Objectives: Intrauterine adhesions (IUA) refers to the adhesions between the myometrium of the uterine cavity, which is secondary to damage to the basal layer of the endometrium due to trauma or infection. The occurrence of IUA is mainly related to intrauterine operations. Hysteroscopic adhesiolysis (HA) is the standard surgical treatment for IUA. But the recurrence rate of IUA after HA is still high. Importantly, endometrium recovery is difficult, resulting in unsatisfied prognosis for moderate to severer IUA patients. Therefore, it is important to take effective primary preventive measures against the etiology to avoid endometrium damage from medical surgery. In this paper, we discuss and analyze predilection and severer sites of intrauterine adhesions, aiming to provide a basis for how to avoid and reduce injuries during intrauterine operations, such as abortion, dilation and curettage.
Methods: In this study, we retrospectively analyzed the surgical videos of patients who underwent HA for the first time from January 2019 to December 2021 in the Third Xiangya Hospital of Central South University so as to assess the area of adhesions and predilection and severer sites of occurrence of adhesions, and we collected 657 patients who underwent HA for the first time, including 81 patients with total IUA and 576 patients with partial IUA. We counted and analyzed the number and composition ratio of partial IUA patients with severer sites of damage to the lateral wall of the uterine cavity and severerr sites of damage to each segment of the uterine cavity.
Results: Among 576 patients with partial IUA, there were 60 patients with no significant difference in the degree of adhesions between the right and left sides, 143 patients with severer adhesions on the left side of the uterine cavity, and 373 patients with severer adhesions on the right side of the uterine cavity. There was a difference in the severity of damage of left and right lateral wall. The proportion of patients with severer adhesions on the right side of the uterine cavity (64.8%) was higher than that of patients with adhesions on the left side of the uterine cavity (24.8%), and there was statistically difference (P<0.05). There was 93 patients with severer adhesions at the fundus or bilateral horn of the uterus, 190 patients with severer adhesions at the middle and upper part of the uterine cavity, 245 patients with severer adhesions at the middle and lower part of the uterine cavity and at the endocervix, and 48 patients with no significant difference in the degree of adhesions in each part. The proportion of patients with severer adhesions at the middle and lower part of the uterine cavity and at the endocervix was higher (42.5%) than those with adhesions in the fundus or bilateral horn of the uterus (16.1%) and in the middle and upper part of the uterine cavity (33.0%), and there were statistically differences (both P<0.05).
Conclusions: The predilection site of IUA is the lateral wall of the uterine cavity. The severer adhesions is in the right lateral wall of the uterine cavity, the middle and lower segments and the endocervix, which may be related to the operating habits of the surgeon. Therefore, gynecologists should minimize damage to the lateral wall of the uterine cavity, especially the right lateral wall in performing uterine operations (more attention should be paid by right-handed physicians). Besides, we should pay attention to protecting the middle and lower segments of the uterine cavity and the endocervix, avoiding maintaining negative pressure to withdraw the uterine tissue suction tube from the uterine cavity during abortion procedures to minimize damage.
目的: 宫腔粘连(intrauterine adhesions，IUA)是指创伤或感染等病因造成子宫内膜基底层损伤后继发的宫腔肌壁间的粘连，其发生主要与宫腔内手术操作有关。宫腔镜宫腔粘连分离术(hysteroscopic adhesiolysis，HA)是治疗IUA的标准手术方式，但术后复发率高，而且宫内膜恢复往往困难，中重度IUA患者术后的妊娠率及活产率仍不理想。因此，针对病因采取有效的一级预防措施，尽可能避免或减轻医源性子宫内膜损伤至关重要。本文探讨IUA患者粘连及宫内膜损伤的好发部位以及损伤相对严重的部位，希望能够为未来宫腔操作(人工流产、清宫、宫内膜息肉切除等)时避免或减轻损伤宫腔提供研究基础。方法: 回顾性分析2019年1月至2021年12月于中南大学湘雅三医院首次进行HA的657例患者的手术录像，评估IUA的面积及主要发生部位以及损伤相对严重的部位，其中全IUA患者81例，部分IUA患者576例。统计并分析部分IUA患者宫腔侧壁损伤相对严重部位和宫腔各段损伤相对严重部位的例数和构成比。结果: 576例部分IUA患者中宫腔左右侧壁损伤程度无明显差别者60例，左侧壁损伤相对严重者143例，右侧壁损伤相对严重者373例，左右侧壁损伤严重程度存在差异，且右侧壁损伤相对严重的患者比例(64.8%)高于左侧壁损伤相对严重的患者比例(24.8%)，差异有统计学意义(P<0.05)；宫底或双侧宫角损伤相对严重者93例，宫腔中上段损伤相对严重者190例，宫腔中下段及宫颈内口损伤相对严重者245例，各部分损伤程度无明显差别者48例；宫腔中下段及宫颈内口损伤相对严重的患者比例(42.5%)高于宫底或双侧宫角损伤相对严重(16.1%)和宫腔中上段损伤相对严重的患者比例(33.0%)，差异均有统计学意义(均P<0.05)。结论: IUA最好发于宫腔侧壁，粘连程度相对严重的部位是宫腔右侧壁、中下段及宫颈内口，这可能与手术医生操作习惯有关。因此建议妇科医生进行宫腔操作时，要尽量减少对宫腔侧壁，特别是右侧壁的损伤(右势手医生更加要注意)，同时也要注意保护宫腔中下段和宫颈内口，尤其要注意在人工流产手术中避免维持负压从宫腔中撤出宫腔组织吸引管，以减少损伤宫腔中下段和宫颈内口。.
Keywords: complications; hysteroscopic surgery; induced abortion; intrauterine adhesions; predilection of intrauterine adhesions.