腹腔镜辅助阴式子宫切除术38例分析

目的 :通过对 38例患者行腹腔镜辅助阴式子宫切除术 (LAVH)后分析LAVH的适应证、手术要点和并发症的预防。方法 :38例因各种妇科良性疾病需行子宫全切除术的患者 ,采用LAVH术式。患者平均年龄 5 3岁 (36～ 6 5岁 ) ,术前子宫正常大小者 2例 ,子宫增大≤ 12孕周者 2 3例 ,>12孕周 13例。有下腹部手术史 4例。结果 :38例LAVH中有 37例顺利完成 ,1例因膀胱损伤行开腹膀胱修补术。平均手术时间 112(6 8～ 2 2 0 )min ,术中出血量 110 (4 0～ 2 30 )ml。平均住院 4d。结论 :LAVH拓宽了阴式子宫切除的适应证 ,可避免开腹 ,减少手术创伤     

腹腔镜辅助阴式子宫切除术78例临床分析

目的:探讨腹腔镜辅助阴式子宫切除术(LAVH)的手术指征、手术操作及临床应用价值。方法:回顾分析LAVH78例的临床资料。结果:76例顺利完成手术,2例因粘连严重而中转开腹,手术成功率为98.7%(76/78),平均手术时间为(91.30±21.32)m in,平均术中出血量(112±25.24)m l,平均术后住院4~6d,无严重并发症发生。结论:LAVH具有安全、微创、患者出血少、康复快、术式简单易掌握等优点。     

腹腔镜子宫肌瘤切除术中子宫动脉预处理的方法和临床意义(附24例报告)

目的:探讨腹腔镜子宫肌瘤切除术中子宫动脉预处理的必要性、方法及临床意义。方法:为42例浆膜下或肌壁间子宫肌瘤患者行腹腔镜子宫肌瘤切除术。24例先于腹腔镜下电凝阻断双侧子宫动脉,再行子宫肌瘤切除术。对照组18例未行腹腔镜下子宫动脉电凝阻断,直接行腹腔镜下子宫肌瘤切除术。结果:腹腔镜下子宫动脉阻断组23例成功实施了腹腔镜平滑肌瘤切除术,1例中转开腹。术中平均出血80m l。手术时间40~180m in,平均90m in。术后最高体温38.3℃,2d后恢复正常。对照组16例成功实施了腹腔镜肌瘤切除术,2例因术中出血较多中转开腹。术中平均出血180m l,手术时间50~210m in,平均110m in。两组术中出血量和手术时间差异有统计学意义(P<0.05)。结论:腹腔镜下子宫动脉阻断后行子宫肌瘤切除术可明显减少术中出血,术野清晰,创面电凝少,明显减少了组织坏死,术后渗血少,并发症少,患者术后月经正常。     

超声刀在腹腔镜子宫切除术中的应用

目的 :探讨腹腔镜下应用超声刀行筋膜内子宫切除术 (CISH)、腹腔镜协助阴式子宫切除术(LAVH)的可行性。方法 :对用超声刀施术 2 4 0例与用单极电刀行子宫切除 16 0例和用双极电凝行子宫切除16 0例的手术时间、手术难度、术中腹腔出血量及患者术后恢复情况进行比较。结果 :超声刀手术组在手术时间 ,术中腹腔出血量 ,术后体温恢复 ,术后肛门排气时间 ,术后患者自觉症状等方面明显优于单极电刀手术组和双极电凝手术组。结论 :超声刀在子宫切除手术中具有安全、可靠、作用迅速、操作便捷等优点 ,有很高的临床应用价值     

微创子宫切除术1027例临床分析

目的:评价阴式子宫切除术(transvaginal hysterectomy,TVH)、腹腔镜辅助阴式子宫切除术(laparoscopic assisted vaginal hysterectomy,LAVH)、腹腔镜子宫次全切除术(laparoscopic subtotal hysterectomy,LSH)及完全腹腔镜子宫切除术(laparoscopically total hysterectomy,LTH)4种微创手术的价值及手术适应证。方法:回顾分析1027例患者4种子宫切除术的手术时间、术中出血量、术后康复时间及住院费用。结果:TVH组手术时间、术中出血量、住院费用均优于腹腔镜组(P<0.01);3组腹腔镜手术中LTH手术时间最长,LSH次之,LAVH最短;LAVH组出血最少,而LSH与LTH差异无统计学意义(P>0.05);4组术后病率、平均住院时间差异无统计学意义(P>0.05);TVH组与LSH组术中并发症发生率差异无统计学意义(P>0.05),2组的并发症均在开展此术式的早期发生。术后并发症发生率LSH组明显高于TVH、LAVH、LTH组(P<0.01),LTH组高于TVH组(P<0.01),而与LAVH组差异无统计学意义(P>0.05),TVH组与LAVH组差异无统计学意义(P>0.05)。结论:4种术式均为微创子宫切除的有效术式,各有利弊;应根据患者的病情及术者技术水平选择术式。     

应用腹腔镜行困难子宫全切除术102例临床分析

目的:探讨应用腹腔镜行困难子宫全切除术的方法及手术原则。方法:对102例诊断为子宫内膜异位症、宫颈肌瘤、阔韧带肌瘤及盆腔粘连、剖腹产术后行腹腔镜全子宫切除手术的病例进行临床分析。结果:102例患者全部行腹腔镜下子宫全切除术,平均手术时间(158.3±43.7)m in,术中出血量平均(236.6±87.8)m l,术后平均住院时间(6.4±2.2)d。无1例出现输尿管、膀胱、直肠等脏器损伤。结论:复杂及困难的全子宫切除术也可在腹腔镜下完成。熟悉盆腔解剖、熟练掌握腹腔镜操作技巧、灵活运用各种手术器械是手术成功的重要保证因素。     

腹腔镜辅助下阴式子宫切除82例分析

目的总结腹腔镜辅助下阴式子宫切除(LAVH)的手术技巧、并发症、临床效果、安全性、可行性及应用前景。方法回顾分析LAHV82例患者临床资料、手术方式、治疗效果并进行总结。结果 2例因盆腔严重粘连中转开腹手术。其余均施行LAVH+单侧或双侧附件切除。平均术中出血量130ml,平均手术时间126min。发生会阴部皮下气肿和阴道残端出血各1例,经对症处理后痊愈。术后2个进行月随访,阴道残端均愈合良好,B超检查盆腔无异常,已恢复正常工作和生活。结论 LAVH具有腹腔镜子宫切除(LTH),开腹子宫切除术(TAH),阴式子宫切除术(TVH)的共同优点。视野好、创伤小、术后恢复快、住院时间短、痛苦少、易操作、对腹腔干扰少,具有广阔的应用空间和发展前景,值得推广。     

腹腔镜巨大子宫肌瘤切除术147例报告

目的:探讨腹腔镜巨大子宫肌瘤切除的可行性及临床应用价值。方法:对147例子宫超过12孕周的患者行腹腔镜手术,针对不同情况采用不同手术方式。结果:147例患者均在腹腔镜下完成手术,无术中、术后并发症发生。手术时间(103.7±65.7)m in,术中出血量(136±43)m l。术后平均住院时间6.2d。结论:腹腔镜巨大子宫肌瘤切除术是安全可行的,但应具备丰富的腹腔镜手术经验及镜下缝合技术。     

腹腔镜下广泛全子宫切除加盆腔淋巴结清扫治疗子宫恶性肿瘤11例临床研究

目的:探讨腹腔镜广泛全子宫切除和盆腹腔淋巴结切除术治疗子宫恶性肿瘤的可行性及临床价值。方法:回顾分析我院行腹腔镜子宫广泛切除和盆腔淋巴结切除术治疗11例经活检证实的早期子宫恶性肿瘤患者的临床资料,其中子宫颈癌8例,子宫内膜癌3例,总结其手术时间、术中出血量、淋巴结切除数、手术并发症及近期预后情况。结果:11例均用腹腔镜完成手术,手术时间平均(298.2±40.5)min,术中平均出血(255.5±158.5)ml,平均淋巴结切除(12.3±3.0)枚,术中无脏器损伤,11例术后随访1～13个月,无死亡及复发病例。结论:腹腔镜广泛全子宫切除和盆腔淋巴结切除术治疗子宫恶性肿瘤安全、可行,有临床应用价值。     

腹腔镜子宫全切除改良术92例临床分析

目的:探讨腹腔镜子宫全切除改良术手术操作及临床应用价值。方法:回顾分析2003年8月至2006年12月行腹腔镜子宫全切除改良术92例患者的临床资料。结果:92例均于腹腔镜下完成,平均手术时间(128.3±40.7)min,术中平均出血(186.6±85.4)ml,术后平均住院时间(4.1±2.2)d。术中发生输尿管损伤1例,腹腔镜下行输尿管吻合术。结论:此术式具有患者创伤小,出血少,康复快等优点,是一种安全、理想的手术方式。腹部手术史并非腹腔镜手术的绝对禁忌证。     

腹腔镜在阴式非脱垂全子宫切除术中的应用

目的:比较改良的非脱垂子宫腹腔镜辅助下阴式全子宫切除术(laparoscop ic-assisted vaginal hysterectony,LAVH)与传统腹式全子宫切除术(trans abdom inal hysterectomy,TAH)的临床应用价值。方法:回顾性分析我院2004年1月至2006年3月86例LAVH和90例TAH患者的临床资料。结果:LAVH组的平均肛门排气时间、平均住院天数、术后疼痛时间明显短于TAH组(P<0.05)。LAVH组的术后并发症明显少于TAH组(P<0.01)。LAVH组手术时间及术中出血量少于TAH组,但无统计学意义。结论:LAVH优于TAH,在临床上有广阔的应用前景。     

Natural Orifice-Assisted Laparoscopic Appendectomy

Background and Objectives:

Natural orifice transluminal endoscopic surgery involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. We report the utilization of the vaginal opening at the time of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy as a natural orifice for appendectomy.

Methods:

We reviewed cases of 42 patients who underwent total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy followed by appendectomy, performed by applying a stapler and removing the appendix transvaginally. By using a small-diameter laparoscope, the appendix was mobilized, especially in patients with adhesions, endometriosis, or retrocecal appendix, to facilitate transvaginal access with the stapler.

Results:

All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 5 minutes to 10 minutes. Appendiceal pathology included serosal adhesions (14), fibrous obliteration of the lumen (12), endometriosis (4), serositis (2), and carcinoid tumor (1), among others.

Conclusions:

Appendectomy performed with an endoscopic stapler introduced transvaginally for amputation and retrieval following total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy appears to be a safe and effective modification of established techniques with acceptable outcomes.     

腹腔镜辅助阴式子宫全切除术12例分析

目的：探讨腹腔镜辅助阴式子宫全切除术的效果及手术要点。方法：对12例子宫肌瘤、腺肌瘤、子宫内膜轻度不典型增生等有子宫切除指征的患者行腹腔镜辅助阴式子宫全切除术。结果：手术均获成功,无中转开腹。平均手术时间105min（90—200min）,术中平均出血120ml（100～300ml）,术后住院4—6d。结论：腹腔镜辅助阴式子宫全切除术患者创伤小,肠道干扰少,康复快。手术关键是适应证选择合适及术者有丰富的操作经验。     

经脐单孔腹腔镜辅助阴式全子宫切除术

目的:总结早期开展经脐单孔腹腔镜辅助阴式全子宫切除术的经验.方法:回顾分析2009年10月至2010年5月为34例患者施行经脐单孔腹腔镜辅助阴式全子宫切除术的临床资料.结果:1例因附件与肠管粘连出血较多,增加了1个Trocar,余者手术均获成功.手术时间30～90min,术后无并发症发生.术后住院3～6d,随访1～3个...     

悬吊式经脐入路腹腔镜辅助阴式子宫切除术的临床分析（附32例报告）

目的：探讨悬吊式经脐入路腹腔镜辅助阴式子宫切除术的应用价值。方法：回顾分析为32例子宫、宫颈良性病变患者行悬吊式经脐腹腔镜辅助阴式子宫切除术的临床资料。结果：4例因盆腔空间狭小辅助低气腹（压力8mmHg）完成手术,余均顺利完成悬吊式经脐腹腔镜辅助阴式子宫切除术。手术时间75～130min,平均（95±8）rain;术中出血量50-160m1．平均（110±10）ml;术后肛门排气时间〈6h8例,6～12h19例,12～24h5例。4例术后48h内体温〉37．5℃。均无肩胛疼痛、出血及邻近脏器损伤等并发症发生。术后住院4—6d,平均（5．2±0．4）d。结论：悬吊式经脐入路腹腔镜辅助阴式子宫切除术是安全、可行的,具有并发症少、微创美观等优点,更符合微创经自然腔道手术的理念;但受手术空间暴露、术者技术水平等因素的影响,选择病例时应全面评估患者的子宫大小、阴道条件,尽量避免有盆、腹腔手术史的患者,以减少手术并发症的发生。     

Progressive reduction in abdominal hysterectomy rates: impact of laparoscopy,robotics and surgeon factors

The objective of this study is to describe changes in rates of types of hysterectomy at a tertiary care community teaching hospital since the introduction of laparoscopic and robotic techniques and to determine the effect of surgeon characteristics on route of hysterectomy. This is a retrospective analysis of types of hysterectomies performed for benign disease during five different years (1989, 1994, 1999, 2004, 2009) at a large community teaching hospital. Hospital discharge data was reviewed to identify all hysterectomies performed during the first six months of each year of the study. Hospital charts were reviewed and patient characteristics, indication for surgery, type of hysterectomy and surgeon characteristics were recorded. Hysterectomies performed for malignancy, suspected malignancy, or postpartum hemorrhage were excluded. Types of hysterectomies included abdominal (AH), vaginal (VH), laparoscopic-assisted vaginal (LAVH), total laparoscopic (TLH), laparoscopic supracervical (LSH) and robotic-assisted (RH). The progressive introduction of newer minimally invasive surgical techniques (LAVH, TLH, LSH, and RH) resulted in an overall reduction in the abdominal hysterectomy rate from 77 to 35.2 % during the time of the study. The majority of abdominal, laparoscopic supracervical and robotic hysterectomies were performed by generalists, while the majority of vaginal, laparoscopic-assisted vaginal and total laparoscopic hysterectomies were performed by fellowship trained subspecialists. Minimally invasive hysterectomy techniques significantly reduced the rate of abdominal hysterectomies. The LSH and RH were the techniques utilized by generalists as their most preferred minimally invasive surgical approaches to hysterectomy.     

Abdominal, laparoscopic, and vaginal hysterectomy with bilateral salpingo-oophorectomy

Background: The abdominal route is the traditional method of performing hysterectomy with bilateral salpingo-oophorectomy. In a feasibility study, we compared a nonconventional (vaginal) route for bilateral salpingo-oophorectomy at the time of vaginal hysterectomy (VH + BSO) to similar forms of hysterectomy performed abdominally or with operative laparoscopy. Methods: Fifty-nine patients were subject to either total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO; n= 19), or laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy (LAVH + BSO; n= 19) or VH + BSO (n= 21). Results: VH + BSO resulted in a shorter operating time compared to LAVH + BSO (p < 0.001), shorter hospital stay compared with TAH + BSO (p= 0.001), and quicker long-term recovery compared to the other two operations. Conclusion: This preliminary but significant study shows that the vaginal route for salpingo-oophorectomy at the time of vaginal hysterectomy is superior to other methods of hysterectomy. A randomized trial is needed to confirm these initial findings. Received: 20 February 1998/Accepted: 18 August 1998     

Laparoscopic-assisted vaginal hysterectomy with lateral transsection of the uterine vessels

Background: Increased safety and diminished blood loss are achieved through laparoscopic-assisted vaginal hysterectomy by selective coagulation and transsection of the uterine vessels at their origin. Methods: Three laparoscopic steps are performed: coagulation and transsection of the round ligament, of the uterine artery at its origin, and of the fallopian tube and ovarian ligament or (in BSO) the infundibulopelvic ligament. The uterine vessels are identified from the pararectal space and, following the internal liliac artery, and the ureter. Hysterectomy is completed transvaginally. Results: Two hundred and sixty-seven patients underwent this procedure. Mean operation time was 121 min, and hemoglobin decreased to 0.6 g/dl by postoperative day 3. It took 8.4 min on average to identify and coagulate the uterine artery. Conclusions: Lateral transsection of the uterine vessels is safe and blood sparing and can be used in patients in whom blood loss must be minimized.     

Delayed presentation and successful repair of a recurrent vesicovaginal fistula after hysterectomy and primary abdominal repair

Urogenital fistulae are an uncommon consequence of gynecologic surgery. Vesicovaginal fistulae due to gynecologic surgery generally appear 1–6 weeks after surgery and recurrent fistulae within 3 months of their repair. The pathogenesis of vesicovaginal fistula formation remains unclear. We present the case of a 36-year-old woman with a spontaneously recurring vesicovaginal fistula 21 months after abdominal repair of a vesicovaginal fistula caused by a laparoscopic-assisted vaginal hysterectomy. During the repair of the fistula and excision of the vaginal cuff, two small fluid-filled cysts between the bladder mucosa and the vaginal epithelium were encountered. Vesicovaginal fistulae can occur spontaneously and remote from surgery. The finding of small fluid-filled cysts in the cuff suggests that rupture of a similar cyst may have led to the formation of the fistula. Abbreviations LAVH Laparoscopically assisted vaginal hysterectomy