腹腔镜困难性子宫全切除术避免损伤膀胱的技巧

The technique of laparoscopic difficult total hysterectomy to avoid bladder injury

目的探讨有剖宫产史的腹腔镜困难性子宫全切除术(LTH)避免膀胱损伤技巧。方法选取2013年5月至2016年5月在东莞市第三人民医院行腹腔镜子宫切除手术的患者85例进行回顾性研究,全部患者均有剖宫产病史2次以上。总共85例患者,其中50例应用举宫杯并在分离及下推膀胱腹膜反折前膀胱注射含亚甲蓝生理盐水300 ml(A组),35例应用普通举宫器及下推膀胱腹膜反折前膀胱注射含亚甲蓝生理盐水300 ml(B组),B组患者手术技巧为开始时使用,后期改用A组手术技巧。比较两者膀胱损伤出现例数、损伤程度、出血量、手术时间、手术后住院时间等情况。结果在患者孕产次、年龄、剖宫产次数、末次剖宫产至今时间、体质量指数(BMI)等方面,两组患者差异无统计学意义(P>0.05)。A组术中损伤膀胱1例,B组术中损伤膀胱6例,A组平均出血量为58 ml,B组130 ml;A组平均手术时间78 min,B组126 min;A组术后平均住院时间7 d,B组10 d,在膀胱损伤、出血量、手术时间、术后下床活动时间、术后住院时间A组明显少于B组,差异有统计学意义(P<0.05)。手术后胃肠道恢复时间两组差异无统计学意义(P>0.05)。结论腹腔镜困难性子宫全切除术中应用举宫杯、下推膀胱腹膜反折前膀胱注射美蓝液充分暴露膀胱腹膜反折可有效避免膀胱损伤,从而减少术中出血量、手术时间及术后住院时间,值得广泛推广应用。

Objective To explore the technique of laparoscopic difficult total hysterectomy （LTH） to avoid bladder injury in the patients who underwent caesarean section. Methods A total of 85 patients who underwent laparoscopic hysterectomy in the Third People＇s Hospital of Dongguan from May 2013 to May 2016 were retrospectively studied. All the patients had a history of cesarean section for more than 2 times. Among the 85 patients, 50 patients received uterine cup and were injected with 300 mL normal saline containing methylene blue into bladders before separation and push-down vesical peritoneal reflection （group A）; 35 patients received normal uterine manipulator and were injected with 300 mL normal saline containing methylene blue into bladders before push-down vesical peritoneal reflection （group B）. The technique used in group B was used at the beginning, and switched to that used in group A later. The number of cases of bladder injury, degree of injury, estimated blood loss, operation time and postoperative hospital stay were compared between the two groups. Results The two groups presented no significant difference （P〉0.05）in gravidity and parity history, age, number of cesarean section, period since the last cesarean section and body mass index （BMI）. Bladder injury occurred in 1 patient in Group A and 6 patients in groupB. The average estimated bleed loss was 58 mL in group A and 130 mL in group B. The average operation time was 78 min in group A and 126 min in group B. The average postoperative hospital stay was 7 d in group A and 10 d in group B. The cases of bladder injury, estimated bleed loss, operation time, postoperative activity time and postoperative hospital stay in group A were significantly less than those of group B, which presented statistically significant differences （P〈0.05）. There was no significant difference in postoperative recovery time of gastrointestinal tract between the two groups （/9〉0.05）. Conclusion The use of uterine cup and injection of methylene blue solution into bladder before push-down vesical peritoneal reflection to make the vesical peritoneal reflection fully exposed during laparoscopic difficult total hysterectomy can effectively advoid bladder injury, thereby reducing the intraoperative bleeding, operation time and postoperative hospital stay. It is worth popularizing.