腹腔镜子宫切除术腹膜后游离解剖输尿管和子宫血管的必要性探讨

目的寻求安全、高效进行腹腔镜子宫切除术的技术方法,并比较腹膜后解剖技术游离盆腔段输尿管、子宫血管的手术效果。方法对50例患妇科良性疾病,须行腹腔镜子宫切除术者,用腹膜后解剖技术游离右侧子宫动脉、盆腔段输尿管;在直视输尿管走行的情况下电凝、横断子宫血管、子宫骶骨韧带、阔韧带前后叶和膀胱反折腹膜;用常规剖腹子宫切除术的步骤电凝、横断左侧相应的血管、韧带,前瞻性对照比较用两种不同技术方法游离暴露盆腔段输尿管、子宫血管的效果,及其后电凝、横断子宫血管、各子宫韧带的效果。结果50例腹腔镜子宫切除术均顺利完成,无并发症发生。平均手术时间102min(63~165min),腹腔镜下手术时间55分(38~76min),其中右侧盆腔腹膜后解剖平均时间21min(17~31min),加电凝、横断子宫血管、各子宫韧带时间共33min(22~39min);左侧相应手术时间20min(15~30min),P<0.05;右侧术时出血量12ml(0~20ml),左侧出血量30ml(10~40ml),P<0.05。结论腹腔镜下腹膜后解剖、游离盆腔段输尿管和子宫血管是可以通过不断训练而掌握的技术,它能彻底暴露子宫血管和子宫骶骨韧带旁的输尿管,这样,手术者能很自信地处理子宫血管和子宫骶骨韧带,有效避免输尿管的损伤,采用这一技术能使腹腔镜子宫切除术更安全、出血更少。

Dissecting and Identifying the Ureter and Uterine Arteries is Necessary at the Laparoscopic Hsterectomy

Objective To search for the technique of increased safety and diminished blood loss through laparoscopic hysterectomy. Methods A technique for dissecting the pelvic retroperitoneum and identifying the ureters and uterine arteries was used in the right pelvic side wall. The left side was used a non-anatomical approach. Visualization of the right ureter necessitate opening the peritoneum of the right pelvic side wall. A technique of identification and dissection the right ureter and the uterine vessels retroperitoneal at the initiation of laparoscopic hysterectomy was used. First, the obliterated hypogastric arteries were identified retroperitoneally. Second,the paravesical and the pararectal spaces are developed. Finally, the ureter and the uterine vessels were easily identified from the pararectal space. Once the retroperitoneal dissection had been completed and vital structures identified, hysterectomy be carried out. Results WT Fifty patients underwent this procedure. Right pelvic side wall versus left mean operation time was 33 min versus 22 min, and the mean blood loss was 12 versus 30 ml. It took 21 min on average to identify the right ureter and the uterine vessels retroperitoneal. Conclusion Identification and dissection of the ureter and the uterine vessels retroperitoneal is an acquired skill. This technique increases safety and diminishes blood loss. The uterine arteries and the uterosacral ligament are confidently desiccated once the path of the ureter near is identified. A non-anatomical approach to laparoscopic hysterectomy may be easier to learn, but it is neither very versatile nor safe.