RU2722874C1 - Method of removal of uterus from abdominal cavity at performance of single-port laparoscopic supravaginal amputation of uterus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to surgical gynecology. Single-port laparoscopic supravaginal amputation is performed, after which the uterus is removed from the abdominal cavity by morcellation involving the Morcellator installation with visualization control by means of a laparoscope. Morcellator is inserted into the central port, and the laparoscope is inserted into the cervical canal through a laparoscopic trocar with length of 15 cm.

EFFECT: method enables creating the conditions for better visualization of the removed preparation when performing the method of removing the uterine preparation from the abdominal cavity when performing the single-port laparoscopic supravaginal ablation of the uterus, which reduces the risk of traumatisation of nearby organs, and also reduces the time of the declared method.

1 cl, 1 tbl, 2 ex

Description

The invention relates to medicine, in particular to operative gynecology, and can be used to remove a uterine preparation from the abdominal cavity when performing a single-port laparoscopic supravaginal amputation of the uterus.

Morcellation during laparoscopic hysterectomy is a method of removing the drug from the abdominal cavity without the need for additional incisions on the anterior abdominal wall or conversion using minimally invasive access. Despite the advantages of minimally invasive technologies for removal of the uterus, such as reducing the severity of pain, reducing the duration of hospitalization, less trauma, cosmetic, improving the quality of life of patients, the use of morcellation can lead to negative consequences: damage to large vessels, adjacent organs [1]. However, the complications associated with the implementation of morcellation are still insufficiently illuminated.

A meta-analysis conducted in the USA from 1993 to 2013 showed that 55 complications associated with the use of morcellation were noted over the indicated period of time. Among the identified complications were injuries of the small and large intestines (n = 31), blood vessels (n = 27), kidneys (n = 3), the ureter (n = 3), the bladder (n = 1) and the diaphragm (n = 1) . 11 of these complications affected more than 1 organ. In most patients (n = 37 [66%]), complications were diagnosed intraoperatively, in the rest - on the 10th day of the postoperative period. The main factor in the occurrence of complications was called the lack of sufficient experience of the operating surgeon, since most often they were recorded at the beginning of the development of this technique. 6 deaths were associated with the effects of morcellation [2].

In a study by Graziano, Angela et al, when performing a single-port laparoscopic hysterectomy using transcervical morcellation, complications were observed in 14 of 365 patients. In 2 cases, it was necessary to perform relaparoscopy due to intraperitoneal bleeding, in 5 cases, asymptomatic ulcerative hematoma was observed, in 7 patients pain was noted [3]. According to the authors of Estrade, J.P et al, complications from single-port laparoscopic hysterectomy using transcervical morcellation were observed in 4 out of 40 patients (10%), requiring repeated surgery due to vaginal bleeding [4].

The use of a morcellator during laparoscopic hysterectomy has led to a significant expansion of the boundaries of the use of minimally invasive approaches. However, along with this, an increase in the incidence of serious and minor intraoperative complications was noted. Understanding and implementing safe methods of laparoscopic morcellation can lead to a decrease in the frequency of these complications [5].

Known laparoscopic technique of supravaginal amputation of the uterus. Three-four-port technology includes coagulation and intersection of the round ligaments of the uterus, own ligaments of the ovaries and the proximal ends of the fallopian tubes, opening the vesicoureteral folds and dissection of the bladder from the uterus, mobilizing the uterus, coagulating or flashing uterine vessels, and cutting off the uterus from the neck followed by its removal through a mini-incision in the navel (Proceeding of the world congress of gynecologic endoscopy, Laporoscopic Supracervical Hysterectomy Using a Single-Umbilical Puncture (Mini-Laparoscopy) Marco A. Pelosi. AAGL 20th Annual meeting proceeding, Las Vegas , Nevada, 1993) [6].

Among the disadvantages of this method, the possibility of trauma to the abdominal organs and the need for an additional increase in the incision in the navel to remove the uterus, which leads to greater trauma, an increased risk of adhesions, herniation, as well as an increase in the duration of surgery and the recovery period of patients.

There is a method of manual morcellation of the uterine body using a scalpel in the endobahe when performing a robot-assisted single-port hysterectomy. After performing a hysterectomy, the removed uterine body is placed in the endobeg. The wire strands together with the upper part of the endobeg are brought out through a paraumbilical incision after removing the port. The drug is captured by bullet forceps and, with the help of a scalpel, is gradually fragmented and removed from the abdominal cavity along with the package. The disadvantage of this method is the lack of visual control, the need to expand the skin incision and wounds in the navel, increasing the duration of the operation [9].

A known method of crushing the uterus with a Zemma morphizer, which is a hollow tube with an external cutting edge. A metal corkscrew moves inside it, which is screwed into the body of the uterus, and the outer tube cuts the tissue around the corkscrew. Then, holding the corkscrew by hand, the outer tube is lowered along the corkscrew with force. In this case, the outer tube cuts out part of the tissue around the corkscrew. Then the corkscrew with the tissues fixed on it is removed and cleaned, and the procedure is repeated until the volume of the removed tissue (uterus) is significantly reduced. This method of grinding requires a long time, it is dangerous due to the uncontrolled introduction of a corkscrew. The operation was proposed by the German gynecologist K. Semm in 1983 [7].

As a prototype for the closest technical essence, we have chosen a method for removing the uterine preparation from the abdominal cavity when performing a single-port laparoscopic supravaginal uterine amputation. Morcellation is carried out by introducing a morcellator into the abdominal cavity transvaginally through the cervical canal. This method involves performing supravaginal amputation of the uterus by coagulation and intersection of the uterine round ligaments, own ligaments of the ovaries and mesosalpinges, opening the vesicoureteral folds and separating the bladder from the uterus, mobilizing the uterine body, coagulating the uterine vessels and cutting off the uterine body from the cervix its subsequent removal through the cervical canal. For this, the cervical canal is expanded to No. 10 with Geghar expanders. A morcelator is transvaginally injected through the cervical canal, uterine body morcellation is performed using special elongated morcellator knives (20 cm long) under visual control using a laparoscope inserted into the central port [8].

The disadvantages of the method selected as a prototype is the difficulty in visualizing the tissues of the pelvis with the removed drug, as well as the risk of trauma to nearby organs. The disadvantage of the prototype should also include the duration of removal of the uterine drug from the abdominal cavity, which is 15.17 ± 1.95 minutes (95% CI: 13.93-16.4 minutes), as well as the duration of the single-port laparoscopic supravaginal amputation of the uterus, which is 140 , 0 ± 25.5 minutes (95% CI: 123.8-156.2 minutes) and including removal of the uterine preparation from the abdominal cavity.

The technical result of the invention is the creation of conditions for better visualization of the removed drug when performing the method of removing the uterine preparation from the abdominal cavity when performing a single-port laparoscopic supravaginal amputation of the uterus, which will reduce the risk of trauma to nearby organs, as well as reduce the time of the proposed method, as well as performing a single-port laparoscopic supravaginal amputation uterus.

The technical result of the invention is achieved by the fact that after performing a single-port laparoscopic supravaginal amputation of the uterus, the uterus preparation is removed from the abdominal cavity by means of morcellation, including the installation of a morcellator, into the central port with visualization using a laparoscope inserted into the cervical canal through a 15 cm laparoscopic trocar pre-installed there .

The method is as follows:

The operating team consists of one surgeon and two assistants. The endovideo surgical position is placed to the right of the patient at the foot end of the operating table, the operator and the first assistant to the left of the patient. The first assistant is to the right of the operator closer to the head end of the patient, the second assistant is with the uterine manipulator between the patient's legs.

The patient in a lithotomy position on the operating table perform general combined anesthesia. After processing the surgical field, a minimally invasive access to the abdominal cavity is made: an omega-shaped incision above the navel, 2-2.5 cm long. After layer-by-layer opening of the anterior abdominal wall, the central port SILS-port ™, manufactured by Covidien (Medtronic), USA, is installed in the wound. Trocars are introduced into the port for insufflation of carbon dioxide and operating instruments. The pressure of CO _{2 is} pumped up to a level of 14 mm Hg. A uterine manipulator is installed in the cervical canal for the second assistant to perform traction and countertraction of the uterine body. Using a LigaSure ™ apparatus, 5 mm diameter, 36 cm long, Covidien (Medtronic), USA, or using the ROBI gripping forceps on KELLY 5 mm, 36 cm long, and CLICKline scissors on METZENBAUM, 5 mm, 36 cm long, ROTATIP grasping forceps, size 5 mm, length 36 cm, (Karl Storz, Germany), coagulate and intersect the round ligaments of the uterus, own ligaments of the ovaries and mesosalpinges (funnel-pelvic ligaments with supravaginal amputation of the uterus with appendages), opening the vesicoureteral fold and bladder dissection, mobilization of the uterine body, coagulation of the uterine vessels and cutting off the uterine body from the cervix 1 cm above the stumps of blood vessels. Cutting off the uterine body from the cervix at the level of the internal pharynx is carried out using a disposable monopolar loop, SupraLoop according to BRUCKER / MESSROGHLI, 200 × 150 mm, (Karl Storz, Germany).

Next, the assistant after processing the vagina sets the spoon-shaped mirrors of Sims. The cervix is fixed and pulled down with bullet forceps, a laparoscopic trocar with a diameter of 6 mm, length 15 cm, is inserted into the cervical canal (Karl Storz, Germany), through which a laparoscope with a diameter of 5 mm and a length of 45 cm is installed. Under control of vision, a morcellator is introduced into the central port, ROTOCUT G2 , (Karl Storz, Germany), with a diameter of 10 mm. By means of gradual traction with the help of bullet forceps, the uterine body tissue is captured and retracted into the tube of the morcellator. Rotary knives of the morcellator produce tissue grinding and phased removal of the drug from the abdominal cavity.

Distinctive essential features and a causal relationship between them and the achieved result:

• Install the morcellator in the central port.

Thanks to the installation of the morcellator in the central port and the traditional position of the patient in a lithotomy position with the head down, the morcellated preparation is located at a considerable distance from the underlying tissues (intestinal loops, large vessels, locks of the greater omentum), which creates conditions for better visualization of the removed preparation, ensuring safe operation bullet forceps and a morcellator, which, in turn, reduces the risk of trauma to nearby organs. When performing morcellation by the method of the prototype, the range of motion of the bullet forceps is limited to the bony ring of the small pelvis. The range of motion of the branches of the bullet forceps is 3.6 cm, which can lead to the capture of the underlying tissue when installing the morcellator in the cervical canal.

• The insertion of a laparoscope into the cervical canal provides the surgeon with a complete overview of the abdominal cavity. In the prototype method and in the claimed method, an endoscopic rack is located to the right of the patient at the foot end of the operating table. When performing transcervical morcellation, the surgeon is located between the patient’s legs, and in order to look at the screen behind the movements of the bullet forceps, he must turn quite sharply to the right, or you can move the stance, but this takes extra time. When performing morcellation through the central port, an assistant is in this position, while the operator freely looks at the screen and performs the movement of the bullet forceps. The inventive method is more convenient for the operator and does not require rearrangement of the endoscopic rack.

• A laparoscope is inserted into the cervical canal through a 15 cm laparoscopic trocar pre-installed there.

The use of a 15 cm long laparoscopic trocar reduces the risk of vaginal microflora contamination of the laparoscope and, thus, does not lead to image deterioration, since the average vaginal length is between 4.08-9.5 cm (6.27 ± 1.125 cm), while cervical canal length from 2.5 to 5.0 cm (4.19 ± 1.20 cm). A trocar 15 cm long in this case is a “tunnel” for conducting an optical system.

The set of distinctive essential features is new and made it possible to create conditions for better visualization of the removed product when performing the method of removing the uterine drug from the abdominal cavity when performing a single-port laparoscopic supravaginal amputation of the uterus, which reduces the risk of trauma to nearby organs and also reduces the time of the proposed method, as well as performing a single-port laparoscopic supravaginal amputation of the uterus.

We present clinical examples of the method:

Example 1

Patient A., 35 years old, was treated with a diagnosis of multiple uterine fibroids. Violation of the menstrual cycle as hyperpolymenorrhea. The examination was carried out on an outpatient basis according to a single plan - a complete clinical and laboratory examination, including special methods: ultrasound examination of the pelvic organs, hysteroscopy, separate diagnostic curettage of the endometrium, endocervix, smear examination for oncocytology, investigation by the method of PNR for human papillomavirus (HPV) )

In a planned manner, the patient performed a single-port laparoscopic supravaginal amputation of the uterus with fallopian tubes, including removal of the uterine preparation from the abdominal cavity by the present method.

Description of the operation: Under aseptic conditions under combined anesthesia, an omega-shaped cut of the skin with a length of 20 mm was made in the lower pole of the umbilical ring. SILS-port ™, Covidien, Medtronic, USA, is installed in the abdominal cavity. Pneumoperitoneum up to 14 mm RT. Three trocars for operational instruments have been introduced into the port. With the help of a bipolar clamp, round ligaments of the uterus, own ligaments of the ovaries and mesosalpinges on both sides are coagulated and crossed, the peritoneum of the vesicoureteral fold is opened, the bladder is reduced. With the help of bipolar coagulation and scissors, the uterine vessels are coagulated and crossed. The uterine body was cut off from the cervix 1 cm above the stumps of blood vessels using a disposable monopolar loop, SupraLoop according to BRUCKER / MESSROGHLI, 200 × 150 mm (Karl Storz, Germany). Then, after treatment, Sims vaginal mirrors were inserted into the vagina, the cervix was pulled down by bullet forceps, a laparoscopic trocar with a diameter of 6 mm 15 cm long (Karl Storz, Germany) was inserted through which a laparoscope with a diameter of 5 mm and a length of 45 cm was inserted (Karl Storz, Germany). Under the control of vision, a morcellator, ROTOCUT G2 (Karl Storz, Germany), with a diameter of 10 mm, was introduced into the central port. The drug from the abdominal cavity was removed by morcellation through the central port. The laparoscope, laparoscopic trocar and bullet forceps from the cervical canal are removed. After appropriate treatment, the laparoscope was inserted into the trocar of the central port to suture the cervical stump and control hemostasis. The cervix stump is sutured with separate Vicryl 2.0 sutures using an ENDOSTICH stapler (Karl Storz, Germany). Hemostasis control - stable hemostasis. Instruments from the abdominal cavity removed. The tampon and tool count is correct. The abdominal cavity is sutured in layers tightly. Intradermal suture on the skin.

Operation time - 96 minutes, morcellation time - 13 minutes.

The value of intraoperative blood loss is 50 ml. The study of blood and urine indicators in the postoperative period did not reveal any significant negative dynamics - the indicators remained within normal limits. No intraoperative complications, namely trauma to nearby organs, were observed. The postoperative period was uneventful. The patient was discharged on the 2nd day after surgery. Performance restored 8 days after discharge.

Example 2

Patient M., 47 years old, was treated with a diagnosis of Uterine fibroids, intramural-submucous form. Violation of the menstrual cycle as a polymenorrhea. Bilateral ovarian cysts. According to an outpatient study, including magnetic resonance imaging (MRI) of the pelvic organs, endometrial aspiration biopsy, examination of smears from the surface of the cervix and from the cervical canal for oncocytology, PCR for the presence of HPV, blood tests for tumor markers: CA -125, HE4, ROMA index, no pathological changes were detected.

In a planned manner, the patient performed a single-port laparoscopic supravaginal amputation of the uterus with appendages, including removal of the uterine preparation from the abdominal cavity by the present method.

Description of the operation: Under aseptic conditions under combined anesthesia, an omega-shaped incision of the skin with a length of 20 mm was made in the upper pole of the umbilical ring. SILS-port ™, Covidien, Medtronic, USA, is installed in the abdominal cavity. Pneumoperitoneum up to 14 mm RT. Three trocars for operational instruments have been introduced into the port. Using the ROBI grasping forceps on KELLY 5 mm, 36 cm long, and CLICKline scissors on METZENBAUM, 5 mm, 36 cm long, Karl Storz, Germany, uterine ligaments, funnel-pelvic ligaments on both sides are coagulated and crossed, peritoneum is opened vesicoureteral folds, the bladder is reduced. Using a LigaSure ™ apparatus, 5 mm diameter, 36 cm long, Covidien (Medtronic), USA, coagulated and crossed uterine vessels. The uterine body was cut off from the cervix at the level of the internal pharynx using a disposable monopolar loop, SupraLoop according to BRUCKER / MESSROGHLI, 200 × 150 mm, Karl Storz, Germany. Then, after treatment, Sims vaginal mirrors were introduced, the cervix was fixed and pulled down by bullet forceps, a laparoscopic trocar with a diameter of 6 mm 15 cm long was inserted into the cervical canal, Karl Storz, Germany, through which a laparoscope 5 mm in diameter, 45 cm long was inserted, Karl Storz, Germany . Under the control of vision, a morcellator, ROTOCUT G2, Karl Storz, Germany, with a diameter of 12 mm was introduced into the central port. The drug from the abdominal cavity was removed by morcellation through the central port. The laparoscope, laparoscopic trocar and bullet forceps from the cervical canal are removed. A laparoscope is inserted into the central port after appropriate treatment for suturing the cervical stump and controlling hemostasis. The cervix stump is sutured with separate Vicryl 2.0 sutures using an ENDOSTICH stapler, Karl Storz, Germany. Hemostasis control - stable hemostasis. Instruments from the abdominal cavity removed. The tampon and tool count is correct. The abdominal cavity is sutured in layers tightly. Intradermal suture on the skin.

Operation time - 119 minutes, time of morcellation - 11 minutes. The value of intraoperative blood loss is 80 ml. The study of blood and urine parameters in the postoperative period did not reveal significant dynamics - the indicators remained within normal limits. No intraoperative complications, namely trauma to nearby organs, were observed. The postoperative period was uneventful. The patient was discharged on the 3rd day after surgery. Performance restored 10 days after discharge.

The method was tested in the gynecology department of St. Petersburg GBUZ "City hospital No. 40". In the period from January 2016 to July 2018, 8 single-port laparoscopic supravaginal amputations of the uterus were performed, including removal of the uterine preparation from the abdominal cavity according to the claimed method. No intra- or postoperative complications were observed. There were no inconveniences at the time of surgery. The results of the interventions are presented in table 1.

According to the prototype method, 12 operations were performed in the amount of: a single-port laparoscopic supravaginal amputation of the uterus with fallopian tubes., Including removal of the uterine preparation from the abdominal cavity.

In group 2 (by the prototype method), the duration of the method averaged 15.17 ± 1.95 min, while when testing the proposed method (group 1), the duration of it was 10.44 ± 2.19 min (P <0.005) . The duration of surgery in group 2 averaged 140.0 min, while when testing the proposed method (group 1) - 109.4 min (P <0.005).

Thus, the inventive method of removing a uterine preparation from the abdominal cavity when performing a single-port laparoscopic supravaginal amputation of the uterus has created the conditions for better visualization of the removed drug, which reduces the risk of trauma to nearby organs, and also reduces the time of the proposed method, as well as performing a single-port laparoscopic supravaginal amputation of the uterus .

Bibliography:

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HA, Sizzi O., Hehenkamp WJ, Rossetti A. Laparoscopic power morcellation of presumed fibroids. Minerva Ginecol 2016 June; 68 (3): 352-63.

2. Laparoscopic Morcellator-Related Complications Milad, Magdy P. et al. Journal of Minimally Invasive Gynecology, Volume 21, Issue 3, 486-491

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Claims (1)

A method of removing the uterus from the abdominal cavity when performing a single-port laparoscopic supravaginal amputation of the uterus, after which the uterus is removed from the abdominal cavity by means of morcellation, including installing a morcellator with visualization using a laparoscope, characterized in that the morcellator is installed in the central port and the laparoscope is inserted into the cervical channel through a 15 cm long laparoscopic trocar pre-installed there.