腹腔镜下膀胱阴道瘘修补术ppt课件

.,1,腹腔镜下膀胱阴道瘘修补术,张大宏浙江省人民医院泌尿外科泌尿腔镜中心,Laparoscopictransabdominaltransvesicalrepairofvesicovaginalfistula,DahongZhangZhejiangProvincialPeoplesHospitalLaparoscopicSurgeryandEndourologyCenter,.,2,概况,分娩损伤obstetrictrauma妇科手术损伤iatrogeniceventduringgynecologicalsurgery盆腔肿瘤手术损伤resectionofpelvictumor约75%与全子宫切除术及盆腔淋巴结清扫术相关,.,3,严重影响患者生活质量保守治疗一般无效国内目前多采用开放手术修补MedicallydevastatingconditionsConservativeTherapyisgenerallyineffectiveOpensurgeryismorepopulardomestic,.,4,传统手术路径,腹膜外经膀胱abdominaltransvesical腹膜外不经膀胱abdominalextravesical腹膜外膀胱内外结合transvesicalandextravesical经腹腔transabdominalTransvesical经阴道transvaginal,.,5,传统手术的问题,手术操作难度高：位置深空间小复发率或修补失败率高LaparoscopicVVFrepairattemptstoachievesuccessratessimilartothoseoftransabdominalrepairandavoidsthemorbidityofopensurgery,.,6,单中心5年手术例数39例,SingleCenterExperience39cases腹腔镜下修补手术经腹腔路径Laparoscopictransabdominaltransvesicalrepair,.,7,手术准备,阴道冲洗消毒肠道准备全麻平卧位或截石位34个Trocar人工CO2气腹,.,8,.,9,手术步骤SurgicalProcedure,.,10,建立工作通道,athreeorfour-porttransabdominalapproachwasused,.,11,粘连分离,.,12,录像,.,13,打开膀胱,.,14,录像,.,15,录像,.,16,录像,.,17,三角区膀胱阴道瘘,.,18,复杂膀胱阴道瘘（放疗后膀胱或巨大瘘口，瘘口位于颈口6点）,.,19,.,20,录像,.,21,.,22,膀胱阴道瘘合并输尿管阴道瘘,.,23,.,24,合并输尿管阴道瘘术中损伤输尿管瘘扣较大无法满意缝合同时行腹腔镜输尿管膀胱再植术（直接吻合或膀胱壁袢法）,.,25,.,26,.,27,填充材料,大网膜Omentum带蒂肠系膜Mesenteric生物蛋白胶Fibringlue生物补片Surgisismesh？引流,.,28,录像,.,29,一般资料,本组39例年龄3252岁三角区32例（近尿道口11）三角区上6例合并输尿管阴道瘘3例,.,30,妇科腹腔镜手术21例单纯子宫切除15例、盆清6例开放手术17例盆清14例、宫颈大肌瘤切除3例腹腔镜直肠癌根治术1例有修补史4例放疗史2例,.,31,手术情况,手术时间80170m出血量50-150ml无一例中转开放术后漏尿3例术后921d拔导尿管术后平均住院时间10d无失败病例,.,32,手术要点,经腹腔路径窦道切除膀胱阴道完全分离网膜或带蒂系膜隔离膀胱减张缝合双侧输尿管单J管留置,.,33,手术时机,术后三月？Waitfor36months?即刻？Earlyintervention?无明显炎症情况下即可Degreeofinflammationandpotentialinfection,.,34,手术方式,腹腔镜膀胱阴道瘘修补术腹腔镜膀胱阴道瘘修补+输尿管膀胱再植术腹腔镜膀胱阴道瘘修补+膀胱扩大术LaparoscopictransabdominaltransvesicalrepairwithrotationalbladderflapLaparoscopicureteralreimplantationwithBoriflapLaparo