RU2523647C2 - Method of treating patients with stage i uterine body cancer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: bipolar coagulation of uterine tubes, utero-ovarian ligaments, round and suspensory ligaments of uterus with the latter being transected. The uterine arteries and veins are clipped at 1 cm from a junction to internal iliac vessels. A uterine manipulator tip is inserted into the uterine cavity. Pelvic fat is removed with lymph nodes along the external iliac vessels and from obturation regions. The fat is evacuated from an abdominal cavity from each side in a hermetically sealed container. A pangysterectomia is performed through the vagina.

EFFECT: prevented intraoperative tumour expansion in the patients with stage I uterine body cancer.

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Description

The invention relates to medicine, namely to surgical methods for the treatment of gynecological diseases, and can be used to treat patients with stage I malignant tumors.

A method of laparoscopic surgical treatment of endometrial cancer is known and is currently used [The Linde's Operative Gynecology, 10th Edition Rock, John A., 2008, page 771-773, 1303].

The known method is performed in compliance with the following sequence of steps:

- Installation of the uterine manipulator in the uterine cavity.

- the imposition of carboxyperitoneum, the introduction of trocars.

- clipping (bipolar coagulation) of the proximal fallopian tubes.

- coagulation and intersection of the round ligaments of the uterus.

- bilateral ileo-obstructive lymphadenectomy.

- coagulation and intersection of the vessels of the funnel-pelvic ligaments.

- opening the peritoneum of the cystic-uterine fold, lowering the bladder.

- doping of the uterine vessels.

- uterine clipping.

- removal of the removed uterus from the abdominal cavity through the vagina.

- suturing of the vaginal stump.

However, when performing laparoscopic surgery in accordance with the known method, the possibility of intraoperative spread of tumor cells due to the use of the uterine manipulator is great.

When performing laparoscopic extirpation of the uterus with ileo-obstructive (pelvic) lymphadenectomy in gynecology at one of the first stages, a manipulator is installed in the uterine cavity in order to ensure the necessary position of the uterus and the expansion of the surgical field. However, a prolonged presence of the manipulator tip in the uterine cavity (on average about 3 hours) leads to trauma and destruction of the tumor structure, the spread of its individual cells through the vessels and directly from the uterine cavity through the fallopian tubes to the abdominal cavity. Thus, the well-known algorithm for using the uterine manipulator is justified from the standpoint of surgical safety, but does not meet the specific requirements of operations for cancer patients.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- the ability to prevent the intraoperative spread of tumor cells due to preliminary blocking of the lymph-venous and tubal paths;

- the possibility of safe use of the uterine manipulator in patients with malignant tumors of the uterus;

- the ability to reduce the risk of intraoperative bleeding from the uterus in case of perforation by the uterine manipulator due to doping of the main vessels supplying the uterus;

- facilitation of the operation after the preparatory stage, namely: on the one hand, the medial border of lymphadenectomy becomes available, on the other hand, bleeding does not occur and the risk of ureteral injury decreases due to the fact that blood flow in the uterus is blocked proximal to the separation site of the main vascular bundle.

The invention is aimed at solving the problem of treating patients with malignant tumors of the uterus of the uterus stage I.

The specified technical (therapeutic) results in the implementation of the invention are achieved due to the fact that, as in the known method of treating patients with malignant tumors of the uterine body of the first stage, they are performed by surgical intervention in the volume of laparoscopic extirpation of the uterus with ileo-obstructive (pelvic) lymphadenectomy.

A feature of the proposed method is that the surgical intervention is carried out in the following sequence: produce bipolar coagulation of the fallopian tubes, own ligaments of the ovaries, round and funnel-pelvic ligaments of the uterus with the intersection of the latter, perform clipping of the uterine arteries and veins at a distance of 1 cm from the place of their departure from the internal iliac vessels, the tip of the uterine manipulator is inserted into the uterine cavity, pelvic fiber with lymph nodes along the external iliac vessels and from obturator are removed areas, evacuate it from the abdominal cavity separately on each side in sealed containers, extirpate the uterus with appendages, which is removed from the abdominal cavity through the vagina.

The invention consists in the following.

The goal of oncogynecological surgery - laparoscopic extirpation of the uterus in patients with malignant tumors of the uterus is not only to remove a localized tumor, but also to prevent the intraoperative spread of the tumor. The essence of the proposed method consists in changing the sequence of surgical techniques when performing this operation, which allows you to achieve the specified goal and the above technical (medical) results.

At the first stage of the operation, bipolar coagulation of the fallopian tubes, own ligaments of the ovaries and round ligaments of the uterus, with the intersection of the latter, dissection of the anterior leaf of the wide ligament of the uterus, the formation of a “window” in the posterior leaf of the wide ligament of the uterus, the sides of which are anterior and lateral-funnel-pelvic, is performed ligament and ovary, posterior and medial - ureter and uterine rib. Coagulate and cross the funnel-pelvic ligaments.

Next, clipping of the uterine vessels from the most convenient access without using the uterine manipulator is performed. For this purpose, focusing on the medial umbilical fold on the anterior abdominal wall, the umbilical artery trunk is separated from the paravisical space, separated proximal to the level of discharge in the medial direction of the uterine artery, under which the same veins are located. At a distance of 1 cm from the internal iliac vessels, the uterine arteries and veins are clipped with tantalum clips.

Thus, the main vessels involved in the blood supply to the uterus and the fallopian tubes are alloyed.

From the standpoint of cancer safety, the use of the uterine manipulator in patients with malignant tumors of the uterine body is possible only after the completion of the first stage of the operation.

In addition, the uterine wall affected by the tumor becomes less resistant to damage, which can easily lead to its perforation. This situation is accompanied by bleeding, stopping which requires additional time and is not always successful. The authors of the proposed method noted the absence of bleeding in case of accidental occurrence of perforation of the uterus with the tip of the manipulator after preliminary doping of the main vessels involved in its blood supply.

Further stages of the operation are performed after the tip of the uterine manipulator is inserted into the uterine cavity. Namely: according to the standard method, pelvic tissue with lymph nodes along the external iliac vessels and from the obstructive areas is removed. Then it is evacuated from the abdominal cavity separately on each side in airtight containers. Next, the uterus with appendages is extirpated, which is removed from the abdominal cavity through the vagina.

When performing the operation in accordance with the claimed method, the reduced blood flow in the uterus allows to reduce the amount of blood loss, as well as the risk of possible bleeding with its possible perforation, a uterine probe, or a manipulator. The access used for clipping the uterine vessels allows you to visualize the medial border of the upcoming lymphadenectomy without additional technical techniques, since the blood flow in the uterus is blocked most proximal. At the stage of separation of the main vascular bundle, there is no bleeding and the risk of ureter injury is reduced.

Blocked lymphatic and venous and tube pathways of the possible intraoperative spread of the tumor enable the uterine manipulator to be used oncologically safely during laparoscopic hysterectomy.

The method is as follows.

Laparoscopic surgery is performed under multicomponent anesthesia.

For the surgical intervention, along with the standard sets of equipment and instruments used to perform laparoscopic surgical interventions in gynecology, the following additions are used: a second video monitor at the head end of the table, special plastic containers for evacuating the removed organs from the abdominal cavity, and an endoscopic clipper.

The patient's position on the operating table is standard for performing vaginal operations.

Operational access is carried out using four trocars:

- The first trocar with a laparoscope is introduced into the umbilical region at a distance of 1 cm below the navel.

- Three additional trocars (for introducing surgical instruments) are installed symmetrically in the right (diameter 5 mm) and left (diameter 11 mm) iliac regions of the abdomen, and in the middle of the distance between the pubis and the navel (diameter 5 mm). Trocars are introduced in stages under the control of a laparoscope.

In the first stage of the operation, a thorough video audit of the abdominal cavity is performed. In the presence of viscero-parietal adhesions, adhesiolysis is performed.

Free fluid is aspirated from the abdominal cavity followed by an urgent cytological examination.

The patient is transferred to the Trendelenburg position. The main surgical stage begins with bipolar coagulation of the fallopian tubes on both sides, in the area of the isthmus, the own ligaments of the ovaries and round ligaments, with the intersection of the latter. Using the clamp, the medial end of the uterine round ligament is taken up and back, and the anterior leaf of the wide uterine ligament is dissected medially to the bladder in the oblique direction. The stump of the round ligament of the uterus is moved to the anterior abdominal wall and laterally. As a result, the posterior leaf of the broad ligament in the form of a “sail” becomes available. After a topographic and anatomical assessment of the location of the vessels of the funnel-pelvic ligament and ureter, a partly sharp, partly obtuse way is made to form a “window” in such a way that its sides are in front and laterally - the funnel-pelvic ligament and ovary, behind and medially - the ureter and rib uterus. These manipulations are performed on the opposite side. The funnel-pelvic ligaments coagulate and cross on both sides.

This stage provides partial access to the parameter spaces. Next, clipping of the uterine vessels from the most convenient access without using the uterine manipulator is performed. For this purpose, focusing on the medial umbilical fold on the anterior abdominal wall, the umbilical artery trunk is separated from the paravisical space, separated proximal to the level of discharge in the medial direction of the uterine artery, under which the same veins are located. At a distance of 1 cm from the internal iliac vessels, they are individually clipped with two tantalum clips.

Thus, doping of the main vascular structures involved in the blood supply to the uterus, as well as the fallopian tubes, is ensured.

The cervical canal is dilated with 8.5 mm Geghar expanders, respectively. The tip of the uterine manipulator is inserted into the uterine cavity.

The uterus is diverted in the opposite direction from performing lymphadenectomy. In this position, maximum visual control of the surgical field is ensured. Fiber and lymph nodes are removed along the common and external iliac vessels and from the obstructive areas. The conditional anatomical boundaries of lymphadenectomy performed are: proximal - 2 cm higher - bifurcation of the common iliac vessels, distal - vein, envelope of the ilium, lateral - iliac-lumbar muscle, medial - umbilical artery, posterior - obturator nerve. The removed fiber in a single block separately on each side is placed in airtight containers, removed from the abdominal cavity.

At the final stage of the operation, the main vascular bundle of the uterus is separated distally, the mobilized uterus is cut off from the vagina at the level of the arches, evacuated from the abdominal cavity with the removed pelvic tissue through the vagina. The vagina is sutured tightly with separate interrupted 8-shaped sutures.

The operation is completed by repeated video audit with additional hemostasis, abdominal drainage is performed with a single-lumen silicone drainage introduced into the Douglas space through one of the trocars installed in the iliac regions.

In the postoperative period, a standard complex of therapeutic measures is carried out, including antibacterial, infusion and anti-inflammatory therapy.

In the case of an uncomplicated course of the postoperative period, the patient can be discharged for 4-5 days.

Further therapeutic tactics are developed according to generally accepted standards for the treatment of malignant tumors of the uterus, depending on the results of a planned histological examination of the removed drugs.

Execution example

Patient C., 60 years old. Clinical diagnosis: Endometrial Cancer IB st T1bNoMo. Concomitant diseases: Chronic pancreatitis, chronic gastritis without exacerbation. Hypertension of the II stage, II degree. Risk 3.

Anamnesis. In October 2011, the patient underwent cervicogysteroscopy with separate diagnostic curettage of the uterine cavity for bleeding from the genital tract against the background of 6 years of postmenopause at the place of residence. A histological examination in a scraping from the uterine cavity (glasses of preparations were consulted at the P. Herzen Moscow Scientific Research Institute for Advanced Research) show a moderately differentiated endometrioid adenocarcinoma. For further examination and treatment, she turned to the Moscow Scientific Research Institute of Medicine. P.A. Herzen.

With a comprehensive preoperative follow-up examination: moderately differentiated endometrioid adenocarcinoma of the uterine body, with invasion of the myometrium to a depth of 1/3. In November 2012, at the Moscow Scientific Research Institute for Advanced Medicine - laparoscopic extirpation of the uterus with appendages, iliac-obstructive lymphadenectomy.

With the use of bipolar coagulation, the fallopian tubes are alloyed on both sides, in the isthmus, their own ligaments of the ovaries, round and funnel-pelvic ligaments, with the intersection of the latter. The umbilical artery trunk was isolated from the paravizical space, separated proximal to the level of discharge in the medial direction of the uterine artery, under which the veins of the same name are located. At a distance of 1 cm from the internal iliac vessels, they were separately clipped with tantalum clips.

The cervical canal is enlarged with 8.5 mm Geghar expanders, respectively. The tip of the uterine manipulator is introduced into the uterine cavity.

Fiber and lymph nodes were removed along the common and external iliac vessels and from the obturator areas. The removed fiber in a single block is removed from the abdominal cavity separately on each side in airtight containers.

The main vascular bundle of the uterus is separated distally, the mobilized uterus is cut off from the vagina at the level of the arches, evacuated from the abdominal cavity. The vagina is tightly sutured with separate interrupted 8-shaped sutures.

The duration of the operation is 180 minutes, minimal blood loss. During the extirpation of the uterus, repeated repeated coagulation was not required at the stage of separation of the vascular bundle and dissection from the vagina, an aspirator-irrigator was not used, and the maximum visual control of the surgical field was ensured.

Smooth postoperative period. Drainage removed on the 4th day. In a planned histological examination, a moderately differentiated endometrioid adenocarcinoma of the uterine body, with an invasion of the myometrium of 4 mm (thickness of the myometrium of 15 mm). Given the prevalence of the tumor process with a slight invasion of the myometrium (up to 1/3), the volume of surgical intervention performed, despite the moderate degree of tumor differentiation, it was decided to abstain from adjuvant radiation therapy. The patient in satisfactory condition was discharged from the hospital on the 6th day after the operation.

Thus, the patient was diagnosed with cancer of the uterus of the uterus. In stage I, a radical amount of surgery was performed by laparoscopic access, and strict dynamic observation was recommended. One year after surgical treatment, data for relapse were not obtained.

Claims (1)

A method of treating patients with malignant tumors of the uterus of the uterus stage I by surgical intervention in the volume of laparoscopic extirpation of the uterus with iliac-obstructive lymphadenectomy, characterized in that the surgical intervention is performed in the following sequence: bipolar coagulation of the fallopian tubes, own ligaments of the ovaries, round and funnel-pelvic uterine ligaments with the intersection of the latter, perform clipping of the uterine arteries and veins at a distance of 1 cm from the place of their departure from the internal of ileal vessels, the tip of the uterine manipulator is inserted into the uterine cavity, pelvic fiber with lymph nodes along the external iliac vessels and from the obturator areas are removed, it is evacuated from the abdominal cavity separately on each side in sealed containers, the uterus with appendages is extirpated, which is removed from the abdominal cavity through vagina.