腹腔镜辅助阴式子宫切除阴侧理想手术路径探讨

Study on ideal operation approach from vagina in laparoscopic assisted vaginal hysterectomy

目的：探讨腹腔镜辅助阴式子宫切除术中阴侧路径解剖关系及阴侧理想手术路径对临床的适用性、可行性和指导性。方法：对我院47例行腹腔镜辅助阴式子宫切除术患者的临床资料进行回顾性分析。结果：本组47例中46例手术成功,分离前后穹窿时宜注射经稀释的垂体后叶素能有效止血,术中发现距离宫颈及峡部2~3 mm远断离缝扎主韧带及骶韧带后,即可显露子宫动脉的下行支及伴随静脉;断离缝扎后,向下牵拉子宫,沿血管内侧向上断离又发现子宫动脉上行支及（或）分支,子宫动脉上行支或其分支与其下行动脉直径十分相似,且动静脉可为1~2支;术中未发现断离子宫动脉主干。宫颈一侧钳夹为4~5次。无输尿管损伤。结论：腹腔镜辅助阴式子宫切除术阴侧的理想手术路径是：前后方路径沿宫颈、峡部表面疏松组织分离;侧方路径为骶、主韧带及子宫动脉上下行支及伴随静脉作为路径外侧的手术引导标志,宫颈、峡部、宫体外侧作为路径内侧的引导标志;注意辨别子宫动脉上行支是否有分支及伴随静脉。

Objective：To study the anatomy relation of transvaginal approach and the applicability,feasibility and instruction of ideal transvaginal operation approach in clinic.Methods：The clinical data in 47 cases received laparoscopic assisted vaginal hysterectomy in our hospital were performed the retrospective analysis.Results：Among 47 cases,46 cases were successfully operated.In separating anterior fornix from posterior fornix,injecting diluted hypophysin could effectively stop bleeding.During operation,the uterine artery descending branch and the accompanying vein were revealed after breaking off and suturing the main ligaments and sacral ligament at 2-3mm from the cervix and the isthmus uteri.After breaking off and suturing,the uterus was pulled down.Ascending uterine artery and（or） branch were discovered when breaking up along the inside of blood vessels.Ascending uterine artery or its branches and its downstream artery diameter were very similar to each other.Breaking away from the trunk of arteria uterine did not appear in operation.Clamping for 4-5 times were performed on cervical side.There was no ureteral injury.Conclusion：The ideal transvaginal operation approach in laparoscopic assisted vaginal hysterectomy is that separating anterior fornix from posterior fornix along the cervix,isthmus surface loose organizations.Sacrolignament,cardinal ligament and ascending branch and ramus descendens of arteria uterine work as the lateral approach guide signs for operation.Cervix,isthmus and outside uterus work as the inside path guide signs for operation.Attention should be paid to whether the ascending uterine artery has branches or accompanying vein.