腹腔鏡子宮切除術治療婦科良性疾病療效的系統評價_《中國循證醫學雜志》

作者：

賀紅英 ¹ ,  李力 ² , 陳江鴻 ¹ , 李晶晶 ¹ , 唐移忠 ¹ , 鐘華 ¹

1. 廣西醫科大學第四附屬醫院（柳州 545005）；2. 廣西醫科大學附屬腫瘤醫院（南寧 530021）;

關鍵詞：

腹腔鏡子宮切除術開腹子宮切除術婦科良性疾病 Meta分析系統評價隨機對照試驗

DOI：

10.7507/1672-2531.20130013

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目的　系統評價腹腔鏡子宮切除術治療婦科良性疾病的療效和安全性。
方法　計算機檢索CENTRAL（Cochrane圖書館2012年第5期）、MEDLINE、EMbase、CNKI、WanFang Data、VIP和CBM數據庫，檢索時間從建庫截至2012年5月，同時手工檢索相關灰色文獻，查找腹腔鏡與開腹手術切除子宮治療婦科良性病的隨機對照試驗。由2位研究者按照納入排除標準篩選文獻、提取資料并評價質量后，采用RevMan 5.1軟件進行Meta分析。
結果　納入22個RCT，共3 304例患者。Meta分析結果顯示：與開腹術相比，腹腔鏡子宮切除術的住院時間［MD=–2.31，95%CI（–3.03，–1.60)，P lt;0.000 01］和術后恢復正常活動的時間更短［MD=–13.86，95%CI（–17.70， –10.03），P lt;0.000 01］，術后發熱及其他非特異性感染發生率更低［OR=0.72，95%CI（0.54，0.95），P=0.02］，但術中泌尿系損傷發生率更高［OR=2.41，95%CI（1.21，4.82），P=0.012］且手術時間延長［MD=20.27，95%CI（3.95，36.59），P=0.03］。兩組在術中腸道損傷、血管損傷、術后瘺管形成、術后排尿功能障礙及術后陰道殘端感染等并發癥發生率方面，其差異均無統計學意義（P gt;0.05）。
結論　本系統評價結果顯示，腹腔鏡子宮切除術治療婦科良性疾病在縮短住院時間及術后恢復正常活動時間優于傳統開腹手術，且術后發熱及其他非特異性感染發生率更低，但術中泌尿系損傷發生率更高且手術時間更長。由于缺乏術后長期生活質量結局指標的結果，期待未來更多高質量的隨機對照試驗結果驗證。

引用本文： 賀紅英,李力,陳江鴻,李晶晶,唐移忠,鐘華. 腹腔鏡子宮切除術治療婦科良性疾病療效的系統評價. 中國循證醫學雜志, 2013, 13(1): 62-69. doi: 10.7507/1672-2531.20130013 復制

1.	Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol, 2007, 110(5): 1091-1095.
2.	Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol, 2008, 198(1): 34 -37.
3.	Clayton RD. Hysterectomy. Best Pract Res Clin Obstet Gynaecol, 2006, 20(1): 73-87.
4.	Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gyneco Surg, 1989, (5): 213-216.
5.	Reich H. Total laparoscopic hysterectomy: indications, techniques and outcomes. Curr Opin Obstet Gynecol, 2007, 19(4): 337-344.
6.	Reich H, Roberts L. Laparoscopic hysterectomy in current gynecological practice. Reviews in Gynaecological Practice, 2003, (3): 32-40.
7.	Johns DA, Carrera B, Jones J, et al. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol, 1995, 6(172): 1715-1719.
8.	Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev, 2006, (2): CD003677.
9.	Brill AI. Hysterectomy in the 21st century: different approaches, different challenges. Clin Obstet Gynecol, 2006, 49(4): 722-735.
10.	Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ, 2004, 328(7432): 129.
11.	Englund M, Robson S. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. J Minim Invasive Gynecol, 2007, 14(6): 724-728.
12.	Johnson N, Barlow D, Lethaby A, et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ, 2005, 330(7506): 1478.
13.	Kluivers, Riphagen I, Vierhout ME, et al. Comparison of laparoscopic and abdominal hysterectomy in terms of quality of life: a systematic review. Eur J Obstet Gynecol Reprod Biol, 2008, 136(1): 3-8.
14.	Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol, 1994, 101(12): 1068-1071.
15.	Kunz G, Plath T, Leyendecker G. [Comparison of laparoscopically assisted vaginal hysterectomy with abdominal hysterectomy. Technique and results]. Geburtshilfe Frauenheilkd, 1996, 56(9): 453-457.
16.	Langebrekke A, Eraker R, Nesheim BI, et al. Abdominal hysterectomy should not be considered as a primary method for uterine removal. A prospective randomised study of 100 patients referred to hysterectomy. Acta Obstet Gynecol Scand, 1996, 75(4): 404-407.
17.	Olsson JH, Ellstrom M, Hahlin M, et al. A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol, 1996, 103(4): 345-350.
18.	Ellström M, Olsén MF, Olsson JH, et al. Pain and pulmonary function following laparoscopic and abdominal hysterectomy: a randomized study. Acta Obstet Gynecol Scand, 1998, 77(9): 923-928.
19.	Summitt RL, Stovall TG, Steege JF, et al. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol, 1998, 92(3): 321-326.
20.	Yuen PM, Mak TW, Yim SF, et al. Metabolic and inflammatory responses after laparoscopic and abdominal hysterectomy. Am J Obstet Gynecol, 1998, 179(1): 1-5.
21.	Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol, 1999, 180(4): 955-962.
22.	Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol, 1999, 180(2 Pt 1): 270-275.
23.	Perino A, Cucinella G, Venezia R, et al. Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study. Hum Reprod, 1999, 14(12): 2996-2999.
24.	Ferrari M, Berlanda N, Mezzopane R, et al. Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids. BJOG, 2000, 107(5):620-625.
25.	Harkki-Siren P, Sjoberg J, Toivonen J, et al. Clinical outcome and tissue trauma after laparoscopic and abdominal hysterectomy: a randomized controlled study. Acta Obstet Gynecol Scand, 2000, 79(10): 866-871.
26.	Lumsden MA, Twaddle S, Hawthorn R, et al. A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy. BJOG, 2000, 107(11): 1386-1391.
27.	Ottosen C, Lingman G, Ottosen L. Three methods for hysterectomy: a randomised, prospective study of short term outcome. BJOG, 2000, 107(11): 1380-1385.
28.	Hwang JL, Seow KM, Tsai YL, et al. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study. Acta Obstet Gynecol Scand, 2002, 81(12): 1132-1138.
29.	Schutz K, Possover M, Merker A, et al. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g. Surg Endosc, 2002, 16(1): 121-125.
30.	Seracchioli R, Venturoli S, Vianello F, et al. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. J Am Assoc Gynecol Laparosc, 2002, 9(3): 333-338.
31.	Ribeiro SC, Ribeiro RM, Santos NC, et al. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynaecol Obstet, 2003, 83(1): 37-43.
32.	Tsai EM, Chen HS, Long CY, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a study of 100 cases on light-endorsed transvaginal section. Gynecol Obstet Invest, 2003, 55(2): 105-109.
33.	Persson P, Wijma K, Hammar M, et al. Psychological wellbeing after laparoscopic and abdominal hysterectomy--a randomised controlled multicentre study. BJOG, 2006, 113(9): 1023-1030.
34.	Kluivers KB, Mol BW, Bremer GL, et al. Pelvic organ function in randomized patients undergoing laparoscopic or abdominal hysterectomy. J Minim Invasive Gynecol, 2007, 14(4): 442-448.
35.	Garry R, PG. How safe is the laparoscopic approach to hysterectomy? Gynaecological Endoscopy, 1995, 4: 77-79.
36.	Härkki-Sirén P, Sjöberg J, Mäkinen J, et al. Finnish national register of laparoscopic hysterectomies: a review and complications of 1165 operations. Am J Obstet Gynecol, 1997, 176(1 Pt 1): 118-122.
37.	Wattiez A, Soriano D, Cohen SB, et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc, 2002, 9(3): 339-345.
38.	Kluivers KB, Hendriks JC, Mol BW, et al. Quality of life and surgical outcome after total laparoscopic hysterectomy versus total abdominal hysterectomy for benign disease: a randomized, controlled trial. J Minim Invasive Gynecol, 2007, 14(2): 145-152.
39.	Chien P, Khan K, Mol BW. How to interpret the findings of the eVALuate study. BJOG, 2005, 112(4): 391-393.
40.	Kluivers KB, Riphagen I, Vierhout ME, et al. Systematic review on recovery specific quality-of-life instruments. Surgery, 2008, 143(2): 206-215.

1. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol, 2007, 110(5): 1091-1095.
2. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol, 2008, 198(1): 34 -37.
3. Clayton RD. Hysterectomy. Best Pract Res Clin Obstet Gynaecol, 2006, 20(1): 73-87.
4. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gyneco Surg, 1989, (5): 213-216.
5. Reich H. Total laparoscopic hysterectomy: indications, techniques and outcomes. Curr Opin Obstet Gynecol, 2007, 19(4): 337-344.
6. Reich H, Roberts L. Laparoscopic hysterectomy in current gynecological practice. Reviews in Gynaecological Practice, 2003, (3): 32-40.
7. Johns DA, Carrera B, Jones J, et al. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol, 1995, 6(172): 1715-1719.
8. Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev, 2006, (2): CD003677.
9. Brill AI. Hysterectomy in the 21st century: different approaches, different challenges. Clin Obstet Gynecol, 2006, 49(4): 722-735.
10. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ, 2004, 328(7432): 129.
11. Englund M, Robson S. Why has the acceptance of laparoscopic hysterectomy been slow? Results of an anonymous survey of Australian gynecologists. J Minim Invasive Gynecol, 2007, 14(6): 724-728.
12. Johnson N, Barlow D, Lethaby A, et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ, 2005, 330(7506): 1478.
13. Kluivers, Riphagen I, Vierhout ME, et al. Comparison of laparoscopic and abdominal hysterectomy in terms of quality of life: a systematic review. Eur J Obstet Gynecol Reprod Biol, 2008, 136(1): 3-8.
14. Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol, 1994, 101(12): 1068-1071.
15. Kunz G, Plath T, Leyendecker G. [Comparison of laparoscopically assisted vaginal hysterectomy with abdominal hysterectomy. Technique and results]. Geburtshilfe Frauenheilkd, 1996, 56(9): 453-457.
16. Langebrekke A, Eraker R, Nesheim BI, et al. Abdominal hysterectomy should not be considered as a primary method for uterine removal. A prospective randomised study of 100 patients referred to hysterectomy. Acta Obstet Gynecol Scand, 1996, 75(4): 404-407.
17. Olsson JH, Ellstrom M, Hahlin M, et al. A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol, 1996, 103(4): 345-350.
18. Ellström M, Olsén MF, Olsson JH, et al. Pain and pulmonary function following laparoscopic and abdominal hysterectomy: a randomized study. Acta Obstet Gynecol Scand, 1998, 77(9): 923-928.
19. Summitt RL, Stovall TG, Steege JF, et al. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol, 1998, 92(3): 321-326.
20. Yuen PM, Mak TW, Yim SF, et al. Metabolic and inflammatory responses after laparoscopic and abdominal hysterectomy. Am J Obstet Gynecol, 1998, 179(1): 1-5.
21. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol, 1999, 180(4): 955-962.
22. Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol, 1999, 180(2 Pt 1): 270-275.
23. Perino A, Cucinella G, Venezia R, et al. Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study. Hum Reprod, 1999, 14(12): 2996-2999.
24. Ferrari M, Berlanda N, Mezzopane R, et al. Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids. BJOG, 2000, 107(5):620-625.
25. Harkki-Siren P, Sjoberg J, Toivonen J, et al. Clinical outcome and tissue trauma after laparoscopic and abdominal hysterectomy: a randomized controlled study. Acta Obstet Gynecol Scand, 2000, 79(10): 866-871.
26. Lumsden MA, Twaddle S, Hawthorn R, et al. A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy. BJOG, 2000, 107(11): 1386-1391.
27. Ottosen C, Lingman G, Ottosen L. Three methods for hysterectomy: a randomised, prospective study of short term outcome. BJOG, 2000, 107(11): 1380-1385.
28. Hwang JL, Seow KM, Tsai YL, et al. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study. Acta Obstet Gynecol Scand, 2002, 81(12): 1132-1138.
29. Schutz K, Possover M, Merker A, et al. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g. Surg Endosc, 2002, 16(1): 121-125.
30. Seracchioli R, Venturoli S, Vianello F, et al. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. J Am Assoc Gynecol Laparosc, 2002, 9(3): 333-338.
31. Ribeiro SC, Ribeiro RM, Santos NC, et al. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. Int J Gynaecol Obstet, 2003, 83(1): 37-43.
32. Tsai EM, Chen HS, Long CY, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a study of 100 cases on light-endorsed transvaginal section. Gynecol Obstet Invest, 2003, 55(2): 105-109.
33. Persson P, Wijma K, Hammar M, et al. Psychological wellbeing after laparoscopic and abdominal hysterectomy--a randomised controlled multicentre study. BJOG, 2006, 113(9): 1023-1030.
34. Kluivers KB, Mol BW, Bremer GL, et al. Pelvic organ function in randomized patients undergoing laparoscopic or abdominal hysterectomy. J Minim Invasive Gynecol, 2007, 14(4): 442-448.
35. Garry R, PG. How safe is the laparoscopic approach to hysterectomy? Gynaecological Endoscopy, 1995, 4: 77-79.
36. Härkki-Sirén P, Sjöberg J, Mäkinen J, et al. Finnish national register of laparoscopic hysterectomies: a review and complications of 1165 operations. Am J Obstet Gynecol, 1997, 176(1 Pt 1): 118-122.
37. Wattiez A, Soriano D, Cohen SB, et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc, 2002, 9(3): 339-345.
38. Kluivers KB, Hendriks JC, Mol BW, et al. Quality of life and surgical outcome after total laparoscopic hysterectomy versus total abdominal hysterectomy for benign disease: a randomized, controlled trial. J Minim Invasive Gynecol, 2007, 14(2): 145-152.
39. Chien P, Khan K, Mol BW. How to interpret the findings of the eVALuate study. BJOG, 2005, 112(4): 391-393.
40. Kluivers KB, Riphagen I, Vierhout ME, et al. Systematic review on recovery specific quality-of-life instruments. Surgery, 2008, 143(2): 206-215.

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《中國循證醫學雜志》

腹腔鏡子宮切除術治療婦科良性疾病療效的系統評價

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