免气腹单孔腹腔镜辅助阴式大子宫重500克或更多

免气腹单孔腹腔镜辅助阴式大子宫重500克或更多
Gasless single-port laparoscopic-assisted vaginal hysterectomy for large uteri weighing 500 g or more

Abstract
OBJECTIVE:
To evaluate the safety and feasibility of gasless transumbilical single-port laparoscopic-assisted vaginal hysterectomy (LAVH) for the management of large uteri weighing 500g or more.
摘要
目的：
评价其安全性和无气腹经脐单孔腹腔镜辅助阴式子宫切除术（LAVH）的可行性，为大子宫称重500g以上管理。

STUDY DESIGN:
We conducted a retrospective comparative study of women with large uteri, each undergoing gasless multi-port or single-port LAVH. Preoperatively, gonadotropin-releasing hormone agonist was administered and autologous blood was donated except for cases requiring immediate surgery. Additionally, intraoperative blood salvage and donation was performed in select cases. In single-port LAVH, a wound retractor was used to make a working port through umbilical incision. After the surgical view was secured using an abdominal wall-lift device, the surgical procedures were performed using conventional laparoscopic instruments. In select cases, temporary endovascular occlusion of the bilateral internal iliac arteries was performed to reduce intraoperative hemorrhaging.
研究设计：
我们进行了一个大子宫的妇女进行回顾性对比研究，每行无气腹多端口或单孔腹腔镜辅助阴式子宫切除术。术前，促性腺激素释放激素激动剂注射、自体血捐除需要立即手术的病例。此外，在选择的情况下，进行术中血液打捞和捐赠。在单端口LAVH，伤口拉钩通过脐切口做一个工作口。手术后的视图是使用腹壁解除装置固定，手术程序，使用传统的腹腔镜器械。在特定的情况下，临时的双侧髂内动脉血管内闭塞以减少术中出血。

RESULTS:
Of the 650 women managed by multi-port or single-port LAVH, 55 and 67 women each with uteri weighing 500g or more, respectively, were included. In single-port LAVH group, the median age was 47 years. Twelve women were nulliparous and 3 women with 2 cesarean deliveries each, had never had a vaginal delivery. The most frequent surgical indication was uterine myoma. In the single-port LAVH group, the surgical procedures included LAVH alone (n=36), LAVH and bilateral salpingo-oophorectomy (n=22), LAVH and unilateral salpingo-oophorectomy (n=8), and LAVH and appendectomy (n=1). Extensive adhesiolysis was required in eight cases. The median extirpated tissue weight was 652g with a median estimated intraoperative blood loss of 450mL. A significant positive linear correlation was observed between the operative time or estimated blood loss and the extirpated uterine weigh. Although excessive bleeding exceeding 1000mL was noted in 15 cases, a transfusion of bank blood was not required by using preoperatively donated autologous blood and intraoperative autologous blood salvage and donation. Extended hospitalization was required in six cases. The median surgical duration in the single-port LAVH group was significantly longer than that in the multi-port LAVH group.
结果:
650位女性通过多端口或单端口管理，55和67位女性子宫称重500g以上，分别包括，在单端口LAVH组，中位年龄为47岁。十二例剖宫产产妇3 2每个女人，从未有过阴道分娩。最常见的手术指征是子宫肌瘤。在单端口LAVH组，手术采用LAVH单独（N = 36），腹腔镜辅助阴式子宫切除术及双侧输卵管卵巢切除术（n = 22），LAVH与单侧输卵管卵巢切除术（n = 8），和LAVH及阑尾切除术（n = 1）。广泛粘连松解术在八例。平均体重652g摘除的组织与一个平均术中出血量450ml。手术时间、失血量、摘除子宫重量显著的线性正相关。虽然过度出血超过1000ml指出在15种情况下，输库血不采用术前自体血、术中自体血液捐赠救助和捐赠要求。需要延长住院时间六例。在单端口LAVH组平均手术时间明显比在多端口LAVH组延长。

CONCLUSION:
Gasless single-port LAVH is a feasible alternative that can yield similar major surgical outcomes as multi-port LAVH, with potential cosmetic benefit.
结论：
免气腹单孔腹腔镜辅助阴式子宫切除术是一种可行的替代方案，可以产生类似的重大手术结果为多端口LAVH，潜在的美容效果。

KEYWORDS:
Abdominal wall-lift method; Autologous blood transfusion; Gasless laparoscopy; Laparoscopic-assisted vaginal hysterectomy; Single-port laparoscopy; Wound retractor
关键词：
腹壁悬吊法；自体输血；气腹腹腔镜；腹腔镜辅助阴式子宫切除术；单孔腹腔镜手术；切口牵开器

免气腹单孔腹腔镜辅助阴式大子宫重500克或更多

Fig. 1. Gasless single-port laparoscopic-assisted vaginal hysterectomy (LAVH) for the management of multiple myomas with bowel adhesion in a 44-year-old nulligravida with no remarkable history of disease.
(A) A coronal view of magnetic resonance imaging showing multiple myomas when the patient was referred to the emergency department for severe abdominal pain. The degeneration of the pedunculated subserosal myoma (arrow) was diagnosed and conservatively managed by the administration of antibiotics and analgesics. Then, after undergoing monthly administration of a gonadotropin-releasing hormone agonist six times, single-port LAVH was performed.
(B) The bilateral round ligaments, fallopian tubes and utero-ovarian ligaments were transected using a LigaSure Atlas (Covidien Japan, Tokyo, Japan) under laparoscopic guidance.
(C) Extensive adhesiolysis between the degenerated myoma (arrowhead) and bowel was performed by blunt and sharp dissection, followed by appendectomy (arrow) with an EndoGIA 45-mm linear stapler (Ethicon Japan, Tokyo, Japan), which was performed with the assistance of a gastrointestinal surgeon.
(D) The vesicocervical ligaments,cardinal-uterosacral ligament complex and uterine arteries were vaginally sealed using LigaSure Max (Covidien Japan) and cut with scissors.
(E) Hysterectomy was completed with vaginal extraction of the myoma and uterus using uterine size reduction techniques, such as wedge morcellation, uterine bisection, and intramyometrial coring with a surgical scalpel and scissors. The extirpated tissue weight was 908 g. The surgical duration was 197 min. The estimated blood loss was 600 mL. (F) The umbilical wound was closed by subcutaneous suturing.
图1.免气腹单孔腹腔镜辅助阴式子宫切除术（LAVH）以无明显疾病史在44岁未孕妇肠粘连多发肌瘤的管理。
（A）显示多个肌瘤磁共振成像的冠状面，当患者被转诊到急诊科严重腹痛。带蒂的浆膜下肌瘤的变性（箭头）是诊断和抗生素和止痛药的行政管理保守。然后，接受促性腺激素释放激素激动剂六次月度管理后，进行单端口LAVH。
（B）双侧圆韧带、输卵管和子宫卵巢韧带横断使用LigaSure Atlas（Covidien的日本，东京，日本）腹腔镜下。
（C）广泛粘连变性肌瘤之间（箭头）和肠是由钝性与锐性解剖，其次是阑尾切除术（箭头）与endogia 45毫米的线性吻合器（Ethicon日本，东京，日本），这是一个胃肠外科医师的协助执行。
（D）膀胱宫颈韧带、主骶韧带复杂子宫动脉阴道密封采用LigaSure Max（Covidien日本），用剪刀剪。
（E）子宫切除术完成了阴道提取的肌瘤和子宫的子宫大小减少技术，如楔分碎术，子宫等分，和子宫肌内心外科手术刀和剪刀。摘除的组织量为908 g，手术时间为197分钟，出血约600 ml（F）脐皮下缝合关闭伤口。

原文全文：
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