Saidi M H, Sarosdy M F, Hollimon P W, Sadler R K
Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
J Am Assoc Gynecol Laparosc. 1995 May;2(3):355-8. doi: 10.1016/s1074-3804(05)80124-0.
The overall frequency of ureteral injury during laparoscopic adnexectomy for endometriosis is unknown, and intestinal obstruction after laparoscopy is rare. Our patient had two postoperative complications: small bowel obstruction and bilateral ureteral injuries discovered 2 and 39 days, respectively, after outpatient laparoscopic adhesiolysis and bilateral salpingo-oophorectomy for severe endometriosis. Pelvic examination and vaginal sonography revealed a large unilocular cystic mass. Laparoscopy showed a fixed large endometrioma firmly attached to pelvic peritoneum and intestines in the pelvic cavity, and significant adhesions in the upper part of a midline incision from prior abdominal hysterectomy. These midabdominal adhesions were not released. The patient underwent laparoscopic bilateral adnexectomy as an outpatient. Two days later she was admitted with small bowel obstruction. Thirty-nine days later, diagnostic evaluation revealed urinary ascites with right ureteral stricture at the uterine artery level, and complete ligation and resection of the left ureter at the pelvic brim near the infundibulopelvic ligament stump. She underwent left ureteral implantation with psoas hitch and right ureterolysis. Follow-up cystogram and intravenous pyelography at 6 and 20 weeks revealed complete recovery. In cases of severe endometriosis with significant ureteral and intestinal involvement, laparotomy may have to be considered.
腹腔镜下子宫内膜异位症附件切除术期间输尿管损伤的总体发生率尚不清楚，腹腔镜术后肠梗阻也较为罕见。我们的患者出现了两种术后并发症：分别在门诊腹腔镜粘连松解术及双侧输卵管卵巢切除术治疗重度子宫内膜异位症后2天和39天发现的小肠梗阻和双侧输尿管损伤。盆腔检查和阴道超声检查发现一个大的单房囊性肿物。腹腔镜检查显示盆腔内有一个固定的大子宫内膜瘤，牢固地附着于盆腔腹膜和肠管，且既往腹部子宫切除术后中线切口上部有明显粘连。这些中腹部粘连未予松解。该患者作为门诊患者接受了腹腔镜双侧附件切除术。两天后她因小肠梗阻入院。39天后，诊断评估显示有尿腹水，右侧输尿管在子宫动脉水平处狭窄，左侧输尿管在骨盆缘靠近漏斗骨盆韧带残端处完全结扎并切除。她接受了左输尿管腰大肌悬吊植入术及右侧输尿管松解术。术后6周和20周的膀胱造影和静脉肾盂造影显示完全恢复。对于有明显输尿管和肠道受累的重度子宫内膜异位症病例，可能不得不考虑开腹手术。
