单孔腹腔镜子宫肌瘤旋切隔离保护技术的应用

doi:10.3877/cma.j.issn.1674-6899.2023.04.005

目的

比较袋内一体化电动旋切与袋内手动冷刀旋切在经脐单孔腹腔镜子宫肌瘤剔除术中的应用效果。

方法

回顾性分析2021年7月至2023年6月期间在武汉大学中南医院妇科行经脐单孔腹腔镜子宫肌瘤剔除术患者的病历信息，包括袋内一体化电动旋切组52例，袋内手动冷刀旋切组61例。分析比较两组患者住院时长、手术时间、术中出血量、术中输血率、术后并发症发生率、术后24 h视觉模拟评分法(visual analogue scale，VAS)疼痛评分、取物袋破损率、术后引流管拔除时间、术后尿管拔除时间、术后肠道通气时间、术前与术后(1 d和3 d)血红蛋白差值及术后病理。

结果

与袋内手动冷刀旋切组相比，袋内一体化电动旋切组手术时间更短[(152.88±43.37)min vs. (176.23±59.45)min，P＝0.021]、取物袋破损率更低[0(0.0%) vs. 8(13.1%)，P＝0.019]差异存在统计学意义(P<0.05)。住院时长、术中出血量、术中输血率、术后并发症发生率、术后24 h VAS疼痛评分、术后引流管拔除时间、术后尿管拔除时间、术后肠道通气时间、术前与术后(1 d和3 d)血红蛋白差值及术后病理，两组差异无统计学意义(P>0.05)。

结论

在经脐单孔腹腔镜子宫肌瘤剔除术中，袋内一体化电动旋切是一种安全可行的方案，可与单孔腹腔镜及电动旋切器配套使用，与袋内手动冷刀旋切相比手术时长更短、取物袋破损率更低，但仍需大样本前瞻性研究进一步验证。

关键词: 子宫肌瘤剔除术, 袋内粉碎, 电动旋切, 经脐单孔腹腔镜, 妇科

Objective

To compare the application of in-bag integrated power morcellation and contained manual scalpel morcellation in transumbilical single-port laparoscopic myomectomy.

Methods

The medical records of patients who underwent transumbilical single-port laparoscopic myomectomy at the Department of Gynecology, Zhongnan Hospital of Wuhan University from Jul. 2021 to Jun. 2023 were retrospectively analyzed. There were 52 patients who underwent in-bag integrated power morcellation and 61 patients who underwent contained manual scalpel morcellation. Compare and analyze the hospitalization time, operation time, intraoperative blood loss, intraoperative blood transfusion rate, postoperative complications, visual analogue scale (VAS) pain score of 24 h after surgery, the rate of bag breakage, postoperative drainage tube removal time, postoperative urinary catheter removal time, postoperative intestinal ventilation time, hemoglobin difference between preoperative and postoperative (1 d and 3 d) and postoperative pathology.

Results

Compared with the contained manual scalpel morcellation group, the in-bag integrated power morcellation group had shorter operation time [(152.88±43.37)min vs. (176.23±59.45)min, P=0.021] and lower rate of bag breakage [0 (0.0%) vs. 8 (13.1%), P=0.019]. The difference was statistically significant (P<0.05). Compared the in-bag integrated power morcellation group with the contained manual scalpel morcellation group, there was no significantly statistical difference (P>0.05) in the hospitalization time, intraoperative blood loss, intraoperative blood transfusion rate, postoperative complications rate, VAS pain score of 24 h after surgery, postoperative drainage tube removal time, postoperative catheter removal time, postoperative intestinal ventilation time, hemoglobin difference between preoperative and postoperative (1 d and 3 d), and postoperative pathology.

Conclusion

In transumbilical single-port laparoscopic myomectomy, in-bag integrated power morcellation is a safe and feasible solution. It can be used with single-port laparoscope and electric rotator. Compared with contained manual scalpel morcellation, in-bag integrated power morcellation has shorter operation time and lower bag breakage rate, but it still needs further verification in large-sample prospective studies.

Key words: Myomectomy, In-bag morcellation, Power morcellation, Transumbilical laparoendoscopic single-site surgery, Gynecology

图1 经脐单孔腹腔镜子宫肌瘤剔除术中袋内一体化电动旋切注：A.腹腔镜下已剥离的子宫肌瘤；B.取物袋经入路平台port置入腹腔内；C.将剔除的肌瘤装入取物袋中；D.牵拉取物袋至脐部切口平面；E.内窥镜下，电动旋切器钳夹住肌瘤；F.内窥镜下电动旋切器钳夹后下推套管，刀头收缩于套管内；G.助手辅助撑开取物袋，电动旋切器钳夹住肌瘤；H.助手辅助撑开取物袋，电动旋切器套管下推，刀头收缩于套管内。

图2 单孔腹腔镜一体化电动旋切专用取物袋与普通一次性标本取物袋的对比注：A．装有单孔腹腔镜专用取物袋的取物器(取物袋未弹出)；B.推动单孔腹腔镜专用取物器的白色内管，专用取物袋弹出；C.装有普通一次性标本取物袋的取物器(取物袋未弹出)；D.推动普通一次性标本取物器的内管，取物袋弹出。

图3 经单孔腹腔镜入路平台port实现一体化器械放置注：A.专用取物袋套在切口保护套上；B.入路平台port；C.电动旋切器；D内窥镜。

图4 袋内手动冷刀旋切

表1 两组患者一般情况对比

特征	袋内一体化电动旋切组(n＝52)	袋内手动冷刀旋切组(n＝61)	统计量值	P值
年龄(岁)	39.98±7.08	39.30±7.329	t＝0.504	0.616
BMI(kg/m²)	22.48±3.03	23.14±2.83	t＝－1.187	0.238
症状[n(%)]			/	0.557^a
腹痛	11(47.8)	24(47.1)^b
经量增多	5(21.7)	12(23.5)^b
经期不规则	7(30.4)	8(15.7)^b
乏力	0(0.0)	1(2.0)^b
排尿困难	0(0.0)	4(7.8)^b
腹胀	0(0.0)	2(3.9)^b
分娩史[n(%)]	38(73.1)	47(77.0)	χ²＝0.238	0.626
盆腹腔手术史[n(%)]	20(38.5)	27(44.3)	χ²＝0.389	0.533
术前CA125>35 kU/L[n(%)]	4(8.9)	9(15.5)	χ²＝1.009	0.315
肌瘤个数			χ²＝2.455	0.117
1个	38(73.1)	36(59.0)
≥2个	14(26.9)	25(41.0)
肌瘤大小^c
肌瘤体积(cm³)	215.01±138.61	247.21±224.98	t＝－0.837	0.405
肌瘤直径(cm)	6.27±1.36	6.24±1.67	t＝0.084	0.933

表1 两组患者一般情况对比

特征	袋内一体化电动旋切组(n＝52)	袋内手动冷刀旋切组(n＝61)	统计量值	P值
年龄(岁)	39.98±7.08	39.30±7.329	t＝0.504	0.616
BMI(kg/m²)	22.48±3.03	23.14±2.83	t＝－1.187	0.238
症状[n(%)]			/	0.557^a
腹痛	11(47.8)	24(47.1)^b
经量增多	5(21.7)	12(23.5)^b
经期不规则	7(30.4)	8(15.7)^b
乏力	0(0.0)	1(2.0)^b
排尿困难	0(0.0)	4(7.8)^b
腹胀	0(0.0)	2(3.9)^b
分娩史[n(%)]	38(73.1)	47(77.0)	χ²＝0.238	0.626
盆腹腔手术史[n(%)]	20(38.5)	27(44.3)	χ²＝0.389	0.533
术前CA125>35 kU/L[n(%)]	4(8.9)	9(15.5)	χ²＝1.009	0.315
肌瘤个数			χ²＝2.455	0.117
1个	38(73.1)	36(59.0)
≥2个	14(26.9)	25(41.0)
肌瘤大小^c
肌瘤体积(cm³)	215.01±138.61	247.21±224.98	t＝－0.837	0.405
肌瘤直径(cm)	6.27±1.36	6.24±1.67	t＝0.084	0.933

表2 两组患者观察指标对比

指标	袋内一体化电动旋切组(n＝52)	袋内手动冷刀旋切组(n＝61)	统计量值	P值
住院时长(d)	4.65±1.45	4.75±1.56	t＝－0.352	0.726
手术时间(min)	152.88±43.37	176.23±59.45	t＝－2.348	0.021^*
术中出血量(ml)	75.00(20.00，100.00)	50.00(20.00，100.00)	Z＝－0.728	0.467
术中输血[n(%)]	2(3.8)	3(4.9)	<0.001	>0.999
术后并发症[n(%)]	0(0.0)	0(0.0)	/	/
术后24 h VAS疼痛评分	1.00(1.00，1.00)	1.00(1.00，1.00)	Z＝－0.109	0.835
取物袋破损率[n(%)]	0(0.0)	8(13.1)	χ²＝5.481	0.019^*
术后引流管拔除时间(d)	2.55±0.76	2.40±0.70	t＝0.745	0.460
术后尿管拔除时间(d)	1.00(1.00，1.00)	1.00(1.00，1.00)	Z＝－0.665	0.506
术后肠道通气时间(d)	2.00±0.53	2.15±0.82	t＝－1.123	0.264
术前-术后1 d血红蛋白差值(g/L)	18.02±10.65	20.13±9.45	t＝－1.098	0.275
术前-术后3 d血红蛋白差值(g/L)	14.25±10.52	16.45±10.84	t＝－0.878	0.383
术后病理[n(%)]			/	0.720^a
子宫平滑肌瘤	49(94.2)	58(95.1)^b
CL	1(1.9)	2(3.3)^b
MAL	0(0.0)	1(1.6)^b
uIMT	1(1.9)	0(0.0)^b
LG-ESS	1(6.7)	0(0.0)^b

表2 两组患者观察指标对比

指标	袋内一体化电动旋切组(n＝52)	袋内手动冷刀旋切组(n＝61)	统计量值	P值
住院时长(d)	4.65±1.45	4.75±1.56	t＝－0.352	0.726
手术时间(min)	152.88±43.37	176.23±59.45	t＝－2.348	0.021^*
术中出血量(ml)	75.00(20.00，100.00)	50.00(20.00，100.00)	Z＝－0.728	0.467
术中输血[n(%)]	2(3.8)	3(4.9)	<0.001	>0.999
术后并发症[n(%)]	0(0.0)	0(0.0)	/	/
术后24 h VAS疼痛评分	1.00(1.00，1.00)	1.00(1.00，1.00)	Z＝－0.109	0.835
取物袋破损率[n(%)]	0(0.0)	8(13.1)	χ²＝5.481	0.019^*
术后引流管拔除时间(d)	2.55±0.76	2.40±0.70	t＝0.745	0.460
术后尿管拔除时间(d)	1.00(1.00，1.00)	1.00(1.00，1.00)	Z＝－0.665	0.506
术后肠道通气时间(d)	2.00±0.53	2.15±0.82	t＝－1.123	0.264
术前-术后1 d血红蛋白差值(g/L)	18.02±10.65	20.13±9.45	t＝－1.098	0.275
术前-术后3 d血红蛋白差值(g/L)	14.25±10.52	16.45±10.84	t＝－0.878	0.383
术后病理[n(%)]			/	0.720^a
子宫平滑肌瘤	49(94.2)	58(95.1)^b
CL	1(1.9)	2(3.3)^b
MAL	0(0.0)	1(1.6)^b
uIMT	1(1.9)	0(0.0)^b
LG-ESS	1(6.7)	0(0.0)^b

1	Stewart E, Cookson C, Gandolfo R, et al. Epidemiology of uterine fibroids: a systematic review[J]. BJOG: An International Journal of Obstetrics & Gynaecology, 2017, 124(10): 1501-1512.
2	Jin C, Hu Y, Chen X, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials[J]. European Journal of Obstetrics & Gynecology and Reproductive Biology, 2009, 145(1): 14-21.
3	杨慧琼，佐满珍，马会改. 腹腔镜下子宫肌瘤切除术应用进展[J]. 实用医学杂志，2015, 31(22): 3675-3677.
4	Lee D, Kim SK, Kim K, et al. Advantages of single-port laparoscopic myomectomy compared with conventional laparoscopic myomectomy: a randomized controlled study[J]. Journal of Minimally Invasive Gynecology, 2018, 25(1): 124-132.
5	Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma[J]. Gynecologic Oncology, 2011, 122(2): 255-259.
6	Steiner RA, Wight E, Tadir Y, et al. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity[J]. Obstetrics and Gynecology, 1993, 81(3): 471-474.
7	Hampton T. Use of morcellation to remove fibroids scrutinized at fda hearings[J]. JAMA, 2014, 312(6): 588.
8	Uterine morcellation for presumed leiomyomas: ACOG Committee opinion, number 822[J]. Obstetrics and Gynecology, 2021, 137(3): e63-e74.
9	Miyake T, Enomoto T, Ueda Y, et al. A case of disseminated peritoneal leiomyomatosis developing after laparoscope-assisted myomectomy[J]. Gynecologic and Obstetric Investigation, 2009, 67(2): 96-102.
10	Seidman MA, Oduyebo T, Muto MG, et al. Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms[J]. PloS One, 2012, 7(11): e50058.
11	Barron KI, Richard T, Robinson PS, et al. Association of the U．S. Food and Drug Administration morcellation warning with rates of minimally invasive hysterectomy and myomectomy[J]. Obstetrics and Gynecology, 2015, 126(6): 1174-1180.
12	Zullo F, Venturella R, Raffone A, et al. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy[J]. Cochrane Database of Systematic Reviews, 2020, 2020(5): CD013352.
13	Nishijima Y, Suzuki T, Sato K, et al. Retrospective study of collection methods in laparoscopic myomectomy[J]. The Tokai Journal of Experimental and Clinical Medicine, 2019, 44(3): 54-58.
14	Güven CM, Uysal D. In-bag abdominal manual morcellation versus contained power morcellation in laparoscopic myomectomy: a comparison of surgical outcomes and costs[J]. BMC Surgery, 2023, 23(1): 106.
15	王晓翊, 熊宙芳. 手工旋切法在腹腔镜子宫肌瘤剔除术中的应用[J]. 实用医学杂志，2020, 36(10): 1330-1333.
16	Cohen SL, Morris SN, Brown DN, et al. Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters[J]. American Journal of Obstetrics and Gynecology, 2016, 214(2): 257.e1-257.e6.
17	Vargas MV, Cohen SL, Fuchs-Weizman N, et al. Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes[J]. Journal of Minimally Invasive Gynecology, 2015, 22(3): 433-438.
18	李东林，刘彩虹，王珺，等. 腹腔镜下子宫肌瘤旋切方法探讨[J]. 中国实用妇科与产科杂志，2016, 32(5): 485-488.
19	Won YB, Lee HJ, Eoh KJ, et al. In-bag power morcellation technique in single-port laparoscopic myomectomy[J]. Obstetrics & Gynecology Science, 2018, 61(2): 267-273.
20	Yang H, Li X-C, Yao C, et al. Proportion of uterine malignant tumors in patients with laparoscopic myomectomy: a national multicenter study in China[J]. Chinese Medical Journal, 2017, 130(22): 2661-2665.
21	Glaser LM, Friedman J, Tsai S, et al. Laparoscopic myomectomy and morcellation: a review of techniques, outcomes, and practice guidelines[J]. Best Practice & Research Clinical Obstetrics & Gynaecology, 2018, 46: 99-112.

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选择文件类型/文献管理软件名称

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Application of single-port laparoscopic hysteromyoma excision and isolation protection technology

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Application of single-port laparoscopic hysteromyoma excision and isolation protection technology