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1、腹腔镜子宫肌瘤剔除术 Laparoscopic Myomectomy,20140626,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,治疗手段：Watchful waitingMedical therapyMyomectomyhysteroscopic laparoscopic abdominal Hysterectomyabdominalvaginal laparoscopicUterine artery embolization（no longer desire fertility）Uterine artery occlus
2、ionEndometrial ablationFocused ultrasoundParker WH.Fertil Steril.2007,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,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-assi
3、sted LM Short-term surgical outcomes were similar after robotic and laparoscopic myomectomy（Bedient CE,Am J Obstet Gynecol.2009，USA）,LM适应证,适应症：导致明显临床症状肌瘤直径5cm10cm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,子宫16孕周状或肌瘤直径 10cm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,LM
4、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,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,子宫后壁肌瘤剔除术CYM,切开包膜,剔除肌瘤,缝
5、合切口,创面粘连预防,前壁肌瘤剔除术,多发性子宫肌瘤剔除术七个共250克,LM-阔韧带大肌瘤,多发肌瘤-肠管表面种植-LM,CS-LM-ADE-穿刺孔肌瘤腹膜肌瘤,子宫峡部肌瘤剔除技巧,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)mlAM:100(50400)ml,P0.05平均手术时间：LM：80.8 29.3 minAM:71.1 22.6 min,P0.05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.,子宫腺肌病病灶挖除术,年轻、要求保留生育功能者
6、，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,囊性腺肌病病灶切除术,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
7、手术相似,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,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 traine
8、d surgeon.,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？）,GnRH-a治疗后肌瘤体积缩小,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
9、 S，et al，Fertil Steril.2009，Iran,Italian multicenter study on complications of laparoscopic myomectomy,4 referral centers,2050 casesA 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 po
10、stoperative 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 complications of laparoscopic myomectomy,Failure to complete planned surgery occurred in 7 cases(0.
11、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 ligamentA 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 sp
12、ontaneous uterine rupture at 33 weeks gestation.Sizzi O,et al.J Minim Invasive Gynecol.2007,14(4):453-62.,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,Predictors of leiomyoma recurrence after laparoscopic myomectomy,Five university hospitals（Seoul）512（1995 2004）with a follow
13、-up for a median 13 monthsThe cumulativeprobability of leiomyoma recurrence increased steadily during the follow-up period11.7%after 1 year36.1%after 3 years52.9%at 5 years84.4%at 8 yearsThe cumulative probability of reoperation for recurrentleiomyoma was much lower:6.7%at 5 years 16%at 8 yearsYoo E
14、H,J Minim Invasive Gynecol.2007,14(6):690-7.,Predictors of leiomyoma recurrence after laparoscopic myomectomy,Risk factors Agepreoperative number of leiomyomapreoperative uterine sizepresence of associated pelvic diseasechildbirth after surgeryYoo EH,J Minim Invasive Gynecol.2007,14(6):690-7.,LM术后肌瘤
15、复发,位于肌壁间的小肌瘤的残留，是复发的根源因此，在手术之前应用超声和宫腔镜进行肌瘤数目和位置的评价很重要即便LM的肌瘤复发率高于开腹手术，但是需进一步行子宫全切术的发生率二者之间并没有明显的差异Rossetti的随机对比研究发现LM与AM的复发率相81例术后随诊40个月：LM与开腹肌瘤剔除术的复发率分别为27%及23%,LM术后妊娠结局,不孕患者肌瘤剔除后妊娠率约为50%LM后的妊娠率可接近70%，存在其他的不孕因素，则LM后妊娠率仅为33%妊娠率和肌瘤的大小、数目和位置无明显相关,LM术后妊娠结局,生育结果Author/Method Preg Rate Term Del.No.Berkel
16、ey83/open 50%40%50Smith90/open 63%53%32Ghelbach93/open 57%48%37Hasson92/Lap 71%47%17Miller96/Lap 75%65%40Rossetti2001/Lap 65.5%57.1%29 腹腔镜肌瘤剔除达到与开腹同样的效果,LM术后妊娠子宫破裂,LM后妊娠子宫破裂一直是关注的焦点（新技术）发生率约为0.5%-1%，与开腹手术相似（约为0-5%）均为个案报道均为临产前破裂预防少用电凝分层缝合,Risk factors for uterine rupture after LM,19 cases of uterine
17、rupture after laparoscopic myomectomy were identified The myomas ringed 1 11 cm(mean 4.5 cm)Only 3 used multilayered closure Electrosurgery used for hemostasis in 17 No plausible contributing factor could be found Parker WH,J Minim Invasive Gynecol.2010,USA,Risk factors for uterine rupture after LM,
18、It seems reasonable for surgeonsto adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery multilayered closure of the myometriumindividual wound healing characteristics may predispose to uterine rupture Parker WH,J Minim Invasive Gynecol.2010,USA,小 结,LM应用日益增多，疗效已经得到肯定LM成功的秘诀：正确的手术适应证适当的腹腔镜手术技巧良好的医患沟通,
