[对于超过500克的大子宫，经阴道子宫切除术重要吗？与剖腹手术的比较]

Switala I, Cosson M, Lanvin D, Querleu D, Crepin G

Université Lille II, Roubaix.

J Gynecol Obstet Biol Reprod (Paris). 1998 Oct;27(6):585-92.

OBJECTIVE

Vaginal hysterectomy is an advantageous surgical technique as compared with abdominal hysterectomy: operating time is shorter, it is safer and hospitalization stay and recovery time are shorter. However in France, 2/3 of all hysterectomies are still performed by laparotomy. Would the vaginal approach be reasonable if a difficult hysterectomy is expected? The purpose of our study was to compare the per- and postoperative complications and the period following vaginal hysterectomy versus the abdominal route in patients with a large uterus.

PATIENTS AND METHODS

Forty-nine vaginal hysterectomies were compared retrospectively with 22 abdominal hysterectomies for fibroma during the period from 01.01.91 to 31.12.95. Uterine weight in all cases was between 500 to 1,000 g.

RESULTS

The average uterine weight was significantly different between the vaginal and the abdominal groups (644 g vs 747 g, p = 0.02). Operating time, pre- and postoperative complications and analgesic use were not significantly different between the two groups. Operative bleeding was significantly higher in the abdominal group than in the vaginal group (659 ml vs. 359 ml, p = 0.006), as well as hemoglobin loss (2.49 vs. 1.82, p = 0.04). There was also a statistical difference between the vaginal group and the abdominal groups in terms of hospital stay (4 d vs. 6 d respectively, p = 0.0002).

CONCLUSION

Vaginal hysterectomy with morcellation is advantageous in comparison with abdominal hysterectomy even when the uterine weight is over 500 g, since it offers better post-operative comfort than laparotomy without endangering the patients. The main contraindications for the vaginal route are uterus beyond the ombilicus and vaginal atresia. Excepting these cases, the indication for the vaginal approach depends on the patient's past surgical history, uterine mobility and vaginal access. In more difficult cases, these factors are assessed under anesthesia.

目的

与腹式子宫切除术相比，阴式子宫切除术是一种具有优势的手术技术：手术时间更短、更安全，住院时间和恢复时间也更短。然而在法国，所有子宫切除术中仍有2/3是通过剖腹手术进行的。如果预期子宫切除术难度较大，采用阴式手术方法是否合理？我们研究的目的是比较子宫较大患者阴式子宫切除术与腹式子宫切除术的围手术期及术后并发症以及术后恢复情况。

患者与方法

对1991年1月1日至1995年12月31日期间49例因子宫肌瘤行阴式子宫切除术的患者与22例因子宫肌瘤行腹式子宫切除术的患者进行回顾性比较。所有病例子宫重量均在500至1000克之间。

结果

阴式手术组与腹式手术组的平均子宫重量有显著差异（644克对747克，p = 0.02）。两组的手术时间、围手术期及术后并发症和镇痛药物使用情况无显著差异。腹式手术组的术中出血量显著高于阴式手术组（659毫升对359毫升，p = 0.006），血红蛋白丢失量也高于阴式手术组（2.49对1.82，p = 0.04）。阴式手术组与腹式手术组在住院时间方面也存在统计学差异（分别为4天对6天，p = 0.0002）。

结论

即使子宫重量超过500克，与腹式子宫切除术相比，采用碎宫术的阴式子宫切除术仍具有优势，因为它能为患者提供比剖腹手术更好的术后舒适度，且不危及患者安全。阴式手术途径的主要禁忌症是子宫超过脐部及阴道闭锁。除这些情况外，阴式手术的适应症取决于患者既往手术史、子宫活动度及阴道情况。在更复杂的病例中，需在麻醉下评估这些因素。