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中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2017, Vol. 13 ›› Issue (02): 183 -188. doi: 10.3877/cma.j.issn.1673-5250.2017.02.011

Special Issue: ；

Original Article

Disseminated peritoneal leiomyomatosis after laparoscopic surgery and literatures review

Xiaohui Huang1, Liqin Zeng1,†(), Wenyan Jin1   

  1. 1. Department of Gynecology, Guangdong Women and Children′s Hospital, Guangzhou 510010, Guangdong Province, China
  • Received:2016-12-16 Revised:2017-02-17 Published:2017-04-01
  • Corresponding author: Liqin Zeng
  • About author:
    Corresponding author: Zeng Liqin, Email:
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Objective

To explore the prevention, diagnosis and treatment of disseminated peritoneal leiomyomatosis (DPL) after laparoscopic surgery.

Methods

Retrospectively analyzed the clinical data of 3 cases of DPL patients after laparoscopic surgery in Guangdong Women and Children′s Hospital, and reviewed 14 domestic and foreign literatures about the DPL after laparoscopic surgery by literature retrieval.And summarized the clinical characteristics, prevention, diagnosis and treatment of DPL after laparoscopic surgery.

Results

① The cases histories data of 3 patients with DPL after laparoscopic surgery were as following: all cases had laparoscopic myomectomy(LM) histories, and used uterine shredder to remove fibroids; no obvious symptoms and signs were shown, just found pelvic mass by routine health examination; preoperative diagnosises were uterine leiomyoma, and intraoperative DPL was found and took surgical resection with good postoperative recovery. ② Clinical characteristics of DPL patients in 14 domestic and foreign literatures and this paper were analyzed. There were 24 DPL patients after laparoscopic surgery, pathological results were leiomyoma, all had LM or laparoscopic subtotal hysterectomy (LSH) histories, and the histories of removing the fibroids by uterine shredder. All patients were women of childbearing age, 20.8%(5/24) patients were not yet pregnant and childbearing; 8.3%(2/24) patients had taken estrogen or progesterone treatment; 58.3%(14/24) patients had no special symptoms and signs, only found pelvic or uterine mass by routine health examination, 25.0%(6/24) patients with the symptom of abdominal pain, others had abdominal distensions and discomforts, or menstrual flow increased; 33.3%(8/24) patients had twice or more histories of uterine surgery.

Conclusions

Patients with uterine leiomyoma should be carefully selected for their abdominal surgery mode and the use of uterine shredder, and should take measures to prevent fragment tissues of fibroids disseminating in pelvic and abdominal cavity. Individualized treatment should be taken for DPL patients.

Key words: Uterine neoplasms, Leiomyomatosis, Laparoscopy, Peritoneal neoplasms, Morcellation, Women
表1 3例腹腔镜术后DPL患者主要病历资料结果
病例 年龄、主诉及入院时间 既往子宫手术史 腹部超声检查结果
患者1 33岁， "超声发现子宫肿物1年" ， 2015年2月9日入本院 2012年，在外院接受LM，用子宫旋切器取出肌瘤 子宫前壁肌瘤大小约为59 mm×44 mm
患者2 28岁， "体检发现子宫肿物1年" ， 2015年12月22日入本院 2010年12月21日，在本院接受LM，用子宫旋　切器取出肌瘤a2013年1月，在本院接受剖宫产术＋子宫肌瘤　剔除术 子宫后方见低回声声像，约为79 mm×55 mm，边界清，内部回声欠均匀，与子宫及卵巢分界清；见2个子宫后壁肌瘤，低回声团，分别为17 mm×14 mm和11 mm×10 mm，边界清，内部回声分布均匀
患者3 26岁， "超声发现子宫肿物4年" ，2015年4月8日入本院 2011年10月，在本院接受LM，用子宫旋切器取出肌瘤 子宫后壁肌瘤大小约为103 mm×70 mm，局部向外隆起
病例 本次入院处理 本次术中所见 术后病理学检查结果
患者1 于2015年2月11日行LM＋肠管及腹膜肌瘤大小结节剔除术 子宫前壁下段肌瘤大小约为6 cm×5 cm，左骶韧带、左阔韧带、直肠前壁及肠系膜表面散在多个肌瘤结节，直径为1～2 cm，见图1 子宫富于细胞平滑肌瘤，局灶伴子宫内膜间质增生；肠管及腹膜表面结节播散性平滑肌瘤，局部子宫内膜间质细胞增生
患者2 于2015年12月25日行腹腔镜转剖腹子宫肌瘤、直肠前壁及腹膜平滑肌瘤剔除术 子宫后壁下段见直径约为2 cm肌瘤结节，左侧输卵管峡部浆膜面见直径约为1 cm肌瘤结节；子宫直肠窝见约为10 cm×8 cm×8 cm肌瘤结节，蒂部位于直肠前壁，宽约为4 cm，与直肠前壁致密黏连，见图2 子宫平滑肌瘤，部分富于细胞性；腹膜平滑肌瘤
患者3 于2015年4月9日行LM＋直肠前壁及腹膜肌瘤结节剔除术 子宫后壁下段见约为10 cm×7 cm肌瘤结节，直肠前壁表面及盆腔前侧壁腹膜散在多个直径约1～2 cm肌瘤结节，见图3 多发性平滑肌瘤，部分区域细胞丰富
图3 腹腔镜术后腹膜播散性平滑肌瘤病患者3术中所见结果(图3A：子宫后壁下段肌瘤结节；图3B：直肠前壁表面肌瘤结节；图3C、3D：盆腔前侧壁腹膜肌瘤结节)
表2 14篇腹腔镜术后DPL文献报道及本研究DPL患者临床特点
文献作者 例数(例) 年龄(岁)及生育史 使用雌、孕激素 前次手术方式 DPL发生距上次手术间隔时间(月) 症状或体征 再次手术方式 再次手术剔除肌瘤数量(个)/最大者直径(cm) 播散部位
Al-Talib和　Tulandi[1] ? 48，G3P1A2 否 LSH 120 腹痛 经腹 多个/8 网膜、盆腔腹膜
Lee和Noh[2] 1 31，G0 是 LM 12 腹痛 经腹 多个/4 阑尾、盆腔腹膜
Bisceglia等[3] 3 31，G2P2 是 LM/LM/LM 12/6/3 盆腔包块 LM 7/10 腹膜结节
? ? 34，G0 否 LM/LM 51/43 盆腔包块 经腹 10/10 腹腔结节
? ? 41，不详 否 LM/LM 144/120 腹部不适 经腹 多个/1.5 盆腔腹膜
Sinha等[4] 2 48，多产 否 LM/LH 84/36 腹痛 经腹 3/15 盆腔腹膜
? ? 41，G2P2 否 LM/LSH 96/8 盆腔包块 腹腔镜 2/10 左侧腹壁
Kumar等[5] 1 24，G0 否 LM 11 腹胀 经腹 6/30 网膜、直肠、腹膜
Miyake等[6] 1 36，G0 否 LM/LM 36/84 盆腔包块 经腹 17/18 胃浆膜、网膜、穿刺孔
Thian等[7] 1 35，G3P1A2 否 LM 31 盆腔包块 经腹 多个/14 盆腔、腹壁、结肠
Ordulu等[8] 1 48，G0 否 LSH 84 盆腔包块 经腹 16/9 腹腔、盆腔
Yang等[9] 1 34，G1P0A1 否 LM/经腹 33/16 盆腔包块 经腹 4/5 肠系膜、骶韧带
赵秀敏等[10] 3 36，不详 否 LM 24 腹痛 腹腔镜 多个/3 腹膜、腹壁
? ? 35，不详 否 LM 36 盆腔包块 腹腔镜 6/3 网膜、盆壁
? ? 45，不详 否 LM 40 月经增多 腹腔镜 3/5 网膜、盆壁
蔡鹏宇等[11] 2 48，G1P1 否 LSH 58 盆腔包块 经腹 多个/6 网膜、盆侧壁
? ? 49，不详 否 LM 42 子宫肿物 经腹 多个/4 子宫、肠壁
高志红等[12] 1 43，不详 否 LM 85 盆腔包块 经腹 1/4 穿刺孔
肖晓岚等[13] 1 35，G6P2A4 否 LM 24 腹痛 经腹 多个/6 腹壁、网膜、小肠表面
徐立新等[14] 2 38，不详 否 LM 120 盆腔包块 LM 5/9 阔韧带
? ? 38，不详 否 LM 48 腹痛 经腹 2/6 肠系膜
黄晓晖等(本研究) 3 33，G2P1A1 否 LM 36 盆腔包块 腹腔镜 多个/6 肠系膜、腹膜
? ? 28，G1P1 否 LM/剖宫产 60/23 盆腔包块 经腹 3/10 直肠窝
? ? 26，G3P0A3 否 LM 42 盆腔包块 腹腔镜 多个/10 系膜、盆壁
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