薛海峰

471900河南省偃師市人民醫(yī)院婦產(chǎn)科

陰式與腹腔鏡子宮全切除術(shù)的臨床效果比較

薛海峰

471900河南省偃師市人民醫(yī)院婦產(chǎn)科

目的：探討陰式與腹腔鏡子宮全切除術(shù)的療效差異。方法：2013年2月-2014年3月收治行子宮全切除術(shù)患者368例，根據(jù)患者自愿分為陰式子宮切除術(shù)(TVH)組158例和腹腔鏡輔助經(jīng)陰道全子宮切除術(shù)(LAVH)組210例，TVH組采用陰式子宮切除術(shù)進(jìn)行治療，LAVH組采用腹腔鏡輔助經(jīng)陰道全子宮切除術(shù)。結(jié)果：LAVH組術(shù)后應(yīng)用鎮(zhèn)痛藥物11例(5.2%)，術(shù)后肛門排氣時(shí)間(11.2±3.6)h，住院時(shí)間(4.9±1.3)d，發(fā)生并發(fā)癥22例，并發(fā)癥發(fā)生率10.5%。TVH組術(shù)后應(yīng)用鎮(zhèn)痛藥物18例(11.4%)，術(shù)后肛門排氣時(shí)間(16.3±3.1)h，住院時(shí)間(7.3±1.1)d，發(fā)生并發(fā)癥15例，并發(fā)癥發(fā)生率9.5%。兩組術(shù)后鎮(zhèn)痛藥物應(yīng)用、術(shù)后肛門排氣時(shí)間、住院時(shí)間比較差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)，并發(fā)癥發(fā)生率比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。TVH組中轉(zhuǎn)開腹1例，LAVH組中轉(zhuǎn)開腹1例，對出現(xiàn)的并發(fā)癥患者進(jìn)行對癥處理，所有患者均治愈出院。結(jié)論：LAVH組術(shù)后鎮(zhèn)痛藥物應(yīng)用、術(shù)后肛門排氣時(shí)間、住院時(shí)間明顯優(yōu)于TVH組，兩組患者均各出現(xiàn)1例中轉(zhuǎn)開腹，因此，要結(jié)合患者的具體實(shí)際，選擇手術(shù)方式，減輕患者痛苦，提高臨床療效。

全子宮切除術(shù)；LAVH；TVH

子宮全切除術(shù)是治療子宮疾病重要的手段，臨床常用的手術(shù)方法有開腹、經(jīng)陰道及腹腔鏡手術(shù)治療。為探討陰式與腹腔鏡子宮全切除術(shù)的療效差異，2013年2月-2014年3月收治行宮全切除術(shù)的患者368例，進(jìn)行總結(jié)和分析，現(xiàn)報(bào)告如下。

資料與方法

2013年2月-2014年3月收治行宮全切除術(shù)的患者368例，均有全子宮切除術(shù)指征，根據(jù)患者自愿選擇進(jìn)行分組，其中陰式子宮切除術(shù)(TVH)組158例和腹腔鏡輔助經(jīng)陰道全子宮切除術(shù)(LAVH)210例。其中TVH組年齡31～64歲，平均46.6歲，體重8～70 kg，平均52.2 kg，疾病類型：宮頸癌12例，功能失調(diào)性子宮出血36例，子宮腺肌病26例，子宮肌瘤84例；LAVH組年齡30～66歲，平均45.9歲，體重36～71 kg，平均53.2 kg，疾病類型：宮頸癌19例，功能失調(diào)性子宮出血55例，子宮腺肌病44例，子宮肌瘤92例；兩組患者在年齡、體重、疾病類型比較，差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。

手術(shù)方法：LAVH組采用腹腔鏡輔助陰式全子宮切除術(shù)。首先人工氣腹，切斷子宮圓韌帶、輸卵管及卵巢固有韌帶，用超聲刀打開闊韌帶前后葉腹膜，前方向下達(dá)膀胱腹膜反折處，并剪開膀胱腹膜反折并推下膀胱；后方向下分離至子宮骶骨韌帶處，將宮旁疏松組織推開即暴露出子宮血管，用電凝將子宮血管凝固，再用超聲刀切斷子宮血管。血管斷端用1號結(jié)福線自制的套圈結(jié)扎。在腹腔鏡下用超聲刀切開陰道前壁、陰道穹窿。然后從陰道牽出子宮體，子宮取、縫合術(shù)畢。TVH組采用經(jīng)陰道全子宮切除術(shù)。

統(tǒng)計(jì)學(xué)方法：所有數(shù)據(jù)采用SPSS 16.0進(jìn)行統(tǒng)計(jì)分析，計(jì)量資料用(±s)表示，采用t檢驗(yàn)；計(jì)數(shù)資料采用χ2檢驗(yàn)；P＜0.05為差異具有統(tǒng)計(jì)學(xué)意義。

結(jié)果

兩組患者術(shù)后鎮(zhèn)痛藥物應(yīng)用、術(shù)后肛門排氣時(shí)間、住院時(shí)間、膀胱損傷例數(shù)、血管損傷出血、陰道殘端感染情況比較：LAVH組術(shù)后應(yīng)用鎮(zhèn)痛藥物11例(5.2%)，術(shù)后肛門排氣時(shí)間(11.2±3.6)h，住院時(shí)間(4.9±1.3)d，發(fā)生并發(fā)癥22例，并發(fā)癥發(fā)生率10.5%。TVH組術(shù)后應(yīng)用鎮(zhèn)痛藥物18例(11.4%)，術(shù)后肛門排氣時(shí)間(16.3±3.1)h，住院時(shí)間(7.3±1.1)d，發(fā)生并發(fā)癥15例，并發(fā)癥發(fā)生率9.5%。兩組后鎮(zhèn)痛藥物應(yīng)用、術(shù)后肛門排氣時(shí)間、住院時(shí)間比較有統(tǒng)計(jì)學(xué)意義(P＜0.05)，并發(fā)癥發(fā)生率比較無統(tǒng)計(jì)學(xué)意義(P＞0.05)，見表1。

TVH組中轉(zhuǎn)開腹1例，LAVH組中轉(zhuǎn)開腹1例，對出現(xiàn)的并發(fā)癥患者進(jìn)行對癥處理，所有患者均治愈出院。

表1 兩組患者術(shù)后鎮(zhèn)痛藥物應(yīng)用、術(shù)后肛門排氣時(shí)間、住院時(shí)間、膀胱損傷例數(shù)、血管損傷出血、陰道殘端感染情況比較

討論

近年來，因腹腔鏡技術(shù)的普及，LAVH得到了很大的發(fā)展，有條件醫(yī)院已將其作為子宮切除術(shù)的首選方式。子宮切除方法的選擇，應(yīng)根據(jù)術(shù)者的經(jīng)驗(yàn)、子宮的大小和活動度以及是否合并附件病變等因素綜合考慮[1]。經(jīng)陰道全子宮切除術(shù)術(shù)后病率低、住院時(shí)間短、費(fèi)用低，是較佳的全子宮切除方式[2]。所以應(yīng)根據(jù)患者的情況、手術(shù)醫(yī)生的技術(shù)水平、醫(yī)院的條件等綜合考慮，盡量選擇經(jīng)濟(jì)的方式[3]。但由于手術(shù)野狹窄、盆腔情況不能探查等常導(dǎo)致操作困難、手術(shù)難度增加。本陰式組中有1例改開腹完成。腹腔鏡輔助陰式全子宮切除術(shù)實(shí)際上是腹腔鏡手術(shù)和陰道手術(shù)的聯(lián)合，它避免了單純陰式子宮切除術(shù)對盆腔不能清楚檢查的缺陷，也可同時(shí)處理盆腔粘連、附件腫瘤等并存問題，擴(kuò)大了陰式子宮切除術(shù)的適應(yīng)證。腹腔鏡輔助陰式全子宮切除術(shù)作為微創(chuàng)手術(shù)有著傳統(tǒng)開腹手術(shù)不可比擬的優(yōu)點(diǎn)，但要嚴(yán)格掌握好手術(shù)指征，根據(jù)具體情況選擇手術(shù)方式，盡量避免嚴(yán)重副損傷的發(fā)生。經(jīng)陰道操作變得相對簡單，降低了手術(shù)難度，增加了安全性[4]。

本組資料結(jié)果顯示，LAVH組術(shù)后鎮(zhèn)痛藥物應(yīng)用、術(shù)后肛門排氣時(shí)間、住院時(shí)間明顯優(yōu)于TVH組，兩組患者均各出現(xiàn)1例中轉(zhuǎn)開腹，因此，要結(jié)合患者的具體實(shí)際，選擇手術(shù)方式，減輕患者痛苦，提高臨床療效。

[1]朱蘭,郎景和.3種途徑子宮切除術(shù)的臨床評估[J].中國實(shí)用婦科與產(chǎn)科雜志,2003,19 (10):623.

[2]郎景和,姚書忠.腹腔鏡手術(shù)的熱點(diǎn)問題探討[J].現(xiàn)代婦產(chǎn)科進(jìn)展,2004,13(2):82-84.

[3]譚亞林.陰式及腹腔鏡輔助陰式子宮切除術(shù)臨床效果觀察[J].山東醫(yī)藥,2009,49(42): 99-100.

[4]焦榕芳,黃浩,李末娟,等.四種術(shù)式用于子宮切除的效果比較[J].實(shí)用臨床醫(yī)學(xué),2008, 9(10):92-93.

Comparison of clinical effect of vaginal and laparoscopic hysterectomy

Xue Haifeng
Obstetrics and Gynecology Department,the People's Hospital of Yanshi City,Henan Province 471900

Objective:To explore the curative effect difference of vaginal and laparoscopic hysterectomy.Methods:368 patients with total hysterectomy patients were selected from February 2013 to March 2014.According to the voluntary of patients,they were divided into the vaginal hysterectomy(TVH)group of 158 cases and laparoscopic assisted vaginal hysterectomy(LAVH)group of 210 cases.TVH group was treated with vaginal hysterectomy,and LAVH group was treated with laparoscopic assisted vaginal hysterectomy.Results:In LAVH group,11 cases(5.2%)used analgesics after operation;postoperative anal exhaust time was(11.2±3.6)hours;the time of hospitalization was(4.9±1.3)days;22 cases had complications;the complication rate was 10.5%.In TVH group,18 cases(11.4%)used analgesics after operation;postoperative anal exhaust time was(16.3±3.1)hours;the time of hospitalization was(7.3±1.1)days;15 cases had complications;the complication rate was 10.5%.We compared the postoperative analgesic drug application,anal exhaust time,postoperative hospitalization time of the two gourps,and the difference was statistically significant(P＜0.05).We compared the incidence of complications of the two gourps,and there was no significant difference(P＞0.05).In TVH group,1 case was converted to open operation.In LAVH group,1 case was converted to open operation; patients with complications were given symptomatic treatment;all the patients were cured and discharged.Conclusion:In the LAVH group,the analgesic drug application after operation,postoperative anal exhaust time,hospitalization time were obviously better than those of TVH group.In each group,1 case was converted to laparotomy.Therefore,we should combine the concrete reality of patients to select the surgical approach,in order to alleviate the suffering of patients,and improve clinical curative effect.

Hysterectomy;LAVH;TVH

10.3969/j.issn.1007-614x.2015.7.38