腹腔镜开窗取胚术联合甲氨蝶呤局部注射与药物保守治疗异位妊娠后再次妊娠的临床对比研究

目的:分析腹腔镜开窗取胚术联合甲氨蝶呤局部注射与药物保守治疗异位妊娠的临床疗效,探讨其对再次妊娠的影响。方法:回顾分析2011年3月至2014年9月未破裂异位妊娠且有生育要求的111例患者的临床资料,分为腹腔镜开窗取胚术组(A组,n=56)与药物保守治疗组(B组,n=55)。观察并记录两组治疗后的β-HCG值、再次妊娠率、输卵管通畅率、异位妊娠复发率及妊娠结局。结果:A组住院时间、出院时血清β-HCG值低于B组,差异有统计学意义(P0.05);在2年的随访中,A组再次宫内妊娠率、输卵管通畅率、正常分娩率均高于B组,异位妊娠复发率、流产率低于B组,差异有统计学意义(P0.05)。结论:腹腔镜开窗取胚术联合甲氨蝶呤局部注射治疗异位妊娠临床效果较好,住院时间短,出院时血清β-HCG值低,术后再次宫内妊娠率及正常分娩率高,临床疗效确切,值得临床推广。     

腹腔镜在宫角妊娠中的应用

目的:探讨腹腔镜诊治宫角妊娠的价值及其安全性。方法:将19例宫角妊娠随机分为两组(剖腹组、腹腔镜组),对其治疗结果、优越性进行比较。结果:腹腔镜检查的诊断率达100%,治疗成功率91.7%,达到剖腹手术的效果,虽然手术时间略长,但术中出血少、损伤小,术后病率低,恢复快。结论:腹腔镜治疗宫角妊娠安全有效,值得临床应用推广。     

腹腔镜手术联合吸宫术治疗输卵管间质部妊娠及子宫角妊娠

目的探讨腹腔镜手术联合吸宫术治疗输卵管间质部妊娠及子宫角妊娠的疗效。方法2004年1月～2007年1月对31例输卵管间质部妊娠和25例子宫角妊娠行腹腔镜下保守手术,切开取胚清除异位妊娠组织,常规联合吸宫术治疗。结果56例均在腹腔镜下完成手术,无中转开腹。1例持续异位妊娠,肌注MTX后治愈。患侧输卵管通畅率为33.9%（19/56）,术后18个月宫内妊娠率71.4%（40/56）,异位妊娠率16.1%（9/56）,继发不孕率1.2%（7/56）。结论腹腔镜手术联合吸宫术治疗输卵管间质部妊娠及子宫角妊娠安全有效。     

腹腔镜手术治疗异位妊娠146例临床分析

目的探讨腹腔镜手术治疗异位妊娠的临床应用价值。方法回顾性分析146例异位妊娠患者的临床资料,分别实施腹腔镜下输卵管切除或部分切除术、输卵管开窗取胚术、输卵管妊娠物挤出术、输卵管简质部切除术。同时对合并盆腔炎性疾病者行粘连松解术、浆膜下子宫肌瘤行肌瘤切除术、对侧输卵管伞部成形术等。结果 146例患者均在腹腔镜下成功完成手术,无一例中转开腹,无持续性异位妊娠发生。结论腹腔镜治疗异位妊娠具有创伤小、疼痛轻、恢复快、并发症少、住院时间短等优点,腹腔镜手术治疗异位妊娠优于开腹手术。     

经阴道子宫下段切开取胚与子宫动脉栓塞术治疗剖宫产瘢痕妊娠的比较性研究

目的 探讨经阴道前穹隆子宫下段切开取胚术和子宫动脉栓塞术对治疗剖宫产瘢痕妊娠的临床价值.方法 2010年1月～2012年2月,在我院确诊的38例剖宫产瘢痕妊娠中,21例行子宫动脉化疗栓塞术+清宫术,17例行经阴道子宫下段切开取胚并修补子宫缺陷手术.比较2种术式的术中出血量、术后血hCG降至正常的时间、住院时间、住院费用.结果 2种术式术后血hCG下降至正常的时间差异无显著性(P＞0.05),经阴道子宫下段切开取胚术的术中出血更少[(28.8±7.4)mlvs.(48.6±38.2) ml,t=-2.097,P=0.043],总住院时间更短[(6.2±1.5)d vs.(9.0±1.4)d,t=-6.012,P=0.000],住院费用更少[(7779.1±343.0)元vs.(13 299.6±712.2)元,t=-31.318,P=0.000].结论 经阴道子宫下段切开取胚并修补子宫缺陷手术是治疗剖宫产瘢痕妊娠的一种安全、有效、微创、经济的手术方式.     

腹腔镜子宫动脉阻断及子宫病灶切除在初治失败的剖宫产瘢痕妊娠中的应用

目的探讨腹腔镜下子宫动脉阻断及子宫病灶切除在初治失败的剖宫产瘢痕妊娠中应用的可行性及价值。方法2006年5月～2009年5月我院对4例经外院治疗失败的剖宫产瘢痕妊娠,采用在腹腔镜下先分离出双侧子宫动脉并进行动脉阻断,然后行剖宫产瘢痕妊娠病灶切除及缝合修补。结果4例均在腹腔镜下成功行子宫动脉阻断及病灶切除修补,无中转开腹及手术并发症。手术时间60～80min,术中出血量30～70ml。术后血hCG4周内均降至正常,月经规律来潮。结论腹腔镜下子宫动脉阻断及子宫病灶切除具有微创、疗效确切等优点,将成为治疗初治失败的剖宫产瘢痕妊娠病例的最佳方法。     

腹腔镜在异位妊娠保守手术中的应用

目的探讨腹腔镜在异位妊娠保守手术中的应用价值.方法回顾分析我院1999年12月～2004年3月168例异位妊娠保守手术病例,其中113例经腹腔镜手术,55例行开腹手术,比较两组的手术时间、术中出血量及术后妊娠率.结果113例腹腔镜手术中,109例(96.46%)顺利完成手术,4例(3.54%)中转开腹.腹腔镜手术组与开腹组相比,手术时间明显缩短(P＜0.001),术中出血量明显减少(P＜0.001),术后宫内妊娠率明显升高(P＜0.05).结论腹腔镜手术是异位妊娠保守手术治疗中安全、可靠的方法之一.     

宫腔放置水囊联合腹腔镜下子宫病灶切除在抢救剖宫产瘢痕妊娠初治出血中的应用

目的探讨官腔放置水囊联合腹腔镜下子宫病灶切除在抢救剖宫产瘢痕妊娠初治出血中的可行性及价值。方法2010年10月～2019年6月,对5例初治出血的剖宫产瘢痕妊娠,先在宫腔内放置水囊压迫止血,然后立即行腹腔镜下剖宫产瘢痕妊娠病灶切除及缝合修补。结果5例均获成功,无中转开腹及手术并发症。手术时间35～50min,平均42min。术中出血量10～30ml,平均21ml。术后4周内血β-hCG均降至正常,月经规律来潮。结论官腔放置水囊联合腹腔镜子宫病灶切除具有微创、疗效确切等优点,是抢救初治出血的剖宫产瘢痕妊娠病例的有效方法。     

血管内介入治疗子宫特殊部位妊娠

目的探讨血管内介入治疗在子宫特殊部位异位妊娠治疗中的临床意义。方法对22例子宫特殊部位妊娠患者行双侧子宫动脉灌注氨甲蝶呤加栓塞术治疗,其中宫颈妊娠6例、子宫切口妊娠15例、宫角妊娠1例,分析其临床疗效。结果 20例经子宫动脉栓塞术后血β-HCG水平呈进行性显著下降,2～3周均降至正常。6例因仍有少量阴道出血及妊娠物残留,于术后5～19天行清宫术,无子宫破裂和大出血发生,随访2个月后月经周期均恢复正常。结论血管内介入治疗子宫特殊部位异位妊娠微创、安全有效、并发症少,可保留患者子宫及生育功能。     

Three-dimensional power Doppler ultrasound diagnosis and laparoscopic management of a pregancy in a previous cesarean scar

An ectopic pregnancy developing in a previous Cesarean section scar is a rare event, and there is still a lack of information concerning the adequacy of management strategies. So far, no modality can guarantee the integrity of the uterus. We report the case of a 29-year-old woman with three Cesarean deliveries who was transferred to our hospital with a diagnosis of cervical pregnancy. Transvaginal three-dimensional power Doppler ultrasound revealed a well-encapsulated bulging mass displacing anteriorly over the lower anterior uterine wall sounding with an irregular course and branching vessels. The diagnosis of pregnancy in a previous Cesarean scar was made. Laparoscopic ligation of bilateral uterine arteries followed by excision of the ectopic pregnant mass was undertaken, and the patient's uterus was successfully preserved. Conservative management with the laparoscopic approach may be a safe and effective alternative to hysterectomy in patients with a pregnacy in a previous Cesarean scar.     

剖宫产瘢痕妊娠两种手术治疗方式安全性及有效性的比较

目的比较开腹剖宫产瘢痕妊娠病灶切除联合子宫下段修补术和双侧子宫动脉栓塞联合清宫术两种治疗方式在剖宫产瘢痕妊娠治疗中的安全性和有效性。方法选择2009~2014年就诊于北京协和医院并接受手术治疗的剖宫产瘢痕妊娠患者245例,将符合本研究纳入标准的100例患者随机分为开腹剖宫产瘢痕妊娠病灶切除联合子宫下段修补术组(开腹组)和双侧子宫动脉栓塞联合清宫术组(栓塞后清宫组)。收集患者的基本信息、围术期资料及门诊随诊资料,并进行统计学分析。结果两种治疗方法的成功率比较无显著性差异(98.0%vs.96.0%,P0.05)。开腹组患者术中出血量显著多于栓塞后清宫组[(95.0±48.4)ml vs.(23.0±17.6)ml](P=0.000)。开腹组患者术后血清β-HCG降至正常所需时间显著短于栓塞后清宫组[(30.7±10.7)d vs.(34.7±9.6)d](P0.05)。术后子宫下段前壁剖宫产瘢痕处异常回声消失的时间两组比较无显著性差异[(35.7±10.8)d vs.(24.4±13.6)d](P0.05)。开腹组手术时间显著长于栓塞后清宫组[(77.0±15.0)min vs.(30.0±16.0)min](P=0.00)。开腹组患者的住院治疗费用显著低于栓塞后清宫组[(7 919.6±3 680.6)元vs.(15 285.6±2 962.9)元](P=0.00)。电话随访两组患者术后月经复潮的时间,开腹组显著短于栓塞后清宫组[(37.4±8.9)d vs.(40.9±7.2)d](P0.05)。结论开腹剖宫产瘢痕妊娠病灶切除联合子宫下段修补术和双侧子宫动脉栓塞联合清宫术各有优点,均为安全、有效的剖宫产瘢痕妊娠治疗方案。     

Incarcerated femoral hernia containing the right uterine tube. A pre-operative diagnosis is possible

The incarcerated femoral hernia containing the right uterine tube is very rare to see. The case report is important to accumulate knowledge of very rare cases. The diagnosis of the case was established pre-operatively with abdominal computerized tomography (CT) On CT examination, the mass in the hernia sac was not connected with the intestines and a tubal structure on the right side of the uterus was shown to extend out of the abdomen. In the operation, the right uterine tube(RUT) was reduced into the abdomen after its blood supply was shown to be normal. A hernia repair was performed. Sometimes in obese patients, incarcerated femoral or inguinal hernias may not been noted. Ultrasonography, CT and magnetic resonance imaging (MRI) is used frequently to diagnose abdominal wall hernias. The organs in the incarcerated sac must be examined carefully and the viability must be checked. The surgeon must decide whether or not to resect the organs. In our case, strangulation was not found and polypropylene mesh was not used for hernia repair due to a fear of infection of the prosthesis. Incarceration of the uterine tube in the sac is traumatic and this condition may lead to infection. Such conditions may lead to ectopic pregnancy. The patient must be informed about ectopic pregnancy due to a previous incarceration of the tube because ectopic pregnancy may be fatal.     

腹腔镜手术诊疗特殊部位异位妊娠的价值

目的:探讨腹腔镜早期诊断与治疗特殊部位异位妊娠的价值。方法:回顾分析2003年7月至2005年10月经腹腔镜手术治疗的特殊部位异位妊娠41例的临床资料,包括输卵管间质部妊娠23例,宫角妊娠9例,卵巢妊娠4例,腹腔妊娠2例,残角子宫妊娠1例,子宫肌壁间妊娠1例,输卵管残端妊娠1例。结果:41例均经腹腔镜手术完成。手术时间20~80m in,平均45m in,术后28d内血β-hCG降至正常。结论:腹腔镜用于特殊部位异位妊娠,可早期作出诊断,且手术安全、可行。     

腹腔镜早期诊断及治疗特殊部位异位妊娠的价值

目的:探讨腹腔镜早期诊断及治疗特殊部位异位妊娠的价值。方法:回顾分析2002年7月至2007年7月经腹腔镜诊治45例特殊部位异位妊娠患者的临床资料,其中输卵管间质部妊娠23例,卵巢妊娠13例,宫角妊娠5例,腹腔妊娠2例,输卵管残端妊娠2例。结果:腹腔镜手术成功41例,成功率91.1%,平均手术时间(40.2±23.6)min,平均手术出血(66.5±35.5)ml;中转开腹4例;腹腔镜手术无术中、术后并发症发生。结论:腹腔镜用于早期诊断及治疗特殊部位异位妊娠安全可行,不断提高手术技巧,结合术中情况选择合适的手术方式,有助于提高手术成功率。     

腹腔镜诊治特殊部位异位妊娠的临床意义

目的：探讨腹腔镜手术治疗特殊部位异位妊娠的指征、可行性及安全性。方法：回顾分析2002年1月至2006年12月经腹腔镜手术治疗特殊部位异位妊娠的临床资料,其中输卵管间质部妊娠6例,卵巢妊娠4例,腹腔妊娠2例,输卵管残端妊娠1例。结果：腹腔妊娠因止血困难,手术出血多,手术时间长;输卵管残端妊娠只需单纯套扎盲端,出血少,手术时间短。腹腔镜手术治疗特殊部位异位妊娠平均手术时间为（93.35±48.24）min,术中平均出血量（41.43±5.05）ml,腹腔镜手术成功率92.3%。结论：腹腔镜手术治疗特殊部位异位妊娠是最佳方法,创伤小,安全可行。     

Robot-assisted laparoscopic surgery of a 12-week scar pregnancy with temporary occlusion of the uterine blood supply

A Cesarean section scar pregnancy is a serious obstetric complication. For all treatment modalities there are risks of heavy bleeding and emergency hysterectomy. Here we report the use of the da Vinci robot for removal of the pregnancy with adequate bleeding control. A 36-year-old para-3 was diagnosed having a 11 + 3 week live cesarean scar pregnancy and a complete placenta previa. S-hCG was 52 726 IU/l. One week after methotrexate treatment the pregnancy was uneventfully and completely removed by robot-assisted laparoscopy with minimal blood loss. The uterine defect was repaired. Bleeding was controlled by temporary application of metal clips to the distal internal iliac arteries and the propria ligaments. Postoperative color Doppler ultrasonography revealed normal uterine blood flow, a repaired uterine defect, and no remaining pregnancy tissue. S-hCG was normalized (<3 IU/l) 38 days after surgery. Robot-assisted laparoscopic surgery with temporary occlusion of the main uterine blood supply is a feasible and safe technique for surgery of a Cesarean scar pregnancy.     

Laparoscopic Management or Laparoscopy Combined with Transvaginal Management of Type II Cesarean Scar Pregnancy

Objective:

To evaluate the clinical effectiveness of laparoscopic management of cesarean scar pregnancy (CSP) by deep implantation.

Background:

A pregnancy implanting within the scar from a previous cesarean delivery is a rare condition of ectopic pregnancy. There are two different types of CSPs. Type I is caused by implantation of the amniotic sac on the scar with progression toward either the cervicoisthmic space or the uterine cavity. Type II (CSP-II) is caused by deep implantation into a previous CS defect with infiltrating growth into the uterine myometrium and bulging from the uterine serosal surface, which may result in uterine rupture and severe bleeding during the first trimester of pregnancy. Thus, timely management with an early and accurate diagnosis of CSP-II is important. However, laparoscopic management in CSP-II has not yet been evaluated.

Methods:

Eleven patients with CSP-II underwent conservative laparoscopic surgery or laparoscopy combined with transvaginal bilateral uterine artery ligation and resection of the scar with gestational tissue and wound repair to preserve the uterus from March 2008 to November 2011. Patients with CSP-II were diagnosed using color Doppler sonography, and the diagnosis was confirmed by laparoscopy. The operation time, the blood loss during surgery, the levels of β-human chorionic gonadotropin (β-hCG) before surgery, the time taken for serum β-hCG levels to return to <100 mIU/mL postoperatively, and the time for the uterine body to revert to its original state were retrospectively analyzed.

Results:

All 11 operations were successfully performed using laparoscopy with preservation of the uterus. One patient underwent a dilation and curettage after laparoscopic bilateral uterine artery ligation. Eight patients were treated solely by laparoscopic bilateral uterine artery ligation and resection of the scar with gestational tissue and wound repair. The remaining two patients underwent laparoscopic bilateral uterine artery ligation and transvaginal resection of the CS with gestational tissue and wound repair because of dense adhesions and heavy bleeding. The average operation time was 85.5 (±17.5) minutes, and the blood loss was 250.0 (±221.4) mL. The blood serum level of β-hCG returned to <100 mIU/mL in 16.4 (±5.3) days postoperatively. Among the 10 patients who underwent resection of CS and wound repair, the time for the uterus to revert to its original state (judged by ultrasonography) was 10.8 (±3.0) days postoperatively.

Conclusions:

Laparoscopy can remove ectopic gestational tissue and allow subsequent wound repair, as well as provide diagnostic confirmation. Being a minimally invasive procedure, laparoscopic or laparoscopy combined with transvaginal bilateral uterine artery ligation and resection of the scar with gestational tissue and wound repair can become an effective alternative for the treatment of CSP-II.     

腹腔镜下剥除黄体预防持续性异位妊娠的临床研究

目的:评价腹腔镜下输卵管妊娠保守手术的同时剥除黄体预防持续性异位妊娠的临床效果。方法:采用单中心、前瞻性、随机对照的研究方法,评价146例异位妊娠患者的治疗效果,其中腹腔镜下输卵管妊娠保守手术同时剥除黄体91例为研究组,单纯腹腔镜下输卵管妊娠保守手术55例为对照组。结果:研究组持续性异位妊娠(persistent ectopic pregnancy,PEP)发生率1.1%(1/91),对照组为14.5%(8/55),两组差异有统计学意义(P<0.01)。术后β-HCG降至正常所需时间研究组为(11.4±5.6)d,对照组为(14.7±5.2)d,两组差异有统计学意义(P<0.01)。结论:腹腔镜下输卵管妊娠保守手术同时剥除黄体是预防PEP的有效方法,其疗效优于单纯腹腔镜下保守手术。     

腹腔镜未确诊10例疑似宫外孕的回顾分析

目的:分析腹腔镜下未能确诊的10例疑似宫外孕患者的特点和原因。方法:对因宫外孕或宫外孕待排行腹腔镜手术529例患者的临床资料进行回顾性分析,对未确诊组与确诊组病例作对照研究。结果:与确诊组比较,未确诊组月经逾期天数短[(12.7±10.15)d vs.(20.84±8.0)d(P=0.01)],三联征发生率低(30%vs.78.13%),后穹窿穿刺抽出不凝血率低(30%vs.93.75%),未确诊组最终诊断为黄体囊肿合并不明位置的妊娠状态6例(1例经术后随访证实为早期输卵管妊娠),黄体囊肿合并宫内早孕或不全流产3例,浆膜下子宫肌瘤变性合并不全流产1例。结论:疑似宫外孕患者如病情稳定,不必按宫外孕急诊手术,有生育要求的患者可用期待疗法,无生育要求的患者可诊刮与宫内妊娠鉴别。     

胚胎移植术后21例输卵管间质部妊娠临床分析

目的探讨胚胎移植术后输卵管间质部妊娠的发生率、发病影响因素、治疗、妊娠结局等,以加强临床医生对输卵管间质部妊娠的认识。方法回顾性分析我中心2014年1月1日至2016年12月31日胚胎移植术后输卵管间质部妊娠的21例病例的临床资料。结果我中心2014年1月1日至2016年12月31日胚胎移植术后临床妊娠病例共6 487例,输卵管间质部妊娠21例,发病率为0.32%(21/6 487),其中14例(66.67%)有输卵管手术史;20例行腹腔镜治疗,1例保守治疗成功;输卵管间质部合并宫内妊娠8例,经腹腔镜治疗后3例成功抱婴,1例术后宫内胎儿存活(目前妊娠至28周),2例术后宫内妊娠难免流产行清宫术,2例因胚胎停育行清宫术。结论输卵管手术史是导致输卵管间质部妊娠的重要因素;腹腔镜是治疗输卵管间质部妊娠的有效方法;腹腔镜治疗输卵管间质部合并宫内妊娠,有利于宫内妊娠获得良好的妊娠结局。现有的输卵管切除和阻断方式需改进,以减少输卵管间质部妊娠的发生。