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中华妇幼临床医学杂志(电子版) ›› 2023, Vol. 19 ›› Issue (03) : 330 -337. doi: 10.3877/cma.j.issn.1673-5250.2023.03.013

论著

腹腔镜折叠对接缝合联合宫腔镜憩室开渠法治疗剖宫产瘢痕憩室的疗效
杨一君1, 董雯2, 刘晓平1, 石灿1, 张磊1, 谷琎1, 龚咪1, 华馥1,†()   
  1. 1南京医科大学附属淮安第一医院妇科，淮安　223300
    2泗阳康达医院妇科，泗阳　223700
  • 收稿日期:2022-12-21 修回日期:2023-05-04 出版日期:2023-06-01
  • 通信作者: 华馥

Efficacy of laparoscopic folding suture combined with hysteroscopic iverticulum incision in the treatment of cesarean scar diverticulum

Yijun Yang1, Wen Dong2, Xiaoping Liu1, Can Shi1, Lei Zhang1, jin Gu1, Mi Gong1, Fu Hua1,†()   

  1. 1Department of Gynecology, the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University, Huai′an 223300, Jiangsu Province, China
    2Department of Gynecology, Siyang Kangda Hospital, Siyang 223700, Jiangsu Province, China
  • Received:2022-12-21 Revised:2023-05-04 Published:2023-06-01
  • Corresponding author: Fu Hua
  • Supported by:
    Project of Jiangsu Maternal and Child Health Association(FYX202117); Huai′an Science and Technology Projects(HAB202105); Development Funds of the Affiliated Hospital of Xuzhou Medical University(XYFM2021035); Young Innovative Talents of the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University(QC202214)
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引用本文：

杨一君, 董雯, 刘晓平, 石灿, 张磊, 谷琎, 龚咪, 华馥. 腹腔镜折叠对接缝合联合宫腔镜憩室开渠法治疗剖宫产瘢痕憩室的疗效[J]. 中华妇幼临床医学杂志(电子版), 2023, 19(03): 330-337.

Yijun Yang, Wen Dong, Xiaoping Liu, Can Shi, Lei Zhang, jin Gu, Mi Gong, Fu Hua. Efficacy of laparoscopic folding suture combined with hysteroscopic iverticulum incision in the treatment of cesarean scar diverticulum[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2023, 19(03): 330-337.

目的

探讨腹腔镜折叠对接缝合联合宫腔镜憩室开渠术治疗剖宫产瘢痕憩室(CSD)的疗效。

方法

选择2018年5月至2022年12月在南京医科大学附属淮安第一医院因CSD接受手术治疗86例患者的临床病例资料为研究对象。根据手术治疗方式不同，将其分为实验组(n＝56，接受腹腔镜下折叠对接缝合法联合宫腔镜憩室开渠法者)和对照组(n＝30，接受腹腔镜下折叠对接缝合法者)。回顾性分析2组患者一般临床资料、围手术期相关指标、术前及术后6个月经期持续时间，以及治疗总有效率等。本研究所遵循的程序符合南京医科大学附属淮安第一医院医学伦理委员会制定的标准，得到该委员会批准(审批文号：YX-P-2018-012-01)，并与患者本人或其家属签署临床研究知情同意书。

结果

①2组CSD患者年龄与CSD残余肌层处厚度、深度及剖宫产次数、子宫位置构成比等一般临床资料比较，差异均无统计学意义(P>0.05)。②2组患者术中出血量、总住院时间、术后住院时间、术后留置尿管时间和术后排气时间比较，差异均无统计学意义(P>0.05)。③实验组与对照组CSD患者术后平均经期分别为(7.9± 3.2)d与(8.4± 3.2)d，均明显短于术前的(15.2± 5.7)d与(12.6± 5.1)d，差异均有统计学意义(t＝9.59、4.79，P<0.001)。④实验组患者的治疗总有效率为83.9%(47/56)，显著高于对照组的63.3%(19/30)，并且差异有统计学意义(χ2＝4.64，P＝0.031)。

结论

腹腔镜折叠对接缝合联合宫腔镜憩室开渠法治疗CSD患者具有临床效果确切、可保留子宫完整性、缩短经期的优点，适宜临床推广。

关键词: 憩室, 剖宫产术, 宫腔镜检查, 腹腔镜检查, 剖宫产瘢痕憩室, 伤口缝合技术, 子宫肌层, 月经周期, 妇女
Objective

To explore the efficacy of laparoscopic folding suture combined with hysteroscopic iverticulum incision in the treatment of cesarean scar diverticulum (CSD).

Methods

A total of 86 patients with CSD in the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University from May 2018 to December 2022 were selected into this study. They were randomly divided into experimental group (n=56, patients received laparoscopic folding suture combined with hysteroscopic hysteroscopy diverticulum incision) and control group (n=30, patients received laparoscopic folding suture) according to the different surgical method. The general clinical data, perioperative related indicators, preoperative and post-operative menstruation period, and the total treatment response rate of two groups were retrospectively analyzed. This study was approved by the Ethics Committee of the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University (Approve No. YX-P-2018-012-01). The patients or their family members signed the clinical research informed consent.

Results

①There were no statistically significant differences between two groups of general clinical data such as age, residual uterine thickness, depth of defect, number of caesarean sections and uterine position composition ratio (P>0.05). ②There were no statistically significant differences in intraoperative blood loss, total hospital stay, postoperative hospital stay, postoperative indwelling catheter time, and postoperative exhaust time between two groups (P>0.05). ③The mean postoperative menstrual period in the experimental group was (7.9±3.2) d, significantly shorter than that of preoperative menstrual period [(15.2±5.7) d]. The mean postoperative menstrual period in control group was (8.4± 3.2) d, also significantly shorter than that of preoperative menstrual period of (12.6±5.1) d. The above differences between two groups were all statistically significant (t=9.59, 4.79; P<0.001). ④The total effective rate of experimental group was 83.9% (47/56), significantly higher than 63.3% (19/30) in control group, the difference between two groups was statistically significant (χ2=4.64, P=0.031).

Conclusions

Laparoscopic folding suture combined with hysteroscopic iverticulum incision has the advantages of definite clinical effects, preserve uterine integrity, shorten menstrual period, which is suitable for clinical promotion.

Key words: Diverticulum, Cesarean section, Hysteroscopy, Laparoscopy, Cesarean scar diverticulum, Wound closure techniques, Myometrium, Menstrual cycle, Women
图1 对1例CSD患者的诊断(35岁)(图1A：阴道超声声像图，红色箭头所示为CSD；图1B：CSD的MRI检查图像，红色箭头所示为CSD；图1C：CSD矢状面示意图，直线a表示憩室宽度，直线b表示憩室深度，直线c表示子宫下段残余肌层处厚度)注：CSD为剖宫产瘢痕憩室
图2 实验组1例CSD患者(34岁，病程为0.5年)接受腹腔镜下折叠对接缝合联合宫腔镜憩室开渠的手术步骤图(图2A：腹腔镜下打开膀胱子宫返折腹膜；图2B：腹腔镜下充分下推膀胱至宫颈下方2 cm；图2C：宫腔镜下探查CSD部位及范围；图2D：电凝棒电灼CSD上、下方子宫浆膜面，上、下宽度各约为1.5 cm，使子宫浆膜面变粗糙；图2E：采用1-0可吸收线连续缝合憩室上、下极；图2F：采用1-0可吸收线连续缝合憩室并加强；图2G：腹腔镜下折叠闭合CSD；图2H：宫腔镜下再次探查CSD可见剖宫产瘢痕憩室仍存在，但较前变浅；图2I：宫腔镜下电切环电切CSD内膜侧边；图2J：宫腔镜下电切环电切CSD内膜底边；图2K：宫腔镜下电切环电切CSD下方明显形成瘢痕隆起处组织；图2L：腹腔镜再次探查腹腔情况，创面无渗血)注：CSD为剖宫产瘢痕憩室
图3 CSD患者行腹腔镜下折叠对接缝合联合宫腔镜憩室开渠的手术步骤示意图(图3A：CSD矢状面；图3B：腹腔镜下分离子宫、膀胱黏连并下推膀胱；图3C：确定CSD位置及范围；图3D：1-0可吸收线于CSD上方、距离CSD 1.5 cm处进针；图3E：1-0可吸收线于CSD正上方出针；图3F：1-0可吸收线于CSD正上方进针；图3G：1-0可吸收线于CSD下方子宫浆膜面1.5 cm处出针；图3H：腹腔镜下连续缝合CSD；图3I：手术后子宫矢状面；图3J：宫腔镜下再次探查CSD；图3K：宫腔镜下切除CSD近端、内膜底边及远端边缘；图3L：术后子宫矢状面)注：CSD为剖宫产瘢痕憩室
表1 2组CSD患者的一般临床资料比较
组别 例数 年龄(岁，±s) 残余肌层处厚度[mm，M(Q1，Q3)] 憩室深度(mm，±s) 剖宫产术分娩次数(次，±s) 子宫位置[例数(%)]
前位 中位或后位
实验组 56 33.5±5.3 3.7(2.5，5.6) 5.7(4.1，7.7) 1.8±0.6 24(42.9) 32(57.1)
对照组 30 32.4±6.0 3.6(2.3，4.5) 7.1(5.0，7.7) 1.5±0.6 9(30.0) 21(70.0)
统计值   t＝0.84 Z＝－0.69 Z＝1.47 t＝1.60 χ2＝1.37
P值   0.404 0.488 0.142 0.114 0.243
表2 2组CSD患者围手术期临床指标比较[M(Q1，Q3)]
组别 例数 术中出血量(mL) 总住院时间(d) 术后住院时间(d) 术后留置尿管时间(d) 术后排气时间(d)
实验组 56 50(20，100) 6(6，7) 4(3，4) 3(2，3) 2.0(1.2，2.0)
对照组 30 100(50，100) 6(5，7) 4(3，4) 2(2，3) 2.0(2.0，2.0)
Z值   1.46 －0.77 －0.80 －0.80 1.26
P值   0.144 0.444 0.426 0.426 0.208
表3 2组CSD患者术前及术后6个月经期持续时间组内比较(±s)
组别 例数 术前经期持续时间(d) 术后经期持续时间(d) t值 P值
实验组 56 15.2±5.7 7.9±3.2 9.59 <0.001
对照组 30 12.6±5.1 8.4±3.2 4.79 <0.001
表4 2组CSD患者疗效比较
组别 例数 治愈 好转 无效 总有效率
实验组 56 37(66.1) 10(17.9) 9(16.1) 47(83.9)
对照组 30 14(46.7) 5(16.7) 11(36.7) 19(63.3)
χ2值   － － － 4.64
P值   － － － 0.031
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