腹腔镜子宫切除术四种术式的临床分析

目的：探讨4种腹腔镜子宫切除术：腹腔镜子宫次全切除术（laparoscopic subtotal hysterectomy,LSH）、腹腔镜鞘膜内子宫切除术（laparoscopic intrafascial supercervical hysterectomy,LISH）、腹腔镜辅助阴式子宫切除术（laparoscopic assistedvaginal hysterectomy,LAVH）、腹腔镜全子宫切除术（laparoscopic total hysterectomy,LTH）的临床应用价值。方法：回顾分析2006年1月至2009年1月为664例患者行腹腔镜子宫切除术的临床资料,对比分析4种术式的手术适应证及临床应用情况。结果：612例成功完成腹腔镜子宫切除术,29例因盆腔严重粘连、23例因术中并发症中转开腹,手术成功率92.2%。手术时间LSH组最短,平均（70.13±32.75）min,LSH组与LISH组平均（131.78±33.36）min,LTH组平均（140.32±27.13）min,组间比较差异有统计学意义（t=16.93,P〈0.01;t=22.60,P〈0.01）。术中出血LTH组最多,平均（305.78±85.23）ml,与其他3组相比差异有统计学意义（t=29.64/13.83/5.87,P〈0.01）。术后住院时间LSH组最短,平均（4.3±0.3）d,LTH组最长,平均（5.8±0.5）d,两组相比差异有统计学意义（t=37.22,P〈0.01）。术后3d平均体温,LAVH组超过38℃,其他3组均在38℃以下。术后肛门排气时间LTH组最长,平均（40.27±15.28）h,LSH组最短,平均（29.28±2.23）h。结论：LSH、LISH、LAVH、LTH均是临床上成熟的子宫切除术式。患者〈40岁,宫颈光滑,TCT无癌性发现时建议首选LSH术式;患者〈40岁,宫颈糜烂中至重度伴宫颈肥大多选择LISH术式;患者〉40岁,宫颈疾病重,宫体病变较大但阴道宽松宜选择LAVH术式;患者〉40岁,宫颈疾病重,宫颈上皮内瘤变或子宫内膜上皮内瘤变建议选择LTH术式。

Clinical analysis of four kinds of laparoscopic hysterectomies

Objective:To evaluate the clinical application value of four kinds of hysterectomies,including laparoscopic subtotal hysterectomy(LSH),laparoscopic intrafascial supercervical hysterectomy(LISH),laparoscopic assisted vaginal hysterectomy(LAVH) and laparoscopic total hysterectomy(LTH).Methods:The clinical data of 664 patients who underwent laparoscopic hysterectomy from Jan.2006 to Jan.2009 was retrospectively analyzed.The clinical application and operative indication of 4 approaches were compared and analyzed.Results:The 612 cases of laparoscopic hysterectomy were successful,29 cases and 23 cases were converted to laparotomy because of severe adherence or intraoperative complication respectively.The success rate of operation was 92.2%.The operation time of LSH group was the shortest,mean(70.13±32.75)min,there was significant difference(t=16.93,P<0.01;t=22.60,P<0.01) compared with LSH group mean(131.78±33.36)min] and LTH group mean(140.32±27.13)min].The bleeding volume of LTH group was the most,mean(305.78±85.23)ml,there was significant difference(t=29.64/13.83/5.87,P<0.01) compared with other three groups.LSH group was the shortest in postoperative hospital stay(4.3±0.3)d],LTH group was the longest (5.8±0.5)d],there was significant difference(t=37.22,P<0.01) between the two groups.The average body temperature of LAVH group exceeded 38℃ on the 3 days after operation while other three groups were below 38℃.The mean intestinal function recovery time of LTH group was(40.27±15.28)h which was the longest,LSH group was the shortest,mean(29.28±2.23)h.Conclusions:LSH,LISH,LAVH and LTH are mature hysterectomy in clinic.Patients who are less than 40 years old with smooth cervix and no carcinomatous discovery in TCT are suggested to receive LSH.LISH is a choice for patients who are less than 40 years old,suffer from moderate to severe cervical erosion complicated with cervical hypertrophy.Patients who are more than 40 years old companied by severe cervical diseases,uterine body comparatively large pathological changes and loose vagina is appropriate to choose LAVH.LTH is proposed for patients who are more than 40 years old with severe cervical diseases,cervical intraepithelial neoplasia or intraendometrial neoplasia.