RU2184503C2 - Surgical method for treating the cases of falling of the womb and incomplete prolapse of the uterus - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves separating triangular flap from the vagina with external surface of the uterine cervix being involved. Incision is continued around the whole uterine cervix through ruptures. Rupture boundaries are cut wedge- like. Rectangular mucous flaps are separated turned with one side towards the vagina. The injured portion of the uterine cervix around the external ostium of the uterine cervix is excised as cone turned towards the internal ostium of the uterus. The sutures are put layer-by-layer on the muscle tissue of renewed rupture edges. Cardinal ligaments are cut, legated and sutured to each other in front of the uterus. The neighboring flaps are used when putting-in sutures. The sutures are put in beginning from the position o.5 cm remote from the external angle of a flap. Ligature end is conducted from the cervical canal through the whole thickness of the muscular cervix tissue layer to the separated mucous membrane of the cervix 1.5- 2 cm higher and somewhat outward from the first pierce. Then, the other end of the same ligature and the ligature path is repeated near the first one using an adjacent flap. The ligature ends are tied connecting in this way the lateral edges of the separated flaps radially in the 12 o'clock position and at the places of former ruptures. External edges of the flaps are turned down into the cervical canal. Anterior colporrhaphy is carried out. Posterior colporrhaphy with perineolevatoroplastic repair are carried out. EFFECT: enhanced effectiveness in restoring uterus cervix and vagina functions. 4 dwg

Description

 The invention relates to medicine, namely to operative gynecology.

 Analogues of the proposed method of surgical treatment are reconstructive plastic surgery on the cervix, vagina and pelvic floor. A known method of restoring the cervix according to Emmett (Kulakov V.I., Selezneva N.D., Krasnopolsky V.I. Operational gynecology. M: Medicine, 1990, p. 221). Emmett surgery is used for old lateral ruptures of the cervix. The edges of the old lateral rupture are freshened with a scalpel, brought together by single nodal catgut sutures in such a way as to form the external pharynx of the cervix.

 A known method of cervical amputation according to Sturmdorf (Kulakov V.I., Selezneva N.D., Krasnopolsky V.I. Operative gynecology. M .: Medicine, 1990, p. 225), which is undertaken with recurrent ectropions and significant elongation and deformation cervix. A scalpel makes a circular incision of the vaginal mucosa 1 cm above the affected area. The mucous membrane of the vaginal part of the cervix is separated from muscle tissue by 1.5-2 cm. Part of the affected neck is excised in the form of a cone. Then, by pulling the separated mucous membrane, the wound surface of the muscular part of the cervix is covered.

 A known method of surgical treatment for erosive ectropions, elongation and deformation of the cervix according to Schroeder (Kulakov V.I., Selezneva N.D., Krasnopolsky V.I. Operational gynecology. M .: Medicine, 1990, p.223). With this operation, a wedge-shaped amputation of the cervix in the transverse direction through the cervical canal is performed. Sutures are applied in a radial direction through the cervical canal, the thickness of the cervix and the rest of the mucous membrane of the outer surface of the cervix, first on the front, then on the back of the excised neck.

 Known operation on Yeltsov-Strelkov (Kulakov V.I., Selezneva N.D., Krasnopolsky V.I. Operational gynecology, M .: Medicine, 1990, p.226), which is performed during cervical deformity. During the operation according to Yeltsov-Strelkov, the cervix is stratified into external and internal flaps, excision of scar-changed tissues in place of old lateral gaps. The excised edges of the internal flap are connected with single catgut sutures, the nodes are immersed in the lumen of the canal. Radial seams connect the inner and outer flaps. Separate catgut sutures are then placed on the lateral edges of the wound of the musculoskeletal external flap of the vaginal part of the cervix.

 To restore the vagina and pelvic floor, anterior and posterior colporography with perineolevatoroplasty is used. (Kulakov V.I., Selezneva N.D., Krasnopolsky V.I. Operational gynecology. M: Medicine, 1990, p. 287-294).

 However, the use of these methods does not allow the formation of a macroscopically healthy cervix and vagina with a combination of prolapse or incomplete prolapse of the uterus with elongation and deformation of the cervix by deep ruptures.

 The prototype of the proposed method of surgical treatment is the Manchester operation. This operation is effective for prolapse and partial prolapse of the uterus, with lengthening of the neck. The operation is as follows. From the front wall of the vagina 1.5-2 cm below the external opening of the urethra, a triangular flap is turned off, facing down with its base. A circular incision is made around the cervix at the level of the last transverse fold of the vagina only in front to the level of the cardinal ligaments. The bladder and vaginal mucosa are separated upward. A wedge-shaped amputation of the cervix is performed. The cardinal ligaments are dissected, ligated and stitched together in front of the uterus. Wedge-shaped sections on the anterior and posterior lips of the cervix are sutured with single sutures. The side parts of the cuts on both sides are connected by separate seams. Anterior and posterior colporography with perineolevatoroplasty is performed. (L. S. Persianinov. Operational gynecology. M.: Medicine, 1976, p. 297, 298).

 But the use of this method does not allow the formation of a macroscopically healthy cylindrical cervix in the presence of deep ruptures and elongation of the cervix in combination with prolapse and incomplete prolapse of the uterus and in some cases causes narrowing of the cervical canal and shortening of the cervix in women of reproductive age. Restoring the cervix and vagina to eliminate the adverse effects of birth injury in order to restore the specific functions of the female body continues to be one of the urgent problems of operative gynecology.

 The aim of the invention is the anatomical and functional restoration of the cervix and vagina with prolapse and incomplete prolapse of the uterus with elongation and deformation of the cervix by deep ruptures in an operative way.

 In FIG. 1 shows a method for separating a vaginal flap with a transition to the vaginal part of the cervix, making a circular incision around the cervix with the maximum possible preservation of the healthy part of the mucous membrane of the vaginal cervix and excising old lateral ruptures. Figure 2 shows a method of separating the flap of the vagina and the vaginal mucosa of the cervix, cone-shaped excision of the affected area of the cervix and the application of single-row single sutures on the muscle tissue of the freshened edges of the gaps. Figure 3 shows a method for stitching dissected cardinal ligaments in front of the uterus and a method for forming the mucous membrane of the cervix using previously separated flaps. Figure 4 shows the radially spaced joints of the edges of the mucosa and anterior colporography.

 Our proposed method of surgical treatment is as follows. At 1.5-2 cm below the external opening of the urethra from the anterior wall of the vagina 1 with the transition to the vaginal part of the mucous membrane of the cervix, a triangular flap 2 is turned off, facing down. Section 3 continues circularly around the entire cervix at the level of healthy tissues through breaks, and not above them, with the maximum possible preservation of the mucous membrane of the outer surface of the cervix. Old tears 4 are wedge-shaped excised. Flaps 5 of the mucous membrane are separated from the cervix. The number of flaps depends on the number of breaks. The flaps are in the form of rectangles, one side facing the vagina. The bladder separates up. The changed part of the cervix is amputated with a cone 6 in the direction of the internal pharynx. The muscle tissue of the freshened edges of the cervical tears is sutured with single-row single sutures 7. The cardinal ligaments 8 are dissected, ligated and stitched together in front of the uterus. The mucous membrane of the cervix is formed using previously separated flaps 5 as follows. The seams begin to be laid back 0.5 cm from the outer corner of one flap. Then the end of the ligature is carried out from the cervical canal through the entire thickness of the neck tissue to the mucosa with a puncture 1.5-2 cm higher and somewhat outwards from the first injection. After that, the other end of the same ligature is inserted into the needle and the ligature is repeated next to the first, using the adjacent flap of the mucosa. The ends of the ligature are interconnected. Thus, the leaves of the separated mucosa are screwed into the cervical canal and connected to each other. Radially located joints of the edges of the mucosa 9 are obtained at 12 o’clock and at the site of the former breaks. The next step is the front and rear colporography with perineolevatoroplasty.

 Example 1. Patient B., 32 years old, East. 2522. Was admitted to the hospital with a diagnosis of Elongation, cervical deformity, eroded ectropion, uterine prolapse. Poor pelvic floor muscle failure.

 Complaints of discomfort in the external genital organs, sexual disorders.

 A history of 2 births, 3 medical abortions. During the first birth, a cervical rupture of 3 degrees, a perineal rupture of 2 degrees. Secondary healing.

 Objectively when viewed in mirrors and bimanual research: the genital gap gapes, the neck extends beyond the genital gap when straining, the uterus is lowered, the neck is elongated to 5 cm, deformed by the old lateral rupture to the arch for 9 hours, around the external pharynx there is erosion of ectropion, failure pelvic floor muscles.

 The patient underwent a complete clinical and laboratory examination. Plastic surgery is shown as planned.

 Given the totality of clinical data, the woman was operated on by our proposed method. At 1.5 cm below the external opening of the urethra from the anterior wall of the vagina and the mucous membrane of the vaginal part of the cervix, a triangular flap is separated, facing down. The incision is circularly continued around the entire neck at the level of healthy tissues through a lateral rupture. The old lateral rupture of the cervix at 9 o'clock is wedge-shaped excised. The flaps of the mucosa are separated from the neck, are 2 rectangular flaps of different sizes, one side facing the vagina. The bladder is separated up. The altered part of the cervix is amputated by a cone towards the internal pharynx. The refreshed side incision at 9 o'clock is sutured with single-row single seams. The cardinal ligaments are dissected, ligated, stitched together in front of the uterus. The cervical mucosa is formed using previously separated flaps. Sutures are laid as follows. The first injection was made departing 0.5 cm from the outer corner of the flap, then the ligature was drawn from the cervical canal through the entire thickness of the neck tissue to the mucous membrane with a puncture 2 cm higher and somewhat outward from the first injection. The other end of the same ligature was inserted into the needle and the ligature was repeated next to the first using a neighboring flap of the mucosa. The ends of the ligature are interconnected. Thus, the leaves of the separated mucosa were partially screwed into the cervical canal and connected to each other at 12 o’clock. In the same way, a seam was made in the region of 9 hours. The mucous membrane completely screwed into the cervical canal, the second connection of the edges of the mucosa turned out at 9 o’clock. Then anterior and posterior colporography with perineolevatoroplasty was performed. The postoperative period was uneventful. Healing of the perineal skin by primary intention. The condition of the cervix was evaluated after 1.5 months when examined in the mirrors and colposcopic examination. The cervix is cylindrical in shape, of normal length, macroscopically healthy, the external pharynx is punctate. Colposcopy - uniform staining with Lugol's solution.

 Example 2. Patient I., 30 years old, East. 4361. I came to the hospital with a diagnosis of Elongation, cervical deformity, eroded ectropion, uterine prolapse. Poor pelvic floor muscle failure.

 Complaints of sexual dysfunctions, persistent profuse mucous discharge from the genital tract.

 A history of 2 births, 2 medical abortions. During the first birth - a rupture of the cervix of the 2nd degree, a large fetus. After the second birth, diathermoconization of the cervix without effect.

 Objectively, when examined in mirrors, colposcopic examination, bimanual examination: the genital gap is gaping, the uterus is omitted, the cervix is elongated, deformed by old tears at 11 and 5 hours, after diathermoconization around the external pharynx of the cervix is performed, a crater-like eroded surface 1 cm in diameter.

 Passed a clinical laboratory examination. Plastic surgery is indicated. Given the totality of clinical data, the operation was performed by our proposed method. At 1.5 cm below the external opening of the urethra from the anterior wall of the vagina and the mucous membrane of the vaginal part of the cervix, a triangular flap is separated, facing down. The incision is circularly continued around the neck at the level of healthy tissues through the gaps. The edges of the old cervical ruptures at 11 and 5 hours are wedge-shaped excised. The left edge of the cervical mucosa, which remained after the triangular flap separation, and the left edge of the excised gap at 11 o'clock coincided. The flaps of the mucosa are separated from the neck, are 2 rectangular flaps of different sizes, facing one side of the vagina. The bladder is separated up. The altered part of the cervix is amputated by a cone facing the internal pharynx. The muscle tissue of the freshened edges of the gaps at 11 and 5 hours is sutured with single single-row sutures. The cardinal ligaments are dissected, ligated and stitched together in front of the uterus. The cervical mucosa is formed using previously separated flaps. Sutures are laid as follows. The first injection was made by departing 0.5 cm from the outer corner of the flap, then the ligature was drawn from the cervical canal through the entire thickness of the cervical muscle tissue to the mucous membrane of the cervix with a puncture 2 cm higher and somewhat outward from the first injection. The other end of the ligature is inserted into the needle and the course is repeated next to the first, using the adjacent flap of the mucosa. The ends of the ligature are interconnected. Thus, the leaves of the separated mucosa were partially screwed into the cervical canal and connected to each other at 12 o’clock. In the same way, a suture was made in the region of 5 hours. The mucous membrane completely screwed into the cervical canal, the second connection of the edges of the mucosa turned out at 5 o’clock. Then the anterior and posterior colporography with colpoperineolevatoroplasty was performed.

 The postoperative period without complications. Healing of the perineal skin by primary intention. The condition of the cervix was evaluated after 1.5 months when examined in the mirrors and colposcopically. Macroscopically, the neck is cylindrical in shape, of normal length, the external pharynx is spotted, and colposcopically - uniform staining with Lugol's solution.

 With the combination of elongation, cervical deformation with old deep gaps, eroded ectropion, prolapse or incomplete prolapse of the uterus, the method of surgical treatment we have proposed is optimal for women of reproductive age, as it helps to restore the specific functions of the female body. At the same time, the neck restored according to our technique looks macroscopically healthy, maintains a normal length, which cannot be achieved using other techniques with combined pathology. Thanks to the gentle and rational technique for excising the mucous flaps and muscle tissue of the cervix, this operation eliminates the shortening of the cervix, the method of forming the mucous membrane of the cervix excludes narrowing and contraction of the cervical canal.

 This method operated on 7 patients with positive immediate and long-term results.

Claims (1)

 A method for the surgical treatment of prolapse and incomplete prolapse of the uterus with elongation and deformation of the cervix by deep tears by performing anterior colpography, dissection and stitching of the cardinal ligaments in front of the uterus, formation of the cervix, posterior colporography with perineoleuroplasty, characterized in that the triangular flap of the mucosa is separated from the vagina on the outer surface of the cervix, the incision is circularly continued around the entire cervix through the gaps, the edges of the gaps are tapered out wedge-shaped, then about rectangular flaps of the mucosa are milled, one side facing the vagina, the affected part of the cervix around the external pharynx of the cervix is excised with a cone facing the internal pharynx, the sutures are laid in layers first on the muscle tissue of the freshened edges of the gaps, then the mucosa is formed, when suturing the mucosa is used adjacent flaps, sutures begin to be applied, departing 0.5 cm from the outer corner of the flap, then the end of the ligature is carried out from the cervical canal through the entire thickness of the muscle tissue of the neck to otepar the mucous neck mucosa 1.5-2 cm higher and somewhat outward from the first injection, then the other end of the same ligature is inserted into the needle and the ligature is repeated next to the first using a neighboring flap, then the ligature ends are connected to each other, resulting in lateral the edges of the separated flaps are connected radially at 12 o'clock and at the site of the former breaks, and the outer edges of the flaps are tucked into the cervical canal.

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