腹腔镜下膀胱阴道瘘修补术

腹腔镜下膀胱阴道瘘修补术

Laparoscopictransabdominal

transvesicalrepairofvesicovaginalfistula1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2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MedicallydevastatingconditionsConservativeTherapyisgenerallyineffectiveOpensurgeryismorepopulardomestic3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transvesicaland

extravesical经腹腔transabdominal

Transvesical经阴道transvaginal

4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

5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Laparoscopictransabdominal

transvesicalrepair6手术准备阴道冲洗消毒肠道准备全麻平卧位或截石位3~4个Trocar人工CO2气腹78手术步骤SurgicalProcedure9建立工作通道athreeorfour-porttransabdominal

approachwasused10粘连分离11录像12打开膀胱13录像14录像15录像16三角区膀胱阴道瘘17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）1819录像2021膀胱阴道瘘合并输尿管阴道瘘2223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）242526填充材料大网膜Omentum带蒂肠系膜Mesenteric生物蛋白胶Fibringlue生物补片Surgisis™mesh？引流27录像28一般资料本组39例年龄32~52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29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30手术情况手术时间80~170m出血量50-150ml无一例中转开放术后漏尿3例术后9~21d拔导尿管术后平均住院时间10d无失败病例31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32手术时机术后三月？Waitfor3–6months?即刻？Earlyintervention?无明显炎症情况下即可Degreeofinflammationandpotentialinfection33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Laparoscopictransabdominal

transvesicalrepairwithrotationalbladderflapLaparoscopicureteral

reimplantationwithBor