RU2208403C1 - Method for hemostasis at laparoscopic supracervical hysterectomy - Google Patents

Abstract

FIELD: medicine, gynecology. SUBSTANCE: the present innovation deals with carrying out hysterectomy either with removal or saving uterine adnexa. Three endoloops are successively applied onto uterine cervix at 0.5 cm against internal opening. The first endoloop is applied when uterus is on manipulator. Loop is tightened till cyanosis of uterine body is observed. Then the second endoloop is applied. It is tightened after removal of uterine manipulator. After dissecting uterine body the third endoloop is applied. EFFECT: higher reliability of hemostasis. 1 dwg, 1 ex

Description

 The invention relates to medicine, namely to gynecology. It can be used when performing a hysterectomy with the removal or preservation of the uterine appendages.

 Laparoscopic hysterectomy for uterine fibroids was first performed by Harry Rich in January 1988. However, this operation can most likely be considered a laparoscopically assisted hysterectomy, since the removal of the removed uterus was carried out through a colpotomy opening, i.e. surgical technique was associated with the vaginal stage of the operation. The author of the classic abdominal pelvioscopic hysterectomy was the German gynecologist K. Semm in 1991.

 Laparoscopic subtotal hysterectomy was first proposed by T. Lyons in 1990. An open laparoscopic technique is used to accelerate the extraction of the macrodrug at the end of the operation. Currently, most hysterectomies requiring glancing can be performed by laparoscopic access followed by organ harvesting after morcellation.

 With laparoscopic supracervical hysterectomy, a uterine manipulator is used, with which a certain position is given to the uterus (axial displacement, rotational displacement, combined displacement).

 After revision of the abdominal cavity, the ligamentous apparatus is mobilized, the vesicoureteral fold is opened. The bladder is bluntly separated from the anterior wall of the cervix and vaginal wall and displaced down. The posterior leaf of the broad ligament is carefully prepared along the uterine rib, allowing the ureter to move laterally. After the uterine vessels are separated and the ureter is identified, the uterine vessels can be stitched, clipped or coagulated, followed by their intersection.

 The disadvantages of these methods are: slipping clips or teething clipping structures; when flashing, local hemostasis is achieved (only the main vessels); the development of postoperative complications associated with the use of coagulation.

 After occlusion of the considered vascular formations, uterine cyanosis should develop - a criterion for the dissection of vascular formations. The uterus is cut off from the cervix at the level of the internal pharynx or lower, after which the upper part of the cervical canal is excised around the uterine manipulator. After removal of the uterus, a cervical stump is formed. After the end of the main stage of the operation, the abdominal cavity is washed and examined in order to detect signs of bleeding, while reducing intra-abdominal pressure. After this, the uterus is removed from the abdominal cavity. Surgical gynecology - surgical energies. V.I. Kulakov, L.V. Adomyan, O.A. Mynbayev. M.:, Medicine, 2000.

 We set the task to develop a simple, reliable method of hemostasis in laparoscopic supracervical hysterectomy. The technical result consists in increasing the reliability of hemostasis, reducing blood loss due to complete hemostasis with the cessation of blood flow in all vessels supplying the uterus simultaneously without prior isolation.

 The method is carried out in the following way.

 Round ligaments, fallopian tubes and the ovarian ligaments of their own or the funnel-ligamentous ligaments on both sides coagulate with a bipolar and cross. Open the vesicle-uterine fold and move the bladder down. Get access to the uterine vessels. Endo Loops Polysorb-0 are pre-labeled with a sterile marker. Labels are applied at intervals of 0.5 cm.

 We focus on these marks when assessing the degree of loop tightening, determining the necessary circumference of the coverage.

 Through the central trocar pin inject Polysorb-0 endo loop. The first endo loop is applied when the uterus is on the manipulator.

 The body of the uterus is pulled into the pelvis. Using two tools, the loop is straightened. The body of the uterus is maximally fed into the abdominal cavity. A loop is thrown over the body of the uterus using two tools, assisted by a uterine manipulator, and placed 0.5 cm above the internal pharynx. The loop with the formed Roeder assembly is slightly tightened, after which the correct position of the loop is evaluated.

 Evaluation criteria are: the position of the loop 0.5 cm above the level of the internal pharynx, the vesicoureteral fold is below the loop 1.0 cm.

 With an adequate position of the loop, the final tightening is performed.

 Then impose a second endo loop. The uterine manipulator is removed. Tighten the second endo loop so that the circumference of the cervix uteri is less than that of the first loop not less than the circumference of the uterine manipulator.

 After occlusion of the uterine vessels, cyanosis of the uterus should develop - a criterion for dissecting vascular formations. To assess the effectiveness of hemostasis, we conducted a set of studies: intracorporeal ultrasound with Doppler mapping before and after looping.

 The uterus is cut off from the cervix at least 0.8-1.0 cm above the level of the applied loops, after which the upper part of the mucous membrane of the cervical canal is excised with its subsequent bipolar coagulation.

 On the stump of the cervix impose a third third endo loop. Tighten it in such a way that the circumference of the cervix around it is less than that of the second loop by at least half the circumference of the uterine manipulator.

 After the end of the main stage of the operation, the abdominal cavity is washed and examined to identify signs of bleeding, while reducing intra-abdominal pressure. After that, fragmentation and removal of the uterus by a morphicator is performed.

 This technique was tested on a control group of 50 patients.

 An example implementation of the method.

 Nikolaeva Lyubov Viktorovna, 47 years old. Medical history 6676.

 Was in the gynecological department from 11/08/01.no 11/17/01. Clinical diagnosis: plural. uterine fibroids 7-8 weeks. with a submucous arrangement of one of the nodes. Adenomyosis Glandular endometrial hyperplasia. Anemia. Complaints upon admission to heavy menstruation. From the anamnesis: for the first time, uterine fibroids of small sizes were found in 1996. In 1999, the size of fibroids was up to 6-7 weeks, in 2001, 7-8 weeks. According to ultrasound, centripetal growth of the node. On September 28, 01, GS + WFD was produced: a submucous node was revealed in the bottom area up to 1.5 cm in D and a node with centripital growth along the front wall; adenomyosis. Histology 25226-230V01: biopsy w / m: without visible pathology; c / c: scraps of cervical mucosa; p / m: reverse development of the endometrium. Oncocytology 16458-61: b / features. Received outpatiently examined for planned surgical treatment.

 11/12/01. Laparoscopy, supracervical hysterectomy without appendages, with excision and coagulation of the c / channel.

 Under aseptic conditions, under endotracheal anesthesia, at the point under the navel through the Veress needle, pneumoperitoneum in the amount of 2.5 l of CO2 is applied. After introducing a 10 mm trocar into the abdominal cavity, a laparoscope was inserted. 5 mm were introduced into the right iliac region and at the midpoint between the womb and the navel, and 10 mm trocar for the instrument in the left iliac. When revising the abdominal organs, pathology was not detected. When examining the pelvic organs found: the body of the uterus in the middle position, increased to 8 weeks. pregnancy, on the back surface of the interstitial-subserous node up to 6 cm, its serosa with a marble tint. The right ovary with dimensions 3.0 x 3.0 x 2.0 cm, the left ovary 2.5 x 3.0 x 2.0 cm - without pathology. Fallopian tubes on both sides without features.

 Operation progress: round ligaments, fallopian tubes and own ovarian ligaments on both sides are coagulated by a bipolar and crossed. The vesicle-uterine fold is opened and the bladder is shifted down. Got access to the uterine vessels.

Endo Loops Polysorb-0 are marked as follows (see drawing):
The first endo-loop of Polysorb-0 is placed and tightened on the cervix, slightly above the internal pharynx. A second endo loop is applied. The uterine manipulator is removed. Tighten the second endo loop so that the circumference of the cervix around it is less than that of the first loop by 2.0 cm
The radius of the uterine manipulator is 0.3 cm. The circumference of the uterine manipulator is 1.9 cm.

 The uterus is cut off from the cervix 1.0 cm above the level of the superimposed loops, after which the upper part of the mucous membrane of the cervical canal is excised with its subsequent bipolar coagulation.

 On the stump of the cervix impose a third third endo loop. Tighten it in such a way that the circumference of the cervix around it is less than that of the second loop by 1.0 cm.

 The abdominal cavity is washed with saline. Check for hemostasis "water breakdown" with a decrease in intra-abdominal pressure - no ongoing bleeding. The body of the uterus is removed using a marcellator.

 Re-checking for hemostasis is dry. The trocars are removed from the abdominal cavity. Post-laparoscopic openings are sutured by Polysorb 3-0. Aseptic stickers.

 Urine catheter 300 ml - clear. Total blood loss = 50.0 ml.

 The department conducted antibacterial, anti-inflammatory, anti-anemic, detoxification therapy.

 Histology 29185-199. In the endometrium, glandular hyperplasia. In myometrium, endometriosis of the inner layer of the myometrium. Tumor nodes have the structure of fibromyomas with necrosis, the deposition of lime in the necrosis zone.

 Discharged from the hospital in satisfactory condition on the 5th day after the operation under the supervision of a gynecologist at the place of residence.

Claims (1)

 The method of hemostasis in laparoscopic supracervical hysterectomy, including the termination of blood flow through the uterine vessels, characterized in that three endo-loops are sequentially applied to the cervix 0.5 cm above the internal pharynx, while the first endo-loop is applied when the uterus is on the manipulator, and tightened until cyanosis of the uterine body, then impose a second endo loop and tighten it after removal of the uterine manipulator so that the circumference of the cervix around it is less than that of the first etli not less than the length of the circumference of the manipulator, after uterine body clipping endopetlyu superimposed third and tighten it in such a way as to cover the circumference of the cervix it was less than that of the second loop is not less than half the circumference of the uterine manipulator.