宫腔镜电切术子宫穿孔16例分析

Analysis of 16 cases of uterine perforation during hysteroscopic electro-surgeries

目的 探讨宫腔镜电切术子宫穿孔的发生原因、诊断、处理和预防方法。方法 1 990年 5月至 2 0 0 2年 7月 ,5家医院共行宫腔镜电切术 3 541例次 ,其中宫腔镜子宫内膜切除术 (TCRE)1 4 31例 ,1 4 68例次 ,宫腔镜子宫肌瘤切除术 (TCRM) 797例 ,宫腔镜子宫内膜息肉切除术 (TCRP) 783例 ,宫腔镜子宫纵隔切除术 (TCRS) 1 89例 ,宫腔镜子宫粘连切除术 (TCRA) 1 1 2例 ,宫腔镜宫腔异物取出术 (TCRF) 1 92例。术时均行B超和 (或 )腹腔镜监护 ,手术日前晚放置宫颈扩张棒或于阴道后穹窿放置米索前列醇 2 0 0 μg,手术步骤按不同的指征及目的进行。 结果 发生子宫穿孔 1 6例 (0 45 % ) ,8例因放置器械所致 ,其中 7例扩宫时穿孔 ,1例置镜时穿孔 ,8例为电切电极引起。子宫穿孔发生率 ,TCRA 4 46 % (5/1 1 2 ) ,TCRF 3 1 2 % (6/1 92 ) ,TCRE 0 2 7% (4/1 4 68) ,TCRM 0 1 3 % (1 /797) ;TCRP及TCRS无子宫穿孔发生。 1 6例穿孔均于术中发现 ,其中B超和 (或 )腹腔镜监护发现 1 0例 (62 % ) ,宫腔镜及临床发现 6例 (38% )。 1 3例为完全子宫穿孔 ,其中腹腔镜监护发现 2例 ,B超监护发现 5例 ,宫腔镜先于B超发现 4例 ,患者首先出现症状 ,然后B超证实子宫穿孔 2例 ;子宫不全穿孔 3例 ,2例腹腔镜监护发现 。

Objective To analyse the cause,diagnosis,treatment and preventive methods of uterine perforation resulting from hysteroscopic electro surgeries Methods Data of cases with uterine perforation were colleated from 5 hospitals where overall 3 541 hysteroscopic electro surgeries were done from May 1990 to July 2002 There were 1 468 transcervical resections of endometrium (TCRE),797 cases of transcervical resection of myoma (TCRM),783 cases of transcervical resection of endometrial polyp (TCRP),189 cases of transcervical resection of uterine septa (TCRS),112 cases of transcervical resection of uterine adhesion (TCRA) and 192 cases of transcervical removal of foreign body (TCRF) All operations were performed under B ultrasonographic or laparoscopic monitoring Cervical dilator stick was inserted into cervical canal or 200 μg of misoprostol put in the posterior fornix the evening before operation The procedures were done according to different indications and purposes Cases of uterine perforation were divided into two groups: caused by approaching (entry related) and by surgical instruments (technique related) Results Totally sixteen cases(0 45%)of uterine perforation occurred Seven cases occurred during cerivcal dilatation and 1 during hysteroscopy inserting lentry related Eight cases were technique related caused by electrode The incidences of uterine perforation of different operations were: TCRA 4 46% (5/112),TCRF 3 12%(6/192),TCRE 0 27%(4/1 468),TCRM 0 13%(1/797).TCRP and TCRS none These 16 cases were all diagnosed during operations 10 cases (62%) by B ultrasound and (or) laparoscopy,6 cases(38%) by hysteroscopy and clinical features 13 cases were complete uterine perforations,among them 2 were diagnosed by laparoscopic monitoring,5 by B ultrasonic monitoring,4 by hysteroscopy and 2 by symptoms and B ultrasound, 3 cases were incomplete uterine perforations in which 2 were diagnosed by laparoscopic monitoring and one by B ultrasound monitoring Conclusions Half of uterine perforation cases were entry related,so attention has to be paid to entry of Hegar or hysteroscope (i e ,not dilate the cervix as possible and introduce the scope under direct vision) The other half were related to surgeons′ experience and type of operation TCRA and TCRF run more risks B ultrasound and (or) laparoscopy monitoring during hysteroscopic electro surgery may help to prevent but not completely avoid uterine perforation