腹腔鏡廣泛宮頸切除術(shù)

腹腔鏡廣泛宮頸切除術(shù)

---技術(shù)要點和爭議問題探討

FERTILITYSPARINGSURGERYINCERVICALCANCER---R(S)TRACHELECTOMY

指

征

－廣泛宮頸切除術(shù)(1)患者有明確的生育要求；(2)臨床上無不孕癥證據(jù)(?)；(3)FIGO分期為IA期或IB期；(4)病灶直徑<2cm；肌層浸潤<1/2；(5)宮旁組織內(nèi)無腫瘤細胞累及；(6)病灶距頸管內(nèi)口(0.8~1cm)；(7)盆腔淋巴結(jié)未累及；(8)IA1,LVSI(+)。全面術(shù)前

評估病灶大?。号枨粰z查，B超，MRI最準確：MRI:病灶大小，浸潤深度

宮旁，距宮頸內(nèi)口距離腫瘤類型：小細胞癌，肉瘤…..禁忌淋巴結(jié)：CT或PET/CT，

取代MRI和淋巴管造影Ameta-analysisof72studiesincluding5042womenwithcervicalcancerfoundthatPEThasabettersensitivityandspecificityforthedetectionoflymphnodemetastases(sensitivity:75%,specificity:98%);thanMRI(56%and93%)orCT(58%and92%)充分的術(shù)前準備：腸道準備，輸尿管支架放置，

切除長度的初級評估細致的知情同意3TCT+HPV，血SCC，陰道鏡，MRI，B超，必要的小錐切2025/2/264宮頸根治術(shù)的手術(shù)方式(RVT,RAT,TLRT,RRT)①經(jīng)陰道根治性宮頸切除術(shù)(1994年，Dargent)

(Radicalvaginaltrachelectomy，RVT)

②經(jīng)腹根治性宮頸切除術(shù)(1997年Smith)

(Radicalabdominaltrachelectomy，RAT)③全腹腔鏡廣泛宮頸切除術(shù)(2005年Cibula)

(totallaparoscopicradicaltrachelectomy，TLRT)④機器人根治性宮頸切除術(shù)(2008年Geisler)

(Roboticradicaltrachelectomy，RRT)2025/2/26GHY5宮頸根治術(shù)的手術(shù)步驟①腹腔鏡（經(jīng)腹）盆腔淋巴結(jié)清除

(LaparoscopicPelvicLymphadenectomy)*第一次冰凍病理檢查淋巴結(jié)（-）②根治性子宮頸切除 （RadicalTrachelectomy）*第二次冰凍病理檢查標本切緣（-）③子宮頸內(nèi)口環(huán)扎 （UterineCervicalCerclage）④縫接殘余宮頸和陰道粘膜(Closurenewcervicalexternalosandvaginalmucosa)Radicalvaginaltrachelectomy

---經(jīng)陰道宮頸根治術(shù)最早的術(shù)式，也是目前開展最多的術(shù)式。報道了1000多例要求術(shù)者同時具備腹腔鏡和陰式手術(shù)的經(jīng)驗，大部分婦科腫瘤醫(yī)師陰式手術(shù)經(jīng)驗少，手術(shù)訓練周期長，陰道術(shù)野暴露困難6Radicalvaginaltrachelectomy

---經(jīng)陰道宮頸根治術(shù)經(jīng)陰道宮旁組織切除不夠?qū)挘菀撞≡顨埩?。Einstein等比較28例陰道及15例開腹手術(shù)，宮旁組織的長度為1.45cm對3.97cm(p<0.0001)。Radicalabdomianltrachelectomy

---經(jīng)腹部宮頸根治術(shù)，RAT目前文獻報道開展300-400多例，即開腹盆腔淋巴切除術(shù)聯(lián)合廣泛宮頸切除術(shù)與傳統(tǒng)的廣泛子宮切除術(shù)類似，婦科腫瘤醫(yī)師容易掌握手術(shù)，無需腹腔鏡及陰式手術(shù)訓練2025/2/26GHY8經(jīng)腹部宮頸根治術(shù)，RAT6、分離切開子宮直腸反折腹膜，分離陰道直腸膈至陰道中段；7、于輸尿管外側(cè)，切斷宮頸膀胱韌帶和主韌帶；8、切斷宮骶韌帶，切斷陰道旁組織；9、距穹隆2cm處切開陰道及陰道旁組織；10、自子宮峽部切斷，將宮體與宮頸分離；11、取下宮頸標本送檢，確定宮頸和陰道切緣距腫瘤邊緣的距離：12、5#不可吸收線環(huán)扎縫合子宮下段；2—0#可吸收線將陰道與子宮下段吻合；14、縫合盆腔腹膜，并置腹膜后引流管。9Laproscopicradicaltrachelectomy

---腹腔鏡下廣泛宮頸切除術(shù)結(jié)合了RVT和RAT的優(yōu)點，手術(shù)視野大、暴露充分，術(shù)后恢復快TLRT能更清晰的辨認盆底的血管、淋巴及神經(jīng)解剖結(jié)構(gòu)，如主韌帶表層血管及深層的神經(jīng)走向，膀胱宮頸韌帶，輸尿管與宮旁陰道旁組織的關(guān)系，2025/2/26GHY10腹腔鏡下廣泛宮頸切除術(shù)：步驟A

----腹腔鏡下盆腔淋巴清掃術(shù)

(1)探查盆腹腔后，打開后腹膜，不切斷圓韌帶，充分暴露一側(cè)盆腔血管及淋巴組織，依次將髂總、髂外、腹股溝深部、髂內(nèi)及閉孔淋巴組織順序切除，可疑淋巴結(jié)送病理，確定無轉(zhuǎn)移；

保留的卵巢血管對暴露的影響;

盡量減少對腹膜的破壞11淋巴結(jié)冰凍？與清掃時機？每一個淋巴結(jié)冰凍？可疑淋巴結(jié)冰凍冰凍不準確性：10%-20%等待時間較長等待淋巴結(jié)石蠟病理結(jié)果，二次手術(shù)？陰式可以考慮，但開腹和腹腔鏡？2025/2/26GHY12Case21cm多點病灶1點、11點、12點1例術(shù)后病理提示一側(cè)盆腔淋巴結(jié)轉(zhuǎn)移（宮頸未見殘存病灶），患者要求保留子宮，術(shù)后行放化療7.5mmLVSI?2/200/13腹腔鏡下廣泛宮頸切除術(shù)：步驟B-分離保留子宮動脈（1）暴露，打開前后腹膜（2）打開膀胱返折腹膜，分離膀胱正側(cè)窩，下推膀胱至子宮頸外口以下3~4cm水平；（3）分離和暴露子宮動脈，全程骨化血管：13腹腔鏡廣泛宮頸切除術(shù)步驟C-分離輸尿管打開隧道腹腔鏡下廣泛宮頸切除術(shù)步驟D-主骶韌帶腹腔鏡下廣泛宮頸切除術(shù)步驟E-修復切緣問題？對于鱗癌來說有5mm的正常組織切緣安全，但是對于腺癌可能10mm相對更安全1例術(shù)后病理提示脈管瘤栓，腫瘤臨近上切緣4mm，術(shù)后10天行二次手術(shù)切除子宮上切緣而非旁切緣：單純宮頸切除術(shù)？2025/2/26GHY14338IB10.5x1.6

鱗癌G2SimpleextrafascialtracheletomyandpelvicbilateraLNCinearlystageCC

palalaL,MusellaA,BellatiF,etal.GynecolOncol2012,120:78-8114patients5StageIA29stageIB1Mediantumorsize:17mmConclusion:lowriskearlyCCsafelytreatedL.Robetal./GynecologicOncology111(2008)S116–S12016Havingsentthesentinelnodesforfrozen-sectionanalysis,weperformacompletelaparoscopicpelviclymphnodedissectionandparametrialnodedissectionasthefirststepofourmanagement.Ifthefrozensectionispositive,laparoscopyisabandonedandwecontinuewithalaparotomicradicalhysterectomy(WertheimtypeIII)andlowerpara-aorticlymphadenectomy.DuringthesecondstepofourLAP-Iprotocol,patientswithnegativepelvicnodesandstageIA2diseasearetreatedwithalargeconetrachelectomy,andpatientswithnegativepelvicnodesandstageIB1diseasearetreatedwithasimpletrachelectomy7daysafterthefinalhistopathologicalprocessingofthedissectednodes.

針對不同狀況采用不同手術(shù)方式Excisionalconeasfertility-sparingtreatmentinearlystageCC

FagettiA,GagliardiM,Moruzzieetal

FertilitySteril201195(3)1109-12StageIA2:4StageIB1:13LVSI:4Recurrence:0Livebirth:2(5trying)SimpleconizationandLNDforIB1cervicalcancer.Anitalianexperience36cases,IB1,tumorsize11.7mm(8-25mm)Adenocarcinoma12(33%),G34(14%),LVST(+)4(14%),.Follow-up:66M(6-168M),1REPLASE(pelvicLN).Pregnancy:21/17cases,15livebirth2025/2/26AndreaManeo,etal.GynecolOncol,201118SimpleconizationandLNDforIB1cervicalcancer.AnitalianexperienceCervicalconizationrepresentsafeasibleconservativemanagementofstageIB1cervicalcancerandshowsalowriskofrelapse,providedthatpatientsareselectedcarefully.ConizationwouldbesuitabletotreatstageIBlesionssmallerthan15-20mmwithpathologicnegativeLNs.

2025/2/26AndreaManeo,etal.GynecolOncol,201119宮頸根治術(shù)術(shù)中和術(shù)后并發(fā)癥

RVT術(shù)中并發(fā)癥的發(fā)生率平均為4%，主要是膀胱、輸尿管、血管等損傷術(shù)后并發(fā)癥發(fā)生率12%，可能出現(xiàn)淋巴囊腫、下肢疼痛、宮頸管孔狹窄粘連術(shù)后宮頸管孔狹窄粘連對患者的生育功能和生活質(zhì)量均造成很大影響，據(jù)報道發(fā)生宮頸粘連8-13%目前國內(nèi)外均有文獻報道采用術(shù)中放置弗類氏導尿管或?qū)m內(nèi)節(jié)育器防止粘連形成2025/2/26GHY201547patients：stenosisTheincidenceratesofcervicalstenosisrangedfrom0%to73.3%withanaveragerateof10.5%.Amongpatientswithabdominal,vaginal,laparoscopicandroboticradicaltrachelectomy,theincidencesofcervicalstenosiswere11.0%,8.1%,9.3%and0%,respectively.Inpatientsinwhomwhethercerclagewasplacedornot,theincidenceratesofcervicalstenosiswere8.6%and3.0%。Amongthoseinwhomwhetheranti-stenosistoolswereplacedornot,theincidencesofcervicalstenosiswere4.6%and12.7%,(P<0.001).Surgicaldilatationresolvedstenosisinthemajorityofcasesbuthadtoberepeated.宮頸癌保留生育功能手術(shù)---復發(fā)Mofice等認為，根治性宮頸切除術(shù)后復發(fā)的危險因素與根治性子宮切除術(shù)后相同，術(shù)后腫瘤復發(fā)率4~8％。Beiner總結(jié)術(shù)后復發(fā)率為5．1％，死亡率為3．1％。2025/2/26GHY22HY23LVRT

術(shù)后復發(fā):（3~5%）

size,LVSI,marginBeinerME,CovensA.NATURECLINICALPRACTICEONCOLOGY2007,4(6):353-361NACT:Robetal.report9patientswhounderwentthreecycleswithisofosfamideandcisplatinorcisplatinandadriamycin.Cervicalconizationorsimpletrachelectomyandpelviclymphadenectomywasperformedafterchemotherapyandnorecurrenceshavebeenreported.Sixpatientsconceived.Maneoetal.report21patientswithlargertumors<3cm,instageIB1,whounderwentneoadjuvantchemotherapy(threecyclesofisofosfamide,paclitaxel,andcisplatin)followedbyconizationandpelviclymphadenectomy.Noresidualdiseasewasfoundinfivepatientsandnorecurrence