腹腔镜下大子宫（肌瘤）组织取出技术的研究进展

doi:10.12280/gjfckx.20230297

摘要/Abstract

摘要：

妇科手术中子宫及子宫肌瘤标本组织的分碎及取出技术已发展了数十年，包括电动分碎技术、经阴道分碎技术及经腹小切口分碎技术等。近年来，随着腹腔镜等微创手术的广泛开展，妇科手术医生对无瘤观念、无瘤技术愈发重视，对标本的分碎及取出技术提出了更高的要求。不同的技术各有其优点和局限性，各种技术的围手术期并发症发生率无明显差异，但存在经阴道分碎技术标本袋破碎率更高，经腹小切口分碎技术手术时间偏长等的局限性。各种技术的实用性及安全性仍需高质量的前瞻性临床研究来验证。在选择分碎及取出标本方式时，术者应严格遵循治疗原则，进行个体化决策，让患者获得更好的预后。综述大子宫（肌瘤）的分碎及取出技术的相关研究进展，以供临床参考。

关键词: 腹腔镜检查, 分碎术, 子宫切除术, 子宫肌瘤切除术, 提取法

Abstract:

The techniques of uterine and uterine leiomyoma specimen tissue morcellation and extraction in gynecological surgery have been developed for decades, including electromechanical morcellation, transvaginal morcellation and small abdominal incision morcellation. In recent years, with the wide spread development of minimally invasive surgery such as laparoscopy, gynecologic surgeons have paid more and more attention to the tumor-free concept and tumor-free technology, and put forward higher requirements for the specimen morcellation and extraction technology. Different techniques have their own advantages and limitations, and there is no significant difference in the incidence of perioperative complications among them, but there are some limitations, such as the higher crushing rate of specimen bags by vaginal morcellation technique and the longer operation time by minilaparotomy morcellation technique. The practicability and safety of various technologies still need high-quality prospective clinical research to verify. When choosing the method of breaking and taking out specimens removal, the operator should strictly follow the principles of treatment and make individualized decisions so that patients can get a better prognosis. This paper reviews the research progress of large uterine (leiomyoma) tissue morcellation and extraction technology for clinical reference.

Key words: Laparoscopy, Morcellation, Hysterectomy, Uterine myomectomy, Extraction

邵思齐, 吴再归, 陈凯, 阮菲. 腹腔镜下大子宫（肌瘤）组织取出技术的研究进展[J]. 国际妇产科学杂志, 2023, 50(5): 578-582.

SHAO Si-qi, WU Zai-gui, CHEN Kai, RUAN Fei. Research Progress of Laparoscopic Uterine (Leiomyoma) Tissue Extraction Technology[J]. Journal of International Obstetrics and Gynecology, 2023, 50(5): 578-582.

参考文献 43

[1]	中国医师协会妇产科医师分会妇科肿瘤专业委员会学组. 良性子宫疾病子宫切除术手术路径的中国专家共识(2021年版)[J]. 中国实用妇科与产科杂志, 2021, 37(8):821-825. doi: 10.19538/j.fk2021080109.
[2]	Billfeldt NK, Borgfeldt C, Lindkvist H, et al. A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery[J]. Eur J Obstet Gynecol Reprod Biol, 2018, 222:113-118. doi: 10.1016/j.ejogrb.2018.01.019. pmid: 29408741
[3]	Settnes A, Topsoee MF, Moeller C, et al. Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study of Minimally Invasive Benign Gynecologic Surgery between 2004 and 2018[J]. J Minim Invasive Gynecol, 2020, 27(6):1344-1353.e3. doi: 10.1016/j.jmig.2019.11.005.
[4]	Uccella S, Morosi C, Marconi N, et al. Laparoscopic Versus Open Hysterectomy for Benign Disease in Uteri Weighing >1 kg: A Retrospective Analysis on 258 Patients[J]. J Minim Invasive Gynecol, 2018, 25(1):62-69. doi: 10.1016/j.jmig.2017.07.005.
[5]	Uccella S, Casarin J, Marconi N, et al. Laparoscopic Versus Open Hysterectomy for Benign Disease in Women with Giant Uteri (≥1500 g): Feasibility and Outcomes[J]. J Minim Invasive Gynecol, 2016, 23(6):922-927. doi: 10.1016/j.jmig.2016.05.002.
[6]	Mercorio A, Della Corte L, Vetrella M, et al. Uterine fibroids morcellation: a puzzle topic[J]. Minim Invasive Ther Allied Technol, 2022, 31(7):1008-1016. doi: 10.1080/13645706.2022.2095872.
[7]	Milad MP, Milad EA. Laparoscopic morcellator-related complications[J]. J Minim Invasive Gynecol, 2014, 21(3):486-491. doi: 10.1016/j.jmig.2013.12.003.
[8]	Tulandi T, Leung A, Jan N. Nonmalignant Sequelae of Unconfined Morcellation at Laparoscopic Hysterectomy or Myomectomy[J]. J Minim Invasive Gynecol, 2016, 23(3):331-337. doi: 10.1016/j.jmig.2016.01.017.
[9]	Sparić R, Andjić M, D′Oria O, et al. Fibroid Removal after Myomectomy: An Overview on the Problems of Power Morcellation[J]. Healthcare(Basel), 2022, 10(10):2087. doi: 10.3390/healthcare10102087.
[10]	Multinu F, Casarin J, Tortorella L, et al. Incidence of sarcoma in patients undergoing hysterectomy for benign indications: a population-based study[J]. Am J Obstet Gynecol, 2019, 220(2):179.e1-179.e10. doi: 10.1016/j.ajog.2018.11.1086.
[11]	Gitas G, Alkatout I, Allahqoli L, et al. Severe direct and indirect complications of morcellation after hysterectomy or myomectomy[J]. Minim Invasive Ther Allied Technol, 2022, 31(3):418-425. doi: 10.1080/13645706.2020.1802292.
[12]	Gitas G, Alkatout I, Mettler L, et al. Incidence of unexpected uterine malignancies after electromechanical power morcellation: a retrospective multicenter analysis in Germany[J]. Arch Gynecol Obstet, 2020, 302(2):447-453. doi: 10.1007/s00404-020-05620-4. pmid: 32488399
[13]	Asgari Z, Hashemi M, Hosseini R, et al. Comparison of the Number of Spindle Cells in Peritoneal Washings between Laparoscopic Myomectomy with Morcellation and Open Myomectomy without Morcellation[J]. J Minim Invasive Gynecol, 2021, 28(7):1391-1396. doi: 10.1016/j.jmig.2020.10.024.
[14]	Multinu F, Casarin J, Hanson KT, et al. Practice Patterns and Complications of Benign Hysterectomy Following the FDA Statement Warning Against the Use of Power Morcellation[J]. JAMA Surg, 2018, 153(6):e180141. doi: 10.1001/jamasurg.2018.0141.
[15]	Pepin K, Cope A, Einarsson JI, et al. Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review[J]. J Minim Invasive Gynecol, 2021, 28(3):619-643. doi: 10.1016/j.jmig.2020.09.013.
[16]	中国医师协会妇产科医师分会妇科肿瘤专业委员会学组. 实施腹腔镜下子宫(肌瘤)分碎术的中国专家共识[J]. 中国实用妇科与产科杂志, 2020, 36(7):626-632. doi: 10.19538/j.fk2020070113.
[17]	Bensouda-Miguet C, Nohuz E, Cerruto E, et al. Inbag Morcellation Applied to the Laparoscopic Surgery of Leiomyoma: A Randomized Controlled Trial[J]. Biomed Res Int, 2021, 2021:6611448. doi: 10.1155/2021/6611448.
[18]	Trivedi PH, Trivedi S, Patil S. Laparoscopic In-Bag Morcellation Compared with Conventional Morcellation of Myomas and Uterus with Myomas[J]. J Obstet Gynaecol India, 2020, 70(1):69-77. doi: 10.1007/s13224-019-01273-9.
[19]	Marchand G, Masoud A, Christensen A, et al. Contained and uncontained morcellation in hysterectomy and myomectomy: A systematic review and meta-analysis[J]. Turk J Obstet Gynecol, 2021, 18(4):311-321. doi: 10.4274/tjod.galenos.2021.50607. pmid: 34955114
[20]	Lambat Emery S, Pluchino N, Petignat P, et al. Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study[J]. J Minim Invasive Gynecol, 2019, 26(7):1351-1356. doi: 10.1016/j.jmig.2019.01.014.
[21]	Gil-Gimeno A, Laberge PY, Lemyre M, et al. Morcellation During Total Laparoscopic Hysterectomies: Implications of the Use of a Contained Bag System[J]. J Obstet Gynaecol Can, 2020, 42(7):839-845. doi: 10.1016/j.jogc.2019.11.004. pmid: 32273084
[22]	Rimbach S, Holzknecht A, Schmedler C, et al. First clinical experiences using a new in-bag morcellation system during laparoscopic hysterectomy[J]. Arch Gynecol Obstet, 2016, 294(1):83-93. doi: 10.1007/s00404-015-3986-5. pmid: 26690354
[23]	Obrzut B, Wasyluk T, Obrzut M, et al. Laparoscopic in-bag morcellation - a comparison of two tissue extraction systems[J]. Ginekol Pol, 2022, 93(5):369-373. doi: 10.5603/GP.a2022.0001. pmid: 35315008
[24]	Pomeranz M, Schonman R, Yagur Y, et al. An intrauterine cavity morcellator: A novel approach to high volume uterus morcellation. Ex-vivo study[J]. PLoS One, 2023, 18(3):e0282149. doi: 10.1371/journal.pone.0282149.
[25]	Feghali EJ, Laganà AS, Daccache A, et al. Endobag use in laparoscopic gynecological surgeries: a systematic review[J]. Minim Invasive Ther Allied Technol, 2022, 31(5):698-703. doi: 10.1080/13645706.2021.1982727.
[26]	Wong WS, Lee TC, Lim CE. Novel Vaginal "paper roll" uterine morcellation technique for removal of large (>500 g) uterus[J]. J Minim Invasive Gynecol, 2010, 17(3):374-378. doi: 10.1016/j.jmig.2010.02.005.
[27]	Clark Donat L, Clark M, Tower AM, et al. Transvaginal morcellation[J]. JSLS, 2015, 19(2): e2014.00255. doi: 10.4293/JSLS.2014.00255.
[28]	Kliethermes C, Walsh T, Guan Z, et al. Vaginal Tissue Extraction Made Easy[J]. J Minim Invasive Gynecol, 2017, 24(5):726. doi: 10.1016/j.jmig.2017.02.005.
[29]	Serur E, Zambrano N, Brown K, et al. Extracorporeal Manual Morcellation of Very Large Uteri Within an Enclosed Endoscopic Bag: Our 5-Year Experience[J]. J Minim Invasive Gynecol, 2016, 23(6):903-908. doi: 10.1016/j.jmig.2016.03.016.
[30]	Ghezzi F, Casarin J, De Francesco G, et al. Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort study[J]. BJOG, 2018, 125(3):367-373. doi: 10.1111/1471-0528.14720.
[31]	Laganà AS, Casarin J, Uccella S, et al. Outcomes of In-bag Transvaginal Extraction in a Series of 692 Laparoscopic Myomectomies: Results from a Large Retrospective Analysis[J]. J Minim Invasive Gynecol, 2022, 29(12):1331-1338. doi: 10.1016/j.jmig.2022.09.009.
[32]	Akdemir A, Ari SA, Taylan E, et al. Comparison of laparoscopic enclosed electromechanical morcellation and vaginal enclosed scalpel morcellation at laparoscopic myomectomy: A prospective randomized trial[J]. J Obstet Gynaecol Res, 2023, 49(2):691-700. doi: 10.1111/jog.15507.
[33]	Laganà AS, Vitagliano A, Casarin J, et al. Transvaginal versus Port-Site Specimen Retrieval after Laparoscopic Myomectomy: A Systematic Review and Meta-Analysis[J]. Gynecol Obstet Invest, 2022, 87(3/4):177-183. doi: 10.1159/000525624.
[34]	Casarin J, Ghezzi F, Dri M, et al. Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series[J]. Eur J Obstet Gynecol Reprod Biol, 2023, 282:124-127. doi: 10.1016/j.ejogrb.2023.01.015. pmid: 36708659
[35]	Rosen D, Conrad DH, Saar TD, et al. Removing the large uterus without morcellation - The Colpo-V incision for specimen extraction at hysterectomy[J]. Aust N Z J Obstet Gynaecol, 2021, 61(5):773-776. doi: 10.1111/ajo.13395. pmid: 34097304
[36]	Kho KA, Brown DN. Surgical Treatment of Uterine Fibroids Within a Containment System and Without Power Morcellation[J]. Clin Obstet Gynecol, 2016, 59(1):85-92. doi: 10.1097/GRF.0000000000000168. pmid: 26670832
[37]	Siedhoff MT, Cohen SL. Tissue Extraction Techniques for Leiomyomas and Uteri During Minimally Invasive Surgery[J]. Obstet Gynecol, 2017, 130(6):1251-1260. doi: 10.1097/AOG.0000000000002334. pmid: 29112659
[38]	Griffith KC, Clark NV, Mushinski AA, et al. Incisional Outcomes of Umbilical vs Suprapubic Mini-laparotomy for Tissue Extraction: A Retrospective Cohort Study[J]. J Minim Invasive Gynecol, 2018, 25(6):1024-1030. doi: 10.1016/j.jmig.2018.01.021.
[39]	Zapardiel I, Boria F, Halaska MJ, et al. Laparoscopic Power Morcellation: Techniques to Avoid Tumoral Spread[J]. J Minim Invasive Gynecol, 2021, 28(8):1442-1443. doi: 10.1016/j.jmig.2020.09.012.
[40]	Macciò A, Sanna E, Lavra F, et al. Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports[J]. World J Clin Cases, 2021, 9(20):5655-5660. doi: 10.12998/wjcc.v9.i20.5655. pmid: 34307621
[41]	Oh SJ, Lee SY, Kim WY, et al. Comparison between transumbilical and transvaginal morcellation of a large uterus during single-port-access total laparoscopic hysterectomy[J]. Obstet Gynecol Sci, 2020, 63(3):379-386. doi: 10.5468/ogs.2020.63.3.379. pmid: 32489984
[42]	Meurs E, Brito LG, Ajao MO, et al. Comparison of Morcellation Techniques at the Time of Laparoscopic Hysterectomy and Myomectomy[J]. J Minim Invasive Gynecol, 2017, 24(5):843-849. doi: 10.1016/j.jmig.2017.04.023.
[43]	Cohen SL, Clark NV, Ajao MO, et al. Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach[J]. J Minim Invasive Gynecol, 2019, 26(4):702-708. doi: 10.1016/j.jmig.2018.07.020.