Nyangoh Timoh Krystel, Paquet Caroline, Lavoué Vincent, Touboul Cyril, Fauconnier Arnaud
Département de Gynécologie-Obstétrique, Hôpital Universitaire de Rennes, Université de Rennes 1, Rennes, France.
Laboratoire D'Anatomie, Faculté de Médecine, Avenue du Professeur Léon-Bernard, Rennes Cedex, France.
Surg Radiol Anat. 2019 Aug;41(8):859-867. doi: 10.1007/s00276-019-02242-7. Epub 2019 May 6.
To describe the procedure of laparoscopic extrafascial hysterectomy to avoid ureter injury.
Data were obtained from: (1) anatomic study of ten fresh female cadavers to measure the distance between the point where the ureter and uterine artery cross and the level of section of the ascending branch of the uterine artery during extrafascial dissection of the uterine pedicle and uterosacral ligament (Paris School of Surgery). The Wilcoxon test was used to compare measurements within each subject. P < 0.05 was considered to denote significance; (2) prospectively collected clinical data from women undergoing laparoscopic extrafascial hysterectomy from July 2006 to March 2014 at Poissy University Hospital, to describe the laparoscopic extrafascial hysterectomy technique with analysis of surgical complications using the Clavien-Dindo classification.
Anatomic study: The mean (SD) distance between the point where the ureter and uterine artery cross and the level of the section of the ascending branch of the uterine artery were: 11.6 mm (5.2) in neutral position and 25 mm (7.5) after pulling the uterus laterally; and 25mm (8.9) after sectioning the ascending portion of the uterine pedicle and 38.6 mm (4.5) after complete uterine artery pedicle dissection through the uterosacral ligaments. After release of the ureter, the curve in front of the uterine artery disappeared. Clinical laparoscopic study: Sixty-eight patients underwent laparoscopic extrafascial hysterectomy. No ureteral complications occurred.
Laparoscopic extrafascial hysterectomy is a safe and feasible procedure. Combined lateralization and elevation of the uterus, section of the ascending branch of the uterine artery, and its extrafascial dissection along the uterosacral ligament contribute to protecting the ureter during the procedure.
描述腹腔镜筋膜外子宫切除术的操作步骤以避免输尿管损伤。
数据来源于：（1）对10具新鲜女性尸体进行解剖学研究，以测量在子宫蒂和子宫骶韧带筋膜外解剖过程中输尿管与子宫动脉交叉点至子宫动脉升支切断水平的距离（巴黎外科学院）。采用Wilcoxon检验比较每个受试者的测量值。P < 0.05被认为具有统计学意义；（2）前瞻性收集2006年7月至2014年3月在普瓦西大学医院接受腹腔镜筋膜外子宫切除术的女性的临床数据，描述腹腔镜筋膜外子宫切除术技术，并使用Clavien-Dindo分类法分析手术并发症。
解剖学研究：输尿管与子宫动脉交叉点至子宫动脉升支切断水平的平均（标准差）距离为：中立位时11.6 mm（5.2），子宫向外侧牵拉后25 mm（7.5）；子宫蒂升部切断后25 mm（8.9），通过子宫骶韧带完全解剖子宫动脉蒂后38.6 mm（4.5）。输尿管松解后，子宫动脉前方的曲线消失。临床腹腔镜研究：68例患者接受了腹腔镜筋膜外子宫切除术。未发生输尿管并发症。
腹腔镜筋膜外子宫切除术是一种安全可行的手术。子宫的侧方移位和上提、子宫动脉升支的切断及其沿子宫骶韧带的筋膜外解剖有助于在手术过程中保护输尿管。
