宫腔镜联合腹腔镜下剖宫产瘢痕憩室修补术效果的相关因素分析

Clinical and surgical factors associated with effectiveness of laparoscopy combined with hysteroscopy in repair of cesarean scar defect

目的评估宫腔镜联合腹腔镜下剖宫产瘢痕憩室(CSD)修补术疗效的影响因素。方法收集并随访2010年8月—2019年8月间在复旦大学附属妇产科医院行宫腔镜联合腹腔镜下CSD修补术的228例CSD患者临床资料,筛选并采用单因素和多因素分析13个变量(年龄是否<35岁,是否初次剖宫产,术前平均经期是否≤14 d,术前憩室深度是否<7 mm,术前憩室宽度是否≤15 mm,剖宫产距症状出现时间是否<1年,术中出血量是否≤50 mL,前次剖宫产手术医院级别,术中缝线是否为延迟可吸收缝合线,术中是否合并其他手术,术前是否使用雌、孕激素治疗,围手术期是否使用抗生素,是否为巨大儿或双胎妊娠)对宫腔镜联合腹腔镜下CSD修补术效果的影响。结果228例患者中有176例完成了随访,176例患者均曾行子宫下段剖宫产手术。手术指征占比前3位的分别为瘢痕子宫57例(32.4%)、社会因素46例(26.1%)和产程异常14例(7.9%)。176例患者术前憩室深度均>3 mm。142例(80.7%)患者术后月经经期较前缩短。达到手术有效的共129例,无效47例,总体有效率为73.3%。其中,瘢痕子宫和产程异常的患者手术有效率分别为68.4%(39/57)和9/14。单因素分析显示,术前憩室深度是否<7 mm和手术缝合线类型为影响手术疗效的危险因素(P值均<0.05)。多因素分析显示,术前憩室深度≥7 mm、术前憩室宽度>15 mm和使用延迟可吸收缝合线为影响手术疗效的危险因素(P值均<0.05)。结论憩室深度<7 mm的患者更有可能从宫腔镜联合腹腔镜下CSD修补术中获益,而采用延迟可吸收缝合线可提高手术疗效。

Objective To evaluate factors related to the therapeutic effect of laparoscopy combined with hysteroscopy in repair of cesarean scar defect(CSD).Methods Clinical data of 228 CSD patients who underwent diverticulum repair of CSD by laparoscopy and hysteroscopy at Obstetrics and Gynecology Hospital of Fudan University between August 2010 and August 2019 were collected.Univariate and multivariate analyses were used to assess the correlation between effectiveness of CSD repair by laparoscopy and hysteroscopy and 13 potential parameters associated with surgical effectiveness,including age<35 years old,the first cesarean section or not,menstrual duration≤14 d,diverticulum depth less than 7 mm,diverticulum width≤15 mm,the time between cesarean section and symptom<1 year,intraoperative bleeding≤50 mL,hospital level of previous cesarean section,delayed absorbable suture or not,any other operations during cesarean,preoperative estrogen and progesterone therapy,perioperative use of antibiotics,macrosomia or twins.Results Among the 228 patients,176 completed the follow-up and all underwent lower uterine cesarean section.The first three surgical indications were scarred uterus(57 cases,32.4%),sociodemographic factor(46 cases,26.1%),and abnormal labor(14 cases,7.9%).Diverticulum depth was more than 3 mm in all the 176 patients,and 142(80.7%)patients had shortened menstrual periods after surgery.The effective rate of operation was 73.3%(129/176).The effective rates for scarred uterus and abnormal labor were 68.4%(39/57)and 9/14,respectively.Univariate analysis showed that suture type and diverticulum depth≤7 mm were significantly associated with surgical effectiveness(both P<0.05).Multivariate analysis showed that diverticulum depth≥7 mm,diverticulum width>15 mm,and using delayed absorbable suture type were significantly related to surgical effectiveness(all P<0.05).Conclusion Patients with diverticulum depth less than 7 mm are more likely to benefit from CSD repair by hysteroscopy combined with laparoscopy.The use of delayed absorbable suture can obtain better surgical results.