乳腺多发性肿块的微创手术方式选择

Different surgical manners for the excision of multiple mammary lumps by ultrasound-guided Mammotome techniques

目的研究运用微创技术(Mammotome)切除不同分布类型的乳腺多发性肿块的手术方式选择。方法选择2006年1月至2008年8月在复旦大学附属妇产科医院行Mammotome手术的1017例患者(单侧乳房肿块数量≥3个,共3 253个乳腺多发肿块),按肿块分布位置分为乳房多发性深部肿块组(A组,320例,997个肿块),乳房多发性浅表肿块组(B组,257例,804个肿块),乳房深部及浅表混合多发性肿块组(C组,440例,1 452个肿块),分析比较各组手术方式。结果 A组中,200例选择乳腺后间隙切除,平均手术时间(40±3)min、术中活动性出血9例(4.3%)、残留率(6月后)0.5%(1例)、术中疼痛发生率10.5%(21例);120例选择腺体内切除,平均手术时间(65±4)min、术中活动性出血14例(11.7%)、残留率(6月后)2.5%(3例)、术中疼痛发生率18.3%(22例)。两种术式结果比较,差异具有统计学意义(P<0.01)。B组为腺体内切除方式,进针方向分为由内而外、由外而内及由乳晕放射。105例选择由内而外手术方式,平均手术时间(48±5)min、术中活动性出血17例(16.2%)、残留率(6月后)2.8%(3例)、术中疼痛发生率15.2%(16例);64例选择由乳晕放射切除手术方式,平均手术时间(64±3)min、术中活动性出血5例(7.8%)、残留率(6月后)2.3%(2例)、术中疼痛发生率20.3%(13例);88例选择由外而内切除手术方式,平均手术时间(68±4)min、术中活动性出血16例(18.2%)、残留率(6月后)3.1%(2例)、术中疼痛发生率14.8%(13例)。残留率差异无统计学意义,其余各项指标差异具有统计学意义(P<0.01)。C组440例患者的肿块分布浅部、深部均有,根据肿块分布位置选择手术方式,平均手术时间(64±6)min、术中活动性出血70例(15.9%)、残留率(6月后)2.5%(11例)、术中疼痛发生率14.1%(62例)。结论运用微创技术切除乳腺多发肿块,手术方式应根据肿块分布的深浅选择进针位置及方向。深部肿块首先考虑乳腺后间隙切除,浅部肿块根据就近原则选择由内而外进针方向,乳晕切口适用于美观要求很高且为浅部肿块的患者。

Objective To evaluate and describe different surgical manners for the excision of multiple mammary lumps by ultrasound-guided Mammotome techniques.Methods One thousand and seventeen patients with 3253 mammary lumps who underwent Mammotome surgery in our hospital from Jan.2006 to Aug.2008 were divided into 3 groups according to the distribution of the lumps：group A were the patients with all the lumps at the deep layer of the mammary glands（320 patients,997 lumps）;group B were the patients with all the lumps at the shallow layer of the mammary glands（257 patients,804 lumps） and group C were the patients with the lumps at both shallow and deep layers of the mammary glands（440 patients,1 452 lumps）.The operational effects were compared between the 3 groups. Results In group A,200 patients underwent the lumps excision through the space behind the mammary glands,whose average surgical time was（40±3）min,9 cases bled（4.3%） and 21 had a pain（10.5%） in the procedure,and the residence rate was 0.5%（1 case）.Another 120 cases underwent the lumps excision through the mammary glands,whose average surgical time was（65±4）min,14 cases bled（11.7%） and 22 had a pain（18.3%） in the procedure,and the residence rate was 2.5%（3 cases）.The results had statistical differences（P 0.01）.Patients in group B underwent 3 surgical manners which were from inner to lateral,from lateral to inner and radial from the periareola.In group B,105 patients underwent lumps excision from inner to lateral,whose average surgical time was（48±5）min,17 cases bled（16.2%） and 16 had a pain（15.2%） in the procedure,and the residence rate was 2.8%（3 cases）.Sixty-four patients of group B underwent lumps excision radial from the periareola,whose average surgical time was（64±3）min,5 cases bled（7.8%） and 13 had a pain（20.3%） in the procedure,and the residence rate was 2.3%（2 cases）.Eighty-eight patients of group B underwent lumps excision from lateral to inner,whose average surgical time was（68±4）min,16 cases bled（18.2%） and 13 had a pain（14.8%） in the procedure,and the residence rate was 3.1%.The residence rates between the 3 subgroups had no statistical difference（P0.05）,and the other results had statistical difference（P0.01）.The surgical manners were more complicated in 440 patients of group C for their complicated lumps distribution,whose average procedure time was（64±6）min,70 cases bled（15.9%） and 62 had a pain（14.1%） in the procedure,and the residence rate was 2.5%（11 cases）.Conclusions When multiple mammary lumps were excided by ultrasound-guided Mammotome techniques,surgical manners may determined by the distribution of lumps.Excision behind the gland was the first choice for lumps at deep layer of the gland,while manner from inner to lateral was better for lumps at shallow layer of the gland.Patients with lumps at shallow layer of the gland who had high demand for incision look could chose periareola incision.