直肠阴道隔严重粘连的腹腔镜辅助下阴式全子宫切除36例报告

Laparoscopic-assisted Vaginal Hysterectomy in Patients with Severe Rectovaginal Adhesion

目的探讨直肠阴道隔严重粘连的腹腔镜辅助下阴式全子宫切除的可行性。方法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。切开阴道黏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,从已打开的子宫前穹隆翻转子宫,自阴道前穹隆翻出子宫,暴露子宫后壁与直肠粘连,直视下沿子宫后壁锐性剪开、分离并切除粘连组织。结果 35例腹腔镜辅助下阴式子宫切除术顺利完成,1例因子宫直肠间隙粘连严重,镜下及经阴道分离时出血多而中转开腹。35例手术时间(134±38)min,术中出血(138±36)ml,无直肠及膀胱输尿管损伤。35例随访12～36个月,平均18.5月,33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。结论自阴道前穹隆翻出子宫,暴露子宫后壁与直肠粘连,在直视下切除直肠阴道隔严重粘连的全子宫可行,提高了手术的安全性。

Objective To investigate the feasibility of laparoscopic-assisted vaginal hysterectomy in patients with severe rectovagina] adhesion. Methods Under a laparoscope, we cut the round ligament of uterus, proper ligament of the ovary, fallopian tubes, and uterine vessels, and then bluntly dissected the recto-uterine pouch down to the dense adhesion site, where we started transvagina] procedures. After cutting the vaginal mucosa, we dissected the space between the cervix and vagina until the abdominal cavity, and then the uterosacral and cardinal ligaments were cut so that to rcsect the cervix at the level of the cardinal ligament. Afterwards, the uterus was turned out from the anterior fornix of the vagina to expose the adhesion between the posterior wall of the uterus and the rectum. Finally, under a direct vision, we cut the posterior wall of the uterus, and resected the adherent tissues. Results The procedure was completed in 35 patients without conversion to open surgery expect for one, who was converted to open surgery because of the severe adhesion between the uterus and rectum caused massive hemorrhage when the vagina was separated. The mean operation time of this series was （134 ＋ 38）min, and intraoperative blood loss was （138 -＋ 36）ml. No patient developed injuries to the rectum, bladder, or ureter. Follow-up was achieved in all the patients for 12 to 36 months with a mean of 18.5 months. The lesion was completed removed in 33 of them, who recovered well afterwards; in the other 2 patients, the lesion was incompletely resected, and the symptoms were relieved. Conclusion In patients with severe rectovaginal adhesion, it is feasible and safe to turn out the uterus from the anterior fornix of the vagina so that to expose the posterior wall of the uterus and adherent rectal tissues for vaginal hysterectomy under a direct vision.