子宫肌瘤的腹腔镜手术课件

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,腹腔镜子宫肌瘤剔除术,Laparoscopic Myomectomy,北 大 医 院,周应芳,20140626,腹腔镜子宫肌瘤剔除术 Laparoscopic Myome,1,子宫肌瘤,发病率,是女性生殖器官最常见的良性肿瘤，发生率为20%-30%,合并不育的发生率为5%-10%,子宫肌瘤发病率,2,子宫肌瘤,治疗手段：,Watchful waiting,Medical therapy,Myomectomy,hysteroscopic,laparoscopic,abdominal,Hysterectomy,abdominal,vaginal,laparoscopic,Uterine artery embolization（,no longer desire fertility,）,Uterine artery occlusion,Endometrial ablation,Focused ultrasound,Parker WH.Fertil Steril.2007,子宫肌瘤治疗手段：,3,子宫肌瘤,治疗趋势,以往常用子宫切除术（Hysterectomy）,是治疗子宫疾病最常用的手术方式之一,美国每年约有60万例子宫切除术,我国每年子宫切除术例数在280万左右,现在保守性治疗受到欢迎：,希望保留生育功能,保留身体器官的完整性,考虑子宫切除对卵巢功能的负面影响,卵巢功能衰退提前3-4年,子宫肌瘤治疗趋势,4,子宫肌瘤,子宫肌瘤剔除术方式：,开腹子宫肌瘤剔除术（AM）,经阴道子宫肌瘤剔除术（VM）,腹腔镜子宫肌瘤剔除术（LM）,1979年开始,1990年后应用增多,近年来，robot-assisted LM,Short-term surgical outcomes were similar after robotic and laparoscopic myomectomy,（Bedient CE,Am J Obstet Gynecol.2009,，,USA,）,子宫肌瘤子宫肌瘤剔除术方式：,5,LM适应证,适应症：,导致明显临床症状,肌瘤直径5cm,10cm,合并不孕者肌瘤直径,4cm者,尤其是位于粘膜下或靠近输卵管开口的肌瘤,肌瘤生长迅速,肌瘤位于阔韧带或宫颈,患者过分担心肿瘤恶变,LM适应证适应症：,6,子宫16孕周状或肌瘤直径,10,cm,多发子宫肌瘤，3cm肌瘤多于4个以上,黏膜下肌瘤,子宫腺肌病？,肌瘤恶变可能性大,取决于术者的经验与操作熟练程度,LM禁忌证,子宫16孕周状或肌瘤直径 10cmLM禁忌证,7,LM术前评估,影像学检查,肌瘤的大小、数目以及位置等,宫腔镜检查,必要时用。是否有粘膜下肌瘤、宫腔是否有变形以及内膜是否异常等,不育原因的检查,男方因素、输卵管因素以及排卵问题等,LM术前评估影像学检查,8,LM的手术步骤,水分离技术,垂体后叶素(vasopresin,6-12u+50ml 生理盐水）,切开包膜,单极电切、双级凝切、超声刀等,直线切开、梭型切开,剥除瘤体,缝合切口,少凝、快缝,切口深时分层缝,取出肌瘤,预防粘连,LM的手术步骤水分离技术,9,LM的手术步骤,取出肌瘤,肌瘤粉碎器（Morcellator，首选）,后穹窿切开（次选）,腹腔镜下剪刀切开,腹部小切口（mini-lap，不得已）,耻骨上作3-5cm的横切口,术后粘连形成增加,LM的手术步骤取出肌瘤,10,子宫后壁肌瘤剔除术,CYM,子宫后壁肌瘤剔除术,11,切开包膜,剔除肌瘤,缝合切口,创面粘连预防,前壁肌瘤剔除术,切开包膜剔除肌瘤缝合切口创面粘连预防前壁肌瘤剔除术,12,多发性子宫肌瘤剔除术,七个共250克,多发性子宫肌瘤剔除术,13,LM-阔韧带大肌瘤,LM-阔韧带大肌瘤,14,多发肌瘤-肠管表面种植-LM,多发肌瘤-肠管表面种植-LM,15,CS-LM-ADE-穿刺孔肌瘤,腹膜肌瘤,CS-LM-ADE-穿刺孔肌瘤,16,子宫峡部肌瘤剔除技巧,子宫峡部肌瘤剔除技巧,17,北大医院资料,2000年-2005年子宫肌瘤剔除术160例,LM82例，AM78例,平均手术出血:,LM：20(20400)ml,AM:100(50400)ml,P,0.05,平均手术时间：,LM：80.8,29.3 min,AM:71.1,22.6 min,P,0.05,白文佩，穆兰芳，周应芳等.腹腔镜下和经腹子宫肌瘤剔出术的临床比较，中国内镜杂志,2007,13:903-905.,北大医院资料2000年-2005年子宫肌瘤剔除术160例,18,子宫腺肌病病灶挖除术,年轻、要求保留生育功能者，术前可使用GnRH-a 治疗3个月,手术步骤,手术部位注射稀释的垂体后叶素盐水,单极电勾切开浆肌层,冷刀挖除病灶,缝合肌层,子宫腺肌病病灶挖除术年轻、要求保留生育功能者，术前可使用Gn,19,囊性腺肌病病灶切除术,囊性腺肌病病灶切除术,20,LM优缺点,优点,出血少,并发症少,对盆腹腔脏器干扰小,术后疼痛轻微,恢复快,术后粘连少,开腹在90%以上,腹腔镜手术为35.6%,腹部美观,住院日短,缺点,腹腔镜触摸不如手敏感，可能遗漏小肌瘤,要求医生有良好的镜下缝合技术，然而，学习曲线长,取出肌瘤费力,要求医生有良好的体力,费用较高（中国）,LM优缺点优点缺点,21,LM并发症,并发症种类：,术中并发症,出血,损伤：如肌瘤粉碎器造成的脏器损伤,术后并发症,出血,感染,宫腔粘连,切口愈合不良（原因：肌层对合不良、血肿及感染）,妊娠子宫破裂,有经验医生的手术并发症的危险性与开腹手术相似,LM并发症并发症种类：,22,子宫粉碎器使用后发生小肠疝,Henia-S-bowl-1,Henia-S-bowl-3,Henia-S-bowl-4,Henia-S-bowl-5,Henia-S-bowl-6,Henia-S-bowl-2,Henia-S-bowl-7,Henia-S-bowl-8,子宫粉碎器使用后发生小肠疝Henia-S-bowl-1Hen,23,LM并发症,高危因素：,肌瘤数目过多,肌瘤过大,肌瘤嵌入子宫肌层较深,后壁肌瘤或伴有子宫肌腺症,肌瘤在腹腔镜下暴露和剥离困难,手术医生技巧？,手术时间、术中出血量及中转开腹率明显增加,Risk of conversion ranges between 1 to 3%when technique is realized by trained surgeon.,LM并发症高危因素：,24,LM术中出血,LM的失血量多低于AM（20050ml：23044ml）,出血危险主要是子宫创面缝合困难导致的,较大的子宫肌瘤术前应用促性腺激素释放素治疗3个月，子宫体积可缩小约50%，从而减少了手术的难度,由于子宫弓状动脉及螺旋动脉的横形走向,故横切口可减少手术出血,出血多，难控制时及时中转开腹！或改变术式（子宫切除？阴式手术？）,LM术中出血LM的失血量多低于AM（20050ml：230,25,GnRH-a治疗后,肌瘤体积缩小,GnRH-a治疗后肌瘤体积缩小,26,laparoscopic uterine artery ligation 可以减少LM出血,例数手术时间（分）出血量（ML）,动脉,结扎65112,18173 91,组,常规,手术87 95 14402 131,组,Alborzi S，et al，Fertil Steril.2009，Iran,laparoscopic uterine artery li,27,Italian multicenter study on complications of laparoscopic myomectomy,4 referral centers,2050 cases,A total complication rate of 11.1%(225/2050 cases),Minor 9.1%(187/2050 cases),major 2.02%(38/2050 cases),hemorrhages,14 requiring blood transfusions in 3 cases(0.14%),10 postoperative hematomas,1 bowel injury(0.04%),1 postoperative acute kidney failure(0.04%),2 unexpected sarcomas(0.09%),Sizzi O,et al.,J Minim Invasive Gynecol.2007,14(4):453-62.,Italian multicenter study on c,28,Italian multicenter study on complications of laparoscopic myomectomy,Failure to complete planned surgery occurred in 7 cases(0.34%).,2 were readmitted for surgery(0.09%),1 had a laparoscopic hysterectomy because of a severe blood loss,1 had drainage of a hematoma in the broad ligament,A follow-up of 41.70 23.03 months,386(22.9%)patients conceived,with a pregnancy rate in patients wishing pregnancy of 69.8%,One(0.26%)recorded spontaneous uterine rupture at 33 weeks gestation.,Sizzi O,et al.,J Minim Invasive Gynecol.2007,14(4):453-62.,Italian multicenter study on c,29,LM术后肌瘤复发,复发率：,由于不同的检测手段以及诊断标准，子宫肌瘤剔出术后的复发率较难估计,术后5年累积复发率可高达51%,平均在术后2年复发,LM术后肌瘤复发复发率：,30,Predictors of leiomyoma recurrence after laparoscopic myomectomy,Five university hospitals（Seoul）,512（1995 2004）with a follow-up for a median 13 months,The cumulative,probability of leiomyoma recurrence increased steadily during the follow-up period,11.7%after 1 year,36.1%after 3 years,52.9%at 5 years,84.4%at 8 years,The cumulative probability of reoperation for recurrent,leiomyoma was much lower:,6.7%at 5 years,16%at 8 years,Yoo EH,J Minim Invasive Gynecol.2007,14(6):690-7,.,Predictors of leiomyoma recurr,31,Predictors of leiomyoma recurrence after laparoscopic myomectomy,Risk factors,Age,preoperative number of leiomyoma,preoperative uterine size,presence of associated pelvic disease,childbirth after sur