EA025132B1 - Method for low-invasive perineal plastics - Google Patents

Abstract

The invention relates to medicine, particularly gynaecology, and may be applied to low-invasive pelvic diaphragm restoration in cases of perineal deformation, pelvic floor deficiency, and consequent opening of pudendal fissure. According to the invention, skin incisions are made at level 1 - posterior commissure of greater pudental lips; level 2 - 1 to 0.5 cm from remnants of hymen; levels 3-4 - along passing of superficial transverse muscles of perineum on both sides; wherein synthetic resorbable suture material with notches and long resorption period is sewn. The method has the following advantages, compared to the prior art: minimal surgical aggression and low-invasive procedure; considerably shorter time of operation; better treatment effect, aesthetic and functional results; the operation can be performed under only local anaesthesia; quick recovery period; Caesarian section is not necessary in subsequent delivery; the operation can be performed in the outpatient setting.

Description

The invention relates to medicine, namely to gynecology, and can be used for minimally invasive restoration of the pelvic diaphragm during crotch deformity, pelvic floor muscle failure and associated gaping of the genital gap.

The omission and prolapse of the internal genital organs is one of the important gynecological problems. Among women of reproductive age, the frequency of genital prolapse is 63.1%, of which under 30 years old - 10.1%, from 30 to 45 years old - 40.2% (1, 3, 4), and in women over 50 years old - 50 % [3, 8].

The disease often begins at a reproductive age and is progressive in nature. Clinical manifestations and dysfunctions of the pelvic organs bring physical and mental suffering to women, negatively affect their general health, sexual activity, make patients partially or completely disabled, lead to depression, neurosis and estrangement of the individual from society, disruptions in family life.

Currently, a large number of publications are devoted to the development of classifications, the improvement of surgical technologies for the treatment of severe degrees of genital prolapse (GH). At the same time, numerous studies (2, 3, 4) show that the first signs of genital prolapse appear at the age of 40-46 years, so a significant period of time passes from the onset of a disease that occurs at a young age to surgery. It was found that surgical treatment is carried out only after 5-15 years from the onset of the disease.

Patients of the older age group undergo surgical treatment, while young able-bodied women with initial signs of the disease find themselves outside the field of medical and preventive measures.

So, according to some authors, with minor defects of the supporting structures, unexpressed prolapse of the genitals, when there are no complaints about the dysfunction of adjacent organs, treatment can not be carried out. Some researchers claim that degree I pelvic prolapse can sometimes regress on its own.

At the same time, even at the first degree of genital prolapse, the first physiological barrier is violated, namely the closure of the sexual gap, separating the vagina from the external environment, preventing the penetration and spread of infection. Under these conditions, the colonization of the vaginal mucosa by lactobacilli decreases, which determines not only the development of bacterial vaginosis, but also determines the high frequency of inflammatory diseases of the female genital organs associated with the penetration of microorganisms from the perineal skin, including from the anal area. Deterioration of trophic processes, metabolic disorders in the tissues of the pelvic floor on the background of inflammation lead to aggravation of genital prolapse.

The absence of closure of the genital gap prevents synchronous contraction of the muscles of the pelvic floor with an increase in intra-abdominal pressure, thus, without support, the pelvic organs will lower.

Even with small degrees of genital prolapse, 46.26% of women report sexual disorders: soreness and discomfort during intercourse, dyspareunia, postcoital spotting from the genital tract.

Emotional experiences associated with impaired normal functioning of the genitals, urinary incontinence during αοίΐιΐδ. dyspareunia, can lead to anorgasmia.

It has now been established that for all types of pelvic organ prolapse, the primary violation concerns the pelvic floor organs. Impaired fixation always implies a defect in the internal fixation layer, the pelvic fascia.

The pelvic fascia, which is a unique connective tissue, does not stretch, as previously suggested, but, experiencing excessive loads, breaks in one or more areas. The prolapse of all the pelvic organs is the final stage, the result of multiple defects in the support apparatus due to excessive load and / or anatomical disorders. It is proved that the loss of the point of support of the muscles of the perineum leads to further progression of the pathology.

An important goal of the initial stage of treatment of GHG is the elimination of factors leading to disease progression. At the present stage, with prolapses of the internal genital organs that do not reach the vestibule of the vagina, and without impairing the functions of neighboring organs, conservative therapy is used as preventive measures, which is also acceptable if it is not possible or if necessary to delay surgical correction.

Currently, there are two fundamentally different approaches to the treatment of genital prolapse, conservative and surgical.

The following conservative methods for treating this pathology exist:

1) physical exercises, such as Kegel exercises - isometric contractions of the striated muscle fibers that make up the pelvic floor [1, 2, 5, 6];

2) reflexology [1];

3) physiotherapy (electrical stimulation of the muscles of the pelvic floor, acupuncture) [1];

4) wearing vaginal pessaries [4];

5) hormone replacement therapy [7].

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But these methods today, separately from surgical treatment, are rarely used. Their main disadvantage is that the scope of these conservative measures is limited to the earliest stages of genital prolapse without significant anatomical and functional disorders, the presence of contraindications for surgical treatment, pregnancy or planning it in the coming year, preoperative preparation, postpartum rehabilitation of the pelvic floor.

Surgical methods.

To reduce the diameter of the entrance to the vagina, a plastic technique of the vestibule of the vagina is used. This is a minimally invasive operation that affects the surface layers and strengthens the ring of entry into the vagina. If the perineum was dissected during childbirth, then the scars are excised simultaneously and the antenatal appearance is formed. Postoperative care: a strict bed rest is indicated for four days. Restrictions of physical activity and sexual life for two months after surgery. It is also contraindicated to sit on the crotch for 2 weeks. Diet with the exception of products that provoke constipation. Antibacterial therapy for 7 days, prevention of thromboembolic complications with low molecular weight heparins, the use of uroseptics, non-steroidal anti-inflammatory drugs in the form of rectal suppositories, discharge for 4-7 days (3).

The main disadvantages of this method include the lack of the possibility of an outpatient operation, a long postoperative period, the need to comply with the regimen (a woman should not sit down for 2 weeks, dieting with the exception of products that provoke constipation, a course of antibacterial therapy).

There is a method for correcting the prolapse and incomplete prolapse of the internal genital organs in women (RF patent 2235517), which provides for the preservation of reproductive function - hysterosuspension, including vaginal access, incision of the anterior wall of the vagina and its separation with exposure of the side walls of the cervix and cardinal ligaments on both sides, different the fact that they form paraurethral canals behind the bosom so that the angle between the direction of the canal and symphysis is 30-40 on each side; atura from non-absorbable material, remove and fix the middle of the ligatures above the aponeurosis of the external oblique muscles of the abdomen in the suprapubic region on each side, leaving the ends of the ligatures free in the vaginal wound on both sides, the cardinal ligaments from the side of the vaginal wound are alternately sutured by one of the free ends of the ligatures, then visual control pull and tie the ends of the ligatures to each other, hanging the uterus by the aponeurosis, and then restore the front wall of the vagina. This method is indicated for incomplete prolapse of the internal genital organs in women and is mainly aimed at correcting the prolapse of the anterior vaginal wall, cystocele with urethral incontinence. It requires hospitalization in a hospital, an operation under general or regional anesthesia, and postoperative inpatient monitoring.

There is also known a method of surgical treatment of prolapse of the uterus and vaginal walls (published application RB ΒΥ0000017233), which consists in performing anterior colpotomy, securing the cardinal ligaments of the cervix, clamping and crossing them, fixing with each other, and installing the front part of the mesh polypropylene prosthesis between the anterior wall the vagina and the bladder, fix the cardinal ligaments of the cervix to it, then perform posterior colpotomy, secrete the sacro-uterine ligaments, clamp and cross them, amputate uterine cervix, the sacro-uterine ligaments are moved to the tunnel created previously in the tissues of the posterior vaginal fornix between the retroperitoneal part of the cervix, the peritoneum of the utero-rectal cavity and the rectum, the back of the mesh polypropylene prosthesis is installed between the posterior wall of the vagina and the rectum, fixed to it sacro-uterine ligaments and sutured anterior and posterior colpotomy.

These methods are complex surgical operations using ligatures or mesh prostheses from non-absorbable material. Their disadvantages are the lack of the possibility of outpatient operations, the lengthy recovery process and the impossibility of subsequent delivery without cesarean section due to the presence of prostheses and the formation of a fibrous scar.

Closest to the proposed and serving as a prototype is a method of surgical correction of genital prolapse - coloperineolevatoroplasty, including the allocation of a flap from the skin of the perineum and the mucous membrane of the posterior wall of the vagina.

Separate the skin and mucosa with a thin flap. The application of three separate sutures to the muscles that lift the anus without isolation from the fascial bed from a material with a resorption period of 70-90 days (vicryl or PHA-polyglycolide), the thickness of the I8R thread is 1 or 2, which forms the formation of fibrinous tissue in the form of a scar.

A continuous suture is applied to the mucosa of the posterior wall of the vagina according to Reverden. On the skin of the perineum - a cosmetic seam. The duration of the operation in the absence of technical difficulties due to anatomical features is about 60 minutes (3).

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The lack of the possibility of outpatient surgery, a long postoperative period, the need to comply with the regimen in the hospital and after discharge (the patient should not sit down for 2 weeks, dieting with the exception of products that provoke constipation, a course of antibacterial therapy). The main disadvantage is that the relatively fast period of resorption of the thread predisposes to relapse prolapse, which in the future will require repeated surgical treatment.

The objectives of the invention are to increase the effectiveness of surgical intervention, to ensure a pronounced local fibrous reaction that forms a strong frame of the pelvic floor muscles without loss of tissue elasticity, to develop a minimally invasive technology of perineoplasty, which allows to reduce the time of surgery, use local anesthesia in the absence of contraindications for its use and provide the possibility of surgery outpatient settings. The proposed method of minimally invasive perineoplasty does not require hospitalization in a hospital, postoperative inpatient monitoring, can be performed under local anesthesia on an outpatient basis. Accompanied by minimal blood loss (5-10 ml).

The problem is solved by the proposed method of low-invasive perineoplasty, namely, under local anesthesia with 2% lidocaine solution of the peripheral branches of the lumbosacral nerve plexus and processing the surgical field, we make skin incisions at the level 1 - posterior commissure of the labia majora; 2 - 1-0.5 cm from the remains of the hymen; 3-4 - at the level of the superficial transverse muscles of the perineum lying on both sides, along which a monofilament synthetic absorbable thread with notches and a long absorbable period is carried out (ErdopEM. Dar-Vinmono ΕΌΤ-414-ΚΜδΚΜ, synthetic absorbable monofilament from P (L-C) И8Р 0). Skin incisions are made with a scalpel. A monofilament synthetic absorbable thread with clockwise notches is made into these sections. The term for resorption of the thread is up to 210 days. The thread is passed through the fibers of the transverse muscle of the perineum. The ends of the thread are connected without excessive tension, forming the correct anatomy of the pelvic floor. Cuts on the skin are sutured with PG A 2/0 sutures, which are removed on the 5th day. The duration of the operation is 15-20 minutes.

In FIG. 1 shows a diagram of preliminary incisions at points 1-4, where 1 is the posterior commissure of the labia majora; 2 - remains of hymen tissue; 3, 4 - superficial transverse muscle of the perineum

Indications for use of this method: perineal deformation; pelvic floor muscle failure;

gaping genital fissure, the associated increase in the frequency of infectious lesions of the vulva; discomfort of sexual life (inability to contract the muscles of the pelvic floor).

The claimed method has the following advantages compared to the prototype: minimal surgical aggression and invasiveness of technology; significantly shorter duration of surgery; more pronounced therapeutic effect, aesthetic and functional result; long-term improvement;

the possibility of surgery only under local anesthesia; fast recovery period;

does not require subsequent delivery by cesarean section, due to the fact that the formation of a fibrous scar does not occur;

the possibility of an operation on an outpatient basis.

The following are clinical examples of the use of the claimed method.

Clinical example No. 1.

Patient S., 42 years old, was sent for consultation to resolve the issue of surgical treatment. Complaints about the sensation of a foreign body in the vagina and perineum, leucorrhoea, recurrent colpitis.

A history of pregnancy is 6, childbirth is 3, and abortion is 3.

In labor, a large fetus (3800.0-4200.0-500.0), perineal injury.

The alleged causes of the disease: birth injury to the pelvic floor.

Diagnosis: insufficiency of the muscles of the pelvic floor, gaping genital gap, prolapse of the posterior wall of the vagina of the 1st degree.

Conclusion: surgical treatment is indicated.

During preoperative preparation, a survey was conducted. It was revealed that the purity of the vagina corresponds to stage III, the titer of lactobacilli is 10'-10 ² CFU / ml, which indicates a pronounced vaginal dysbiosis. In crops of vaginal discharge, cultures of E. coli and hemolytic streptococcus were isolated. The vagina was sanitized.

The operation was carried out in accordance with the claimed method in conditions equivalent to outpatient.

The patient after surgery with a satisfactory clinical and cosmetic effect.

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A follow-up examination after 4 months showed that there were no complaints, the quality of life improved significantly. The purity of the vaginal smear corresponded to II tbsp. The titer of LB was 10 ⁶ CFU / ml. When examining the genitals: the sexual gap is closed, does not respond to straining; the mucous membrane of the vestibule and the vagina is not changed, the walls of the vagina are closed.

Conclusion: the cosmetic and functional effect of surgical treatment is complete.

Thus, the proposed method can be used in general clinical practice to restore the diaphragm of the pelvis.

Clinical example No. 2.

Patient R., 39 years old, came to the clinic with complaints of discomfort in the perineum. Unpleasant and painful sensations during sexual activity. A history of two births, accompanied by perineal tears.

With vaginal examination: the external genitalia are developed correctly. There is a deformation of the entrance to the vagina. The uterus is of normal size and shape, appendages on both sides without features, their area is painless. Clinical and laboratory examination - without pathology. Diagnosis: perineal deformity. Operation: minimally invasive perineoplasty.

The operation was carried out in accordance with the claimed method in conditions equivalent to outpatient.

The total duration of 30 minutes, blood loss - 5 ml.

Postoperative period: a single administration of antibiotics, non-steroidal anti-inflammatory rectal suppositories, no analgesia is required, you can sit on the perineum, sexual rest for 3 weeks.

Ultrasound examination without ECHO structural changes, pain is absent.

Dynamic observation was carried out after 4 and 12 months. The patient has a pronounced aesthetic and functional improvement. No complications were detected.

The invention is illustrated in the photographs shown in FIG. 2-5.

In FIG. 2 shows patient 1 before surgery with perineal deformation, gaping genital gap.

In FIG. 3 shows the same patient after minimally invasive perineoplasty.

In FIG. 4 shows patient 2 before surgery with perineal deformity, gaping genital gap.

In FIG. 5 shows the same patient after minimally invasive perineoplasty after 2 weeks.

The proposed method is illustrated by examples of operations that prove its industrial feasibility

The method also satisfies the criteria of novelty and inventive step, because it solves a problem that was previously solved by complex surgical methods only in stationary conditions. The method also provides a significant positive effect compared with all known.

List of references.

1. V.M. Bogolyubov. Balneology and physiotherapy. - M .: Medicine, 1985.- t. 2, p. 32-37.

2. V.I. Krasnopolsky. Combined treatment of patients with prolapse and prolapse of the internal genital organs and urinary incontinence using anti-stress technologies. - Grew up. Bulletin of the obstetrician-gynecologist. - 2004. - No. 1, p. 61-64.

3. V.I. Kulakov, N.D. Selezneva, V.I. Krasnopolsky. Operational Gynecology.- M .: Medicine, 1990, p. 299.

4. V.V. Mikhedko, A.V. Kotov. - Reptile. - No. 2, 2009, p. 23.

5. A.I. Neymark, M.V. Ryapolova. Conservative treatment of imperative and mixed urinary incontinence in women. - Kazan Medical Journal, 2010, v. 91, No. 4, p. 508-510.

6. O.A. Peresada, A.N. Barsukov, A.A. Kulikov, N.A. Odintsova, L.Z. Sheremetyeva. - Medical News, 2010, No. 10, p. 35-40.

7. V.P. Estimator. Menopause medicine. - M., 2009, p. 217-236.

8. H.A. Hirsch, O. Keyser, F.A. On Operative gynecology: Atlas: Per. from English / Ed. IN AND. Kulakova, I.V. Fedorova. - M.: GEOTAR MEDICINE, 1999, p. 243.

Claims (6)

CLAIM 1. A method of minimally invasive perineoplasty aimed at increasing the efficiency of surgical treatment of genital deformity and prolapse, characterized in that skin incisions are made with a scalpel at the level of 1 - posterior commissure of the labia majora; 2 - outside 1-0.5 cm from the remains of hymen tissue; 3-4 - at the level of the superficial transverse perineal muscles lying on both sides, synthetic resorbable suture with incisions clockwise and a long time of resorption is introduced into the incisions through the fibers of the transverse perineal muscle, then the ends of the suture are connected without excessive tension, forming the correct anatomy of the pelvic floor, cuts on the skin are sutured with PHA 2/0 sutures, which are removed on the 5th day, and the total duration of the operation is 20-30 minutes. 2. The method according to claim 1, characterized in that during this operation a monofilament synthetic thread with notches (ΕίβοηΕδΐ, Dar-Vinmono ΕΌΤ-414-ΚΜ8ΑΗ, synthetic absorbable monofilament from P (BA-SB) И8Р 0) is used. 3. The method according to claims 1, 2, characterized in that the monofilament synthetic thread with notches (ΕίβοηΕδΐ, Dar-Vinmono ΕΌΤ-414-ΚΜ8ΑΗ, synthetic absorbable monofilament from P (BA-SB) И8Р 0) has a long resolving time - up to 210 days. 4. The method according to claims 1-3, characterized in that the chemical-physical properties of the monofilament synthetic thread with notches (ΕίβοηΕδΐ, Dar-Vinmono ΕΌΤ-414-ΚΜ8ΑΗ, synthetic absorbable monofilament from P (BA-SB) И8Р 0) provide a pronounced local fibrotic reaction, forming a strong frame of the muscles of the pelvic floor without loss of tissue elasticity with the specified surgical technique for performing surgery. 5. The method according to claims 1 to 4, characterized in that the operation is performed using local anesthesia in the absence of contraindications for its use. 6. The method according to claims 1-5, characterized in that the operation is performed on an outpatient basis.