RU2469669C1 - Method of surgical management of female genital prolapse - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: vaginal hysterectomy is followed by connecting front and back vaginal walls. Rectangular flaps are cut out a vaginal mucosa. Distal ends of the flap within vaginal fornix; a proximal border is at 0.2-0.3 mm along a vaginal cross joint. A distance between lateral edges of the front and back flap makes 0.3-0.5 cm. A vaginal stump is immersed in a small pelvis cavity. Colpoperineolevatoroplasty is conducted.

EFFECT: method provides prevention of recurrent prolapse with vaginal preservation.

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Description

The invention relates to gynecology, in particular to operative gynecology.

Interest in the problem of genital prolapse is supported by dissatisfaction with the results of surgical treatment, while the number of relapses reaches 10-40% according to different authors (Whiteside JL, Weber AM, Meyn LA, Walters MD // Risk factors for prolapsed recurrence after vaginal repair // Am J Obstet Gynecol. - 2004, Nov 191 (5): p. 1533-8).

Numerous surgical treatments are available. The most commonly performed are: vaginal extirpation of the uterus, median colporagraphy according to the Neugebauer-Lefour method, Labgart operation, Manchester operation, vaginal hysterectomy with laparoscopic assistant, methods using synthetic prostheses. The most popular operation is vaginal hysterectomy with colporrafia, as a radical elimination of prolapse of the internal genital organs (Pathology of the cervix / Ed. By V.I. Krasnopolsky. - M .: Medicine, 1997. - P.219; Hirsch H.A., Kezer O., Ikle F.A. Operational Gynecology: Atlas: Translated from English / Edited by V.I. Kulakov, I.V. Fedorov. - M.: GEOTAR MEDICINE, 1999. - P. 243). However, with severe degrees of prolapse, there is a high risk of enterocele and prolapse of the vaginal vault after hysterectomy (Barrington JW, Edwards G. // Post hysterectomy vault prolapse. // Int Urogynecol J Pelvic Floor Dysfunct. - 2000. - 11 - p. 241).

The prototype of the proposed method for the surgical treatment of genital prolapse is median colporagraphy according to the Neugebauer-Lefora method (V.I. Kulakov, ND Selezneva, V.I. Krasnopolsky. Operational gynecology. - M., Medicine, 1990 - p.299). It is indicated for the loss of the uterus and vagina in elderly women who do not live sexually, with contraindications to radical operations for health reasons. The method is as follows. The cervix is captured by bullet forceps and reduced. A trapezoidal flap 4-5 cm wide and 6-7 cm long is cut from the mucous membrane of the posterior wall of the vagina. Its base is located in the upper corner of the wound. Further, in a partially sharp, partially blunt way, the mucous membrane is peeled from top to bottom by pulling on the clamps. The same flap of the vaginal mucosa is cut out from the front wall of the vagina (at a distance of 1.5 cm from the external opening of the urethra down and 2 cm anterior to the external pharynx of the cervix). Then the wound surfaces of the anterior and posterior walls of the vagina are connected. Initially, the edges of the wound adjacent to the cervix are connected. To do this, a needle is injected from the side of the vaginal mucosa of the posterior wall, and a puncture from the wound surface of the same side, then the needle is pricked from the side of the wound surface of the anterior vaginal wall and punctured from the side of the vaginal mucosa of the same side, i.e. the front wall of the vagina. Thus, the knot of the knotted suture faces the canal that forms as the edges of the wound join. Subsequent sutures are alternately applied from one side to the other to connect the lateral edges of the wound. An injection from the lower edge of the wound is done from the side of the vaginal mucosa. A puncture - on the front edge of the wound surface on the vaginal mucosa. If necessary, additional nodal sutures can be applied in the center of the wound surface. After the side walls are connected, two narrow side channels are formed, which communicate with each other through the formed upper channel, near the cervix. The last row of sutures is applied to the edges of the wound at the opening of the vagina. It is generally accepted that the shape and size of the separated front and back flaps of the vaginal wall must be the same (Davydov S.P., Khromov B.M., Sheiko V.Z. Atlas of gynecological operations. - L .: M., 1973. - C .106). Failure to do so leads to a relapse of the disease.

The disadvantages of the method selected as a prototype are:

- it is difficult to examine the cervix and study the endometrium when bleeding occurs;

- Relapses of the disease due to stretching and thinning of the created vaginal septum under the influence of persisting intra-abdominal, intravesical and intrarectal pressure are observed;

- the impossibility of surgery before menopause;

- sex life is excluded.

The objective of the invention is to prevent the occurrence of uterine diseases in the future and the exclusion of recurrence of prolapse, the possibility of this surgery in women before menopause, maintaining sexual function.

This object is achieved by the fact that in the method of surgical treatment of genital prolapse in women, including circular dissection of the vaginal mucosa and its separation, opening the rectal uterine cavity, ligation of the ligaments and uterine vessels, opening the vesicoureteral cavity, ligation of the remaining ligamentous apparatus and uterine appendages , restoration of the integrity of the peritoneum, the connection of the anterior and posterior walls of the vagina in the transverse direction, cutting out flaps from the mucosa of the anterior and posterior walls of moisture looking for a gradual immersion of the vaginal stump in the pelvic cavity, after the vaginal hysterectomy, the anterior and posterior walls of the vagina are connected in the transverse direction, the suture threads are fixed with clamps, rags from the vaginal mucosa are cut out in a rectangular shape, the distal edges of which are located directly in the area of the vaginal arches, the proximal border passes at a distance of 0.2-0.3 mm along the transverse seam of the vagina, while the distance between the lateral edges of the front and back flap is 0.3-0.5 cm, After immersion vaginal stump into the pelvic cavity kolpoperineolevatoroplastiku performed.

The method is as follows. The first stage is a vaginal hysterectomy: both lips of the cervix are captured by bullet forceps and reduced. Dissect the mucous membrane of the vaginal wall at the point of transition to the vaginal arches. Partially sharp, partially blunt way, the mucous membrane is separated from the underlying tissues. In the area of the posterior arch, the vaginal mucosa is pulled, and the rectal-uterine cavity is opened with a transverse incision. A wide mirror is inserted into the rectal uterine cavity. For ligation of the sacro-uterine ligament, the lateral wall of the vagina is removed, and the cervix is displaced in the opposite direction. The clamp is applied perpendicular to the axis of the cervix. The ligament is crossed, ligated. The ligature is necessarily imposed with firmware. The length of the stumps should not exceed 0.5 cm, the ligatures are not cut, but taken to the clamps. The cervix is displaced down and the bladder is separated. Then he is taken upward by a curved mirror. It protects the bladder until the vesico-uterine cavity is opened. The cervix is displaced downward, secrete, intersect, and the cardinal ligaments are ligated with stitching, first from one side, then from the other side. Proceed to ligation of the uterine vessels. For this, the cervix is pulled down and to the side opposite to the ligated vessels. They capture, cross and bandage the wide ligament of the uterus, secrete the uterine vessels and bandage them. Ligatures in the area of the uterine vessels are cut off. An autopsy of the vesico-uterine cavity is possible both before and after vascular ligation. The main condition is confidence in the complete separation of the bladder. When the peritoneum of the vesico-uterine cavity is clearly defined, it is gripped by a clamp, pulled and cut with scissors, the ends of which are facing the uterus. A Heaney or Diver mirror is inserted into the abdominal cavity, with which the bladder is brought up. The bottom of the uterus is captured by bullet forceps and removed through the posterior colpot hole. With the index finger, the surgeon finds the fallopian tube, the round ligament of the uterus and its own ligament of the ovary and puts a clamp on them. When the appendage is preserved, these anatomical structures intersect, are stitched, and the ligatures are clamped. If the uterine appendages are removed, then the round ligament of the uterus is ligated separately.

The next step is to examine the stumps of all ligaments and blood vessels to control hemostasis. The integrity of the pelvic peritoneum is restored by applying a purse string suture, sequentially capturing the stumps of the left round uterine ligament, left uterine tube, left own ligament of the ovary, left wide uterine ligament, then the left sacro-uterine ligament, then grasp and tighten the peritoneum of the rectum-uterine cavity and posterior wall the vagina. After this, the stumps of the ligaments on the right are stitched. The needle is punctured at the site of the first injection. Hemostasis is checked with a tupfer, the purse string suture is tightened. The bladder is emptied with a catheter.

The second stage of the operation begins with the connection of the anterior and posterior walls of the vagina after a hysterectomy in the transverse direction. The ends of the ligatures at the edges of the suture are not cut, taken to the clamps, for them the stump of the vagina is reduced. Further cutting of the flaps from the mucous membrane of the posterior and anterior walls of the vagina differs from the Neugebauer-Lefour technique in the large size of the flaps and their shape (rectangular instead of trapezoidal). Their distal edges are located directly in the area of the vaginal arches, and the lateral parts of the flaps are located at a distance of 0.3-0.5 cm from each other, which contributes to the formation of narrower lateral channels and prevents relapse. The border of the proximal edge of the flap is at a distance of 0.2-0.3 cm from the seam connecting the front and back walls of the vagina after a hysterectomy. After separation of the mucous membrane, wound surfaces of the anterior and posterior walls of the vagina are connected, forming a transverse channel running along this suture. Then begin the gradual immersion of the vaginal stump by connecting the front and back wound surfaces and the formation of lateral channels. It is necessary to monitor the symmetrical immersion of the walls of the vagina. The last row of sutures is applied to the edges of the wound in the area of the vaginal arches. Then, colpoperineoplasty is performed with individual synthetic sutures applied to the isolated levators; A two-story submersible suture connects the muscles and fascia of the perineum.

Thus, the possibility of future uterine diseases is eliminated; a double barrier is created against the occurrence of relapse: two narrow lateral channels are formed and the defect in the pelvic floor, which creates the conditions for prolapse of the pelvic organs, is eliminated. The "deep" location of the distal edges of the flap, levator plastic form the vagina, which allows you to maintain sexual function.

Clinical example.

Patient P., 58 years old, who complained of a foreign body feeling in the perineum and urinary retention, was diagnosed with a complete uterine prolapse with the formation of cystocele IV Art. and rectocele (according to POP - Q). Produced vaginal extirpation of the uterus. Middle colporography by the proposed method. Within 3 years of observing relapse, incomplete healing and other complications were not observed. The patient lives sexually.

Claims (1)

A method for the surgical treatment of female genital prolapse, including circular dissection of the vaginal mucosa and its separation, opening the rectum-uterine cavity, ligation of the ligaments and uterine vessels, opening the vesicoureteral cavity, ligation of the remaining ligamentous apparatus and appendages of the uterus, restoration of the integrity of the peritoneum, connection of the anterior peritoneum, connection of the anterior peritoneum, and the back walls of the vagina in the transverse direction, cutting out flaps from the mucosa of the front and back walls of the vagina, the gradual immersion of the stump of the vagina and into the pelvic cavity, characterized in that after the vaginal hysterectomy, the anterior and posterior walls of the vagina are connected in the transverse direction, the suture threads are fixed with clamps, rags from the vaginal mucosa are cut out in a rectangular shape, the distal edges of which are located directly in the area of the vaginal arches, the proximal border passes at a distance of 0.2-0.3 mm along the transverse suture of the vagina, while the distance between the lateral edges of the anterior and posterior flap is 0.3-0.5 cm, after immersion the cult and vagina into the pelvic cavity carry out colpoperineolevatoroplasty.