發(fā)布時間：2018-02-02 21:01

  本文關(guān)鍵詞： 盆腔器官脫垂 腹腔鏡 骶骨固定術(shù) 并發(fā)癥　出處：《山東大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：背景及目的 盆腔器官脫垂(Pelvic Organ Prolapse,POP)是一種影響中老年女性身體健康和生活質(zhì)量的常見盆底功能障礙性疾病(Pelvic Floor Dysfunction,PFD)�？杀憩F(xiàn)為不同程度的子宮脫垂、陰道穹窿脫垂和陰道前后壁脫垂,嚴(yán)重影響患者的泌尿功能、排便功能及性生活質(zhì)量。手術(shù)是中重度盆腔器官脫垂的主要治療手段。 關(guān)于盆腔器官脫垂手術(shù)治療的研究已證實(shí)傳統(tǒng)手術(shù)(如經(jīng)陰子宮切除術(shù)+陰道前、后壁修補(bǔ)術(shù))的復(fù)發(fā)率較高。近十年來,經(jīng)陰植入網(wǎng)片(transvaginal mesh,TVM)的盆底修復(fù)術(shù)廣泛應(yīng)用于臨床。在2008年及2011年,美國食品藥品監(jiān)督管理局(Food and Drug Administration,FDA)先后兩次提出了與TVM副作用有關(guān)的安全警示,2012年8月美國強(qiáng)生公司的Prolift盆底修補(bǔ)系統(tǒng)宣布全球退市。由于受適應(yīng)癥的嚴(yán)格限制,現(xiàn)在TVM在臨床上的應(yīng)用較前明顯減少。 1962年Lane首次報(bào)道了陰道骶骨固定術(shù)治療陰道穹窿脫垂,1994年Nezhat報(bào)道了腹腔鏡陰道骶骨固定術(shù)。陰道骶骨固定術(shù)通過采用自身筋膜或人工合成補(bǔ)片將陰道穹窿于腹膜后懸吊于S1前縱韌帶,達(dá)到上提陰道頂端的目的,并能保留年輕患者的生育功能和性功能。此術(shù)式經(jīng)歷了幾十年的改進(jìn)后,被認(rèn)為是中盆腔缺陷治療的經(jīng)典金標(biāo)準(zhǔn)。 2012年,我院開始開展腹腔鏡子宮／陰道骶骨固定術(shù)(Laparoscopy Sacrocolpopexy, LSC)治療中重度POP患者,并對所有手術(shù)患者術(shù)后恢復(fù)情況進(jìn)行跟蹤,定期隨訪并行問卷調(diào)查。本文旨在對我院行LSC治療患者的臨床資料進(jìn)行研究,評價該手術(shù)的臨床療效,為選擇適合POP患者的最佳術(shù)式提供試驗(yàn)依據(jù),為提高手術(shù)安全性和有效性提供理論參考。 對象和方法 對2012年1月至2013年12月山東大學(xué)第二醫(yī)院婦科診斷為“中重度子宮/陰道穹窿脫垂伴不同程度陰道壁脫垂”的63例中老年女性患者行腹腔鏡骶骨固定術(shù)治療。 采用統(tǒng)計(jì)學(xué)SPSS19.0統(tǒng)計(jì)軟件對手術(shù)患者的臨床資料及術(shù)后隨訪數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)量資料采用均數(shù)士標(biāo)準(zhǔn)差(Mean±SD)表示,手術(shù)前后的指標(biāo)變化及問卷評分進(jìn)行配對t檢驗(yàn)處理。 本文從以下幾個方面展開了本研究： 1.查閱病歷及手術(shù)記錄,分析腹腔鏡骶骨固定術(shù)用于治療器官脫垂患者的一般資料、術(shù)中及圍手術(shù)期相關(guān)指標(biāo)及圍手術(shù)期并發(fā)癥的發(fā)生情況； 2.術(shù)后復(fù)查,通過盆腔器官脫垂定量分期法(POP-Q)比較手術(shù)前后器官的脫垂分度來評價解剖學(xué)療效； 3.術(shù)后跟蹤隨訪,通過盆底功能障礙性疾病癥狀問卷(PFDI-20)和盆底疾病生活質(zhì)量影響問卷簡表(PFIQ-7)得分來評價手術(shù)的功能學(xué)療效； 4.術(shù)后跟蹤隨訪,通過性生活質(zhì)量問卷(PISQ-12)得分,評價患者術(shù)后性生活情況,評估患者對手術(shù)的滿意度； 5.通過對術(shù)后患者的隨訪問診,了解患者術(shù)后有無出現(xiàn)相關(guān)不適癥狀及有無并發(fā)癥,了解患者的主觀滿意度,記錄患者術(shù)后中期并發(fā)癥情況。結(jié)果 1.患者術(shù)前脫垂分度(僅統(tǒng)計(jì)POP-QⅡ-Ⅳ度脫垂例數(shù)) (1)子宮脫垂Ⅱ-Ⅳ度33例,陰道穹窿脫垂Ⅱ度12例； (2)陰道前壁脫垂Ⅱ-Ⅳ度63例； (3)陰道后壁脫垂Ⅱ-Ⅳ度27例。 2.手術(shù)相關(guān)參數(shù)及圍手術(shù)期并發(fā)癥 (1)平均手術(shù)時間為(144.92.±32.27)min,術(shù)中平均出血量為(44.97±13.22)ml,術(shù)后平均住院天數(shù)為(5.94±2.60)天。 (2)圍手術(shù)期并發(fā)癥：1例急性尿潴留,1例下腹墜痛,1例下肢靜脈血栓。對癥治療及時有效,3例患者均在對應(yīng)治療后均治愈或好轉(zhuǎn)出院。 3.隨訪期臨床療效、患者主觀滿意度 (1)解剖學(xué)恢復(fù)：術(shù)后POP-Q分度指示點(diǎn)與術(shù)前相比,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后門診復(fù)查,解剖位置恢復(fù)理想。腹腔鏡骶骨固定術(shù)的客觀治愈率約為98.4%,主觀治愈率為100%；Burch手術(shù)的治愈率為94.44%。 (2)盆底功能恢復(fù)：術(shù)后PFDI-20和PFIQ-7評分與術(shù)前相比差異具有統(tǒng)計(jì)學(xué)意義(P0.05),腸道功能、泌尿功能較前改善,生活質(zhì)量明顯提高。 (3)性生活改善：術(shù)后1年P(guān)ISQ-12評分與術(shù)前相比差異具有統(tǒng)計(jì)學(xué)意義(P0.05),自訴性生活質(zhì)量改善明顯,性生活滿意度提高。 4.手術(shù)中期并發(fā)癥 術(shù)后隨訪：1例腰部疼痛,對癥治療后緩解；1例新發(fā)下尿路癥狀,癥狀輕,暫觀察。 結(jié)論 1.腹腔鏡骶骨固定術(shù)適應(yīng)癥(中盆腔缺陷)可適當(dāng)拓寬：該手術(shù)也適用POP-Q分度為子宮中重度脫垂(Ⅱ-Ⅳ度)伴陰道前壁重度脫垂(Ⅲ-Ⅳ度)的患者。 2.腹腔鏡骶骨固定術(shù)創(chuàng)傷較小,恢復(fù)較快,但手術(shù)操作相對復(fù)雜,對手術(shù)者腹腔鏡下操作技術(shù)要求高。 3.腹腔鏡骶骨固定術(shù)恢復(fù)脫垂臟器解剖位置理想,能夠保留足夠的陰道長度及容納度,患者性生活滿意度高。 4.腹腔鏡骶骨固定術(shù)近期治愈率高,圍手術(shù)期并發(fā)癥少,出現(xiàn)急性尿潴留、下腹墜痛、下肢靜脈血栓各1例；中期并發(fā)癥出現(xiàn)腰部疼痛和新發(fā)下尿路癥狀各1例；遠(yuǎn)期治愈率及并發(fā)癥有待進(jìn)一步進(jìn)行隨訪及研究。
[Abstract]:Background and purpose
Pelvic organ prolapse (Pelvic Organ, Prolapse, POP) is a kind of elderly women's health and quality of life of common pelvic floor dysfunction (Pelvic Floor, Dysfunction, PFD). The performance of different degrees of uterine prolapse, vaginal vault prolapse and anterior vaginal wall prolapse after, seriously affect the patient's urinary function, quality function and sexual life in defecation. Surgery is the main treatment of severe pelvic organ prolapse.
Study on pelvic organ prolapse surgery confirmed the traditional surgery (such as vaginal hysterectomy and vaginal wall repair, after) the high recurrence rate. In the recent ten years, transvaginal mesh implantation (transvaginal mesh, TVM) of the pelvic floor repair is widely used in clinic. In 2008 and 2011, the United States the food and Drug Administration (Food and Drug Administration, FDA) two times successively put forward safety warning related side effect of TVM, Prolift pelvic floor repair system in August 2012 Johnson announced the delisting. Due to the global restrictions in TVM, now in the clinical application of significantly reduced.
In 1962 Lane first reported sacrolcolpopexy treatment of vaginal vault prolapse, 1994 Nezhat reported laparoscopic sacrolcolpopexy. Sacrolcolpopexy by using self fascia or synthetic patch will be suspended in the vaginal fornix in retroperitoneal S1 anterior longitudinal ligament, to mention at the top of the vagina to, and can retain the young patients reproductive function and sexual function. This type of operation has improved after decades are considered in the classical gold standard treatment of pelvic defects.
In 2012, our hospital laparoscopic uterine / sacrolcolpopexy (Laparoscopy Sacrocolpopexy, LSC) in the treatment of patients with severe POP, and the recovery of all patients after the operation of tracking, regular follow-up parallel questionnaire. This paper aims to study on the clinical data of LSC patients in our hospital, the clinical curative effect evaluation of the operation and to provide the experimental basis for selection for optimal operation of patients with POP, in order to improve the operation safety and effectiveness and provide a theoretical reference.
Objects and methods
From January 2012 to December 2013, 63 cases of middle-aged and elderly women diagnosed as "moderate severe uteri / vaginal vault prolapse with different degrees of vaginal wall prolapse" were treated by laparoscopic sacral fixation in the second hospital of Shandong University.
The clinical data and postoperative follow-up data of the operative patients were statistically analyzed by statistical SPSS19.0 software. The data were measured by mean standard deviation (Mean + SD). The changes of indicators before and after operation and the score of the questionnaire were processed by paired t test.
This paper has carried out this study from the following aspects:
1. consult the medical records and operation records, analyze the general data, intraoperative and perioperative related indicators and perioperative complications of laparoscopic sacral fixation for the treatment of organ prolapse.
2. to evaluate the anatomical effect by comparing the prolapse of the organs before and after the operation of pelvic organ prolapse (POP-Q).
3. follow up and follow up were performed to evaluate the functional efficacy of the operation through the pelvic floor dysfunction symptom questionnaire (PFDI-20) and the pelvic floor disease quality of life questionnaire (PFIQ-7) score.
4. after the follow-up, the sexual life quality questionnaire (PISQ-12) was used to evaluate the patient's sexual life, and to evaluate the patient's satisfaction with the operation.
5. through postoperative follow-up visit, we can know whether there is any postoperative discomfort and complications, understand the subjective satisfaction of patients, and record postoperative complications.
Preoperation prolapse score of 1. patients (only the number of POP-Q II - IV prolapse cases)
(1) 33 cases of uterine prolapse and 12 cases of vaginal dome prolapse.
(2) 63 cases of prolapse of anterior vaginal wall and degree II - IV;
(3) 27 cases of the posterior wall prolapse of the vagina.
2. operation related parameters and perioperative complications
(1) the average operation time was (144.92. + 32.27) min, and the average bleeding amount was (44.97 + 13.22) ml during the operation, and the average postoperative hospital days were (5.94 + 2.60) days.
(2) perioperative complications: 1 cases of acute urinary retention, 1 cases of lower abdominal pain, 1 cases of venous thrombosis of lower extremities. Symptomatic treatment is timely and effective. 3 patients were cured or improved after corresponding treatment.
3. clinical efficacy of follow-up period and subjective satisfaction of patients
(1) anatomical recovery: postoperative POP-Q compared with preoperative indexing, the difference was statistically significant (P0.05). The patients were recovered. The anatomic location of laparoscopic sacral colpopexy objective cure rate is about 98.4%, the subjective cure rate was 100%; the cure rate of operation was 94.44%. Burch
(2) pelvic floor function recovery: postoperative PFDI-20 and PFIQ-7 scores were significantly different from those before operation (P0.05), intestinal function, urinary function improved and quality of life improved significantly.
(3) sexual life improved: there was a statistically significant difference in PISQ-12 score between 1 years after operation and preoperative period (P0.05).
4. medium-term complications of surgery
Postoperative follow-up: 1 cases of lumbar pain relieved after symptomatic treatment; 1 cases of new lower urinary tract symptoms, mild symptoms, temporary observation.
conclusion
1., the indications for laparoscopic sacral fixation (middle pelvic defects) can be widened: this operation is also suitable for patients with severe POP-Q prolapse (stage II to IV degree) and severe anterior vaginal wall prolapse (grade III to IV).
2. laparoscopic sacral fixation has less trauma and faster recovery, but the operation is relatively complicated, and the operation technique of the operator is high.
3. laparoscopic sacral fixation to restore the anatomical position of the prolapse organ is ideal. It can retain enough vaginal length and capacity, and the patient's sexual life satisfaction is high.
4. laparoscopic sacral fixation has high cure rate, perioperative complications, acute urinary retention, lower abdominal pain, lower extremity venous thrombosis in 1 cases; mid back pain and complications under the new urinary tract symptoms in 1 cases; long term cure rate and complications need further study and follow-up.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R713

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