RU2212860C1 - Method for treating rectocele and vaginal prolapse - Google Patents

Abstract

FIELD: medicine, gynecology, proctology. SUBSTANCE: one should carry out posterior colpotomy. Posterior vaginal wall is dissected as triangular fragment with its top towards the depth. Sacraluterine ligaments are opened. Trapezoid surgical netting is introduced with its foundation towards the depth, fixed to sacral-uterine ligaments in the site of their branching and to anterior rectal wall, to anus- lifting muscles, to anterior semicircumference of sphincter. Netting should be sutured up to edges of posterior vaginal wall. Vaginal excess is resected. The present method enables to strengthen rectovaginal septum. EFFECT: higher efficiency of therapy. 1 ex

Description

 The invention relates to medicine, namely to gynecology and proctology, and can be used in the practice of surgical, gynecological, proctological hospitals.

 There are various methods of surgical treatment of rectocele and prolapse of the posterior wall of the vagina. In particular, the method of sacro-spinal fixation of a lobed uterus (Operative gynecology. Atlas. Editor-in-chief V. Kulakov, prof., Academician of the Russian Academy of Medical Sciences H. Hirsch, O. Kozer, F. Ikle. Moscow, GEOTAR MEDICINE, 1999, p. . 269).

 The disadvantage of the described analogue is that over time, the stitched sacro-uterine ligaments weaken, overstretch due to trophic changes, which leads to the re-development of rectocele and prolapse of the genitals.

 The closest set of essential features to the claimed invention is a method of treating prolapse of the posterior wall of the vagina and rectocele, taken by the authors as a prototype - surgery for rectocele (Proctology. V.D. Fedorov, Yu.V. Dultsev. - M .: Medicine, 1984, p. 134).

 The prototype and the claimed invention have the following essential features: a posterior colpotomy is performed, consisting of excising the posterior wall of the vagina in the form of a triangular flap with the apex facing in depth, excretion of the muscles that raise the anus, posterior colporography and anterior sphincterolevator.

 The disadvantage of the prototype is that in order to achieve the desired effect, it is impossible to carry out levoroplasty in a sufficient volume due to levator atrophy in the elderly and large diastasis, as a result of which the percentage of relapses is high, and in young people excessive convergence of levators and too high a crotch after reconstruction can become the cause of dyspareunia.

 The invention is aimed at solving the problem of developing a method for treating rectocele and lowering the posterior wall of the vagina.

 The solution to this problem provides the strengthening of the rectovaginal septum, which allows combined treatment of rectocele and prolapse of the posterior vaginal wall and prevents the development of relapses, thereby reducing treatment time, eliminating functional disorders of the rectum, and improving the quality of life.

 To achieve this technical result, the claimed invention of a method for treating rectocele and lowering the posterior wall of the vagina includes the following essential features: treatment of rectocele and lowering the posterior wall of the vagina is carried out by introducing the alloplastic material of the polypropylene artificial surgical mesh in the region of the opened rectovaginal septum with further fixation to the sacro-uterine ligaments in places of their discharge and along these ligaments, to the front wall of the rectum, on the sides to the muscles, under cerned anus, the sphincter to the front semicircle. After cutting and separating from the posterior wall of the vagina a triangular flap with the apex facing in depth (according to Geghar) and isolating the muscles that raise the anus, the sacro-uterine ligaments are exposed and the alloplastic material is inserted into the wound - a polypropylene trapezoidal artificial surgical mesh with a wide base directed to the place of discharge of the sacro-uterine ligaments, mesh fixation is carried out at the place of discharge and along these ligaments to the anterior wall of the rectum, on the sides to the muscles that lift behind Nij extending toward the front semicircle sphincter.

 In relation to the prototype, the claimed invention has the following distinctive features: after performing the posterior colpotomy, the sacro-uterine ligaments are exposed, a polypropylene artificial surgical mesh of trapezoidal shape is introduced, the size of which is selected individually, with a large base in depth, fixed with non-absorbable ligatures to the sacro-uterine ligaments in the place of their discharge and along the front wall of the rectum, on the sides to the muscles that raise the anus, to the anterior semicircle sphincter a, the mesh is hemmed to the mobilized edges of the back wall of the vagina with single seams in the longitudinal direction at a distance of 10 mm from each other and at a distance of 6-7 mm from the edge of the mesh, the excess vagina is resected.

 The following causal relationship exists between the distinguishing features and the result: the use of alloplastic material as an operative treatment for rectocele and prolapse of the posterior wall of the vagina leads to the restoration of topographic and anatomical relationships of internal organs, to elimination of functional disorders from the rectum, to prevent the possibility of relapse, and It also contributes to the ability to maintain and restore sexual and sexual function.

 According to the information available to the authors, the set of essential features characterizing the essence of the claimed invention is not known, which allows us to conclude that the invention meets the criterion of "novelty."

 According to the authors, the essence of the claimed invention for a specialist should not be explicitly from a known level of medicine, because it does not reveal the above technical effect, which consists in developing a method for treating rectocele and lowering the posterior wall of the vagina, ensuring the restoration of topographic and anatomical relationships of internal organs, eliminating functional disorders from the rectum, preventing the possibility of relapse, and also contributing to the possibility of preservation and restoration of sexual and sexual function, which allows us to conclude that the criterion of "inventive step" is met.

 The set of essential features characterizing the essence of the invention, in principle, can be used repeatedly in medicine with obtaining a technical result consisting in a more complete restoration of the anatomical, physiological and functional properties of the pelvic organs, which allows us to conclude that the invention meets the criterion of "industrial applicability".

 This method is as follows.

 The operation is performed under general anesthesia, the position of the patient on the operating table is on the back with the lower limbs bent to the sides and bent at the knee and hip joints; silk 5-6 large labia are sutured on both sides to the skin of the perineum, a narrow gynecological lift inserted into the vagina, protecting the urethra and the anterior wall of the vagina, rectovaginal septum from the side of the vagina infiltrate 20-30 ml of 0.25% novocaine solution with the addition of a solution of adrenoline at a rate of 1: 1000, on the border of the perineal skin and the mucous membrane of the vaginal opening in the region of the former posterior commissure, two Kocher clamps are applied, between which an incision is made. Next, the peri-vaginal and periorectal tissue stupidly stratified upwards to the upper third of the vagina, where a Kocher clamp is applied along the middle line to its wall and a triangular flap is cut from the severed posterior wall of the vagina. The edges of the vaginal wound are separated and the muscles that raise the anus and sacro-uterine ligaments are separated. Next, an alloplastic material is introduced into the wound - a trapezoidal prolene flap, with a large base directed in depth, the size of which is selected individually, fix it with non-absorbable ligatures to the sacro-uterine ligaments at the place of their discharge and along the length to the front wall of the rectum, on the sides to the muscles lifting the anus to the anterior semicircle of the sphincter, then the mesh is sutured to the mobilized edges of the posterior wall of the vagina with single seams in the longitudinal direction at a distance of 10 mm from each other and at a distance of 6-7 mm from the edge of the mesh, the excess vagina is resected.

 The method is illustrated by the following examples.

 Example 1. Patient Tekoeva EN, 40 years old, was admitted to the emergency department of the KBSP with complaints of drawing pains in the lower abdomen, frequent constipation, and a sensation of a foreign body in the vagina.

 From the anamnesis it is known: 5 years ago, during a childbirth, obstetric forceps were placed on the patient, the indication for which was persistent secondary weakness of labor activity, as a result, a third-degree perineal rupture occurred. One year after the birth, the described complaints appeared. Gradually, the patient's condition worsened and she was sent for surgical treatment with a diagnosis of genital prolapse, rectocele I st.

 At the time of admission, a vaginal examination revealed: the body of the uterus is normal in size, the external pharynx of the cervix is below the interstinal plane, when straining it does not go beyond the genital gap. Appendages on both sides without features. In the clinic, an operation was performed under endotracheal anesthesia: in the position of the patient for vaginal surgery, the rectovaginal septum was infiltrated from the vagina with a 20-30 mm 0.25% solution of novocaine with the addition of an adrenaline solution at a rate of 1: 1000, acute and bluntly delimited near the vaginal and periorectal fiber to the upper third of the vagina, a triangular flap is cut out. The edges of the vaginal wound are separated to the side and the muscles that raise the anus and sacro-uterine ligaments are highlighted. Then, an alloplastic material was introduced into the wound - a trapezoidal polypropylene flap, with a large base directed in depth, the size of which is selected individually, fix it with non-absorbable ligatures to the sacro-uterine ligaments at the place of their discharge and along the length to the front wall of the rectum, on the sides to the muscles raising the anus to the anterior semicircle of the sphincter, then the mesh is sutured to the mobilized edges of the posterior wall of the vagina with single seams in the longitudinal direction at a distance of 10 mm dr ug from each other and at a distance of 6-7 mm from the edge of the mesh, the excess vagina is resected. Blood loss - 100 ml. The duration of the operation is 40 minutes.

 The postoperative period without complications, suture healing by first intention. On the 10th day after the operation in satisfactory condition, the woman was discharged home.

 For 2 years after the operation, the woman's condition is satisfactory, there is no relapse. Performs physical activity.

 The proposed method is technically simple, does not violate the correct position of the uterus, firmly strengthens the rectovaginal septum, does not cause disturbance of blood and lymph circulation of the pelvic organs, completely prevents the occurrence of rectocele relapses and prolapse of the posterior wall of the vagina, does not violate the function of adjacent organs, and remains functional.

Claims (1)

 A method of treating rectocele and vaginal prolapse by performing posterior colpotomy, which consists in excising the posterior vaginal wall in the form of a triangular flap with the apex facing in depth, isolating the muscles that raise the anus, posterior colporography and anterior sphincteroleoplasty, characterized in that after the posterior colpotomy is exposed sacro-uterine ligaments, a polypropylene artificial surgical mesh of a trapezoidal shape is introduced, the size of which is selected individually, with a large base in depth, fix it with non-absorbable ligatures to the sacro-uterine ligaments at the place of their discharge and along the front wall of the rectum, on the sides to the muscles that raise the anus, to the anterior semicircle of the sphincter, the mesh is sutured to the mobilized edges of the posterior wall of the vagina with single seams in the longitudinal direction at a distance of 10 mm from each other and at a distance of 6-7 mm from the edge of the mesh, the excess vagina is resected.