经阴道自然腔道内镜全子宫切除手术的临床对比分析

Clinical study of total hysterectomy via transvaginal natural orifice transluminal endoscopic surgery

目的探讨经阴道自然腔道内镜手术(vaginal natural orifice transluminal endoscopic surgery,vNOTES)在全子宫切除中应用的可行性和安全性。方法回顾性分析2019年4月至12月在中国医学科学院肿瘤医院深圳医院接受vNOTES全子宫切除术(vNOTES组)35例患者情况,结合文献报道的分析经脐单孔腹腔镜手术(经脐单孔腹腔镜组)、传统腹腔镜手术(传统腹腔镜组)患者数据,分析不同途径全子宫切除术的患者基线信息和手术情况。结果vNOTES组、经脐单孔腹腔镜组、传统腹腔镜组患者基线情况基本均衡具有可比性。vNOTES组手术时间45~172 min,平均(92.9±29.8)min;术中出血量20~400 ml,平均(119.4±83.9)ml;留置尿管时间10~41 h,平均(22.0±7.4)h;术后下床时间5~24 h,平均(17.3±4.2)h;肛门排气时间5~32 h,平均(16.8±6.8)h;术前术后血红蛋白差值0~45 g/L,平均(13.6±11.1)g/L;术后24 h的术后视觉模拟评分法疼痛评分(visual analogue scale,VAS)0~3分,平均(1.0±1.1)分。术后患者满意度评分8~10分,平均(9.6±0.6)分。无邻近器官损伤、无输血、无术后感染等并发症的发生。三组手术时间比较,差异无统计学意义(P>0.05)。与经脐单孔腹腔镜组、传统腹腔镜组相比,vNOTES组术中出血量较多、肛门排气时较短,差异均有统计学意义(P<0.01)。vNOTES组术后24 h VAS较传统腹腔镜组低,差异有统计学意义(P<0.01)。亚组比较结果显示,vNOTES大子宫组和传统腹腔镜组在手术时间方面提示较长,差异存在统计学意义(P<0.05)。与经脐单孔腹腔镜组和传统腹腔镜组相比,vNOTES大子宫组术中出血较多、肛门排气时间较短(P<0.01)。结论vNOTES全子宫切除是一种安全、可行的手术方式,在术后恢复及患者满意度方面优于经脐单孔腹腔镜及传统腹腔镜。vNOTES大子宫切除可能具有优势。

Objective To discuss the feasibility and safety of vaginal natural orifice transluminal endoscopic surgery(vNOTES)in total hysterectomy.Methods A retrospective analysis was carried on the patients who underwent vNOTES total hysterectomy at the Shenzhen Hospital of the Chinese Academy of Medical Sciences Cancer Hospital from Apr.to Dec.2019.The 35 patients baseline information and surgical status of patients were compared with transumbilical single-hole laparoscopy and traditional laparoscopy approaches which had reported in literatures.Results The baseline conditions of patients in vNOTES group,transumbilical single-hole laparoscopy group and traditional laparoscopy group were basically balanced and comparable.The operation time of vNOTES group was 45 to 172 min,with an average of(92.9±29.8)min;the intraoperative blood loss was 20 to 400 ml,with an average of(119.4±83.9)ml;the indwelling catheter time was 10 to 41h,with an average of(22.0±7.4)h;The postoperative bed leaving time was 5 to 24 h,with an average of(17.3±4.2)h;the postoperative exhaust time was 5 to 32 h,with an average of(16.8±6.8)hours;the preoperative and postoperative hemoglobin difference was 0 to 45 g/L,with an average of(13.6±11.1)g/L;the VAS score was 0 to 3 at 24 h after operation,with an average of(1.0±1.1)points;Postoperative patient satisfaction score was 8 to 10,with an average of(9.6±0.6)points.No adjacent organ damage,blood transfusion and postoperative infections occurred.There was no statistical difference in operation time among the three groups(>0.05).The intraoperative blood loss in the vNOTES group were more than those in the transumbilical single-hole laparoscopic group and the traditional laparoscopic group(<0.01).The vNOTES group had shorter postoperative exhaust time than the other two groups,The VAS score is lower than the traditional laparoscopic group,and the differences are statistically significant(<0.01).The results of the subgroup comparison showed that the operation time of vNOTES in hysterectomy of large uterus group is longer than the traditional laparoscopic group(<0.05).Compared with the transumbilical single-hole laparoscopic group and the traditional laparoscopic group,the vNOTES in hysterectomy of large uterus group had more intraoperative blood loss and shorter postoperative exhaust time,the differences are both statistically significant(<0.01).ConclusionsvNOTES total hysterectomy is a safe and feasible surgical method,which is superior to transumbilical single-hole laparoscopy and traditional laparoscopy in terms of postoperative recovery and patient satisfaction.vNOTES in total hysterectomy of large uterus may have advantages.