RU2559281C1 - Method for uterine suture reinforcement in caesarean section with using synthetic prosthetic implant - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: mesh prosthetic implant flap exceeding a size of an uterine wound defect cover a repaired uterine incision. One interrupted suture fixes a flap centre. Flap angles are fixed with separate interrupted sutures within healthy tissues. The flap edges are underrun with interrupted sutures at an equal distance of no more than 3 cm from each other with synthetic absorbable filaments. From above the prosthetic implant, separated edges of leaves of an intestinal peritoneum are brought together, and a continuous twisted suture is applied.

EFFECT: method ensures the scar durability and makes it possible to ensure the following normal delivery by prosthetic reinforcement and formation of a connective tissue capsule in the thinnest lower segment.

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Description

The method relates to medicine, namely to surgical obstetrics, and can be used to strengthen the suture on the uterus during cesarean section.

The postulate "once a cesarean section is always a cesarean section" does not satisfy many surgeons, since repeated surgical labor is not such a harmless operation (Abramchenko VV, 2000). All this dictates the need for further development of the problem of the formation of a full uterine scar capable of withstanding the load during subsequent pregnancy and childbirth, introducing appropriate adjustments in surgical obstetrics. One of the promising areas of scientific research should be recognized as the development and improvement of new ways to restore the integrity of the uterus, creating optimal conditions for its healing. (Krasnopolsky V.I., 2007).

Currently, the evolution of the technique for restoring uterine integrity has gone through a number of stages: separate, continuous, one-, two-, three-layer sutures were used, with and without endometrial puncture (Dodd J.M .. 2008). Special sophisticated options were also proposed (Karimov Z.D., 2001). The advantage of individual sutures is a better comparison for torn wound edges that do not coincide in thickness, whereas with a continuous suture, the technique is simpler, the duration of the operation is reduced, and the amount of suture material is reduced.

Comparison of a single-layer and two-layer wound closure technique shows that the first is combined with less blood loss, the duration of the operation, and also reduces the severity of pain in the postoperative period. (Bamigboye A.A., 2003).

In this regard, from the late 1990s - early 2000s. The technique of continuous single-layer suture on the uterus is recommended for suturing a wound of the uterus with cesarean section in most studies and has spread widely around the world. (O.R.Baev, R.G. Shmakov. The modern technique of cesarean section surgery in evidence-based medicine. Obstetrics and gynecology 2013.-No. 2. - S. 129-135).

The disadvantages of this method are: 1) poor comparison of the edges of the wound with unequal thickness of the edges of the section; 2) the need for additional hemostatic sutures; 3) a high percentage of postoperative complications, the most important of which is the inconsistency of the postoperative scar during repeated births.

The analysis performed indicates that in the literature there are no data on the use of mesh materials to strengthen the sutures on the uterus.

Closest to the proposed method is a method of restoring the lower segment of the uterus during cesarean section (application for the invention of the Russian Federation No. 20011112517). The authors propose "an additional comparison of the upper edges of the wound, departing from 0.2-0.1 cm from the edge to a depth of 0.1 cm with picking up the superficial fascia."

The disadvantages of this method are: 1) a high probability of insolvency of scars during subsequent pregnancy and childbirth; 2) a high incidence of postoperative complications; 3) the inability to strengthen with a sharply thinned lower segment of the uterus.

Technical result: to propose a method for strengthening the postoperative scar on the uterus, which allows to prevent the progression of anatomical and functional insufficiency of the lower segment of the uterus during repeated operations, to reduce the incidence of insolvency of postoperative scars on the uterus.

The technical result is achieved by the fact that after applying a single-row twisted suture to the uterus, an additional mesh endoprosthesis flap is used that is 1 cm larger than the size of the wound defect of the uterus by 1 cm from each corner and edge of the uterine wound, a mesh endoprosthesis flap is applied to the reconstructed uterine incision, and a fixation the center of the flap of the mesh endoprosthesis, then the corners of the flap are fixed with separate nodal sutures within healthy tissues, after which the edges of the flap are also sutured with nodal sutures at an equal distance at an angle not exceeding 3 cm, from each other with synthetic absorbable sutures, the divorced edges of the leaves of the visceral peritoneum are brought together on top of the mesh of the endoprosthesis and a continuous twisted suture is applied.

The invention is illustrated by figures.

In FIG. 1 shows the reaction of uterine tissue on the 7th day of the experiment when using a uniflex-based endoprosthesis. Microphoto. Hematoxylin-eosin stain. SW X 100

In FIG. Figure 2 shows the reaction of uterine tissue on the 7th day of the experiment when using a uniflex-based endoprosthesis. Microphoto. Hematoxylin-eosin stain. SW X 400

In FIG. Figure 3 shows the reaction of uterine tissue on the 30th day of the experiment when using a uniflex-based endoprosthesis. Microphoto. Hematoxylin-eosin stain. SW X 100.

In FIG. Figure 4 shows the reaction of uterine tissue on the 30th day of the experiment when using a uniflex-based endoprosthesis. Microphoto. Hematoxylin-eosin stain. SW X 400.

In FIG. 5 shows the reaction of uterine tissue on the 60th day of the experiment when using a uniflex-based endoprosthesis. Microphoto. Hematoxylin-eosin stain. SW X 100.

In FIG. Figure 6 shows the reaction of uterine tissue on the 60th day of the experiment when using a uniflex-based endoprosthesis. Microphoto. Hematoxylin-eosin stain. SW X 400.

In FIG. 7 depicts the stage of the operation to restore the uterine incision in the lower segment with a single-row twisted suture with synthetic absorbable sutures

1 - The lower segment of the uterus;

2 - Visceral sheet of peritoneum;

3 - A section of the uterus in the lower segment;

4 - A single-row twisted suture on the uterus.

In FIG. 8 shows the stage of the operation to strengthen the suture on the uterus by fixing the mesh endoprosthesis with interrupted sutures

2 - Separated sheet of visceral peritoneum;

3 - The restored incision on the uterus;

5 - Mesh endoprosthesis;

6 - Fixation points of the mesh endoprosthesis with interrupted sutures.

In FIG. 9 shows the stage of peritonization of the uterus with visceral peritoneum

1 - The lower segment of the uterus;

5 - Fixed mesh endoprosthesis;

2 - A sheet of visceral peritoneum of the uterus;

7 - A single-row twisted stitch on the visceral peritoneum covering the reconstructed uterine incision with a mesh endoprosthesis.

THE METHOD IS CARRIED OUT AS FOLLOWS.

We performed a series of experimental studies using mesh Uniflex endoprostheses.

Surgery was performed under sterile conditions of the operating unit. A lower middle laparotomy was performed with a sexually mature female chinchilla rabbit without signs of disease. Made isolation "with sterile material. The body of the uterus with horns was taken to the wound. The visceral sheet of the peritoneum and uterus were cut in the longitudinal direction, separated from the body of the uterus, then after an additional dissection, the edges of the uterine incision 2 cm long were bluntly bred with a scalpel, and ligatures were applied to the corners. The uterine incision was restored with a continuous polyglycolide continuous suture. Of

the mesh endoprosthesis was cut with a flap for reliable fixation, 3.0 * 0.7 cm in size. The mesh endoprosthesis was fixed with nodal sutures on the uterine wall (myometrium) over the suture, within healthy tissues, the peritoneum was restored with a continuous twisted suture. Performed drainage of the abdominal cavity, layered restoration of the anterior abdominal wall.

Animals were removed from the experiment on days 7, 30, and 60.

Macroscopic analysis of changes in the abdominal cavity on the 7th day showed that animals in the area of the postoperative scar on the uterine wall have small point hemorrhages along the course of the scar on myometrium, tissue edema.

Macroscopic analysis of changes in the abdominal cavity on day 30 showed that animals had a mild adhesion process. There were minor edematous infiltrations in the area of mesh endoprosthesis implantation, thin fibrin deposits along the scar along the peritoneum.

On the 60th day: In the area of implantation of the mesh endoprosthesis, there are no signs of suppuration, no abscess formation. The mesh endoprosthesis is well fixed, no deformation of the uterine wall is detected.

Morphological study: When using “Uniflex” on the 7th day, the infiltrate area is insignificant, lymphocytes and plasmocytes predominate among the cells, there are few macrophages, and the edema is slightly expressed. The cellular component also prevails over the fibrous, capsule formation is observed (Fig. 1, 2).

When using Uniflex, a well-formed connective tissue capsule of high maturity is observed on day 30. Fibrocytes predominate in the fibrous layers of the capsule. Only resident cells are located in the cell layer of the capsule, with a significant predominance of fibrocytes, lymphocytes and plasmocytes are found between the threads of the mesh endoprosthesis, macrophages are found in isolated cases (Figs. 3, 4).

When using a uniflex, a well-formed connective tissue capsule consists of a dense fibrous connective tissue of a high degree of maturity, as evidenced by the high degree of oxyphilia of the fibers, their orderliness and the prevalence of fibroblast cells and fibrocytes among the cells. (Fig. 5, 6).

Conclusion: A morphological study of the reaction of uterine tissues to the use of mesh endoprostheses showed that when using uniflex-based endoprostheses, the degree of severity of reactive changes in tissues is inversely proportional to the duration of the experiment, and the degree of spatial organization of the capsule and the degree of maturity of the connective tissue are directly dependent on the duration of the experiment.

Histological examination (to assess the severity of the inflammatory or regenerative stage). To objectify the formation of a conclusion about the state of the inflammation process around the threads of the mesh endoprosthesis, we used the original method of calculating the cell index developed at the Department of Histology, GBOU VPO KSMU of the Ministry of Health of the Russian Federation according to the following formula:

where: resident cells - the total number of macrophages, fibroblasts and fibrocytes; non-resident cells - the total number of granulocytes (all three species), lymphocytes and plasmocytes recruited to the site of inflammation. S - the prevalence of the process (0.25 - the infiltrate uniformly covers the endoprosthesis thread around the entire perimeter and without a visible border passes into the fibrous part of the capsule, spreading to adjacent sections of the anterior abdominal wall; 0.5 - the infiltrate uniformly covers the endoprosthesis thread around the entire perimeter and without the visible of the border passes into the fibrous part of the capsule, not spreading to adjacent sections of the anterior abdominal wall; 0.75 - the infiltrate evenly covers the thread of the mesh endoprosthesis along the entire perimeter and is clearly delimited from the fibrous layer oia capsules; 1.0 - infiltrate is weak or is present only at one of the walls of the thread).

In order to confirm the statistical significance of differences in the composition of cell infiltrate in the compared groups of animals, after determining the values of the arithmetic mean and mean square deviation, we calculated the values of the confidence interval at a given value of p <0.05 and determined their discrepancy.

Received data:

Cell index with the use of mesh endoprosthesis Uniflex:

7 days - 0.75

30 days - 1,148

60 days - 2.27 *

* at p≤0.05

When performing the method in clinical conditions during cesarean section, the edges of the wound of the uterus are brought closer together, having previously separated the visceral sheet of the peritoneum. Impose a single-row continuous entwining seam with synthetic suture material (Fig. 7). Then, a mesh endoprosthesis flap is used that is larger than the size of the wound defect of the uterus by 1 cm from each corner and edge of the uterine wound. A mesh endoprosthesis flap is placed on the reconstructed uterine incision. With one nodal suture, the center of the mesh endoprosthesis flap is fixed. Then the corners of the flap are fixed with separate interrupted sutures within healthy tissues. After that, the edges of the flap are also sutured with interrupted sutures at an equal distance not exceeding 3 cm from each other in order to prevent trophic disorders in the uterine wall due to the frequent application of interrupted sutures (Fig. 8). Above the flap of the mesh endoprosthesis, the edges of the leaves of the visceral peritoneum are brought together. Fix its corners and impose a continuous twisting seam (Fig. 9).

Then, drainage of the abdominal cavity and layer-by-layer restoration of the anterior abdominal wall are performed.

The mesh endoprosthesis performs its fixing function due to the location of the fibers and the strength of the material and also the ability to form a strong connective tissue capsule that prevents thinning and rupture of the uterus in the thinnest and most malleable place - the lower segment, this ensures the quality of the postoperative scar and the possibility of labor through the birth canal.

SPECIFIC USE EXAMPLE

Surgery was performed under sterile conditions of the operating unit. A lower middle laparotomy was performed for a sexually mature female chinchilla rabbit without signs of disease weighing 2900 g. They made isolation with sterile material. The body of the uterus with horns was taken to the wound. Dissected the visceral sheet of the peritoneum of the uterus in the longitudinal direction, separated from the body of the uterus, then after additional dissection with a scalpel, the edges of the uterine incision 2 cm long were bluntly diluted, ligatures were applied to the corners. The uterine incision was restored with a continuous polyglycolide continuous suture. A flap was cut out of the mesh endoprosthesis for reliable fixation, 3.0 * 0.7 cm in size. The mesh endoprosthesis was fixed with interrupted sutures on the uterine wall (myometrium) over the suture, within healthy tissues, and the peritoneum was restored with a continuous upholstery. Performed drainage of the abdominal cavity, layered restoration of the anterior abdominal wall.

In the postoperative period, antibiotic prophylaxis was carried out for 3 days.

The postoperative period was uneventful, the animal was active, the appetite was preserved, and there was no hyperthermia.

Claims (1)

A method of strengthening the suture on the uterus during cesarean section using a mesh endoprosthesis, including the application of a single-row continuous suture with synthetic absorbable sutures, characterized in that they additionally use a mesh of the mesh endoprosthesis that is 1 cm larger than the size of the wound defect of the uterus from each corner and edge of the uterine wound impose a flap of the mesh endoprosthesis on the reconstructed uterine incision, fix the center of the flap of the mesh endoprosthesis with one nodal suture, then the corners of the flap fix a separate nodal sutures within healthy tissues, after which the edges of the flap are also sutured with nodal sutures at an equal distance not exceeding 3 cm, synthetic absorbable sutures from each other, the divorced edges of the leaves of the visceral peritoneum are brought together on top of the flap of the mesh endoprosthesis and a continuous twisted suture is applied.

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