發表日期：2026/3/28
發表人：婦產科 吳加仁醫師、潘景賓醫師、 張紅淇醫師
發表場合：台灣婦產科醫學會年會

一、前言

子宮內膜異位症影響約10%的生育年齡女性，其中卵巢型表現為「子宮內膜異位瘤（endometrioma）」，在懷孕期間可能持續存在。多數孕期中的內膜異位瘤維持穩定，但若出現以下情況則需考慮手術：
1. 快速增大
2. 扭轉
3. 破裂
4. 懷疑惡性變化

腹腔鏡手術因具備以下優點而日益受到青睞：
1. 微創
2. 恢復快
3. 術後疼痛較低

然而，晚期妊娠手術具有挑戰：
1. 手術空間受限
2. 需持續胎兒監測

本案例展示第三孕期進行腹腔鏡手術的可行性與安全性。

二、病例介紹

• 37歲，經產婦（G3P2），妊娠32週。
• 主訴：數週左下腹痛，過去24小時明顯惡化。
• 檢查：壓痛（無反彈痛）、生命徵象穩定。
• 超音波：
  • 右側卵巢囊腫約10 cm
  • 均質低回音＋細微碎屑 → 符合內膜異位瘤
  • 胎兒與胎盤正常
• 處置：
  • 初期止痛保守治療 → 效果不佳
  • 懷疑卵巢扭轉→ 一週後安排手術

Surgical Procedure（手術方式）

• 體位：左側傾15–30°（避免主動脈/下腔靜脈壓迫）
• 進入方式：臍上開放式（Hasson）進入，避免子宮損傷
• Trocar：
  • 左上腹區（子宮底以上）置入兩支
  • 氣腹壓力：8–12 mmHg
• 監測：母體 end-tidal CO₂、胎心率（持續監測）
• 術中發現：
  • 右側10 cm內膜異位瘤
  • 合併壞死變化
• 手術技術：
  • 鈍性＋銳性剝離
  • Stripping technique（剝除術）
  • 保留卵巢組織
• 止血：最小化雙極電燒
• 標本取出：使用 endobag（避免內容物外漏）
• 結果：無子宮收縮、無胎兒窘迫

三、討論

（一）手術適應症：

建議在以下情況考慮腹腔鏡手術：
1. 懷疑扭轉（最常見急症）
2. 快速增大（>6–8 cm）
3. 出血或破裂
4. 疑似惡性（實心或乳突結構）
5. 嚴重且無法控制的疼痛
6. 壓迫症狀（如膀胱壓迫、腎水腫）
7. 若無急迫性或惡性疑慮 → 可延後至產後處理

（二）晚期妊娠腹腔鏡挑戰：

1. 解剖限制
2. 子宮增大 → 手術空間受限
3. Trocar需避開子宮
4. 橫膈上升 → 呼吸影響
5. 麻醉與胎兒考量
6. 氣腹壓 ≤12 mmHg
7. 持續胎心監測
8. 避免：高碳酸血症、酸中毒
9. 手術策略：優先 cystectomy（降低復發）、溫和操作（保留卵巢功能）、使用 endobag（防止化學性腹膜炎）。
10. 文獻支持：近期研究顯示：第二、三孕期腹腔鏡手術在經驗豐富團隊下是安全的。本案例：低併發症、成功延續妊娠至足月。

四、結論

第三孕期進行腹腔鏡手術治療卵巢內膜異位瘤：

• 在適當適應症下是安全且可行的
• 成功關鍵包括：
  • 術前完善評估
  • Trocar位置調整
  • 低壓氣腹
  • 嚴密母胎監測

Introduction

    Endometriosis affects approximately 10% of reproductive-age women, and its ovarian manifestation-endometrioma-may persist during pregnancy. Most endometriomas during gestation remain stable; however, surgical intervention is considered when complications such as rapid enlargement, torsion, rupture, or suspicion of malignancy occur.
    Laparoscopy is increasingly favored for its minimal invasiveness, faster recovery, and reduced postoperative pain. However, surgery in late pregnancy is complicated by restricted operative space and fetal monitoring requirements. We present a case that demonstrates the feasibility and safety of laparoendoscopic management in the third trimester.

Case Presentation

    A 37-year-old multigravida (G3P2), at 32 weeks’ gestation, presented with progressive left lower abdominal pain for several weeks, worsening acutely in the past 24 hours. Physical examination revealed localized tenderness without rebound pain. Vital signs were stable.
    Ultrasound showed a 10 cm right ovarian cyst with homogenous low-level internal echoes and fine debris, consistent with an endometrioma. (Fig 1) Fetal growth and placenta were normal.
    Conservative management with analgesia was attempted but poorly tolerated. Given severe refractory pain and ovarian torsion was suspected (Fig 2), elective surgical intervention was planned.

Surgical Procedure

    The patient was placed in a 15-30° left lateral tilt to reduce aortocaval compression. Entry was obtained via supraumbilical/open Hasson approach to avoid uterine injury. Two additional trocars were inserted in the left upper quadrants, positioned above the uterine fundus. Pneumoperitoneum was maintained at 8-12 mmHg.   
    Maternal end-tidal CO₂ and fetal heart rate were monitored continuously. A 10 cm right ovarian endometrioma was identified with necrotic change.  (Fig 3&4) Blunt and sharp dissection facilitated cystectomy using a stripping technique, preserving ovarian tissue. 
    Bipolar energy was applied minimally for hemostasis. The specimen was retrieved in an endobag to prevent spillage. No immediate uterine contractions or fetal distress occurred. 

Postoperative Course
    The patient recovered uneventfully. Tocolytics were administered prophylactically for 24 hours. Fetal monitoring remained reassuring. She was discharged on postoperative day 2, and the pregnancy progressed without complication.
    At 38 weeks’ gestation, she delivered a healthy neonate via cesarean section. Pathology confirmed endometrioma with no evidence of malignancy.

Discussion

Indications for Surgery

Consider laparo-endoscopic intervention when any of the following occur:
Torsion suspicion (acute pain, vascular compromise): Most common emergency indication.
Rapid cyst enlargement (>6-8 cm), hemorrhage/rupture: Risk of rupture, infection, preterm labor.
Atypical features suggesting malignancy: Solid areas, papillary structures,.
Severe, refractory pain:    Failure of conservative treatment.
Pressure-related complications: Bladder compression, hydronephrosis.
Non-urgency and absence of malignancy may allow postponement to postpartum period.

Performing laparoscopy in late pregnancy  presents unique challenges:

Anatomic considerations
Uterine enlargement limits workspace.
Trocar placement must avoid uterine injury.
Higher diaphragm position affects ventilation.
Anesthetic and fetal considerations
Lower insufflation pressure (≤12 mmHg) recommended.
Continuous fetal heart rate surveillance.
Avoid maternal hypercapnia and acidosis.
Operative choices
Cystectomy is preferred for recurrence prevention.
Gentle tissue handling preserves ovarian reserve.
Endobag retrieval prevents chemical peritonitis.
    Recent studies support the safety of second and third trimester laparoscopy when performed by experienced surgeons with multidisciplinary support. Our case aligns with this evidence, demonstrating low morbidity and successful continuation of pregnancy to term.

Conclusion

    This case highlights that laparoendoscopic surgery for endometrioma in the third trimester can be safe and effective when appropriately indicated. Key factors include careful preoperative planning, modified trocar placement, low-pressure pneumoperitoneum, and vigilant maternal-fetal monitoring.