宮腔鏡手術時出現子宮穿孔的原因1

子宮肌瘤：寬蒂(di)或無蒂(di)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)粘(zhan)膜下肌(ji)(ji)瘤(liu)(liu)(liu)(liu)，其(qi)基底(di)部往往深達肌(ji)(ji)層(ceng)。內(nei)突型子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)壁肌(ji)(ji)瘤(liu)(liu)(liu)(liu)，瘤(liu)(liu)(liu)(liu)體的(de)1/2-2/3位(wei)于子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)壁內(nei)，使(shi)肌(ji)(ji)瘤(liu)(liu)(liu)(liu)外緣的(de)正常(chang)肌(ji)(ji)壁被擠壓的(de)很(hen)薄。二者(zhe)在超(chao)聲監護(hu)下經宮(gong)(gong)(gong)(gong)(gong)腔鏡手術單純(chun)切除瘤(liu)(liu)(liu)(liu)體很(hen)少發生子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)穿(chuan)孔。切除肌(ji)(ji)瘤(liu)(liu)(liu)(liu)后子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)內(nei)壁因瘤(liu)(liu)(liu)(liu)體的(de)剖出而形成凹陷、內(nei)突或不平整(zheng)。較(jiao)大的(de)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)瘤(liu)(liu)(liu)(liu)使(shi)肌(ji)(ji)瘤(liu)(liu)(liu)(liu)周圍正常(chang)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖維過(guo)度牽拉致(zhi)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)收縮功能差。如切除瘤(liu)(liu)(liu)(liu)體后在不平整(zheng)、收縮能力差的(de)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)壁上行TCRE術極易(yi)造(zao)成子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)穿(chuan)孔。

胎盤殘留：當(dang)蛻(tui)膜發育(yu)不(bu)(bu)良、殘留的胎(tai)盤(pan)(pan)粘(zhan)連(lian)于子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)壁上，不(bu)(bu)能自行剝落，則形(xing)成(cheng)胎(tai)盤(pan)(pan)粘(zhan)連(lian)。如果子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)蛻(tui)膜層發育(yu)不(bu)(bu)良或(huo)(huo)完全(quan)缺如，胎(tai)盤(pan)(pan)絨毛直接植(zhi)(zhi)(zhi)入(ru)(ru)(ru)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)肌(ji)層內，則構成(cheng)植(zhi)(zhi)(zhi)入(ru)(ru)(ru)性(xing)胎(tai)盤(pan)(pan)。不(bu)(bu)論是(shi)(shi)胎(tai)盤(pan)(pan)，不(bu)(bu)論胎(tai)盤(pan)(pan)部(bu)(bu)分(fen)(fen)粘(zhan)連(lian)還是(shi)(shi)胎(tai)盤(pan)(pan)部(bu)(bu)分(fen)(fen)植(zhi)(zhi)(zhi)入(ru)(ru)(ru)均(jun)可(ke)影響子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)的正常(chang)收縮(suo)和縮(suo)復。陳舊性(xing)胎(tai)盤(pan)(pan)粘(zhan)連(lian)和植(zhi)(zhi)(zhi)入(ru)(ru)(ru)可(ke)致病(bing)人產后(hou)(hou)或(huo)(huo)人工流(liu)產后(hou)(hou)出現不(bu)(bu)規則出血(xue)。聲(sheng)像(xiang)圖顯示(shi)殘留胎(tai)盤(pan)(pan)呈不(bu)(bu)均(jun)勻(yun)回(hui)聲(sheng)團塊突(tu)入(ru)(ru)(ru)宮(gong)(gong)(gong)腔。粘(zhan)連(lian)或(huo)(huo)植(zhi)(zhi)(zhi)入(ru)(ru)(ru)部(bu)(bu)分(fen)(fen)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)肌(ji)壁產生炎性(xing)細胞(bao)浸潤，肉芽組織增生，最(zui)后(hou)(hou)形(xing)成(cheng)纖維瘢(ban)痕，聲(sheng)像(xiang)圖顯示(shi)局部(bu)(bu)回(hui)聲(sheng)增強(qiang)。粘(zhan)連(lian)或(huo)(huo)植(zhi)(zhi)(zhi)入(ru)(ru)(ru)部(bu)(bu)分(fen)(fen)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)肌(ji)壁質地較(jiao)硬，而周圍正常(chang)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)壁則相(xiang)對松軟。宮(gong)(gong)(gong)腔鏡環(huan)形(xing)電極在硬度(du)不(bu)(bu)均(jun)的肌(ji)壁上切除陳舊的粘(zhan)連(lian)組織或(huo)(huo)植(zhi)(zhi)(zhi)入(ru)(ru)(ru)的胎(tai)盤(pan)(pan)組織是(shi)(shi)，容易造成(cheng)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)穿孔(kong)，如果胎(tai)盤(pan)(pan)植(zhi)(zhi)(zhi)入(ru)(ru)(ru)肌(ji)壁深層，當(dang)電切深層病(bing)變時，子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)穿孔(kong)的幾(ji)率則更大。

胎骨殘留宮腔及嵌頓：大(da)塊胎(tai)骨(gu)殘留宮(gong)(gong)腔可導致不孕，但一般不引(yin)起(qi)子宮(gong)(gong)肌(ji)壁結(jie)構(gou)的(de)改(gai)變(bian)，如(ru)果胎(tai)骨(gu)碎(sui)片(pian)嵌(qian)入子宮(gong)(gong)肌(ji)壁，則引(yin)起(qi)局(ju)部(bu)肌(ji)壁的(de)排異反應(ying)，繼而引(yin)起(qi)周(zhou)圍組(zu)織的(de)炎性細胞浸潤(run)，纖維組(zu)織包(bao)裹，最(zui)后(hou)形成(cheng)玻璃樣變(bian)，使局(ju)部(bu)組(zu)織質地較硬(ying)且彈性差。聲(sheng)像(xiang)圖顯示肌(ji)壁內(nei)(nei)有點片(pian)狀強回聲(sheng)，其周(zhou)邊(bian)呈不均質中(zhong)等(deng)回聲(sheng)，如(ru)胎(tai)骨(gu)嵌(qian)入較深(shen)，宮(gong)(gong)腔鏡環(huan)形電(dian)極切除時易造(zao)成(cheng)子宮(gong)(gong)穿孔(kong)。如(ru)果為(wei)多(duo)發胎(tai)骨(gu)碎(sui)片(pian)較密集地嵌(qian)在一側肌(ji)壁，則導致局(ju)部(bu)子宮(gong)(gong)壁結(jie)構(gou)呈軟硬(ying)交錯狀排列。當宮(gong)(gong)腔鏡環(huan)形電(dian)極切開表(biao)面(mian)內(nei)(nei)膜及(ji)肌(ji)層暴露出胎(tai)骨(gu)后(hou)，即(ji)使用刮勺刮除肌(ji)壁內(nei)(nei)的(de)胎(tai)骨(gu)碎(sui)片(pian)也容(rong)易造(zao)成(cheng)子宮(gong)(gong)穿孔(kong)。