缝合方式与阴道穹窿并发症相关

拉斯维加斯——一项针对604例患者的回顾性分析显示，阴道穹窿并发症风险并不受子宫切除术类型的影响，而与所采用的缝合技术有关。

韩国高丽大学医院的Yoon Byoung Kim博士在第41届全球微创妇科学大会(AAGL)上报告：“在我们的研究中，腔内穹窿缝合在避免腹腔镜子宫切除术的阴道穹窿并发症方面优于阴道缝合。”

尽管阴道穹窿裂开在子宫切除术后较罕见，但腹腔镜子宫切除术的这一并发症风险有所升高。Beth Israel女执事医学中心的研究者近来报告，腹腔镜子宫切除术后阴道穹窿裂开的发生率为1.35%，在各种子宫切除术式中最高(Obstet. Gynecol. 2011;118:794-801)。不过这比他们之前报告的4.93%要低得多(J. Minim. Invasive Gynecol. 2007;14:311-7)。

Kim博士及其同事观察了2007~2011年间在韩国高丽大学医院接受子宫切除术的604例患者的阴道穹窿并发症危险因素。具体的术式包括6种：机器人子宫切除术7例、机器人根治性子宫切除术联合淋巴结清扫(RRHND)9例、腹腔镜子宫切除术(TLH)276例、腹腔镜辅助阴道子宫切除术(LAVH)238例、腹腔镜根治性子宫切除术联合淋巴结清扫(LRHND)11例，以及腹部根治性子宫切除术63例。

缝合技术方面，对于机器人子宫切除术、RRHND和LRHND采用腔内连续缝合，对于腹腔镜子宫切除术采用腔内或阴道连续锁边缝合，对于LAVH采用阴道连续锁边缝合，对于腹部根治性子宫切除术采用5分缝合联合8字阴道缝合。2例采用3分腔内缝合和8字阴道缝合的TLH患者被排除在TLH分析之外。

在其余274例TLH女性中，腔内连续缝合组发生了1例去脏术和4例裂开，而阴道连续锁边缝合组发生了0例去脏术和11例裂开(2.63% vs. 10.47%，P=0.02)。此外，从手术至阴道穹窿并发症的间隔时间，腔内缝合组明显长于阴道缝合组(72.8天 vs. 23.6天，P=0.01)。“可能原因是感染或黏膜下层微妙分层。”

在所有604例女性中，共发生3例去脏术(0.49%)和21例裂开(3.43%)。机器人子宫切除术的去脏术发生率为0，RRHND为11.1%，腹腔镜子宫切除术为0.36%，LAVH为0，LRHND为0，腹部根治性子宫切除术为1.5%。根治性子宫切除术的阴道裂开发生率为0，RRHND为0，腹腔镜子宫切除术为5.43%，LAVH为1.68%，LRHND为0，腹部根治性子宫切除术为3.17%。

尽管腹腔镜子宫切除术与穹窿并发症风险增加有关，但差异未达到统计学意义。总体而言，手术类型或缝合技术与穹窿并发症发生率无显著关联。研究者还进行了亚组分析，对年龄、体重指数、手术时间、估计失血量、术后发热和抗生素使用等因素进行了校正。结果这些危险因素均与裂开或去脏术无关(P值分别为0.99、0.32、0.46、0.32、0.06和0.42)。

本项研究的局限性在于，样本量较小、有明显异质性，以及不同组别间样本量差异大等。

Kim博士报告称无相关利益冲突。

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By: PATRICE WENDLING, Internal Medicine News Digital Network

LAS VEGAS – The risk of vaginal cuff complications was not influenced by the type of hysterectomy performed, although suture technique was a factor, in a retrospective analysis of 604 patients.

"In our study, the intracorporeal cuff suture was superior to the vaginal suture to prevent the vaginal cuff complications of evisceration and dehiscence in total laparoscopic hysterectomy," Dr. Yoon Byoung Kim said at the 41st AAGL Global Congress.

Although vaginal cuff dehiscence is a rare complication of hysterectomy, concerns have been raised that total laparoscopic hysterectomies may be associated with an increased risk of this potentially morbid complication.

Researchers at Beth Israel Deaconess Medical Center recently reported an updated incidence of vaginal cuff dehiscence of 1.35% after total laparoscopic hysterectomy, the highest rate among all hysterectomy modes evaluated (Obstet. Gynecol. 2011;118:794-801). This was dramatically lower, however, than the 4.93% incidence the group reported in a previous study (J. Minim. Invasive Gynecol. 2007;14:311-7).

Dr. Kim and her associates looked at the risk factors for vaginal cuff complications for six types of hysterectomies performed in 604 women between June 2007 and June 2011 at Korea University Anam Hospital, Seoul, Korea. The approach was robotic hysterectomy in 7, robotic radical hysterectomy and node dissection (RRHND) in 9, total laparoscopic hysterectomy (TLH) in 276, laparoscopically assisted vaginal hysterectomy (LAVH) in 238, laparoscopic radical hysterectomy and node dissection (LRHND) in 11, and abdominal radical hysterectomy in 63.

The suture technique was intracorporeal continuous for robotic hysterectomy, RRHND, and LRHND; intracorporeal or vaginal continuous locking for total laparoscopic hysterectomy; vaginal continuous locking for LAVH; and a 5-point suture with figure-8 vaginal suture for abdominal radical hysterectomy. Two TLH patients closed with a 3-point intracorporeal suture and figure-8 vaginal suture were excluded from the TLH analysis.

Among the remaining 274 TLH women, there were 1 case of evisceration and 4 cases of dehiscence with the intracorporeal continuous suture, compared with 0 cases of evisceration and 11 cases of dehiscence with the vaginal continuous locking suture (2.63% vs. 10.47%; P = .02).

In addition, the duration between surgery and the vaginal cuff complication was significantly longer with the intracorporeal suture than the vaginal suture (72.8 days vs. 23.6 days; P = .01), Dr. Kim said.

"The possible reasons for this result can be infection or delicate layering of the submucosal layer," she said.

Among all 604 women, there were 3 eviscerations (0.49%) and 21 cases of dehiscence (3.43%).

The incidence of evisceration was 0% for robotic hysterectomy, 11.1% for RRHND, 0.36% for total laparoscopic hysterectomy, 0% for LAVH, 0% for LRHND, and 1.5% for abdominal radical hysterectomy. The incidence of vaginal dehiscence was 0% for radical hysterectomy, 0% for RRHND, 5.43% for total laparoscopic hysterectomy, 1.68% for LAVH, 0% for LRHND, and 3.17% for abdominal radical hysterectomy.

Although total laparoscopic hysterectomy was associated with a higher incidence of cuff complications, the finding was not statistically significant, Dr. Kim said. Overall, there was no significant correlation between the incidence of cuff complications and the type of operation or suture technique.

The investigators then performed a subgroup analysis that included age, body mass index, operation time, estimated blood loss, postoperative fever, and antibiotic use. None of these risk factors correlated with dehiscence or evisceration (P = 0.99, 0.32, 0.46, 0.32, .06, and 0.42, respectively), Dr. Kim reported.

The limitations of the study were its small sample size, significant heterogeneity, and variation in sample size between groups, she said.

Dr. Kim reported no relevant financial disclosures.