骨盤臓器脱に対するTVM（tension-free vaginal mesh）手術100例の周術期合併症

Perioperative complications of TVM（tension-free vaginal mesh）operation for the treatment of pelvic organ prolapse

　ポリプロピレンメッシュを用いた低侵襲手術は，腹圧性尿失禁に次いで骨盤臓器脱の治療でも注目されている。TVM（tension-free vaginal mesh）手術の初期100例（前後壁60例，前壁39例，後壁1例）で周術期合併症を検討した。当初はメッシュの脚を引き出すためのナイロン糸ループの糸絡み，腟壁誤穿刺がみられた。膀胱損傷2例，直腸損傷1例は経腟的に修復し，前壁メッシュは続行，後壁メッシュは断念した。腟壁血腫が後腟壁側で2例に起こり，腟壁びらんを続発した。間欠自己導尿を要した例はなかった。TVM手術には女性骨盤底医療を変えるインパクトがあるが，導入にあたり術式のポイントをよく知る必要がある。

　The aim of this paper is to describe the experience of perioperative complications in 100 cases of TVM（tension-free vaginal mesh）for the treatment of pelvic organ prolapse in our general hospital. We applied both anterior and posterior mesh in 60 cases, isolated anterior mesh in 39, and isolated posterior mesh in 1. In our early experience, the nylon thread loops used to draw out the mesh arms were often tangled up or snapped, resulting in elongation of the operative time. During the transobturator needle passage, the anterior vaginal wall was mistakenly stabbed in the early three cases, but careful finger-guidance of needles prevented this complication thereafter. Bladder injury（two cases）and rectal injury（one case）were not due to needle passage but resulted from dissection of the vaginal wall. These injuries were recognized and sutured during surgery. Afterwards, the anterior mesh was inserted as usual, whereas the posterior mesh was aborted for fear of an increased risk of infection. Two cases of obvious hematoma in the posterior vaginal wall were managed by vaginal gauze tamponade, but later developed vaginal erosion requiring surgical management. Gentle dissection and cautious hemostasis are important during this procedure. None of our patients needed intermittent bladder catheterization at home. Minimally-invasive mesh procedures such as TVM are expected to become decisive innovation in the treatment of pelvic organ prolapse, but surgeons must learn the technical details before practice.（Rinsho Hinyokika 62：133-140, 2008）