RU2777243C1 - Method for vaginal myomectomy in localization of myomatous node in the cervic - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to gynecology and vascular surgery. Selective catheterization of the common iliac arteries (CIA) is performed by transradial access. Angiography is performed. Balloon catheters are introduced into the CIA and positioned in the distal sections of the CIA above the bifurcation, inflating the balloons to completely occlude the vessel. Vaginal access fixes the cervix behind the posterior lip and deflects upward to the womb. 0.1 ml of adrenaline solution and 5 ml of oxytocin solution are injected into the capsule of the myomatous node. An incision is made in the region of the posterior fornix above the capsule of the myomatous node, the myomatous node is excised without opening the abdominal cavity and cervical canal. The myomatous node is removed, the bed of the myomatous node is sutured by applying Z-shaped sutures, double-row sutures are applied from above, the cervical defect is sutured. Balloon catheters and conductors are removed, control angiography is performed, and the arteriotomy is sutured.

EFFECT: method provides the possibility of removal of myomatous nodes with localization in the cervical region, while maintaining the uterus itself and, consequently, reproductive function while significantly reducing the time of surgery and the time of occlusion of the common iliac arteries, which leads to a significant reduction in postoperative complications in the form of peripheral neuropathy of the lower extremities, paralysis of the pudendal nerve and ischemic complications, as well as a decrease in the possibility of complications due to the absence of opening the abdominal cavity, a decrease in the volume of intraoperative blood loss, a more thorough comparison of cervical defects and suturing the bed of the myomatous node.

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Description

The field of technology to which the invention belongs

The invention relates to the field of medicine, namely to gynecology and vascular surgery, and can be used when performing myomectomy by vaginal access with localization of myomatous nodes in the cervical region, with temporary occlusion of the common iliac arteries.

State of the art

Surgical treatment of patients of reproductive age with different localization of uterine fibroids can be performed by laparoscopic myomectomy, laparotomy myomectomy, and vaginal access myomectomy.

A known method of laparoscopic myomectomy with temporary occlusion of the uterine arteries, described in patent RU 2407467, 27.12.2010. To perform the intervention, the patient is placed in a lithotomy position, a uterine manipulator is installed. After the imposition of pneumoperitoneum and the introduction of trocars, the patient is transferred to the Trendelenburg position. During revision of the small pelvis, the bifurcation zone of the common iliac arteries and ureters are visualized on both sides. The parietal peritoneum above the internal iliac arteries (IIA) is opened for 2-3 cm on both sides, the ureters are retracted laterally. VPAs are isolated by layer-by-layer dissection. Soft DeBakey vascular clamps are applied to the selected vessels using the Endo Clinch clamp. The subsequent course of the operation involves making an incision in the myometrium above the myomatous node (which can be done using various types of energy), after which the myoma node is captured by a crocodile-type clamp and husked from the surrounding tissues by successive tractions in different directions and with the help of a second clamp. After two-thirds of the node is isolated, 10 IU of oxytocin is injected intravenously - the bed of the node is reduced, and the node is “squeezed out” into the wound, which facilitates its subsequent release. For suturing the myometrium, the anchor thread V-Loc 180.0 (Covidien, USA) is used, which allows the first rows of sutures to be applied continuously and without knotting, and/or the thread Monocryl 0 (Ethicon, USA) for the application of individual Z-shaped sutures followed by extracorporeal tying knots. After suturing the wound on the uterus, the vascular clamps are removed from the VPA and the blood flow in the uterus is completely restored. Knots are morcelized and removed. The average time to perform myomectomy with temporary occlusion of the VPA was 60±20 minutes, of which 13±8 minutes accounted for the application of vascular clamps. The volume of blood loss averaged 40±10 ml.

This method of laparoscopic myomectomy is not applicable in patients with cervical uterine myoma, when it is not technically possible to isolate the cervical myomatous node by laparoscopic access. Also, this method has limitations for use in patients with adhesive process, with a violation of fat metabolism II and III degree, since there are technical difficulties in the selection of the internal iliac arteries by laparoscopic method.

A known method of laparoscopic myomectomy with temporary balloon occlusion of the internal iliac arteries (RU 2663437, 08/06/2018). At the first stage, under aseptic conditions under endotracheal anesthesia in the area of the femoral triangle, both femoral arteries are punctured. Install conductors 6 Fr in the femoral arteries. Perform subtraction angiography. Using hydrophilic 0.035 inch (0.00889 cm) wires and catheters, both VPAs are selectively catheterized by contralateral access. Balloon catheters 8×30 mm are inserted into the VPA and positioned below the bifurcation of the common iliac artery, the balloons are inflated under a pressure of 6 atm. At the control angiography, the VPAs are not contrasted. At the second stage, a Veress needle is inserted through the umbilical approach, CO2 pneumoperitoneum is applied, a 10-mm trocar and optics are inserted. Three manipulator trocars 10 mm each are inserted into the abdominal cavity in the right and left hypogastric regions, above the womb (in typical places). Using a puncture needle, 0.1 ml of adrenaline solution with 5 ml of oxytocin solution is injected into the capsule of the myomatous node. Using a bipolar endohook, an incision is made in the capsule of the myomatous node. The myomatous node is captured with a crocodile clip, and the myomatous node is removed using a dissector. After two-thirds of the node is isolated, 5 ml of oxytocin solution is injected intravenously. As a result, the bed of the node is reduced, and the node is squeezed into the wound, which facilitates its subsequent release.

With this technique, at the stage of isolating the node, its border is very clearly visible, and all layers of the uterine wall are visible, which reduces the risk of accidental opening of the uterine cavity.

Sewing of the myometrial defect after removal of the myomatous node will be performed with V-Loc 180.0 thread (Covidien, USA). The myomatous node is removed from the abdominal cavity using a morcilator. Hemostasis is complete. Sanitation of the abdominal cavity is carried out. In the third step, after the myomectomy is performed, the balloon catheters are deflated. Control angiography is performed: common iliac arteries, external and internal iliac arteries are patent. At the fourth stage, after the balloon catheters are deflated, a control revision of the abdominal cavity and small pelvis is carried out. There is no bleeding in the area of operation. Drainage is introduced into the small pelvis through the right trocar opening. Stitches are applied to wounds, aseptic stickers. At the fifth stage, the conductors are removed and the arteriotomy opening is sutured. The time of cross-clamping of the internal iliac arteries was 60±10 minutes, blood loss was 40±10 ml.

However, this method is also inapplicable in patients with cervical uterine fibroids, with extraperitoneal nodes, which is associated with the peculiarities of the blood supply to the cervix, which receives the main blood supply from the descending branches of the uterine arteries and from the ascending branches of the vaginal arteries, which directly depart from the internal iliac arteries, and from the vaginal plexuses, which form powerful vascular plexuses, which receive the main blood supply from the common iliac arteries, as well as difficulties in enucleation of myomatous nodes by laparoscopic access at this localization, suturing of cervical defects, which increases the duration of balloon catheters in the internal iliac arteries, the duration of surgical intervention, and , respectively, the number of postoperative complications.

There is a method of temporary endovascular balloon occlusion of the bilateral internal iliac arteries for control of hemorrhage during laparoscopic-assisted myomectomy in a nulligravida with a large cervical myoma. Takeda A, Koyama K, Imoto S, Mori M, Sakai K, Nakamura H. Fertil Steril. 2009 Mar;91(3):935.e5-9. doi: 10.1016/j.fertnstert.2008.09.040. Epub 2008 Nov 6]. In the preoperative period, in the interventional radiology room, under local anesthesia, using digital subtraction angiography, endovascularly, a 9 mm balloon catheter is inserted into the iliac artery. According to the standard Seldinger technique, both femoral arteries are punctured under local anesthesia, and selective catheterization of both internal iliac arteries is performed using a contralateral approach. After gaining access to the lumen of the contralateral VPA, a 5.2-inch catheter with an occluding balloon is inserted into its proximal part, immediately at the bifurcation from the common iliac artery. After the balloons have been inflated to the optimal size, contrast angiography checks the optimal location of the balloon and the adequacy of the occlusion of the lumen of the internal iliac artery. After that, balloon catheters are deflated and patients with introduced sheaths and catheters are transferred to the operating room for the next gynecological stage.

Gas-free laparoscopic-assisted myomectomy is performed under general anesthesia, suprapubic incision, the transverse length of which is 3.5 cm in this case. Bilateral stenting of the ureters is performed under cystoscopic control. After a local injection of vasopressin into the capsule of the myoma node, an incision is made above the cervical node with a harmonic scalpel. Then, through the suprapubic port, the myomatous node is captured with forceps and pulled up. The knot is morcelized and removed through a suprapubic port. Bleeding during surgery is minimal. The myometrial defect is sutured. Balloon catheters are deflated after 15 minutes and left for a day in case of postoperative bleeding. The duration of the operation was 130 minutes. Blood loss - 70.0 ml.

The disadvantages of this method include the difficulty of removing myomatous nodes by laparoscopic access when they are localized in the cervix, suturing defects of the cervix, which is associated with the peculiarities of the blood supply to the cervix, which, accordingly, increases the duration of the balloon catheters in the internal iliac arteries, as well as the duration of the surgical procedure. intervention.

There is a method of temporary endovascular bilateral balloon occlusion of the internal iliac arteries to control bleeding during myomectomy when the node is located in the cervix [Temporary endovascular balloon occlusion of the internal iliac arteries to prevent hemorrhage during uterine cervical myomectomy. Tsuyoshi Ota, Hiroshi Kaneda, 2018. Gynecologic and Obstetric Prophylactic Hemostasis by Intra-arterial Balloon Occlusion, 2018 by S. Takeda, R. Kuwatsuru (eds.): 22-33.doi.org/10.1007/978-981-10- 8833-9] comprising the following steps.

In the preoperative period, in the interventional radiology room, under local anesthesia, using digital subtraction angiography, endovascularly, a 9 mm balloon catheter is inserted into the iliac artery. According to the standard Seldinger technique, both femoral arteries are punctured under local anesthesia, and selective catheterization of both internal iliac arteries is performed using a contralateral approach. After gaining access to the lumen to the contralateral VPA, a catheter with an occluding balloon is inserted into its proximal part, immediately at the bifurcation from the common iliac artery. After the balloons are inflated to the optimal size, the optimal location of the balloon and the adequacy of the occlusion of the lumen of the internal iliac artery are checked by means of contrast angiography. The patient with introduced sheaths and catheters is transferred to the operating room for the next step. A standard laparotomy is performed, in which considerable attention is paid to the possibility of damage to the bladder due to the close proximity of a huge fibroid. The iliac arteries are then temporarily closed by inflating balloon catheters and a dilute solution of vasopressin (X-100) is injected into the myometrium. A horizontal incision is made above the myomatous node and fixed with forceps. The cervical myomatous node is sequentially removed. After its removal, multiple Z-shaped sutures are applied, placed in the myoma bed to ensure hemostasis, and the bed is carefully closed with two or three row sutures to avoid the formation of dead space. After the bed is closed, balloon catheters are deflated and hemostasis is checked. Drainage is installed in the pelvic cavity and balloon catheters are removed. The drain is removed the next day after confirmation of hemostasis. The duration of the operation was 60 minutes. Blood loss - 60.0 ml.

However, this method causes great technical difficulties if it is necessary to remove large myomatous nodes by laparotomic access when they are localized in the cervix, suturing cervical defects, which is associated with the peculiarities of the blood supply to the cervix, which increases the duration of the balloon catheters in the internal iliac arteries and the duration of the surgical intervention.

It is important to note that the balloon occlusion time should not exceed 60 minutes to avoid lower extremity peripheral neuropathy, pudendal nerve palsy, and ischemic complications such as tissue necrosis. It is also necessary to monitor the oxygen saturation of the blood flow from the external iliac artery to the femoral artery with a pulse oximeter.

The known method of temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy was chosen as the closest analogue. for cervical myoma. Takeda A1, Koyama K, Imoto S, Mori M, Nakano T, Nakamura H., 2011. Eur J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):319-24. doi: 10.1016/j.ejogrb.2011.05.015. Epub 2011 Jun 11].

In the preoperative period, in the interventional radiology room, under local anesthesia, using digital subtraction angiography, endovascularly, a 9 mm balloon catheter (Selecon MP; Clinical Supply, Gifu, Japan) is inserted into the iliac artery. According to the standard Seldinger technique, under local anesthesia, both femoral arteries are punctured, and selective catheterization of both internal iliac arteries is performed using a contralateral approach. After gaining access to the lumen to the contralateral (internal iliac artery) VPA, a catheter with an occluding balloon is inserted into its proximal part, immediately at the bifurcation with the common iliac artery. After the balloons are inflated to the optimal size, contrast angiography checks the optimal location of the balloon and the adequacy of the occlusion of the lumen of the VPA. After that, balloon catheters are deflated and the patient is transferred to the operating room for the next, gynecological stage. Gas-free laparoscopically-assisted vaginal hysterectomy (LAVH) is performed with fixation of the surgical field by the method of subcutaneous abdominal wall tightening. A 5 mm Optiview port (Ethicon Japan, Tokyo, Japan) is placed on the upper edge of the umbilicus for insertion of a 5 mm OES laparoscope (Olympus, Tokyo, Japan). Two auxiliary 12 mm Optiview ports are placed on both sides at a right angle at the level of the navel. Under laparoscopic supervision, the laparoscopic phase of LAAVH is performed, including sealing and transection of the round ligaments on both sides with the Ligasure Atlas apparatus (Covidien Japan, Tokyo, Japan). While preserving the adnexal tissues, the proximal stump of the fallopian tube and the utero-ovarian ligaments are transected with the Ligasure Atlas apparatus. Install bilateral ureteral stents. Then, under fluoroscopic control, bilateral temporary balloon occlusion of the VPA is performed by inflating the occlusal balloons. With extracervical myoma, a dilute solution of epinephrine (1/200,000) is injected into the incision area of the cervico-vaginal node. With a monopolar needle, an incision is made over the myomatous node to expose the surface of the myomatous node emanating from the cervix. The myomatous node is then grasped with a myomatous screw or tenaculum. With the help of downward traction movements, the myomatous node is brought out into the wound and morcellated. After the size of the node is reduced by morcellation, the cervix is fixed behind the posterior lip with two-pronged clamps and reduced as much as possible to the entrance to the vagina. Anterior and posterior colpotomy is performed through the accessible parts of the vaginal fornix, followed by dissection of the bladder. Vesico-cervical ligaments, cardio-utero-sacral ligament and uterine arteries are clamped and crossed. The uterus is taken out into the wound. The hysterectomy is completed by vaginal extraction of the uterus. Apply Z-shaped seams. After the initial complete hemostasis is achieved, the endovascular balloon occlusive catheters are deflated. The pelvic cavity is drained, the drainage is removed the next day after confirmation of hemostasis. The deflated balloon catheters are left for 3 hours, then removed. The operating wound is closed. The average duration of temporary balloon occlusion of the VPA was 60 minutes, the average duration of the surgical stage of the operation was 98.5 minutes, the average blood loss was 355 ml.

However, this method does not imply the possibility of preserving the uterus in patients with fibroids in the cervix, with extraperitoneal nodes, which is associated with the peculiarities of the blood supply to the cervix, which receives the main blood supply from the descending branches of the uterine arteries and from the ascending branches of the vaginal arteries, which directly depart from internal iliac arteries, and from the vaginal plexuses, which form powerful vascular plexuses, which are supplied with blood from the common iliac arteries, which increases the duration of balloon catheters in the internal iliac arteries, the duration of surgery, and the number of postoperative complications.

The technical problem solved by the invention is the development of a method for vaginal myomectomy with the removal of myoma nodes with localization in the cervical region, which ensures the preservation of the uterus.

Disclosure of the essence of the invention

The technical result of the invention is to provide the possibility of removing myomatous nodes with localization in the cervical region, while maintaining the uterus itself.

The listed aspects of the technical result are achieved through the following methods:

1. reduction in the duration of the operation due to more favorable access (vaginal access) with the cervical location of the myomatous node;

2. The introduction of 0.1 ml of adrenaline solution and 5 ml of oxytocin solution for the purpose of hydropreparation provides visualization of the myomatous node, its capsule, its borders, and at the same time eliminates the risk of accidental opening of the abdominal cavity and cervix, and also ensures its easier removal ;

3. lack of opening of the abdominal cavity, leads to a low risk of postoperative purulent-septic complications, cosmetic defects of the anterior abdominal wall, reduced blood loss;

4. temporary balloon occlusion of the common iliac arteries, leads to a decrease in blood loss to minimal values;

5. The application of Z-shaped sutures provides reliable suturing of the bed of the myomatous node, eliminating the risk of dead spaces.

The technical result is achieved through the following methods:

- selective catheterization of the common iliac arteries (CIA) is carried out by transradial access,

- perform angiography

- Balloon catheters are inserted into the PVA and positioned in the distal sections of the PSA above the bifurcation, the balloons are inflated until the vessel lumen is blocked (not higher than the nominal pressure of the balloons, which ensures complete occlusion (closure) of the common iliac arteries, which ensures the blood supply is blocked below the introduction of balloon catheters);

vaginal access fixes the cervix by the posterior lip and deflects upward to the womb,

0.1 ml of adrenaline solution and 5 ml of oxytocin solution are injected into the capsule of the myomatous node (drugs are administered for the purpose of hydropreparation, which provides visualization of the myomatous node, its capsule, its borders, which in turn eliminates the risk of accidental opening of the abdominal cavity or cervix, and also makes it easier to remove)

in the region of the posterior fornix above the capsule of the myomatous node, an incision is made, the myomatous node is excised, without opening the abdominal cavity and cervical canal,

the myomatous node is removed,

the bed of the myomatous node is sutured by applying Z-shaped sutures, double-row sutures are applied from above,

the cervical defect is sutured, balloon catheters and conductors are removed, control angiography is performed, and the arteriotomy opening is sutured.

Implementation of the invention

The developed method of vaginal myomectomy with temporary balloon occlusion of the common iliac arteries is carried out as follows.

Under aseptic conditions under endotracheal anesthesia, catheterization of the common iliac arteries (CIA) is carried out by transradial access - the right and left radial arteries are punctured with the installation of sheaths and conductors of balloon catheters in them. With the help of hydrophilic conductors and catheters, both OPAs are selectively catheterized by contralateral access. Perform subtraction angiography. Balloon catheters are inserted into the OPA and positioned above the bifurcation of the common iliac artery, inflated under pressure up to 4 atm (that is, until it is completely occluded). Control angiography did not contrast the internal iliac arteries (IIA) and external iliac arteries (IIA).

Then, through the vaginal access, the cervix is fixed with bullet forceps behind the posterior lip and deflected as far as possible upwards to the womb. 0.1 ml of adrenaline solution and 5 ml of oxytocin solution are introduced into the capsule of the myomatous node, an incision is made in the region of the posterior fornix above the capsule of the myomatous node and its excision, without opening the abdominal cavity and cervical canal. The myomatous node is removed, the bed is sutured using multiple Z-shaped sutures (for example, Polyglycolide thread), which are placed in the bed of the myomatous node, then double-row sutures are applied to avoid the formation of dead space, the cervical defect is sutured with single-row sutures (for example, the thread polyglycolide). Carry out hemostasis and sanitation of the vagina.

After the myomectomy is performed, the balloon catheters are deflated. Control angiography is carried out: it is necessary to verify the patency of the common iliac arteries, external and internal iliac arteries.

After deflation of balloon catheters, a control revision of the vagina is carried out. There is no bleeding in the area of operation. A tight swab is inserted into the vagina.

Conductors and balloon catheters are removed, manual hemostasis of the puncture site is performed.

The clamping time of the common iliac arteries is 20±10 minutes, blood loss is 50±10 ml.

Clinical example 1.

Patient M., 38 years old, was admitted for planned surgical treatment for uterine fibroids with cervical nodes. In the anamnesis for 5 years, the gynecologist was not observed. During the year, constant pulling pains in the lower abdomen, constipation are disturbing. Interested in reproduction. She has a history of one pregnancy that ended in spontaneous delivery in 2008. Ultrasound diagnosed large uterine fibroids with cervical nodes. The largest cervical node originated from the posterior lip of the cervix up to 10 cm in diameter, the second node originated from the right rib of the cervix up to 7 cm in diameter.

The patient underwent vaginal myomectomy with temporary balloon occlusion of the common iliac arteries.

Stage I: under aseptic conditions under endotracheal anesthesia, the right and left radial arteries are punctured with the installation of introducers 6 Fr. and installation of conductors of balloon catheters 6 Fr. Using hydrophilic 0.035 inch (0.00889 cm) guidewires and catheters, both common iliac arteries (CIA) are selectively catheterized by contralateral access. Perform subtraction angiography. Balloon catheters 8×30 mm are inserted into the OPA and positioned distally and above the bifurcation of the common iliac artery, inflated under pressure up to 4 atm. At control angiography, the ICA and external iliac arteries (IIA) are not contrasted.

Stage II: through the vaginal access, the neck was fixed with bullet forceps behind the posterior lip and deflected as far as possible upwards to the womb. The introduction of 0.1 ml of adrenaline solution and 5 ml of oxytocin solution into the capsule of the myomatous node, an incision was made in the region of the posterior fornix above the capsule of the maximum diameter of the myomatous node and its excision, without opening the abdominal cavity and cervical canal, extraction of the myomatous node, suturing the bed of the myomatous node with Using the imposition of multiple Z-sutures with a Polyglycolide thread, which were placed in the bed of the myomatous node, then double-row sutures were applied to avoid the formation of dead space, the cervical defect was sutured with single-row sutures with a Polyglycolide thread. A similar technique was used with the removal of the cervical myomatous node 7 cm in diameter coming from the right rib of the cervix. Hemostasis is complete. The sanitation of the vagina was made.

Stage III: After performing a vaginal myomectomy, the balloon catheters are deflated. Control angiography common iliac arteries, external and internal iliac arteries are patent.

Stage IV: after deflation of the balloon catheters, the control revision of the vagina, there is no bleeding in the area of the operation. A tight tampon in the vagina.

Stage V: Conductors removed. The arteriotomy was sutured with an Exoseal device.

The time of cross-clamping of the common iliac arteries is 20 min.

During the operation, 500 ml of urine was released through the urinary catheter.

Blood loss - 40 ml.

Examination 2 weeks after surgery: no signs of peripheral neuropathy of the lower extremities, pudendal nerve palsy and any ischemic complications were found.

Thus, the developed method provides temporary balloon occlusion of the AVA during vaginal removal of the myomatous node located in the cervix without opening the abdominal cavity, which allows to reduce the volume of blood loss and operate without bloodshed, more carefully sutured the bed of the myomatous node emanating from the cervix, carefully compare the defects of the cervix after myomectomy, reduce the duration of the operation, and most importantly, preserve the organ, and, consequently, the reproductive function.

Claims (1)

A method for vaginal myomectomy in the localization of a myomatous node in the cervix, including occlusion of the iliac arteries, characterized in that selective catheterization of the common iliac arteries (CIA) is carried out by transradial access, angiography is performed, balloon catheters are introduced into the CIA and positioned in the distal sections of the CIA above the bifurcation, balloons are inflated to complete occlusion of the common iliac arteries; by vaginal access, the cervix is fixed by the posterior lip and deflected upward to the womb, 0.1 ml of adrenaline solution and 5 ml of oxytocin solution are injected into the capsule of the myomatous node, an incision is made in the region of the posterior fornix of the vagina above the capsule of the myomatous node, the myomatous node is excised, without opening at In this case, the abdominal cavity and cervical canal, the myomatous node are removed, the bed of the myomatous node is sutured by applying Z-shaped sutures, double-row sutures are applied from above, the cervical defect is sutured, balloon catheters and conductors are removed, control angiography is performed, and the arteriotomy opening is sutured.