镜下扩宫法在宫腔镜宫腔粘连分离术中的应用  

Hysteroscopic dilation techniques in hysteroscopic adhesiolysis

作　　者：周曾梓 赵美丹 邹凌霄[1] 伍美容[2] 徐大宝[1] ZHOU Zengzi;ZHAO Meidan;ZOU Lingxiao;WU Meirong;XU Dabao(Department of Gynecology,Third Xiangya Hospital,Central South University,Changsha 410013;Operating Room,Third Xiangya Hospital,Central South University,Changsha 410013,China)

机构地区：[1]中南大学湘雅三医院妇科,长沙410013 [2]中南大学湘雅三医院手术室,长沙410013

出　　处：《中南大学学报（医学版）》2022年第11期1586-1592,共7页Journal of Central South University ：Medical Science

基　　金：湖南省临床医疗技术创新引导项目(2020SK53605);湖南省自然科学基金(2021JJ40953)。

摘　　要：目的:宫腔粘连是一种严重影响女性生育力的疾病,多继发于妊娠相关的清宫术或宫腔镜手术等宫腔内操作,因损伤子宫内膜基底层所致。宫腔镜宫腔粘连分离术是宫腔粘连治疗环节中最关键的一步,其最常见的并发症是子宫穿孔。一半以上的子宫穿孔发生在镜体或者探针/扩宫棒通过宫颈内口阶段。在这一阶段,不恰当的手术操作还可导致内膜损伤、粘连复发加重、宫颈裂伤及假道形成等手术并发症的发生。本研究旨在提出一种宫腔镜直视下通过镜体侧入后摆动或者镜下器械直接撑开来扩张宫颈内口及宫腔下段的方法,我们称之为镜下扩宫法,以提高宫颈内口和/或宫腔下段粘连患者扩宫的有效性及安全性。方法:收集中南大学湘雅三医院2020年1月至2021年6月行宫腔镜宫腔粘连分离术的282例患者,年龄21~46(33.0±4.8)岁,根据美国生育协会(American Fertility Society,AFS)的宫腔粘连评分标准评为5~12分,其中有2例因外院传统扩宫分离粘连所致假道形成的患者。所有患者使用具有5Fr器械通道、4.9 mm外鞘直径的一体式宫腔镜行宫腔镜检查。采用镜下扩宫法扩张宫颈内口及宫腔下段。宫腔镜进入宫腔后,常规行宫腔粘连分离术及向宫腔内放置宫型节育环或者宫腔支架等。收集所有纳入病例的年龄、手术记录及手术视频资料,并统计其术中镜下扩宫的成功率和手术并发症发生率。结果:所有患者均成功利用镜下扩宫法将宫腔镜置入宫腔,2例因外院扩宫导致假道形成的患者也在镜下扩宫的过程中及时识别并成功找到宫腔。无1例在术中因宫颈内口和宫腔下段扩张失败而中转使用传统宫颈扩张棒扩宫。整个宫腔镜手术过程中,手术视野清晰,且无假道形成、子宫穿孔或宫颈撕裂等并发症的发生。术后1至3个月复查宫腔镜,所有患者均未见宫颈内口及宫腔下段明显的粘连狭窄。结�Objective:Intrauterine adhesion(IUA)is mainly caused by intrauterine operations such as pregnancy-related curettage and hysteroscopic surgery,resulting in the trauma to the basal layer of the endometrium.Hysteroscopic adhesiolysis is a crucial step in the comprehensive treatment of IUA,and the most common complication is uterine perforation.More than half of all uterine perforations occur during the hysteroscopy or probe/dilator pass through the internal os.Furthermore,inappropriate surgical procedures may lead to endometrial injury,recurrence or even aggravation of adhesions,and complications such as cervix laceration and false passage formation.This study aims to explore the usage of the hysteroscopic dilatation techniques to dilate the internal os and lower uterine segment,which is via hysteroscopy entering the internal os laterally and swinging,or by directly opening the forceps or scissors and bluntly spreading dissection under direct hysteroscopic vision.By using the hysteroscopic dilatation techniques,we intend to improve the effectiveness and safety of cervical dilation in patients with IUA in the internal os and/or lower uterine segment.Methods:A total of 282 patients with adhesions in the internal os or lower uterine segment underwent HA in the Third Xiangya Hospital of Central South University from January 2020 to June 2021 were included,ranging from 21 to 46(33.0±4.8)years old in age and 5 to 12 in the American Fertility Society score.Among them,there were 2 cases of false passage formation caused by traditional dilatation in other hospitals.All patients underwent hysteroscopy with integrated hysteroscopy with 5Fr instrument channel and 4.9 mm outer sheath diameter.The internal orifice of cervix and the lower segment of uterine cavity were dilated under the microscope.After the hysteroscopy entered the uterine cavity,the separation of uterine cavity adhesion and the placement of uterine contraceptive ring or uterine stent into the uterine cavity were performed routinely.Age,surgical records,and surgi

关 键 词：宫腔粘连 宫腔镜技术 扩宫 手术并发症 不孕 

分 类 号：R713.4[医药卫生—妇产科学]