腹腔镜下带血管蒂回肠移植阴道成形术2种术式比较

目的 总结全腹腔镜和腹腔镜辅助下带血管蒂回肠移植再造阴道2种术式的临床效果.方法 2004年1月～2005年11月我院行腹腔镜下带血管蒂回肠移植阴道成形术40例,其中全腹腔镜下回肠代阴道成形术18例(全腹腔镜组)腹腔镜引导下,配合使用超声刀、直线切割闭合器,不开腹完成肠系膜分离、回肠段切取、肠端吻合、回肠段下拉移植成形阴道;腹腔镜辅助下回肠代阴道成形术22例(腹腔镜辅助组)腹腔镜下选择移植肠段,肠系膜游离后,延长耻骨联合上穿刺孔至3～4 cm进入腹腔,经该切口将回肠拉出腹腔外,直视下切取移植肠襻及回肠端端吻合术,将移植肠段及吻合后的回肠送入腹腔,腹腔镜辅助下造洞穴,打开盆底腹膜,完成回肠段下拉移植成形阴道.结果 40例手术均获得成功.全腹腔镜组与腹腔镜辅助组术中出血量、术后排气时间、住院时间无统计学差异,分别为(48.1±9.4)ml vs.(50.5±7.7)ml(t=-0.888,P=0.380),(33.9±9.1)h vs.(33.3±8.3)h(t=0.218,P=0.829),(12.3±2.4)d vs.(11.4±2.0)d(t=1.294,P=0.203).全腹腔镜组手术时间、住院费用显著高于腹腔镜辅助组,分别为(213.2±37.4)min vs.(139.2±29.5)min(t=6.999,P=0.000),(22 386.5±2153.7)元vs.(10 027.4±1758.5)元(t=19.991,P=0.000).40例随访3～18个月,平均13个月,移植回肠段成活良好,再造阴道符合生理要求.结论 全腹腔镜下回肠代阴道手术在腹壁上不留手术瘢痕,美容效果理想,但操作难度大,费用较高;腹腔镜辅助下回肠代阴道成形,腹壁留有小手术瘢痕,操作简便,手术时间短,手术费用低,可根据患者需求选择相应术式.     

腹腔镜辅助下截取带血管蒂回肠段转移阴道成形术

目的 探索在腹腔镜辅助下截取带血管蒂回肠段转移再造阴道的可能性，为临床提供阴道成形术的新方法。方法 应用腹腔镜引导下，配合使用超声刀，通过小切口完成肠系膜分离、回肠段截取、肠端吻合、回肠段下拉转移形成阴道。结果 2002年2月至2006年7月，共为38例需再造阴道患者成功地施行腹腔镜辅助下截取带血管蒂回肠段转移阴道成形术。随访1个月～4年，其中36例移植回肠段成活良好，再造阴道符合生理要求。结论 由于避免了剖腹和以往术式的供区瘢痕，较好地缓解了此类患者巨大的心理压力，腹腔镜下回肠段代阴道是目前较为理想的阴道成形术新方法。     

腹腔镜下带血管蒂回肠移植阴道成形术

目的探讨腹腔镜下带血管蒂回肠移植阴道成形术的手术方法及疗效。方法回顾性分析2004年3月~2006年3月,我院62例腹腔镜下带血管蒂回肠移植阴道成形术的临床资料,其中全腹腔镜手术16例,腹腔镜辅助下手术46例。结果62例手术均成功,术中出血量30~50 m l,(40.0±0.6)m l;手术时间90~313 m in,(165.0±5.6)m in。1例全腹腔镜手术后1个月发生肠梗阻,二次手术切除梗阻段回肠,回肠端端吻合后恢复顺利。4例术后因未坚持佩带模具出现阴道口狭窄,余58例阴道及阴道口扩张满意。结论腹腔镜下带血管蒂回肠移植阴道成形术创伤小,较符合生理状态,是目前较理想的阴道成形方法。     

腹腔镜下带蒂回肠襻转移阴道再造术

目的:探讨一种操作简便,更符合阴道生理特征的阴道再造术。方法:应用腹腔镜下带蒂回肠襻转移阴道再造术治疗7例有阴道再造需求的患者。结果:本组共7例,均采用腹腔镜下带蒂回肠襻转移阴道再造,术后恢复时间短,无肠道手术并发症发生,7例患者肠襻全部成活,术后瘢痕轻微,仅腹部腹腔镜切口可见瘢痕,再造阴道腔隙宽敞,质地柔软,分泌物量适中,无异味。结论:腹腔镜下带蒂回肠襻转移阴道再造术,术后再造阴道与正常阴道生理状态接近,会阴、大腿等处不产生新的可见手术瘢痕,易被患者接受,具有广泛的临床应用前景。     

腹腔镜下带血管蒂回肠移植阴道成形术

目的:探讨在腹腔镜下带血管蒂回肠移植阴道成形术的手术方法及治疗效果。方法:回顾性分析8例腹腔镜下带血管蒂回肠移植阴道成形术病例,其中全腹腔镜手术3例,腹腔镜辅助下手术5例。结果:8例患者手术均成功,痊愈出院。结论:腹腔镜下带血管蒂回肠移植阴道成形术创伤小、美容效果好,符合生理状态,是较理想的阴道成形方法。     

机器人带血管蒂回肠段移植阴道成形术：病例报告并文献复习

目的：初步探讨应用机器人带血管蒂回肠段移植阴道成形术的临床疗效。方法回顾性分析1例应用机器人带血管蒂回肠段移植阴道成形术病例,并复习相关文献进行讨论。结果机器人带血管蒂回肠段移植阴道成形术失血量较少,再造的阴道可达到足够的深度和宽敞度,阴道壁柔软、滑润、有弹性,合乎生理需求,有感觉且稳定不挛缩,手术创伤小,可作为治疗先天无阴道的一种手术方式。结论机器人带血管蒂回肠段移植阴道成形术治疗先天阴道发育不全,观察手术疗效满意,有一定的优势,具有临床应用前景。     

非气腹腹腔镜乙状结肠代阴道成形术的护理体会

先天性无阴道及男性易性癖患者需施行阴道成形手术,部分建立女性生殖系统的解剖特征及功能。阴道成形术的方法很多,经临床观察[1,2],肠段移植阴道成形术是一种效果比较满意的方法,包括乙状结肠和回肠段移植阴道成形术。非气腹腹腔镜手术不存在CO2气腹的危险,同时具有腹部瘢痕小的优势。2007年1月～2011年6月,我科对46例先天性无阴道患者行非气腹腹腔镜下乙状结肠代阴道成形术,手术均获成功,临床效果满意。该术式比较复杂,对护理质量要求高,医护需严密配合方可取得成功。现将临床观察与护理经验报道如下。     

1例腹腔镜下带血管蒂回肠代阴道成形术的护理

对 1例先天性无阴道无子宫患者采用腹腔镜下带血管蒂回肠代阴道成形术 ,术前给予心理护理、术前准备、术后给予饮食指导、人工阴道护理以及出院阴道模具自护指导。结果随访 2个月移植肠段存活良好 ,粘膜红润无明显狭窄和闭锁 ,分泌物为乳白色水样 ,无异味 ,再造阴道可容纳直径为 2 .5cm ,长度为 12cm的柱状假体 ,功能和形状基本达到生理要求。     

1例腹腔镜下带血管蒂回肠代阴道成形术的护理

对1例先天性无阴道无子宫患者采用腹腔镜下带血管蒂回肠代阴道成形术，术前给予心理护理、术前准备、术后给予饮食指导、人工阴道护理以及出院阴道模具自护指导。结果随访2个月移植肠段存活良好，粘膜红润无明显狭窄和闭锁．分泌物为乳白色水样，无异味．再造阴道可容纳直径为2．5cm．长度为12cm的柱状假体．功能和形状基本达到生理要求。     

单孔腹腔镜联合经会阴入路乙状结肠代阴道成形术

目的探讨经脐单孔腹腔镜联合经会阴入路乙状结肠代阴道成形术治疗先天性无阴道(Mayer-RokitanskyKüster-Hauser syndrome,MRKHS)可行性和效果。方法 2013年7月～2017年12月我们对25例MRKHS施行经脐单孔腹腔镜联合经会阴入路乙状结肠代阴道成形术。通过脐部trocar置入腹腔镜,在直肠和尿道之间分离穴道放置Tri Port,游离切取带血管蒂的乙状结肠肠段,经会阴穴道游离牵出降结肠,远端置入钉钻头荷包缝合固定后送还腹腔,经直肠插入腔内圆型吻合器端端吻合结直肠,再将带血管蒂的移植肠段经穴道拖出成形新阴道。结果 25例手术顺利完成。手术时间(152.6±13.3) min,住院时间(7.5±0.7) d。术后1例盆腹腔积血再手术引流;1例术后新阴道放置支撑磨具穿透后壁及直肠前壁再手术修补直肠,重新截取回肠代阴道成形术;1例术后新阴道肠管迟发坏死脱落保守治疗待其上皮修复。21例随访6～36个月,重建阴道正常且均具有良好的性行为功能。结论经脐单孔腹腔镜联合会阴入路乙状结肠代阴道成形术为MRKHS患者提供一种安全可行的无可见瘢痕的手术方法。     

Vaginal construction

Construction of the vagina was performed in 5 46 XY, phenotypic female children, by utilizing a vascularized segment of ileum, which is folded and converted into a pouch, then placed between the rectum and bladder, and transplanted to the perineum. The neovaginal opening remained patent in all, mucus discharge decreased with time, and one teenager experienced a satisfactory sexual relationship.     

阴道分娩会阴Ⅲ～Ⅳ度裂伤原因分析及缝合修复对阴道、肛门直肠功能的影响

为提高阴道分娩会阴Ⅲ～Ⅳ度裂伤的诊治水平．及探讨缝合修复对阴道、肛门直肠功能的影响．本研究对足月妊娠阴道分娩的15例会阴Ⅲ～Ⅳ度裂伤的原因及诊治过程进行分析。结果发现,本组巨大儿（体重≥4000g）2例,急产2例,胎儿即将娩出时产妇不合作1例,会阴瘢痕3例,会阴体较短、发育薄弱3例,会阴体过长伴肥厚1例,胎位不正以持续性枕后位娩出2例,外阴未完全扩张助产人员急于让胎儿娩出在宫底部加压1例。且经产妇多于初产妇。给予严格消毒、止血、缝合后阴道及肛门直肠功能均恢复良好。结果表明,减少产生会阴裂伤的关键在于预防,一旦发生应及时处理,对阴道及肛门直肠功能无明显影响。     

皮下蒂会阴轴型皮瓣再造阴道

目的：探求如何通过手术使再造道形态的功能良好,方法：用含有阴唇后动脉的皮下蒂会阴轴型皮瓣,经小阴唇皮下隧道再造阴道,结果：治疗无天性无阴道患者39例,再造阴道不挛缩,外阴形态自然,功能良好,结论：皮下蒂会阴轴型皮瓣再造阴道,是一种方便有效的方法。     

A novel antireflux uretero-ileal anastomosis for urinary diversion: an experimental study

OBJECTIVES: To assess a new antireflux valve technique in a dog model of urinary diversion, and thus provide a reliable and easily constructed antireflux system for an ileal reservoir. MATERIALS AND METHODS: In five female beagle dogs, 3 cm of ileum were intussuscepted into the reservoir formed using the adjacent 10 cm of ileum. The intussuscepted ileum was sutured to the reservoir wall after stripping the mucosa of the reservoir in a trapezoidal zone opposite the similarly stripped mucosa of the intussuscepted ileum, to avoid dessusception. After the distal 4 cm of the ureters was united and pulled through the intussuscepted segment of ileum, the combined distal ureter was sutured to the labial edge of the intussuscepted segment. Finally, the reservoir was anastomosed to the bladder as an enterocystoplasty. Dogs were evaluated by ascending cystography and intravenous pyelography at 1 and 6 months. The valve and upper urinary tract were evaluated histopathologically at 6 months. RESULTS: In all dogs the antireflux system remained intact and prevented reflux. The intussuscepted ileum was firmly attached to the reservoir wall and the submucosa of each segment was united. The upper urinary tract was normal with no ureteric stenosis. Histopathologically, the ureter was surrounded by intact ileal serosa and showed no inflammation or scarring. CONCLUSIONS: The very short ileal segment required and the firm attachment of the constructed valve to the reservoir were the advantages of this practical and reliable new antireflux system.     

直肠癌盆腔清扫术后带蒂回肠段修复阴道

目的探讨直肠癌行扩大的后盆腔清扫术,其全阴道切除或后侧壁切除后修复阴道的方法。方法１９９０年～１９９７年,对５例直肠癌行盆腔后清扫术,采用带蒂回肠段修复阴道,其中带蒂回肠段修复全阴道２例,带蒂回肠段,从对系膜缘剪开作阴道后侧壁修复３例。结果５例手术均获成功。随访６个月～６年,修复后的阴道宽度适当,壁较厚,弹性良好,周围瘢痕组织少。结论用带蒂回肠段作阴道修复,取材简便,回肠系膜血管弓有足够的长度可将回肠段移位至会阴部。回肠血供良好,易于愈合,是直肠癌后盆腔清扫术后阴道成形的理想方法     

Urinary undiversion using the existing ileal loop and distal right ureter

Urinary undiversion is an accepted technique in a highly selective patient population. We reconstructed the urinary tract in six female mongrel dogs. A 15 cm. segment of ileum was isolated, both ends were closed and bowel continuity re-established. The proximal two-thirds of each ureter were anastomosed to the proximal end of the ileal segment. The distal one-third right ureteral segment, in continuity with the bladder, was anastomosed end-to-side to the distal ileal segment. Information from the intravenous pyelograms, renal function tests, electrolytes and pathological studies showed normal upper tracts without dilatation or obstruction, preservation of renal function and normal electrolytes except for mild hyperchloremia in all 6 animals. There was chronic pyelonephritis in one animal and mild focal renal inflammation in two animals. The uretero-ileal anastomoses were patent and the ureters were not dilated. The interposed ileum functions well as a conduit and does not become a reservoir over time. We believe incorporating ileum into the urinary tract in this technique of undiversion is a safe and effective clinical alternative in selected patients.     

Giant primary vaginal calculus secondary to vesicovaginal fistula with partial vaginal outlet obstruction in a 12-year-old girl

A vesicovaginal fistula with vagina obstruction associated with vaginal calculi is an extremely rare medical condition. We report a giant primary vaginal calculus resulting from vesicovaginal fistula with partial vaginal outlet obstruction secondary to perineum trauma and surgery in a 12-year-old girl. Episiotomy was performed and the adhesive labia minora was split. After the removal of a giant calculus in the vagina, approximately 8 cm in diameter, the fistula tract was completely excised, followed by the repair of the vesicovagina fistula and the vagina. The patient was symptom-free at 6-month follow-up examination.     

悬吊式腹腔镜联合经阴道前庭入路乙状结肠阴道成形术

目的:探讨悬吊式腹腔镜联合经阴道前庭入路行乙状结肠阴道成形术的可行性。方法:应用悬吊式腹腔镜为5例先天无阴道女性患者施行乙状结肠代阴道成形术,术中联合阴道前庭人工阴道造穴通路完成乙状结肠代阴道成形术和消化道的重建。结果:5例患者均成功完成手术,无中转开腹和围手术期并发症发生。手术时间90～130min,术中出血50～100ml,术后肠功能恢复时间2～3d。结论:悬吊式腹腔镜联合经阴道前庭入路乙状结肠代阴道成形术无腹部可视切口,是安全可行的新术式。     

Late occurrence of perineal wound abscess years after total colectomy

Seven patients presented with a large perineal abscess eight months to seven years after complete healing of the perineal wound following proctocolectomy. Six patients had had total proctocolectomies for ulcerative colitis and a seventh had undergone abdominoperineal resection for cancer. A typical clinical picture of perineal pain, fever, urinary tract complaints (including retention), and minimal local perineal findings was present. Prostatitis or a urinary tract infection was considered in five patients, but none of them responded to antibiotics. Ultrasound examination of the perineum may confirm the diagnosis; however, diagnostic and therapeutic surgical exploration of the healed perineum is recommended when this diagnosis is unclear.