经阴道注水腹腔镜下通液术 Laparoscopic catheterization via vaginal water injection转载2008-05-05

　　3. 6 经阴道注水腹腔镜下通液术可在门诊局部麻醉下进行，操作简单，安全，患者耐受性良好，检查原因不明的不孕症较腹腔镜创伤小，易发现输卵管周围的粘连，用美蓝染色通液评估输卵管通畅度较 HSG准确，并可观察输卵管与卵巢间的解剖关系，对某些特定的生殖和妇科疾病THL作为首选方法可替代 HSG和标准腹腔镜，使因不孕症行 THL者 45%避免腹腔镜，因妇科疾病行 THL者 40%避免腹腔镜。(23)THL联合染色通液试验，输卵管伞镜，甚至和输卵管镜、微型官腔镜可最有效的完成女性不孕的内镜检查。

　　3. 6 Laparoscopic vaginal water injection can be performed under local anesthesia in the clinic. The operation is simple, safe, the patient is well tolerated, and the sterility with unknown cause is less than the laparoscopic trauma, and it is easy to find adhesion around the fallopian tubes. The evaluation of fallopian tube fluency with blue staining liquid is more accurate than that of HSG, and the anatomical relationship between fallopian tubes and ovaries can be observed. For certain specific reproductive and gynecological diseases, THL is the preferred method to replace HSG and standard laparoscopy. To avoid laparoscopy in those who are infertile and 40 in those who are gynecological. (23) The most effective endoscopic examination of female infertility can be performed by THL combined with staining liquid test, fallopian umbrella mirror, and even tubal mirror and micro-endoscope.

　　3.7 腹腔镜检查是当今输卵管通畅性判断最准确的方法，腹腔镜检查不但可以观察输卵管伞端染液溢出情况 ,还可观察输卵管周围的粘连情况及盆腔病变。准确性明显优于子宫输卵管通液术及子宫输卵管造影术。世界卫生组织认为镜下通液是迄今为止估价输卵管通畅的最好方法。毛菊芳认为腹腔镜检查对不孕症病因的诊断可得到多因素的诊断 ,精确度高 ,并兼有治疗作用(6)。有不少输卵管通畅的患者在镜检查后不久怀孕。推测可能这些外观正常盆腔的妇女中 ,输卵管内存在着轻度粘连和异物阻塞 ,通液本身起了灌注、疏通管腔的治疗作用 ,直视下的加压通液术 ,其治疗作用可取代部分手术操作。慢性盆腔炎及输卵管炎是不孕症的主要原因 ,慢性盆腔炎中多有不同程度的盆腔粘连 ,镜下可见子宫输卵管及卵巢被包裹 ,盆腔内可见不同程度的粘连带形成 ,严重粘连可见盆腔封闭难以窥视。输卵管炎多见输卵管粘连扭曲 ,积液者可见输卵管增粗管腔中有液体潴留。慢性盆腔炎及输卵管炎主要是感染所致 ,尤其是近年来性传播疾病的增加 ,使女性盆腔炎症性疾病的发生率明显上升 ,而不少病原体如衣原体、支原体及一些病毒感染常为亚临床性。临床上上述疾病大多无临床症状 ,必须通过腹腔镜检查才能明确诊断。但腹腔镜检查毕竟是一种有创检查 ,有一些并发症与禁忌证而且需一定的设备 ,在基层医院尚未开展。

　　3.7 Laparoscopic examination is the most accurate method for judging the patency of the fallopian tubes today. Laparoscopic examination can not only observe the overflow of the fallopian tube umbrella, but also observe the adhesion around the fallopian tubes and pelvic lesions. The accuracy is superior to that of hysterectomy and hysterectomy. The World Health Organization believes that the best way to estimate fallopian tube patency so far is through the lens. Maojufang believes that laparoscopy can be used to diagnose multiple factors in the diagnosis of infertility, with high accuracy and therapeutic effect(6). Many patients with open fallopian tubes became pregnant shortly after the mirror examination. Presumably these appearance normal pelvic cavity of women, fallopian tube has mild adhesion and foreign body blockage, the liquid itself has played a role in perfusion, dredge the treatment of the lumen, under the direct view of pressurized liquid surgery, its treatment can replace part of the operation. Chronic pelvic inflammatory disease and salpingitis are the main causes of infertility, chronic pelvic inflammation, there are many different degrees of pelvic adhesion, under the mirror can be seen uterine fallopian tubes and ovaries are wrapped, pelvic cavity can be seen in different degrees of adhesion formation, serious adhesion Visible pelvic closure is difficult to peep. Salpingitis often see tubal adhesion distortion, the accumulation of fluid can be seen in the tubal tube cavity with fluid retention. Chronic pelvic inflammation and salpingitis are mainly caused by infection, especially the increase of sexually transmitted diseases in recent years, which has led to a significant increase in the incidence of inflammatory diseases in the female pelvic, and many pathogens such as chlamydia, Mycoplasma and some viral infections are often sub-clinical. Most of the above diseases have no clinical symptoms, and they must be diagnosed by laparoscopic examination. However, laparoscopy is a invasive examination. There are some complications and contraindications and certain equipment is required. It has not yet been carried out in basic hospitals.

　　4 输卵管通畅性检测常用的检查方法的价值比较

　　4 Comparison of the value of commonly used test methods for oviduct patency

　　4. 1 B型超声监测下输卵管通液术与子宫输卵管碘油造影术比较声学造影同时可观察卵泡发育情况并可观察到由阻塞到通畅的变化过程，但B超显像不清晰，不能判断输卵管形态和盆腔粘连情况，是其缺点。碘油造影术亦可显示子宫腔及输卵管的全部形态，可以相当精确判定宫腔和输卵管腔内的病变及通畅情况。两者相比子宫输卵管通液术较B型超声监测下输卵管通液术具有更高的临床诊断价值，缺点是医患均需接触 x线，造影剂可刺激子宫输卵管粘膜肉芽组织增生.对腹膜也有类似作用。

　　4. Type 1 B ultrasound monitoring of tubal fluid and uterine tubal iodine oil contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast contrast can observe follicular development and can observe from obstruction to patency change process, but B ultrasound is not clear, The inability to judge the tubal morphology and pelvic adhesion is its shortcoming. Iodine oil imaging can also show the entire shape of the uterus and fallopian tubes. It can be quite accurate to determine the lesions and patency in the uterine cavity and fallopian tube cavity. Both compared with the uterine tubal liquid surgery than the B-type ultrasound monitoring of the tubal liquid surgery has a higher clinical diagnostic value, the disadvantage is that doctors and patients need to contact the X-line, contrast agent can stimulate uterine tubal mucosa granulation. The peritoneum also has a similar effect.

　　4. 2 子宫输卵管造影术与宫腹腔镜对输卵管通畅情况检查的比较在宫腹腔镜技术尚未开展及广泛推广之前 ,临床上常以子宫输卵管碘油造影来判断输卵管的通畅情况。通过对子宫输卵管造影片的分析 ,可以了解输卵管的阻塞情况。有盆腔及子宫输卵管炎症且时间较长时 ,造影显示输卵管壁僵硬 ,壶腹部黏膜皱摺消失 ,输卵管呈串珠状改变 ,严重炎症者 ,双侧输卵管阻塞 ,碘油无法通过 ,故不显影。除诊断作用外 ,对于炎症轻或伴轻度粘连的患者 ,输卵管近端病变的患者 ,还可以通过反复注入的液体对管壁起分离和静压的作用 ,使输卵管得到有效的疏导与扩张。但据报道 , HSG诊断输卵管异常者经腹腔镜证实 37 %是错误的,因此可见 ,HSG对不孕症患者只可作出初筛检查。应用宫腹腔镜判断输卵管是否通畅是目前公认的最可靠的方法。

　　4.2 The comparison between uterine tubal imaging and uterine laparoscopic examination of tubal patency has not been carried out and has not been widely promoted before the uterine laparoscopic technique. Through the analysis of the uterine tubal film, we can understand the obstruction of the tubal. When pelvic and uterine fallopian tube inflammation and time is long, the angiography shows that the fallopian tube wall is rigid, the ampullary mucosa folds disappear, the fallopian tube is beaded, the severe inflammation, the bilateral fallopian tube is blocked, the iodine oil can not pass, so it does not develop. In addition to the diagnostic function, for patients with light inflammation or mild adhesion, patients with fallopian tube proximal lesions, but also through repeated injection of liquid to the wall of the tube separation and static pressure, so that the fallopian tube can be effectively guided and expanded. However, it was reported that 37 % of those diagnosed by HSG with fallopian tube abnormalities were confirmed to be wrong by laparoscopy. Therefore, it can be seen that HSG can only make initial screening examinations for infertility patients. The most reliable method to determine whether the fallopian tubes are open by using the laparoscopy is recognized at present.

　　4. 3 THL与腹腔镜、HSG 比较 2002年 Moore等前瞻比较 60例原因不明不孕患者THL和腹腔镜诊断结果。先作THL，然后由不知道THL结果的另一医师做腹腔镜，10%未能进入盆腔。腹腔镜检查 ll例诊断 EMs，而THL仅发现 6例，THL30例盆腔正常，而腹腔镜仅 24例盆腔正常。所有异常THL患者均有腹腔镜异常，故 THL无假阳性，因盆腔粘连防碍THL的全面检查，故有假阴性。研究者认为 THL为水下检查盆腔，比CO2气腹易于识别纤细，薄层的粘连，THL可使 40%以上的不明原因不孕患者避免腹腔镜。多年来 HSG为检查子宫和输卵管的首选方法但诊断盆腔和腹膜病变的准确性不高。Swartdeng报道HSG诊断输卵管病变的敏感度和特异性分别为65%和 83%，特异性高说明 HSG诊断输卵管阻塞较可靠，敏感度低说明HSG诊断输卵管通畅的可信度受限。Darai等报道 54例 THL全面检查盆腔的敏感度和特异性分别为 92.3%和 100%，均明显高HSG。THL的缺点：①它不能提供如传统腹腔镜手术那样全景式的逼真视野，可能影响术者术中判断。而且因视角关系有时影响到完整的诊断;②THL术有后穹隆穿刺失败而导致手术失败的可能;⑧THL术也有一定并发症发生。因此THL手术尽管在一些轻微的病变诊断方面有时优于传统腹腔镜手术，但对于有明显盆腔病变的患者来说，传统的腹腔镜诊断手术仍是第一选择。

　　4. 3 THL compared with laparoscopy, HSG, 2002 Moore and other prospective comparison of 60 patients with unknown cause infertility THL and laparoscopic diagnosis results. After THL was performed first and then laparoscopic by another doctor who did not know the results of THL, 10 <UNK> failed to enter the pelvic cavity. Laparoscopic examination of ll diagnosis of EMs, THL only found 6 cases, THL 30 cases of pelvic cavity normal, while laparoscopy only 24 cases of pelvic cavity normal. All abnormal THL patients had laparoscopic abnormalities, so THL had no false positive. Because pelvic adhesion prevented the full examination of THL, it was false negative. The researchers believe that THL is an underwater examination of the pelvic cavity, which is easier to identify than the CO2 bellies, thin layers of adhesion, and THL can prevent laparoscopy in patients with unknown infertility of more than 40 degrees. For many years, HSG was the preferred method for the detection of uterus and fallopian tubes, but the accuracy of the diagnosis of pelvic and peritoneal lesions was not high. Swartdeng reported that the sensitivity and specificity of HSG in diagnosing fallopian tube lesions were 65 and 83, respectively. The high specificity indicated that HSG diagnosis of tubal obstruction was more reliable and the low sensitivity indicated that HSG diagnosis of fallopian tubes was less reliable. Darai et al. reported that the sensitivity and specificity of 54 cases of THL comprehensive examination of pelvic cavity were 92.3 and 100, respectively, all of which were significantly higher than HSG. THL's Disadvantages: It does not provide a panoramic realistic vision such as traditional laparoscopic surgery, which may affect the operative judgment of the surgeon. And because of the angle of view relationship, it sometimes affects the complete diagnosis; 2 THL surgery has the possibility of failure of the posterior vault puncture leading to failure of the operation; There are also certain complications in the operation. Therefore, although THL surgery is sometimes superior to traditional laparoscopic surgery in the diagnosis of some minor lesions, traditional laparoscopic diagnosis surgery is still the first choice for patients with obvious pelvic lesions.

　　4. 4宫腔镜下输卵管口插管通液术与输卵管通气术、输卵管通液术、子宫输卵管碘油造影术、腹镜下通液术的比较输卵管通气、通液检查由于其设备简单，操作简便，价格低廉等优点，在 80年代前曾被普遍应用。但在临床实际工作中却发现该方法误诊率高。经 x线的子宫输卵管造影检查是一种影像学检查，能确定输卵管梗阻性质及子宫大小形态是否有畸形，为检查输卵管是否通畅的首选检查方法，但输卵管痉挛还是输卵管阻塞，有高达30%～40%的假阳性同时在检查过程中医生和患者都不同程度的接触 x线，有损身体健康。腹腔镜和输卵管镜检查比较直接、准确，但费用较高，技术复杂，创伤大，适应范围小。宫腔镜直视下输卵管插管诊断并治疗输卵管近端梗阻的报道日渐增多，并取得一定的疗效。另一方面，输卵管插管加压通液进行诊断的同时，对较轻的输卵管近端梗阻起到治疗作用，因而，通过插管诊断的梗阻输卵管数明显少于采用传统方法诊断的梗阻输卵管数。

　　4. 4 hysteroscopic tubal opening intubation and tubal ventilation, tubal ventilation, uterine tubal iodine oil imaging, compared tubal ventilation under peritoneoscopy, and liquid examination due to its simple equipment, simple operation, and low price. It was widely used before the 1980s. However, it is found that this method has a high misdiagnosis rate in clinical practice. The X-line hysterectomy is a imaging examination that can determine the nature of the oviduct obstruction and whether the uterine size pattern is malformed. It is the preferred method for checking whether the fallopian tube is open, but the fallopian tube is still blocked. There are up to 30 to 40 false positives at the same time that doctors and patients have different degrees of contact with X-rays during the examination process, which is detrimental to physical health. Laparoscopic and tubal examination is direct and accurate, but the cost is high, the technology is complex, the trauma is large, and the adaptation range is small. The diagnosis and treatment of tubal proximal obstruction under hysteroscopic direct view of the tubal intubation has been reported more and more. On the other hand, the diagnosis of the tube intubation pressurised liquid at the same time, it has a therapeutic effect on the lighter tubal proximal obstruction. Therefore, the number of tubal obstruction diagnosed by intubation is significantly less than the number of tubal obstruction diagnosed by traditional methods.

　　5 结论输卵管通气术、输卵管通液术具有操作简单 ,安全经济 ,病人痛苦轻等优点。由于准确性明显低于造影术 ,目前更多地用作治疗疏通输卵管。子宫输卵管造影术可作为输卵管通畅性检测的常规检查，是一种无创检查 ,不但可以了解输卵管通畅性 ,还可观察宫腔及输卵管内腔的病变，但对盆腔的病变及输卵管周围粘连情况诊断价值较低。腹腔镜检查是当今输卵管通畅性判断最准确的方法，腹腔镜检查不但可以观察输卵管伞端染液溢出情况 ,还可观察输卵管周围的粘连情况及盆腔病变。腹腔镜检查毕竟是一种有创检查 ,有一些并发症与禁忌证 ,而且需一定的设备。THL具有准确、微刨，安全、快速、经济、不需住院，不需接受全身麻醉等优点，在未来的输卵管检查中具有一定的优势。

　　Conclusion Tubal ventilation and tubal catheterization have the advantages of simple operation, safe economy and light pain. Because accuracy is significantly lower than angiography, it is now more used as a treatment to dredge fallopian tubes. Uterine tubal angiography can be used as a routine examination of tubal patency. It is a non-invasive examination. It can not only understand the tubal patency, but also observe the lesions in the uterine cavity and the tubal cavity, but it has lower diagnostic value for pelvic lesions and adhesion around the fallopian tube. Laparoscopic examination is the most accurate method to determine the patency of the fallopian tubes. Laparoscopic examination can not only observe the overflow of the fallopian tube umbrella, but also observe the adhesion around the fallopian tubes and pelvic lesions. After all, laparoscopy is a invasive examination, there are some complications and taboo signs, and it requires certain equipment. THL has the advantages of accuracy, micro-planing, safety, speed, economy, no need to be hospitalized, no need to accept general anesthesia, etc., and has certain advantages in future tubal examinations.