宫腔镜操作严重并发症35例的治疗与预防探讨

目的:探讨宫腔镜操作严重并发症的诊治及预防措施.方法:回顾性分析2001年10月到2009年7月两所医院宫腔镜操作1891例,其中宫腔镜检查术1159例,宫腔镜取IUD及电切手术732例.结果:35例发生严重并发症,占1.85%,其中宫腔镜检查术发生率为0.78%,治疗性宫腔镜手术发生率为3.55%.35例中子宫穿孔11例,其中有3例经腹腔镜下修补治愈;TURP综合征3例,其中1例经ICU抢救治愈;出血5例,其中3例经球囊尿管压迫止血;盆腔感染8例,其中1例盆腔脓肿经腹腔镜手术治愈;宫腔粘连10例,全部经二次分粘后放置IUD同时人工周期治疗.结论:宫腔镜电切术早期出血用球囊尿管压迫止血效果好;严格控制手术时间是预防TURP综合征的重要环节;腹腔镜或B超监测是避免和及时发现穿孔的有效措施.     

宫腔镜电切术中并发症的临床分析

目的 探讨宫腔镜手术中诱发并发症的潜在因素。临床特点及防治措施。方法 对1995年1月-2001年1月,在行各类宫腔镜手术中发生并发症的17例患者进行临床分析。结果 发生子宫穿孔3例和不全子宫穿孔7例,分别发生在较大的子宫肌瘤切除术,宫腔粘连分离术,子宫纵隔切除术和胎骨嵌入切除术中,均在B超或腹腔镜下诊断并经腹腔镜缝合止血,避免了开腹手术;发生术中大出血4例,分别在宽蒂,多发性黏膜下肌瘤切除和子宫腺肌病内膜切除术中,除1例开腹行子宫切除外,3例经宫腔放置球囊导管压迫止血;发生经尿道前列腺切除（TURP）综合征3例,其中载例为宽蒂黏膜下肌瘤和内突壁间肌瘤切除,1例为子宫腺肌病行内膜切除,经补钠,利尿和纠正左心功能衰竭,症状得到控制。结论 复杂的宫腔内操作是宫腔镜单极电切手术中并发症发生的潜在危险,进行术前预处理,术中监护等,是预防及检查手术并发症的基本措施。     

宫腔镜电切术子宫穿孔16例分析

目的 探讨宫腔镜电切术子宫穿孔的发生原因、诊断、处理和预防方法。方法 1990年5月至2002年7月,5家医院共行宫腔镜电切术3541例次,其中宫腔镜子宫内膜切除术(TCRE)1431例,1468例次,宫腔镜子宫肌瘤切除术(TCRM)797例,宫腔镜子宫内膜息肉切除术(TCRP)783例,宫腔镜子宫纵隔切除术(TCRS)189例,宫腔镜子宫粘连切除术(TCRA)112例,宫腔镜宫腔异物取出术(TCRF)192例。术时均行B超和(或)腹腔镜监护,手术日前晚放置宫颈扩张棒或于阴道后穹窿放置米索前列醇200μg,手术步骤按不同的指征及目的进行。结果 发生子宫穿孔16例(0．45％),8例因放置器械所致,其中7例扩宫时穿孔,1例置镜时穿孔,8例为电切电极引起。子宫穿孔发生率,TCRA 4．46％(5／112),TCRF 3．12％(6／192),TCRE 0．27％(4／1468),TCRM 0．13％(1／797);TCRP及TCRS无子宫穿孔发生。16例穿孔均于术中发现,其中B超和(或)腹腔镜监护发现10例(62％),宫腔镜及临床发现6例(38％)。13例为完全子宫穿孔,其中腹腔镜监护发现2例,B超监护发现5例,宫腔镜先于B超发现4例,患者首先出现症状,然后B超证实子宫穿孔2例;子宫不全穿孔3例,2例腹腔镜监护发现,1例B超监护发现。结论 应尽量减少扩宫,置镜在直视下进行;术者的经验及手术类型如TCRA和TCRF与子宫穿孔的发生有关。宫腔镜电切术时B超、腹腔镜监护有助于预防,但不能完全防止子宫穿孔。     

电视宫腔镜联合B超诊治宫腔内妊娠物残留51例分析

目的:探讨宫腔镜联合B超对宫腔内妊娠物残留的诊治价值.方法:对5例流产后不规则阴道流血和(或)B超显示宫腔内有异常回声的患者联合B超行宫腔镜检查,观察宫腔内情况.对单纯妊娠物残留患者行B超监护下刮宫术;刮宫失败和(或)合并其他异常者,B超监护下宫腔镜电切术.结果:单纯宫腔内妊娠物残留34例;合并宫腔粘连6例、子宫中隔3例、子宫内膜息肉6例、粘膜下子宫肌瘤2例.宫腔镜检查同时B超监护手术32例,择期B超监护电切治疗19例.51例患者均治愈.结论:电视宫腔镜联合B超对流产后妊娠物残留的诊治具有直接、准确、有效、创伤小的特点,可作为诊治妊娠物残留的首选方法.     

电视腹腔镜监护宫腔镜手术128例体会

目的探讨宫腔镜手术时腹腔镜监护的临床应用价值。方法1995年3月至1999年3月宫腔镜电切术672例,128例高危病例行腹腔镜监护。结果腹腔镜检查发现有盆腔并存病变20例,术时见局部浆膜起水泡1例,子宫不全穿孔1例,术终发现子宫穿孔2例,1例切除子宫,1例腹腔镜处理。结论腹腔镜监护宫腔镜手术可及时发现子宫穿孔的先兆及子宫穿孔,并进行腹腔镜下电凝止血及缝合,但不能完全避免子宫穿孔的发生,故术终应再次腹腔镜检查盆腔。     

宫腔镜手术并发症36例临床分析

目的 探讨官腔镜手术并发症发生的原因、处理方法与预防措施。方法 对我院1993年1月至2004年11月10余年间,36例官腔镜手术并发症患者的临床资料进行回顾性分析。结果 36例并发症中,子宫穿孔或不全子宫穿孔11例,均发生在复杂的官腔内手术操作中,除1例中转开腹外,均在腹腔镜下行缝合修补;术中大出血5例,均由于对子宫肌壁破坏过深所致,经官腔放置双腔导管压迫止血或子宫切除治愈;灌流液过量吸收综合征3例,给予利尿及补钠治疗,预后良好;空气栓塞1例,早期发现后积极抢救成功;输卵管绝育一子宫内膜去除术后综合征4例,行子宫切除加单侧或双侧输卵管切除、宫腔扩探及粘连分离,治愈;官腔粘连12例,分别行官腔扩探、粘连分离、排除积血或子宫切除。结论 复杂的官腔内操作、官腔灌流压力过高、子宫肌壁破坏较深以及子宫内膜残留,是发生官腔镜手术并发症的潜在危险因素;术中腹腔镜或B超监护、提高术者处理复杂官腔手术的能力和加强围手术期管理,是降低并发症的必要措施。     

宫腔镜电切术治疗Ⅱ型子宫粘膜下肌瘤的安全性研究

目的:探讨宫腔镜电切术治疗Ⅱ型子宫粘膜下肌瘤的可行性和安全性.方法:选择35例术前诊断为Ⅱ型子宫粘膜下肌瘤的患者,在超声监护下行宫腔镜电切术,根据患者的年龄及生育要求采用直接切除或开窗后切除,观察宫腔镜电切术治疗的可行性、安全性及疗效.结果:35例中32例一次手术切除肌瘤,一次手术成功率为91.42%,手术时间25～75分钟,术中出血量10～150 ml.3例因肌瘤较大,1～3个月后行第二次手术切除.未发生经尿道前列腺电切综合征、子宫穿孔及邻近脏器的损伤.术后住院时间1～3天,术后2个月时月经量均正常.超声检查宫腔内膜光滑、均质.3例要求妊娠者,于手术1年后妊娠,均已足月分娩.结论:宫腔镜电切术治疗Ⅱ型子宫粘膜下肌瘤是安全、可行的,但术前一定要选择好肌瘤类型、大小,术中注意手术技巧和良好的监护.     

宫腔镜宫内异物取出术及其监护方法的探讨

目的：探讨宫腔镜宫内异物取出术的方法及术中各种监护方法的作用。方法：宫内节育器，残留胚物，胎骨、子宫内膜钙化，水吸收缝合线和取环钩断铯嵌顿115例，其中82例曾经行常规取环或刮宫未能取全，部患者在B超介入下行宫腔镜宫内异物取出术，3例植入胎盘和1例胎骨残狼狈为奸残入2／3肌壁同时腹腔镜监护，1例多块胎骨残留并嵌入宫壁行腹腔镜超声监护，结果：111例宫内异物经宫腔镜取出，术后子宫出血，闭经，排液，腹痛，尿频及血尿等症状消失。4例嵌入宫壁的胎骨未能完全取出，其中1例术后4个月妊娠，1例于夹取嵌入2／3肌壁的胎骨时子宫穿孔，B超见灌流液翻滚进入盆腔，腹腔镜缝合创口治愈，结论：B超监护下宫腔镜宫内异物取出术安全，有效，B超监护无损伤，有效，可作为首选或常规监护方法.     

宫腔镜与腹腔镜联合手术235例临床分析

目的 探讨应用宫腔镜与腹腔镜联合手术在诊台妇科疾病中的价值。方法 对1995年1月至2001年1月收治的235例患者应用宫腔镜、腹腔镜联合手术的指征、方法、并发症处理进行临床分析。结果 235例患者均于宫腔与腹腔内实施了2种以上手术操作。除1例子宫肌瘤术中大出血改行开腹手术外,其余234例均在宫腔镜下切除了宫腔内病变,包括子宫纵隔切除、严重宫腔粘连分离、胎骨碎片和宫内节育器（IUD）残片嵌入子宫肌壁切除,以及直径≥4.5cm、壁间内突或多发子宫肌瘤切除等复杂的宫腔内手术。联合手术发现,宫腔镜手术中不全子宫穿孔7例及子宫穿孔3例,及时在腹腔镜下缝合处理,避免了开腹手术。应用腹腔镜还对子宫内膜异位症、卵巢囊肿、盆腔粘连、子宫浆膜下肌瘤及输卵管病变等进行了手术治疗,共计218项操作,未发生因联合手术而引起的严重并发症。结论 宫腔镜、腹腔镜联合手术只需一次麻醉,一期手术,解决了以往单纯宫腔镜或腹腔镜不能同时治疗的宫腔与腹腔内病变;通过腹腔镜监护疑难宫腔镜手术,可及时发现和处理手术过程中的子宫穿孔,提高了手术安全性。     

宫腔镜并发症防治的现代观点

宫腔镜临床应用已有20年的历史,一直被认为是安全、有效、简单、微创技术.随着宫腔镜广泛应用,术后随访时间延长,临床资料的积累和科学研究的深入,现在认为其并发症虽少,但有些并发症会危及生命,如空气栓塞、经尿道前列腺电切术(TURP)综合征、出血、感染和未及时发现的子宫穿孔等,但这些并发症严加预防是可以避免的.     

Long-term results of hysteroscopic myomectomy in 235 patients

OBJECTIVE: To assess the efficacy of transcervical resection of submucous fibroids according to type and size. MATERIALS AND METHODS: Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered. RESULTS: Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18-66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up. CONCLUSION: The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.     

Results of hysteroscopic myomectomy

Main symptoms related to submucous fibroids are menorrhagia, infertility, and postmenopausal bleeding. First experiences of hysteroscopic transcervical resection of fibroids have been published by Neuwirth in the late seventies. Reports with long-term follow-up in patients with abnormal uterine bleeding are available. After a follow-up period of five years and more, results are satisfactory in 70-85% of the patients. Intramural class 2 and larger fibroids (> 4 cm) constitute the limits of the endoscopic technique. Prior to hysteroscopic myoma resection, pretreatment with GnRH agonists may be indicated in selected cases (large myomas, patients suffering from secondary anemia). Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate. In infertile women with submucosal or intracavitary fibroids, pregnancy and delivery rates are increased after hysteroscopic myomectomy. Operative hysteroscopy is also safe and effective in controlling persistent postmenopausal bleeding. To conclude, hysteroscopic resection is the gold standard for the treatment of symptomatic submucous fibroids.     

Emergency endometrial resection in women with acute, severe uterine bleeding

STUDY OBJECTIVE: To evaluate the efficacy and safety of endometrial hysteroscopic resection in the treatment of severe uterine bleeding. DESIGN: Pilot feasibility study (Canadian Task Force classification II-2). SETTING: Department of gynecology at a general hospital. PATIENTS: Twenty-six women with severe uterine bleeding. INTERVENTION: Hysteroscopic transcervical endometrial resection under general anesthesia. MEASUREMENTS AND MAIN RESULTS: Bleeding had a benign organic cause in 25 women. One endometrial carcinoma was detected in endometrial chips in a postmenopausal woman and was managed with hysterectomy. Fifteen cycling women experienced complete remission of uterine bleeding; one underwent hysterectomy during follow-up. Atrophic endometrium was present in nine menopausal women during follow up. CONCLUSION: Endometrial transcervical resection was effective in controlling heavy bleeding, preventing future episodes of severe bleeding, and avoiding further medical or surgical treatment during 19 months of follow-up.     

Accuracy of three-dimensional ultrasonography in differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging

Study ObjectiveTo estimate the accuracy of 3-dimensional (3-D) ultrasonography in the differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging (MRI).DesignProspective cohort study (Canadian Task Force Classification II-2).SettingUniversity hospital.PatientsThirty-one patients referred with a suspected diagnosis of septate (n = 20) or bicornuate (n = 11) uterus.InterventionsAll patients underwent 3-D ultrasonography displaying the rebuilt coronal view of the uterus, office hysteroscopy, and pelvic MRI. Operative hysteroscopic assessment and treatment was performed in case of sonographically diagnosed septate uterus. Bicornuate uterus was confirmed by laparoscopy.Main Outcomes MeasuresConcordance between suspected diagnosis with 3-D ultrasonography, hysteroscopy, and pelvic MRI and final diagnosis.ResultsA septate uterus was diagnosed with 3-D ultrasonography in 29 patients and bicornuate uterus in 2 patients. Hysteroscopic transcervical section of the uterine septum was achieved in the 29 patients. Bicornuate uterus was laparoscopically confirmed in the 2 patients. Concordance between ultrasonography and operative hysteroscopy or laparoscopy was verified in all 31 cases. Twenty-five uterine septa and 5 bicornuate uteri were diagnosed by hysteroscopy (3 false-positive diagnoses of bicornuate uterus, 1 unfeasible hysteroscopy). Hysteroscopic diagnosis was correct in 27/30 patients. Twenty-four septate uteri and 7 bicornuate uteri were diagnosed by MRI (5 false-positive diagnoses of bicornuate uterus). Two complete septate uteri diagnosed by MRI were finally confirmed as incomplete septate uteri after 3-D ultrasonography and operative hysteroscopy. MRI diagnosis was correct in 24/31 patients.ConclusionTransvaginal 3-D ultrasonography appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies, more than office hysteroscopy and MRI. It may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus.     

Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding

OBJECTIVE: Our purpose was to compare office hysteroscopy with transvaginal ultrasonography for diagnosing intrauterine pathologic disorders in patients with excessive uterine bleeding, with specimens obtained from either hysterectomy or operative hysteroscopy used to represent the true diagnosis. STUDY DESIGN: A total of 149 patients underwent office hysteroscopy between July 1993 and December 1994. They were evaluated for complaints of menorrhagia, metrorrhagia, or postmenopausal bleeding. Data encompassing patient age, gravidity, parity, indication, ultrasonographic and hysteroscopic findings, comfort level, time required, and complications were gathered by resident physicians. Most hysteroscopic examinations were preceded by transvaginal ultrasonography. All patients received premedication with 600 mg of ibuprofen and a paracervical block with 1% lidocaine without epinephrine. Sixty-five patients underwent operative hysteroscopy or hysterectomy later. The pathologic diagnoses of these specimens were compared with hysteroscopic and ultrasonographic findings, and the sensitivity and specificity of each test were calculated. RESULTS: Hysteroscopy was 79% sensitive and 93% specific in diagnosing intracavitary pathologic disorders, whereas transvaginal ultrasonography was only 54% sensitive and 90% specific. One hundred forty-one patients were comfortable during the procedure, and inspection of the uterine cavity was considered adequate in 136. The majority of procedures were completed in <10 minutes. Twenty-six patients underwent operative hysteroscopy and another 39 underwent hysterectomy. No patient who underwent operative hysteroscopy has had a recurrence of abnormal bleeding over a 12- to 30-month follow-up. CONCLUSION: Office hysteroscopy is a rapid, safe, well-tolerated, and highly accurate means of diagnosing the cause of excessive uterine bleeding. It permits patient and physician to discuss more treatment options before surgery, including outpatient operative hysteroscopic procedures. This means savings in time and in drug, procedure, professional, and hospital costs. (Am J Obstet Gynecol 1996;174:1678-82.)