RU2720081C1 - Method for laparoscopic correction of vaginal, uterine, bladder and rectal deposition - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to operative gynecology. Two autonomous synthetic implants are made from polypropylene mesh, which are placed in rectovaginal and uterine-vaginal-puzyr spaces, fixed behind to muscles raising an anus, to posterior wall of vagina and to cervix, in front – to anterior wall of vagina and to cervix. First implant having width of 5 cm and a length corresponding to the length from the fixation point to the muscles raising the anus to the fixation point to the uterine cervix is placed longitudinally in the rectovaginal space between the posterior wall of the vagina and the rectum. Second is a basic implant having length of 15 cm and a width which is determined by the degree of prolapse and corresponds to the distance from the point of upper fixation – cervical uteri – to the point of lower fixation – vagina is arranged in the transverse direction. Z-shaped sutures are fixed with non-absorbable suture material from both sides to lateral scallop ligaments.

EFFECT: method enables providing more effective surgical management of anterior, posterior and, primarily, apical prolapse, reducing a risk of postoperative complications due to the fact that the surgical intervention is carried out at a greater distance from the important anatomical structures compared to other methods: iliac vessels, sacral artery, epigastric nerve, obstruction vessels and nerves, corona mortis, the method allows not to remove uterus in surgical treatment of pelvic lowering in females.

1 cl, 4 dwg, 2 ex

Description

The invention relates to medicine, in particular to obstetrics-gynecology and can be used for surgical correction of prolapse of the walls of the vagina, uterus, bladder and rectum.

K.G. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study / K.G.

S. Schiermeier, I. Alkatout [et al.] // J. Endourol. - 2015.- Vol.29, №2. - P. 210-215; Wagner, L. Laparoscopic sacrocolpopexy for pelvic organ prolapse: guidelines for clinical practice / L. Wagner, G. Meurette, A. Vidart [et al.] // Prog. Urol. - 2016. - Jul. 26, Suppl. 1. - P. 27-37]. Основные недостатки, о которых чаще всего говорят, - это длительность операции и сложность ее выполнения. Кроме того, многие методики эндоскопической сакрокольпопексии связаны с удалением матки, что приветствуется не всеми пациентками.The problem of surgical correction of genital prolapse today for many reasons remains very relevant and is probably far from the final solution. The most difficult and key for pelvic floor surgery are apical prolapses, when in addition to the reconstruction of fascial defects, it is necessary to solve the suspension problems. And promontofiksatsiya successfully solves them, being pathogenetically substantiated with this type of prolapse

KG Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study / KG

S. Schiermeier, I. Alkatout [et al.] // J. Endourol. - 2015.- Vol.29, No. 2. - P. 210-215; Wagner, L. Laparoscopic sacrocolpopexy for pelvic organ prolapse: guidelines for clinical practice / L. Wagner, G. Meurette, A. Vidart [et al.] // Prog. Urol. - 2016 .-- Jul. 26, Suppl. 1. - P. 27-37]. The main disadvantages that are most often talked about are the duration of the operation and the complexity of its implementation. In addition, many endoscopic sacrocolpopexy techniques are associated with removal of the uterus, which is not welcomed by all patients.

Currently, alternative methods of laparoscopic correction of the prolapse and prolapse of the apical and anterior vagina and cystocele [Subbotin D.N., Kiselev S.N., Belosludtsev D.N. Application 2017127673 RU PMK А61В 17/42. Method; publ. 09/05/18]. The melon method involves the installation of a synthetic implant from a polypropylene mesh between the posterior wall of the bladder and the pubocervical fascia within the borders of the internal opening of the urethra to the cervix. Fixation of the implant is carried out by removing the sleeves of the mesh into the subcutaneous region through the pubocervical and transobturator fascia. The opposite narrow part of the implant is attached to the sacral ligament. The specified analogue of the invention is successfully used in surgery, but has limitations in terms of correcting only apical prolapse, prolapse of the anterior vagina and cystocele. In addition, for reliable fixation of the mesh implant to the dense structures of the pelvis (sacral ligament), the method involves the absence of the uterus or its removal.

K.G. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study /K.G.

S. Schiermeier, I. Alkatout [et al.] // J. Endourol. - 2015. - Vol.29, №2. - P. 210-215]. Данный способ взят за прототип. Предложенная методика заключается в фиксации шейки матки к латеральным и каудальным отделам гребешковых связок (связки Купера, lig. Iliopectineum). Доступ к гребешковым связкам начинается с выделения наружных подвздошных вен и продолжается медиально и каудально. Для фиксации шейки матки или купола влагалища к гребешковым связкам используется монофиламентная синтетическая сетка размерами 3×15 cm (DynaMesh® PVDF). Но описанная методика имеет ограничения в части коррекции только апикального пролапса. Кроме того, перед фиксацией сетчатого импланта к шейке матки авторы также рекомендуют проводить субтотальную гистерэктомию. Помимо этого, дисекция гребешковых связок от латеральных ее отделов к медиальным (от наружных подвздошных вен) технически сложнее в виду близкого расположения запирательных сосудов и нервов (a. et v. Obturatoria, n. Obturatorius) и опасности повреждения анастомоза между запирательной артерией и нижней надчревной артерией (corona mortis).Closest to the technical solution is a new method of endoscopic correction of apical prolapse of genitalia in obese women in view of the technical complexity of performing promontofixation in them

KG Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study / KG

S. Schiermeier, I. Alkatout [et al.] // J. Endourol. - 2015. - Vol.29, No. 2. - P. 210-215]. This method is taken as a prototype. The proposed method consists in fixing the cervix to the lateral and caudal sections of the scallop ligaments (Cooper ligament, lig. Iliopectineum). Access to the scallop ligaments begins with the allocation of the external iliac veins and continues medially and caudally. To fix the cervix or the dome of the vagina to the scallop ligaments, a monofilament synthetic mesh 3 × 15 cm in size (DynaMesh® PVDF) is used. But the described technique has limitations in terms of correcting only apical prolapse. In addition, before fixing the mesh implant to the cervix, the authors also recommend a subtotal hysterectomy. In addition, the scission of scallop ligaments from its lateral to medial (from the external iliac veins) is technically more difficult due to the close location of the obstructive vessels and nerves (a. Et v. Obturatoria, n. Obturatorius) and the risk of damage to the anastomosis between the obstructive artery and the lower epigastric artery (corona mortis).

From the analysis of patent and specialized literature, we found that the proposed technical solution has features that distinguish it not only from the prototype, but also from other technical solutions in this field of medicine.

The basis of the invention is the task of improving the laparoscopic organ-preserving correction of prolapse of the walls of the vagina, uterus, bladder and rectum.

To solve this problem, at the first stage of the operation, scallop ligaments (Cooper ligaments, lig. Iliopectineum) are extracted 3-4 cm laterally than obliterated lateral umbilical arteries (a. Umbilicalis lateralis) and more medially than obturator vessels and nerves (a. Et v. Obturatoria , n. Obturatorius). To do this, using bipolar coagulation, the peritoneum is opened over the inner surfaces of the pubic bones at the level of obliterated umbilical arteries with further disection laterally and caudally. This area is the safest for fixing synthetic mesh implants. The next stage of the operation is the dissection of the uterine-vaginal-cystic and rectovaginal spaces. The degree of disection directly depends on the severity of prolapse.

After that, they begin to install and fix synthetic mesh implants from a polypropylene mesh. The 1st implant installed in the recto-vaginal space between the posterior wall of the vagina and the rectum has a characteristic shape (Fig. 1), width up to 5 cm, the length depends on the distance from the point of distal fixation (m. Levator ani) to the point ventral fixation (cervix). To fix the implant to m. levator ani uses a synthetic absorbable suture material with a long absorbable period; non-absorbable suture material is used for fixation to the posterior wall of the cervix (Fig. 2). The 2nd implant, which is installed in the utero-vaginal-cystic space between the bladder and the pubocervical fascia, has a rectangular shape 15 cm long, the width directly depends on the severity of prolapse and varies on average from 5 to 7 cm (Fig. 3). The front implant is evenly fixed to the front wall of the vagina from the internal opening of the urethra to the cervix with non-absorbable suture material (Fig. 4). After installing mesh implants in these spaces, the uterus is “exposed” in the correct position (entrance level to the small pelvis, S1-S2). The lateral sections of the anterior mesh implant are tightly fixed to the scallop ligaments (Cooper ligaments) with Z-shaped sutures using non-absorbable suture material (pectopexy is performed) so that the uterus is located in the small pelvis freely, without tension. The strength and integrity of the design is ensured by tight fixation of the implants to the cervix in front and back. The final stage of the operation is peritonization of mesh implants.

Example 1

Patient F., 68 years old, medical history No. 115738, was admitted to the gynecological department of the Clinic of South Ural State Medical University on 12.12.18 with complaints of a foreign body feeling in the perineum. Drawing pains in the lower back, lower abdomen.

Diagnosis at admission: Genital prolapse (genital prolapse) III. Incomplete prolapse of the uterus and vagina. Cystocele. Enterrocele. Code according to MKB-10.N81.2.

Staging of prolapse according to the classification of POP-Q: Aa + 2; Ba + 3; C + 4; D + l; Ar + 2; Bp + 1; tvl 10.

Surgical treatment was performed in a planned manner in the amount of: Laparoscopy. Complete reconstruction of the pelvic floor using two Gineflex mesh implants (Pectopexy of the walls of the vagina, cervix, bladder).

Blood loss was 30.0 ml. The duration of the operation is 2 hours 40 meters.

Treatment: antibiotic prophylaxis, prevention of pulmonary embolism, analgesia.

The course of the postoperative period without features. Suture healing by primary intention. The patient was discharged from the department without complaints on the 5th day under the supervision of a doctor of female consultation.

Inspection results after 3 months:

There are no complaints.

Status genitalis data: pink mucous membrane of the vagina; mesh implants are not palpable. The prolapse staging according to the POP-Q classification corresponds to: Aa-3; Ba-3; C-7; D-9; Ar-3; VR-3; tvl 10.

Example 2

Patient K., 55 years old, case history No. 120707, was admitted to the gynecological department of the Clinic of South Ural State Medical University 03/21/19 with complaints of a foreign body feeling in the perineum. Drawing pains in the lower back, lower abdomen, difficulty urinating, which were corrected by the reduction of the bladder, constipation.

Diagnosis: Genital prolapse (genital prolapse) IV. Complete prolapse of the uterus and vagina. Cystocele. Enterrocele. Rectocele 2. Code according to MKB-10.N81.3.

Staging of prolapse according to the classification of POP-Q: Aa + 2; Ba + 5; C + 8; D + 5; Ar + 3; Bp + 5; tvl 10.

Surgical treatment was performed in a planned manner in the amount of: Laparoscopy. Complete reconstruction of the pelvic floor using two Gineflex mesh implants (Pectopexy of the walls of the vagina, cervix, bladder).

Blood loss was 50.0 ml. The duration of the operation is 3 hours 10 m. Treatment: antibiotic prophylaxis, prevention of pulmonary embolism, analgesia.

The course of the postoperative period without features. Suture healing by primary intention. The patient was discharged from the department without complaint on the 6th day under the supervision of a female doctor.

Inspection results after 3 months:

There are no complaints.

Status genitalis data: pink mucous membrane of the vagina; mesh implants are not palpable. The prolapse staging according to the POP-Q classification corresponds to: Aa-2; Ba-2; C-6; D-8; Ar -2; VR-2; tvl 10. There is no rectocele.

Thus, the proposed method allows to increase the effectiveness of surgical treatment of anterior, posterior and, first of all, apical prolapse, to reduce the risk of postoperative complications due to the fact that the surgical intervention is carried out at a greater distance, compared with other surgical methods, from important anatomical structures ( iliac vessels, sacral artery, epigastric nerve, obstructive vessels and nerves, corona mortis). In addition, the method makes it possible not to remove the uterus during surgical treatment of prolapse of the pelvic organs in women, which is very important for many patients.

Claims (1)

The method of laparoscopic correction of the prolapse of the walls of the vagina, uterus, bladder and rectum by installing two autonomous synthetic implants made of polypropylene mesh, which are located in the rectovaginal and uterine-vaginal-vesicular spaces, is fixed back to the muscles that raise the anus, to the back wall of the vagina and to the cervix, in front to the anterior wall of the vagina and to the cervix, characterized in that the first implant having a width of 5 cm and a length corresponding to the length from the fixation point to the muscles under dull the anus, to the fixation point to the cervix, set longitudinally in the rectovaginal space between the posterior wall of the vagina and the rectum, and the second is a basic implant having a length of 15 cm and a width that is determined by the degree of prolapse and corresponds to the distance from the upper fixation point - the neck the uterus - to the point of lower fixation - the vagina, is placed in the transverse direction, fixed with Z-shaped sutures with non-absorbable suture material from both sides to the lateral parts of the scallop ligaments.

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