腹腔镜大子宫切除术中经阴道和分碎器取出标本的安全性的对比研究

Comparative Study on Safety of Removal of Large Uterus Through Vagina or Morcellator in Laparoscopic Hysterectomy

目的探讨腹腔镜下大子宫（≥12孕周）切除术不同子宫取出方法的安全性。方法回顾性分析2002年1月～2012年1月大子宫行腹腔镜全子宫切除术416例资料,均由同一手术者及助手配合。由患者选择子宫标本取出方法。经阴道组162例,完全离断子宫后自阴道采取分段、劈半、剖块等方法取出;分碎器组254例,离断子宫动静脉上行支后用肌瘤分碎器将大部分子宫体以及肌瘤逐条取出,移除影响手术操作的子宫体,再按常规方法切除剩余子宫颈自阴道取出。比较2组的手术时间、术中出血量及安全性。结果分碎器组手术时间短于经阴道组[（116.4±44.6）min vs.（128.6±56.4）min,t=-2.444,P=0.015];阴道残端及周围损伤分碎器组2例（0.8%）,经阴道组6例（3.7%）,2组差异无显著性（χ^2=3.061,P=0.080）。2组术中出血量、子宫重量、术后排气时间、住院时间差异无显著性（P〉0.05）,术后并发症分碎器组7例（2.8%）,经阴道组6例（3.7%）,2组差异无显著性（χ^2=0.298,P=0.585）。随访3～10年,（5.4±4.3）年,5例病理报告为富于细胞者（经阴道组1例,分碎器组4例）,经妇科检查、阴道超声等检查均无恶变发生。结论腹腔镜下大子宫切除术用肌瘤分碎器取出可明显缩短手术时间,降低手术难度,减少对周围组织的损伤,随访无恶变、转移或播散发生,在术前充分告知患者子宫分碎的风险后,可选择性应用于大子宫的腹腔镜切除。

Objective To investigate the safety of different methods to take out large uterus（ ≥12 gestational weeks） in laparoscopic hysterectomy. Methods Clinical data of 416 laparoscopic total hysterectomies of large uterus by a same operation team from January 2002 to January 2012 were retrospectively analyzed. Taking-out methods of the large uterus were chosen by patients.There were 162 cases of transvaginal removal,in which the large uterus was severed and taken out with segmentation,splitting,or cutting into blocks. There were 254 cases of removal with morcellator,in which the large uterus was taken out with the bulk uterine body pieced one by one after the uterine arteriovenous ascending branches being cut off,with remained cervix resected with routine method and removed through the vagina. The operation time,intraoperative blood loss and safety were compared between the two groups. Results The operation time in the morcellator group was shorter than that in the transvaginal group [（ 116. 4 ± 44. 6） min vs.（ 128. 6 ± 56. 4） min,t =- 2. 444,P = 0. 015]. The vaginal stump and surrounding tissues damage rate in the morcellator group was lower than that in the transvaginal group but with no significantly statistical difference [2 cases（ 0. 8%） vs. 6 cases（ 3. 7%）,χ~2= 3. 061,P = 0. 080]. There were no statistical differences in the operative blood loss,postoperative flatus time,length of hospital stay,and postoperative complications between the two groups. Follow-up reviews for 3- 10 years（ mean,5. 4 ± 4. 3 years） showed all the 5 cases of cellular uterine leiomyoma by pathological reports（ 1 case in the transvaginal group and 4 cases in the morcellator group）had no canceration changes. Conclusions Removal of large uterus through morcellator in laparoscopic hysterectomy can obviously shorten the operation time,lessen the operation difficulty,and reduce the damage to the surrounding tissues. No canceration changes,metastasis,or spread are found during follow-ups. The method can be selectively applied in large uterus laparoscopic hysterectomy after patients are fully informed of operation risks.