2子宫肌瘤的腹腔镜手术

北大医院

周应芳

20210626发病率是女性生殖器官最常见的良性肿瘤，发生率为20%-30%合并不育的发生率为5%-10%治疗手段：WatchfulwaitingMedicaltherapyMyomectomyhysteroscopiclaparoscopicabdominalHysterectomyabdominalvaginallaparoscopicUterinearteryembolization〔nolongerdesirefertility〕UterinearteryocclusionEndometrialablationFocusedultrasoundParkerWH.FertilSteril.2007LM适应证LM禁忌证切开包膜剔除肌瘤缝合切口创面粘连预防LM-阔韧带大肌瘤多发肌瘤-肠管外表种植-LMCS-LM-ADE-穿刺孔肌瘤腹膜肌瘤北大医院资料LM优缺点LM并发症Henia-S-bowl-1Henia-S-bowl-3Henia-S-bowl-4Henia-S-bowl-5Henia-S-bowl-6Henia-S-bowl-2Henia-S-bowl-7Henia-S-bowl-8LM并发症GnRH-a治疗后

肌瘤体积缩小laparoscopicuterinearteryligation可以

减少LM出血AlborziS，etal，FertilSteril.2021，IranItalianmulticenterstudyoncomplicationsoflaparoscopicmyomectomy

4referralcenters,2050casesAtotalcomplicationrateof11.1%(225/2050cases)Minor9.1%(187/2050cases)major2.02%(38/2050cases)hemorrhages14requiringbloodtransfusionsin3cases(0.14%)10postoperativehematomas1bowelinjury(0.04%)1postoperativeacutekidneyfailure(0.04%)2unexpectedsarcomas(0.09%)

SizziO,etal.JMinimInvasiveGynecol.2007,14(4):453-62.ItalianmulticenterstudyoncomplicationsoflaparoscopicmyomectomyFailuretocompleteplannedsurgeryoccurredin7cases(0.34%).2werereadmittedforsurgery(0.09%)1hadalaparoscopichysterectomybecauseofaseverebloodloss,1haddrainageofahematomainthebroadligamentAfollow-upof41.70±23.03months,386(22.9%)patientsconceived,withapregnancyrateinpatientswishingpregnancyof69.8%One(0.26%)recordedspontaneousuterineruptureat33weeksgestation.

SizziO,etal.JMinimInvasiveGynecol.2007,14(4):453-62.Predictorsofleiomyomarecurrenceafter

laparoscopicmyomectomy

Fiveuniversityhospitals〔Seoul〕512〔1995–2004〕withafollow-upforamedian13monthsThecumulativeprobabilityofleiomyomarecurrenceincreasedsteadilyduringthefollow-upperiod11.7%after1year36.1%after3years52.9%at5years84.4%at8yearsThecumulativeprobabilityofreoperationforrecurrentleiomyomawasmuchlower:6.7%at5years16%at8yearsYooEH,JMinimInvasiveGynecol.2007,14(6):690-7.Predictorsofleiomyomarecurrenceafter

laparoscopicmyomectomyRiskfactorsAgepreoperativenumberofleiomyomapreoperativeuterinesizepresenceofassociatedpelvicdiseasechildbirthaftersurgeryYooEH,JMinimInvasiveGynecol.2007,14(6):690-7.不孕患者肌瘤剔除后妊娠率约为50%LM后的妊娠率可接近70%，存在其他的不孕因素，那么LM后妊娠率仅为33%妊娠率和肌瘤的大小、数目和位置无明显相关生育结果Author/MethodPregRateTermDel.No.Berkeley’83/open50%40%50Smith’90/open63%53%32Ghelbach’93/open57%48%37Hasson’92/Lap71%47%17Miller’96/Lap75%65%40Rossetti’2001/Lap65.5%57.1%29

腹腔镜肌瘤剔除到达与开腹同样的效果Riskfactorsforuterinerupture

afterLM19casesofuterineruptureafterlaparoscopicmyomectomywereidentifiedThemyomasringed1～11cm(mean4.5cm)Only3usedmultilayeredclosureElectrosurgeryusedforhemostasisin17NoplausiblecontributingfactorcouldbefoundParkerWH,JMinimInvasiveGynecol.2021,USARiskfactorsforuterinerupture

afterLMItseemsreasonableforsurgeonstoadheretotechniquesdevelopedforabdominalmyomectomyincludinglimiteduseofelectros