腹腔镜困难子宫全切除术280例临床分析

Analysis of complicated total laparoscopic hysterectomy (a report of 280 cases)

目的探讨腹腔镜困难子宫全切除术的手术要点和临床价值。方法 2005年3月～2009年9月对280例有子宫全切除指征且腹腔镜手术困难的患者,全部施行了腹腔镜子宫全切除术。其中大子宫(子宫≥12孕周)180例、阔韧带肌瘤15例、宫颈肌瘤19例、盆腔手术史42例、盆腔内异症并存重度粘连24例。大子宫采用结扎子宫动脉后处理圆韧带和附件;阔韧带肌瘤、颈部肌瘤的患者采取贴近子宫壁处理子宫动脉的上下分支;对于子宫与膀胱、直肠粘连的患者,分别采用膀胱注水、直肠指检的方法帮助辨认解剖层次,紧贴子宫肌层松解粘连。结果 280例全部在腹腔镜下完成子宫全切除术,手术时间(161.2±32.5)min,术中出血量(258.8±96.2)mL,术后肠功能恢复时间(36.9±11.8)h,术后住院时间(6.1±2.4)d。并发症2例:直肠阴道瘘1例,于3个月后在充分准备下施行直肠和阴道修补术治愈;1例为继发腹腔出血,经输血及止血治疗痊愈。随访223例,除8例在术后有少量阴道出血治愈外,其余病例无并发症。结论充分术前准备,掌握子宫动脉处理技巧,遵循宁伤子宫勿伤膀胱及直肠的原则,腹腔镜困难子宫全切术是安全可行的。

【Objective】To investigate the operative techniques and clinical value of complicated total laparoscopic hysterectomy.【Methods】Total laparoscopic hysterectomy was operated in 280 cases diagnosed of gigantic uteri （180 cases）, broad ligament leiomyoma （15 cases）, cervical myoma （19 cases）, pelvic adhesion （42 cases） and previous cesarean section （24 cases）. Operated accessories and round ligament after the ligation of uterine artery in gigantic uteri operation. Close to the uterine wall, operated the up-and-down branch of uterine artery in broad ligament leiomyoma and cervical myoma operation. For the patients of uterus adhesion to bladder and intestine, operated bladder filling and digital rectal examination respectively to help identify anatomical layers, and released adhesions close to myometrium.【Results】All cases were operated under laparoscopy. The average operative time was （161.2± 32.5） min, the average blood loss in operation was （258.8±96.2） mL, the average time of bowel function recovery was （36.9±11.8） h, the postoperative hospital stay was （6.1±2.4） d. Postoperative surgery complications occurred in 2 patients. One patient cured by rectal and vaginal repair operation had a rectovaginal fistula and the other one suffering secondary abdominal bleeding was cured by blood transfusion and hemostasis. All the complications were successfully cured by operative or non-operative method. 【Conclusions】Complicated total hysterectomy can be performedunder laparoscopy. It is important for the operator to be familiar with pelvic anatomy and skilled operative techniques must be mastered.