Chang W-C, Hsu W-C, Sheu B-C, Huang S-C, Torng P-L, Chang D-Y
Department of Obstetrics and Gynecology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan.
Surg Endosc. 2008 Jan;22(1):171-6. doi: 10.1007/s00464-007-9404-8. Epub 2007 May 24.
This study demonstrated a method to prevent bladder injury during laparoscopically assisted vaginal hysterectomy (LAVH) to patients with vesicocervical adhesion after previous cesarean deliveries.
Between July 2004 and July 2005, 50 women with vesicocervical adhesion who had given birth by cesarean delivery underwent LAVH. To minimize the chance of bladder injury, transvaginal lateral intervention was used to enter the anterior cul-de-sac during laparoscopic intrafascial hysterectomy. The lateral windows of the vesicocervical space were opened first. Usually, the potential spaces lateral to the adhesions could be developed easily by blunt finger dissection. Once adequate lateral spaces were created, an index finger was swept medially to define the margin of the midline adhesions secondary to the cesarean delivery scar. Under direct vision and finger guidance, the dense adhesions were dissected with more confidence and safety. Subsequently, the bladder was pushed gently aside to avert unexpected tearing or injury along the intrafascial hysterectomy. Because the vesico-uterine fold had been cut open previously under laparoscopy, the anterior cul-de-sac could be entered without much resistance.
The average age of the patients was 45 +/- 7 years, and the extirpated uterine weight was 323 +/- 170.8 g (range, 85-730 g). Intraoperatively, the mean operation time was 124.6 +/- 28.5 min (range, 80-235 min), and the average blood loss was 79.1 +/- 47.8 ml (range, 20-250 ml). The mean intramuscular meperidine requirements were 1.2 +/- 0.8 ampules (range, 0-2 ampules) (1 ampule = 50 mg), and the average hospital stay was 3.2 +/- 0.9 days (range, 2-5 days). Of these 50 patients, 24 (48%) had one, 22 (44%) had two, and 4 (8%) had three previous cesarean deliveries. No bladder injury occurred among the patients, and there was no other complication.
Transvaginal lateral intervention may help to minimize bladder injuries during LAVH for patients with previous cesarean deliveries.
本研究展示了一种针对既往剖宫产术后存在膀胱宫颈粘连的患者，在腹腔镜辅助下阴式子宫切除术（LAVH）中预防膀胱损伤的方法。
2004年7月至2005年7月期间，50例既往剖宫产分娩且有膀胱宫颈粘连的女性接受了LAVH。为将膀胱损伤的几率降至最低，在腹腔镜筋膜内子宫切除术期间采用经阴道侧向干预进入阴道后穹窿。首先打开膀胱宫颈间隙的侧窗。通常，通过手指钝性分离可轻松分离粘连外侧的潜在间隙。一旦形成足够的外侧间隙，将食指向内侧扫过以确定剖宫产瘢痕继发的中线粘连边缘。在直视和手指引导下，更有信心且安全地分离致密粘连。随后，将膀胱轻轻推开，以避免在筋膜内子宫切除术中意外撕裂或损伤。由于膀胱子宫反折先前已在腹腔镜下切开，进入阴道后穹窿时阻力不大。
患者的平均年龄为45±7岁，切除子宫重量为323±170.8 g（范围85 - 730 g）。术中，平均手术时间为124.6±28.5分钟（范围80 - 235分钟），平均失血量为79.1±47.8 ml（范围20 - 250 ml）。平均哌替啶肌肉注射用量为1.2±0.8支（范围0 - 2支）（1支 = 50 mg），平均住院时间为3.2±0.9天（范围2 - 5天）。这50例患者中，24例（48%）既往有1次剖宫产，22例（44%）有2次剖宫产，4例（8%）有3次剖宫产。患者中未发生膀胱损伤，也无其他并发症。
经阴道侧向干预可能有助于将既往剖宫产患者在LAVH期间的膀胱损伤降至最低。
