RU2269310C1 - Method for reconstructing rectovaginal septum at prolapse or descensus of posterior vaginal wall and rectocele - Google Patents

Abstract

FIELD: medicine, gynecology.

SUBSTANCE: one should cut and remove a triangular fragment out of posterior vaginal wall, perform longitudinal median incision of vaginal wall from the top of separated triangle up to posterior arch, maximally separate vaginal walls laterally towards pelvic walls at opening a rectovaginal fascia, dissect opened rectovaginal fascia in longitudinal direction and separate it against anterior wall of rectum up to lateral walls, suture in anterior wall of rectum with either one or two purse-string sutures, remove rectocele at returning the rectum into natural anatomical borders, fix the netting out of super-elastic titanium nickelide ligature with separate sutures to restored anterior wall of rectum along the whole rectovaginal septum by capturing lateral walls of rectum, restore rectovaginal fascia with adjacent muscular elements with separate sutures, isolate and suture anus-lifting muscles and muscular-fascial foundation of perineum, suture the edges of vaginal wound, subcutaneous layer and perineum skin. The suggested innovation enables to restore normal anatomotopographic position of anterior wall of rectum and posterior vaginal wall, as well and prevent the relapse of posterior vaginal wall descensus and rectocele.

EFFECT: higher efficiency of reconstruction.

9 dwg, 2 ex

Description

The invention relates to medicine, namely to urogynecology.

The problem of prolapse and prolapse of the vagina and uterus remains relevant for many years. According to most authors, the results of surgical treatment of genital prolapse are far from satisfactory. Despite the variety of proposed methods of surgical treatment, relapses persist, which is associated with the failure of the restored muscles of the pelvic floor and with the imperfection of the surgical treatment [Surgical gynecology / Ed. V.I. Kulakova. - N. Novgorod: Publishing House NMGA, 1999. - S.285].

The main reason for the prolapse and prolapse of the posterior vaginal wall, the formation of rectocele in women is birth trauma [Surgical gynecology / Rembez I.N. - 2nd ed., Revised. and add. - K .: Health'ya, 1985. - P.138.]. Damage occurs (tears and tears) of the rectovaginal fascia, muscle and connective tissue elements connecting the fascia with the rectum and back wall of the vagina, as well as the perineum and levator legs. Rectovaginal fascia loses its functional anatomical and topographic perfection, laid down by nature, and ceases to play the role of a functional support for the vagina and rectum. Under the action of intra-abdominal and intrarectal pressures, the rectovaginal fascia is overstretched along the midline, which leads to the prolapse and prolapse of the posterior wall of the vagina and the anterior wall of the rectum with the formation of rectocele. This is facilitated by a decrease in estrogen levels in menopause. As a result of prolonged "wearing" of a hernia in the rectovaginal septum, significant muscle diastases, atrophy and rigidity of the latter occur. The fascial frame is overstretched, thinned, loses strength and the ability to secure adhesion after surgical reconstruction.

Prolapse along with the vagina of the anterior rectal wall (rectocele) is often accompanied by rectal dysfunction (constipation, gas incontinence, hemorrhoids, etc.). The rectovaginal septum ceases to be a support for the posterior wall of the vagina and the anterior wall of the rectum, which contributes to their prolapse and prolapse. The failure of the pelvic floor muscles is formed. Therefore, in the surgical treatment of prolapses and prolapses of the female internal genital organs, reconstruction of the rectovaginal septum and perineum (colpoperineoplasty) is of paramount importance [Khirsch H.A., Kezer O., Ikle F.A. Operative gynecology: Atlas: Per. from English / Ed. V.I. Kulakova, I.V. Fedorova.- M .: GEOTAR MEDICINE, 1999. - P.243; Aminev A.M. Proctology Guide. - Kuibyshev Book Publishing House, 1971. - V.2. - S.448-449].

The omission of the posterior wall of the vagina and the anterior wall of the rectum in combination with rectocele is an indication for surgical treatment.

The most common method for surgical treatment of prolapse and prolapse of the posterior vaginal wall and rectocele is posterior colporography (colpoperineorography) with levatoroplasty. The main goal of the operation is to restore normal anatomical relationships. In this regard, the most important is not the choice of a refreshment figure (triangular, anchor or otherwise), but the suturing of deep muscular-fascial formations of the pelvic floor, i.e. m. levator ani and its fascia, as well as fascia of the vagina and rectum [Multivolume guide to obstetrics and gynecology. - M: Medgiz, 1961. - T.VI. - Book 2. - P.527]. During this operation, defects in the muscles and fascia of the rectovaginal area are restored.

A known variant of colpoperineorography with suturing of the fascia of the vagina and rectum. From the back wall of the vagina, a triangular flap is cut out and removed. The edges of the vagina are maximally separated to the sides of the walls of the pelvis, exposing the rectovaginal fascia. After that, immersion sutures are placed on the rectovaginal fascia. The second tier of sutures is applied to the selected muscles that raise the anus and the muscular-fascial basis of the perineum. The third tier of sutures sutures the edges of the vaginal wound. The subcutaneous layer and several sutures of the perineal skin are sutured with a continuous suture [Chukhrienko DP, Lyulko AV, Romanenko NT Atlas of urological operations. - Kiev: Vishka school. Head Publishing House, 1981. - S.286-288].

The disadvantage of this method is:

- high relapse rate [Aminev A.M. Proctology Guide. - Kuibyshev Book Publishing House, 1971. - V.2. - S.449].

The main causes of disease recurrence after surgical reconstruction of the rectovaginal septum by restoring damaged tissues are:

- trophic processes in the tissues adjacent to the rectum, muscles, fascia, the anterior wall of the vagina remain unchanged;

- the hormonal background before and after the operation remains the same;

- intra-abdominal and intrarectal pressure before and after surgery practically does not change and is often elevated;

- non-compliance by patients with recommendations for the prevention of disease recurrence (diet, light labor, therapeutic exercises, wearing a bandage, physiotherapy, etc.).

Object of the invention: restoration of the normal anatomotopographic position of the anterior rectal wall and posterior vaginal wall, prevention of recurrence of prolapse of the posterior vaginal wall and rectocele after surgical correction of prolapse of the posterior vaginal wall and anterior rectal wall.

The task is achieved by the fact that they carry out the reconstruction of the rectovaginal septum with the prolapse and prolapse of the posterior wall of the vagina in combination with a rectocele. A triangular flap is cut out and removed from the posterior wall of the vagina. From the top of the separated triangle, a longitudinal midline section of the vaginal wall is made to the posterior fornix. Make the maximum separation of the vaginal wall to the sides of the pelvic walls with exposure of the rectovaginal fascia. The exposed rectovaginal fascia is dissected in the longitudinal direction and is separated from the anterior wall of the rectum to the side walls. The front wall of the rectum is sutured with one or two purse-string sutures and rectocele is removed with the rectum returning to the natural anatomical borders. A mesh of superelastic titanium nickelide filament with capture of the side walls of the rectum is fixed to the restored front wall of the rectum throughout the entire rectovaginal septum with separate sutures. Rectovaginal fascia with adjacent muscle elements is restored with separate sutures. The muscles that raise the anus and the muscular-fascial basis of the perineum are isolated and sutured. Suture the edges of the vaginal wound, subcutaneous layer and perineal skin.

The novelty of the method:

- for the first time, the reconstruction of the rectovaginal septum during the prolapse and prolapse of the posterior vaginal wall with the formation of a rectocele is performed using reinforcement of the anterior rectal wall with a mesh of ultrafine titanium nickelide;

- the mesh of ultrafine titanium nickelide filament has high elasticity, is able to repeat the shape of any surface without preliminary deformation, which allows you to fix not only the restored front wall of the rectum throughout the rectovaginal septum, but also the side walls of the rectum, which significantly increases the area of the strengthened rectovaginal septum in its weakest department.

Using the proposed method, we obtain the following effect:

- a network of ultrafine filaments of titanium nickelide has a shape memory effect and, when the rectum is filled with feces under the influence of increasing intrarectal pressure and with its subsequent emptying, participates in all deformation processes of the tissues surrounding it, providing reliable strength of the formed rectovaginal septum;

- superelasticity of the titanium nickelide filament allows you to save the strength of the mesh with repeated deformations;

- the use of a mesh of ultrafine filament of titanium nickelide during reconstruction of the rectovaginal septum eliminates injury to surrounding tissues during their fusion;

- the use of an implant in the form of a mesh of titanium nickelide filament allows reconstructing the vesicovaginal septum during relapses, huge sizes of the rectocele, and the impossibility of suturing the rectovaginal fascia as a double-breasted coat.

Titanium nickelide is referred to as biomechanical materials. It meets the following requirements: high corrosion resistance; slight elution of the alloy ingredients; electrochemical stability; lack of biological problems (toxicity, carcinogenicity, discomfort); affinity for body tissues; the presence of high mechanical properties (hardness, elasticity, low fatigue, abrasion); elasticity similar to the elasticity of living tissues [Zotov V.A. Treatment of patients with complex ventral hernias using titanium nickelide // Implants with shape memory. - Tomsk, 2000. - No. 1-2. - S.111].

It has been experimentally established that titanium nickelide products are easily disinfected and sterilized, do not have toxicity, do not have a carcinogenic effect, are biologically compatible with the tissues of the human body [Gunter V.E., Dambaev G.Ts. Ts., Sysolyatin P.G., Ziganypin R. AT. et al. Medical materials and shape memory implants. - Tomsk: Publishing house of Tomsk University, 1998. - S.168-193]. Porous titanium nickelide implants germinate well with soft tissues and acquire the elastic properties of these tissues [Dambaev G.Ts., Gunter V.E., Rodionchenko A.A., Itin V.I. et al. Porous permeable implants in surgery. - Tomsk: Publishing house of TPU, 1999. - S.116-119].

A mesh of titanium nickelide was used as an implant. Mesh dimensions: width 4-5 cm, length 5-7 cm. It was prepared before surgery by weaving a strand with a diameter of 0.01 mm with a mesh size of 3-5 mm. The mesh of titanium nickelide filament (brand TN-10) does not absorb, does not interfere with the growth of adjacent rectal tissues and the surrounding muscle-fascial elements with rectovaginal fascia. Fused with surrounding tissues, the mesh ensures the stability of surrounding tissues to excessive deformation. It takes on the main function of the rectovaginal fascia, providing functional support for the anterior wall of the rectum and the posterior wall of the vagina and ensures the stability of the vesicovaginal septum to the effects of intrarectal and intraperitoneal pressures.

Thus, the reconstruction of the rectovaginal septum with the reinforcement of the reconstructed anterior rectal wall with a mesh of titanium nickelide during surgical treatment of prolapse of the posterior vaginal wall and rectocele in women is theoretically and experimentally substantiated.

The invention is illustrated by drawings in figures 1-9. Figure 1 shows a grid of titanium nickelide filament (1 - a grid of titanium nickelide). Figure 2 shows the general scheme of the operation (1 - a mesh of titanium nickelide fixed to the restored front wall of the rectum; 2 - sutures on the rectovaginal fascia; 3 - a suture on the back wall of the vagina; 4 - sutures on the skin of the perineum; 5 - rectum ) Figure 3 shows a view of the separated front wall of the rectum covered with rectovaginal fascia (6 - the back wall of the vagina; 7 - the front wall of the rectum). Figure 4 shows the imposition of purse string sutures on the anterior wall of the rectum (6 - posterior wall of the vagina; 8 - purse string sutures on the anterior wall of the rectum; 9 - rectovaginal fascia). Figure 5 shows the fixation of the mesh of titanium nickelide to the restored front wall of the rectum (1 - mesh of titanium nickelide; 6 - back wall of the vagina; 9 - rectovaginal fascia; 10 - sutures that fix the mesh to the rectum). Figure 6 shows the closure of the rectovaginal fascia (2 - sutures on the rectovaginal fascia; 6 - the back wall of the vagina). Figure 7 shows the stitching of the selected muscles that raise the anus (11 - levators; 12 - sutures on the levators). On Fig shows the suturing of the superficial muscle-fascial layer and perineal skin (3 - a seam on the back wall of the vagina; 4 - stitches on the skin of the perineum; 13 - stitches on the surface muscular-fascial elements of the perineum). Figure 9 shows a General view after the reconstruction of the rectovaginal septum (3 - suture on the back wall of the vagina; 4 - sutures on the skin of the perineum).

The method is as follows:

From the back wall of the vagina, a triangular flap is cut out and removed. From the top of the triangle, a longitudinal midline section of the posterior vaginal wall is made to the posterior fornix. The edges of the vaginal wall are separated as far as possible to the sides of the pelvic wall, exposing the rectovaginal fascia (9), which is dissected in the longitudinal direction. Rectovaginal fascia is separated from the overstretched anterior wall of the rectum (7) and the side walls. A rectocele is eliminated with one or two purse string sutures (8), placed on the front wall of the rectum (7). In this case, the rectum (5) returns to its natural anatomical boundaries. Then, to the reconstructed front wall of the rectum throughout the rectovaginal septum, a suture (10) is used to fix a mesh of ultrafine titanium nickelide filament (filament thickness 0.01 mm) 3-5 cm wide and 5-7 cm long with capture of the side walls of the rectum. Rectovaginal fascia (9) with adjacent muscle elements is restored with separate sutures (2). The next tier of sutures (12) is used to suture the selected muscles that lift the anus (11) from Vicryl. The fourth tier of sutures (13) on both sides is captured by muscles and fascia lying more superficially. After economical excision of the excess posterior wall of the vagina, it is sutured (3) to the formed posterior commissure. The subcutaneous layer and several percutaneous skin sutures are sutured with a continuous suture (4).

Clinical example 1.

Patient N., 60 years old, was admitted to the department of planned operative gynecology on March 7, 01 with a diagnosis of Poor pelvic floor muscles of the III degree, incomplete prolapse of the uterus, urethro-, cysto- and rectocele.

On March 13, 01, an operation was performed under epidural anesthesia: urethro-vesicosphincterocolorography, posterior colpoperineorography with levatoroplasty, reconstruction of the rectovaginal septum with reinforcing the anterior rectal wall with a mesh of superelastic titanium nickelide filament.

After the front plastic surgery, the rectovaginal septum was reconstructed. A triangular flap was cut out and removed from the posterior wall of the vagina. From the top of the triangle, a longitudinal midline section of the anterior vaginal wall to the posterior fornix is made. The edges of the vaginal wall are separated as far as possible to the sides of the pelvic walls, rectovaginal fascia is exposed, which was dissected in the longitudinal direction. Rectovaginal fascia is separated from the overstretched anterior wall of the rectum to the side walls. Two purse string sutures placed on the front wall of the rectum eliminated rectocele. In this case, the rectum is returned to its natural anatomical boundaries. Then, a mesh of superelastic titanium nickelide filament (filament thickness 0.01 mm) 5 cm wide and 5 cm long with a capture of the lateral rectal walls is fixed with separate sutures to the restored front wall of the rectum along the entire rectovaginal septum. Rectovaginal fascia with adjacent muscle elements was restored with separate sutures. The next tier of sutures stitches out the selected muscles that raise the anus. The fourth tier of sutures on both sides captured muscles and fascia lying more superficially. After economical excision of the excess posterior wall of the vagina, it is sutured to the formed posterior commissure. The subcutaneous layer and the perineal skin are sutured with a continuous suture.

In the postoperative period, analgesics, antibiotics, and physiotherapy were prescribed. Self urination from the 4th day, stool on the 6th day. The postoperative period was uneventful, healing of sutures by primary intention. Discharged home 02/28/01

Examined in dynamics: after 3, 6, 12, 18, 24 and 36 months. There were no signs of relapse of genital prolapse; the implant did not manifest itself negatively. The woman did not present urogynecological and proctological complaints. According to ultrasound and overview radiographs of the pelvis around the tissue implant of a conventional echostructure. There is no discomfort in the vagina, no perineum, does not live a sexual life.

Clinical example 2.

Patient D., 69 years old, was admitted to the department of planned operative gynecology on 02/19/01 with a diagnosis of relapse of rectocele after plasty of the pelvic floor muscles due to insolvency of the pelvic floor muscles of the third century, urethro-, cysto-and rectocele, incomplete prolapse of the uterus, dysfunction bladder and rectum.

02.22.01, an operation was performed under epidural anesthesia: posterior colpoperineorography with levatoroplasty, reconstruction of the rectovaginal septum with reinforcement of the anterior rectal wall with a mesh of superelastic titanium nickelide filament.

A triangular flap was cut out and removed from the posterior wall of the vagina. From the top of the triangle, a longitudinal midline incision is made of the anterior vaginal wall to the posterior fornix. The edges of the vaginal wall are separated as far as possible to the sides of the pelvic walls, rectovaginal fascia is exposed, which was dissected in the longitudinal direction. Rectovaginal fascia is separated from the overstretched anterior wall of the rectum to the side walls. Two purse string sutures placed on the front wall of the rectum eliminated rectocele. In this case, the rectum is returned to its natural anatomical boundaries. Then, a mesh of superelastic titanium nickelide filament (filament thickness 0.01 mm) with a width of 5 cm and a length of 7 cm with a capture of the side walls of the rectum was fixed with separate sutures to the restored front wall of the rectum along the entire rectovaginal septum. Rectovaginal fascia with adjacent muscle elements was restored with separate sutures. The next tier of sutures stitches out the selected muscles that raise the anus. The fourth tier of sutures on both sides captured muscles and fascia lying more superficially. After economical excision of the excess posterior wall of the vagina, it is sutured to the formed posterior commissure. The subcutaneous layer and the perineal skin are sutured with a continuous suture.

In the postoperative period, analgesics, antibiotics, and physiotherapy were prescribed. Self urination from 1 day, stool on the 6th day. The postoperative period was uneventful, healing of sutures by primary intention. Discharged home 03/11/01

Examined in dynamics: after 3, 6, 12, 18, 24 and 36 months. There were no signs of recurrence of genital prolapse, the implant does not manifest itself negatively. The woman did not present urogynecological and proctological complaints. According to ultrasound data and survey radiographs of the pelvis around the tissue implant of a conventional echostructure. There is no discomfort in the vagina and perineum. Sex life does not live.

Thus, 5 patients aged 39-69 years with a failure of the muscles of the pelvic floor III tbsp. in combination with cysto and rectocele, dysfunction of the bladder and rectum. All operated on control examinations had no signs of recurrence of prolapse of the posterior wall of the vagina and rectocele. The implant did not manifest itself negatively, was well visualized on echo and radiographs.

Using this method gives the following effect:

1. A strong support is created for the posterior wall of the vagina and the anterior wall of the rectum, protecting them from damage (repeated tears and overstretching) under conditions of increased intra-abdominal and intravesical pressure.

2. The size and shape of the implant used, its ability not to interfere with the accretion of adjacent tissues, allows to recreate the lost function of the rectovaginal septum to be a support for the posterior vaginal wall and the anterior rectal wall and reliably eliminate prolapse of the anterior vaginal wall and rectocele.

3. Girth of the anterior wall of the rectum to the side walls and tissues supporting them ensures the strengthening of the muscles of the pelvic floor as a whole.

4. Increases the effectiveness of the posterior colpoperineorography, which allows to abandon its more complex and traumatic options while eliminating the prolapse and prolapse of the posterior vaginal wall and rectocele.

5. Allows you to abandon additional methods of fixing the anterior wall of the rectum of the posterior wall of the vagina, even with severe rectocele.

Claims (1)

A method for reconstructing a rectovaginal septum during lowering and prolapse of the posterior vaginal wall and rectocele, including cutting and removing a triangular flap from the posterior vaginal wall, maximizing the vaginal wall to the sides of the pelvic wall with exposing the rectovaginal fascia, suturing it, securing and suturing muscles, raising the anus, and the muscular-fascial basis of the perineum, suturing the edges of the vaginal wound, subcutaneous layer and perineal skin, characterized in that it is cut off from the top of the triangle make a longitudinal midline incision of the vaginal wall to the posterior fornix, exposed rectovaginal fascia is dissected in the longitudinal direction and separated from the anterior wall of the rectum to the lateral walls, the anterior wall of the rectum is sutured with one or two purse string sutures and the rectocele is removed with the rectum returning to the natural anatomical boundaries, to the restored anterior wall of the rectum throughout the rectovaginal septum with separate sutures fix a net of light elastic It is titanium nickelide with the capture of the lateral walls of the rectum, with separate sutures, the rectovaginal fascia with adjacent muscle elements is restored.

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