腹腔镜手术治疗早期输卵管妊娠78例临床观察

目的:探讨腹腔镜手术治疗早期输卵管妊娠的临床效果。方法:分析2010年1月-2010年12月在我院经腹腔镜治疗的早期输卵管妊娠患者78例。结果:27例行输卵管切除术,51例行输卵管保守性手术,其中25例行输卵管挤压术,9例行输卵管取胚术,17例行输卵管开窗术。手术时间30分钟～1小时,术中出血量30～200ml,住院时间3～5天。结论:腹腔镜手术是治疗早期输卵管妊娠的首选方案,对于下腹有手术史及盆腔粘连的患者,依然可行。     

腹腔镜下输卵管间质部妊娠切开取胚术13例临床分析

目的:探讨腹腔镜下输卵管间质部妊娠切开取胚术辅以患侧宫角及输卵管系膜注射垂体后叶素及宫角肌层内注射MTX可行性。方法:回顾分析2006年6月至2010年10月我科以腹腔镜治疗13例输卵管间质部妊娠的手术时间、术中失血量、β-HCG下降、持续性异位妊娠发生情况。结果:13例患者均在腹腔镜下明确诊断并完成手术,无术中及术后并发症。手术时间30～60min,平均47min;术中失血20～250ml,术后48小时及第五天测血β-HCG均进行性下降,术后5天复查血常规WBC及BPC正常范围,术后随访β-HCG直至正常,无持续性异位妊娠发生。结论:腹腔镜下输卵管间质部妊娠切开取胚术辅以患侧宫角及输卵管系膜注射垂体后叶素及宫角肌层内注射MTX是一项值得推广的技术。     

常规器械经脐单孔腹腔镜输卵管切除术41例分析

目的 探讨常规器械经脐单孔腹腔镜输卵管切除术的临床疗效、安全性及其优点。方法 对嘉兴学院附属第一医院2011年8月至2012年8月41例输卵管妊娠患者行常规器械经脐单孔腹腔镜输卵管切除术,并与同期45例常规腹腔镜下输卵管切除术比较。结果　两组相比,单孔腹腔镜组术后切口美观优于传统腹腔镜组,单孔腹腔镜组手术时间（30.43±5.83） min,术中出血量（8.63±3.79 ）mL,术后排气时间（28.35±7.41） h,住院时间（5.03±0.72） d。传统腹腔镜组手术时间（21.09±3.82 ）min,术中出血量（8.23±3.31） mL,术后排气时间（29.85±6.24） h,住院时间（5.24±0.63） d。单孔腹腔镜组手术时间略长于传统腹腔镜组,差异有统计学意义（P<0.05）,术中出血量、术后排气时间及住院时间两组差异无统计学意义（P>0.05）。结论　经脐单孔腹腔镜输卵管切除术在常规腹腔镜器械下可以安全、可靠地完成,术后腹壁瘢痕不明显,易被患者接受。     

输卵管妊娠患者输卵管开窗取胚术及切除术后继发不孕原因及输卵管损伤比较研究

目的探讨输卵管妊娠患者经输卵管开窗取胚术和切除术后继发不孕的原因及输卵管受损情况。方法收集2008年12月至2010年10月在武警后勤学院附属医院住院治疗,既往有输卵管妊娠、经输卵管开窗取胚术或切除术病史的不孕患者130例。根据既往输卵管妊娠手术方式分为开窗取胚组(37例)和切除组(93例)。采用腹腔镜观察盆腔粘连程度、输卵管形态、输卵管伞端等情况;并在腹腔镜监护下行宫腔镜下输卵管口插管通液,观察输卵管管腔是否通畅。结果 94.62%患者存在输卵管性不孕因素,包括宫腔及输卵管形态异常或周围粘连、伞端闭锁、管腔堵塞,至少有1个或多个因素合并存在;盆腔粘连发生率91.54%。两组患者无妊娠史的输卵管形态异常在开窗取胚组发生率为62.16%,在切除组为48.39%;伞端闭锁或积水在开窗取胚组为62.16%,在切除术组为44.09%;管腔堵塞在开窗取胚组为81.08%,在切除术组为82.80%,两组间差异均无统计学意义(P0.05)。盆腔粘连程度方面,Ⅰ、Ⅱ、Ⅲ度粘连发生率在开窗取胚组分别为21.62%、32.43%、35.14%,在切除组分别为29.03%、27.96%、33.33%,两组在粘连发生率、发生程度上差异均无统计学意义(P0.05)。开窗取胚组有妊娠史和无妊娠史的输卵管形态异常发生率分别为48.65%和62.16%,伞端闭锁或积水发生率为45.95%和62.16%,管腔通畅发生率为24.32%和18.92%,差异无统计学意义(P0.05)。结论输卵管妊娠开窗取胚术后的不孕患者,不孕的主要原因为输卵管因素和盆腔粘连,包括输卵管形态异常及周围粘连和伞端异常、管腔堵塞。输卵管开窗取胚术和切除术对无妊娠史的输卵管形态、伞端异常和管腔通畅度影响无明显区别。在开窗取胚术后不孕患者中,保留的患侧输卵管与无妊娠史的输卵管受损无明显差异。     

改良的腹腔镜下输卵管间质部妊娠手术16例临床应用分析

目的:探讨改良的腹腔镜下子宫动脉上行支缝扎阻断法,行输卵管间质部妊娠切开取胚术的安全性和可行性。方法:31例未破裂型输卵管间质部妊娠均行腹腔镜下输卵管间质部妊娠切开取胚术,其中采用改良的子宫动脉上行支缝扎阻断法16例(研究组),荷包缝合阻断法15例(对照组)。比较两组的术中、术后情况及预后。结果:研究组术中出血量(47.8±9.5ml)、手术时间(34.3±5.6分钟)明显少于对照组(69.0±18.4ml和42.3±7.2分钟),差异有高度统计学意义(P<0.01);两组术后3天血β-HCG值水平和血β-HCG值恢复至正常时间比较,差异无统计学意义(P>0.05)。两组术后均无持续性异位妊娠发生。结论:改良的腹腔镜下子宫动脉上行支缝扎阻断法行输卵管间质部妊娠切开取胚术,是一种简便、安全、有效的手术方法。     

腹腔镜手术治疗异位妊娠68例临床分析

目的:探讨腹腔镜手术治疗异位妊娠的临床价值。方法:回顾分析2006年-2008年10月68例腹腔镜手术治疗异位妊娠的临床资料。结果:68例腹腔镜均获成功,无1例中转开腹,无1例发生并发症。其中输卵管切除术38例,输卵管开窗取胚术24例,输卵管妊娠物挤出术5例,卵巢楔形切除术1例。结论:腹腔镜治疗异位妊娠安全、有效,是一种理想的手术方式。     

经脐单孔腹腔镜与多孔腹腔镜输卵管切除术疗效比较

目的探讨经脐单孔腹腔镜输卵管切除术治疗输卵管妊娠的安全性和可行性。方法 2012年7月至2014年6月佛山市妇幼保健院有48例输卵管妊娠患者行经脐单孔腹腔镜输卵管切除术(single-port laparoscopic salpingectomy,SPLS),随机选择同期的55例传统多孔腹腔镜输卵管切除术(multi-port laparoscopic salpingectomy,MPLS)为对照组,收集两组的病历资料进行比较分析。结果手术时间比较:SPLS组(35.90±9.99)min多于MPLS组(31.60±6.88)min,差异有统计学意义(t=2.567,P=0.012);SPLS组术后第1天疼痛评分高于MPLS组,差异有统计学意义(Z=-3.193,P=0.001)。术中盆腔积血量、术后24 h肛门排气、术后止痛剂使用、术后血红蛋白(Hb)变化、术后白细胞(WBC)总数变化、术后血β-HCG转阴时间等比较,差异无统计学意义(P0.05),持续性异位妊娠发生率均为0。结论对部分输卵管妊娠患者,SPLS能达到与MPLS相似的治疗效果,安全、可行,且具备隐藏瘢痕、术后伤口更美观的优点,值得临床推广。     

垂体后叶素在腹腔镜下输卵管妊娠切开取胚术中的临床应用

目的探讨垂体后叶素在腹腔镜下输卵管妊娠切开取胚术中的临床应用价值。方法将腹腔镜下输卵管妊娠切开取胚术患者144例按手术方法分为对照组和观察组,各72例。对照组在单纯腹腔镜下行输卵管妊娠切开取胚术,不用止血药;观察组在腹腔镜下切开妊娠病灶前给予妊娠病灶基底部注射垂体后叶素。观察两组术中出血量及手术时间。结果术中出血量,对照组(50±5)m L;观察组(10±8)m L;手术时间,对照组(90±30)min;观察组(60±20)min,差异有统计学意义(P0.05)结论垂体后叶素应用于腹腔镜下输卵管妊娠切开取胚术中,能有效减少术中出血量并减少手术时间,提高生存质量。     

简易法经脐单孔腹腔镜治疗剖宫产瘢痕部位妊娠5例报道

目的:探讨经脐单孔腹腔镜治疗剖宫产瘢痕部位妊娠(CSP)的临床效果。方法:对5例单孔腹腔镜手术治疗CSP的手术时间、术中出血、术后并发症、术后住院时间、术后月经恢复情况等进行分析。结果:5例患者术中平均出血29.00±19.49 ml,手术平均用时175.60±58.35分钟,术后住院天数5.00±1.87天,术后血β-人绒毛膜促性腺激素(β-hCG)降至正常时间为34.40±9.97天,月经恢复正常时间33.00±8.09天,术中1例发生膀胱不完全破裂,术后1例出现上呼吸道感染,未发生其他术中术后并发症。术后1例月经量减少,余月经量均正常。结论:对于部分Ⅱ型和Ⅲ型CSP,单孔腹腔镜手术可以去除病灶,同时行子宫下段修复,且微创、安全。     

腹腔镜下输卵管切开取胚术54例临床观察

目的:探讨腹腔镜下输卵管切开取胚术治疗输卵管妊娠的临床效果与价值。方法:选择我院2006年1月至2010年12月期间输卵管妊娠患者99例,随机分为54例作研究组,采用腹腔镜下输卵管切开取胚术治疗;另45例作对照组,采用剖腹输卵管切开取胚术治疗。比较两组的手术时间、术中出血量、住院时间、术后使用止痛剂、手术并发症(PEP)、通水通畅率等观察指标。结果:研究组的手术时间、术中出血量、术后使用止痛剂、住院时间明显少于对照组(P<0.05。两组的PEP的发生率、通水通畅率无显著性差异(P>0.05)。结论:腹腔镜下输卵管切开取胚术治疗输卵管妊娠具有操作简便创伤小、恢复快,患者痛苦轻等优势。     

Omental trophoblastic implants and hemoperitoneum after laparoscopic salpingostomy for ectopic pregnancy. A case report

BACKGROUND: In this era of cost containment, laparoscopic management of ectopic pregnancy has become the mainstay of dealing with this common gynecologic emergency. The aim of surgical intervention remains conservation of the fallopian tube, if possible; salpingectomy is reserved for cases of tubal rupture and/or recurrent ectopic pregnancy, where little hope exists of salvaging tubal function. CASE: A 28-year-old woman, para 2, underwent laparoscopic salpingostomy for ectopic pregnancy. She experienced intraabdominal bleeding within the initial 12 hours of the postoperative period. On exploratory laparotomy, there was active bleeding from the site of the salpingostomy, and a salpingectomy was performed. The patient was lost to follow-up and on postoperative day 21 presented with signs of intraabdominal bleeding; repeat laparotomy revealed active bleeding from trophoblastic implants within the greater omentum. The omentum was adherent to the anterior abdominal wall at the site of umbilical trocar placement. An infracolic omentectomy was performed, with a subsequent uneventful postoperative course; the patient was followed until resolution of the serum beta-hCG. CONCLUSION: Postoperative surveillance is important. Positive intraabdominal pressure during laparoscopic surgery and the Trendelenburg position may be contributory to cephalad migration of trophoblast remnants, with the scavenging action of the omentum and adherence to the site of umbilical trocar placement theoretically providing a mechanism for neovascularization and sustenance of the parasitic trophoblast.     

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary referral center.PatientsNinety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy.InterventionsSeventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy.Measurements and Main ResultsFactors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m² was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy.ConclusionsChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.     

Laparoscopic Salpingostomy with Electrocautery in the Management of Tubal Pregnancy

From August, 1990 to May, 1991, all cases of tubal pregnancy presenting to King George V Hospital for Mothers and Infants were considered for laparoscopic salpingostomy. This procedure involved opening the affected Fallopian tube with diathermy, removal of ectopic tissue via the laparoscope, achieving haemostasis and leaving the tubal incision to heal by secondary intention. The procedure was undertaken in 35 patients and was successfully performed in 31 patients with an average operating time of 66.4 minutes (+/- 20.1 minutes). Average hospital stay was 2.1 days (+/- 1.3). This paper examines the technique and results of the initial learning curve for laparoscopic salpingostomy and finds that with knowledge of potential hazards and care in surgery, this operation can be safely carried out in a selected group of patients.     

Surgical treatment of ectopic pregnancy

In most cases of ectopic pregnancy, medical treatment with methotrexate is successful. However, some cases still require surgery and laparoscopy is an effective approach. The candidates for surgical treatment include women who are not suitable to or have failed methotrexate treatment, those with heterotopic pregnancy, or those who are hemodynamically unstable. In women of reproductive age with tubal pregnancy, salpingostomy is the preferred surgical method. Conversely, salpingectomy is a better treatment for women with severely damaged fallopian tube, recurrent ectopic pregnancy in the same tube, uncontrolled bleeding after salpingostomy, large tubal pregnancy (> 5 cm), heterotopic pregnancy, and for those who have completed their family. Similar to treatment of a tubal pregnancy, cervical and interstitial pregnancy could be treated medically first. Most abdominal pregnancies are diagnosed late in pregnancy. However, when the diagnosis is made early, laparoscopic removal of the pregnancy should be performed.     

高渗葡萄糖注入输卵管内预防腹腔镜手术后持续性异位妊娠83例临床分析

目的:探讨预防异位妊娠腹腔镜保守性手术后持续性异位妊娠(PEP)的方法.方法:对236例输卵管妊娠患者行腹腔镜保守手术后按入院先后分成3组:高渗葡萄糖组(83例)采用50%葡萄糖液注入患侧输卵管残腔,甲氨蝶呤组(81例)采用甲氨堞呤注射,方法同高渗葡萄糖组,对照组(72例)不用任何药物.所有患者均于术前及术后第1天、第3天、第7天检测血β-HCG值.结果:高渗葡萄糖组PEP发生1例,甲氨蝶呤组1例,对照组4例,高渗葡萄糖组与甲氨蝶呤组比较,差异无统计学意义(P>0.05),高渗葡萄糖组与对照组比较,差异有统计学意义(P<0.05);术后第1天血β-HCG值较术前明显下降,但3组间差异无统计学意义(P>0.05);术后3天、7天血β-HCG值高渗葡萄糖组与甲氨蝶呤组比较,差异无统计学意义,高渗葡萄糖组与对照组比较,差异有统计学意义(P<0.05).结论:与甲氨蝶呤相比,高渗葡萄糖也可预防腹腔镜保守性手术后PEP的发生,但没有甲氨蝶呤的药物不良反应,使用安全有效.     

221 cases of laparoscopic laser therapy]

Laparoscopic laser therapy, using a Nd:YAG laser and an Olympus laparoscope, was performed in 221 cases. 0.5% dicaine spray was used intraperitoneally. The types of operations performed were tubal sterilization in 110 cases, vaporization of endometriotic lesions in 76 cases, lysis of pelvic adhesions in 13 cases, salpingostomy in 11 cases, salpingostomy for tubal pregnancy in 10 cases, and fenestration of cyst of Morgagni in one, the rate of success was 98.2% in tubal/sterilization. In 71 cases of endometriosis the pregnancy rate was 32.7% for R-AFS stage I-II, and 25.0% for stage III-IV cases. The advantages and techniques of the laparoscopic laser therapy were discussed.     

黄体血流分级对未破裂型输卵管妊娠保守治疗的影响

目的:研究黄体血流分级对于未破裂型输卵管妊娠保守治疗的影响,为患者临床治疗提供参考。方法:回顾性分析2013年6月至2016年12月在西安交通大学第一附属医院妇产科就诊的未破裂型输卵管妊娠保守治疗132例患者的临床资料,根据妊娠黄体的血流分级分为0级组(31例)、1级组(34例)、2级组(38例)、3级组(29例)。比较各组患者治疗后血β-人绒毛膜促性腺激素(β-HCG)下降、包块缩小情况及疗效。结果:(1)黄体血流分级中0级组患者治疗后不同时间点血β-HCG水平均最低、下降至正常所需时间最短(14.39±2.67天),保守治疗后不同时间点包块直径均最小,包块完全消失所需时间最短(13.30±2.24天);3级组患者血β-HCG水平均最高,下降至正常所需时间最长(27.04±4.56天),保守治疗后不同时间点包块直径均最大,包块完全消失所需时间最长(24.11±3.44天),4组间比较,差异有统计学意义(P0.05)。(2)黄体血流分级中0级组患者治疗有效率最高(90.32%),3级组最低(72.41%),4组间比较,差异有统计学意义(P0.05)。(3)所有患者中不良反应包括血清转氨酶升高5例、胃肠道反应9例、困乏嗜睡4例,4组间不良反应比较经Fisher确切概率法检验,差异无统计学意义(P0.05),保守治疗结束后患者不良反应均消失。结论:黄体血流分级对未破裂型输卵管妊娠保守治疗有影响,血流分级越高,治疗所需时间越长,疗效越差。     

Prognostic factors of fimbrial microsurgery

From January 1978 to December 1983, 600 infertile women underwent microsurgery for tubal infertility. Only 257 women with the same extent of distal lesions on both sides or with unilateral occlusion (after contralateral salpingectomy) were considered. Patients were classified in four subgroups on the basis of the extent of occlusion. After fimbrioplasty for occlusion of degree I and salpingostomy for occlusion of degree II, the term pregnancy rate was more than 50%. After salpingostomy for occlusion of degrees III and IV, the term pregnancy rate was, respectively, 25% and 22%. The ectopic pregnancy rate was the highest (12%) after salpingostomy for occlusion of degree IV. After microsurgical salpingolysis, the term pregnancy rate reached 64%, whereas the ectopic pregnancy rate was as low as 2%. Ampullary dilatation, as determined by hysterosalpingography and laparoscopy, influences the postoperative pregnancy rate. Fimbrial microbiopsies were taken, and the ciliated cell percentage was obtained. Results suggest that the ciliation index is a valuable method of prognosis of tubal surgery. In conclusion, the pregnancy rate after distal surgery is related to the tubal morphologic findings: ampullary dilatation, fimbrial ciliated cell percentage, and tubal wall thickness.     

输卵管妊娠腹腔镜两种术式对照分析

目的:观察腹腔镜两种手术方式治疗输卵管妊娠的结局和术后再妊娠情况,并探讨其影响因素.方法:对2002年1月至2005年12月天津市中心妇产科医院接受腹腔镜手术治疗输卵管妊娠的107例患者,分为保守性手术治疗组(A组)75例和输卵管大部分切除术治疗组(B组)32例患者,对比分析两组围手术期情况和术后再次宫内妊娠率、异位妊娠率;采用Logistic回归分析盆腔粘连情况等因素对保守性手术术后生育结局的影响.结果:A组术中出血量大于B组,手术时间长于B组,差异有统计学意义(P<0.05).随访3～6年,A组和B组再次宫内妊娠率分别为45%、34%,两组比较差异无统计学意义(P>0.05).在单因素分析中,腹腔镜保守性手术治疗输卵管妊娠术后宫内妊娠率分别与盆腔粘连情况、对侧输卵管闭锁与否相关(P<0.05).结论:腹腔镜下保守性手术再次宫内妊娠率高于腹腔镜下输卵管大部分切除术.盆腔粘连情况、对侧输卵管闭锁与否是术后宫内妊娠率的相关因素.对于严重盆腔粘连或患侧输卵管破坏严重而对侧输卵管正常者,不建议行保守性手术.     

Treatment of female infertility due to tubal obstruction by operative laparoscopy.

The advent in recent years of safe endocoagulation (thermocoagulation within the abdomen) has permitted operative laparoscopic treatment of the tubal factor in infertility in selected cases. This paper reviews the results of operative laparoscopy in 223 cases treated for infertility between 1971 and 1976. Tubal occlusion was present in 133 patients before surgical intervention. Following operative laparoscopy, tubal patency was demonstrated in 67% on testing at the time of operation and in 12% at the first postoperative hydrotubation. In only 21% of cases was tubal patency not achieved by these methods. Those cases requiring isthmic salpingostomy, ampullary or isthmic-tubal implantation, or end-to-end anastomosis were further treated by laparotomy and microsurgery. Ninety cases of pelvic endometriosis were treated by a combination treatment of thermocoagulation, ovarian cyst resection, and the antigonadotropin agent, danazol. Ovariolysis, salpingolysis, fimbrioplasty, and salpingostomy can easily be performed using operative laparoscopy as the method of choice with a minimum of complications, shortened hospitalization time (2 days), and the potential for a repeat procedure or a follow-up laparotomy should this be necessary. The pregnancy rate following laparoscopic treatment for the correction of distal tubal occlusion was 30.5% and for endometriosis genitalis externa, 40%. These rates compare favorably with the rates following procedures involving laparotomy and microsurgery for correction of similar lesions.