RU2398536C1 - Method of transcervical intrauterine introduction of dye with intraoperational dyagnostics of uterine tube patency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to methods of examination in gynecology, and can be used for diagnostics of infertility. Into cavity of cervical canal of neck, neck cannula is introduced. It is fixed with gynecological forceps for closing cervical canal of uterine neck, which contain hingedly connected to each other handles and stepped rack lock, branches with jaws, made in form of semicircle and facing each other concave working surfaces, jaws in longitudinal and transverse section have internal diametre 30 mm. Occlusion section is surgically removed and patency is restored.

EFFECT: application of invention ensures intraoperational visual diagnostics of uterine tube occlusion and restoration of patency, tight fixation of neck cannula, prevents flowing out of contrast substance, eliminates radial load.

2 cl, 5 dwg, 1 ex

Description

The proposed method relates to medicine, namely to diagnostic research methods, and can be used for intraoperative diagnosis and treatment of infertility in gynecology.

The problem of barren marriage has remained relevant for many years and has no tendency to decrease. Despite successes in the treatment of infertility with endoscopic and assisted reproductive technologies (ART), the widespread use of these techniques is limited by accessibility, complexity and high cost, which limits their use (Ziganshin AM, Kulavsky VA Reproduction problems. Special issue. III international congress on reproductive medicine. M: 2009.267-278 p.). An alternative is the use of traditional methods of classical and minimally invasive laparotomy, which allow reconstructive plastic surgery. One of the forms of infertility is tubal-peritoneal, which occupies a leading position in the structure of infertile marriage, having a frequency of 35 to 60% (V.I. Kulakov., V.N. Serov. Rational pharmacotherapy in obstetrics and gynecology / Guide for practicing doctors / M .: "Litterra", 2005. 797-798 p.).

Of great importance in the formation of tubal-peritoneal infertility is the adhesion process in the small pelvis, which develops as a result of previous inflammatory processes, endometriosis, abdominal and endoscopic operations on the organs of the abdominal cavity and small pelvis (T.Ya. Pshenichnikova, G.T. Sukhikh. Akush. And Gin. M: Medicine, 1994: No. 4. 57 p.). Depending on the condition of the fallopian tubes, the severity and localization of adhesions, 4 degrees of the adhesion process are distinguished according to Hilk et al., 1998. But the lack of an easy-to-use method (transcervical intrauterine dye administration with intraoperative diagnosis of patency of the fallopian tubes) and device (gynecological forceps) limits widespread use in practice. The low reliability of hysterosalpingography (60-80%) during a preliminary examination of patients, forces the surgeon to re-determine the level of occlusion of the fallopian tube during surgery and after restoring patency of the fallopian tube to check the result. (V.I. Kulakov. Obstetrics and Gynecology. / Clinical recommendations / M .: "GEOTAR-Media", 2006: 488-490 p.). The available positive results of the onset of uterine pregnancy after various types of surgical interventions are in the amount of 10 to 45%, which indicates a reserve in the treatment of patients with this form of infertility.

Today, there are the following methods for introducing contrast agents into the uterine cavity and tubes - it is transcervical (method of hysterosalpingography, perturbation, hydrotubation) and intraoperative (method of probing the fallopian tube, antegrade injection into the tubes from the fimbrial part and retrograde injection of contrast into the uterine cavity). The use of methods has the following disadvantages and advantages:

- trauma and hemorrhage of the cervix with bullet clamps;

- leakage of the dye due to loose closure of the cervical canal and the lumen of the fallopian tube;

- pain during the procedure of varying degrees;

- exacerbation of inflammatory processes;

- the inability to visually determine the level of occlusion of the fallopian tube. (Clifford R. Uiliss, Atlas of operative gynecology. M: Medical literature, 2004: 257-269 p.);

- the difficulty of clamping the isthmus of the cervix with forceps of Collen;

- Errors in transmural injection of dye into the uterine cavity;

- the need for a wide laparotomy to install the Collen forceps in the region of the lower segment, which complicates the widespread use of these techniques.

The prototype of the invention is a method of transcervical administration of a contrast agent, which consists in the fact that, using bullet forceps and a cervical cannula, the contrast agent is injected into the uterine cavity, which penetrates the fallopian tubes and allows to diagnose the patency / obstruction of the fallopian tubes (V.I. Kulakov. Obstetrics and Gynecology. / Clinical recommendations / M .: "GEOTAR-Media", 2006: 488-490 p.). The disadvantages of this method are the impossibility of visual diagnosis and elimination of patency / obstruction of the fallopian tubes, the use of x-ray diagnostic equipment, poor fixation of the cervical cannula to the cervical canal, leakage of contrast in the vagina.

The objective of the invention is to develop a method that provides transcervical administration of an intrauterine dye with reliable closure of the cervical canal for intraoperative, visual determination and elimination of the occlusion site of the fallopian tube.

EFFECT: intraoperative visual diagnosis of fallopian tube occlusion and restoration of patency, tight fixation of the cervical cannula, prevention of leakage of contrast medium, absence of radiation exposure.

The proposed method is as follows: use gynecological forceps to close the lumen of the cervical canal of the cervix, which contain jaws 1 made in the form of a semicircle, they have concave working surfaces, are facing each other, attached to the jaws 2 of the forceps, interconnected by a hinge 3 handles 4 and lock 5. Jaws 1 in the longitudinal and transverse directions have the same inner diameter of 30 mm, corresponding to the anatomical dimensions of the cervix. When closing the handles 4 of the tongs, the lock 5 has a stepped ratchet mechanism.

- before the main stage of the operation, the cervix 6 is exposed in the mirrors 7, the cervical canal 9 is inserted into the cervical canal 8, then the cervix 6 is fixed with gynecological forceps to seal the uterine cavity (figure 2);

- a sterile system connected to a syringe with a contrast medium containing 0.4% indigo carmine is connected to the cervical cannula 9

- 20.0 ml syringe is on the operating table;

- carry out local or general anesthesia;

- perform a classic or minimally invasive laparotomy;

- after the release of the fallopian tube 10 from the adhesions 11, the dye is gradually introduced into the uterine cavity, watching the dye exit out into the abdominal cavity. With obstruction of the fallopian tube, further dye administration leads to stretching of the fallopian tube 10 and the appearance of a thinned section 12 (asterisks), which indicates the place of occlusion (Fig. 3);

- at the site of maximum thinning 12, a longitudinal section is made by an electric needle 13 2-3 cm long until a dye appears from the lumen of the fallopian tube. Hemostasis of the wound edges is carried out with an electric knife 13 by electrocoagulation, a general view of the fallopian tube 14, the incision is not sutured. The ovary is further freed from adhesions (Fig. 4);

re-conduct a control introduction to determine the patency of the fallopian tube, making sure the patency of the fallopian tube, complete the steps of abdominal surgery (Fig 5);

- the anterior abdominal wall is restored in layers tightly.

The proposed method is illustrated by the following figures.

Figure 1 shows a General view of the used gynecological forceps.

Figure 2 - the introduction of contrast medium according to the proposed method.

Figure 3 - intraoperative image of the fallopian tube at the time of maximum stretching (on the distal part of the tube 6, after the introduction of contrast, a dark blue asterisk 12 appears, the tube is captured by anatomical forceps, the ovary is bundled with adhesions 11). Figure 4 - image of the fallopian tube at the time of dissection by an electric needle 13; Figure 5 - image of the fallopian tube after restoration of patency.

INDICATIONS FOR USING THE METHOD

The application of this method is shown:

- women of reproductive age with infertility;

- to restore obstruction of the fallopian tubes with tubal-peritoneal form I-II degree according to Hilk.

RESTRICTIONS AND CONTRAINDICATIONS FOR USING THE METHOD

Contraindications to the use of this method are:

- General contraindications for surgical intervention;

- active inflammatory process (in less than 4-6 months);

- genital tuberculosis;

- hormonal disorders that are not amenable to correction;

- Adhesive process 3-4 degrees Hilk;

- medical and physiological contraindications for pregnancy;

- the absence of the ampullar segment of the fallopian tube;

- lack of healthy ovarian tissue sufficient for follicular maturation;

- bilateral obstructional fallopian tubes in the form of huge sactosalpingitis or sclerotically altered, after removal of which the remainder of the fallopian tube is less than 4 cm.

RESULTS OF CLINICAL STUDIES

In this way, we operated on 24 patients aged 23 to 36 years, regarding infertility. There were no significant fluctuations in the age of the onset of the menarche, the time it took to establish the menstrual cycle and the reproductive function. A history of gynecological diseases was in 19 (79%) patients. 12 (50%) women had a history of surgical interventions; 4 of them (33%) underwent 2 operations each: ovarian resection, ectopic pregnancy, appendectomy, cesarean section, cholecystectomy. The duration of infertility disease was: from 1 to 2 years - in 4 (17%), from 3 to 5 years - in 12 (50%), from 6 or more years - in 8 (33%). The volume of surgical interventions: salpingostomy in 8 - 33%; lysis of epididymic adhesions in 7 - 29%; lysis of extra-adherent adhesions in 6 - 25%; fimbrioplasty in 3 - 13%; a combination of these types of operations in 9 - 38%. During the year, pregnancy occurred in 7 - 29% of patients, 1 (4%) case of ectopic pregnancy. Patients whose spontaneous pregnancy did not occur within 6-12 months after surgical treatment are subsequently referred to assisted reproductive technology (IVF) programs.

An example of clinical use of the proposed method.

Patient S., 25 years old, was admitted to planned surgical treatment with a diagnosis of tubal-peritoneal infertility II, inflammatory genesis. A history of 2-year-old right-sided inflammation of the appendages, followed by hysterosalpingography. The patient underwent minimally invasive laparotomy using the Prudkov apparatus, salpingostomy with dissection of adhesions and subsequent use of the “Interceed” anti-adhesion barrier:

- the cervix is exposed in the mirrors, the cervical canal is inserted into the cervical canal, the cervix is fixed with gynecological forceps, an extension cord with a syringe filled with dye of indigo carmine dye 0.4% -20.0 ml is displayed on the operating table.

- under general intubation anesthesia, a minimally invasive laparotomy was performed, the Prudkov apparatus was installed.

- examined the right uterine appendages: the right tube is moderately thickened over the entire length of 1-1.5 cm in diameter, the ovary is within 35% in commissures, dissected. Adhesion process II degree according to Hilk.

- a contrast was introduced by a syringe, the right tube in the distal section was stretched up to 2.5 cm in diameter, a dark blue sprocket appeared at the place of greatest thinning, an electric needle was longitudinally cut up to 2 cm long, bleeding sections of the fallopian tube were coagulated, the wound was not sutured, the tube was deployed , while controlling the patency of the sample is positive. Left appendages were examined, a dye was reintroduced, the passability of the pipe was not impaired.

- after drainage of the abdominal cavity, for local prevention of the adhesive process, the right and left tubes are wrapped with an absorbable “Interceed” barrier and laid in place of the anatomical location. The anterior abdominal wall is restored in layers, tightly. An aseptic alcohol dressing was applied to the postoperative wound. In the postoperative period, the patient was performed complex therapy, including antibiotic therapy, analgesics, proteolytic enzymes, from 2 days - efferent methods of detoxification (UFO blood), hormone therapy (COC). the operative period was uneventful, the sutures were healed by first intention, removed on the 7th day and the patient was discharged home. Sexual life is allowed after 3 months. Examination in dynamics: after 3, 5 months. At the time of examination after 3 months the woman did not make complaints At 5 months, the woman spontaneously began a pregnancy, which ended in spontaneous birth through the natural birth canal, the birth of a healthy fetus.

Using this method (transcervical intrauterine dye administration with intraoperative diagnosis of patency of the fallopian tubes using gynecological forceps) allows you to:

- painlessly, atraumatic, bloodlessly transcervical, intrauterine enter a dye, use this method repeatedly;

- intraoperatively visually diagnose the level of occlusion of the fallopian tube and control the patency of the fallopian tube after surgery;

- provides the patient with an alternative when choosing surgical treatment for infertility compared with more expensive, limitedly available methods of endoscopic treatment.

Claims (1)

A method for transcervical dye administration, including exposure of the cervix, insertion of the cervical cannula into the cervical canal, fixation with gynecological forceps, injection of contrast medium into the uterine cavity and fallopian tube, characterized in that gynecological forceps are used to close the cervical canal of the cervix, which are articulated between handles and a stepped cremeler lock, jaws with jaws made in the form of a semicircle and facing each other with concave working surfaces, with sponge that in the longitudinal and transverse direction have an inner diameter of 30 mm, and further performing a laparotomy performed visual assessment of patency of the fallopian tube, and in determining the occlusion portion is carried out eliminating obstruction.

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