RU2181569C2 - Method for fixing vagina stump after performing uterus extirpation - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves creating tunnels in retroperitoneal access in paravesical fat on both sides after performing uterus extirpation in the cases of ptosed vagina walls and relative enuresis condition. The vagina stump is fixed through the tunnels to posterior surface of the pubic bone in the lower, middle or upper part. EFFECT: enhanced effectiveness of vagina position adjustment. 1 dwg, 1 tbl

Description

 The invention relates to the field of gynecology and can be used in the surgical practice of clinics, hospitals and hospitals.

 Known surgery is postadilone colpourethropexy according to the Marshall-Marchetti-Krantz method, performed when indicated: vaginal wall prolapse, cystocele and relative urinary incontinence. This operation involves dissecting the anterior abdominal wall to the preperitoneal layer of fat; autopsy of the retsi or backward space; separation of the bottom and front wall of the bladder; displacement of the bladder in the neck towards the urethra and the release of the lateral vaults of the vagina. With the help of an assistant, the right and left vaginal arches are flashed with Dacron thread 5-6 twice on each side and the ligatures are fixed to the periosteum of the pubic bone behind. Then, suturing of the anterior abdominal wall with drainage of the retia space is performed [1].

 The main disadvantage of posadilon colpourethropexy is the impossibility of performing a surgical operation with concomitant pathology of the cervix or uterine body (cervical cancer, uterine cancer, uterine fibroids, uterine adenomyosis, endometrial adenomatosis, cervical dysplasia), which requires its extirpation.

Other disadvantages of the operation include:
1. Relapse of prolapse of the vaginal wall.

 2. Violation of the function of the sphincter apparatus of the lower urinary tract.

 3. The possibility of trauma to the wall of the bladder when suturing the vaults of the vagina, which leads to the formation of urinary fistulas.

 4. The possibility of dressing the mouths of the ureters when suturing the vaults of the vagina, which leads to the need for emergency surgery to restore the passage of urine.

 5. Dissenergic dysfunction of the pelvis.

 6. The operation is not feasible with concomitant uterine pathology (uterine myoma, uterine adenomyosis, endometrial adenomatosis, cervical dysplasia).

 The closest medical-technical solution adopted by us as a prototype method is the extirpation of the uterus with or without appendages in case of pathology of the cervix or uterine body [2].

 The prototype uterine extirpation surgery includes disinfection of the skin of the anterior abdominal wall, vagina and vaginal part of the cervix, general (endotracheal or intravenous anesthesia) or conduction (epidural anesthesia) analgesia, incision of the anterior abdominal wall and opening of the abdominal cavity, withdrawal to the surgical wound of the uterus, delineation pelvic area and area of operation from the rest of the abdominal cavity with gauze napkins. Then clamps are applied, cut off, stitched and bandaged round uterine ligaments, their own ovarian ligaments and fallopian tubes (when extirpation of the uterus without appendages) or funnel-pelvic ligaments (when extirpation of the uterus with appendages). After that, both leaves of the wide uterine ligament are incised up to the uterine rib, the peritoneum of the vesicoureteral fold is arcuately cut from one stump of the round uterine ligament to the other. The bladder is completely separated from the cervix and moved down to the vaginal vault. After the vesicle-uterine fold of the peritoneum is opened by transverse incision, clamps are applied, dissected, stitched and bandaged the uterine vessels (uterine artery trunk and uterine veins) with two catgut sutures 5-6, bandaging the main vascular bundles on both sides, applying clamps down parallel to the rib the uterus on the descending branches of the uterine arteries, which also dissect, stitch and bandage. Then they begin to separate the sacro-uterine ligaments, which are also clamped, the sacro-uterine ligaments are cut off from the uterus, stitched and ligated with catgut sutures 5-6. Separate the perivascular and peri-vaginal tissue with scissors, separate the lateral vaginal arches, on which the clamps are applied, dissecting them, as well as the anterior and posterior vaginal arches and remove the uterus. Then the lateral vaginal arches are stitched and bandaged with catgut sutures 5-6, the front and back walls of the vagina are sheathed with a catgut suture. Then they begin to peritonize the stumps of the ligaments, vessels and vagina, for which the front and back leaf of the dissected wide uterine ligament is sutured with catgut thread. The anterior abdominal wall is sutured in the reverse order.

 The main disadvantages of the protopit method are the impossibility of performing surgery by posadillon colpourethropexy according to the Marshall-Marchetti-Krantz method with concomitant prolapse of the vaginal walls and relative urinary incontinence, due to the lack of vaginal arches, as well as reliable fixation of the vaginal stump after uterine extirpation.

 The objective of the invention is to increase the efficiency of the surgical operation of uterine extirpation with the pathology of her neck and body in combination with the prolapse of the walls of the vagina and relative urinary incontinence by expanding the capabilities of the operation of uterine extirpation with and without appendages due to the simultaneous extirpation of the uterus and postadilone colpourethropexy according to the modified Marshall method Marchetti-Krantza followed by post-cylindrical fixation of the vaginal stump after extirpation of the uterus through a tunnel in paravesical tissue.

 The problem is solved by simultaneously performing surgical operations of uterine extirpation and colonic urethral colic urethropexy according to the modified Marshall-Marchetti-Krantz method with subsequent colonic fixation of the vaginal stump after extirpation of the uterus through a tunnel in paravesical tissue. For this, after cutting off the vaginal part of the cervix from the vaginal arches, the lateral parts of the vaginal stump are sutured with catgut sutures 5-6 in the region of the former right and left vaginal arches, and the front and back walls of the vagina are sheathed with a catgut suture. Then, through the lower end of the surgical incision, the posterior space is exposed, performing the stage of the modified operation of the posterior colposurethropexy according to the Marshall-Marchetti-Krantz method. Next, catgut sutures from the vaginal stump are passed through the peri-bubble cell space to the posterior surface of the pubic bone. Then, the periosteum of the pubic bone is sutured with the same threads, and the threads are tied. As a result, the vaginal stump is fixed to the periosteum of the posterior surface of the pubic bone in its lower, middle or upper third through a tunnel in paravesical tissue.

 Extirpation of the uterus is carried out under the influence of endotracheal anesthesia or conduction anesthesia - epidural anesthesia, and when extirpating the uterus without appendages, clamps are cut, cut, stitched and bandaged round uterine ligaments, own ovarian ligaments and fallopian tubes. During extirpation of the uterus with appendages, round uterine ligaments and funnel-ligamentous ligaments are cut off, stitched and bandaged. In this case, clamps are applied, dissected, stitched and bandaged the uterine vessels (uterine artery trunk and uterine veins) with two catgut sutures 5-6. After bandaging the main vascular bundles on both sides, clamps are placed down parallel to the lateral surface of the isthmus and cervix of the uterus on the descending branches of the uterine vessels, which are also cut off, stitched and bandaged. Then proceed to the separation of the sacro-uterine ligaments. The sacro-uterine ligaments are cut off from the uterus, stitched and bandaged with catgut sutures 5-6, the peri-bubble and peri-vaginal tissue are separated with scissors, the lateral vaginal arches are secured, which are clamped, dissecting them, as well as the anterior and posterior vaginal arches and the uterus is removed. In addition, an autopsy of the retzieva or the posterior space 5 is performed, the bladder 12 is displaced to the center and tunnels 7 are created on both sides retroperitoneally in the paravesical tissue 6. After this, ligatures 10 are sewn into them, flashing the lateral sections of the vaginal wall, and the former lateral sections of the vaginal wall, and fix them to the periosteum of the pubic bone from behind 2. Then peritonize the stumps of the ligaments, blood vessels and vagina, for which the front and back leaf of the dissected wide uterine ligament is sutured with catgut thread, and the anterior th abdominal wall is sutured in reverse order.

 Until now, when performing the operation of uterine extirpation with or without appendages according to the prototype method, the vaginal stump after cutting off the vaginal part of the cervix from the vaginal arches was fixed to the elements of the uterine suspensory apparatus: round uterine ligaments, funnel-pelvic ligaments (if the uterus was extirpated with appendages) or Own ligaments of the ovaries and fallopian tubes (if hysterectomy was performed without appendages).

 The applicant and the authors proposed a new method for fixing the vaginal stump behind the periosteum of the posterior surface of the pubic bone in its lower, middle or upper third. To do this, after cutting off the vaginal part of the cervix from the vaginal arches, the latter are stitched in the area of the former right and left arches with lavsan thread 5-6.

 After that, the stage of the modified Marshall-Marchetti-Krantz operation is performed - the back-wall space is exposed. Lavsan filaments from the vaginal stump are passed through the near-bubble cell space to the posterior surface of the pubic bone. With the same threads, the periosteum of the pubic bone is sutured. The threads are tied.

 Thus, the vaginal stump is fixed to the periosteum of the posterior surface of the pubic bone.

 The drawing shows the steps of the operation according to the claimed method of fixing the stump of the vagina after extirpation of the uterus.

In the inventive method, the following elements are used:
1 - vaginal stump,
2 - periosteum of the posterior surface of the pubic bone,
3 - region of the former right and left vaginal arches,
4 - suprapubic region,
5 - lateral space,
6 - peri-bubble cellular space,
7 - tunnel in paravesical tissue,
8 - front and back walls of the vagina,
9 - entwined catgut seam,
10 - lavsan ligatures,
11 - urethra,
12 - bladder,
13 - the uterus.

 The claimed method of fixing the vaginal stump after extirpation of the uterus is as follows.

 Before surgery, a Foley catheter 24 is inserted into the bladder 12, a balloon of which is filled with 5 ml of isotonic sodium solution. First, the uterus is extirpated 13. For this, the skin of the anterior abdominal wall, vagina 1 and the vaginal part of the cervix 13 are disinfected, general (endotracheal or intravenous anesthesia) or conduction (epidural anesthesia) analgesia, anterior abdominal wall incision and opening of the abdominal cavity, uterine surgical wound 13, delimitation of the pelvis and the area of operation from the rest of the abdominal cavity with gauze napkins. Then clamps are applied, cut off, stitched and bandaged round uterine ligaments, their own ovarian ligaments and fallopian tubes (when extirpation of the uterus without appendages) or funnel-pelvic ligaments (when extirpation of the uterus with appendages). After that, both leaves of the wide uterine ligament are incised up to the uterine rib, the peritoneum of the vesicoureteral fold is arcuately cut from one stump of the round uterine ligament to the other, the bladder is completely separated from the cervix and moved down to the vaginal vault. After the vesicle-uterine fold of the peritoneum is opened by a transverse incision, clamps are applied, dissected, stitched and bandaged the uterine vessels (uterine artery trunk and uterine veins) with two catgut sutures 5-6. After bandaging the main vascular bundles on both sides, clamps are placed down parallel to the uterine rib on the descending branches of the uterine arteries, which are also dissected, stitched and bandaged. Then proceed to the separation of the sacro-uterine ligaments, which are also clamped. The sacro-uterine ligaments are cut off from the uterus, stitched and bandaged with catgut sutures 5-6. Separate the perivascular and peri-vaginal tissue with scissors, separate the lateral vaginal arches, on which the clamps are applied, dissecting them, as well as the anterior and posterior vaginal arches and remove the uterus. Then the lateral vaginal arches are stitched and bandaged with dacron threads 5-6, the front and back walls of the vagina are sheathed with a catgut suture 9.

 Then carry out post-colonic colpourethropexy. Why expose the posterior space 5. Then the neck of the bladder and the urethra are secreted wide down from the back surface of the pubic joint, not reaching 1 cm to the external opening of the urethra. Moreover, the lateral vaginal arches are widely mobilized, and bleeding vessels are ligated. In this case, the assistant inserts the fingers into the vagina and, having groped the catheter and balloon, fixes the urethra and the neck of the bladder in the surgical field. Then, three chrome-plated atraumatic catgut sutures 4-5 are applied at the same distance from each other in the transverse direction from the urethra, picking up but not piercing the mucous membrane of the front wall of the bladder. Moreover, a separate transverse suture is also imposed on the front wall of the neck of the bladder. After that, all performed ligatures 10 are tied, thereby reducing the lumen of the enlarged urethra and its elongation, eliminating the funnel-shaped change in the neck of the bladder 12, strengthening the sphincter of the neck of the bladder 12, and cutting off the free ends of the ligatures 10. Then, under the control of the assistant’s fingers introduced into the vagina, 10–5–6 maximally mobilized anterolateral anterolateral vaginal arches outside the urethra, at least 2.5 cm from each side of the urethral margin at least 2.5 cm to the closest ligature, are maximally mobilized outside. The ends of the ligatures with a sharp curved needle are passed through the periosteum of the upper edge of the horizontal branches of the pubic bones in the area of attachment of the rectus and pyramidal muscles of the anterior abdominal wall, and when tying lavsan ligatures 10, the front wall of the vagina is displaced high upwards, dragging the bladder up and anteriorly. 12, restore the physiological relationship between them. So, additionally opening the nadilon space and shifting the bladder to the center, create tunnels on both sides retroperitoneally in the paravesical tissue, ligatures are performed in them, the lateral walls of the vagina are stitched and the stump of the vagina is fixed to the periosteum of the pubic bone in the back in its lower, middle or upper third.

 Then proceed to the peritonization of the stumps of the ligaments, blood vessels and vagina 1, for which the front and back leaf of the dissected wide uterine ligament is sutured with catgut thread, the anterior abdominal wall is sutured in the reverse order.

 In the gynecological department of GVKG them. NN Burdenko was treated 42 patients.

In the main group there were 15 patients. Concomitant gynecological pathology requiring surgical intervention in the amount of uterine extirpation:
- uterine fibroids - 11;
- uterine adenomyosis, hormone-resistant form - 2;
- pathology of the cervix (dysplasia of the cervix 3 tbsp.) - 1;
- endometrial adenomatosis - 1.

 The main group of patients underwent surgery according to the claimed and implemented method of hysterectomy.

 The control group included 27 patients with concomitant gynecological pathology. He performed uterine extirpation operations according to the prototype method.

 The table shows the indicators of operations performed by the present method of fixing the stump of the vagina and hysterectomy according to the prototype method.

 Example.

 Patient K., 64 years old, was admitted to the department with a diagnosis of uterine fibroids corresponding to a 14-week pregnancy, old postpartum ruptures of the cervix, prolapse of the walls of the vagina, cystocele, relative urinary incontinence.

 After examination, the diagnosis is confirmed. Due to the presence of synchronous pathology requiring surgical treatment, the patient is shown to perform the following volume of surgical interventions.

 Regarding uterine fibroids, corresponding to a 14-week pregnancy, old postpartum ruptures of the cervix uteri - hysterectomy with appendages. Regarding the prolapse of the walls of the vagina, cystocele, relative urinary incontinence - posadilon colpourethropexia according to the Marshall-Marchetti-Krantz method. Due to the impossibility of combining the data of two operations when performed by the traditional method, the surgical intervention was performed in the proposed modification: extirpation of the uterus with appendages, posterior colposureropexy by stitching the vaginal stump to the pubic bone through a tunnel in paravesical tissue.

 In the postoperative period, no complications were noted. A follow-up examination after 3 years showed no recurrence of prolapse of the vaginal walls.

The claimed method of fixing the vaginal stump after extirpation of the uterus allows you to:
to expand the possibilities of surgical treatment of patients with concomitant uterine pathology (uterine myoma, uterine adenomyosis, endometrial adenomatosis, cervical dysplasia);
to avoid trauma to the wall of the bladder when suturing the vaults of the vagina and to prevent the formation of urinary fistulas;
to avoid ligation of the ureteral orifice when suturing the vaginal vaults, which, in turn, does not contribute to impaired function of the pelvic organs and upper urinary tract and the need to perform emergency surgery to restore the passage of urine;
allows to achieve stability of fixation of the vaginal stump;
allows not to violate the act of urination due to the restoration of anatomical structures;
to prevent recurrence of prolapse of the vaginal wall.

Sources of information
1. Klimov M. M. Surgical treatment of stress urinary incontinence in women suffering from prolapse of the walls of the vagina // - Diss. Cand. Honey. Science. - GVKG them. N.N. Burdenko. - M. - 1990. - P.31-40.

 2. Braude, N.L. Operative gynecology // Uterine fibromyoma, section 2. - Medgiz. - M. - 1952. - S.243-267 (prototype).

Claims (1)

 A method of fixing the vaginal stump after hysterectomy with lowering of the vaginal walls and relative urinary incontinence, characterized in that tunnels are created retroperitoneally in the paravesical tissue on both sides and the vaginal stump is fixed through them to the periosteum of the posterior surface of the pubic bone in the lower, middle or upper third.

Images