腹腔镜下困难性子宫肌瘤剔除120例分析

The analysis of 120 cases with difficult laparoscopic myomectomy

目的探讨腹腔镜下进行困难性子宫肌瘤剔除术的可行性。方法收集我院2009年1月至2012年2月巨大、多发、特殊部位的子宫肌瘤患者120例。在腹腔镜下,术中采用腹腔镜超声监护、输尿管插管,必要时联合宫腔镜行子宫肌瘤剔除术,观察手术并发症、手术时间、术中出血量及术后恢复情况。结果在全部120例患者中,多发子宫肌瘤肌瘤数目>5个者59例,单发子宫肌瘤直径>8cm者43例(其中子宫肌壁间肌瘤29例,子宫浆膜下肌瘤14例),子宫阔韧带肌瘤9例,子宫颈肌瘤9例。剔除子宫肌瘤最多达15个,子宫肌瘤直径≥10cm者11例,其中直径最大的达12cm(为阔韧带肌瘤,重1800g)。患者手术均在腹腔镜下顺利完成,无一例中转开腹。平均手术时间(114±32)min,平均术中出血量(106±35)ml,术后平均住院时间5.1d。结论困难性子宫肌瘤剔除术可以在腹腔镜下完成,术中适当进行输尿管插管可降低输尿管损伤,术中超声的应用有助于彻底剔除肌瘤,降低术后复发率。联合宫腔镜手术可同时剔除粘膜下肌瘤,术后月经量增多症状明显缓解,合理应用辅助检查及熟练的手术技巧是手术成功的关键。

Objective To investigate the feasibility of complicate myomectomy by laparoscopy.Methods Clinical data,including operation complications,operation time,blood loss and postoperative recovery time,of 120 patients with large,multiple,located at special site uterine myoma,who underwent laparoscopic myomectomy in our hospital from January 2009 to February 2012 were retrospectively analyzed.The myomectomy was done through intra-urethral cannula,guided by laparoscopic ultrasonography,and with the help of hysteroscopy.Results Among all patients,59 cases of multiple myomas（the number of myomas 5） and 43 cases with single myoma（the diameter of myoma8 cm,including 29 cases of intramural myoma,14 cases of subserous myoma）,9 cases with myoma of broad ligament of uterus and 9 cases with cervical myoma.The most myoma removed was 15.Eleven removed myoma were more than 10 cm in diameter,in which the largest was 12 cm in diameter.All cases were performed successfully with the help of laparoscopy.No intra-operative laparatomy was needed.The average operating time and blood loss were（114±32）min and（106±35）ml respectively.The average time of hospital stay was 5.1 d.Conclusion Laparoscopic guided operation for complicated myomectomy can be performed.The use of intra-urethral cannula can reduce the occurrence of urethral injury.Laparoscopy ultrasound is helpful in thorough removing of myoma and decreasing postoperative recurrence.The combined hysteroscopic surgery could reject submucous myoma,meanwhile,this approach could relieve heavy menstruation.Application of auxiliary examination and experienced operating skills are the key to successful operation.