【作者】 黄玉华；

【导师】 刘惜时； 屠蕊沁；

【作者基本信息】 复旦大学 ， 妇产科学（专业学位）， 2013， 硕士

【摘要】 目的：通过对病史进行回顾性分析,对比和评估因良性疾病导致子宫切除的三种手术方式(LAVH、TAH、TVH)的相关临床因素及治疗成本,进行卫生经济学分析,以期指导临床选择,为医疗卫生决策提供理论依据。方法：本研究为回顾性队列分析,对象为复旦大学附属中山医院2011年1月1日至2012年12月31日因良性疾病行子宫切除术的患者。对比其年龄、孕产次、住院天数、术中出血量、输血率、子宫体积、住院费、手术费、检查费及药物费用等。结果：2011年1月1日至2012年12月31日共790例患者行子宫切除术,其中LAVH占54.56%(431/790),TAH占40.13%(317/790),TVH占5.32%(42/790)。子宫切除术的主要适应症(以术后病理结果为准)为子宫肌瘤(48.03%),其次为附件良性肿瘤(21.34%)、子宫脱垂(7.42%)、子宫肌腺症(5.57%)、子宫肌瘤合并附件良性肿瘤(5.34%)、功能失调性子宫出血(4.87%)、子宫肌瘤合并子宫肌腺症(3.48%)、子宫肌腺症合并子宫内膜异位症(1.39%)、子宫内膜异位症(1.39%)、子宫肌腺症合并附件良性肿瘤(0.93%)、盆腔炎症(0.23%)。对比术前诊断与术后病理结果,计算得出诊断符合率为87.34%。LAVH组平均年龄为52.73岁,TAH组平均年龄为52.52岁,TVH组平均年龄为67.90岁,P<0.05,有显著差异性。LAVH组、TAH组、TVH组妊娠次数分别为2.82次、2.62次、3.40次,P<0.05,有显著差异性。分娩次数LAVH组、TAH组、TVH组分别为1.50次、1.48次、2.43次,P<0.05,有显著性差异。术前血红蛋白值LAVH组、TAH组、TVH组分别为117.45g/L、112.06g/L、122.07g/L,P<0.05,有显著差异性。术前住院天数LAVH组、TAH组、TVH组分别为3.54天、3.77天、4.12天,P>0.05,无显著差异性。平均总住院天数为9.46天,LAVH组8.22天,TAH组11.07天,TVH组10.07天,P<0.05,有显著性差异。术后住院日LAVH组、TAH组、TVH组分别为4.68天、7.30天、5.95天,P<0.05,有显著性差异。术中出血量LAVH组、TAH组、TVH组分别为81.57m1、105.89m1、89.29m1,P值<0.05,有显著性差异。子宫体积LAVH组、TAH组及TVH组分别为7.45cm、8.68cm、4.48cm,P值<0.05,有显著性差异。三组手术方式分别比较总费用、手术费、药品费及检查费,三组间均有统计学差异。两两比较得出,除了TAH组和TVH组在手术费用上无明显差异,其它各项比较均见显著差异性。其中,LAVH的总住院平均费用为16015.58元,手术平均费用为6503.04元。TAH总住院平均费用为12522.88元,手术平均费用为3914.75元。TVH总住院平均费用为10684.65元,手术平均费用为3916.55元。手术方式、术中出血量、手术费用及住院天数与总住院费用相关。而手术费用与患者年龄、手术方式、住院天数、子宫体积、术后住院天数相关。结论：LAVH组患者的临床效果优于其他两组。三种手术方式中LAVH总住院费用最高,其差异主要表现在手术费用上。随着手术器械费用的降低,其成本效益有望提高。患者住院费用受手术方式影响显著。更多还原

【Abstract】 Objective:Retrospective analysis of surgical experience data and health economics comparing different methods of benign hysterectomy including abdominal, vaginal and laparoscopic techniques. Methods:We performed a retrospective cohort analysis of all patients who underwent a hysterectomy for benign reasons in2011and2012at Zhongshan Hospital of Fudan University using the X2test and t test. A multivariate regression analysis was also performed for predictor of costs. Results:In2011and2012,790patients underwent a benign hysterectomy;431(54.56%) hysterectomies were laparoscopic,317(40.13%) abdominal42(5.32%) vaginal. The common indications for surgery included uterine leiomyoma(48.03%), benign ovarian tumor(21.34%), genital prolapsed (7.42%) and adenomyosis(5.57%). Compared to preoperative diagnosis and postoperative pathological results, we calculated diagnostic coincidence rate was87.34%. There were no statistically significant differences in the preoperative hospitalization days and blood transfusion rate. There were statistically significant differences of LAVH group, TAH group and TVH group in the age(52.73vs.52.52vs.67.90, P<0.05), the length of stay(8.22vs.11.07vs.10.07days, P<0.05), the postoperative hospitalization days (4.68vs.7.30vs.5.95days, P<0.05), estimated blood loss (81.57vs.105.89vs.89.29ml, P<0.05) and uterine body diameter (7.45vs.8.68vs.4.48days, P<0.05). Mean total patient costs were16015.58yuan for laparoscopic, and12522.88yuan for abdominal and10684.65yuan for vaginal hysterectomies. The OR costs were6503.04yuan for laparoscopic, and3914.75yuan for abdominal and3916.55yuan for vaginal hysterectomies. Total costs were significantly influenced by method of hysterectomy, OR costs, length of stay and estimated blood loss. Conclusion:The clinical effect of LAVH group is better than the other two groups’. The advantages are less blood loss and a shorter length of hospital stay for qualified patients. The total costs of LAVH group is larger than the others, but it has a better future. Patient costs are significantly influenced by the method of hysterectomy.更多还原