广泛性全子宫切除术加全阴道切除术

广泛性全子宫切除术加全阴道切除术 广泛全宫加全阴道切除术 ( 关键词:阴道癌 ) 广泛全宫加全阴道切除术 广泛全宫加全阴道切除术(radical hysterectomy and total vaginectomy) 1-1 切口 1-2 显露棘上棘带 1-3 剥离骶棘肌 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 1-4 干纱布填塞止血 1-5 切除棘间韧带 1-6 剪除棘突 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 1-7 切除椎板 1-8 全椎板切除 1-9 单侧椎板切除 1-10 切开硬脊膜 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 1-11 找出齿状韧带 1-12 切断齿状韧带 1-13 缝合硬脊膜 1-14 逐层紧密缝合切口 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 1-5 切除棘间韧带 1-6 剪除棘突 1-7 切除椎板 1-8 全椎板切除 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 1-9 单侧椎板切除 1-10 切开硬脊膜 1-11 找出齿状韧带 1-12 切断齿状韧带 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 1-13 缝合硬脊膜 图1 椎管-脊髓探查术 [适应证] 原发性阴道癌或其他妇科肿瘤侵犯阴道大部分，但未波及直肠、尿道、 膀胱及盆侧壁。 [手术时机] 1.手术应在月经期后3,5天进行。 2.阴道感染者，应先控制感染。 [术前准备] 1.阴道冲洗3,5天，每天一次。 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 2.口服肠道抗生素3,5天。 [麻醉方法] 1.持续硬脊膜外腔阻滞麻醉。 2.气管内插管全身麻醉。 [手术范围] 广泛子宫、全阴道切除(图1)。 [体位] 本术式先采用仰卧位，后采用截石位。或采用人字体位。 [手术步骤与操作技术要点] 手术顺序 广泛全宫?全阴道切除。 腹部手术步骤: 1.切口 中、下腹正中切口。 2.探查 了解肿瘤与盆腔器官及阴道前后壁的关系，进一步确定手术范围。 3.子宫广泛切除 高位剪开骨盆漏斗韧带面的盆腹膜，向前延至圆韧带(图2)，向内下方沿输尿管达宫骶韧带(图3)。盆腹膜切线for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 如图4。在髂总动脉水平结扎、切断骨盆漏斗韧带(图5)，于圆韧带外1/3切断后缝扎(图6)，同法处理另侧。打开膀胱腹膜反折，向下锐性分离膀胱宫颈和膀胱阴道膈(图7)。剪开子宫直肠窝的腹膜反折，向下分离直肠阴道间隙(图8)。切除骶韧带3cm，缝扎残端(图9)。分离输尿管隧道(图10)，切断主韧带约2,3cm，缝扎残端(图11)。 4.游离阴道中上段 完全游离子宫后，继续向下将阴道膀胱、直肠壁分离。直视下靠近盆壁切断阴道旁组织直至大部分阴道游离(图12)。 会阴手术步骤: 1.阴道切口 沿处女膜缘为切口(图13)。 2.分离尿道阴道隔、膀胱阴道隔 用电刀沿处女膜缘切开阴道，沿尿道方向分离阴道前壁，直至阴道中下段(图14)。必要时用金属导尿管探测，辨别尿道、膀胱。 3.分离阴道直肠隔 将阴道后壁与直肠分离，直至阴道中下段(图15)。必要时左手中指进入直肠作指引(图16)。 4.闭合阴道口 阴道前后壁游离2,3cm后，阴道内堵塞适量纱布，连续缝合阴道口(图17)。 5.处理阴道旁组织 从阴道前、后壁向两侧壁分离，暴露阴道旁尿生殖膈肌、耻骨直肠肌，靠近骨盆切断，直至中上段(图18)。 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 6.贯通膀胱阴道隔和阴道直肠隔 腹部手术组用右手食指或中指分别放于膀胱阴道隔(图19)和阴道直肠隔之间(图20)，向下及向阴道方向顶出，指示分离平面。 阴道组术者在同一平面进行分离，直至贯通。 7.翻出子宫 将整个子宫由膀胱隔翻出(图21)。继续切除双侧剩余的阴道旁组织，直至整个子宫、全阴道切除。 8.关闭盆腹膜和腹壁各层 腹组手术者在直视下充分止血，关闭盆腹膜(图22)和腹壁各层。 9.阴道引流和堵塞 将阴道残腔尽量缝合止血和缩小。并在腹组配合下，以凡士林纱布敷贴直肠、膀胱下段创面，其中置胶管2条引流。再于凡士林纱布中间加压堵塞碘仿纱自盆底至阴道口，引流胶管、凡士林纱布碘仿纱的外端均在阴道口固定及做好标志(图23、图24)。 10.阴道成形术 老年患者可在阴道拔纱后，任其肉芽自然生长，直至原阴道腔隙填满封闭。年轻患者需行阴道成形术者，应待拔纱布后创面有肉芽生长时才能进行。 [术后护理] 1.积极抗感染治疗。 for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's 2.术后3,4天开始逐渐拔除阴道塞纱，拔除顺序是碘纺纱?凡士林纱?阴道胶管引流，分2,3天拔完。 [术后并发症及处理] 1.阴道出血 术后阴道引流量多，色鲜红，可能有活动性出血，应使用止血药物，必要时重新堵塞阴道纱。保守治疗无效时，应及时开腹止血。 2.术后感染 此手术创面较大，容易污染，术后宜选用较强抗菌药物。体温持续在39?以上者，应及时取阴道分泌物和血液样本作细菌培养和药敏试验，并在药敏结果指导下用药. for the national strategy of developing the West, Yibin city as "Yangtze towns" and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqing's