Appendix I: by Pan, Yaogui
Extraperitoneal cesarean section
Clinical Summary of 8 Cases
为结束妊娠必须娩出胎儿及其附属物，以恢复孕妇原先的生理状态。若因产道障碍无法由阴道分娩，或胎儿窘迫不及等待自然分娩，就需另寻分娩途径。
It is necessary to deliver the fetus and its appendages in order to end the pregnancy and restore the original physiological state of the pregnant woman. If vaginal delivery is not possible due to birth canal obstruction, or if the fetus is embarrassed and cannot wait for natural delivery, alternative routes of delivery may be necessary.
有史可查，早在500年前即有“帝王切开”古典式剖腹产，近代发展到子宫下段剖腹产，而此两术式均属腹膜内剖腹产术，可导致羊水、胎粪、血液等污染腹腔，引起肠麻痹、腹胀、腹痛等症状，甚至招致肠粘连、腹膜炎等严重並发症，带来不良预后，尤其是宫内感染者，更形不利。
According to available history, as early as 500 years ago, there was a classical cesarean section called “imperial incision”. In modern times, it has developed to the cesarean section at the lower part of the uterus. Both of these operations are intraperitoneal cesarean sections, which can cause amniotic fluid, meconium and blood to contaminate the abdominal cavity, causing symptoms such as enteroparalysis, abdominal distension and abdominal pain, and even causing serious complications such as intestinal adhesion and peritonitis, with a poor prognosis. Particularly, people infected in the uterus are even more disadvantageous.
1909年拉氏Latzk首创了腹膜外剖腹产。国内60年代逐渐开展(1)，直到近来才开始普及，并作了改进。80年10月份我省妇产科年会上省立医院报告了该院同年元月份起施行的30例临床小结(3)。会议以后，我院由11月份起开展了此项手术，两月来共施行8例。现将初步体会报告如下。
The extraperitoneal caesarean section was first performed by laplace Latzk in 1909. It was gradually carried out in the 1960s in China (1) until recently it began to be popularized and improved. The clinical summary of 30 cases implemented in the provincial hospital since January of the same year was reported at the annual meeting of obstetrics and gynecology department of our province in October of 80 years (3). Since the meeting, we have performed this procedure since November. A total of eight cases have been performed in the past two months. The preliminary experience is reported as follows.
临床资料
1980年我科剖腹产共45例 (小型剖腹产除外），分别为古典式12例, 子宫下段25例，腹膜外8例，其中11月份以后10例剖腹产中8例施行了腹膜外术式，全部病例均已痊愈出院。
现将8例腹膜外剖腹产的有关临床情况，列表与其它术式比较 (取其平均值):
* 该术式11月份新开展，故与全年其它术式例数无比较意义。
clinical data
In 1980, 45 caesarean sections were performed in our department, including 12 cases of classical cesarean section, 25 cases of lower uterine segment, and 8 cases of extraperitoneal. Among the 10 caesarean sections performed after November, 8 cases underwent extraperitoneal surgery, and all the cases were discharged after recovery. The clinical conditions of 8 cases of extraperitoneal cesarean section were listed and compared with other operations (the average value was taken): * This procedure was newly performed in November, so it had no significant comparison with other procedures throughout the year.
上表显示腹膜外剖腹产术式最大特点为肠排气时间短，平均术14分12秒, 而另两术式均需2~3天，因而可以进食早，输液少，节省费用，增进机体恢复。
The above table shows that the greatest feature of the extraperitoneal cesarean section is the short time of intestinal flatus, with an average of 14 minutes and 12 seconds, while the other two procedures require two to three days, thus leading to early intake of food, less infusion, cost saving, and improved body recovery.
(一) 手术指征:
凡剖腹产术的手术指征，皆适於此术，若有宫内感染，指征则更为强烈。本组手术对象为： 1 产道障碍 (头盆不称) 3例；2 宫内窘迫 (早期破水) 4例；3 头盆不称並发先兆子宫破裂 (死胎) 一例。
1, Surgical indications: All indications for cesarean section are suitable for this operation, and the indication is more intense if intrauterine infection exists. The surgical objects in this group were as follows: 1) 3 cases with birth canal disorder (cephalopelvic disproportion); 2 intrauterine distress (early water breakthrough) 4 cases; One case of threatened uterine rupture (stillbirth) complicated with cephalopelvic disproportion.
2, Anesthesia: Total epidural anesthesia. Good muscle relaxation facilitates blunt dissection and the patient is quiet during surgery.
(二) 麻醉:
全部硬膜外麻醉。良好的肌肉松弛，便於钝性剥离，术中病人安静。
(三) 手术方法:
我们全部采用诺通式 (Noton) 法。取脐耻间正中纵型切口10 –12厘米，逐层切开腹壁，仅留腹膜不切开，常在左侧腹壁连同腹横筋膜深入钝性分离膀胱侧壁筋膜寻找黄色脂肪垫，推去此脂肪块后即见腹膜反折与膀胱侧壁及闭锁的腹下A形成的“三角区”，以此为基点向右、向前、然后向后，作钝、锐性分离。若剥破腹膜即予缝合。待子宫下段显露足够时开宫。胎儿及其附属物的娩出、宫壁缝合等均同子宫下段术式。膀胱及腹膜反折自然复位，不需缝合。但需仔细止血，清理创野以减少术后渗血及吸收热。常规分层缝合腹壁各层，可不予引流(4)。
3, Surgical methods: We all adopt the Noton method. A longitudinal incision 10–12 cm was made in the middle of the area between navel and disgrace. The abdominal wall was incised layer by layer, leaving only the peritoneum without incision. The fascia on the lateral wall of bladder was often deeply and bluntly separated from the fascia on the left abdominal wall together with the transverse abdominal fascia to find the yellow fat pad. After the fat mass was pushed out, the “triangle area” formed by retroperitoneum, the lateral wall of bladder and the atretic infraabdomen A was seen, and the blunt and sharp separation was performed rightward, forward, and then backward based on this. If the peritoneum is peeled off, it is sutured immediately. Open the uterus when the lower part of the uterus is exposed enough. The delivery of the fetus and its appendages, and the suture of the uterine wall were all the same as those for the lower uterine segment. The bladder and peritoneum were reversely folded and naturally restored without suture. However, careful hemostasis and clearing of the wound field are needed to reduce postoperative bleeding and heat absorption. The layers of the abdominal wall were sutured conventionally in layers without drainage [4].
充盈膀胱，对初术者似有必要，便于认清解剖关系。我们在第一、二例中，术前曾用美兰液充盈膀胱，第三例用无菌生理盐水灌注膀胱。后即免除此一手续，同样可以辩认榜胱境界。
Filling the bladder may be necessary for the primary operator to understand the anatomical relationship clearly. In the first and second cases, the bladder was filled with methylene blue before surgery, and in the third case, the bladder was filled with sterile normal saline. Later that is exempt from this procedure, also can identify countries.
(四) 並发症:
全组手术无膀胱损伤，仅两例术后24小时内有轻微血尿，后自止转清，但有三例术中剥破腹膜，均於开宫前缝合，术后排气时间並未延长。
4, Complications:
There was no bladder injury during the operation of the whole group. Only two cases had slight hematuria within 24 hours after operation and recovered from scratch. However, in three cases, the peritoneum was torn during the operation, and all of them were sutured before opening the uterus. The postoperative exhaust time was not prolonged.
讨 论
腹膜外剖腹产的最大特点是不经腹，无腹腔搔扰、污染之弊，术后病人恢复顺利，若剥离得当、创野清理得仔细、止血彻底，感染极少，一般无需引流，吸收热亦不高，本组平均4.4天，体温降到正常，无一例感染。
Discussion
Extraperitoneal cesarean section is the biggest characteristic of the abdominal, no abdominal itching, the disadvantages of pollution, postoperative patients recover smoothly, if peeling properly, carefully clean up the field, hemostasis thoroughly, very few infection, generally no drainage, heat absorption is not high also, the average of 4.4 days, the body temperature fell to normal, no infection.
此术操作难点在於腹膜外的钝性剥离，一边是菲薄透亮的腹膜，一边是膀胱壁，两者均顾忌损伤，而致初术者左右为难，也因此长期阻碍着此术式的普及和推广(1)。但近年来大量实践证明，並非如此困难，其实子宫下段剖腹产也就是腹膜外术式操作的一部分，只不过经腹打开膀胱腹膜反折而已。如果复习一下妊娠期该处局部解剖上改变，就能发现由於子宫的增大，子宫下段与膀胱及其腹膜反折的关系都相应发生变化，使膀胱旁窝升出盆腔，因此手术易於将腹膜反折经由腹膜外将其从膀胱顶部和子宫前壁推开，再者膀胱肌层在钝性剥离下並不易损伤全层。即使剥破腹膜，由于在开宫前即可缝合，仍然杜绝了腹腔污染的可能，同样不会减弱“腹膜外”手术意义。而若能够掌握要领，即在左侧 (右侧亦可，但习惯於左侧，除顺手方便之外，产时子宫多向右旋转，此处易於显露) 找到“脂肪垫”和“三角区”以便直入膀胱子宫间隙，获得一个恰当的“层”，在此处开始扩大剥离腹膜反折，亦较方便。但需注意，腹膜不能承受过大张力，尤其着力不均，易致撕破，可在直视下锐性分离来回避这一可能。这样进宫时间较其它术式並不显著延长。国内近年来各院报告，术始到胎儿娩最短为14分至25分。本组最快一例亦为14分钟。 关键在于熟练和得法，在此基础上手术指征可以放宽，凡需要剖腹产者，一般皆能适应。即使胎儿窘迫，产前出血和紧急情况，熟练术者亦不作禁忌之列。本组胎儿窘迫4例，子宫先兆破袭1例，均施此手术，除一例死胎外，余者均母子平安。如同时有剖腹探查指征者，我们的看法，亦可在腹膜外剖腹产操作完成並清理创野之后，隔离下切开腹膜探查。如並行输卵管结扎者，亦可在宫腔操作之后，腹膜打一小洞而行之。故此类病创亦绝非此术的禁忌症，同样可以保持宫腔内容物不污染腹控的优越性。
The difficulty in this operation lies in the blunt dissection outside the peritoneum. One side is the thin and translucent peritoneum, and the other side is the bladder wall. Both of them are not afraid of injury, which causes the dilemma for the initial operator and hinders the popularization and promotion of this operation for a long time (1). However, a large number of practices in recent years have proved that it is not so difficult. In fact, the cesarean section in the lower part of the uterus is part of the extraperitoneal operation, which is just to open the bladder peritoneum and fold it backwards through the abdomen. If we review that anatomic change at this site during pregnancy, we will find that due to the enlargement of uterus, the relationship between the low part of uterus and bladder and its peritoneum reflex will change accordingly, causing the paravesical fossa to rise out of the pelvis. therefore, the operation is easy to push the peritoneum reflex away from the top of bladder and the anterior wall of uterus through extraperitoneum. moreover, the bladder muscular layer is not easy to damage the whole lay under the blunt dissection. Even if the peritoneum is peeled and broken, the possibility of abdominal cavity pollution is still eliminated because the suture can be performed before the uterus is opened, and the significance of “extraperitoneal” surgery is not weakened. If we can grasp the essentials, we should find the “fat pad” and “trigone” on the left side (the right side is also acceptable, but we are used to the left side. In addition to being convenient, the uterus is often rotated to the right during labor, and it is easy to expose here) to directly enter the bladder-uterine space and obtain an appropriate “layer”, where we can begin to expand the stripping peritoneum and reflex, which is also more convenient. However, it should be noted that the peritoneum cannot bear excessive tension, especially due to uneven application of force, which is prone to tear. The possibility can be avoided by sharp separation under direct vision. The time to enter the uterus in this way was not significantly longer than that in other operations. In recent years, various hospitals in China have reported that the shortest score from the start of surgery to the delivery of the fetus is 14 points to 25 points. The fastest case in this group was also 14 minutes. The key lies in proficiency and good method. On this basis, the surgical indications can be relaxed, and patients who need cesarean section can generally adapt to it. Skilled artisans are not contraindicated even in the setting of fetal distress, antepartum hemorrhage, and emergencies. Four cases of fetal distress and one case of threatened uterine rupture were treated. Except for one dead fetus, the mother and child were all safe. In our opinion, laparotomy can also be performed under isolation after the extraperitoneal cesarean section has been completed and the wound field has been cleared. For tubal ligation, a small hole in the peritoneum can be made after uterine cavity manipulation. Therefore, such lesion is not a contraindication for this operation, and it can also maintain the superiority of abdominal control without polluting the intrauterine contents.
最后关于此术式命名问题，我们赞成南京工人医院妇产科意见 (2)。因为此术並不剖腹而仅剖宫，故称之为“腹膜外剖宫取胎术”较之“腹膜外剖腹取胎术”这一含混矛盾的命名为妥。
Finally, regarding the nomenclature of this procedure, we agree with the opinion of the Department of Obstetrics and Gynecology of Nanjing Workers’ Hospital [2]. Because this operation does not involve laparotomy but only dissection of the uterus, it is better to call it “extra-peritoneal dissection of the uterus and fetuses” than the vague and contradictory name of “extra-peritoneal laparotomy and fetuses taking”.
小 结
本文报导我院80年11月份以来开展的腹膜剖腹产8例，並与同年其它术式作一临床比较。结合复习文献，通过操作体会，认为此术式术后恢复快，手术技术亦易掌握，在熟练的基础上，基本上可以取代其它术式。
我们仅在开展初期，体会十分肤浅，犹待积累更正。
Summery
In this paper, we report 8 cases of C-section of peritoneum performed in our hospital since November 80 and make a clinical comparison with other procedures in the same year. Based on literature review and operating experience, it is considered that this operation has a rapid postoperative recovery and easy mastering of surgical techniques. On the basis of proficiency, it can basically replace other operations. We are only in the early stage of development. Our experience is very superficial and we still need to accumulate and correct it.
References
- Clinical application of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology 1965 November (4) P315
- Nanjing Workers’ Hospital: Clinical application value of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology 1965 November (4) P29
- Anhui Provincial Hospital: Clinical summary of extraperitoneal cesarean section. Provincial Annual Meeting of Gynaecology and Obstetrics in 80 Years (Internal Data)
- Su Yingkuan et al. Gynaecology and Obstetrics Surgery (P440) People’s Health Publishing House, 1973 January 5, 1981 nan ling county hospital obstetrics and gynecology pan yaogui This paper is an academic exchange paper of provincial society of obstetrics and gynecology
参考资料
[1] 腹膜外剖腹产手术的临床应用。中华妇产科杂志 1965年11月(4) P315[2] 南京工人医院: 腹膜外剖腹产临床应用价值探讨。中华妇产科杂志 1965年11月(4) P29[3] 安徽省立医院: 腹膜外剖腹产临床小结。80年省妇产科年会 (内部资料)[4] 苏应宽等: 妇产科手术学（P440） 人民卫生出放社，1973年
一九八一年元月五日 南陵县医院妇产科 潘耀桂
本文为省妇产科学会学术交流论文
