RU2790964C2 - Method of suturing the myomatous node bed - Google Patents

Abstract

FIELD: medicine; obstetrics and gynaecology.

SUBSTANCE: ligature of synthetic absorbable suture material with needles at the ends is used, suturing is started from the corner of the wound, with a running suture, as shown in Fig. 1. Injections are carried out from the bottom of the wound, a ligature is carried out through all layers with incisions on the serous membrane of the uterus at a distance of 1 cm from the edge. Next, knot the ends of the ligature in a direction perpendicular to the wound. Having displaced 0.5 cm from the last suture, ligatures are carried out over the aligned edges of the wound, the wound is continued to be sutured to the opposite corner of the wound with a distance of 0.5 cm between the stitches.

EFFECT: method allows to reduce the amount of suture material used, reduce tissue ischemia and trauma, reduce the time required for wound closure, which in turn reduces blood loss during surgery, reduce the likelihood of suture sagging, which is possible for a continuous suture, that is, when one is relaxed, the rest continue to hold compression.

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Description

The invention relates to medicine, in particular to obstetrics and gynecology, and can be used for suturing the bed of the myoma node after myomectomy.

Uterine fibroids are the most common benign pelvic neoplasm. According to a number of authors, up to 70% of women suffer from uterine fibroids, in addition, 80% of surgical interventions, including organ-removing ones, are currently carried out due to the presence of fibroids or a number of its complications.

There are a number of ways to suture the bed of the myomatous node after myomectomy.

An invention is known (see patent for invention RU 2561891 C1, publ. 10.09.2015, Bull. No. 25), in which the authors impose a two-row continuous seam, including step-by-step execution of the seam. When performing the first step, a serous-muscular suture is applied, an injection is performed with the thread being passed to the maximum depth of the wound, followed by the thread being passed to its opposite side with a prick. Moreover, when injecting and puncturing, they retreat from the edge of the wound by 1.0-1.5 cm, then on the same side of the wound the next injection is performed, retreating 0.5-0.7 cm from the edge of the wound to a depth of no more than 0.5 -1.0 cm, and the thread is passed to the opposite side with a prick, retreating 0.5-1.0 cm from the edge of the wound, followed by fixation of the thread. The second step is carried out on the same side along the edge of the wound, 1.0-2.0 cm away from the previous injection. The injection is carried out to the maximum depth of the wound, followed by the thread on its opposite side with a prick, retreating 1.0-1.5 cm from the edge of the wound. Then, on the same side of the wound, the next injection is carried out, retreating 0.5-0.7 cm from the edge of the wound to a depth of no more than 0.5-1.0 cm, and the thread is passed to the opposite side with a prick, retreating 0 .5-1.0 cm from the edge of the wound, tightening the edges of the wound as much as possible. The second step is repeatedly repeated until the wound is completely sutured, while the last step is completed by cutting the thread 0.5-0.7 cm from the edge of the wound without tying a knot. Use "V-loc" thread. EFFECT: method allows to reduce blood loss, increase the consistency of the postoperative scar, reduce the number of postoperative complications, reduce the time for wound closure and the postoperative period. The disadvantages of this method are the possible relaxation of the seam during the development of an infectious process in the wound.

There is also known a method of suturing the wound of the uterus (see the patent for the invention RU No. 2194466 C2, publ. 20.12.2002, bull. No. 35). The method is carried out as follows. The visceral peritoneum and the underlying muscle layer are sutured perpendicularly towards the edge of the wound. The thread is transferred to the other side. Stitch the wall of the uterus through all layers. The thread is transferred to the second side and the muscle layer and visceral peritoneum are sutured from the edge of the wound perpendicular to it. The outer tier is placed in the middle of the inner tier perpendicular to it. Before tying the suture, the ends of the thread are bred perpendicular to the edges of the wound of the uterus away from it. The muscle layer is inverted and compared. When tying the thread, the muscle layer and the visceral peritoneum are compared.

The advantages of this method are careful comparison of the wound edges and high hemostaticity, however, the method has the following disadvantages: repeated stitching and tightening of tissues can cause severe ischemia that prevents the formation of a full-fledged scar, the use of a large amount of suture material creates conditions for an inflammatory reaction in the area of the emerging scar, this method suturing the wound is technically difficult and significantly lengthens the time of the operation.

There is also known a method of suturing a wound on the uterus after surgical treatment of the uterus (see patent for invention RU No. 2139001 C1, publ. 10.10.1999). The method consists in passing the thread from the side of the serous membrane of the uterus through the thickness of the wound wall, stepping back from the edge of the wound, to the bottom of the wound, leaving a loop in the wound cavity. Next, the thread is drawn from the side of the wound wall closer to its edge and further from the side of the serous membrane from the opposite side of the wound in the region of its edge to the bottom of the wound cavity, leaving a loop in it. In the future, the thread is removed through the thickness of the opposite wall of the wound, stepping back from its edge.

When using this method of suturing the wound on the uterus, the following disadvantages are noted: a high risk of eruption of the sutures during their tightening with a large wound surface, despite picking up the bottom of the wound, incomplete connection of the wound walls and the development of hematomas in the resulting dead spaces are inevitable, insufficient scar strength formed when the wound on the uterus is sutured in this way, and, therefore, a high risk of uterine rupture in the scar area is predicted.

There is a known method of suturing the bed of the myomatous node after conservative myomectomy during pregnancy (see patent for invention RU No. 2482798 C1, publ. angle, a needle with a ligature is injected at a distance of 1.5-2 cm from the edge of the wound into the myometrium, passing the ligature under the bottom of the wound, without getting into the uterine cavity, the needle is withdrawn at a distance of 1.5-2 cm from the opposite edge of the wound, then retreating 2.0-2.5 cm from the first stitch in a parallel direction, a ligature is similarly carried out, forming a Z-shaped suture, the suture is tightened in a direction parallel to the wound, while manually closing the edges of the wound, a clamp is applied to the tied ligature, suturing is repeated until the opposite corner of the wound, at the 2nd stage, the ends of the ligatures are injected into the myometrium directly under its node, and they are punctured onto the serous surface of the uterus at a distance of 1.0 cm from the edge of the wound and the ligature is tied into a perpendicular on both sides ular wound direction. The disadvantages of this method: the possible formation of "dead" spaces, the duration of suturing.

The technical result is the development of a method for suturing the bed of the myomatous node, which allows to reduce ischemia, minimize tissue trauma.

The technical result is achieved by the fact that after myomectomy, the bed of the myomatous node is sutured from its corner with the formation of two uniform ligatures, needles with ligatures are injected from the bottom of the wound, passing through all layers with a prick on the serous membrane of the uterus at a distance of 1 cm from the edge, followed by tying ligatures in the perpendicular direction, then retreating 0.5 cm from the last suture, ligatures are similarly carried out, forming a continuous suture, tightening in a direction parallel to the wound, suturing is repeated to the opposite edge of the wound with similar sutures.

In FIG. 1 shows the scheme of suturing the bed of the myomatous node. The numbers indicate:

1 - injection from the bottom of the wound with the needle passing through all layers and puncturing the serous membrane of the uterus;

2 - symmetrical injection from the bottom of the wound with the needle passing through all layers, followed by tightening the knot;

3 - tightening the knot in a direction parallel to the wound;

4 - repetition of suturing to the opposite edge of the wound.

The method is carried out as follows.

After appropriate treatment of the skin of the anterior abdominal wall, a laparotomy is performed. The uterus with a myomatous node is removed into the wound. The myomatous node is enucleated and the wound formed after enucleation on the uterus is sutured. After the knot is husked, a curved needle with a piercing diameter is clamped with a Gegar needle holder. Synthetic absorbable suture material - a ligature - from 90 to 150 cm long, depending on the size of the wound, is threaded into the needle. The suturing of the bed of the myoma node starts from its corner with the formation of two uniform ligatures, needles with ligatures are injected from the bottom of the wound, passing through all layers with a prick on the serous membrane of the uterus at a distance of 1 cm from the edge, followed by tying the ligatures in a perpendicular direction (see Fig. eleven). Further, retreating 0.5 cm from the last seam, ligatures are similarly carried out (see Fig. 1: 2), forming a continuous seam, they are tightened in a direction parallel to the wound (see Fig. 1: 3). Repeat suturing to the opposite edge of the wound with similar sutures (see Fig. 1: 4).

We give clinical examples of the application of the method.

Example #1

Patient N., 37 years old. Was admitted to the gynecological department with a diagnosis of uterine fibroids, complicated by pain and menometrorrhagia. Upon admission, the patient complained of nagging pain in the lower abdomen, heavy menstruation, with clots. After an ultrasound examination in the hospital, the presence of a myomatous node on the anterior wall of the uterus, 8 × 9 cm in size, was confirmed.

During the operation, it was confirmed that the uterus was enlarged up to 15 weeks of pregnancy due to the intramural myomatous node located on the anterior wall of the uterus. The myomatous node was exfoliated.

On the bed of the myomatous node suture is applied according to the claimed method. Additional peritonization was not performed. An abdominal toilet was made. The wound on the anterior abdominal wall is sutured tightly in layers. The total blood loss was 250 ml.

Antibacterial therapy was not carried out. A single intraoperative antibiotic prophylaxis was used.

In the postoperative period, there were no rises in body temperature. The sutures were removed on the 7th day of the postoperative period. Discharged from the hospital on the 7th day of the postoperative period in a satisfactory condition.

Example #2

Patient S., 29 years old. She was admitted to the gynecological department with a diagnosis of interstitial-subserous uterine fibroids of large sizes, complicated by growth. Upon admission - complaints of pulling pain in the lower abdomen. Gynecological history: menstruation from the age of 13 after 28 days for 4 days, moderate, painless. After an ultrasound examination in the hospital, the presence of a myomatous node was confirmed along the posterior wall of the uterus, closer to the left rib, measuring 10×10 cm. Conservative myomectomy was performed without opening the uterine cavity. Node on the back wall of the uterus, closer to the left rib of the uterus. After husking this node, the wound on the uterus is sutured according to the claimed method. The abdominal cavity is sutured tightly in layers. Blood loss was 300 ml. Antibiotics were administered once intraoperatively to prevent purulent-septic complications.

No increase in body temperature was noted. Skin sutures were removed on the 7th day. Discharged for 7 days.

In this way, the bed of the myomatous node was sutured in 15 patients.

The method is simple, cost-effective and can be applied in clinical departments of obstetrics and gynecology profile.

The technical and economic efficiency of the method lies in the fact that its application allows:

- reduce the amount of suture material used;

- reduce ischemia and tissue trauma;

- reduce the time required for wound closure, which in turn reduces blood loss during surgery;

- reduce the possibility of seam sagging, possible for a continuous seam, that is, when one is relaxed, the rest continue to hold compression.

Claims (1)

The method of suturing the bed of the myomatous node, characterized in that the bed is sutured after myomectomy, for this purpose one ligature of synthetic absorbable suture material with needles at the ends is used, suturing begins from the corner of the wound, with a continuous suture, as shown in Fig. 1, injections are carried out from the bottom of the wound, a ligature is passed through all layers with punctures on the serous membrane of the uterus at a distance of 1 cm from the edge, then the ends of the ligature are tied in a knot in a direction perpendicular to the wound, then stepping back 0.5 cm from the last suture, ligatures are passed over the matched edges of the wound, continue to suture the wound to the opposite corner of the wound with a distance of 0.5 cm between the stitches.

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