(2)腹腔鏡を応用した単純子宮全摘術への新しいアプローチ : 標準術式確立のための術式改良と工夫(講演要旨,<特集>第58回学術講演会シンポジウム-4「安全性の向上をめざした婦人科良性腫瘍に対する内視鏡手術」)

概要

論文の詳細を見る
Introduction: Before 1999, we conducted only conventional laparoscopically assisted vaginal hysterectomy(LAVH). A better technique, laparovaginal hysterectomy with the bidirectional procedure(LVH), was performed beginning in 2000. We have diligently sought to make improvements, and a third technique-laparoscopic two-step hysterectomy(LTSH) by supracervical amputation and subsequent trachelectomy via laparoscopy-was created in 2003. The purpose of this study was to compare the outcomes of LTSH with those of LAVH and LVH and to estimate the benefits of LTSH for the treatment of benign uterine tumors. Operative technique: The LTSH procedure was performed by a three-puncture technique. A 10-mm trocar was inserted in the umbilicus, and two 12-mm trocars were placed in lateral to the umbilicus. A CO_2 pneumoperitoneum was established through the first access port. Either the infundibulopelvic ligament or the utero-ovarian ligament and Fallopian tube and then the round ligament were handled using the electrothermal bipolar sealing system(LigaSure Atlas; Valleylab, Boulder, CO). The uterine side, including the ascending branch of the uterine artery, was desiccated with bipolar forceps. The cervix was transected at the level of the internal os with the ultrasonically activated scalpel(Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH). Tracherectomy via laparoscopy was conducted the following manner. The anterior and posterior fornix was extended by the uterine manipulator and opened, and the remaining vaginal cuff, uterine vessels, and cardinal ligament were incised with the Harmonic Scalpel. No vaginal procedure was performed except for closing of the vaginal cuff. The uterus was removed vaginally, laparoscopically, or both using a morcellator. The vaginal stump was peritonealized with intra-corporeal sutures. Study design: A total of 493 patients(laparotomy 80, laparoscopy 413) were operated on between July 1994 and March 2006 at the Department of Obstetrics and Gynecology, Fujita Health University. The patients were assigned to the following groups according to the time of presentation: LAVH(group 1, n=79; 1994〜1996), the transition period from LAVH to LVH(group 2, n=103; 1997〜1999), LVH(group 3, n=118; 2000〜2002), and LTSH(group 4, n=113; 2003〜2006). Clinical evaluation was based on operating time, blood loss, and uterine weight. Numeric variables were expressed as mean ± S.E., and statistical analysis was conducted using a simple linear regression analysis, Mann-Whitney test, and χ^2 test. Results: Simple linear regression analysis of operating time and resected uterine weight revealed that the coefficients of correlation for LVH and LTSH were r=0.2627(n=29; N.S.) and r=0.8036(n=21; p<0.001), respectively. The result clearly showed that LTSH was an excellent procedure, as judged by reproducibility of the operating time, because the regression line showed good linearity. The operating times were 214.5 ± 6.9 minutes, 158.7 ± 4.2 minutes, and 134.1 ± 3.9 minutes, for groups 1, 2, and 3, respectively; the blood loss was 370.7 ± 27.3 mL, 268.0 ± 13.7 mL, and 224.6 ± 14.7 mL, and the uterine weight was 220.9 ± 10.3 g, 231.7 ± 12.4 g, and 332.2 ± 16.8 g for the three groups. In group 4, the operating time was 207.1 ± 4.9 minutes, the blood loss was 105.4 ± 13.6 mL, and the uterine weight was 450.0 ± 25.3 g. Thus, the operating time for group 4 was longer than that of groups 2 and 3, but the blood loss was lower(p<0.001 vs. groups 1〜3) and the resected uterine weight was higher for the other groups(p<0.001 vs. groups 1〜3). Furthermore, the frequency of laparoscopy and laparotomy in group 4 were 90.6% and 9.4%, respectively. The rate of laparotomy in overall hysterectomy was statistically lower in group 4 than in the other three groups(vs. 40.8% for group 1:p<0.001; vs. 25.9% for group 2:p<0.001; vs. 21.3% for group 3:p<0.01). Conclusions: Laparoscopic two-step hysterectomy is an excellent procedure because of the reduction in blood loss and the increase in resected uterine weight. It is important to emphasize that the indications for hysterectomy in our institute were definitely expanded by adopting LTSH. This procedure may be an alternative for conventional hysterectomy with laparoscopy as a standard procedure.
2006-12-01

(2)腹腔鏡を応用した単純子宮全摘術への新しいアプローチ : 標準術式確立のための術式改良と工夫(講演要旨,<特集>第58回学術講演会シンポジウム-4「安全性の向上をめざした婦人科良性腫瘍に対する内視鏡手術」)

スポンサーリンク

概要

著者

関連論文

スポンサーリンク