RU2076645C1 - Method for treating falling of the womb and prolapse of the uterus - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves twice suturing fundus of the uterus to aponeurosis of the anterior abdominal wall under laparoscopic control through micro access path formed by cutting skin 1.0-1.5 cm above the pubis. EFFECT: enhanced effectiveness of treatment.

Description

 The invention relates to medicine and can be used in surgical gynecology in case of prolapse or prolapse of the uterus.

 Ovarian prolapse and prolapse are the most common gynecological diseases and make up 11.5% of all gynecological patients. The problem of uterine prolapse, despite numerous developments, continues to remain in the focus of attention of gynecological surgeons. This is due, firstly, to the failure of the restored muscles of the pelvic floor, as well as the imperfection of conservative and surgical interventions. The rehabilitation of such patients is not only of medical, but also of social importance, because 50-60% of such patients are women of reproductive and working age.

 In the treatment of prolapse and prolapse of the uterus, mainly vaginal and abdominal-wall surgical methods are used.

 There are hundreds of methods for surgical treatment of prolapse and prolapse of the uterus. ("Operational gynecology". A guide for doctors. M. Medicine, 1990). In practice, only some of the proposed operations are used, since a number of popular and effective operational methods violate childbearing, for example, Kocher uterine ventilation. Others deprive a woman of the opportunity to live a sexual life (median colporagraphy according to Lefor Neugebauer, complete and incomplete colposcleisis, etc.). Some methods of operations are non-physiological (vesicovaginal uterine interposition, etc.).

 It is known that to restore the position of the uterus, round ligaments of the uterus are used. At the same time, they are looped through wide ligaments and fixed on the posterior wall of the uterus.

 Sometimes round ligaments are sutured to the anterior wall of the uterus. All major modifications (colpoperineoplasty, cruciform shortening of the round and sacro-uterine ligaments, uterine interposition of the uterus according to the Alexandrov method, middle colporography by the Neugebauer Le Faure method with colpoperineorography and levatoroplasty) are reduced to the goal of restoring the anatomical relationships and physiological functions of the pelvis. A mandatory step in the operation is the narrowing of the genital fissure by means of muscular plasty of the pelvic floor.

 These operations are highly traumatic, entail significant blood loss, a difficult postoperative period and are associated with a risk of relapse (up to 33%). In addition, a number of operations, for example, vaginal extarpation of the uterus, Manchester operation are not indicated at all for women who want to maintain fertility.

 In Manchester surgery, after cutting out the flap, the bladder is repaired upwards after preliminary dissection of the connective tissue cords between the neck and the bladder. Fascia of the bladder is strengthened by transverse sutures, and with pronounced prolapse of the anterior wall of the vagina with the bladder, by circular sutures in the form of a pouch. After cutting, the cardinal ligaments are ligated with catgut, and 2-3 lavsan sutures are sutured between them under the womb of the bladder. The neck is amputated. Then, posterior colpoperineorography and levatoroplasty are performed. In the process of the latter, levator bundles are not isolated from the surrounding tissue in order to avoid excessive trauma and injury to small vessels. (Kazan Medical Journal, 1990, vol. 121, No. 1). The postoperative period is long, the operation is traumatic.

 Combined operations are also known that restore the functions of the uterine support and suspensory apparatus, operations using alloplastic materials (Textbook "Operational Gynecology", M. Publishing House of the University of Friendship of Peoples, 1985). In particular, neck plasty is used by the stratification method (according to indications), anterior colporography and colpoperineorography with levatoroplasty. Then the uterus is repositioned by strengthening the round ligaments of the uterus with a kapron tape according to V.I. Yeltsov Strelkov or an alloplastic antimicrobial tape from letilan-lavsan. These operations have the above disadvantages. Patients often experience pain after surgery, relapses occur in 12-21% of cases.

 Recently, in many clinics around the world, surgical laparoscopy has found widespread use. This method was adopted by us as a prototype (the book "Endoscopy in Gynecology" under the editorship of Corresponding Member of the Academy of Medical Sciences of the USSR Prof. Savelyeva, M. Medicine, 1983).

 The laparoscopic set includes needles, a trocar for puncture of the abdominal cavity, optical tubes, manipulators, a scalpel.

 The patient is prepared for surgery as well as for gluttony. The patient is laid on the table, anesthetized under general anesthesia, the anterior abdominal wall is treated the same as during abdominal surgery and is covered with sterile sheets. Then oxygen, carbon dioxide or nitrous oxide is injected into the abdominal cavity to eliminate the risk of injury to the abdominal organs.

 Then the patient is transferred to the position of Trendelenburg, a 0.5 cm incision is made with a scalpel through the navel, through it an oblique insertion is introduced through it towards the bosom of the II mm trocar. Through such an incision, a laparoscope tube is inserted into the abdominal wall. Under control, a manipulator is introduced through an additional operating channel. With the help of a palpator, intestinal loops, an omentum are displaced, an examination is performed, clamps are inserted, the uterus is moved to a normal median position, and the uterus is brought to the anterior abdominal wall. Then the uterus, aponeurosis and muscle are punctured and sequential ventrofixation of the bottom and body of the uterus is made by separate lavsan or kapron ligatures on the left, on the right.

 The described method has several serious drawbacks: the operation is performed under general anesthesia, is relatively traumatic, and long.

 The aim of the invention is to reduce trauma, reducing the time of the operation and the amount used for pain relief.

 The essence of the invention is the fixation of the bottom of the uterus through the anterior abdominal wall by performing each incision above the womb and applying U-shaped sutures.

 The method is as follows. In a known manner, laparoscopy is performed. Above the bosom, an incision is made on 1.0-1.5 cm of the skin and subcutaneous tissue, the aponeurosis, the muscle of the anterior abdominal wall and the bottom of the uterus are punctured, leaving the end of the suture material inside. Then the needle is removed and reinserted next to the first puncture. Grab the thread, bring it out and strengthen it. Thus, a U-shaped seam is formed, fixing the body of the uterus to the anterior abdominal wall. Thus, 1-2 seams are applied. The operation is performed within 12-15 minutes under general anesthesia. The method was tested in clinical conditions for 12 patients. The limitation period of postoperative observations is 1-2 years. All patients feel quite satisfactory, no complaints.

 Example. Patient K., 33 years old (medical history N 3246), was admitted to the MHC with complaints of pain, inconvenience when walking and having sex, and frequent urination (up to 12-14 times a day). On examination, the diagnosis was established: prolapse of the walls of the vagina II-III Art. cystocele. Recommended laparoscopy, uterine fixation to aponeurosis.

 After processing the surgical field with a solution of podonate, under a general calypsol anesthesia, a 1.5 cm incision is made in the umbilical ring through which a trocar and a tube of a laparoscope are inserted. Under the control of a laparoscope introduced lateral manipulators (in the iliac regions). The abdominal cavity was revised. The uterus is fixed by bullet forceps and brought to the anterior abdominal wall. A needle with a ligature was inserted through a skin incision of the anterior abdominal wall (1-1.5 cm long), the anterior abdominal wall, and the bottom of the uterus. The end of the ligature is left in the abdominal cavity. Then a parallel injection was made with a “single” needle and the end of the ligature was pulled out and fixed to the aponeurosis. Thus, 2 U-shaped seams are applied. Then made an examination of the abdominal cavity. Laparoscope and manipulators removed. Separate silk sutures are applied to the skin. Blood loss 15 ml. The patient was discharged from the hospital on the 4th day in a satisfactory condition.

 After a year, a checkup, no complaints.

Claims (1)

 A method of treating prolapse and prolapse of the uterus, including fixation of the uterus, characterized in that they form micro-access, dissecting the skin and subcutaneous tissue 1.0 1.5 cm above the womb, under the control of a lagaroscope, the aponeurosis of the anterior abdominal wall and the bottom of the uterus are sequentially stitched with a needle, leaving a ligature in the abdominal cavity and remove the needle, then with a single needle make a parallel injection, remove the end of the ligature out and form a U-shaped suture, stitching the aponeurosis and tying the ends of the ligature over the aponeurosis, similarly impose the second seam.