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[摘要]目的:比較腹腔镜乙状结肠法和口腔黏膜法在先天性无阴道综合征(Mayer-Rokitansky-Küster-Hauser syndrome,MRKH综合征)患者阴道再造术中的应用。方法:选择2008年4月至2012年6月就诊于北京大学第三医院成形外科并接受手术治疗的MRKH综合征患者共21例为研究对象,分别采用腹腔镜下带血管蒂乙状结肠法和口腔黏膜微粒移植法阴道再造法,分析比较两组的手术时间、术中出血量、术后阴道短缩或狭窄情况、内壁黏膜情况及阴道湿润程度评分。结果:腹腔镜辅助下带血管蒂乙状结肠组11例,术后18个月阴道外口无狭窄,无缩短,内壁黏膜完整、红润,腹壁可见4处穿刺孔遗留的较小瘢痕,无明显增生样改变;口腔黏膜微粒移植组10例,术后3个月随访,再造阴道内30%无黏膜微粒覆盖,经换药后大部分区域在术后6个月可通过周围黏膜爬行覆盖,术后18个月8例患者再造阴道存在3~5cm的短缩。乙状结肠组手术时间(160±18)min大于口腔黏膜组(90±15)min,差异具有统计学意义(P<0.01);乙状结肠组术中出血量(100±20)ml大于口腔黏膜组(50±8)ml,差异具有统计学意义(P<0.01);再造阴道狭窄和短缩程度方面,口腔黏膜组(4±1.1)cm较乙状结肠组(2±0.4)cm严重,差异具有统计学意义(P<0.05);乙状结肠组再造阴道湿润度评分(7.6±0.6)分优于口腔黏膜组(5.5±0.8)分,差异具有统计学意义(P<0.05)。结论:与口腔黏膜微粒移植法比较,腹腔镜下带血管蒂乙状结肠阴道再造术功能重建效果更为理想。
[关键词]MRKH综合征;阴道再造;乙状结肠;口腔黏膜微粒
[中图分类号]R622 [文献标志码]A [文章编号]1008-6455(2017)09-0015-04
The Comparison of Effect between the Laparoscopic Sigmoid Colon Graft and Buccal Mucosa Graft in Vaginoplasty for Patients with MRKH Syndrome
HOU Jun-jie1,MA Yong-guang2,ZHANG Jie2,YANG Xin2,YUAN Jiong3,LI Jian-ning2
(1.Medical Cosmetic Center,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China;2.Department of Plastic Surgery,Peking University Third Hospital,Beijing 100191,China;3.Department of General Surgery,Peking University Third Hospital,Beijing 100191,China)
Abstract: Objective To compare the effect between laparoscopic sigmoid colon graft and buccal mucosa graft in vaginoplasty for patients with MRKH syndrome. Methods From April 2008 to June 2012, there were altogether 21 patients with MRKH syndrome, receiving vaginoplasty in department of plastic surgery of peking university third hospital. Twenty-one patients with MRKH syndrome have received treatments and are divided into two groups, with one group receiving laparoscopically assisted vascularized sigmoid colon graft and the other group receiving buccal micro-mucosa graft for vaginoplasty. Analyze and compare the time span of these two surgery methods, the bleeding volume in surgery, the degree of narrowing and shortening of the vagina after surgery, the state of mucous membranes and the evaluation of moist degree of the reconstructed vagina. Results There are eleven patients receiving laparoscopically assisted vascularized sigmoid colon graft. After 18 months of follow-up, there was no stenosis in the external orifice of the vagina, no shortening, complete and bright internal mucosal wall, and little scar on the abdominal wall of the 4 puncture holes. Ten cases were treated with oral mucosal microparticle grafting. After 3 months of follow-up, no vaginal reconstruction within 30% micro mucosa covered by dressing after most of the region in 6 months after operation through the mucous membrane around the crawling coverage, 18 months after surgery, 8 patients had vaginal reconstruction shortened 3-5cm. The laparoscopically assisted vascularize sigmoid colon graft for vaginoplasty takes more time than the buccal micro-mucosa graft does (160±18min VS 90±15min, P<0.01). The bleeding state in the laparoscopically assisted vascularize sigmoid colon graft surgery is heavier than that in buccal micro-mucosa graft surgery (100±20ml VS 50±8ml, P<0.01). The degree of narrowing and shortening of the vagina reconstructed by buccal micro-mucosa graft is more serious than that reconstructed by laparoscopically assisted vascularize sigmoid colon graft ( 4±1.1cmVS 2±0.4cm,P<0.05). The evaluation of moist degree of the vagina reconstructed by laparoscopically assisted vascularize sigmoid colon graft is better than that reconstructed by buccal micro-mucosa graft (7.6±0.6points VS 5.5±0.8points, P<0.05). Conclusion Compare to buccal micro-mucosa graft, the laparoscopically assisted vascularized sigmoid colon graft is a relatively ideal surgery method for a better reconstructed vaginal function effect in vaginoplasty. Key words:MRKH syndrome;vaginoplasty;sigmoid colon;buccal micro-mucosa
先天性无阴道综合征亦称为MRKH综合征(Mayer Rokitanksy Kuster Hauser syndrome),其病因目前尚未明确,多数研究者认为该疾病是多基因多因素导致的遗传性疾病[1]。该疾病的临床表现主要包括:无阴道、无子宫或仅为始基子宫,此类患者的性腺(卵巢)发育一般正常,故第二性征发育基本正常,俗称石女。据文献报道,该疾病发病率大概为1/(4000~5000)[2]。罹患此疾病者无法进行正常的性生活,也不能生育,给患者的生活和身心健康带来了严重的影响。
目前临床上对于该疾病的治疗主要集中在器官功能重建方面,即重建阴道,满足患者性生活的需要,术后患者的生活质量得到明显提高[3]。阴道重建的术式有很多种,其基本原则是再造腔穴和在腔穴内覆盖稳定的衬里。随着腹腔镜技术的日益普及,腹腔镜下乙状结肠阴道再造法,可以避免开腹手术,而仅在腹壁留下几个微小的穿刺口瘢痕。而口腔黏膜移植法,口腔颊黏膜残留瘢痕亦很轻微。所以乙状结肠移植法和口腔黏膜移植法是目前临床较为常用的两种方法。本文回顾性分析21例临床病例资料,对腹腔镜下乙状结肠阴道再造法和口腔黏膜微粒移植法进行比较,以期为临床术式的选择提供依据。
1 资料和方法
1.1 临床资料:选择2008年4月至2012年6月就诊于北京大学第三医院整形外科并接受手术治疗的21例MRKH综合征患者作为研究对象,年龄20~27岁,平均年龄24岁,均无月经来潮,未婚16例,已婚5例。查体:均为女性体态,乳房发育正常,阴毛呈倒三角分布,大、小阴唇和阴蒂发育正常,阴道前庭可见处女膜痕,无阴道或仅有很浅的凹陷;妇科超声结果:始基子宫15例,子宫缺如6例,双卵巢均正常,染色体检查均为46XX。术前向患者充分告知两种治疗方案,患者自行选择入组,其中采用腹腔镜辅助下带血管蒂乙状结肠法阴道再造术11例,采用口腔黏膜微粒移植法阴道再造术10例。
1.2 方法
1.2.1 术前准备:腹腔镜下乙状结肠法阴道再造是一个跨系统的手术,其术前准备工作包括:①常规全麻术前检查,评估患者全身状况;②行腹部CTA检查及血管三维重建,明确腹腔肠道血管走行及分支情况;③肠道准备:术前两日少渣饮食,并口服甲硝唑及庆大霉素,术前一日禁食可饮水,并口服清洗肠道药物,如聚乙二醇电解质(舒泰清)等,直到患者排出清水样便。④会阴区常规备皮。
1.2.2 术中操作
1.2.2.1 腹腔镜下乙状结肠法阴道再造:患者取截石位,采用气管插管全身麻醉,腹腔组和会阴组医师同时手术。
腹腔组手术:①腹壁常规穿刺孔,全面探查腹盆腔,结合术前腹部CTA血管三维重建结果,明确乙状结肠血管分布情况;②截取乙状结肠肠管段下端通常为乙状结肠与直肠交界处,拟移植肠管长度为16~18cm,钛夹标记拟截取乙状结肠肠管位置;③超声刀游离乙状结肠及其系膜,注意保护肠襻的血管弓。
会阴组手术:①台上留置导尿管,向直肠内填塞直径约4cm的碘伏纱布卷用于标记定位;②于阴道前庭凹陷处设计手术切口,在尿道直肠间隙浸润麻醉,将阴道前庭凹陷处十字切开,在此间隙内小心钝性分离,后侧壁以纱布卷为定位标记,前侧壁以导尿管为定位标记;③造穴至可容纳3~4指,深部可触及直肠膀胱陷凹处壁层腹膜,在阴道窥器辅助下采用双极电凝确切止血。
协同手术:①待腹腔组将乙状结肠游离足够的长度后,在钛夹标记部位以直线切割闭合器切断乙状结肠;②会阴组医师自会阴造穴伸入两根手指向腹腔组医师告知会师部位,腹腔组术者以超声刀将此处腹膜切开约5cm,会阴组人员将肠道端端闭合器钉座自会阴造穴通道送入腹腔,纱布填塞造穴后重建气腹;③腹腔组人员将钉座送入拟移植肠瓣近端标记以上肠腔,只保留钉座的引导针在肠腔外,以直线切割闭合器在供移植的肠襻近端钛夹标记位置切断;④判断肠管无旋转和扭曲后,腔镜直视下将带有钉座的肠管向下与自肛门伸入直肠的端端肠道闭合器对接,完成肠吻合;⑤检查吻合口完整后,通过阴道造穴将获取的乙状结肠肠瓣下端拉至阴道口,此过程需避免肠襻及其血管蒂发生扭转和过度牵拉;⑥肠管到达造穴后,将肠襻适当缝合固定于盆腔后壁,以免发生内疝或扭转导致坏死;⑦自右下腹穿刺口留置盆腔引流管,缝合腹腔各穿刺口,将获取的乙状结肠肠管外口与造穴口黏膜缝合固定,縫合时注意适当行折线缝合以避免环形狭窄,缝合后肠管内填塞碘伏纱条,无菌敷料包扎。
1.2.2.2 口腔黏膜微粒移植法阴道再造:患者采用经鼻气管插管全身麻醉,取截石位,口腔组和会阴组同时手术。
口腔组:①碘伏消毒口腔后,双侧颊部腮腺导管开口下方标记25mm×10mm黏膜范围,局麻后,切除该区域口腔黏膜,创面减张缝合;②获取的口腔黏膜需去除黏膜下组织,用小剪刀反复修剪,制成粒径0.5mm左右的黏膜微粒混悬液备用。
会阴组:①造穴方式与乙状结肠法相同;②造穴满意后,取6片60mm×20mm×2mm的明胶海绵,将口腔黏膜微粒混悬液尽可能均匀地涂在明胶海绵表面,涂有黏膜微粒面朝向组织贴附在阴道造穴的基底和侧壁;③阴道内置入带有侧孔的硅胶囊袋,囊袋内填塞碘仿纱条,填塞满意后在阴道外口以3-0丝线打包固定。
1.2.3 术后护理
1.2.3.1 乙状结肠组:术后应尽量避免过早排便污染会阴区手术部位。术后给予胃肠外营养,术后3d可进食少量流食,并逐渐过渡为半流食,直至普食。保留导尿管至少1周,避免尿液污染术区。腹腔引流管在排便后(约术后1周)拔除。术后6个月每天佩戴阴道模具30min以防止吻合口狭窄。
1.2.3.2 口腔黏膜组:术后饮食可正常恢复,口腔常规清洁消毒,术后7d拆除口腔内缝线。会阴区6d后更换硅胶囊内敷料,10d后取出硅胶囊袋和敷料,佩戴阴道模具并每天用高锰酸钾溶液坐浴,其余处理同乙状结肠阴道再造术。术后前6个月全天佩戴阴道模具,之后可间断佩戴。
[关键词]MRKH综合征;阴道再造;乙状结肠;口腔黏膜微粒
[中图分类号]R622 [文献标志码]A [文章编号]1008-6455(2017)09-0015-04
The Comparison of Effect between the Laparoscopic Sigmoid Colon Graft and Buccal Mucosa Graft in Vaginoplasty for Patients with MRKH Syndrome
HOU Jun-jie1,MA Yong-guang2,ZHANG Jie2,YANG Xin2,YUAN Jiong3,LI Jian-ning2
(1.Medical Cosmetic Center,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China;2.Department of Plastic Surgery,Peking University Third Hospital,Beijing 100191,China;3.Department of General Surgery,Peking University Third Hospital,Beijing 100191,China)
Abstract: Objective To compare the effect between laparoscopic sigmoid colon graft and buccal mucosa graft in vaginoplasty for patients with MRKH syndrome. Methods From April 2008 to June 2012, there were altogether 21 patients with MRKH syndrome, receiving vaginoplasty in department of plastic surgery of peking university third hospital. Twenty-one patients with MRKH syndrome have received treatments and are divided into two groups, with one group receiving laparoscopically assisted vascularized sigmoid colon graft and the other group receiving buccal micro-mucosa graft for vaginoplasty. Analyze and compare the time span of these two surgery methods, the bleeding volume in surgery, the degree of narrowing and shortening of the vagina after surgery, the state of mucous membranes and the evaluation of moist degree of the reconstructed vagina. Results There are eleven patients receiving laparoscopically assisted vascularized sigmoid colon graft. After 18 months of follow-up, there was no stenosis in the external orifice of the vagina, no shortening, complete and bright internal mucosal wall, and little scar on the abdominal wall of the 4 puncture holes. Ten cases were treated with oral mucosal microparticle grafting. After 3 months of follow-up, no vaginal reconstruction within 30% micro mucosa covered by dressing after most of the region in 6 months after operation through the mucous membrane around the crawling coverage, 18 months after surgery, 8 patients had vaginal reconstruction shortened 3-5cm. The laparoscopically assisted vascularize sigmoid colon graft for vaginoplasty takes more time than the buccal micro-mucosa graft does (160±18min VS 90±15min, P<0.01). The bleeding state in the laparoscopically assisted vascularize sigmoid colon graft surgery is heavier than that in buccal micro-mucosa graft surgery (100±20ml VS 50±8ml, P<0.01). The degree of narrowing and shortening of the vagina reconstructed by buccal micro-mucosa graft is more serious than that reconstructed by laparoscopically assisted vascularize sigmoid colon graft ( 4±1.1cmVS 2±0.4cm,P<0.05). The evaluation of moist degree of the vagina reconstructed by laparoscopically assisted vascularize sigmoid colon graft is better than that reconstructed by buccal micro-mucosa graft (7.6±0.6points VS 5.5±0.8points, P<0.05). Conclusion Compare to buccal micro-mucosa graft, the laparoscopically assisted vascularized sigmoid colon graft is a relatively ideal surgery method for a better reconstructed vaginal function effect in vaginoplasty. Key words:MRKH syndrome;vaginoplasty;sigmoid colon;buccal micro-mucosa
先天性无阴道综合征亦称为MRKH综合征(Mayer Rokitanksy Kuster Hauser syndrome),其病因目前尚未明确,多数研究者认为该疾病是多基因多因素导致的遗传性疾病[1]。该疾病的临床表现主要包括:无阴道、无子宫或仅为始基子宫,此类患者的性腺(卵巢)发育一般正常,故第二性征发育基本正常,俗称石女。据文献报道,该疾病发病率大概为1/(4000~5000)[2]。罹患此疾病者无法进行正常的性生活,也不能生育,给患者的生活和身心健康带来了严重的影响。
目前临床上对于该疾病的治疗主要集中在器官功能重建方面,即重建阴道,满足患者性生活的需要,术后患者的生活质量得到明显提高[3]。阴道重建的术式有很多种,其基本原则是再造腔穴和在腔穴内覆盖稳定的衬里。随着腹腔镜技术的日益普及,腹腔镜下乙状结肠阴道再造法,可以避免开腹手术,而仅在腹壁留下几个微小的穿刺口瘢痕。而口腔黏膜移植法,口腔颊黏膜残留瘢痕亦很轻微。所以乙状结肠移植法和口腔黏膜移植法是目前临床较为常用的两种方法。本文回顾性分析21例临床病例资料,对腹腔镜下乙状结肠阴道再造法和口腔黏膜微粒移植法进行比较,以期为临床术式的选择提供依据。
1 资料和方法
1.1 临床资料:选择2008年4月至2012年6月就诊于北京大学第三医院整形外科并接受手术治疗的21例MRKH综合征患者作为研究对象,年龄20~27岁,平均年龄24岁,均无月经来潮,未婚16例,已婚5例。查体:均为女性体态,乳房发育正常,阴毛呈倒三角分布,大、小阴唇和阴蒂发育正常,阴道前庭可见处女膜痕,无阴道或仅有很浅的凹陷;妇科超声结果:始基子宫15例,子宫缺如6例,双卵巢均正常,染色体检查均为46XX。术前向患者充分告知两种治疗方案,患者自行选择入组,其中采用腹腔镜辅助下带血管蒂乙状结肠法阴道再造术11例,采用口腔黏膜微粒移植法阴道再造术10例。
1.2 方法
1.2.1 术前准备:腹腔镜下乙状结肠法阴道再造是一个跨系统的手术,其术前准备工作包括:①常规全麻术前检查,评估患者全身状况;②行腹部CTA检查及血管三维重建,明确腹腔肠道血管走行及分支情况;③肠道准备:术前两日少渣饮食,并口服甲硝唑及庆大霉素,术前一日禁食可饮水,并口服清洗肠道药物,如聚乙二醇电解质(舒泰清)等,直到患者排出清水样便。④会阴区常规备皮。
1.2.2 术中操作
1.2.2.1 腹腔镜下乙状结肠法阴道再造:患者取截石位,采用气管插管全身麻醉,腹腔组和会阴组医师同时手术。
腹腔组手术:①腹壁常规穿刺孔,全面探查腹盆腔,结合术前腹部CTA血管三维重建结果,明确乙状结肠血管分布情况;②截取乙状结肠肠管段下端通常为乙状结肠与直肠交界处,拟移植肠管长度为16~18cm,钛夹标记拟截取乙状结肠肠管位置;③超声刀游离乙状结肠及其系膜,注意保护肠襻的血管弓。
会阴组手术:①台上留置导尿管,向直肠内填塞直径约4cm的碘伏纱布卷用于标记定位;②于阴道前庭凹陷处设计手术切口,在尿道直肠间隙浸润麻醉,将阴道前庭凹陷处十字切开,在此间隙内小心钝性分离,后侧壁以纱布卷为定位标记,前侧壁以导尿管为定位标记;③造穴至可容纳3~4指,深部可触及直肠膀胱陷凹处壁层腹膜,在阴道窥器辅助下采用双极电凝确切止血。
协同手术:①待腹腔组将乙状结肠游离足够的长度后,在钛夹标记部位以直线切割闭合器切断乙状结肠;②会阴组医师自会阴造穴伸入两根手指向腹腔组医师告知会师部位,腹腔组术者以超声刀将此处腹膜切开约5cm,会阴组人员将肠道端端闭合器钉座自会阴造穴通道送入腹腔,纱布填塞造穴后重建气腹;③腹腔组人员将钉座送入拟移植肠瓣近端标记以上肠腔,只保留钉座的引导针在肠腔外,以直线切割闭合器在供移植的肠襻近端钛夹标记位置切断;④判断肠管无旋转和扭曲后,腔镜直视下将带有钉座的肠管向下与自肛门伸入直肠的端端肠道闭合器对接,完成肠吻合;⑤检查吻合口完整后,通过阴道造穴将获取的乙状结肠肠瓣下端拉至阴道口,此过程需避免肠襻及其血管蒂发生扭转和过度牵拉;⑥肠管到达造穴后,将肠襻适当缝合固定于盆腔后壁,以免发生内疝或扭转导致坏死;⑦自右下腹穿刺口留置盆腔引流管,缝合腹腔各穿刺口,将获取的乙状结肠肠管外口与造穴口黏膜缝合固定,縫合时注意适当行折线缝合以避免环形狭窄,缝合后肠管内填塞碘伏纱条,无菌敷料包扎。
1.2.2.2 口腔黏膜微粒移植法阴道再造:患者采用经鼻气管插管全身麻醉,取截石位,口腔组和会阴组同时手术。
口腔组:①碘伏消毒口腔后,双侧颊部腮腺导管开口下方标记25mm×10mm黏膜范围,局麻后,切除该区域口腔黏膜,创面减张缝合;②获取的口腔黏膜需去除黏膜下组织,用小剪刀反复修剪,制成粒径0.5mm左右的黏膜微粒混悬液备用。
会阴组:①造穴方式与乙状结肠法相同;②造穴满意后,取6片60mm×20mm×2mm的明胶海绵,将口腔黏膜微粒混悬液尽可能均匀地涂在明胶海绵表面,涂有黏膜微粒面朝向组织贴附在阴道造穴的基底和侧壁;③阴道内置入带有侧孔的硅胶囊袋,囊袋内填塞碘仿纱条,填塞满意后在阴道外口以3-0丝线打包固定。
1.2.3 术后护理
1.2.3.1 乙状结肠组:术后应尽量避免过早排便污染会阴区手术部位。术后给予胃肠外营养,术后3d可进食少量流食,并逐渐过渡为半流食,直至普食。保留导尿管至少1周,避免尿液污染术区。腹腔引流管在排便后(约术后1周)拔除。术后6个月每天佩戴阴道模具30min以防止吻合口狭窄。
1.2.3.2 口腔黏膜组:术后饮食可正常恢复,口腔常规清洁消毒,术后7d拆除口腔内缝线。会阴区6d后更换硅胶囊内敷料,10d后取出硅胶囊袋和敷料,佩戴阴道模具并每天用高锰酸钾溶液坐浴,其余处理同乙状结肠阴道再造术。术后前6个月全天佩戴阴道模具,之后可间断佩戴。