大子宫肌瘤剥除术三种术式的临床比较

Clinical comparison of three surgical methods of large hysteromyoma excision

目的探讨腹腔镜下改良大子宫肌瘤剥除术的可行性及临床效果。方法回顾性分析2012年8月至2016年5月在江阴市人民医院妇科行大子宫肌瘤(肌瘤直径大于8cm)剥除术的150例患者的临床资料,按治疗方法随机分为3组,其中55例行开腹手术为A组,50例行腹腔下常规大子宫肌壁间肌瘤剥除为B组,45例行腹腔镜下改良大子肌瘤剥除术为C组,比较3组手术效果。结果 3组患者的手术时间、术中出血量比较有显著性差异(F值分别为123.17、66.61,均P<0.05),B组患者的手术时间、术中出血量均显著高于A组(t值分别为22.06、7.61,均P<0.05)和C组患者(t值分别为11.10、2.57,均P<0.05)。3组患者术后镇痛用药率比较有显著性差异(χ~2=18.36,P<0.05),进一步两组间比较显示B组和C组患者术后镇痛用药率均显著低于A组患者(χ~2值分别为11.46、15.52,均P<0.05),B组和C组患者之间比较无显著性差异(χ~2=0.45,P>0.05)。3组患者肛门排气时间及住院时间比较有显著性差异(F值分别为90.60、104.53,均P<0.05),B组和C组患者上述两指标均显著低于A组患者(t值分别为-12.30、-15.79,均P<0.05),B组和C组患者之间比较无显著性差异(t值分别为1.02、1.08,均P>0.05)。3组患者术后病率、肠粘连和肠梗阻发生率(Fisher精确概率法统计)、术后满意率比较均有显著性差异(χ~2值分别为8.04、9.74,均P<0.05),B组和C组患者术后病率、肠粘连和肠梗阻发生率、术后满意率均显著低于A组患者(χ~2值分别为5.20、4.42、5.26、5.07、5.21,均P<0.05),而B组及C组之间比较无显著性差异(χ~2值分别为0.34、0.64,均P>0.05)。3组患者子宫切除率、子宫血肿发生率、切口愈合不良发生率、皮下气肿发生率、输尿管和膀胱及肠道损伤发生率等方面比较无统计学差异(χ~2=0.66~1.38,均P>0.05)。结论腹腔镜下改良大子宫肌瘤剥除术具有手术时间短,术中出血量少,术后恢复快,未增加手术风险及并发症,值得临床推广应用。

Objective To discuss the feasibility and clinical effects of improved laparoscopic large hysteromyoma excision.Methods The clinical data of 150 cases receiving large hysteromyoma（diameter larger than 8 cm）excision in gynecology department of Jiangyin People＇s Hospital from August 2012 to May 2016 were analyzed retrospectively.These cases were divided into three groups randomly according to therapy method,and among them,55 cases receiving open surgery were regarded as group A,50 cases undergoing laparoscopic normal intramural hysteromyoma excision as group B and 45 cases undergoing laparoscopic improved large hysteromyoma excision as group C.Operative effect in three groups was compared.Results Differences in operation time and intraoperative blood loss among three groups had significance（F value was 123.17 and 66.61,respectively,both P〈0.05）.Operation time and intraoperative blood loss in group B were obviously higher than those in group A（t value was 22.06 and 7.61,respectively,both P〈0.05）and group C（t value was 11.10 and 2.57 respectively,both P〈0.05）.Postoperative analgesic medication rate in three groups had significant difference（χ^2=18.36,P〈0.05）.Further comparison in every two groups showed that postoperative analgesic medication rates in group B and group C were obviously lower than that in group A（χ^2 value was 11.46 and 15.52,respectively,both P〈0.05）,while there was no significant difference between group B and group C（χ^2=0.45,P〈0.05）.Anal exsufflation time and hospitalization time in three groups showed significant differences（F value was 90.60 and104.53,respectively,both P〈0.05）.Anal exsufflation time and hospitalization time in group B and group C were obviously lower than those in group A（t value was-12.30 and-15.79 respectively,both P〈0.05）,while there were no significant differences between group B and group C（t value was 1.02 and 1.08,respectively,both P〉0.05）.There were significant differences in postoperative morbidity,incidences of intestinal adhesion and intestinal obstruction（Fisher exact probability）and postoperative satisfactory rate among three groups（χ^2 value was 8.04 and 9.74,respectively,both P〈0.05）.Postoperative morbidity,incidences of intestinal adhesion and intestinal obstruction and postoperative satisfactory rate in group B and group C were obviously lower than those in group A（χ^2 value was 5.20,4.42,5.26,5.07 and 5.21,respectively,all P〈0.05）,while there were no significant differences between group B and group C（χ^2 value was 0.34 and 0.64 respectively,both P〉0.05）.Hysterectomy rate,incidence of uterine hematoma,poor wound healing,subcutaneous emphysema,injury in ureter,bladder and intestine in three groups showed no significant differences（χ^2 value ranged 0.66-1.38 respectively,all P〉0.05）.Conclusion Laparoscopic improved large hysteromyoma excision has advantages of short operative time,little intraoperative blood loss and faster recovery.It doesn＇t increase operative risk and postoperative complications and is worthy of clinical application.