先天性宫颈阴道闭锁初次手术治疗失败后的再处理:附5例报告

Rearrangement after Failure of Primary Surgery for Congenital Cervical Atresia Complicated with Vaginal Aplasia:Report of Five Cases

目的探讨先天性宫颈阴道闭锁初次手术失败的影响因素及再次手术的处理。方法对2006年5月～2012年2月5例先天性宫颈阴道闭锁外院初次手术失败均以术后周期性持续性腹痛转入我院。5例初次手术前均仅诊断为阴道闭锁行阴道成形术,术中发现合并宫颈闭锁而行宫颈阴道贯通术,分别于术后4年6个月、3个月、3年4个月、1年4个月、3年2个月(二次术后)来我院治疗。2例不完全闭锁在术前检查后出现严重盆腔感染,抗生素治疗无效先行急诊手术治疗。第1例行宫颈粘连松解修补术+宫腔镜检查+宫颈修补术,第2例行部分宫颈切除+宫颈闭锁分离成形+自体皮瓣阴道成形术,第3例行腹腔镜子宫+双侧输卵管切除术,第4、5例行开腹宫体切开宫颈造口术+阴道成形术。4例术后经宫颈在宫腔内留置F18～F20Foley’s尿管或剪短的蘑菇头尿管,术后分别放置2周(因阴道放置模具而取出)、6个月(因结婚而取出)、11个月、1年。结果 5例术后随访0.5～5年,腹痛未再复发。结论对复杂的阴道闭锁初次手术前做影像学的充分评估,使用不脱落的宫颈管支架和适当的阴道成形是手术成功的关键。对不全闭锁首选影像学检查。

Objective To evaluate the risks of the failure of primary operation for congenital cervical and vaginal atresia and to explore a method for a second operation. Methods Five patients with cervical atresia and vaginal aplasia, who had failed in an abdominal or vaginal surgery, suffering from postoperative continuous periodic abdominal pain, were referred to our hospital during May 2006 to February 2012. The primary diagnosis before the primary operation of all the five cases was vaginal atresia, and thus a vaginoplasty surgery was scheduled. However, the cervical atresia was then found during the procedure, therefore a utero-vaginal anastomosis was performed instead. Because the cervical catheter falling off, the cervical atresia relapsed within 1 month to 3 years postoperatively. The interval between the primary survery and admission to our hosptial was four years and six months, three months, three years and four months, one year and four months, and three years and two months, respectively. Severe pelvic infection was developed in two patients, who had incomplete cervical and vaginal atresia, emergency operation was carried out because of failure in antibiotics therapy. The first patient received a cervix adhesiolysis plus hysteroscopic examination and repair of the cervix, and then a hysteroscopic examination; the second one underwent partial cervix resection and cervix canalization, combined with vaginoplasty with autologous flap grafting; the third patient received laparoscopic hysterectomy and bilateral salpingectomy; and the other two patients underwent laparotomy and vaginoplasty combined with utero-vaginal anastomosis. A F18 - F20 or Mushroom Foley catheter was inserted in the cervix in four of the patients after the procedure. The catheter was withdrawn in two weeks （the catheter was removed because a vaginal stent was placed）, 6 months （the catheter was removed because the patient got married） , 11 months, or 1 year, respectively. Results Follow-up was achieved for 0. 5 to 5 years in all the five patients, and none of them had recurrent abdominal pain. Conclusions Sufficient imaging evaluation before primary surgery is necessary for cervical atresia and vaginal aplasia. Falling-off- proof cervical catheter and proper vaginoplasty are the keys to a successful cervical canalization. Imaging examination is preferred for patients with partial atresia.