改良LAVH治疗盆腔后部深部浸润型子宫内膜异位症合并子宫腺肌病

目的探讨改良腹腔镜辅助下阴式子宫切除术（1aparoscopic-assisted vaginal hysterectomy，LAVH）治疗盆腔后部深部浸润型子宫内膜异位症（endometriosis，EM）合并子宫腺肌病患者的效果及手术技巧。方法18例盆腔后部深部浸润型EM合并子宫腺肌病患者行改良LAVH，腹腔镜下离断子宫圆韧带、卵巢固有韧带、输卵管及子宫血管，初步钝性分离子宫直肠间隙，至致密粘连处停止分离，转阴式手术。切开阴道粘膜后先分离宫颈与阴道间隙至腹腔，离断子宫骶韧带及主韧带后，自子宫主韧带断端水平截除宫颈，自子宫与直肠粘连处截除子宫体，从已打开的阴道前穹隆翻转残余子宫体，暴露子宫后壁与直肠粘连处，直视下沿子宫后壁锐性剪开、分离并切除与直肠粘连之子宫体，直肠内手指做指示，切除异位灶。结果18例患者全部按预定术式完成手术，2例因异位灶侵及直肠肌层，患者拒绝切除肠管，异位灶持续存在。18例患者手术时间（144±42）min，术中出血量（155±86）ml，无直肠及膀胱输尿管损伤。18例患者随访12～36个月，16例完整切除病灶者预后良好，2例未能完整切除病灶者症状缓解，病灶持续存在。结论采用自阴道前穹隆翻出残余子宫体，暴露子宫后壁与直肠粘连处，在直视下切除直肠阴道隔异位灶及粘连子宫的方法，提高了手术的安全性，值得临床推广应用。

Application of upgraded laparoscopical-assisted vaginal hysterectomy in treating deep and infiltrating type endometriosis in posterior part of pelvic cavity combined with adenomyosis

Objective To explore curative effects and operation techniques of upgraded laparoscopical-assisted vaginal hyster-ectomy （LAVH） in treating deep and infiltrating type endometfiosis in posterior part of pelvic cavity combined with adenomyosis. Methods Eighteen patients with deep and infiltrating type endometriosis in posterior part of pelvic cavity combined with adenomyosis were operated with upgraded LAVH, mutilating round ligament of uterus, ligament ovarii proprium, fallopian tube and uterus blood vessel ; bluntly dissecting uterus-rectum crevice to pykno-adherence position with laparoscope and then turning to vaginal operation. Af-ter cutting open the vaginal mucosa, we separated crevice between cervix uteri and vagina to abdominal cavity, mutilated uterosacral lig-ament and cardinal ligament, blared cervix uteri at cervical ligament level and uterine body at adherence position between uterus and rectum, turned out the remained uterus body from ante-fornix of vagina, exposed adherence between uterus posterior wall and rectum, sheared posterior wall of uterus, separated and ablated uterus body adhering to rectum and cut ectopic focus guiding by intrarectal ex- amination. Results Eighteen operations were all accomplished according to reservation method. Two patients with tunica muscularis recti ectopic focus didnl recover because they rejected to ablate intestinal canal. For the 18 patients, the operation time was （ 144 ± 42） min, the operative blood loss was（ 155 ± 86）ml and there was no rectum, bladder and ureteral injury. During the 12-36 months follow-up, 16 patients who were cut focus of infection got eusemia. The symptoms of 2 patients who were not cut focus of infection completely got relieved but still had focus of infection. Conclusion This method of turning out uterus body from ante-fornix of vagina, exposing adherence between uterus posterior wall and rectum, separating and ablating ectopic focus and adherence uterine from rectovaginal sep-tum euthyphorialy which improves the operation safety is worth applying for the patients with deep and infiltrating type endometriosis in posterior part of pelvic cavity.