RU2727758C1 - Method for surgical treatment of anterior-apical prolapse of genitals - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to urogynecology. Implant is made from light polypropylene mesh in form of isosceles trapezoid with individual sizes for each patient, which are determined as follows: trapezoid height is equal to the distance from the introitus to the vaginal vault top, the wide trapezoid base being the front part of the implant is equal to half the distance between the inner surfaces of the ischial knots plus two centimeters, narrow trapezoid base, which is the rear part of the implant, is equal to the cervix width plus two centimeters. After that, to the sides of the mesh, 1–1.5 cm from the angles adjacent to the wide trapezoid base, the non-absorbable thread is fixed symmetrically to the left and to the right with two front polypropylene sleeves one centimeter wide and ten centimeters long. Anterior colpotomy is performed with compulsory dissection of the pubis-cervical fascia; a wide mobilization of the posterior wall of the bladder and its right and left lateral sides is performed; a paravaginal space and space around the foramen obturatum are exposed. In addition, from polypropylene mesh tape is made with width of one centimeter and length of twenty centimeters, to the middle part of which the narrow trapezoid base of the implant is fixed with separate interrupted sutures with non-absorbable prolenic suture with the possibility of formation of two back sleeves, with fixation of the middle of the back part of the implant to the cervix of the uterus or to the vaginal vault – in the absence of the uterus and its neck. Front sleeves are delivered through the foramen obturatum on the right and on the left; the rear sleeves of the implant are brought out into the abdominal cavity. Mesh polypropylene implant is placed under the pubis-cervical fascia, finally stretched and without tension is placed under the posterior wall of the urinary bladder. Vaginal mucosa is closed without excising an excess of vaginal mucosa, laparoscopic or laparotomy approach to the abdominal cavity. Back arms of the polypropylene implant are fixed to the Cooper ligament with the fixation device (hernia stapler) or by separate sutures with non-absorbable suture material; the cervix of the uterus and vagina in the form of a hammock is fixed. Peritonisation of the implant is ensured by a continuous suture with an absorbable suture material, sutures are applied on trocar wounds or a laparotomy wound is closed.EFFECT: method enables reliably eliminating anterior-apical prolapse and reducing the number of intraoperative and postoperative complications, such as erosion, contraction of the prosthesis, pyoinflammatory complications.1 cl, 2 dwg, 3 ex

Description

The invention relates to medicine, namely, to urogynecology, and can be used for the surgical treatment of anterior apical prolapse of the genitals (PG).

The problem of surgical treatment of PH remains very urgent. The prevalence of PH in women is 11.4-41%, with a tendency to increase with age (2.7-11%) and the risk of surgery for this disease (Malkhasyan V.A., 2012; Nygaard I., 2013).

The only effective method of treating PG is surgical. Currently, over 300 methods of surgical correction of PG are known (Radzinsky V.E., 2010; Barber M.D., 2013). The goals of surgical treatment of PG are to get rid of symptoms, to instantly restore the normal anatomical position of the organs involved in prolapse, to eliminate all disorders in the structure of the pelvic floor, to restore the function of the pelvic organs. It is fundamentally important to use minimally invasive surgical interventions that give the minimum number of relapses (Totchiev G.F., 2006; Shkarupa D.D., 2013). As a rule, surgical correction of PG using one's own tissues is associated with a risk of recurrence up to 40% due to the failure of one's own tissues (Sharifulin M.A., 2012, Maher C, 2016). Currently, many options for surgical correction of PG using mesh implants have been proposed, which are conditionally subdivided by the type of access used (vaginal, abdominal, or a combination of vaginal and abdominal) and by the method of the biomechanical fixation model - rigid fixation to the pelvic walls or restoration of the supporting structures of the pelvic floor ( Malkhasyan V.A., 2012; Cvach K., 2012; Marks V.K., 2012; Maher S., 2013).

Modern surgical concept of pelvic floor plasty

is based on replacing the damaged and defective pelvic fascia with a new one (creation of neofascia), which is pathogenetically justified and provides a reliable framework for the pelvic organs (Radzinsky V.E., 2010; Malkhasyan V.A., 2012; Sharifulin M.A., 2012 ). The studies have shown the advantages of using synthetic polypropylene nets, the efficiency of which reaches 81-95.8% (Abramyan K.N., 2011; Salimova L.Ya-k., 2012; Shkarupa D.D., 2015; Altman D., 2011 ; Withagen, M.I., 2011).

The most common form of PG is cystocele, which occurs in a third of women aged 50-79, regardless of the position of the uterus. Moreover, in 80% of cases there is a combination of cystocele with apical prolapse (Hendrix SL, Clark A, Nygaard I, et al., 2002; Rooney K, Kenton K, Mueller ER, et al., 2006; Elliott CS, Yeh J, Comiter CV, et al. 2013).

Effective elimination of anterior apical genital prolapse is possible only with the use of full-size mesh implants, which restore damaged structures that keep the uterus in a normal position and replace the damaged vesicovaginal fascia. The existing mesh systems for the restoration of anterior apical prolapse differ in the method of insertion or fixation of the implant sleeves to the anatomical structures of the pelvic floor (obturator membrane, sacrospinous ligaments) into trocar (Pelwix, Lintex; Kit-Nazca, Promedon) and non-trocar (InGYNious, "AM 1."; Calistar A, "Promedon"). The greatest experience in the correction of anterior apical PG in the world has been accumulated with the use of the Elevate Apical & Anterior (AMS) kit - a polypropylene mesh implant with four sleeves for non-troacar fixation, the anterior pair is fixed to the obturator complex, the posterior pair - to the sacrospinous ligaments. The effectiveness of this mesh set at two-year control is in the range of 89.0-90.0% [Castellani D, Galica V, Saldutto P, et al. 2017; Su TH, Lau HH, Huang WC, et al. 2014; Rapp DE, King AB, Rowe B, Wolters JP. 2014; Shkarupa D.D., Kubin N.D., Popov E.N., et al., 2018]. However, to date, the Elevate Apical & Anterior Kit (AMS) has left the market due to the closure of the production of this product.

With all the advantages of using mesh systems for PH correction, the risk of specific complications remains:

1) intraoperative (damage to the rectum, urinary bladder, lower gluteal vessels, pudendal nerves and blood vessels, sciatic nerve), associated with the "blind" passage of trocars through the obturator and ischiorectal spaces, the iliococcygeus muscle and the sacrospinal ligament;

2) mesh - associated (erosion of the vaginal mucosa; erosion of the bladder mucosa; urethro-vaginal fistula; prosthesis wrinkling; chronic pain syndrome; infection and extrusion of meshes) [Abramyan KN, 2011; Withagen, M.I., 2011; Shkarupa D.D., 2013; Brennand E.A. et. al, 2014].

There is a known method for fixing the dome of the vagina to the sacro-uterine ligaments in the surgical treatment of prolapse of the genitals after vaginal hysterectomy (Patent RU No. 2522399, published on July 10, 2014, IPC: А61В 17/42), in which a bilateral suture is performed, which combines the pubocervical and rectovaginal fascia at the edges of the wound of the formed dome of the vagina, characterized in that in the area "1 hour" of the anterior fornix of the vagina with one suture, the peritoneum of the vesicouterine fold, the pubocervical fascia and the vagina are sequentially stitched; in the "2 o'clock" area, the wall of the vagina is stitched with an injection into the peritoneum; the proximal part of the left sacro-uterine ligament is sutured caudal to the ischial spine; from the left sacro-uterine ligament, the peritoneum of the Douglas space in the "5 o'clock" area and the rectovaginal septum with a puncture in the vagina are stitched; in a similar way, the opposite end of the suture is passed symmetrically through the 11 o'clock, 10 o'clock areas, the proximal part of the right sacro-uterine ligament and the 7 o'clock area; the ends of the thread, brought out through the posterior fornix of the vagina, are formed into a knot, smoothly pulled together with the simultaneous advancement of the formed dome of the vagina in the direction of the sacral cavity. The disadvantages of this method of treating PG are:

1) the impossibility of eliminating apical prolapse (prolapse of the uterus) without removing it, and currently, removal of the uterus without indications is not a method of treating PG;

2) the inability to eliminate posthysterectomy apical prolapse, since it will no longer be possible to differentiate the sacro-uterine ligaments;

3) the use of one's own tissues to eliminate PH as mentioned above is associated with a high risk of recurrence of PH;

4) it is impossible to apply this method of treating isolated cystocele.

A known method for the treatment and prevention of posthysterectomy prolapse in previously operated women (Patent RU No. 2446750, published on April 10, 2012, IPC: A61B 7/00), in which vaginal access to the vaginal dome is performed. Then the dome of the vagina, the stumps of the cardinal and sacro-uterine ligaments are extraperitoneally rigidly fixed with a thread to the middle of a synthetic tape measuring 1.5 × 50 centimeters. With a measuring tape, measure the distance from the introitus to the top of the dome of the vagina and set aside the resulting indicator from the middle of the synthetic tape in opposite directions, adding four centimeters to it on each side, and make marks with a marker. Further, two centimeters above the pubic articulation, along the midline, a skin incision is made two centimeters long, and then bilaterally, departing from it three to four centimeters in each direction, two similar incisions are made. Then the synthetic tape is passed through the urogenital diaphragm in the paravesical space with perforation of the aponeurosis of the external oblique muscle of the abdomen and is removed through the lateral skin incisions on the anterior abdominal wall from the corresponding side. By the edges of the synthetic tape, the dome of the vagina is pulled up to the previously applied mark. After that, both free ends of the synthetic tape are passed in the subcutaneous fatty tissue over the aponeurosis and taken out through the midline incision, where they are fixed to each other with a prolene thread, and then freely immersed in the subcutaneous fatty tissue without rigid fixation to the aponeurosis.

The disadvantages of this method of treating pelvic prolapse is that its use is possible only in the case of vaginal hysterectomy or with the development of recurrence of apical PG after a previously underwent hysterectomy, that is, it is impossible to apply this method of treating an isolated cystocele or a combination of apical with anterior PG. Passing a synthetic tape through the urogenital diaphragm in the paravesical space is associated with the risk of developing complications such as perforation of the bladder, bleeding from the vessels of the paravesical tissue with the formation of a hematoma.

Closest to the proposed method is the method of vaginal extraperitoneal colpopexy perforated

polypropylene implant (Patent RU No. 2538796, published 01/10/2015, IPC: A61B 17/42), which is selected as a prototype. The method includes a subfascial vaginal installation of a perforated polypropylene implant (with individual dimensions for each patient) in the form of a trapezoid with two sleeves, with these sleeves being passed through the obturator holes, with fixing the posterior edge of the polypropylene mesh to the paracervical tissues while preserving the uterus or to the McCall suture when performing hysterectomy, and its anterior edge - to the pubic-cervical fascia at the anterior incision of the vagina, with suturing of the vagina without excision of excess mucosa.

The disadvantage of this method of surgical treatment of PG is the impossibility of eliminating prolapse and prolapse of the uterus while maintaining the latter.

The problem solved by the creation of this invention is to create a method that allows for the surgical treatment of anterior apical prolapse of the genitals, providing relief from symptoms, immediate restoration of the normal anatomical position of organs involved in prolapse, elimination of all disorders in the structure of the pelvic floor, restoration of the function of the pelvic organs ...

The technical result of the method of surgical treatment of anterior apical prolapse of the genitals is to reliably eliminate anterior apical prolapse with the possibility of reducing the number of intraoperative (bladder perforation, intestinal damage, bleeding) and postoperative (hematomas of the perineum and vagina, mesh-associated complications - erosion, wrinkling of the prosthesis , pyoinflammatory complications) complications in the correction of PH with the use of a polypropylene implant with combined (vaginal and abdominal) access, as well as with the possibility of reducing the frequency of PH recurrence.

The technical result is achieved due to the fact that the method of surgical treatment of anterior apical prolapse of the genitals consists in making an implant from a light polypropylene mesh in the form of an isosceles trapezium with individual dimensions for each patient, which are determined as follows: the height of the trapezoid is equal to the distance from the introitus to the apex of the vaginal dome, the wide base of the trapezium, which is the front of the implant, is equal to half the distance between the inner surfaces of the ischial tuberosities plus two centimeters, the narrow base of the trapezium, which is the posterior part of the implant, is equal to the width of the cervix plus two centimeters, after which to the lateral sides of the mesh, retreating 1-1.5 centimeters from the corners adjacent to the wide base of the trapezoid, with a non-absorbable suture, two front polypropylene sleeves, one centimeter wide and ten centimeters long, are fixed symmetrically to the left and right. The method differs from the prototype in that an anterior colpotomy is performed with obligatory dissection of the pubic-cervical fascia, a wide mobilization of the posterior wall of the bladder and its right and left lateral sides is performed, the paravaginal space and the space around the obturator openings are exposed. At the same time, in addition, a tape is made of a polypropylene mesh, one centimeter wide and twenty centimeters long, to the middle part of which the narrow base of the trapezium of the implant is fixed with separate interrupted sutures with a non-absorbable prolene thread with the possibility of forming two posterior sleeves, with fixing the middle of the posterior part of the implant to the cervix or to the dome vagina - in the absence of the uterus and its cervix. The front sleeves are passed through the obturator holes on the right and left. The posterior sleeves of the implant are brought out into the abdominal cavity. In this case, the polypropylene mesh implant is placed under the pubic-cervical fascia, finally straightened and without tension placed under the posterior wall of the bladder. In this case, the vaginal mucosa is sutured without excision of the excess vaginal mucosa. A laparoscopic or laparotomic approach is performed into the abdominal cavity. The back sleeves of the polypropylene implant are fixed to the Cooper's ligament using a herniostapler or separate sutures with a non-absorbable suture material, while the cervix and vagina can be fixed in the form of a hammock. Peritonization of the implant is performed with a continuous suture with absorbable suture material. Sutures are applied to trocar wounds or a laparotomic wound is sutured. A polypropylene implant installed by vaginal access restores the damaged vesicovaginal fascia, and the suspension of the implant fixed to the cervix and / or vagina with the back sleeves in the form of a hammock to the Cooper's ligaments on the left and right allows restoring the lost suspension ligamentous apparatus of the uterus and eliminating the anterior-apical prolapse genitals.

The essence of the invention is illustrated by Figs. 1 and FIG. 2. In FIG. 1 shows a schematic representation of a polypropylene implant for the correction of pelvic prolapse, including a polypropylene trapezoidal mesh 1, front sleeves 2, back sleeves 3.

FIG. 2 shows a schematic representation of the location of the polypropylene implant during the reconstruction of the pelvic floor with a combined approach for the anterior apical PG, where 4 is a polypropylene implant, 5 are obturator holes, 6 is the cervix, 7 is the uterus, 8 is the bladder, 9 is Cooper's ligament, 10 - iliac vessels.

The method of surgical treatment of anterior apical genital prolapse is carried out by reconstruction of the pelvic floor with a polypropylene implant with a combined approach as follows.

Under aseptic conditions under endotracheal anesthesia, the patient is placed on the operating table with the legs spread apart, laid on the leg supports (lithotomy position). By giving the Trendelenburg position 30 °, the intestinal loops are displaced from the pelvic cavity. The operating field is processed. In the bladder cavity, a Foley urethral catheter No. 16-20 according to Ch. A vaginal speculum is inserted into the vagina, the cervix is fixed with bullet forceps. Hydropreparation of anterior wall tissues

vagina with saline NaCl in an average volume of forty milliliters with the introduction of the latter under the pubic-cervical fascia. An incision is made in the anterior wall of the vagina with the obligatory dissection of the vaginal mucosa, and the pubic-cervical fascia, retreating two to three centimeters proximal to the external opening of the urethra, not reaching the external os of the cervix by one and a half to two centimeters.

Acute and blunt way, the bladder is separated from the uterus. A wide mobilization of the posterior wall of the bladder and its lateral (right and left) sides is performed. The paravaginal space is exposed, the cellular space around the obturator openings is opened. Manually identify the lower branches of the pubic bones on both sides, the bony tubercle of the ischium, tendon arches of the intrapelvic fascia.

Skin incisions are made in the region of the left inguinal-femoral fold at the level of the clitoris, about 0.8 centimeters long. Further, under the control of the index finger with a guide needle with a cannula (tubular guides), the membrane of the obturator opening 5 is perforated on the left along the anteromedial edge, the needle is removed. As a result, one end of the tubular conductor exits through the skin of the inguinal-femoral fold, the other, perforating the membrane of the obturator opening, exits through the vagina. The installation of a special conductor on the right is carried out in a similar way. Through tubular guides (cannulas), retractors of the sleeves of the polypropylene mesh are installed.

The peritoneum is identified and opened in the area of the vesicouterine fold.

A future implant is cut out of an ultra-light polypropylene mesh (surface density 19 g / m ² ) in the shape of an isosceles trapezoid with individual dimensions for each patient. The height of the trapezium of the implant is equal to the distance from the introitus to the top of the vaginal dome. The wide base of the trapezium (the anterior part of the implant) is equal to half the transverse size of the pelvic outlet (the distance between the inner surfaces of the ischial tuberosities) plus two centimeters. The narrow base (the back of the implant) is equal to the width of the cervix plus two centimeters. Sleeves for the implant in the form of three strips are made of polypropylene mesh (surface density 40-60 g / m ² ). The front sleeves 2 are made in the form of two strips with the same dimensions: 1 cm wide and 10 cm long. The back sleeves 3 are made in the form of a strip 1 centimeter wide and 20 centimeters long. A narrow trapezoidal implant base is fixed to the middle of the strip with 3 separate interrupted sutures with a non-absorbable prolene suture 2/0. Two polypropylene sleeves 2 are symmetrically fixed to the corners of the wide base of the trapezoidal implant with separate interrupted sutures with a non-absorbable prolene suture 2/0: one on the right, the other on the left.

The middle of the anterior part of the polypropylene implant 1 is fixed to the pubic-cervical fascia at the anterior incision of the vagina with an interrupted suture with an absorbable suture (PGA 2/0, vicryl 2/0, USP 2/0), and the middle of the posterior part of the implant 1 is fixed with interrupted sutures with a non-absorbable suture material ( eg prolene 2/0, monophile 2/0, PDS) to the cervix 6 (or vaginal stump in the absence of a cervix). The left and right sleeves of the anterior part 2 of the implant 1 are held by retractors inside the tubular guides (cannulas) - from the inside (from the vagina) to the outside. Sleeves 3 of the back of the polypropylene implant 1 are brought out into the abdominal cavity. The polypropylene mesh implant 1 is finally straightened and placed without tension under the posterior wall of the bladder 8. The vaginal mucosa is sutured with a continuous suture with absorbable suture material (eg PHA 1, Vicryl 1, USP 1) without excising the "excess" of the vaginal mucosa. The tubular guides (cannulas) are removed, and the excess sleeves of the mesh prosthesis are cut off subcutaneously. The vagina is tightly tamponed with sterile napkins moistened with furacillin solution or saline NaCl solution.

Lower midline laparotomy or laparoscopy is performed. With laparoscopic access, CO2 - peritoneum is applied through the umbilical puncture with a Veress needle and a ten-millimeter trocar with a 30 ° laparoscope is introduced. Survey laparoscopy is performed. The rear sleeves 3 of the polypropylene mesh are visualized. Five-millimeter and twelve-millimeter trocars are inserted at standard points. The peritoneum is opened from the place where the polypropylene sleeves of the implant exit (from the place of the previously opened peritoneum in the region of the vesicouterine fold) along the round ligaments of the uterus 7 to the ileo-obturator region on the right and left. Anatomical landmarks are visualized on both sides - iliac vein 10, obturator nerve, Cooper's ligament 9 (ligamentum iliopectineale). The back sleeves 3 of the polypropylene mesh 1 are fixed to the Cooper's ligament 9 using a herniostapler or separate sutures with a non-absorbable suture material. The cervix 6 and the vagina are fixed in the form of a "hammock". Peritonization of the mesh is performed with a continuous suture with absorbable suture material. Sutures are applied to trocar wounds.

The effectiveness of the proposed method of surgical treatment of anterior apical prolapse of the genitals by reconstruction of the pelvic floor with a polypropylene implant with a combined approach is confirmed by clinical examples.

Example 1.

Patient M., 67 years old, was admitted to the hospital with complaints of a feeling of incomplete emptying of the bladder, a feeling of a foreign body in the vagina, the need to strain when urinating. From the anamnesis, she has been suffering from prolapse of the internal genital organs for two years, for the last six months she began to notice a deterioration - complaints about the feeling of incomplete emptying of the bladder, difficulty urinating began to worry. On physical examination: the general condition is satisfactory. The abdomen is of normal shape, not swollen, participates in the act of breathing, on palpation it is soft, painless. Symptoms of peritoneal irritation are negative. The kidney area is not visually changed. The kidneys are not palpable. Swinging of the lumbar region is painless on both sides. Diuresis is adequate. Stool - regular, daily. The external genitals are formed correctly according to the female type, the genital gap is gaping, the vaginal mucosa is pink, moist, without rashes. Outside the vulvar ring during straining, the anterior vaginal wall with unchanged mucous membrane is determined. The cervix is not changed. The uterus is not enlarged, the appendages are not determined, there is pathological mobility of the uterus - when straining, the cervix is determined at the level of the vulvar ring. Meatus is not visually changed, usually located. When coughing with a full bladder, there is no urine output in ortho and clinostasis. Dysuria is obstructive urination. Diagnosed with IV stage genital prolapse (according to POPQ classification): cystocele IV stage, apical prolapse stage III. Hypertension 2 tbsp., 3 tbsp., Risk 4. IHD, exertional angina 2 FC. According to laboratory and instrumental examination methods: general clinical and biochemical blood tests within the reference values, general urine analysis without pathology; according to echo sonography of the pelvic organs, no pathology was revealed, according to ultrasound examination of the perineum, there are signs of a defect in the vesicovaginal fascia. A combined access operation was performed under endotracheal anesthesia - reconstruction of the anterior pelvic floor with a polypropylene mesh with fixation of the anterior implant sleeves in the transobturator holes (vaginal stage) and suspension of the uterus, fixed to the posterior implant, with the posterior sleeves to the Cooper ligaments (laparotomic stage). In the postoperative period, anesthesia, anticoagulant therapy, and dressings were performed. The postoperative period was uneventful. Follow-up examination after 3, 6, 12, 24 months showed no recurrence of genital prolapse and no postoperative complications.

Example 2.

Patient C, 55 years old, was admitted to the clinic for planned surgical treatment with complaints of a sensation of a foreign body in the vagina, the need to strain while urinating, a feeling of incomplete emptying of the bladder, and frequent urination. From the anamnesis of the disease, it was found that the patient has been suffering from prolapse of internal genital organs for five years. A year and a half ago, an operation was performed: vaginal extirpation of the uterus, anterior and posterior colporrhaphy. During the year, complaints began to bother: a feeling of a foreign body in the vagina, frequent urination, a feeling of incomplete emptying of the bladder. A gynecologist diagnosed a relapse of genital prolapse. On physical examination: the general condition is satisfactory. The abdomen of the usual form, not swollen, participates in the act of breathing. Palpation of the abdomen is soft, painless. Symptoms of peritoneal irritation are negative. The kidney area is not visually changed. The kidneys are not palpable. Swinging of the lumbar region is painless on both sides. Diuresis is adequate. Dysuric phenomena - pollakiuria, obstructive urination. Stool - regular, daily. The external genitals are formed correctly according to the female type, the genital slit is gaping, outside the Boulevard Ring, when straining, the anterior wall and dome of the vagina with unchanged mucosa are determined, the cervix is not determined; Meatus does not gap, the vaginal mucosa is pink, moist, without rashes. The uterus and appendages are not defined. There are no levator diastases. During cough tests, there is no incontinence of urine. The diagnosis was made: Recurrence of genital prolapse grade IV (according to POPQ classification): grade IV cystocele, grade IV apical prolapse. According to laboratory and instrumental examination methods: general clinical and biochemical blood tests within the reference values; general urine analysis without pathology; urine culture is sterile; according to echo sonography of the pelvic organs and retroperitoneal space, no pathology was revealed, according to ultrasound examination of the perineum, there are signs of a defect in the vesicovaginal fascia. A combined approach operation was performed under endotracheal anesthesia - reconstruction of the anterior pelvic floor with a polypropylene mesh with fixation of the anterior implant sleeves in the transobturator holes (vaginal stage) and suspension of the vaginal stump fixed to the posterior section of the implant with the posterior sleeves to the Cooper ligaments (laparoscopic stage). In the postoperative period, anesthesia, anticoagulant therapy, and dressings were performed. The postoperative period was uneventful. Follow-up examination after 3, 6, 12, 24 months showed no recurrence of genital prolapse and no postoperative complications.

Example 3.

Patient G., 59 years old, came to the clinic with complaints of a feeling of incomplete emptying of the bladder, sensation of a foreign body in the vagina, constipation, burning sensation in the vagina. From the anamnesis, the patient underwent surgery twelve years ago - laparoscopic supravaginal amputation of the uterus without appendages for uterine fibroids. For three years, she has been suffering from prolapse of the internal genital organs, for the last six months she has begun to notice a deterioration - complaints about a feeling of incomplete emptying of the bladder, a feeling of a foreign body in the vagina, constipation, burning sensation in the vagina began to disturb. On physical examination: the general condition is satisfactory. The abdomen of the usual form, not swollen, participates in the act of breathing. Palpation of the abdomen is soft, painless. Symptoms of peritoneal irritation are negative. The kidney area is not visually changed. The kidneys are not palpable. Swinging of the lumbar region is painless on both sides. Diuresis is adequate. Stool - regular, daily. The external genital organs are formed correctly according to the female type, the genital slit is gaping, outside the Boulevard ring, when straining, the cervix and the anterior wall of the vagina with unchanged mucous membranes are determined; the meatus is not visually changed, the vaginal mucosa is pink, moist, without rashes. The uterus is absent, the appendages are not defined. No urine output when coughing with a full bladder. There is a discrepancy between levators, rectocele 1 tbsp. Dysuria - Difficulty urinating. Diagnosed with Genital prolapse IVst. (according to the POPQ classification): stage IV cystocele, stage IV apical prolapse (prolapse of the cervical stump), stage I rectocele. Hypertension 2 tbsp., 3 tbsp., Risk 3. According to the survey: general clinical and biochemical blood tests within the reference values; general urine analysis - no pathology; ultrasound examination of the pelvic organs - the uterine stump is visualized represented by the cervix, 40 × 25 × 37 millimeters, the cervical canal is closed, the right ovary is 20 × 11 × 13 millimeters, follicles are not detected, the left ovary contains fluid formations of three millimeters, dimensions are 18 × 9 × 16 millimeters, no fluid was detected in the small pelvis; according to echo sonography of the abdominal space, no pathology was revealed; according to the ultrasound examination of the perineum, there are signs of a defect in the vesicovaginal fascia, signs of failure of the pelvic floor muscles. Under endotracheal anesthesia, a combined access operation was performed - reconstruction of the anterior pelvic floor with a polypropylene mesh with fixation of the anterior implant sleeves in the transobturator holes (vaginal stage) and suspension of the cervical stump fixed to the posterior part of the implant, with the posterior sleeves to the Cooper ligaments (posterior laparoscopic stage) colporrhaphy, perineolevatoroplasty. In the postoperative period, anesthesia, anticoagulant therapy, and dressings were performed. The postoperative period was uneventful. Follow-up examination after 3, 6, 12, 24 months showed no recurrence of genital prolapse and no postoperative complications. Thus, the polypropylene implant placed by the vaginal approach restores the damaged vesicovaginal fascia, and the suspension of the cervix and vagina fixed to the implant with the back sleeves in the form of a hammock to the Cooper's ligaments on the left and right restores the lost suspension ligamentous apparatus of the uterus and eliminates the antero-apical prolapse of the genitus.

Claims (1)

A method of surgical treatment of anterior apical genital prolapse, which consists in making an implant from a light polypropylene mesh in the shape of an isosceles trapezium with individual dimensions for each patient, which are determined as follows: the height of the trapezium is equal to the distance from the introitus to the top of the vaginal dome, a wide base of the trapezium , which is the anterior part of the implant, is equal to half the distance between the inner surfaces of the ischial tubercles plus two centimeters, the narrow base of the trapezium, which is the posterior part of the implant, is equal to the width of the cervix plus two centimeters, and then to the sides of the mesh, 1-1.5 centimeters away from of the corners adjacent to the wide base of the trapezium, with a non-absorbable suture, two front polypropylene sleeves, one centimeter wide and ten centimeters long, are fixed symmetrically on the left and on the right, characterized in that an anterior colpotomy is performed with the obligatory dissection of the pubic-cervical fascia, in A wide mobilization of the posterior wall of the urinary bladder and its right and left lateral sides is performed, the paravaginal space and the space around the obturator openings are exposed, while additionally a tape one centimeter wide and twenty centimeters long is made of polypropylene mesh, to the middle part of which the narrow base of the trapezium of the implant is fixed by separate interrupted sutures with a non-absorbable prolene suture with the possibility of forming two posterior sleeves, with fixing the middle of the posterior part of the implant to the cervix or to the dome of the vagina - in the absence of the uterus and its cervix, the front sleeves are passed through the obturator holes on the right and left, the posterior sleeves of the implant are brought out into the abdominal cavity , while a mesh polypropylene implant is placed under the pubic-cervical fascia, finally straightened and without tension is placed under the posterior wall of the bladder, while the vaginal mucosa is sutured without excising the excess vaginal mucosa, laparos is performed copic or laparotomic access to the abdominal cavity, the posterior sleeves of the polypropylene implant are fixed to the Cooper's ligament using a herniostepler or separate sutures with non-absorbable suture material, while it is possible to fix the cervix and vagina in the form of a hammock, peritonization of the implant is applied with a continuous suture with absorbable suture material on trocar wounds or sutured laparotomic wound.

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