PDF《· 新技术· 新方法·》

1998 年美国 Scibetta 等[12] 首报

1 例腹腔镜宫颈峡部环扎术(laparoscopic transabdominal cervicoisthmic cerclage ,LTCC). 同年 Lesser 等[13] 尝 试应用腹腔镜行宫颈环扎术亦取得成功,此后不断有非孕期腹腔镜环扎成功的报道 [14] ,甚至可以在孕期施术. 至今全球已有 腹腔镜宫颈环扎术成功足月分娩

49 例,获活婴

52 例(3 例为双胎)和3例失败的报道,成功率 94%. 腹腔镜环扎术的环扎带 放置在宫颈内口的解剖学位置非常准确,较经阴道环扎避免了阴道异物,克服了在瘢痕和缩短的宫颈上缝合困难的技术问 题,较开腹环扎创伤小,而与开腹环扎有同样的效果. Carter 等[15] 比较

12 例腹腔镜环扎和

7 例开腹环扎的治疗效果. 患者至 少有一次因宫颈功能不全,和至少一次经阴道环扎失败的中期妊娠流产史. 腹腔镜环扎 75%(12 / 19)获活婴,开腹组 71% (5 / 7)获活婴. 其中孕期施术成功率,腹腔镜组为 80%(4 / 5),开腹组为 60%(3 / 5),两组相比,P = 1畅0. 因此,可见腹腔镜环 扎是开腹环扎安全和有效的替代方法. 此法不但可延长胎儿的孕期,并且对孕妇也安全和有效.

2008 年美国报道

2 篇机器 人辅助腹腔镜环扎术 [16唱17] ,为腹腔镜宫颈环扎术的术式又增加了新的选择. 机器人克服了常规腹腔镜二维深度观察和手操 作的局限性,手术更加微创,同样有效,还可在妊娠期辅助经腹环扎,为宫颈环扎术提供了替代传统开腹和快速恢复的方法. 腹腔镜环扎术的问题是缝合环扎带打结时虽然考虑到了早期流产胚物排出的问题,但中期妊娠胎儿死亡或早产仍旧需要开 腹或阴道切开 [2] ,不过也有于妊娠

16 和19 周因早破水难免流产和胎死宫内,经腹腔镜取出环扎带的成功报道 [18唱19] ,多数患 者的生育过程仍为高危妊娠,且有低出生体重儿的倾向. 本文例

4 足月分娩新生儿体重

3600 g,无体重低的问题. 该例剖宫 产时未取出环扎带. 由此可见,孕前环扎带腹腔镜宫颈环扎术可作为有妊娠中期流产病史,经阴道环扎失败的宫颈功能不全患者有效替代治 疗方法. (本文视频见医学视听栏目) ・

6 3

6 3 ・ 中华临床医师杂志(电子版)2011 年6月第

5 卷第

12 期Chin J Clinicians(Electronic Edition),June 15,2011,Vol. 5,No.

12 参考文献[1] Novy MJ. Transabdominal cervicoisthmic cerclage:a reappraisal

25 years after its introduction. Am J Obstet Gynecol,1991,164:1635唱1641畅[2] Harger JH. Cerclage and cervical insufficiency:an evidence唱based analysis. Obstet Gynecol,2002,100:1313唱1327畅[3] Reinold E,Lackner G. Increasing frequency of surgical closure of the incompetent cervix (author′ s transl). Med Klin,1975,70:551唱557畅[4] Katz M, Abrahams C.Transvaginal placement of cervicoisthmic cerclage:report on pregnancy outcome. Am J Obstet Gynecol,2005,192:1989唱1992畅[5] Deffieux X, de Tayrac R, Louafi N,et al. Transvaginal cervico唱isthmic cerclage using polypropylene tape:surgical procedure and pregnancy out唱come:Fernandez′ s procedure. J Gynecol Obstet Biol Reprod (Paris),2006,35:465唱471畅[6] Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency . Obstet Gynecol, 1965,25:145唱155畅[7] Novy MJ. Transabdominal cervicoisthmic cerclage for the management of repetitive abortion and premature delivery . Am J Obstet Gynecol,1982, 143:44唱54畅[8] Kj宝llesdal M,Nielsen S,Stjerndahl JH,et al. Laparoscopic cervico唱uterine cerclage using polypropylene mesh for the treatment of cervical incompe唱tence. Acta Obstet Gynecol Scand,2005,84:823唱824畅[9] Christiansen OB. Transabdominal cervicoisthrnic cerclage in the management of recurrent second trimester miscarriage and preterm delivery . Br J Obstet Gynaecol,1996,103:595唱596畅[10] Pawowicz P, Ordon W,Malinowski A. Laparoscopic abdominal cervical cerclage before conception唱case report. Ginekol Pol,2009,80:949唱952畅[11] Abenhaim HA,Tulandi T. Cervical insufficiency:re唱evaluating the prophylactic cervical cerclage. J Matern Fetal Neonatal Med,2009,22:510唱516畅[12] Scibetta JJ, Sanko SR,Phipps WR. Laparoscopic transabdominal cervicoisthmic cerclage. Fertil Steril,1998,69:161唱163畅[13] Lesser KB, Childers J, Surwitt EA. Transabdominal cerclage:a laparoscopic approach. Obstet Gynecol,1998,91:855唱856畅[14] Ghomi A, Rodgcrs B. Laparoscopic abdominal cerclage during pregnancy:a case report and a review of the described operative techniques. J Minim Invasive Gynecol,2006,13:337唱341畅[15] Carter JF,Soper DE,Goetzl LM,et al. Abdominal cerclage for the treatment of recurrent cervical insufficiency:laparoscopy or laparotomy? Am J Obstet Gynecol,2009,201:111畅e1唱 4畅 [16] Wolfe L,DePasquale S,Adair CD,et al. Robotic唱assisted laparoscopic placement of transabdominal cerclage during pregnancy. Am J Perinatol, 2008,25:653唱655畅[17] Geisler JP,Orr CJ,Manahan KJ. Robotically assisted total laparoscopic radical trachelectomy for fertility sparing in stage IB1 adenosarcoma of the cervix. J Laparoendosc Adv Surg Tech A,2008,18:727唱729畅[18] Carter JF,Soper DE. Laparoscopic removal of abdominal cerclage. JSLS,2007,11:375唱377畅[19] Scarantino SE,Reilly JG,Moretti ML,et al. Laparoscopic removal of a transabdominal cervical cerclage. Am J Obstet Gynecol,2000,182:1086唱1088畅 (收稿日期:2011唱02唱28) (本文编辑: 戚红丹) 夏恩兰,刘玉环,黄晓武,等. 孕前环扎带腹腔镜宫颈环扎术[J / CD]. 中华临床医师杂志:电子版,2011,5(12):3635唱3637. ・