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

單孔腹腔鏡處理子宮角（間質部）妊娠

一、前言

間質部懷孕（Interstitial pregnancy, IP）是指胚胎著床於輸卵管穿過子宮壁的肌層部位（即子宮角處）。雖然它僅佔子宮外孕的 1–4%，但其死亡率比其他部位的輸卵管懷孕高出兩倍。這主要是因為間質部懷孕的臨床表現較晚，且子宮角區域血管分布極其豐富（同時由子宮動脈與卵巢動脈供血），一旦破裂常導致嚴重出血。

隨著經陰道超音波（TVS）技術與血清 β-hCG 定量檢測的進步，早期發現率已顯著提高。然而，一旦發生破裂，必須立即進行手術干預。單孔腹腔鏡手術（Single-port laparoscopy, SPL）已成為傳統多孔手術之外的先進選擇，在維持手術成效的同時，能提供更佳的美容效果並減少腹壁創傷。

二、病例介紹

一名 39 歲女性（懷孕 3 次，生產 2 次），曾接受人工受孕（IVF），於妊娠第 9 週因骨盆腔疼痛至急診就醫。該患者先前已在其他醫院診斷為左側間質部懷孕。
超音波檢查顯示，左側子宮角處有一 4.2 公分的偏心性妊娠囊，周圍包繞的子宮肌層厚度極薄（< 5 mm）。隨後醫療團隊決定經由 2 公分的臍部切口，進行緊急單孔腹腔鏡手術。術中確認左側子宮角處有明顯向外膨出的巨大妊娠囊，證實為間質部懷孕（圖 1）。

手術過程與預後：

• 止血與切除：使用雙極電燒進行止血，並進行子宮角楔形切除術（cornual wedge resection）。
• 重建：使用 1-0 倒鉤縫線（例如 V-Loc）以雙層連續縫合法修復子宮肌層缺損，以確保子宮結構的完整性（圖 2 與 3）。
• 結果：術中總出血量為 150 mL，患者於術後第二天出院，無任何併發症。

三、討論

間質部懷孕的已知危險因子包括：曾發生過子宮外孕、同側輸卵管切除術、接受人工生殖技術（ART）以及骨盆腔發炎性疾病。本病例中確認的主要危險因子為人工受孕（IVF），這與現有文獻的記載是一致的。
由於病灶周圍的子宮肌層具有較佳的擴展性，其臨床表現通常較晚出現，一般發生在妊娠第 9 至 12 週之間，但有時也會更早發生破裂。在過去，傳統治療方式通常需要透過剖腹手術進行子宮切除術或子宮角切除術。然而，隨著早期診斷技術的進步，現在已能進行保守性治療，包括全身性或局部施打滅殺除癌錠（Methotrexate, MTX），以及微創手術（如子宮角切開術和子宮角楔形切除術）。治療方案的選擇主要取決於妊娠囊大小、手術醫師的經驗及患者對生育的意願。

（一）治療方式比較

（二）間質部懷孕的手術核心目標

1.有效的止血（Effective Hemostasis）：
可利用子宮肌層內注射血管加壓素（Vasopressin）、雙極電燒、子宮血管結紮或壓迫縫合法。
2.子宮肌層的完整性（Myometrial Integrity）：
精準的縫合至關重要，這能有效預防未來懷孕時發生子宮破裂（這是子宮角手術後已知的潛在風險）。

（三）單孔腹腔鏡（Single-port）的技術挑戰與優勢

針對間質部懷孕採用「單孔」路徑，在技術上的難度較高，主要是因為手術器械的三角操作空間（Triangulation）減少，且容易發生器械碰撞。然而，透過使用專用的多通道單孔套管（Multichannel ports）和彎曲器械可以緩解這些挑戰。

與傳統的多孔腹腔鏡相比，單孔腹腔鏡手術（SPL）能達到「近乎無疤」的極佳美觀效果，且術後疼痛可能較輕。不過，這需要手術醫師具備極高水準的腹腔鏡操作熟練度，特別是在受限的角度下對血管豐富的子宮肌層進行縫合。

四、結論

對於血液動力學穩定（Hemodynamically stable）的患者而言，單孔腹腔鏡子宮角楔形切除術是一種安全且具可重複性的手術技術，用於治療間質部懷孕。
此手術路徑不僅能保留患者的生育能力，還能將手術創傷降至最低。未來的研究應著重於長期產科預後的追蹤，特別是評估後續懷孕時子宮破裂的實際風險。

Single-port laparoscopic management of interstitial pregnancy: Case report

Introduction

    Interstitial pregnancy (IP) occurs when a gestational sac implants within the intramural portion of the fallopian tube. It accounts for 1–4% of ectopic pregnancies but is associated with a mortality rate twofold higher than other tubal pregnancies. This is primarily due to the late clinical presentation and the high vascularity of the cornual region, supplied by both uterine and ovarian vessels.
    ​Advances in transvaginal ultrasonography (TVS) and quantitative serum beta-hCG have improved early detection. However, when rupture occurs, prompt surgical intervention is mandatory. Single-port laparoscopy (SPL) has emerged as an advanced alternative to traditional multiport surgery, offering superior cosmetic outcomes and reduced parietal trauma while maintaining surgical efficacy.

Case Presentation

    A 39-year-old woman (Gravida 3, Para 2), post IVF, presented to the emergency department at 9 weeks of gestation with pelvic pain.  Left interstitial pregnancy was diagnosed at outside hospital.
    The ultrasound revealed eccentric gestational sac measuring 4.2 cm at the left cornual region, surrounded by a thin myometrial mantle (< 5mm). Emergency surgery was performed using a single-port laparoscopic approach through a 2-cm umbilical incision. Intraoperatively, a large gestational sac was identified eccentrically at the left cornual region, confirming an interstitial pregnancy (Fig 1). 
    Hemostasis was secured using bipolar coagulation, a cornual wedge resection was performed, and the myometrial defect was reconstructed with a 1-0 barbed suture (e.g., V-Loc) in a double-layer continuous fashion to ensure uterine integrity (Fig 2&3). Total blood loss was 150 mL, and the patient was discharged on postoperative day two without complications.

Discussion

    Recognized risk factors for interstitial pregnancy include previous ectopic pregnancy, ipsilateral salpingectomy, assisted reproductive technology, and pelvic inflammatory disease. The primary risk factors identified in this patient—IVF—are consistent with existing literature.

Due to the distensibility of the surrounding myometrium, clinical presentation is often delayed, typically occurring between 9 and 12 weeks of gestation, though earlier rupture may occur. Historically, treatment involved hysterectomy or cornual resection via laparotomy. However, improvements in early diagnosis have enabled conservative management, including systemic or local methotrexate therapy and minimally invasive surgery (cornuostomy and cornual wedge resection), chosen based on gestational size, surgeon expertise, and patient’s fertility desires.

Cornuostomy

•  Incision is made over the interstitial swelling
•  Products of conception are evacuated
•  Uterine incision may be left open or sutured laparoscopically

Cornual Wedge Resection

•  Excision of the affected cornual tissue and pregnancy mass
•  Myometrial reconstruction done with layered suturing
•  Preserves fertility but may increase risk of uterine rupture in future pregnancy → planned cesarean often recommended

Laparoscopic-guided Methotrexate Injection

• Local MTX is injected into the gestational sac ± systemic MTX
• Useful for early, small interstitial pregnancies
• Requires close β-hCG monitoring until complete resolution

For interstitial pregnancies, the key surgical goals are:

Effective Hemostasis: Utilizing intramyometrial vasopressin injection, bipolar coagulation, uterine vessel ligation, and compression sutures.
​Myometrial Integrity: Precise suturing is critical to prevent future uterine rupture, a known risk after cornual surgery.

The "Single-port" approach for IP is technically demanding due to the reduced triangulation and potential for instrument collision. However, the use of specialized multichannel ports and curved instruments can mitigate these challenges. Compared to conventional laparoscopy, SPL offers a "scarless" result and potentially less postoperative pain. However, it requires a high level of laparoscopic proficiency, especially for suturing the vascular myometrium under restricted angles.

Conclusion

Single-port laparoscopic cornual wedge resection is a safe and reproducible technique for the management of interstitial pregnancy, provided the patient is hemodynamically stable. 

This approach preserves fertility and minimizes surgical morbidity. Future studies should focus on the long-term obstetric outcomes, specifically the risk of uterine rupture in subsequent pregnancies.