子宫瘢痕缺损手术指征与手术方式的探讨

Study on surgical indications and surgical methods of previous cesarean scar defect

目的探讨子宫瘢痕缺损的最佳手术指征及手术方式。方法选择2016年1月1日至2021年12月31日厦门大学附属第一医院收治的经阴道超声、宫腔镜诊断为子宫瘢痕缺损患者1251例为研究对象,未行瘢痕缺损手术者859例,行瘢痕缺损手术者392例,其中经阴道子宫瘢痕缺损修补术34例(阴式切开组),宫腹腔镜子宫瘢痕缺损切开缝合术75例(宫腹腔镜切开缝合组),宫腔镜子宫瘢痕缺损电切术168例(宫腔镜组),宫腹腔镜子宫瘢痕缺损折叠缝合术115例(宫腹腔镜折叠缝合组),对比行不同手术方式的患者术后恢复情况。所有患者中再次妊娠者165例,其中瘢痕缺损手术后再妊娠27例,未行瘢痕缺损手术再妊娠138例,比较两组再妊娠情况及结局。结果经期改善的总有效率宫腔镜组为58.3%,阴式切开组为85.3%,宫腹腔镜切开缝合组为82.7%,宫腹腔镜折叠缝合组为88.7%,后3组的有效率明显高于宫腔镜组(P<0.05)。瘢痕缺损修补术后的瘢痕妊娠率3.7%,不完全性子宫破裂率0,均比未行瘢痕缺损修补术组(分别为21.0%和13.0%)低,差异有统计学意义(P<0.05)。结论子宫瘢痕缺损手术治疗可以有效改善患者异常子宫出血症状。4种手术方式均能改善患者症状,具体手术方式需结合患者及当地医疗条件个体化选择。子宫瘢痕缺损修补术能有效降低瘢痕妊娠率、不完全性子宫破裂率,故有生育要求者建议孕前先行子宫瘢痕缺损修补术。宫腹腔镜子宫瘢痕缺损折叠缝合术有望作为有妊娠需求患者的首选手术方式。

Objective To explore the best surgical indications and surgical methods of previous cesarean scar defect(PCSD).Methods A total of 1251 patients admitted to the First Affiliated Hospital of Xiamen University from January 1,2016 to December 31,2021,who were diagnosed with previous cesarean scar defect by transvaginal ultrasound and hysteroscopy were selected as the research subjects.There were 859 patients without scar defect surgery and 392 patients with surgery,including 34 patients with transvaginal uterine defect repair(vaginal incision group),75 patients with laparoscopic uterine defect incision and suture(aparoscopic incision and suture group),168 patients with hysteroscopic uterine defect electrotomy(hysteroscopy group),and 115 cases of laparoscopic uterine defect folding suture(laparoscopic folding suture group).Compare the postoperative recovery of patients receiving different surgical methods.There were 165 cases re-pregnancy in all patients,including 27 cases of re-pregnancy after defect surgery and 138 cases of re-pregnancy without surgery.Results In the treatment of abnormal uterine bleeding,the effective rate of hysteroscopy group was 58.3%,in vaginal incision group it was 85.3%,laparoscopic incision suture group 82.7%,laparoscopic folding suture group 88.7%,and the effective rate of the latter three groups was significantly higher than that of hysteroscopy group(P<0.05).The scar pregnancy rate after scar defect repair was 3.7%,and the incomplete uterine rupture rate was 0,which were lower than those without surgery,and the difference was statistically significant(P<0.05).Conclusions Surgical treatment for PCSD can effectively improve the symptoms of abnormal uterine bleeding in patients.The four surgical methods can improve the symptoms of patients,and the specific surgical methods need to be individualized according to the patients and local medical conditions.The repair for PCSD can effectively reduce the rate of scar pregnancy and incomplete uterine rupture,so it is recommended to repair uterine scar defect before pregnancy.Laparoscopic uterine defect folding suture is expected to be the preferred surgical method for patients with pregnancy needs.