腹腔镜卵巢内异症囊肿剥除术中不同止血方法对卵巢储备功能的影响

摘要

目的 探讨腹腔镜卵巢内异症囊肿剥除术中使用不同止血方法对卵巢储备功能的影响.方法 选择2008年9月至2010年2月在山东大学附属省立医院住院治疗的卵巢内异症囊肿患者162例,于术前月经周期第3天,晨起抽取空腹静脉血查FSH和抗苗勒管激素(AMH)水平,超声测量双侧卵巢基础窦卵泡计数(AFC)和卵巢基质动脉血流的收缩期峰值(PSV).采用随机数字表法将患者分为3组,行常规腹腔镜卵巢内异症囊肿剥除术,术中分别在剥除囊肿后采用双极电凝(双极电凝组,54例)、超声刀(超声刀组,54例)和缝合(缝合组,54例)法止血.术后第1、3、6、12次月经周期第3天,复查FSH、AMH水平及AFC和PSV,比较腹腔镜术中不同止血方法对卵巢储备功能的影响.结果 (1)术前情况:各组患者年龄、卵巢内异症囊肿大小、术前FSH、AMH水平及AFC、PSV水平比较,差异均无统计学意义(P＞0.05).(2)术后卵巢储备功能变化:①FSH:术后1、3、6、12个月时,双极电凝组FSH水平分别为(11.7±4.0)、(9.9±4.0)、(9.5±4.3)、(9.5±3.9)U/L,超声刀组分别为(11.4±4.3)、(9.7±4.0)、(9.2±3.7)、(9.9 ±4.6) U/L,均明显高于缝合组的(9.3±3.8)、(6.7±3.0)、(6.5±3.2)、(6.4±2.2) U/L,分别比较,差异均有统计学意义(P＜0.05).②AMH:术后1、3、6、12个月时,双极电凝组AMH水平分别为(1.8±0.9)、(1.8±1.0)、(1.9±1.0)、(2.0±1.0) μg/L,超声刀组分别为(1.6±0.8)、(1.8±1.0)、(2.0±1.1)、(2.1±1.0)μg/L,均明显低于缝合组的(2.8±1.7)、(2.9±1.6)、(3.0±1.3)、(3.2±1.5)μg/L,分别比较,差异也有统计学意义(P＜0.05).③AFC:手术后1个月时,各组患者的AFC比较,差异无统计学意义(P＞0.05),但术后3、6、12个月时,缝合组的AFC分别为(4.8±1.4)、(5.9±1.5)、(6.1±1.5)个,明显高于双极电凝组的(3.7±1.4)、(4.1±1.4)、(4.0±1.5)个和超声刀组的(3.6±1.3)、(4.0±1.1)、(3.9±1.5)个,分别比较,差异均有统计学意义(P＜0.05).④PSV:术后1、3、6、12个月时,双极电凝组PSV分别为(7.9±3.5)、(8.1±3.3)、(8.4±3.1)、(8.6±3.0) cm/s,超声刀组分别为(8.1±3.5)、(8.0±3.0)、(7.9±3.2)、(8.0±2.9) cm/s,均明显低于缝合组的(10.9±3.3)、(12.0±3.2)、(1 1.8±3.0)、(12.1 ±4.1)cm/s,分别比较,差异均有统计学意义(P＜0.05).结论 腹腔镜卵巢内异症囊肿剥除术中,应用双极电凝或超声刀止血会导致卵巢储备功能下降,应该慎用电凝烧灼方式止血.%Objective To investigate the impact on ovarian reserve function by different hemostasis methods during laparoscopic surgery in treatment of ovarian endometrioma.Methods From September 2008 to February 2010,162 cases with ovarian endometrioma undergoing laparoscopic surgery in Shandong Provincial Hospital were enrolled in this study.At the 3rd day of the menstrual cycle before surgery and the 1 st,3rd,6th and 12th cycle after surgery,serum FSH and anti-mullerian hormone(AMH) and ultrasound basal antral follicle count (AFC) and peak systolic velocity (PSV) were examined and compared.Based on hemostasis method,those patients were divided into 3 groups,including 54 cases in bipolar hemostasis,54 cases in ultrasonic scalpel hemostasis and suture after excision of endometrioma.Results (1) Before surgery:no significant different factors among three groups before surgery were observed,including age,size of endometrioma,the level of FSH,AMH,AFC,PSV (P ＞ 0.05).(2) Ovarian reserve function after surgery:①FSH:at the 1st,3rd,6th and 12th month follow-up,the FSH in the bipolar group was (11.7 ±4.0),(9.9 ± 4.0),(9.5 ± 4.3),(9.5 ± 3.9) U/L,and the FSH in ultrasonic scalpel group was (11.4 ±4.3),(9.7 ± 4.0),(9.2 ± 3.7),(9.9 ± 4.6) U/L,were significantly higher than (9.3 ± 3.8),(6.7 ±3.0),(6.5 ± 3.2),(6.4 ± 2.2) U/L in suture group respectively (all P ＜ 0.05).()AMH:at the 1 st,3rd,6th and 12th month follow-up,the AMH in the bipolar group was (1.8 ±0.9),(1.8 ± 1.0),(1.9 ±1.0),(2.0 ± 1.0) μg/L,and the AMH in the ultrasonic scalpel group was (1.6 ±± 0.8),(1.8 ± 1.0),(2.0 ± 1.1),(2.1 ± 1.0) μg/L,which were significantly lower than (2.8 ± 1.7),(2.9 ± 1.6),(3.0 ±1.3),(3.2 ± 1.5) μg/L in suture group,respectively (all P ＜ 0.05).③AFC:there was no significant difference of APC among the three groups in the 1st month after surgery.However,at the 3rd,6th and 12th month follow-up,the AFC of 4.8 ± 1.4,5.9 ± 1.5,6.1 ± 1.5 in the suture group was significant higher than 3.7 ± 1.4,4.1 ± 1.4,4.0 ± 1.5 in bipolar group and 3.6 ± 1.3,4.0 ± 1.1,3.9 ± 1.5 in ultrasonic group,respectively (all P ＜ 0.05).④PSV:at the 1 st,3rd,6th and 12th month follow-up,the PSV of the bipolar group(7.9 ±3.5),(8.1 ±3.3),(8.4 ±3.1),(8.6±3.0) cm/s in bipolar group and (8.1 ±3.5),(8.0 ± 3.0),(7.9 ± 3.2),(8.0 ± 2.9) cm/s in ultrasonic group were significant lower than (10.9 ± 3.3),(12.0 ± 3.2),(11.8 ± 3.0),(12.1 ± 4.1) cm/s in suture group,respectively.(allP＜0.05).Conclusions Bipolar or ultrasonic scalpel hemostasis during laparoscopic excision of ovarian endometrioma is associated with a significant reduction in ovarian reserve.Electrocoagulation of the ovarian tissue should be avoided.