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次全子宫切除术

2016-03-06 MedSci MedSci原创

次全子宫切除术

(subtotal hysterectomy)

  [适应证]

  1.子宫肌瘤、子宫功能性出血、子宫腺肌瘤,宫颈检查正常,患者要求保留宫颈。

  2.因各种原因需切除子宫,但切除宫颈有困难者。

  [麻醉方法]

  同子宫肌瘤剔除术。

  [术前准备]

  同子宫肌瘤剔除术。

  [手术范围]

  手术切除子宫体部(图1)。

图1 次全子宫切除范围

  [手术步骤和技术要点]

  1.切口 同子宫肌瘤剔除术。

  2.探查 了解子宫大小、活动度及子宫颈情况等。

图2 牵拉子宫 图3 处理圆韧带

  3.切断圆韧带 钳夹两侧宫角,向腹腔外牵拉(图2)。距宫角1cm处钳夹切断圆韧带,缝扎远端(图3)。

图4 切断宫角 图5 宫角断端缝合

  4.处理附件 于宫角钳夹切断卵巢固有韧带及输卵管间质部(图4),“8”字缝扎断端(图5)。

图6 打开膀胱反折腹膜 图7 推下膀胱

  5.暴露子宫下段 沿子宫两侧打开阔韧带前叶及膀胱反折腹膜(图6)。提起膀胱反折腹膜,在膀胱筋膜与子宫颈筋膜间的疏松组织间隙,向下分离膀胱,达子宫峡部(图7),再沿子宫两侧剪开阔韧带后叶至子宫峡部(图8)。

图8 剪开阔韧带 图9 处理子宫血管

  6.处理子宫血管 于子宫峡部水平紧贴子宫侧壁钳夹切断子宫动、静脉及宫旁组织,残端缝扎(图9)。

图10 子宫峡部环形切口 图11 缝合宫颈残端

  7.切除子宫体 拉开膀胱,暴露子宫峡部,在峡部做一环形切口,贯穿宫颈管粘膜层(图10),切出子宫。宫颈残端消毒后,用可吸收线“8”字缝合(图11)。

图12 盆腹膜缝合后

  8.重建盆腹膜 缝合盆腔盆腹膜,将双侧附件断端、圆韧带断端、宫颈残端包埋其中(图12)。

  9.关腹 分层缝合腹壁各层。

  [常见失误分析]

  1.出血 在处理子宫圆韧带、卵巢固有韧带、输卵管时,断端缝扎不紧或线结滑脱导致出血,故双重结扎为妥。在切断子宫动静脉时,应尽量分离子宫动静脉周围组织,认清血管,并紧贴子宫进行钳夹,牢固结扎。下推膀胱时,要分清层次,太浅或太深均会导致出血。

  2.邻近脏器损伤 由于次全子宫切除手术常用于子宫与盆腔脏器粘连明显,特别是膀胱、直肠与宫颈粘连较致密时,解剖层次欠清,易出现膀胱、直肠、输尿管损伤。一旦出现应立即修补。

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