RU2235517C1 - Method for correcting descensus and partial prolapse of internal genital organs - Google Patents

Abstract

FIELD: medicine, gynecology.

SUBSTANCE: the method deals with vaginal access, incision of anterior vaginal wall and its separation by opening lateral walls of uterine cervix and cardinal ligatures from both sides. Moreover, one should form paraurethral canals behind patient's pubis so, that the angle between canal's direction and symphysis should be 30-40 deg. from each side. Through the canals developed one should apply ligatures out of nonabsorbable material. Then one should withdraw and fix the middles of ligatures above aponeurosis of external oblique muscles of abdomen in suprapubic area from each side. The ends of ligatures should be left free in vaginal wound from both sides. One free end is applied to suture up alternately cardinal ligatures from the side of vaginal wound. Then, under visual control, one should tighten and bind these ends together by tightening uterus by aponeurosis. Then anterior vaginal wall should be restored.

EFFECT: decreased traumaticity and risk for relapses.

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Description

The invention relates to medicine, in particular to operative gynecology, and is intended for the surgical correction of prolapse and incomplete prolapse of the internal genital organs.

Closest to the technical nature of the proposed method is a method of correcting the prolapse and incomplete prolapse of the internal genital organs, proposed by Donald and improved Fothergrill from Manchester (Operative Gynecology Hirsch X .; Keser O .; Ikle F. 1999, p. 258-261), which received the name Manchester operation. The principle of operation is to amputate the elongated and lowered cervix, shortening and fixing the cardinal ligaments to the anterior wall of the cervix, which helps to raise and displace the cervix posteriorly, and the body of the uterus anteriorly. The last component is the front colporography. If necessary, you can also apply rear colporography. During this operation, a transverse incision is made using a scalpel at the level of the cystic fold, the front wall of the vagina is separated laterally, the supravaginal septum, the vesicoureteral ligaments cross, moving the bladder up. A circular incision on the cervix is performed laterally and posteriorly. Then the cervix is amputated with a scalpel, followed by suturing. The cardinal ligaments on both sides intersect, bandage and hem to the front of the cervix. When tying the sutures, the stump of the cervix should be pulled up and back, and the uterus from the position of retroflexion move to the position of anteflexia.

The disadvantage of this known method is the high morbidity and risk of hematomas associated with the intersection of the cardinal ligaments together with the descending branches of the uterine vessels, an increase in the duration of the operation and hospital stay. In addition, during this operation, a partial amputation of the cervix is performed, which can lead to the development of cervical stenosis, infertility or premature termination of pregnancy in patients of childbearing age. According to literature data after the Manchester operation, the recurrence rate of genital prolapse varies widely. Moreover, the best results of up to 3% were obtained by domestic authors (Glebova N.N., Vekhnovsky V.O. In the book: Diagnosis and reconstructive surgical treatment of diseases of the female reproductive system. M., 1988, p. 58-62).

The objective of the invention is a method of correcting the prolapse and incomplete prolapse of the internal genital organs, which has less trauma and the risk of relapse.

The problem is solved by correcting the prolapse and incomplete prolapse of the internal genital organs in women by cutting and separating the front wall of the vagina with exposure of the side walls of the cervix and cardinal ligaments on both sides, the formation of paraurethral canals behind the fold, so that the angle between the direction of the channel and the symphysis amounted to 30-40 ° on each side, passing through the formed channels of ligatures from non-absorbable material, removing and fixing the middle of the ligatures over the aponeurosis of the external braids of the abdominal muscles in the suprapubic region on each side, leaving the free ends of the ligatures in the vaginal wound on both sides, alternately stitching the cardinal ligaments from the side of the vaginal wound with one of the free ends of the ligatures, pulling and binding the ends of each ligature to each other under visual control, hanging the uterus behind aponeurosis followed by restoration of the anterior vaginal wall.

If necessary, additional posterior colporography with levator- and perineoplasty is additionally performed according to the usual method.

Clinical example 1

Patient K., 32 years old, came to the ward complaining of discomfort in the perineum, drooping vaginal walls with coughing and sneezing. These complaints are noted 3 years after the second birth, accompanied by tears of the perineum of the II degree. Concussions, injuries, neurological diseases no. The sensitivity of the perineum is preserved.

With vaginal examination: the external genitalia are developed correctly. When straining marked omission of the anterior wall of the vagina. When coughing and straining, there is no leakage of urine. The cervix is not eroded, cylindrical, not deformed. The body of the uterus is rejected anteriorly, not enlarged, mobile, painless on palpation and displacement. Appendages on both sides are not palpable, their areas are painless.

Additional examination: clinical and laboratory data within normal limits, ultrasound examination without features, x-ray examination with a metal marker - I-II degree of genital prolapse.

Diagnosis: Poor pelvic floor muscle failure. The prolapse of the walls of the vagina.

Hysterosuspension for aponeurosis by vaginal access was performed.

Operation progress:

Under aseptic conditions, 1.5-2 cm from the external opening of the urethra, a midline incision was made and the front wall of the vagina was separated from the underlying tissues, the side walls of the neck and cardinal ligaments on both sides were exposed. With the help of water separation, the channels behind the bosom are paraurethrally formed, so that the angle between the direction of the channels and the symphysis is 30-40 °. Non-absorbable ligatures are sequentially passed through the channels with a titanium stop in the middle in the direction from the bottom up, which are brought out above the aponeurosis in the suprapubic region using a hollow metal inflexible conductor with a thread pusher. The cardinal ligaments of the uterus are stitched with free ends of the ligatures on both sides, after which, under visual control, the uterus is suspended by the aponeurosis of the external oblique muscles of the abdomen and the ends of the ligatures are connected. The anterior vaginal wall is restored with separate catgut sutures. Blood loss 50 ml.

The postoperative period was uneventful. Discharged home on the fifth day after surgery. Healing of sutures on the vaginal wall by primary intention. Examined after 1 and 6 months after surgery. At each visit, a vaginal examination, ultrasound and x-ray with a metal marker were performed.

1 examination (1 month after surgery).

The woman does not complain. With vaginal examination: the external genitalia are developed correctly. With a strong cough and straining, prolapse of the walls of the vagina is not observed, there is no leakage of urine. The cervix is not eroded, cylindrical, not deformed. A scar on the wall of the vagina without features. The body of the uterus is rejected anteriorly, not enlarged, mobile, painless on palpation and displacement. Appendages on both sides are not palpable, their areas are painless. Palpation of paraurethral areas is painless. Ultrasound examination without features. X-ray examination with a metal marker at rest and during straining - the degree of genital prolapse is 0.

2 examination (6 months after surgery).

The patient does not complain. Vaginal examination: with severe coughing and straining without features. Palpation of paraurethral areas is painless.

The observation period of the patient is 6 months.

Clinical example 2

Patient N., 34 years old, was admitted to the department complaining of a foreign body sensation in the perineum. These complaints are noted during the last two years after childbirth, accompanied by a rupture of the walls of the vagina and perineum, II tbsp. Concussions, injuries, neurological diseases no. Sensitivity in the perineum saved.

With vaginal examination: the external genitalia are developed correctly. The sex gap gapes, the legs of the levators parted. When straining and coughing, there is a prolapse of the anterior and posterior walls of the vagina and incomplete prolapse of the uterus, no urine leakage. Cystocele and rectocele. The cervix is not eroded, cylindrical, not deformed. The body of the uterus is rejected anteriorly, not enlarged, mobile, painless on palpation and displacement. Appendages on both sides are not palpable, their areas are painless.

Additional examination: clinical and laboratory data are within normal limits, there are no urological disorders. Ultrasound examination without features. X-ray examination with a metal marker revealed II-III degree of prolapse.

Diagnosis: Poor pelvic floor muscle failure. Incomplete prolapse of the uterus. Cystocele. Rectocele.

Surgical treatment was performed: hysterosuspension for aponeurosis by vaginal access. Front kolporrafiya. Colpoperineorography with levatoroplasty.

Operation progress:

Under aseptic conditions, 2 cm away from the external opening of the urethra, a midline section of the anterior vaginal wall was made, its and bladder were separated from the underlying tissues, the side walls of the cervix and cardinal ligaments were exposed on both sides. With the help of water separation, channels are formed paraurethrally behind the bosom at an angle of 30–40 ° with respect to the symphysis. Non-absorbable ligatures with a titanium stopper in the middle in the direction from bottom to top were passed through the channels, which were removed above the aponeurosis in the suprapubic region using a hollow inflexible metal conductor with a thread pusher. The cardinal ligaments on both sides were stitched with free ends of the ligatures, after which, under visual control, the uterus was suspended by the aponeurosis and the ends of the ligatures were tied. Then we performed anterior colporography, colpoperineorography with levatoroplasty according to the standard method.

The postoperative period was uneventful. Discharged home on the 6th day after surgery. Healing of sutures on the walls of the vagina and perineum by primary intention. Examined after 1 and 6 months after surgery. At each visit, a vaginal examination, ultrasound and x-ray with a metal marker were performed.

1 examination (1 month after surgery)

The woman does not complain. When a vaginal examination: the external genitalia without features, with severe coughing and straining of the prolapse of the walls of the vagina is not observed, there is no urine leakage. Scars on the walls of the vagina and perineum without features. The cervix is cylindrical, not eroded, not deformed. The body of the uterus is rejected anteriorly, not enlarged, mobile, painless on palpation and displacement. Appendages on both sides are not palpable, their areas are painless. Palpation of paraurethral areas is painless. Ultrasound examination without features. When x-ray examination with a metal marker at rest and when straining, the degree of genital prolapse is 0.

2 examination (6 months after surgery)

The woman does not complain. Vaginal examination: with severe coughing and straining without features. Palpation of paraurethral areas is painless.

The observation period of the patient is 6 months.

Hysterosuspension operation for aponeurosis is performed within 20-30 minutes under general anesthesia. The method was tested in clinical conditions for 18 patients. There were no intra- and postoperative complications. Blood loss during surgery was 30-100 ml. The limitation period of postoperative observation ranged from 3 months to 2 years. All patients feel satisfactory, have no complaints, in no case have the formation of vaginal or suprapubic hematomas, pain, recurrence of prolapse or incomplete prolapse of the internal genital organs, either at rest or during straining and severe coughing, be noted.

Effect: correction of the omission and incomplete prolapse of the internal genital organs, relapse prevention due to reliable fixation in the physiological position of the internal genital organs by selecting the optimal anatomical structures for fixation, reducing the invasiveness of the intervention and preventing postoperative complications by maintaining the integrity of the cervix, cardinal ligaments and descending branches of the uterine vessels.

The proposed method for correcting the prolapse and incomplete prolapse of the internal genital organs helps to reduce the risk of recurrence of the disease, since such strong anatomical structures for fixation as cardinal ligaments and aponeurosis of the external oblique muscles of the abdomen are selected. It was found that for fixation of these structures, vaginal access is optimal, which allows to maintain the integrity of the anterior abdominal wall. In addition, the fixation of cardinal ligaments on both sides of the aponeurosis of the external oblique muscles of the abdomen with the help of non-absorbable ligatures is performed through the paraurethral channels formed behind the bosom, making an angle from 30 to 40 ° with the symphysis, which helps to fix the internal genital organs in a position close to physiological, reduces the likelihood of trauma to the urinary tract and rectus abdominis muscles. However, the proposed correction method allows you to save the genital function and significantly reduce the invasiveness of the operation, since it does not imply amputation of the cervix, the intersection of cardinal ligaments and descending branches of the uterine arteries, unlike the prototype.

Thus, the proposed method has a low morbidity while maintaining the high efficiency of surgical treatment, which allows to improve the quality of life of women while maintaining reproductive function and significantly reduce the risk of a relapse of the disease.

Claims (1)

A method for correcting the prolapse and incomplete prolapse of the internal genital organs in women, including vaginal access, an incision of the anterior vaginal wall and its separation with exposure of the lateral wall of the cervix and cardinal ligaments on both sides, characterized in that they form paraurethral canals behind the womb so that the angle between the direction of the channel and the symphysis was 30-40 ° on each side, ligatures of non-absorbable material are passed through the formed channels, the middle of the ligatures is removed and fixed outside the aponeurosis the oblique muscles of the abdomen in the suprapubic region on each side, leaving the ends of the ligatures free in the vaginal wound on both sides, one of the free ends of the ligatures alternately sutures the cardinal ligaments from the side of the vaginal wound, then under visual control they pull and bind the ends of the ligatures to each other, hanging the uterus for aponeurosis, then restore the front wall of the vagina.