RU2307618C1 - Method for laparoscopic colpofixation at hysterectomy - Google Patents

Abstract

FIELD: medicine, surgical and laparoscopic gynecology.

SUBSTANCE: after hysterectomy due to applying a vaginal access from one side being about 10-15 mm against free edge of every stump one should suture the stumps of cardinal and sacro-uterine ligaments with nonabsorbable ligature by capturing a vaginal wall. One end of ligature after tightening the knot should be cut, another one should be placed into abdominal cavity; similarly one should suture the stumps of cardinal and sacro-uterine ligaments from another side, after that it is necessary to form a vaginal cupola. Then, under laparoscope's control one should introduce lateral trocars into abdominal cavity by puncturing anterior abdominal wall being about 2-4 cm medially against the upper anterior iliac spine from each side. Moreover, for the purpose to form extraperitoneal canal one trocar should be removed to introduce into the developed canal an uterine guide-probe with a foramen at its working end ("the probe" below) but not reaching the peritoneum to move it under laparoscope's control extraperitoneally being under the bottom of the stump of round ligament of uterus of the same side, then one should perforate peritoneum with the probe in area of the stump of sacro-uterine ligament and direct the probe into abdominal cavity. With the help of a manipulator introduced through lateral trocar of the opposite side one should apply a free end of ligature through the probe's foramen that fixes the stumps of ligaments at the side of the developed extraperitoneal canal to remove it with the probe's back passage out from abdominal cavity. Similarly, it is necessary to remove another end of ligature from the opposite side and then with the help of a guide one should apply one end of ligature above aponeurosis of external oblique muscle of abdomen in subcutaneous fatty fiber towards the site of removal of another end of ligature, the ends of ligatures should be tightened up and bound to complete vaginopexy. The innovation enables to fix vaginal cupola in physiological position and carry out reliable prophylaxis of descensus and prolapse of internal reproductive organs after vaginal hysterectomy.

EFFECT: higher efficiency.

2 ex

Description

The invention relates to medicine, operative and laparoscopic gynecology, can be used to treat patients with prolapse and prolapse of the internal genital organs, as well as the prevention and treatment of this pathology in women who are shown to perform hysterectomy in connection with other gynecological diseases.

Currently, the problem of prolapse and prolapse of the vagina and uterus continues to be relevant among gynecological surgeons, since despite the increasing number of surgical treatment methods for such patients, relapses of the disease are more and more often associated with the imperfection of the surgical treatment and the failure of the restored pelvic floor muscles.

According to the literature, recurrence of the disease in the form of prolapse and prolapse of the vaginal canopy occurs in 3-18% of patients after vaginal hysterectomy, among which a significant number are women of working age. In this regard, the development of new methods of surgical treatment, allowing for reliable rehabilitation of patients with prolapse and prolapse of the vagina and uterus, has not only medical, but also social significance.

A known method of surgical treatment of prolapse of the uterus and vaginal walls, complicated by stress urinary incontinence. This method involves fixing the uterus behind the sacro-uterine ligaments by forming extraperitoneal channels from the womb to the sacro-uterine ligaments on each side under laparoscopic control. Through the channels, a flap of synthetic non-degradable material is carried out. The distal ends of the flaps lead to the sacro-uterine ligaments and fix to them, retreating 5-7 mm from the body of the uterus. Rettsiev space is opened and 0.5-0.6 ml of medical glue is injected on the sides of the cervix. Then they press the front wall of the vagina to the back surface of the womb. Douglas pocket is closed by stitching the sacro-uterine ligaments, the anterior wall of the rectum and the posterior wall of the vagina. The proximal ends of the flaps are tightened until the uterus assumes a physiological position. Then the ends of the flaps are stitched together. Perform colporography (RF Patent No. 2129839, 07/07/1998).

The disadvantages of this method include the development of complications due to the rejection of synthetic flaps used to fix the uterus, as well as the complexity of the method, which, in addition to patchwork fixation, requires additional opening of the Rettsiev space, suturing the rectum and vagina, and the use of glue. Performing these manipulations, especially in obese women, is accompanied by technical difficulties, lengthens the performance of laparoscopic intervention and anesthesia, which is undesirable due to the risk of developing cardiopulmonary complications in this category of patients. In addition, the use of synthetic flaps can lead to the development of pain. This method is designed to treat prolapse and prolapse of the genitals with the uterus preserved.

As a prototype, the closest to the claimed method of laparoscopic colpo-fixation was chosen, which can be performed in combination with a hysterectomy performed by vaginal access (RF patent No. 2182470, 05.20.2002). The known prototype method involves the implementation of vaginopexy as follows. After a hysterectomy, a mersilene or prolene flap in the center is fixed to the stumps of the sacro-uterine ligaments through the vagina. Through extraperitoneal tunnels under laparoscopic control, the free ends of the flap are removed to the anterior abdominal wall and fixed above the aponeurosis of the external oblique muscle of the abdomen.

When performing the known prototype method, it is also possible to develop complications associated with the rejection of a synthetic flap. The formation of wide channels necessary for a volume flap is rather traumatic and is accompanied by the risk of hematomas and the development of infectious complications. The use of synthetic flaps can lead to the development of pain. Using only two ligaments of the same name for fixation may not be enough for reliable prevention of relapse of genital prolapse.

In addition, the hemming of these ligaments implies an increase in the length of extraperitoneal channels from the medially located fixation region of two ligaments in the center of the flap to the lateral points of excretion of the fixing elements (ends of the flap) above the aponeurosis of the external oblique muscle of the abdomen.

We set the task to develop a method for the prevention and treatment of prolapse and prolapse of the internal genital organs during vaginal hysterectomy, which has low trauma, allows us to fix the dome of the vagina in the physiological position and to carry out reliable prevention of prolapse and prolapse of the internal genital organs after vaginal hysterectomy.

The technical result obtained by the implementation of the proposed method is to increase the viability and physiology of vaginopexy while reducing the invasiveness of the intervention by eliminating the weakening, “sagging” of the elements fixing the dome of the vagina by reducing the length and width of the extraperitoneal channels, provided that it is possible to adequately tighten the internal organs to achieve reliable correction and prevention of prolapse during hysterectomy.

Empirically, we selected the areas of fixation of the internal genital organs, the anatomical landmarks used in the formation of extraperitoneal channels designed to remove the fixing elements, and also determined the position of the lateral trocars. Our proposed fixation areas, anatomical landmarks and positions of the lateral trocars in combination with each other ensure the achievement of the above technical result.

Thus, the choice of fixation zones (the stump of the cardinal and sacro-uterine ligaments with vaginal grasp) on each side separately allows reliable vaginopexy through the use of two fixation zones (one on each side), as well as the choice of “strong” anatomical structures for performing vaginopexy .

The choice of the positions of the lateral trocars allows, on the one hand, to minimize the length of the extraperitoneal canals, excluding the “sagging” of the fixing elements, bringing together the selected fixation points in the abdominal cavity and the points of excretion of the fixing elements above the aponeurosis, on the other hand, to enable the “tightening” of the internal genital organs in a physiological position.

The choice of the proposed anatomical landmarks (the area of stitching the stumps, the area of piercing the anterior abdominal wall, the course of the extraperitoneal canal, the area of perforation of the peritoneum) is also due to the stated features of the fixing material used - non-absorbable ligature instead of a synthetic flap in the prototype method. The material used is a non-absorbable ligature, taking into account its thickness, allows to further reduce the width of the formed extraperitoneal channels.

The proposed method of laparoscopic colpofixation during hysterectomy can be used as a radical method for treating prolapse and prolapse of the internal genital organs with significant prolapse and prolapse of the internal genital organs, as well as a method of choice for other gynecological diseases requiring hysterectomy and complicated by prolapse or prolapse of the internal genital organs. The proposed method can also be used to prevent prolapse and prolapse of the internal genital organs after a hysterectomy.

The method is as follows.

The first step is to perform a hysterectomy with vaginal access. A triangular flap is cut from the anterior vaginal wall. The section of the vaginal wall continues circularly around the cervix. Capture, cross and ligate cardinal ligaments on both sides. Sacro-uterine ligaments and vascular bundles are crossed and cleaved on both sides. Open the peritoneum in the back arch. Uterine mobilization is continued, for which round uterine ligaments, uterine ends of the tubes, own ovarian ligaments while maintaining the uterine appendages cross, or round uterine ligaments and funnel-pelvic ligaments during extirpation of the uterus with appendages. The body of the uterus is dislocated into the wound and removed. On the one hand, departing 10-15 mm from the free edge of each stump, the stump of the cardinal and the stump of the sacro-uterine ligaments of the same side are stitched. The seam captures the wall of the vagina. Suture with non-absorbable ligature (Ethibond). After tying the knot, one of the free ends of the ligature is cut off. The other end of the ligature is placed in the abdominal cavity. Similarly, the stumps of the cardinal and sacro-uterine ligaments are stitched on the other hand. The stump of the cardinal and the stump of the sacro-uterine ligaments are stitched. In this case, 10-15 cm retreat from the free edge of each stump. The vaginal wall is taken into the suture. After tying the knot, one of the free ends of the ligature is cut off, the other is placed in the abdominal cavity. The ends of the ligatures are positioned so that when the dome of the vagina is formed, they are not trapped in the seams. Vaginal access is used to stitch ligament stumps.

Then form the dome of the vagina with vaginal access, restoring the vaginal wall with separate vicryl sutures. For subsequent peritonization, vesicoureteral folds, sheets of wide uterine ligaments, peritoneum of the posterior fornix are used.

Then perform the second stage of the operation with laparoscopic access. A laparoscope is inserted into the abdominal cavity and laparoscopy is performed. Then, one lateral trocar, respectively, is introduced into the right and left iliac-inguinal regions. The area of introduction of the lateral trocars is determined as follows: they retreat from the upper anterior iliac spine by a distance of 2-4 cm in the medial direction towards the white line of the abdomen. At this point, the anterior abdominal wall is punctured and a lateral trocar is inserted into the abdominal cavity through the puncture area. In this way, a lateral trocar is introduced on each side. Then an extraperitoneal canal is formed on one side, for example, on the right, for which the right trocar is removed. A uterine probe conductor with an opening at the working end is introduced into the formed channel, not reaching the peritoneum. This probe is advanced extraperitoneally under the control of a laparoscope under the base of the stump of the right round uterine ligament to the stump of the sacro-uterine ligament of the same side. In the stump of the right sacro-uterine ligament, the peritoneum is perforated by the probe and the probe is inserted into the abdominal cavity. A manipulator, for example, an endoscopic clamp, is inserted through the left lateral trocar into the abdominal cavity. With the help of the latter, the free end of the right ligature, that is, the ligature with which the stumps of the cardinal and sacro-uterine ligaments are sewn to the right, is threaded through the opening of the probe conductor. By the reverse stroke of the probe-conductor, the end of the right ligature is withdrawn from the abdominal cavity. Then, similarly, the end of the other ligature is removed, for which the left lateral trocar is removed. A uterine probe conductor with an opening at the working end is introduced into the formed channel, not reaching the peritoneum. This probe is advanced extraperitoneally under the control of a laparoscope under the base of the stump of the left round uterine ligament to the stump of the sacro-uterine ligament of the same side. In the stump of the left sacro-uterine ligament, the peritoneum is perforated with a probe and the probe is inserted into the abdominal cavity. A manipulator, for example, an endoscopic clamp, is inserted into the abdominal cavity through the right lateral trocar. With the help of the latter, the free end of the left ligature, that is, the ligature with which the stumps of the cardinal and sacro-uterine ligaments are sewn to the left, is threaded through the opening of the probe conductor. By the reverse course of the probe-conductor, the end of the left ligature is withdrawn from the abdominal cavity. Then one of the ends of the ligatures using a conductor is carried out over the aponeurosis of the external oblique muscle of the abdomen in the subcutaneous fatty tissue to the exit site of the other end of the ligature. The ends of the ligatures are tightened, giving the dome of the vagina a physiological position. After which the ends of the ligatures are tied together, completing vaginopexy. The vaginal wall is restored with separate catgut sutures. According to indications, colpoperineolevatoroplasty is performed. A triangular flap, the base facing the perineum, is cut out from the back wall of the vagina. Stitches are applied to the muscles that raise the anus. The wall of the vagina and the skin of the perineum are restored with separate vicryl sutures.

The duration of the proposed method of vaginal extirpation of the uterus with laparoscopic vaginopexy is from 60 to 90 minutes. The method was tested in clinical conditions for 14 patients. In 7 cases, the proposed method was performed in women with prolapse of the uterus, in 4 cases to correct concomitant prolapse of the internal organs, and in the remaining three cases to correct the prolapse of the formed dome of the vagina after a previously performed hysterectomy. No intraoperative complications were noted. Blood loss during surgery did not exceed 250 ml. The postoperative period was uneventful. The duration of follow-up is from 3 to 18 months. During the observation period, all patients felt satisfactory, no complaints were made. During the period of observation of recurrence of the disease, loss of the vaginal dome was not observed in any of 8 patients.

The method is illustrated by the following clinical examples.

Clinical example 1.

Patient Ch., 48 years old, came to the clinic with complaints of discomfort in the perineum, drooping of the walls of the vagina during physical exertion, heavy painful menstruation. These complaints are noted 5 years after spontaneous childbirth, accompanied by ruptures of the perineum of the II degree.

With vaginal examination: the external genitalia are developed correctly. When straining marked omission of the anterior and posterior walls 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 increased to 6-7 weeks of pregnancy, spherical, mobile, painless on palpation and displacement. Appendages on both sides are not palpable, their areas are painless.

An ultrasound revealed adenomyosis (diffuse form), endometrioid cyst of the left ovary with a diameter of 2 cm.

Diagnosis: Pelvic floor muscle incompatibility. The prolapse of the walls of the vagina. Adenomyosis, diffuse form. Endometrioid cyst of the left ovary.

Vaginal extirpation of the uterus with left appendages, laparoscopic vaginopexy by the proposed method, and colpoperineolevatoroplasty were performed.

The first step was a hysterectomy with vaginal access. A triangular flap was cut from the front wall of the vagina. The section of the vaginal wall was continued circularly around the cervix. Terminated, crossed and ligated cardinal and sacro-uterine ligaments on both sides. Terminated, crossed and ligated vascular bundles on both sides. They opened the peritoneum in the back arch. The uterine ligaments on both sides were cleaved, crossed and ligated, the uterine end of the tube, the ovarian ligament on the right, and the funnel-pelvic ligament on the left. After the mobilization is completed, the uterine body with the left appendages is dislocated into the wound and removed. Using vaginal access, on the one hand, stepping 11 mm from the free edge of each stump, a non-absorbable ligature (Ethibond) was stitched with a cardinal stump and a stump of the sacro-uterine ligament of the same side. In the seam captured the wall of the vagina. After tying the knot, one of the free ends of the ligature was cut off. The other end of the ligature was placed in the abdominal cavity. Similarly, the stump of the cardinal and sacro-uterine ligaments was stitched on the other hand. The vaginal dome was formed by vaginal access. During peritonization, vesicoureteral folds, sheets of wide uterine ligaments, peritoneum of the posterior fornix were used.

Then, the second stage of the operation was performed by laparoscopic access. One lateral trocar was introduced into the right and left iliac-inguinal regions, respectively. The area of introduction of the lateral trocars was determined as follows. They retreated from the superior anterior iliac spine by 3 cm in the medial direction. At this point, the anterior abdominal wall was punctured and a lateral trocar was inserted into the abdominal cavity through the puncture area. In this way, a lateral trocar was introduced from each side. Then an extraperitoneal canal was formed on the right, for which the right trocar was removed. A uterine probe conductor with an opening at the working end was introduced into the formed channel, not reaching the peritoneum. This probe was advanced extraperitoneally under the control of a laparoscope under the base of the stump of the right round uterine ligament to the stump of the right sacro-uterine ligament. In the stump of the right sacro-uterine ligament, the peritoneum was perforated with a probe and the probe was inserted into the abdominal cavity. An endoscopic clamp was inserted through the left lateral trocar into the abdominal cavity. Using the latter, the free end of the right ligature was passed through the opening of the probe conductor. In reverse, the guide conductor brought the end of the right ligature out of the abdominal cavity. Similarly, the end of another ligature was withdrawn from the abdominal cavity. Then, the right end of the ligature using a guide was carried out over the aponeurosis of the external oblique muscle of the abdomen in the subcutaneous fatty tissue to the site of the removal of the left end of the ligature. The ends of the ligatures tightened, giving the dome of the vagina a physiological position. Then the ends of the ligatures tied together. A triangular flap was cut from the back wall of the vagina. Three vicrylic sutures were applied to the muscles that raise the anus. The wall of the vagina and the skin of the perineum were restored with separate vicryl sutures.

The postoperative period was uneventful. Discharged from the hospital on the 8th day after the operation. Healing by first intention. Examined 1 and 6 months after surgery with vaginal and ultrasound examinations. When viewed after 1 and 6 months after the operation - no complaints, postoperative scars without features, when coughing and straining the prolapse of the walls of the vagina is not observed, there is no urine leakage. The formed dome of the vagina is free. Appendages on both sides are not palpable. Ultrasound examination without features.

Clinical example 2.

Patient R., 53 years old, came to the clinic with complaints of discomfort in the perineum, incomplete prolapse of the uterus during exercise. These complaints are noted over the past 7 years.

With vaginal examination: the external genitalia are developed correctly. When straining, the cervix extends beyond the genital gap. When coughing and straining, there is no leakage of urine. The cervix is not eroded, cylindrical, not deformed. The body of the uterus is not enlarged, mobile, painless on palpation and displacement. Appendages on both sides are not palpable, their areas are painless.

Ultrasound examination without features.

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

Produced vaginal extirpation of the uterus with laparoscopic vaginopexy by the proposed method, kolpoperineolevatoroplasty.

The first step was a hysterectomy with vaginal access. A triangular flap was cut from the front wall of the vagina. The section of the vaginal wall was continued circularly around the cervix. Terminated, crossed and ligated cardinal and sacro-uterine ligaments on both sides. Terminated, crossed and ligated vascular bundles on both sides. They opened the peritoneum in the back arch. The uterine ligaments, the uterine ends of the tubes, and the ovarian ligaments on both sides were cleaved, crossed, and ligated. After the mobilization is completed, the uterine body is dislocated into the wound and removed. Using vaginal access, on the one hand, stepping 15 mm from the free edge of each stump, a non-absorbable ligature (Ethibond) was stitched with a cardinal stump and a stump of the sacro-uterine ligaments of the same side. In the seam captured the wall of the vagina. After tying the knot, one of the free ends of the ligature was cut off. The other end of the ligature was placed in the abdominal cavity. Similarly, the stump of the cardinal and sacro-uterine ligaments was stitched on the other hand. The vaginal dome was formed by vaginal access. During peritonization, vesicoureteral folds, sheets of wide uterine ligaments, peritoneum of the posterior fornix were used.

Then, the second stage of the operation was performed by laparoscopic access. One lateral trocar was introduced into the right and left iliac-inguinal regions, respectively. The area of introduction of the lateral trocars was determined as follows. They retreated from the superior anterior iliac spine by 4 cm in the medial direction. At this point, the anterior abdominal wall was pierced and a lateral trocar was inserted into the abdominal cavity through the puncture area. In this manner, a lateral trocar was introduced on each side. Then an extraperitoneal canal was formed on the right, for which the right trocar was removed. A uterine probe conductor with an opening at the working end was introduced into the formed channel, not reaching the peritoneum. This probe was advanced extraperitoneally under the control of a laparoscope under the base of the stump of the right round uterine ligament to the stump of the right sacro-uterine ligament. In the stump of the right sacro-uterine ligament, the peritoneum was perforated with a probe and the probe was inserted into the abdominal cavity. An endoscopic clamp was inserted through the left lateral trocar into the abdominal cavity. Using the latter, the free end of the right ligature was passed through the opening of the probe conductor. In reverse, the guide conductor brought the end of the right ligature out of the abdominal cavity. Similarly, an extraperitoneal canal was formed on the left and the end of the left ligature was withdrawn from the abdominal cavity. Then, the left end of the ligature using a guide was held over the aponeurosis of the external oblique muscle of the abdomen in the subcutaneous fatty tissue to the site of the removal of the right end of the ligature. The ends of the ligatures tightened, giving the dome of the vagina a physiological position. Then the ends of the ligatures tied together. A triangular flap was cut from the back wall of the vagina. Three vicrylic sutures were applied to the muscles that raise the anus. The wall of the vagina and the skin of the perineum were restored with separate vicryl sutures.

The postoperative period was uneventful. Discharged from the hospital on the 8th day after the operation. Healing by first intention. Examined 2 and 8 months after surgery with vaginal and ultrasound examinations. When viewed after 2 and 8 months after the operation - no complaints, postoperative scars without features, when coughing and straining the prolapse of the walls of the vagina is not observed, there is no urine leakage. The formed dome of the vagina is free. Appendages on both sides are not palpable, their areas are painless. Ultrasound examination without features.

Claims (1)

The method of laparoscopic colpofixation during hysterectomy, including the removal of the uterus and the formation of a vaginal dome by vaginal access, vaginopexy using laparoscopic access, with the formation of extraperitoneal channels, passing through them fixing stumps of the uterine ligaments, excretion and fixation of the latter over the aponeurosis of the external oblique muscle, characterized in that after removal of the uterus, using vaginal access on one side, stepping 10-15 mm from the free edge of each stump, I stitch t of the stump of the cardinal and sacro-uterine ligaments with a non-absorbable ligature with the capture of the vaginal wall, one of the ends of the ligature is cut off after tying the knot, and the other is placed in the abdominal cavity, the stump of the cardinal and sacro-uterine ligaments is stitched on the other side similarly, after which the dome of the vagina is formed, then, under the control of a laparoscope, lateral trocars are inserted into the abdominal cavity, piercing the anterior abdominal wall, retreating medially 2-4 cm from the upper anterior iliac spine on each side, then to form of the extraperitoneal canal, one trocar is removed and, before reaching the peritoneum, a uterine probe-conductor with an opening at the working end (hereinafter referred to as the probe) is inserted, it is advanced extraperitoneally under the control of the stump of the uterine round ligament on the same side, the peritoneum is perforated into the peritoneum the stump of the sacro-uterine ligament and conduct the probe into the abdominal cavity, using the manipulator introduced through the lateral trocar of the opposite side, pass the free end of the ligatures through the probe opening fixing the ligament stump on the side of the formed extraperitoneal canal and removing it with the probe backward from the abdominal cavity, similarly remove the other end of the ligature from the opposite side, after which one of the ends of the ligatures is carried out over the aponeurosis of the external oblique muscle of the abdomen in the subcutaneous adipose tissue removing the other end of the ligature, the ends of the ligatures tighten and bind together, completing vaginopexy.