腹腔镜治疗有妇产科手术史的异位妊娠82例

目的 探讨有妇产科手术史的异位妊娠患者行腹腔镜治疗的可行性、适应证、手术方法和临床价值.方法 对82例有妇产科手术史的异位妊娠患者采用腹腔镜手术治疗.其中有1次手术史者60例,2次者21例,3次者1例.根据不同情况所采取的手术方式有:①腹腔镜直视下穿刺注药法;②输卵管切除术;③输卵管妊娠病灶切除术;④腹腔镜下输卵管切开取胚术;⑤输卵管妊娠孕囊吸出术;⑥间质部妊娠手术新方法,包括注射垂体加压素和电凝术式、妊娠组织排出前内套圈套扎术式和妊娠组织排出前荷包缝合术式等.结果 82例异位妊娠患者经腹腔镜探查发现,73例盆腹腔内有不同程度的粘连,粘连率为89.0%(73/82).其中有1次手术史的60例患者中,51例存在盆腹腔粘连,粘连率为85%;有2次以上手术史的22例患者中,全部有盆腹腔粘连,粘连率100%.70例腹腔镜手术成功,成功率85.4%,其余12例因盆腔粘连严重而中转开腹,占14.6%.12例中,合并子宫内膜异位症5例,慢性盆腔炎6例,既往有宫外孕手术史者9例;剖宫产手术史者2例;有复杂妇科手术史者1例.手术并发症包括合并盆腔子宫内膜异位症患者术中肠管损伤1例,转为开腹手术.合并盆腔子宫内膜异位症患者术后3天确诊输尿管损伤1例,转泌尿科手术治疗.腹腔镜手术时间为30～180min.结论 腹腔镜治疗有妇产科手术史的异位妊娠是一种理想的手术方式.慢性盆腔炎、子宫内膜异位症及宫外孕手术史尤其是2次宫外孕手术史会增加手术难度,中转开放手术几率较高,术前应做好相应的准备.

Laparoscopic surgery for ectopic pregnancy with prior gynecologic operation

Objective To investigate the feasibility, indications, operating technique and the clinical value of laparoscopeic surgery for ectopic pregnancy with prior history of obstetric and gynecologic operations. Methods 82 ectopic pregnancy patients with prior history of the obstetric and gynecologic operation were subjected to laparoscopic surgery. Among them, 60 patients had undergone prior obstetric and gynecologic operation only once, 21 patients had undergone twice, and the remaining one had undergone obstetric and gynecologic operation three times. The laparoscopic operation was completed in different ways as follows: puncture and injection of drug under laparoscopy, salpingectomy, resection of pregnancy in oviduct, removal of embryo through incision of oviduct under laparoscope, suction removal of embryo from oviduct, and new technique for pregnant surgery at interstitial portion. Results Of these 82 patients undergoing laparoscopic surgery, 73 cases had adhesion in different degree, and the adhesion rate was 89.0% (73/82). In the 60 patients with history of one operation, pelvic peritoneal adhesion was found in 51 patients, the adhesion rate was 85.0%. All 22 patients with two prior operations had pelvic peritoneal adhesion, and the rate was 100.0%. The laparoscopic surgery was successful in 70 cases. The rate of success was 85.4%, while in 12 patients, the operation was changed into laparectomy due to dense adhesion, and the rate was 14.6%. Of these 12 patients, in 5 of them there was endometriosis, in 6 patients chronic pelvic inflammation was found, 9 patients had a surgical history for ectopic pregnancy, 2 patients with the history of caesarean section, and one patient had a history of complicated gynecologic operation. Complications included colonic injury in one patient with ectopic pregnancy, and the operation was changed to laparotomy. Injury to the ureter happened in one patient. The operation time for laparoscopic surgery was 30-180 min. Conclusions The laparoscopic operation is an effective procedure and it has become a routine procedure for ectopic pregnancy with prior history of obstetric and gynecologic operation. Because of chronic pelvic inflammation and endometriosis, it is difficult to perform laparoscopic surgery successfully, and laparotomy should be anticipated at all time.