Visualizing the dissectable layer for vaginal hysterectomy with indigo carmine
Visualizing the dissectable layer for vaginal hysterectomy with indigo carmine
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使用靛蓝胭脂红可视化阴道子宫切除术的可解剖层
DOI：
10.1016/j.ejogrb.2022.09.020
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发表时间：
2022
期刊：
影响因子：
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通讯作者：
Tomoyuki Kuwata
中科院分区：
文献类型：
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作者：
Ken Imai;Kenro Chikazawa;Emi Yonemori;Tomoyuki Kuwata
目前，妇产科培训项目的毕业住院医师在阴道子宫切除术方面的经验不足[1,2]。因此，与其他手术相比，她们对阴道子宫切除术的信心较低。其中一个原因是这40名住院医生无法掌握阴道切除术前阴道解剖膀胱和直肠的概念。此外，他们对打开前后腹膜缺乏信心。在此，我们提出了一种新的技术，通过加压素和靛胭脂红染色来观察阴道子宫切除术中可剥离层。染色使可剥离层清晰可见，44便于剥离，简化手术教育。45水解前，用生理盐水100 mL稀释100倍，制备1个抗利尿激素安瓿（20单位）和20 mg靛蓝胭脂红46。阴道阴道切开术，在宫颈附近3-4个点注射7-10 - 47 mL稀释后加压素，不注射子宫肌层。48阴道旁修复时，注射生理盐水10-20 mL进行水解剖。在子宫颈周围做了一个49度的切口，可见一层蓝色染色。对这一层进行了尖锐和钝性解剖，证实了蓝色层的连续性（视频1-A）。蓝色染色层的剥离被认为是安全的，因为在剥离这一层的过程中，膀胱和直肠都没有受到损伤（图1-A， B）。解剖后，我们将子宫附近的蓝筋膜夹紧。然后，我们检测了这一层下的腹膜，54这样就可以精确地切割后腹膜。同样，切开前腹膜进行盆腔器官脱垂手术，对可剥离层进行染色，用于阴道修复（图1-C，视频1-B）。这一层上方的剥离不会导致膀胱损伤，因为膀胱在这一层之下。58
37 Currently, graduating residents in obstetrics and gynecology training programs have 38 less experience in performing vaginal hysterectomies [1, 2]. Consequently, they have low 39 confidence in performing vaginal hysterectomy than other surgeries [3]. One reason is the 40 residents’ inability to grasp the concept of dissecting the bladder and rectum vaginally before 41 colpotomy. Additionally, they lack confidence in opening the anterior and posterior peritoneum. 42 Herein, we present a novel technique to visualize the dissectable layer in vaginal hysterectomy 43 by staining it with vasopressin and indigo carmine. Staining makes the dissectable layer visible, 44 facilitating dissection and simplifying surgical education. 45 Before hydrodissection, one vasopressin ampule (20 units) and 20 mg of indigo carmine 46 were prepared with 100 mL physiologic saline and diluted 100-fold. For vaginal colpotomy, 7–10 47 mL diluted vasopressin was injected at 3–4 points near the cervix, but not the myometrium. 48 During paravaginal repair, 10–20 mL of normal saline solution was injected for hydrodissection. A 49 circumscribing incision was made around the cervix to reveal a blue-stained layer. This layer was 50 followed with both sharp and blunt dissections and confirmed the continuity of the blue layer 51 (Video 1-A). Dissection of the blue-stained layer was considered safe, as neither the bladder nor 52 the rectum was injured during dissection of this layer (Figure 1-A, B). After dissection, we 53 clamped the blue fascia near the uterus. Then, we detected the peritoneum under this layer, 54 which allowed precise cutting of the posterior peritoneum. Similarly, the anterior peritoneum was 55 opened for pelvic organ prolapse surgeries, and the dissectable layer was stained for vaginal 56 repair (Figure 1-C, Video 1-B). Dissection just above this layer does not lead to bladder injury as 57 the bladder is under this layer. 58