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        經(jīng)臍單孔腹腔鏡全子宮切除術(shù)不同途徑縫合陰道殘端的研究

        2021-10-14 21:39:30周明輝紀(jì)燕琴邱華娟
        新醫(yī)學(xué) 2021年7期
        關(guān)鍵詞:全子宮切除術(shù)

        周明輝?紀(jì)燕琴?邱華娟

        【摘要】目的? 比較經(jīng)臍單孔腹腔鏡全子宮切除術(shù)采用倒刺線經(jīng)不同途徑縫合陰道殘端的效果。方法 選取因子宮良性疾病接受經(jīng)臍單孔腹腔鏡全子宮切除術(shù)患者56例。56例均采用倒刺線縫合,經(jīng)腹腔鏡縫合陰道殘端者被納入A組(30例),經(jīng)陰道縫合陰道殘端者被納入B組(26例)。比較2組的術(shù)中失血量、手術(shù)操作時間、術(shù)后住院日數(shù)、陰道殘端總并發(fā)癥(術(shù)后陰道殘端出血、陰道殘端感染、陰道殘端裂開)、術(shù)后陰道殘端息肉形成率。結(jié)果 2組均能順利完成單孔腹腔鏡全子宮切除術(shù)。A組手術(shù)操作時間和縫合時間均少于B組(P均< 0.05)。術(shù)后A組出現(xiàn)1例陰道殘端裂開,B組則無(P > 0.05)。A組術(shù)后陰道殘端息肉形成率高于B組(P < 0.05)。A組術(shù)后陰道殘端總并發(fā)癥發(fā)生率高于B組(P < 0.05),但2組術(shù)后陰道殘端出血、陰道殘端感染、陰道殘端裂開發(fā)生率差異則無統(tǒng)計學(xué)意義(P均> 0.05)。結(jié)論 經(jīng)臍單孔腹腔鏡全子宮切除術(shù)采用倒刺線經(jīng)腹腔鏡縫合陰道殘端有利于陰道殘端的愈合,可降低術(shù)后殘端并發(fā)癥發(fā)生率。

        【關(guān)鍵詞】單孔腹腔鏡;全子宮切除術(shù);陰道殘端縫合;單向倒刺線

        Study of different methods of suture of vaginal stump in transumbilical single-port laparoscopic total hysterectomy Zhou Minghui, Ji Yanqin, Qiu Huajuan. Department of Gynecology, Huizhou Municipal Central Hospital, Huizhou 516001, China Corresponding author, Ji Yanqin

        【Abstract】Objective To compare the effect of different methods of suturing vaginal stump with barbed thread in transumbilical single-port laparoscopic total hysterectomy. Methods A total of 56 patients with benign uterine diseases who underwent transumbilical single-port laparoscopic total hysterectomy were selected in this study. All 56 patients were sutured with barbed thread. Patients undergoing laparoscopic suture of vaginal stump were allocated into group A (n = 30), and those receiving transvaginal suture of vaginal stump were assigned into group B (n = 26). The intraoperative blood loss, operation time, length of postoperative hospital stay, total vaginal stump complications (postoperative vaginal stump bleeding, vaginal stump infection and vaginal stump dehiscence) and incidence of postoperative vaginal stump polyps were statistically compared between two groups. Results All patients in both groups successfully completed single-port laparoscopic total hysterectomy. The operation time and suture time in group A were significantly shorter than those in group B (both P < 0.05). In group A, 1 patient presented with vaginal dehiscence and no vaginal dehiscence in group B (P > 0.05). The incidence of postoperative vaginal stump polyps in group A was considerably higher than that in group B (P < 0.05). In group A, the incidence of vaginal stump complications was significantly higher than that in group B (P < 0.05), whereas the incidence of vaginal stump bleeding, vaginal stump infection and vaginal dehiscence did not significantly differ between two groups (all P > 0.05). Conclusion Transumbilical single-port laparoscopic total hysterectomy via laparoscopic suture of vaginal stump is beneficial to the healing of vaginal stump and reduces the incidence of postoperative vaginal stump complications.

        討論

        腹腔鏡手術(shù)近年來備受婦科醫(yī)師和患者的青睞,但術(shù)后腹部皮膚難免會留下3 ~ 4個小瘢痕,影響美觀。經(jīng)臍單孔腹腔鏡由于利用了臍部作為手術(shù)切口,臍部皺褶可掩蓋瘢,美觀效果明顯優(yōu)于傳統(tǒng)多孔腹腔鏡[5]。經(jīng)臍單孔腹腔鏡全子宮切除術(shù)與傳統(tǒng)多孔腹腔鏡全子宮切除術(shù)相比,中轉(zhuǎn)開腹率、圍術(shù)期并發(fā)癥發(fā)生率無明顯差別,且患者術(shù)后活動更早、疼痛更輕,表明經(jīng)臍單孔腹腔鏡全子宮切除是安全的[3, 6-7]。本研究中所有患者均順利完成手術(shù),無1例中轉(zhuǎn)開腹,無發(fā)生腸管、膀胱損傷。

        縫合是經(jīng)臍單孔全子宮切除術(shù)的難點,本研究中所有患者均用0號V-LOC線縫合,其具有免打結(jié)、無需助手固定、溶解延遲等特點,能有效降低手術(shù)難度、縮短手術(shù)時間、降低陰道殘端并發(fā)癥發(fā)生率[8-11]。經(jīng)陰道縫合能降低經(jīng)臍單孔腹腔鏡全子宮切除術(shù)的難度,縮短手術(shù)時間,本研究經(jīng)腹腔鏡縫合患者的總手術(shù)時間和縫合時間均長于經(jīng)陰道縫合患者,與王曉櫻等[3]的研究結(jié)果相似。

        對于陰道殘端是經(jīng)陰道縫合還是經(jīng)腹腔鏡縫合更有利于陰道殘端愈合,目前尚無定論。一些回顧性研究顯示經(jīng)陰道縫合能降低陰道裂開、腸管脫出風(fēng)險,并提出這可能是由于經(jīng)陰道縫合的打結(jié)力度要大于經(jīng)腹腔鏡縫合所致[12-15]。也有報道稱陰道殘端裂開的發(fā)生率與陰道殘端縫合方法并無影響[16]。本研究結(jié)果顯示,2組術(shù)后發(fā)熱、術(shù)后住院日數(shù)以及術(shù)后殘端出血、裂開、感染率均無差異,但2組術(shù)后陰道殘端息肉形成和陰道殘端總并發(fā)癥發(fā)生率有差異,陰道殘端總并發(fā)癥發(fā)生率結(jié)果與Uccella等[4]的前瞻性隨機對照試驗結(jié)果相似,這可能與腹腔鏡技術(shù)的提高、使用0號V-LOC線縫合、經(jīng)腹腔鏡縫合有助于較好地縫合腹膜(即使僅縫合后腹膜),更好地對合陰道黏膜、封閉陰道以及減少滲出等有關(guān)。

        陰道殘端的縫合是單孔腹腔鏡全子宮切除術(shù)的難點,經(jīng)腹腔鏡縫合更是困難,我們的經(jīng)驗是膀胱下推應(yīng)該更充分,留有足夠的陰道殘端,便于縫合。經(jīng)陰道縫合可以降低手術(shù)難度,但也存在缺點,陰道黏膜難于對合會造成陰道殘端黏膜不平整,增加術(shù)后陰道殘端并發(fā)癥發(fā)生率。而經(jīng)腹腔鏡縫合,可以將陰道黏膜對合整齊,同時可以將骶韌帶縫合固定于陰道,恢復(fù)陰道殘端的軸向,可能降低術(shù)后陰道殘端脫垂風(fēng)險。在本研究中,經(jīng)腹腔鏡縫合雖需時較長,但其術(shù)后陰道殘端息肉形成和陰道殘端并發(fā)癥發(fā)生率更低,與劉維等[17]的報道相近。

        綜上所述,經(jīng)臍單孔腹腔鏡全子宮切除術(shù)經(jīng)腹腔鏡縫合陰道殘端有利于陰道殘端的愈合,降低術(shù)后陰道殘端并發(fā)癥發(fā)生率。本研究存在樣本量小、非前瞻性研究等缺陷,結(jié)論有待大樣本的、前瞻性的研究進一步驗證。

        參考文獻

        [1] 趙洪霞, 張新艷.單孔腹腔鏡在婦科良性疾病中的臨床應(yīng)用.中國實用醫(yī)藥,2020,15(24):25-27.

        [2] Matthews CA. Minimally invasive sacrocolpopexy: how to avoid short-and long-term complications. Curr? Urol Rep,2016,17(11):81.

        [3] 王曉櫻,李妍.單孔腹腔鏡全子宮切除術(shù)臨床療效分析.中國現(xiàn)代手術(shù)學(xué)雜志,2019,23(3):215-219.

        [4] Uccella S, Malzoni M, Cromi A, Seracchioli R, Ciravolo G, Fanfani F, Shakir F, Gueli Alletti S, Legge F, Berretta R, Corrado G, Casarella L, Donarini P, Zanello M, Perrone E, Gisone B, Vizza E, Scambia G, Ghezzi F. Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the italian society of gynecologic endoscopy. Am J Obstet Gynecol,2018,218(5):500.e1-500.e13.

        [5] 黃曉斌, 柳曉春, 鄭玉華.經(jīng)臍單孔腹腔鏡手術(shù)治療卵巢良性腫瘤的研究.新醫(yī)學(xué), 2015, 46(7):482-485.

        [6] Sandberg EM, la Chapelle CF, van den Tweel MM, Schoones JW, Jansen FW. Laparoendoscopic single-site surgery versus conventional laparoscopy for hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet,2017,295(5):1089-1103.

        [7] Yang L, Gao J, Zeng L, Weng Z, Luo S. Systematic review and meta-analysis of single-port versus conventional laparoscopic hysterectomy. Int J Gynaecol Obstet,2016,133(1):9-16.

        [8] 干曉琴, 林海, 劉江, 張凌, 張強, 黃利瓊, 張家佳. Ⅴ-Loc倒刺線在腹腔鏡下子宮腺肌瘤剝除術(shù)中的應(yīng)用效果觀察.中國計劃生育和婦產(chǎn)科,2016,8(7):54-56,62.

        [9] Rettenmaier MA, Abaid LN, Brown JV 3rd, Mendivil AA, Lopez KL, Goldstein BH. Dramatically reduced incidence of vaginal cuff dehiscence in gynecologic patients undergoing endoscopic closure with barbed sutures: a? retrospective cohort study. Int J Surg,2015,19:27-30.

        [10] Smith K, Caceres A. Vaginal cuff closure in minimally invasive hysterectomy: a review of training, techniques, and materials. Cureus, 2017, 9(10):e1766.

        [11] Cong L, Li C, Wei B, Zhan L, Wang W, Xu Y. V-Loc? 180 suture in total laparoscopic hysterectomy: a retrospective study comparing Polysorb to barbed suture used for vaginal cuff closure. Eur J Obstet Gynecol Reprod Biol,2016,207:18-22.

        [12] Nezhat C, Kennedy Burns M, Wood M, Nezhat A, Nezhat F. Vaginal cuff dehiscence and evisceration: a review. Obstet Gynecol,2018,132(4):972-985.

        [13] Lee SH, Oh SR, Cho YJ, Han M, Park JW, Kim SJ, Yun JH, Choe SY, Choi JS, Bae JW. Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis. BMC Womens Health,2019,19(1):83.

        [14] Teoh D, Lowery WJ, Jiang X, Ehrisman J, Halvorson P, Broadwater G, Bentley R, Secord AA, Sobolewski C, Berchuck A, Havrilesky LJ, Valea FA, Lee PS. Vaginal cuff thermal injury by mode of colpotomy at total laparoscopic hysterectomy: a randomized clinical trial. J Minim Invasive Gynecol,2015,22(2):227-233.

        [15] Due?as-Garcia OF, Sullivan GM, Leung K, Billiar KL, Flynn MK. Knot integrity using different suture types and different knot-tying techniques for reconstructive pelvic floor procedures. Int Urogynecol J,2018,29(7):979-985.

        [16] Das D, Sinha A, Yao M, Michener CM. Trends and risk factors for vaginal cuff dehiscence after laparoscopic hysterectomy. J Minim Invasive Gynecol,2020,S1553-4650(20)30883-30889.

        [17] 劉維,李梅,黃淑貞.腹腔鏡下全子宮切除術(shù)中陰道殘端經(jīng)鏡下及經(jīng)陰道縫合對患者預(yù)后的影響觀察.基層醫(yī)學(xué)論壇, 2017, 21(10):1162-1163.

        (收稿日期:2021-01-29)

        (本文編輯:洪悅民)

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