 ml外,其余患者出血量中位数60 ml（5～280 ml）。术中均无并发症发生。3例术后出现臀部及下肢痛,除1例下肢痛持续2个月外,其余患者持续5～7 d后缓解。术后住院2～11 d,平均6 d。9例术后随访6～15个月,平均8个月,7例主观治愈及客观治愈。1例术后6个月感觉阴道肿物脱出,妇科检查为子宫脱垂Ⅰ度、阴道前壁脱垂Ⅰ度;1例术后1年感觉阴道肿物脱出,妇科检查为阴道前壁脱垂Ⅰ度。所有患者术后阴道深度均〉7 cm。结论腹腔镜经腹膜外阴道旁修补术治疗阴道旁缺陷所致的阴道前壁脱垂安全、可行,能保留阴道的原有深度,近期疗效好。     

SIS graft for anterior vaginal wall prolapse repair—a case-controlled study

The purpose of this study was to assess the effect on quality of life and prolapse severity of traditional anterior repair compared to anterior repair with a small intestine submucosa (SIS) graft. This report was designed as a case-control study. The sample of this study consisted of 14 women who underwent traditional anterior repair and 14 women who underwent anterior repair with SIS graft (SG) at a London teaching hospital. All women were assessed preoperatively and at 6 and 24 months postoperatively using a validated prolapse quality of life questionnaire and pelvic organ quantification system (POP-Q). Quality-of-life outcomes included the following: (1) General health perception, (2) Prolapse impact, (3) Role limitations, (4) Physical limitations, (5) Social limitations, (6) Personal relationships, (7) Emotions, (8) Sleep/Energy, and (9) Severity measures. The pelvic organ quantification measurement measured nine specific points relating to the anterior and posterior wall of the vagina, vaginal apex, genital hiatus (GH) and perineal body (PB). At 6-month follow-up, the SG repair group showed significant improvement in all quality-of-life parameters measured. In comparison to traditional repair, it was significantly better in improving role limitations, physical limitations and emotions. Both operations significantly improved prolapse quality-of-life severity measures. SG repair improved all POP-Q measurements significantly, except total vaginal length (TVL), whereas traditional repair improved some measurements (AA, midline point of anterior vaginal wall 3 cm proximal to the external urethral meatus; BA, most distal dependant position of the anterior vaginal wall from the vaginal vault or anterior fornix to AA; C, most distal/dependant edge of cervix or vault; AP, point on midline posterior vaginal wall 3 cm proximal to hymenal ring; BP, most distal/dependant point on the posterior vaginal wall from vault or posterior fornix to AP) but not others (location of posterior fornix (D), TVL, GH and PB). At 2-year follow-up, there was no significant difference between the two groups in terms of quality-of-life outcomes or prolapse severity measurements. Surgery for vaginal prolapse results in marked improvement in quality of life and prolapse severity. The greater improvement seen initially in the SG anterior group was not seen at 2-year follow-up.     

经穹隆结膜入路埋线法重睑成形术应用探讨

目的:通过分析重睑形成原理,综合比较多种重睑成形的方法,讨论埋线法重睑成形术的优点和可行性。方法:对387例患者行经穹隆结膜入路间断缝合埋线法重睑术。其中88例为其他方法埋线后重睑线消失的患者。结果:手术方法可靠,术后所形成的重睑外形良好,重睑维持时间长。最长随访时间38个月。结论:此方法因符合重睑形成原理,可以充分的将较多的上睑提肌腱膜与上睑皮肤结扎固定、故术后所形成的重睑牢固。且在直视下经穹隆结膜入路,降低了对眼球组织损伤的危险性。是埋线法重睑成形术一种可靠的手术方法。