腹腔镜全子宫切除治疗直肠子宫陷凹封闭的内异症

doi:10.3877/cma.j.issn.1674-6899.2025.04.006

目的

探讨腹腔镜全子宫切除在子宫内膜异位症(endometriosis，EM)直肠子宫陷凹完全封闭和未完全封闭患者中的应用。

方法

回顾性分析2022年6月至2024年8月行腹腔镜全子宫切除，术后病理确诊为EM 115例一般临床病理资料，直肠子宫陷凹完全封闭54例，未完全封闭61例，比较2组一般临床资料及围术期情况。

结果

2组均未发生大出血、中转开腹、脏器损伤等严重并发症，术后3个月复诊均恢复良好。完全封闭组复发患者更多[16(29.6%)vs.6(9.8%)，P＝0.007]，痛经更多见[46(85.2%) vs.38(62.3%)，P＝0.006]，子宫切除更年轻[45.61±3.96岁vs. 47.41±3.81岁，P＝0.015]。完全封闭组术中行卵巢、骶韧带及直肠阴道隔EM切除多于未完全封闭组[35(64.8%) vs.18(29.5%)，P<0.001；42(77.8%)vs.26(42.6%)，P<0.001；46(85.2%) vs.8(13.1%)，P<0.001]；腹膜EM(peritoneal endometriosis，PE)切除未完全封闭组更多[22(40.7%) vs.45(73.8%)，P<0.001)]。完全封闭组手术时间、术中出血、术中输尿管游离、术后住院时间均多于未完全封闭组147.00(114.75，176.75)min vs. 95.00(81.00，117.00)min，P<0.001；50.00(20.00，100.00)ml vs. 20.00(10.00，20.00)ml，P<0.001；[44(81.5%) vs.15(24.6%)，P<0.001；4.00(3.00，5.00)d vs. 3.00(2.00，4.00)d，P<0.001]；2组子宫重量、围术期输尿管支架置入、术后发热及其他并发症比较均无显著差异(P>0.05)。

结论

EM直肠子宫陷凹完全封闭患者行腹腔镜全子宫切除，术中术后均未发生严重并发症，术后恢复良好，是一种安全、有效、可行的治疗方式。

关键词: 子宫内膜异位症, 直肠子宫陷凹完全封闭, 腹腔镜, 全子宫切除

Objective

To explore the clinical analysis of laparoscopic total hysterectomy in patients with complete obliterated Cul-de-sac due to endometriosis.

Method

A retrospective analysis was conducted on the general clinical and pathological data of 115 cases of endometriosis diagnosed by postoperative pathology after laparoscopic total hysterectomy from Jun. 2022 to Aug. 2024.Among them, 54 cases had complete obliterated Cul-de-Sac, and 61 cases had incomplete obliterated.The general clinical data and perioperative situation of the two groups were compared.

Result

Both groups did not experience serious complications such as major bleeding, conversion to open surgery, or organ damage.They all recovered well at the 3-month follow-up after surgery. There were more recurrent patients in the completely obliterated group[16 (29.6%) vs. 6 (9.8%), P=0.007], more dysmenorrhea[46(85.2%) vs. 38(62.3%), P=0.006], and younger patients undergoing hysterectomy[45.61±3.96 years vs. 47.41±3.81 years, P=0.015]. The EM resection of ovaries, sacral ligaments, and rectovaginal septum was performed more frequently in the fully obliterated group than in the incompletely obliterated group[35(64.8%) vs.18(29.5%), P<0.001; 42(77.8%) vs.26(42.6%), P<0.001; 46(85.2%) vs. 8(13.1%), P<0.001]; The group with incomplete obliterated of peritoneal EM resection had more cases [22(40.7%) vs. 45(73.8%), P<0.001]. The completely obliterated group had more operation time, intraoperative bleeding, ureteral dissociation and postoperative hospital stay than the incompletely obliterated group 147.00(114.75176.75)min vs. 95.00(81.00117.00)min, P<0.001; 50.00(20.00100.00)ml vs. 20.00(10.00, 20.00)ml, P<0.001; [44(81.5%) vs.15(24.6%), P<0.001; 4.00(3.00, 5.00)d vs. 3.00(2.00, 4.00)d, P<0.001]; There was no significant difference in uterine weight, perioperative ureteral stent placement, postoperative fever, and other complications between the two groups(P>0.05).

Conclusion

Laparoscopic total hysterectomy was performed in patients with endometriosis and complete obliterated Cul-de-Sac, and there were no serious complications occurred during and after the operation, and the postoperative recovery was good, which is a safe, effective and feasible treatment method.

Key words: Endometriosis, Complete Obliteration Cul-de-sac, Laparoscope, Total hysterectomy

表1 2组一般临床资料比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	t/χ²值	P值
年龄(±s，岁)	45.61±3.96	47.41±3.81	2.479^a	0.015^a
BMI(±s，kg/m²)	24.68±4.21	23.92±3.20	－1.099^a	0.274
复发[例(%)]	16(29.6)	6(9.8)	7.254^b	0.007^b
术前用药史[例(%)]	34(63.0)	47(77.0)	2.729^b	0.099
盆腔手术史[例(%)]	37(68.5)	38(62.3)	0.489^b	0.484
痛经史[例(%)]	46(85.2)	38(62.3)	7.622^b	0.006^b

表1 2组一般临床资料比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	t/χ²值	P值
年龄(±s，岁)	45.61±3.96	47.41±3.81	2.479^a	0.015^a
BMI(±s，kg/m²)	24.68±4.21	23.92±3.20	－1.099^a	0.274
复发[例(%)]	16(29.6)	6(9.8)	7.254^b	0.007^b
术前用药史[例(%)]	34(63.0)	47(77.0)	2.729^b	0.099
盆腔手术史[例(%)]	37(68.5)	38(62.3)	0.489^b	0.484
痛经史[例(%)]	46(85.2)	38(62.3)	7.622^b	0.006^b

表2 2组术中不同类型EM切除比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	χ²值	P值
腹膜EM[例(%)]	22(40.7)	45(73.8)	12.850	<0.001^**
卵巢EM[例(%)]	35(64.8)	18(29.5)	14.370	<0.001^a
骶韧带EM [例(%)]	42(77.8)	26(42.6)	14.648	<0.001^a
直肠阴道隔EM [例(%)]	46(85.2)	8(13.1)	59.733	<0.001^a
输尿管EM[例(%)]	8(14.8)	5(8.2)	1.251	0.263

表2 2组术中不同类型EM切除比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	χ²值	P值
腹膜EM[例(%)]	22(40.7)	45(73.8)	12.850	<0.001^**
卵巢EM[例(%)]	35(64.8)	18(29.5)	14.370	<0.001^a
骶韧带EM [例(%)]	42(77.8)	26(42.6)	14.648	<0.001^a
直肠阴道隔EM [例(%)]	46(85.2)	8(13.1)	59.733	<0.001^a
输尿管EM[例(%)]	8(14.8)	5(8.2)	1.251	0.263

表3 2组术中情况比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	Z/χ²值	P值
手术时间[M(P₂₅，P₇₅)，min]	147.00(114.75，176.75)	95.00(81.00，117.00)	－5.997	<0.001
术中出血[M(P₂₅，P₇₅)，ml]	50.00(20.00，100.00)	20.00(10.00，20.00)	－4.753	<0.001
输尿管游离[例(%)]	44(81.5)	15(24.6)	37.108	<0.001
围术期输尿管支架置入[例(%)]	3(5.6)	2(3.3)	－	0.664

表3 2组术中情况比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	Z/χ²值	P值
手术时间[M(P₂₅，P₇₅)，min]	147.00(114.75，176.75)	95.00(81.00，117.00)	－5.997	<0.001
术中出血[M(P₂₅，P₇₅)，ml]	50.00(20.00，100.00)	20.00(10.00，20.00)	－4.753	<0.001
输尿管游离[例(%)]	44(81.5)	15(24.6)	37.108	<0.001
围术期输尿管支架置入[例(%)]	3(5.6)	2(3.3)	－	0.664

表4 2组术后情况比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	Z/χ²值	P值
术后住院时间[M(P₂₅，P₇₅)，d]	4.00(3.00，5.00)	3.00(2.00，4.00)	－3.966	<0.001
子宫重量[M(P₂₅，P₇₅)，g]	185.00(120.00，260.00)	210.00(150.0，310.00)	－1.618	0.106
术后发热[例(%)]	10(18.5)	8(13.1)	0.634	0.426
其他并发症[例(%)]	2(3.7)	0(0.0)	－	0.218

表4 2组术后情况比较

	完全封闭组(n＝54)	未完全封闭组(n＝61)	Z/χ²值	P值
术后住院时间[M(P₂₅，P₇₅)，d]	4.00(3.00，5.00)	3.00(2.00，4.00)	－3.966	<0.001
子宫重量[M(P₂₅，P₇₅)，g]	185.00(120.00，260.00)	210.00(150.0，310.00)	－1.618	0.106
术后发热[例(%)]	10(18.5)	8(13.1)	0.634	0.426
其他并发症[例(%)]	2(3.7)	0(0.0)	－	0.218

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Clinical analysis of laparoscopic total hysterectomy in patients with complete obliterated Cul-de-Sac due to endometriosis

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Clinical analysis of laparoscopic total hysterectomy in patients with complete obliterated Cul-de-Sac due to endometriosis