经阴道自然腔道内镜手术在巨大卵巢良性肿瘤中的应用初探

doi:10.3877/cma.j.issn.1674-6899.2022.06.008

目的

探讨经阴道自然腔道内镜手术(vaginal natural orifice transluminal endoscopic surgery，vNOTES)应用于巨大卵巢良性肿瘤的安全性、可行性及相关优势。

方法

回顾性分析2020年5月至2022年6月在贵州医科大学附属医院和贵州省人民医院开展手术治疗的巨大卵巢良性肿瘤(直径≥10 cm)患者的临床资料，根据不同手术方式分为vNOTES组(16例)、经脐单孔腹腔镜手术(laparoscopic single-site surgery，LESS)组(54例)、传统多孔腹腔镜手术(multiport laparoscopic surgery，MLS)组(38例)，比较分析三组的手术时间、术中囊液外溢率、术中出血量、术后首次肛门排气时间、术后24 h疼痛视觉评分(visual analogue scale，VAS)、术后住院时间、总住院费用、术后切口美容满意度评分( cosmetic score，CS)及术后短期并发症等指标。

结果

vNOTES组术中囊液外溢率、术后首次肛门排气时间、术后24 h VAS与LESS组及MLS组相比，差异有统计学意义(P<0.05)。三组的手术包块直径、术中出血量、手术时间、总住院费用、术后并发症、术后炎症指标、卵巢肿瘤标志物等相比较，差异均无统计学意义(P>0.05)。

结论

vNOTES治疗巨大卵巢良性肿瘤患者是安全、可行的，与LESS和MLS相比，具有更微创、囊液外溢率低、术后加速康复、体表无瘢痕等优势。

关键词: 经阴道自然腔道内镜手术, vNOTES, 巨大卵巢良性肿瘤, 缩瘤术, 腹腔镜手术

Objective

To evaluate the safety, feasibility and advantages of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in the treatment of giant ovarian benign tumors.

Methods

The clinical data of patients who underwent surgery for giant benign ovarian tumors (diameter≥10 cm) in the Affiliated Hospital of Guizhou Medical University and Guizhou Provincial People′s Hospital from May 2020 to Jun. 2022 were retrospectively analyzed. According to different surgery methods, the patients were divided into vNOTES (16 cases), laparoscopic single-site surgery (LESS, 54 cases) and traditional multiport laparoscopic surgery (MLS, 38 cases). The operative time, cyst fluid leakage rate, intraoperative blood loss, postoperative exhaust time, 24 h postoperative pain visual analogue score, hospital stay, hospitalization cost, postoperative incision cosmetic score and short-term postoperative complication were compared and analyzed among the three groups.

Results

Compared with the LESS group and the MLS group, the vNOTES group had statistically significant differences in the cystic fluid leakage rate, postoperative exhaust time and pain score at 24 hours after operation (P< 0.05). There were no significant differences in the mass diameter size, intraoperative blood loss, operation time, total hospitalization cost, postoperative complications, postoperative inflammatory indicators, and ovarian tumor markers among the three groups (P> 0.05).

Conclusions

vNOTES surgery is safe and effective in the giant benign ovarian tumors. Compared with LESS and MLS groups, vNOTES surgery has the advantages of minimally invasive, lower cyst fluid leakage rate, shorter postoperative recovery time, and no scar on the body surface.

Key words: Transvaginal natural orifice endoscopic surgery, vNOTES, Giant benign ovarian tumors, Cyst reduction surgery, Laparoscopic surgery

图1 巨大卵巢良性肿瘤经阴道自然腔道内镜手术注：A.打开阴道后穹隆暴露囊肿；B.经阴道后穹隆置入Port；C.探查上腹部情况；D.缩小瘤体；E.切除附件；F.缝合阴道后穹隆切口

表1 三组巨大卵巢良性肿瘤患者基本资料比较

指标		vNOTES组(16例)	LESS组(54例)	MLS组(38例)	统计量	P值
年龄(岁，±s)		41.50±8.05	37.48±9.16	40.58±8.69	0.606	0.548
BMI(kg/m²，±s)		22.17±6.82	23.68±3.87	23.43±3.08	0.590	0.942
绝经期[例(%)]					2.068	0.356
	是	5(31.25)	9(16.67)	10(26.32)
	否	11(68.75)	45(83.33)	28(73.68)
腹部手术史[例(%)]					2.578	0.276
	无	12(75.00)	32(59.26)	20(52.63)
	1次	3(18.75)	18(33.33)	12(31.58)
	2次	1(6.25)	4(7.41)	6(15.79)
慢性病史[例(%)]					0.897	0.639
	否	13(81.25)	45(83.33)	34(89.47)
	是	3(18.75)	9(16.67)	4(10.53)
生产史[例(%)]					5.075	0.079
	是	13(81.25)	27(50.00)	23(60.53)
	否	3(18.75)	27(50.00)	15(39.47)
CA125[M(P₂₅，P₇₅)]		15.95(11.95，26.34)	25.00(15.46，52.60)	26.59(15.51，55.78)	4.713	0.950
CA199[M(P₂₅，P₇₅)]		17.28(11.35，43.90)	19.29(8.98，32.06)	18.40(9.50，46.10)	1.256	0.534
术前NLR(±s)		1.83±0.52	2.17±1.23	2.07±2.06	0.278	0.758
术前PLR(±s)		123.95±33.08	138.67±44.77	130.67±62.87	0.603	0.549

表1 三组巨大卵巢良性肿瘤患者基本资料比较

指标		vNOTES组(16例)	LESS组(54例)	MLS组(38例)	统计量	P值
年龄(岁，±s)		41.50±8.05	37.48±9.16	40.58±8.69	0.606	0.548
BMI(kg/m²，±s)		22.17±6.82	23.68±3.87	23.43±3.08	0.590	0.942
绝经期[例(%)]					2.068	0.356
	是	5(31.25)	9(16.67)	10(26.32)
	否	11(68.75)	45(83.33)	28(73.68)
腹部手术史[例(%)]					2.578	0.276
	无	12(75.00)	32(59.26)	20(52.63)
	1次	3(18.75)	18(33.33)	12(31.58)
	2次	1(6.25)	4(7.41)	6(15.79)
慢性病史[例(%)]					0.897	0.639
	否	13(81.25)	45(83.33)	34(89.47)
	是	3(18.75)	9(16.67)	4(10.53)
生产史[例(%)]					5.075	0.079
	是	13(81.25)	27(50.00)	23(60.53)
	否	3(18.75)	27(50.00)	15(39.47)
CA125[M(P₂₅，P₇₅)]		15.95(11.95，26.34)	25.00(15.46，52.60)	26.59(15.51，55.78)	4.713	0.950
CA199[M(P₂₅，P₇₅)]		17.28(11.35，43.90)	19.29(8.98，32.06)	18.40(9.50，46.10)	1.256	0.534
术前NLR(±s)		1.83±0.52	2.17±1.23	2.07±2.06	0.278	0.758
术前PLR(±s)		123.95±33.08	138.67±44.77	130.67±62.87	0.603	0.549

表2 三组巨大卵巢良性肿瘤患者术中情况比较

项目		vNOTES组(16例)	LESS组(54例)	MLS组(38例)	统计量	P值
手术时间(min，±s)		106.88±45.09	104.59±40.63	105.66±48.05	0.018	0.982
术中出血量[ml，M(P₂₅，P₇₅)]		50.00(12.50，100.00)	30.00(20.00，50.00)	20.00(10.00，50.00)	1.614	0.446
术中囊液外溢[例(%)]		2(12.50)^a	13(24.07)^a	18(47.37)^b	8.589	0.014
术后病理[例(%)]					6.395	0.041
	成熟性畸胎瘤	10(62.5)	20(37.4)	9(23.68)
	子宫内膜异位囊肿	2(12.50)	7(12.96)	10(26.32)
	黏液性囊腺瘤	2(12.50)	3(5.56)	3(7.89)
	浆液性囊腺瘤	1(6.25)	8(14.81)	7(18.42)
	其他良性肿瘤	1(6.25)	16(29.63)	9(23.68)
手术范围[例(%)]					0.874	0.646
	囊肿剥除术	12(75.00)	39(72.22)	25(65.79)
	附件切除术	4(25.00)	13(24.07)	10(26.32)
	其他良性肿瘤	0(0.00)	2(3.71)	3(7.89)
单双侧[例(%)]					1.061	0.588
	单侧	10(62.50)	39(72.22)	29(76.32)
	双侧	6(37.50)	15(27.78)	9(23.68)
手术包块最大直径[cm，M(P₂₅，P₇₅)]		115.00(100.00，127.50)	120.00(100.00，142.50)	120.00(100.00，130.00)	0.350	0.706

表2 三组巨大卵巢良性肿瘤患者术中情况比较

项目		vNOTES组(16例)	LESS组(54例)	MLS组(38例)	统计量	P值
手术时间(min，±s)		106.88±45.09	104.59±40.63	105.66±48.05	0.018	0.982
术中出血量[ml，M(P₂₅，P₇₅)]		50.00(12.50，100.00)	30.00(20.00，50.00)	20.00(10.00，50.00)	1.614	0.446
术中囊液外溢[例(%)]		2(12.50)^a	13(24.07)^a	18(47.37)^b	8.589	0.014
术后病理[例(%)]					6.395	0.041
	成熟性畸胎瘤	10(62.5)	20(37.4)	9(23.68)
	子宫内膜异位囊肿	2(12.50)	7(12.96)	10(26.32)
	黏液性囊腺瘤	2(12.50)	3(5.56)	3(7.89)
	浆液性囊腺瘤	1(6.25)	8(14.81)	7(18.42)
	其他良性肿瘤	1(6.25)	16(29.63)	9(23.68)
手术范围[例(%)]					0.874	0.646
	囊肿剥除术	12(75.00)	39(72.22)	25(65.79)
	附件切除术	4(25.00)	13(24.07)	10(26.32)
	其他良性肿瘤	0(0.00)	2(3.71)	3(7.89)
单双侧[例(%)]					1.061	0.588
	单侧	10(62.50)	39(72.22)	29(76.32)
	双侧	6(37.50)	15(27.78)	9(23.68)
手术包块最大直径[cm，M(P₂₅，P₇₅)]		115.00(100.00，127.50)	120.00(100.00，142.50)	120.00(100.00，130.00)	0.350	0.706

表3 三组巨大卵巢良性肿瘤患者术后相关情况比较(±s)

项目		vNOTES组(16例)	LESS组(54例)	MLS组(38例)	统计量	P值
首次肛门排气时间(h)		13.69±3.44^a	18.41±3.01^b	20.37±9.30^b	6.830	0.002
术前术后血红蛋白差值(g/L)		16.92±8.23	16.38±12.23	13.03±7.77	1.308	0.275
术后抗生素使用时间(d)		1.25±0.58	1.20±0.49	1.69±1.36	3.503	0.034
术后住院时间(d)		2.00±1.15	2.30±1.02	2.68±1.32	2.333	0.102
总住院费用(元)		13 114.14±4 070.53	14 217.86±3 013.09	13 762.44±2 578.05	0.864	0.425
CS(分)
	3个月	5.00±0.00^a	3.78±0.57^b	3.45±0.56^c	51.431	<0.001
	6个月	5.00±0.00^a	4.30±0.54^b	3.97±0.64^c	20.611	<0.001
	12个月	5.00±0.00^a	4.72±0.45^b	4.53±0.51^c	6.747	0.002
术后24 h VAS(分)		1.60±0.85^a	1.91±1.26^a	2.71±1.57^b	9.322	<0.001
术后NLR		6.88±2.88	8.81±5.62	7.19±3.83	1.608	0.206
术后PLR		174.49±72.20	229.89±134.30	189.02±104.13	1.844	0.164

表3 三组巨大卵巢良性肿瘤患者术后相关情况比较(±s)

项目		vNOTES组(16例)	LESS组(54例)	MLS组(38例)	统计量	P值
首次肛门排气时间(h)		13.69±3.44^a	18.41±3.01^b	20.37±9.30^b	6.830	0.002
术前术后血红蛋白差值(g/L)		16.92±8.23	16.38±12.23	13.03±7.77	1.308	0.275
术后抗生素使用时间(d)		1.25±0.58	1.20±0.49	1.69±1.36	3.503	0.034
术后住院时间(d)		2.00±1.15	2.30±1.02	2.68±1.32	2.333	0.102
总住院费用(元)		13 114.14±4 070.53	14 217.86±3 013.09	13 762.44±2 578.05	0.864	0.425
CS(分)
	3个月	5.00±0.00^a	3.78±0.57^b	3.45±0.56^c	51.431	<0.001
	6个月	5.00±0.00^a	4.30±0.54^b	3.97±0.64^c	20.611	<0.001
	12个月	5.00±0.00^a	4.72±0.45^b	4.53±0.51^c	6.747	0.002
术后24 h VAS(分)		1.60±0.85^a	1.91±1.26^a	2.71±1.57^b	9.322	<0.001
术后NLR		6.88±2.88	8.81±5.62	7.19±3.83	1.608	0.206
术后PLR		174.49±72.20	229.89±134.30	189.02±104.13	1.844	0.164

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Application of transvaginal natural orifice endoscopic surgery in the treatment of giant benign ovarian tumors

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Application of transvaginal natural orifice endoscopic surgery in the treatment of giant benign ovarian tumors