RU2755806C1 - Method for restoring the wall of the uterus with hysterotomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to obstetrics and gynecology. After the laparotomy, the removal of the baby and the delivery of the placenta, the uterus is repaired with a separate two-layer modified U-shaped suture, as shown in fig.1. The first injection is performed through the muscular-mucous layer, departing from the upper edge of the wound 1-1.5 cm with a puncture of the endometrium. An injection is 1-1.5 cm below the lower edge of the wound, 1.5 cm retreat from it along the wound, the next injection is made through the muscular-mucous layer from the lower edge of the uterus to the upper one. Then 0.5 cm retreat from the puncture towards the wound. The muscle layer of the upper and lower edges of the wound is sutured, then 1.5 cm recede, a muscle suture is applied from the lower edge of the wound to the upper one. The ends of the thread are tied, the wound of the anterior abdominal wall is sutured tightly.EFFECT: method allows reducing the amount of blood loss, improve tissue repair, and form a well-to-do scar on the uterus.1 cl, 1 dwg, 2 ex

Description

The invention relates to medicine, in particular to obstetrics and gynecology, and can be used in the restoration of the uterine wall in patients during cesarean section, metroplasty with ingrowth of the placenta and other operations associated with hysterotomy.

This technique is aimed at improving the outcome of surgical delivery, in particular, reducing the amount of total blood loss and improving tissue repair.

In modern surgery, a caesarean section is one of the most frequently performed operations. With an increase in the frequency of operative delivery, the incidence of early and late complications increases. The amount of blood loss after cesarean section is significantly higher than after spontaneous delivery. The increased amount of blood loss during cesarean is associated with a violation of the contractile activity of the myometrium, prolongation of the wound on the uterus and injury of the uterine vessels. With subsequent pregnancies, the risks of uterine rupture, previa and placental ingrowth increase. Women with a uterine scar after a caesarean section have a higher risk of uterine rupture than women without a scar. Currently, the evolution of the technique of restoring the integrity of the uterine wall has gone through a number of stages: the use of separate, continuous, one-, two-, three-layer sutures, with and without capture of the endometrium. The definition of the layer of the uterus includes the amount of capture of the myometrium, without endometrium and serosa. To repair a wound on the uterus, a single or double layer suture is used. However, the advantages and disadvantages are not fully understood. An important condition for good healing of the uterine wall and maintaining the necessary scar strength is the mandatory restoration of the integrity of the uterine fascia, which is located immediately below the serous membrane.

Thus, the use of the optimal surgical technique for restoring the uterine wall is a promising method that improves the repair after surgery and reduces the amount of blood loss.

The presented information was the basis for determining the objectives of the invention.

The task of the invention

Improved results in patients with hysterotomy.

Research methodology

Inclusion criteria: patients with singleton pregnancies and indications for operative delivery.

At the first stage, informed consent was obtained from the patients for operative delivery.

At the 2nd stage, patients who met the selection criteria underwent a cesarean section, or metroplasty of the ingrown placenta. After hysterotomy, the uterine wall was restored with separate two-layer modified U-shaped sutures.

At the third stage, the analysis of complications in the early postoperative period during hospitalization of patients was carried out. Ultrasound monitoring of the state of the suture on the uterus was carried out in the late postoperative period and 3 months after delivery.

Method of invention

The task is solved by a method consisting of several successive stages.

A method for restoring the wall of the uterus after hysterotomy, characterized in that after the laparotomy, the extraction of the child and the birth of the placenta, the uterus is restored with a separate two-layer modified U-shaped suture, as shown in Fig. 1, the first injection is performed through the muscular-mucous layer, departing from the upper edge of the wound 1-1.5 cm with a puncture of the endometrium, the injection is 1-1.5 cm below the lower edge of the wound, 1.5 cm recede from it along the wound, produce the next injection through the muscular-mucous layer from the lower edge of the uterus to the upper one, then retreat 0.5 cm from the injection towards the wound, stitch the muscle layer of the upper and lower edges of the wound, then retreat 1.5 cm, apply a muscle suture from the lower edge of the wound to upper, the ends of the thread are tied, the wound of the anterior abdominal wall is sutured tightly.

Clinical examples.

Patient Sh., 32 years old, was admitted to the Center for a planned operative delivery. History: 1 pregnancy.

03/10/2021 in connection with a full-term pregnancy in a primiparous 32 years old with an Arnold-Chiari anomaly (according to the conclusion of the neurologist of the Center), the patient underwent a cesarean section.

Pain relief: epidural anesthesia.

Operation progress:

The abdominal cavity was opened layer by layer under aseptic conditions. The uterus is presented in the wound, corresponding to full-term pregnancy. The plica vesico-uterina was opened. A 2 cm long incision was made in the lower uterine segment, the edges of the incision were bluntly diluted to 11 cm. The fetal bladder was opened. Light amniotic fluid poured out. The fetal head was inserted into the wound, and at 2 minutes a live full-term girl weighing 3470 g, 54 cm long was removed without difficulty. Assessment of the state on the Apgar scale at 1 minute 8 points, at 5 minutes 9 points. The placenta is separated by the hand, the placenta is highlighted. Placental site along the anterior wall of the uterus. The wound on the uterus was sutured with separate two-layer modified U-shaped sutures. Peritonization due to plica vesico-uterinae.

The appendages were examined from both sides - no visible pathology. Abdominal toilet. Sister's operating room report - wipes and tools are all in stock. The anterior abdominal wall was completely reconstructed in layers. On the skin - a cosmetic suture. Aseptic sticker.

Intraoperatively introduced amoxiclav 1.2 g intravenous cap. Blood loss 500 ml. The duration of the operation is 29 minutes.

The postoperative period was uneventful. She was discharged on the 5th day of postoperative observation in a satisfactory condition.

Patient B., 32 years old, referred at 32-33 weeks of pregnancy to the Center from Karachay-Cherkessia with suspicion of ingrown placenta. History: 4 pregnancies, one ending in caesarean section at full-term in 2018, 4 births were due. Upon admission to the 1st department of pathology of pregnant women, the diagnosis was made: Pregnancy 33 weeks 3 days. Central presentation of the placenta. Ingrown placenta. A scar on the uterus after cesarean section operations. Clinical and laboratory examination and therapy aimed at prolonging pregnancy were carried out.

Ultrasound of the fetus and uterus from 02.19.2021: Pregnancy period 33 weeks. 1 day One living fetus in a transverse position, the fetal head on the left. The size of the fetus corresponds to the gestational age. Placenta previa with signs of ingrowth in the scar zone after CS. Feto-placental blood flow and uteroplacental blood flow are within normal limits.

MRI of the pelvic organs from 03.03.2021. MRI tomographic examination of the pelvic organs in three projections was performed with a slightly full bladder. At 35-36 weeks of gestation. In the uterine cavity, one fetus is detected in a transverse position, above the low-lying placenta. The size of the uterus corresponds to the gestational age - 27.1 × 31.1 × 12.9 cm.The cervix is not shortened, up to 4.8 cm long, the internal pharynx is up to 0.9 cm, the outer one is up to 0.6 cm. the anterior and posterior lips of the cervix are defined by dilated veins. In the area of the isthmus along the posterior wall, there are dilated retroplacental vessels. Serous-hemorrhagic contents are determined in the cervical canal.

The placenta is located along the anterior wall of the uterus with the transition to the left lateral and posterior walls, completely overlaps the area of the internal os of the uterus - signs of central presentation. Placenta with an inhomogeneous MR signal, the presence in the structure of single small lacunae, single vessels perpendicular to the wall of the uterus (centrally and centrally-laterally on the left). The placenta with clear, bumpy contours, with a maximum thickness of up to 8.5 cm, the amount of amniotic fluid is not increased. In the area of the placental site, it is most pronounced in the area of the left lateral wall of the uterus, in the area of the lower uterine segment, as well as in the area of the isthmus, varicose veins and retroplacental vessels are determined, which form a retroplacental shadow along the left lateral wall of the uterus. The wall of the uterus prolapses, with signs of uterine hernia formation - up to 7.3 cm, the contours of the uterus in this area are uneven due to protruding vessels, as well as retroplacental hypointense shadow, the myometrium is thinned. The maternal part of the placenta in the projection of the lower segment of the uterus and above the isthmus with uneven contours, enhanced vascular pattern, the adjacent tissue is not edematous.

The bladder is full, has clear, even contours, the back wall of the bladder is deformed. The utero-vesicle tissue space is not separately differentiated. Vessels reaching the bladder wall are not convincingly identified. Parametric fiber is not changed. Free fluid is not detected in the pelvic cavity. The ovaries are typically located, at the lateral walls of the uterus, the right up to 2.5 × 1.4 cm, the left up to 2.9 × 1.7 cm, the follicles are small.

Conclusion: Pregnancy 35-36 weeks, lateral position of the fetus. MR-picture of the central placenta previa. MP-picture of the bulging of the uterine wall in the local area in the area of the lower uterine segment with the formation of a uterine hernia, with thinning of the myometrium, the presence of vessels in the retroplacental area on the left, the expansion of the veins of the placental area, single dilated lacunae of the maternal part of the placenta, as well as the presence of vessels perpendicular to the uterine wall - does not allow to exclude signs of placental ingrowth by the type of pl.increta (Gr4) along the anterior and left lateral walls of the uterus.

Taking into account the central presentation of the placenta. Suspected ingrowth of the placenta into the uterine scar after caesarean section in 2018

12.03.21 the operation was performed: Mid-lower midline laparotomy with bypassing the navel on the left. Cesarean section in the lower uterine segment with a transverse incision. Complex compression hemostasis. Curettage of the uterus. Metroplastics. Reinfusion of autoerythrocytes.

Anesthesia: spinal epidural anesthesia.

Surgical intervention was started under conditions of autoerythrocyte reinfusion.

Operation progress:

Under aseptic conditions, the anterior abdominal wall was opened in layers with a lower midline incision with a bypass of the navel on the left. A pregnant uterus is presented in the wound, corresponding to a period of 37 weeks. The area of the alleged scar on the uterus in the lower segment is thinned to 1 mm, more on the left. On the front wall of the uterus, more on the left in the lower 1/3, placental vessels dilated to 1.0 cm are visible. In the bottom of the uterus, a longitudinal incision was made 3 cm long and bluntly expanded to 10 cm, light amniotic fluid poured out in a moderate amount. For the inguinal bends of the fetus without difficulty for 5 minutes on 03/12/2021 at 08:25 a live premature boy was retrieved. Assessment of the state on the Apgar scale at the 1st minute 7 points, at the 5th minute 8 points. Body weight 2780 g, body length 47 cm.

When stretching the umbilical cord, there are no signs of separation of the placenta. The incision in the uterus is sewn up with a double-row continuous vicryl suture. Dry. The uterus is brought into the wound. Places of increased bleeding during the descent of the bladder are coagulated with a bipolar electrode. In order to reduce blood loss during reconstructive surgery, a temporary compression hemostasis was performed. The imposition of tourniquet tourniquets was performed over the cervical-isthmus region of the uterus and on the region of the wide ligaments on both sides. 03/12/2021 at 08:40.

The placenta was located along the anterior wall of the uterus, completely overlapping the area of the internal pharynx, with areas of ingrowth into the anterior wall of the uterus of the placenta percreta type measuring 3 * 4 cm. Maximum traction of the uterus in the cephalgic direction was performed. The peritoneum along the edge of the bladder is dissected over the defect in the uterine wall and the placenta ingrowth. A 3 × 4 cm defect is thinned, with varicose veins.

Mikulich's clamps were applied along the edge of the placental ingrowth border. The site of ingrowth, together with the wall of the uterus, is excised within the limits of healthy tissues. The placenta is separated from the bladder by bipolar coagulation. The plastic of the T-shaped incision of the uterine wall was performed, the uterine defect was sutured with separate two-layer modified U-shaped sutures. The uterus is dense, contracted well. Peritonealization due to Plica vesico uterinae. Places of increased bleeding on the visceral peritoneum in the bladder area are coagulated with a bipolar electrode. The turnstiles were removed on 03/12/2021 at 08:51.

Toilet and revision of the abdominal organs. The integrity of the bladder was monitored with mitelite blue; defects in the bladder walls were not visualized.

The appendages were examined from both sides - no anatomical features. The anterior abdominal wall is sutured tightly in layers. An intradermal cosmetic suture was applied to the skin.

Aseptic dressing. Reinfusion of autoerythorcytes 260 ml with Ht 60%.

Blood loss 800 ml.

Given the volume of surgery, antibiotic therapy is indicated.

Considering the volume of the operation performed by the turnstile hemostasis, prophylactic administration of low molecular weight heparins is indicated.

The afterbirth with a site of ingrowth into the anterior wall of the uterus was sent for histopathological examination. The postoperative period was uneventful, without complications. She was discharged on the 8th day of postoperative observation in a satisfactory condition.

Bibliographic list

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Figure 1. Scheme of restoration of the uterine wall after hysterotomy

1 - injection into the muscle layer of the uterine wall by 1.5 cm, stepping back from the upper edge of the wound

2 - a stick out of the mucous layer of the uterine wall of the upper edge of the wound

3 - injection into the mucous layer of the uterine wall by 1.5 cm, stepping back from the lower edge of the wound

4 - puncture from the muscle layer of the uterine wall of the lower edge of the wound

5 - stepping back 1.5 cm from the puncture, an injection is made into the muscle layer of the uterine wall of the lower edge of the wound

6 - a stick out of the mucous layer of the uterine wall of the lower edge of the wound

7 - injection into the mucous layer of the uterine wall by 1.5 cm, stepping back from the upper edge of the wound

8 - puncture from the muscle layer of the uterine wall of the upper edge of the wound

9 - stepping back 1 cm from the puncture, make an injection into the muscle layer of the uterine wall before reaching the upper edge of the uterus 0.5 cm

10 - a puncture from the muscle layer of the uterine wall of the upper edge of the wound

11 - injection into the muscle layer of the uterine wall of the lower edge of the wound

12 - puncture from the muscle layer of the uterine wall of the lower edge of the wound

13 - stepping back 1.5 cm from the puncture, an injection is made into the muscle layer of the uterine wall of the lower edge of the wound

14 - puncture from the muscle layer of the uterine wall of the lower edge of the wound

15 - injection into the muscle layer of the uterine wall of the upper edge of the wound

16 - a stick out of the muscle layer of the uterine wall of the upper edge of the wound.

Claims (1)

A method for restoring the wall of the uterus after hysterotomy, characterized in that after the laparotomy, the extraction of the child and the birth of the placenta, the uterus is restored with a separate two-layer modified U-shaped suture, as shown in Fig. 1, the first injection is performed through the muscular-mucous layer, departing from the upper edge of the wound 1-1.5 cm with a puncture of the endometrium, the injection is 1-1.5 cm below the lower edge of the wound, 1.5 cm recede from it along the wound, produce the next injection through the muscular-mucous layer from the lower edge of the uterus to the upper one, then retreat 0.5 cm from the injection towards the wound, stitch the muscle layer of the upper and lower edges of the wound, then retreat 1.5 cm, apply a muscle suture from the lower edge of the wound to upper, the ends of the thread are tied, the wound of the anterior abdominal wall is sutured tightly.

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