经阴道无张力尿道中段吊带术TVT术课件.ppt

经阴道无张力尿道中段吊带术TVT术,上海第二医科大学附属仁济医院泌尿外科,TVT微创伤手术,1.减少手术时间Reducesurgicaltime2.减少住院时间Reducelengthofhospitalization3.减少并发症Reducecomplicationrates/risks4.复原快Allowquickerreturntonormal,dailyactivities5.减少费用Lowercosts,GYNECARETVTTension-freeSupportforIncontinenceTVT尿失禁的无张力支撑简介I,TVT尿失禁的无张力支撑是一种创新的微创伤手术方法,它对张力性尿失禁治疗的有效性已得到了充分的临床证明GYNECARETVTTension-freeSupportforIncontinenceisaninnovativeminimallyinvasivesurgicalalternativefortheeffectivetreatmentofstressurinaryincontinence,withprovenresults使用Prolene网带进行无张力尿道中段悬吊术TheplacementofapieceofPROLENEmesh(45cmx1.1cmx0.7mm)withouttension,atthemidurethra,GYNECARETVTTension-freeSupportforIncontinenceTVT尿失禁的无张力支撑简介II,局麻,阻滞/硬膜外Localanesthesia,sedation/regional经阴道进路，切口小,分离少Minimalincisionsanddissection网带无张力地置于尿道中段下Tapeplacedatmidurethrawithouttension普理灵聚丙烯网带无需和任何组织固定Nofixation术中使用膀胱镜Cystoscopyperformed术后插尿管时间短Infrequentuseofpost-opcatheters可在门诊进行，当天出院Dischargehomethesameday,GoalofSurgery手术目的,1.修复和/或加强阴道尿道韧带Restoreand/orreinforcethepubourethralligaments.2.修复和/或加强尿道下阴道吊筋膜Restoreand/orreinforcethesuburethralvaginalhammock3.加强尿道旁结缔组织Reinforcetheparaurethralconnectivetissue,GYNECARETVTTension-freeSupportforIncontinenceIndicationsTVT尿失禁的无张力支撑适应症,适应于以下原因引起的女性张力性尿失禁IntendedtobeusedfortreatmentofFemaleStressUrinaryIncontinenceresultingfrom尿道过度活动urethralhypermobility尿道括约肌损伤intrinsicsphincterdeficiency,GYNECARETVTContraindicationsTVT尿失禁的无张力支撑禁忌征,怀孕病人Pregnantpatients未完成发育的病人Patientswithfuturegrowthpotential计划要怀孕的病人Womenwithplansforfuturepregnancy,GYNECARETVTTension-FreeSupportforIncontinenceSystemTVT产品系列,TVT网带GYNECARETVTDevice推针器GYNECARETVTIntroducer导引杆GYNECARETVTRigidCatheterGuide,GYNECARETVTTension-freeSupportforIncontinence,Description:PROLENE*polypropylenemeshcoveredbyaplasticsheathProlene*网带:网状钩形编织,外面套有塑料膜,Prolene*网带,TVT网带,长45公分,宽一公分的网带,成分为聚丙烯网带的两侧边有特意编制的毛刺,增加其在腹壁中的摩擦力,将带子固定在腹壁中外面包有一层塑料套,塑料套在中间分开网带的两头分别为长30公分,直径为5毫米的针.手术中,针通过阴道前壁切口,带着网带穿过腹壁,使其置于尿道中段下网带的网眼大小适中,术后结缔组织会长在网眼中,加强盆底的组织,Prolene普理灵,特点惰性强组织相容性强/组织反应小有延展性表面光滑易于操作心血管吻合的专用缝线,在缝合材料中有“缝线之王”的称号,GYNECARETVTIntroducer推针器,推针器,推针器的方形头部结在真的方形尾部,手术中,术者的手握住推针器的T形手柄,帮助针顺利穿过腹壁,GYNECARETVTRigidCatheterGuide导引杆,导引杆,导引杆在手术中的作用主要是推开膀胱,防止穿针过程中产生膀胱穿孔它从18号导尿杆进入膀胱,从左侧穿针,就将膀胱推向右侧,反之亦然,GYNECARETVTPatientInformation病人情况,手术介绍Procedureoverview病人手术风险Potentialrisks血肿Bleeding-hematomaformation感染Infection膀胱穿孔Bladderperforation尿潴留Urinaryretention排斥反应Mesherosionorrejection复原Recovery期望Expectations,GYNECARETVT-PreOpTVT术前,术前抗菌素Peri-operativeantibiotics停止使用抗凝剂Cessationofanti-coagulants,InstrumentRequirements手术需要的器械,阴道重锤/拉钩弯剪-分蚊式钳-钳住塑料套,抽出.长的硬膜外针头-局麻70度膀胱镜-观察膀胱情况18号(单枪/双枪)导尿管,GYNECARETVT-Procedure手术过程,病人准备Patientpreparation切口Incisions分离，穿针，放置网带Dissection,needlepassageandtapeplacement网带松紧度调整Tensionadjustment结束手术Completingtheprocedure,PatientPosition病人体位,截石位，膝盖与耻骨联合平行插18号导尿管,排空膀胱Insert18frcatheterandemptybladder,Anesthetic麻醉,局麻+静脉加强LocalAnesthesiawithIVsedation,recommended骶麻或全麻RegionalorGeneralanesthesiapossible.,Anesthesia麻醉Abdomen腹部,Anesthesia麻醉VaginalWall阴道前壁,Incisions切口,阴道前壁Vaginal在离尿道外口1cm处作1.5cm纵向切口腹部Abdominal在耻骨联合上方，腹中线两侧各作一个0.5cm-1.0cm切口2incisionseachsideofmidline两切口相距最宽4-5公分justabovesymphysis4-5cmapartmax.,VaginalWallIncision阴道前壁切口,在离尿道外口1cm处作1.5cm纵向切口,AbdominalIncisions腹部切口,在耻骨联合上方，腹中线两侧各作一个0.5cm-1.0cm切口，两切口相距最宽4-5公分,DissectionofAnteriorWall阴道前壁分离BluntDissectionsubandparaurethrally在尿道旁和尿道下进行钝性分离,InsertTVTRigidCatheterGuide插入TVT导引杆,2019/12/16,31,可编辑,2019/12/16,32,可编辑,IntroductionoftheGYNECARETVTDevice推入TVT网带,通过阴道切口推入Introducethroughvaginalincision针头指向髂骨Aimtowardipsilateralshoulder绕过耻骨Hugthepubicbone(donotscrap从腹壁切口出Exitatabdominalincision,IntroductionoftheGYNECARETVTDevice推入TVT网带,GuidetheNeedleTiptotheAbdominalIncision将针头导向腹壁切口,针不要拔出,Cystoscopy膀胱镜,针穿过后,使用膀胱镜确保膀胱完好Aftereachpassageoftheneedle,cystoscopyshouldbecompletedtoverifybladderintegrity将膀胱注液后使用膀胱镜Cystoscopyshouldbedonewithbladderhalf-full,BladderPerforation膀胱穿孔,BladderPerforation膀胱穿孔,SecondPassageoftheGYNECARETVTDevice第二根针的穿入,重新插导尿管,排空膀胱Re-insertthecatheteranddrainthebladder重复第一次穿针的步骤Theoppositesideiscompletedinthesamemannerasthefirst确保网带没有扭转Ensurethatthetapedoesnottwist再次使用膀胱镜CystoscopyafterthesecondpassoftheTVTneedle针从腹壁切口拉出PullTVTneedlethroughtheabdomenincision,TapeAdjustment调整网带,在网带和尿道间放置一把剪刀或止血钳Placescissorsorhemostatbetweenthetapeandtheurethra拉腹壁端的网带,直到网带贴住剪刀Pulltheabdominalendsofthetapeuntilthereiscontactbetweentapeandinstrument将针剪去Separateneedlesfromthetape先不要拉出塑料薄膜Donotremovetheplasticsheath,CoughTest腹压测试,膀胱注液250毫升Fillbladderwith250mlofsaline取出尿道下的剪刀/或止血钳Removeinstrumentundertheurethra取下阴道重锤Removevaginalspeculum要病人用力咳嗽Askpatienttocough调整网带松紧度AdjustTVTtape调整松紧度时,剪刀要置于网带和尿道之间Instrumentshouldbeplacedbetweenthetapeandtheurethraduringadjustment,InitialCoughTest初步腹压测试,AdjustTapewithInstrumentinPlace器械放置在网带和尿道间,调整网带,CompletingtheProcedure完成手术,抽出塑料薄膜Removeplasticsheath剪去腹壁上多余的网带CutProleneMesh缝合皮肤和阴道粘膜切口Closeskinandvaginalepithelium排空膀胱Emptybladder取出导尿管Removecatheter,CompletingtheProcedure完成手术removingplasticsheath取出塑料薄膜,CompletingtheProcedure完成手术Trimmingthemesh剪去多余的网带,GYNECARETVTPostoperativeAssessmentBeforeDischarge出院前的术后评估,出血/血肿Bleeding/hematoma餐饮Eatinganddrinking排尿Voiding,GYNECARETVTPostoperativeInstructions术后要求,术后排尿残留Postvoidresidual3-4天抗菌素Antibiotics3-4Days限制活动Activitylimitations驾驶锻炼性生活工作,GYNECARETVTPostoperativeCareFollow-upappointments随访,3weeks6monthsYearly,GYNECARETVTComplications&Treatment并发症及其治疗方法,尿潴留Urinaryretention,GYNECARETVTComplications&Treatment并发症及其治疗方法,膀胱穿孔Perforationofthebladder使用膀胱镜确认Cystoscopicidentification取出针,重新穿Removeneedleandreposition导尿管留置1-2天Indwellingcatheterx1-2days,GYNECARETVTComplications&Treatment并发症及其治疗方法,阴道出血/后腹膜血肿Vaginalbleeding/Retropubichematoma保守治疗Manageconservatively阴道填塞Vaginalpacking引流Percutaneousdrainageifnecessary,GYNECARETVTComplications&Trea