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.     

Urinary Disturbance after Therapy for Cervical Cancer: Urodynamic Evaluation and β2-Agonist Medication

Urinary disturbance frequently develops following therapy for cervical cancer; however, no effective medical treatment has so far been reported. Sixty-five patients who developed urinary disturbance after radiation therapy, radical hysterectomy or radical hysterectomy with radiation therapy for cervical cancer underwent urodynamic assessment. Those who underwent radical hysterectomy with radiation therapy experienced the most severe urine loss, as determined by the pad test. All patients showed markedly reduced bladder compliance. A β₂-agonist (mabuterol) significantly improved compliance, bladder capacity and flow rate. It is suggested that medication with mabuterol is a potential novel approach to the treatment of urinary disturbance after therapy for cervical cancer.     

吗啡联合布比卡因腹横肌平面阻滞在腹式全子宫切除术术后镇痛中的应用和讨论

目的探讨吗啡联合布比卡因腹横肌平面阻滞(TAPB)在腹式全子宫切除术术后镇痛中的应用效果。方法本研究采用前瞻性方法,选取拟行腹式全子宫切除术患者94例,分成对照组和观察组,每组47例。患者全身麻醉后手术开始前15分钟左右行TAPB,对照组患者TAPB麻醉药物为0.5%盐酸布比卡因20 mL+生理盐水20 mL,共40 mL,观察组患者TAPB麻醉药物为0.5%盐酸布比卡因20 mL+吗啡10 mg+生理盐水20 mL,共40 mL。双侧TAPB分别注入20 mL麻醉药物混合液。结果观察组患者术后2、4、8、12、18和24 h静息疼痛评分和活动疼痛评分均显著低于对照组患者(P0.05)。观察组患者术后24 h内需要使用吗啡静脉患者自控镇痛(IV-PCA)的人数和吗啡IV-PCA总使用量均显著低于对照组患者(P0.05)。观察组患者术后首次使用吗啡IV-PCA时间显著高于对照组患者(P0.05)。观察组术后恶心和呕吐的发生率显著低于对照组患者(P0.05)。结论吗啡联合布比卡因TAPB较单纯布比卡因TAPB可显著降低腹式全子宫切除术术后患者24 h内疼痛评分、阿片类药物用量及其不良反应发生率,延长术后首次需要镇痛时间。     

腹腔镜在子宫颈癌治疗中的应用--附37例分析

目的　探讨腹腔镜下广泛子宫切除和盆腹腔淋巴结切除治疗子宫颈癌的可行性及价值。　方法　采用腹腔镜下广泛子宫切除和盆腔及腹主动脉周围淋巴结切除治疗 37例子宫颈癌。其中有2 5例选择性腹主动脉周围内淋巴结切除。　结果　腹腔镜下手术时间平均 182min ,术中出血平均16 8ml,切除淋巴结数平均 16个 ,术后住院平均 10 2天。术中发生膀胱损伤 1例、静脉损伤 2例 ,均于镜下修补成功 ;1例损伤大肠中转开腹 ;2例出现尿潴留。　结论　腹腔镜下施行广泛子宫切除和盆腹腔淋巴结切除术安全可行 ,且手术创伤小 ,并发症少 ,术后恢复快。     

Complications of laparoscopic radical hysterectomy and lymphadenectomy for invasive cervical cancer: experience based on 317 procedures

Background This report presents the incidence of complications and conversions during laparoscopic radical hysterectomy and lymphadenectomy performed for invasive cervical carcinoma. The data are analyzed, and strategies to help prevent future complications are discussed. Methods From July 2000 to December 2005 at the authors’ institution, 317 laparoscopic radical hysterectomy and lymphadenectomy procedures for invasive cervical carcinoma were performed. The authors reviewed the database of patients who underwent laparoscopic radical hysterectomy and lymphadenectomy to examine complications and analyze factors associated with conversion to an open surgical procedure. Results All but four surgical procedures were laparoscopically completed. Pelvic lymphadenectomy was performed for all the remaining 313 patients, 143 of whom underwent paraaortic lymphadenectomy. Major and minor intraoperative complications occurred for 4.4% (n = 14) of the patients. The overall conversion rate was 1.3% (n = 4), including 3 emergencies and 1 elective conversion. Seven patients had vessel injuries, five of which were repaired or treated laparoscopically. One left external iliac vein required laparotomy, and one patient underwent laparotomy to control bleeding sites. Operative cystotomies occurred in five patients, which were repaired laparoscopically. Two patients underwent laparotomy because of hypercapnia and ascending colon injury. Postoperative surgery complications occurred in 5.1% (n = 16) of the patients, including 5 patients with ureterovaginal fistula, 4 with vesicovaginal fistula requiring reoperation, 1 with ureterostenosis treated by placement of a double-J ureteral stent, and 6 with bladder dysfunctions (retention) that exhibited complete resolution within 3 to 6 months by intermittent training and catheterization. Conclusions Laparoscopic radical hysterectomy and lymphadenectomy is becoming a routine procedure in the armamentarium of many gynecologists. Complications unique to laparoscopy do exist, but they decrease with repeated training of the procedure and gradually enriched experiences.     

术前静注氯诺昔康对子宫切除术病人围术期单核细胞趋化蛋白-1表达的影响

目的 探讨术前静注氯诺昔康对子宫切除术病人围术期单核细胞趋化蛋白-1表达的影响.方法 择期行子宫切除术的病人30例,随机分为3组,对照组、氯诺昔康8 mg组、氯诺昔康16 mg组,每组各10例.氯诺昔康8 mg组在开放静脉后静脉注人氯诺昔康8 mg,氯诺昔康16 mg组在开放静脉后静脉注入氯诺昔康16 mg.分别在开放静脉前、手术开始后30 min、手术结束、术后24 h、术后48 h外周静脉采血4 ml测定血浆单核细胞趋化蛋白-1(MCP-1)浓度.结果 ①三组病人的血浆MCP-1水平在手术开始后升高,到手术结束达到高峰,分别为(76±16)μg/L、(46±7)μg/L和(47±10)μg/L,与开放静脉前比较差异有统计学意义(P＜0.05);②氯诺昔康8 mg组在手术结束时和术后24 h血浆MCP-1水平为(46±7)μg/L和(30±7)μg/L与对照组比要低(P＜0.05),氯诺昔康16 mg组在手术结束时和术后24 h血浆MCP-1水平为(47±10)μg/L和(32±6)μg/L与对照组比要低(P＜0.05);③氯诺昔康8 mg组和16 mg组比较对血浆MCP-1水平影响差异无统计学意义.结论 术前静注氯诺昔康8 mg和16 mg可以有效的抑制子宫切除病人围术期MCP-1的表达的增加,16 mg组并不优于8 mg组,术前静注氯诺昔康有助于维持子宫切除病人围术期的免疫功能稳定.     

宫颈锥形切除术后宫颈组织中TNF-α、IL-6、HMGB1的表达及其意义研究

目的 探讨宫颈锥形切除术后宫颈分泌物及宫颈组织中炎性因子的动态变化及其意义.方法 选取2013-2015年在该院就诊的行宫颈锥形切除术患者,术后定期采集宫颈创面分泌物及周围组织.定量检测肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、高迁移率族蛋白1(HMGB1)的表达,以术前作为对照组,进行统计分析.观察宫颈锥形切除术后行全子宫切除的标本中炎性细胞的浸润及表达.结果 宫颈组织及分泌物中TNF-α、IL-6、HMGB1的表达在宫颈锥形切除术后逐渐升高,术后1～2周达到高峰,与术前比较差异有统计学意义(P＜0.05),之后逐渐下降.在宫颈锥形切除术后1周行全子宫切除的标本病理显示,炎性细胞浸润及炎症反应最严重;其TNF-α、IL-6及HMGB1表达较术后4周明显升高.结论 宫颈锥形切除术后1～2周时宫颈创面炎症最为严重,应避免在此阶段行全子宫切除.     

无症状菌尿与中老年女性开腹子宫切除手术部位感染的相关性

目的 研究无症状菌尿与中老年女性子宫切除手术部位感染的相关性。方法 回顾性分析2011年6月至2018年8月在贵州医科大学第三附属医院行开腹子宫切除术的1469例中老年女性患者临床资料,对其术后手术部位感染相关因素进行单因素及多因素回归模型分析,以明确无症状菌尿等因素与中老年女性开腹子宫切除术后手术部位感染的相关性。 结果 1469例患者中,101例(6.88%)发生手术部位感染;124例伴有无症状菌尿,其中感染14例(11.29%);1345例不伴有无症状菌尿,其中感染87例(6.47%);伴有无症状菌尿患者的感染率明显高于不伴有无症状菌尿患者(χ ²=4.123,P=0.042)。单因素分析结果显示,无症状菌尿、糖尿病史、术式、住院时间(>15d)、手术季节(夏秋)、体质量指数(BMI)(≥25 kg/m ²)、病变性质(恶性肿瘤)、美国麻醉师协会(ASA)评级(>Ⅱ级)、切口长度(≥10 cm)、手术时间(≥3 h)、出血量(≥1000 ml)、血清白蛋白浓度(<30g/L)、血糖(≥10 mmol/L)、血红蛋白浓度(<90g/L)均是中老年女性开腹子宫切除手术部位感染相关因素(P均<0.05)。多因素分析结果显示,无症状菌尿、病变性质(恶性肿瘤)、血糖(≥10 mmol/L)、手术时间(≥3 h)、ASA评级(>Ⅱ级)是中老年女性开腹子宫切除手术部位感染的危险因素(P均<0.05)。 结论 无症状菌尿是中老年女性开腹子宫切除手术部位感染危险因素之一,术前对无症状菌尿的筛查与治疗可降低其手术部位感染率。术前对患者进行ASA评级,给予相应术前准备,监测并有效控制血糖,提高手术技能,减少手术时间,对减少术后手术部位感染也有重要意义。     

阴式全子宫切除术临床结局的危险因素分析

目的 探讨阴式全子宫切除术不良临床结局的危险因素,为临床手术决策提供依据。方法 本研究为单中心回顾性队列研究。收集行阴式子宫切除术(VH)的子宫肌瘤患者102例。记录年龄、腹部手术史、剖腹产史、肥胖、合并内科疾病、子宫大小、瘤体位置、子宫粘连等。将所有患者分为两组:良性临床结局组和不良临床结局组,以手术失败和术后并发症等复合指标定义不良临床结局,采用logistics回归分析阴式子宫切除术不良临床结局的危险因素。结果 术后有18例(17.6%)患者出现了阳性事件。与良性临床结局组比较,不良临床结局组腹部手术史比例、子宫大于12孕周比例,瘤体位于子宫下段比例以及子宫粘连比例显著增高(P＜0.05)。logistics回归分析显示:子宫大小(OR=6.407,P=0.008)、瘤体位置(OR=7.186,P=0.020)、子宫粘连(OR=11.672,P=0.011)是发生不良临床结局的独立危险因素。结论 子宫体积大于12孕周、瘤体位于子宫下段以及子宫粘连显著增加了TVH的手术风险,临床上应该充分考虑这些情况,以确保手术安全。     

伴有淋巴结转移的ⅠB1～ⅡA2期宫颈癌两种治疗方式的回顾性研究

目的:比较盆腔淋巴结切除术中病理检查证实有淋巴结转移的ⅠB1~ⅡA2期宫颈癌患者系统盆腔淋巴结切除术+同步放化疗与广泛子宫切除+系统盆腔淋巴结切除术+同步放化疗两种手术方式的疗效。方法:回顾性分析2007年10月至2016年3月在北京大学肿瘤医院治疗的盆腔淋巴结切除术中病理检查证实有淋巴结转移的ⅠB1~ⅡA2期宫颈癌患者44例的临床资料。19例患者在行系统淋巴结切除术后行同步放化疗治疗(放化疗组);25例患者在系统盆腔淋巴结切除术后继续行广泛子宫切除术,术后行辅助同步放化疗(根治手术组)。比较两种治疗方式患者的无进展生存情况和安全性。结果:44例患者中7例失访,中位随访时间为20月(4~90月)。放化疗组中,1例(1/15,6.7%)复发并死亡;根治手术组中,7例(7/22,31.8%)复发,3例(3/22,13.6%)死亡。放化疗组和根治手术组的无进展生存期中位数分别为49月(95%CI 29.216~68.784)、20月(95%CI17.682~22.318),差异无统计学意义(P=0.120)。放化疗组的2年无进展生存率为79.4%,根治手术组为36.2%,差异有统计学意义(P=0.020);1年无进展生存率差异无统计学意义(P=0.683)。发生Ⅲ~Ⅳ度不良反应放化疗组4例(26.7%),根治手术组7例(31.8%),两组差异无统计学意义(P=0.516)。结论:对于伴有淋巴结转移的ⅠB1~ⅡA2期宫颈癌患者,行系统淋巴结切除术后行同步放化疗的治疗方式与在系统盆腔淋巴结切除术后继续行广泛子宫切除术,术后行同步放化疗的治疗方式相比,安全性相当,而预后和生存结果似乎更好,但尚需大样本量的前瞻性研究证实。