RU2275872C1 - Method for surgical treatment of posthysterectomic vaginal prolapse at the background of perineal descensus syndrome - Google Patents

Abstract

FIELD: medicine, gynecology.

SUBSTANCE: one should make an incision of anterior and posterior vaginal wall mucosa by leaving 1.5 cm against external urethral opening and from perineal skin from the back up to the cupola to separate it laterally. Both anterior and posterior vaginal walls should be strengthen with a synthetic netting of cross-shaped form, at the size of longitudinal part being 12x3 cm, and cross-sectional one - 6x1.5 cm, so, that netting's cross-sectional part to be at the level of vaginal cupola. Vaginal fixation to sacro-spinous ligaments should be performed by both ends of cross-sectional strip at moderate tension. The present innovation enables to carry out sacro-spinous vaginal fixation at any vaginal length, moreover, fulfill it from both sides and achieve good functional results.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to surgery.

There is a method of transvaginal fixation of the vagina during its prolapse to the sacrospinous ligaments of the pelvis, including the allocation of the sacrospinous ligament from one side through the perforation hole from the side of the vaginal canal, its stitching and fixation of the dome to it with the same suture (Richter K. Die operative Behandlung des prolabierten Scheidengrundes nach Uterusexstirpation. Ein Beitrag zur Vaginaefixatio sacrotuberalis nach Amreich. Geburtsh. Frauenheilk., 1967; V.27, P.941.). The disadvantage of this method is that the dome of the vagina is pulled sideways. Therefore, some authors recommend attaching the vaginal fornix bilaterally to both sacrospinous ligaments. However, with both modifications, the vagina should be of sufficient length, which is not always observed with post-hysterectomy prolapse (Hirsch H.A., Keser O., Ikle F.A. Operative gynecology: Atlas: Translated from English. Ed. By V.I. Kulakova, I.V. Fedorova. M.: GEOTAR MEDICINE, 1999; P.266-269; Cespedes RD Anterior approach bilateral sacrospinous ligament fixation for vaginal vault prolapse. Urology, 2000; 56 (6 Suppl. 1): 70-75 ; Maher CF, Murrey CJ, Carey MP, Dwyer PL, Ugoni AM Iliococcygeus or sacrospinous fixation for vaginal vault prolapse. Obstet. GynecoL, 2001; 98 (I): 40-44). One of the drawbacks of surgery is considered to be an increased risk of developing cystocele in approximately 21% of patients (Colombo M., Milani R. Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Am. J. Obstet. GynecoL, 1998; V.179 No. 1, P.13-20). The relapse rate according to these and other authors is about 8% (Brieger G.M., MacGibbon A.L., Atkinson K.H. Sacrospinous colpopexy. Aust. N. Z. J. Obstet. GynecoL, 1995; V.35, No. 1, P.86-87).

The technical result of the invention is the ability to fix the vagina of any length, including the short vagina, to the sacro-spinous ligaments on both sides, while strengthening and raising the perineum, reducing the percentage of relapses.

The technical result is achieved due to the fact that the fixation of the vaginal arch to both sacro-spinous ligaments is carried out through an incision of the mucous membrane of the anterior and posterior vaginal walls in the midline, 1.5 cm indent from the external opening of the urethra in front and from the perineal skin at the back to the dome with its separation to the side, using a cross-shaped marlex or mercilene mesh with dimensions of the longitudinal part 12 × 3 cm, the transverse part 6 × 1.5 cm, which is sutured to the anterior and posterior walls of the vagina and both sacral-spinous ligaments, k, so that the transverse part of the mesh is at the level of the dome of the vagina, and the fixation of the vagina to the sacro-spinous ligaments is carried out not over the wall of the vagina, but at both ends of the transverse strip of the mesh with moderate tension.

Distinctive features of the claimed invention is that:

- make an incision in the mucosa of the anterior and posterior walls of the vagina along the midline, departing 1.5 cm from the external opening of the urethra in front and from the perineal skin from the back to the dome, and detach it to the sides to allow access to the walls of the vagina;

- the front and back walls of the vagina are strengthened with a synthetic cross-shaped mesh, with the dimensions of the longitudinal part 12 × 3 cm, the transverse part 6 × 1.5 cm, so that the transverse part of the mesh is at the level of the dome of the vagina;

- fixation of the vagina to the sacro-spinous ligaments is carried out not for the wall of the vagina, but for both ends of the transverse mesh strip with moderate tension.

Thanks to these signs, the vagina is pulled up, while eliminating the prolapse of the perineum and cystocele.

The method is presented in figures 1 and 2.

The method is as follows. In a patient in a position for lithotomy, the mucous membrane of the anterior vaginal wall is dissected, departing approximately 1.5 cm from the external opening of the urethra, and the posterior wall of the vagina from the level of the perineal skin to the dome of the vagina, and it is separated to the sides. Then, unlike the prototype, a cross-shaped mesh with a length of the longitudinal part 1 equal to 12 cm, the transverse part 2 equal to 6 cm, the width of the longitudinal part 3 equal to 3 cm, transverse to the front and back walls of the vagina with interrupted sutures of slowly absorbable suture material is fixed part 4, equal to 1.5 cm, so that the transverse part of the grid was located at the level of the dome of the vagina 5 (figure 1). As with the traditional sacro-spinal fixation of the vagina, a curved clamp is introduced in the area of its dome, and then a finger is inserted through the same hole, separating the tissues in the rectovaginal space, displacing the medial rectum, the sciatic spine and sacro-awned ligament, going medially and slightly backward. To visualize it, the wound is widened with the help of Farabef hooks. The coccygeal muscle and the fiber that covers it are displaced using tuffers. Through the ligament, 2 cm medial to the sciatic spine, a suture is made from a non-absorbable suture material, the ends of the thread are brought into the vaginal lumen. A similar manipulation is performed on the other hand. Further, in contrast to the prototype, the ends of the transverse parts of the mesh are stitched alternately with the removed threads. After tightening the nodes, the mesh is fixed with moderate tension to the sacro-spinous ligaments 6 on both sides (figure 2), pulling up the vagina, perineum and eliminating or preventing the development of cystocele. Nodal catgut sutures restore the integrity of the vaginal mucosa. Through the perforations in the area of the dome of the vagina for 24 hours, rubber strips are introduced for drainage.

Example. Patient V., 56 years old, was admitted to hospital 15.12.02 with complaints of a foreign body feeling in the perineum in the standing position and during physical exertion, constipation, difficulty urinating. Sick for about six months. A history of a hysterectomy a year ago for fibromyoma. A general clinical examination, ultrasound of the pelvic organs, a study of the passage of barium through the colon, proctography. Sonography and x-ray studies were performed in a standing position at rest and with straining. Anorectal manometry and electromyography of the pelvic floor were also performed. The diagnosis of post hysterectomy prolapse of the dome of the vagina, prolapse of the perineum, cystocele II degree, rectocele III degree. The vagina is short: with a digital examination, it is not possible to bring its dome to the sciatic spine. 12/19/02 the operation was performed: in the position, as for perineal stone cutting, the mucous membrane of the posterior wall of the vagina was cut from the perineal skin to the dome along the middle line and then with the transition to the front wall, not reaching 1.5 cm to the external opening of the urethra. The mucous membrane is separated to the sides. A section of the mesh was cut out of a cross-shaped marlex, 12 × 6 cm in size, which is fixed with interrupted sutures (Polysorb-00) to the front and back walls of the vagina so that both transverse parts of the mesh lie in the region of the vaginal dome. A curved clamp is introduced in the area of its dome, and then a finger is inserted through the same opening, separating tissues in the rectovaginal space, displacing the rectum more medially, the right ischial spine and sacrospinous ligament are identified. The wound is widened by Farabef hooks. The coccygeal muscle and fiber covering it are displaced by a tupfer. Through the ligament, 2 cm medial to the sciatic spine, a suture is made from non-absorbable suture material (nylon No. 3), the ends of the thread are brought into the vaginal lumen.

A similar manipulation was made on the other hand. Derived threads alternately sewn both ends of the transverse part of the mesh. Nodes are tightened. The mesh is fixed to the sacro-spinous ligaments on both sides, pulling up the vagina. In the area of the posterior wall of the vagina above the mesh, levators are additionally sutured. Nodal catgut sutures in the longitudinal direction sutured the vaginal mucosa. Through the perforations in the area of the dome of the vagina, rubber strips were introduced for drainage for 24 hours. The postoperative period was uneventful. Discharged from the hospital on the 8th day in satisfactory condition.

The patient was examined after 3, 6 and 12 months after surgery. There are no clinical data for relapse. Dysuric phenomena do not bother. Significantly decreased constipation. With proctography in a standing position, the level of the anorectal zone is 2 cm higher relative to the pubic-coccygeal line, respectively, than before the operation. There was also a decrease in the amplitude of displacement of the anorectal zone, which was 2.5 cm (before surgery, this figure corresponded to 3.7 cm). When conducting control MRI tomography, the vagina is in the physiological position, cystocele is not observed. There are no complaints of dyspareunia. The patient is completely satisfied with the results of the operation.

Thus, the proposed technique allows sacro-spinous fixation of the vagina at any length, to make it on both sides, which preserves the symmetrical physiological position of the organ, increase the reliability of the operation and achieve good functional results, since at the same time cystocele is eliminated and the position of the perineum is corrected at its omission.

Claims (1)

A method of surgical treatment of post hysterectomy vaginal prolapse, including the allocation of sacro-spinous ligaments from two sides through perforations from the side of the vaginal dome, their stitching, characterized in that the mucosa of the anterior and posterior walls of the vagina is cut along the midline, departing 1.5 cm from the outer urethral openings in front and from the perineal skin from the back to the dome, and separate it to the sides, the front and back walls of the vagina are strengthened with a synthetic cross-shaped mesh, with dimensions the longitudinal part is 12 × 3 cm, the transverse part is 6 × 1.5 cm, so that the transverse part of the mesh is at the level of the dome of the vagina, and the vagina is fixed to the sacro-spinous ligaments at both ends of the transverse strip with moderate tension.

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