剖宫产后腹腔镜子宫切除术中预防泌尿系损伤的处理方法

Minimizing bladder injury in laparoscopic hysterectomy among women with previous cesarean sections

目的研究有剖宫产(cesarean section,CS)手术史的患者进行腹腔镜全子宫切除术(total laporoscopic hyster-ectomy,TLH)及次全子宫切除术(laparoscopic supracervical hysterectomy,LSH)时降低或避免膀胱及输尿管损伤的方法。方法2005年5月至2008年6月,53例既往有过1～2次CS手术史的患者,因各种妇科疾病于中国医科大学附属盛京医院接受TLH及LSH手术。术中通过举宫器用力上推子宫使CS手术瘢痕下方的膀胱腹膜反折充分展平,于瘢痕下缘单极电凝横行切开腹膜。在保持上推子宫状态下使膀胱位置下移并进一步切开瘢痕下方的粘连结缔组织,从而进入膀胱宫颈间隙的下部。膀胱宫颈间隙的两侧不受CS手术瘢痕的影响,因而可安全而充分地将膀胱向阴道穹窿部分离,有效避免由于CS手术粘连而导致膀胱或输尿管的损伤。结果18例TLH手术及35例LSH手术均采用该方法得以顺利完成。无膀胱或输尿管损伤及任何其他并发症的发生。TLH及LSH手术切除的子宫重量分别为(316.24±128.17)g,(375.43±116.27)g;手术时间分别为(115.32±28.63)min,(90.17±24.15)min;出血量分别为(122.46±31.15)mL,(76.12±41.28)mL;术后住院天数分别为(3.18±0.52)d,(3.67±0.43)d。结论该手术方法能有效预防CS术后TLH及LSH中膀胱及输尿管的损伤。

Objective To demonstrate a method to prevent bladder and ureter injury during total laparoscopic hysterectomy（TLH） and laparoscopic supracervical hysterectomy（KSH） to patients with vesicocervical adhesion after previous cesarean deliveries. Methods Between May 2005 and June 2006,53 women in Shengjing Hospital of China Medical University with vesicocervical adhesion who had given birth by cesarean delivery underwent TLH（ 18 cases） and LSH（35 cases）. To minimize the chance of bladder injury, the uterus was pushed upwards and made the utero-vesical fold on tension, short application of monopolar cutting current applied on the fold beneth the cesarean scar allows a clean cut to be made right down to the lower vesicocervical space. With this space exposed centrally, dissection can then be brought laterally to free the bladder. Results 18 cases TLH and 35 cases LSH were all very successfully performed,no complication occurred. The extirpated uterine weight of TLH and LSH were （316. 24 ± 128.17 ）g and （357.43±116, 27）g;The mean operating time of TLH and LSH were （ 115.32 ± 28.63 ） min and （90. 17± 24. 15 ） min; The average blood loss of TLH and KSH were （3. 18 ±0. 52 ）days and （3.67 ±0.43） days. Of the 18 patients in TLH group,16（88. 89% ） had one and 2（11.11% ） had two previous cesarean deliveries. Among 35 patient in LHS group, 31 （88.57%） had one and 4 （ 11.43 % ） had two previoascesarean deliveries. Conclusion The above operating method may help to minimize bladder injuries during TLH and LSH for patient with previous cesarean deliveries.