RU2806872C2 - Method of surgical correction of combined forms of genital prolapse using laparoscopic combined longitudinal-transverse fixation of vaginal dome or cervix (options) - Google Patents

Abstract

FIELD: gynecology.

SUBSTANCE: inventions relate to the surgical treatment of genital prolapse, including relapse of genital prolapse. Laparoscopic combined longitudinal-transverse fixation of the vaginal dome or cervix is performed with the following steps. The peritoneum is opened over the inner surfaces of the pubic bones with further lateral and caudal dissection. The rectovaginal space is dissected, the pectineal ligaments and external iliac vessels — veins and arteries — are isolated. The first implant, made of synthetic mesh material, is placed longitudinally on one side into the rectovaginal space towards the levator ani muscles and sutured with non-absorbable suture material. The second implant, made of the same material as the first, in the form of a rectangular strip, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material. The operated organs are provided with a physiological position, after which the lateral sleeves of the second implant are fixed to the pectineal ligaments with non-absorbable suture material without any tension, and then peritonization is performed. For a patient who has undergone a hysterectomy, after the preparatory stage of the operation, the vagina is treated, and the dome of the vagina is fixed on a pad under aseptic conditions. Under aseptic conditions, pneumoperitoneum CO₂ — 4.5 l is applied through a paraumbilical puncture with a Veress needle, after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar in the midline and two 6 mm trocars are installed in the suprapubic region trocar in the right and left iliac regions. The patient is placed in the Trendelenburg position and the abdominal cavity and pelvic organs are examined. The sigmoid colon is fixed to the left side wall of the pelvis by suturing the fat suspensions, a forceps with a tampon soaked in an antiseptic solution is installed in the vagina, after which the peritoneum is opened in the area of the vaginal stump, 1 cm away from the cervical stump or vaginal dome. Then the rectovaginal space is dissected to the levator ani muscles — mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, the rectum is mobilized. Next, the vesicouterine fold of the peritoneum is opened and the bladder is bluntly brought down with its maximum possible mobilization to the anterior wall of the vagina. Then, along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, and on both sides the descending branches of the pubic bones are isolated to the pectineal ligaments. Anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels — femoral vein and artery, the first implant has an elongated shape with the following dimensions: length: 10–12 cm, the upper narrow base is 4 cm wide, the width of the lower wide base with protrusions on the sides for fixation is determined intraoperatively in accordance with the distance between the levator ani muscles. The specified first implant is fixed with a wide base using separate sutures with a non-absorbable thread to the bundles mm. Iliococcygeus on both sides, and its narrow base is fixed to the stump of the vagina or cervix with two sutures, also with a non-absorbable thread. The second implant is placed in the transverse direction, fixed in its central part to the vaginal stump or cervix, after which both implants are sewn together with three separate sutures with a non-absorbable thread with stitching of the vaginal stump. Next, the second assistant, by apical pressure using a forceps previously installed in the vagina, pushes the vaginal stump in the cephalic direction, after which the ends of the second implant are fixed to the pectineal ligaments with separate sutures with a non-absorbable thread, 1 suture on each side, remove the fixation of the sigmoid colon from the left side wall of the pelvis, return it to its previous physiological position, perform peritonization with a continuous suture of a monofilament absorbable thread, with the stumps and implant flaps located extraperitoneally, perform sanitation of the pelvic cavity, hemostasis, and apply sutures to trocar wounds. Alternatively, the invention is used for surgical correction of combined forms of genital prolapse with synthetic mesh implants, including laparoscopic combined longitudinal-transverse fixation of the vaginal dome with the following steps. The peritoneum is opened over the inner surfaces of the pubic bones with further lateral and caudal dissection. The rectovaginal space is dissected, the pectineal ligaments and external iliac vessels — veins and arteries — are isolated. The first implant, made of synthetic mesh material, is placed longitudinally on one side into the rectovaginal space towards the levator ani muscles and sutured with non-absorbable suture material. The second implant, made of the same material as the first, in the form of a rectangular strip, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material. The operated organs are provided with a physiological position, after which the lateral sleeves of the second implant are fixed to the pectineal ligaments with non-absorbable suture material without any tension, and then peritonization is performed. If a uterus is present, the vagina is treated and the cervix is fixed under aseptic conditions with bullet forceps, and preparations are made for hysterectomy. The length of the uterine cavity is measured using a probe, after preliminary expansion of the cervical canal with Hegar dilators to N9, a uterine manipulator is transcervically inserted into the uterus, under aseptic conditions, pneumoperitoneum CO₂, 4.5 l, is applied through a paraumbilical puncture with a Veress needle, after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar is installed in the suprapubic region along the midline and two 6 mm trocars are installed in the right and left iliac regions. The patient is placed in the Trendelenburg position and the abdominal cavity and pelvic organs are examined. The sigmoid colon is fixed to the left side wall of the pelvis by suturing the fat pads. Then the second assistant forms and visualizes the surgical field performing an apical push of the uterus in the cephalic direction with a previously installed manipulator, after which the peritoneum of the retrouterine space is opened, retreating 1 cm from the cervix. Then the rectovaginal space is dissected to the levator ani muscles — mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, the rectum is mobilized. Next, a hysterectomy is performed. In the case of removal of the uterus with appendages, using a bipolar coagulator, the round uterine ligaments and infundibulopelvic ligaments are coagulated and crossed on both sides, and the uterine vessels, cardinal and uterosacral ligaments are coagulated and crossed on both sides, or, in case of removal of the uterus with fallopian tubes, after preliminary coagulation, the round ligaments of the uterus, mesosalpinxes, fallopian tubes and proper ovarian ligaments are crossed on both sides, and the uterine vessels, cardinal and uterosacral ligaments are coagulated and crossed on both sides. Next, the vesicouterine fold of the peritoneum is opened and the bladder is bluntly brought down with the maximum possible mobilization to the anterior wall of the vagina. Then the uterus is cut off from the vaults of the vaginal wall circularly along the edge of the isoelectric cap of the manipulator. The second assistant removes the macro-preparation — the uterus with appendages or fallopian tubes — together with the manipulator from the small pelvis through the vagina, the vaginal dome is formed with separate sutures using a monofilament absorbable thread, with the stumps of the uterosacral ligaments being fixed to the vaginal stump, a forceps with a tampon soaked in an antiseptic solution is installed in the vagina. Along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, the descending branches of the pubic bones are isolated on both sides to the pectineal ligaments, anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vein and artery, femoral vein and artery. The first implant has an elongated shape with the following dimensions: length: 10–12 cm, the upper narrow base is 4 cm wide, the width of the lower wide base with protrusions on the sides for fixation is determined intraoperatively, in accordance with the distance between the levator ani muscles. The specified implant is fixed with a wide base using separate sutures with a non-absorbable thread to the bundles mm. Iliococcygeus on both sides, to the vaginal stump. The first implant is fixed with a narrow base with two sutures, also with a non-absorbable thread, the second implant, which is placed in the transverse direction, is fixed in its central part to the vaginal stump. After this, both implants are sewn together with three separate sutures using a non-absorbable thread and stitching the vaginal stump. Next, the second assistant, by apical pressure using a forceps previously installed in the vagina, pushes the vaginal stump in the cephalic direction. After which, the ends of the second implant are fixed to the pectineal ligaments with separate sutures using a non-absorbable thread, 1 suture on each side, the fixation of the sigmoid colon is removed from the left side wall of the pelvis, and it is returned to its previous physiological position. Peritonization is carried out using a continuous suture with a monofilament absorbable thread, with the stumps and implant flaps located extraperitoneally, the pelvic cavity is sanitized, complete hemostasis is performed, and trocar wounds are sutured.

EFFECT: methods increase the effectiveness of surgical treatment of genital prolapse, reduce the risk of damage to tissues and pelvic organs, thereby reducing the possibility of subsequent relapse of the disease, and improve the quality of life, including normalization of the functions of the pelvic organs.

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Description

The invention relates to medicine, to surgical gynecology. In particular, to the treatment of genital prolapse.

There are known methods of surgical treatment of genital prolapse in women using mesh technologies, which show significantly better results than without the use of mesh implants (Larsen WI, Yavorek TA. Pelvic organ prolapse and urinary incontinence in nulliparous women at the United States Military Academy // Int Urogynecol J Pelvic Floor Dysfunct. - 2006. - Vol. 17. - N3. - P. 208-10). According to the study, the use of mesh implants increases the effectiveness of treatment to 75-92%.

There are known methods (see article Ishchenko A.I. et al. Improved surgical approach to the treatment of patients with complete uterine prolapse. (Electronic version, Issues of gynecology, obstetrics and perinatology, 2020, volume 19, No. 1, pp. 32-39) .In accordance with the source, prolapse of the vaginal dome, as one of the types of prolapse of the pelvic organs of women, occurs after hysterectomy with a frequency of 13-45%.The data of other authors (Popov A.A.) is confirmed that concomitant defects of the pelvic floor, which can be presented in the form of cystocele, rectocele or enterocele, occur in patients suffering from posthysterectomy prolapse in 85% of cases. Prolapse of the vaginal dome reduces the quality of life of patients. The article presents an improved surgical method for treating patients with complete prolapse of the uterus, tracing the immediate and long-term results of surgical intervention, the frequency of disease relapses in 72 patients of pre- and postmenopausal age, who were divided into two groups depending on the extent of the operation: vaginal hysterectomy followed by colpopexy according to the developed original method and classic vaginal hysterectomy.

According to the surgical program of the authors of this article, the same authors developed a method: Transvaginal surgical prevention of post-hysterectomy prolapse of the vaginal dome. (See RF patent for invention No. 2673916, dated July 19, 2017). Progress of the operation: Vaginal hysterectomy. Extraperitoneal transvaginal colpopexy with a cardinal uterosacral ligamentous monoblock. Sacrospinal-transobturator mesh-ligature cross colpopexy. Anterior colporrhaphy. Colpoperineolevatoplasty. A vaginal hysterectomy was performed using the Mayo technique, leaving the extraperitoneal uterosacral and cardinal ligaments on both sides. The incision of the mucous membrane of the posterior vaginal wall was extended to the introitus vaginae. After peritonization and formation of the vaginal dome, the uterosacral and cardinal ligaments were sutured together alternately on both sides. Then, using slowly dissolving ligatures, the ligaments were connected into a single ligamentous monoblock, which was fixed to the dome of the vagina. Channels were formed to the ischial spines and sacrospinous ligaments. Having retreated 1.5-2 cm from the ischial spines, the sacrospinous ligaments were sutured on the left and right with non-absorbable ligatures, which were then used to fix mesh implants (prolene tapes 1×20 cm) to the ligaments alternately on both sides. After this, the synthetic implants were sutured crosswise (from left to right and right to left) with several slowly absorbable ligatures to the formed ligature monoblock and to the vaginal dome, while simultaneously stitching them together. The free end of the implant, fixed to the right sacrospinous ligament, was guided through the left obturator foramen into the left inguinal fold at the level of the clitoris using a guide. The free end of the implant, fixed to the left sacrospinous ligament, was guided through the right obturator foramen into the right inguinal-femoral fold at the level of the clitoris using a guide. Perineolevatoroplasty and colporrhaphy were performed using traditional methods. Dynamic observation of patients was carried out from 12 to 48 months of the postoperative period.

Disadvantages of analogue. This type of surgical intervention involves additional plication of the distal part of the uterosacral ligaments in the wound of the vaginal dome when creating a monoblock for the prevention of enterocele and closing the wound with sutures. In this regard, the likelihood of tissue ischemia in the suture area increases, conditions are created for the development of postoperative complications and the healing period is extended.

Also, the endoprosthesis is fixed to the sacrospinous ligaments with conventional single sutures, without special devices, which requires wide dissection of the ischiorectal space, which increases the risk of bleeding and disturbances in the innervation of the pelvic organs (rectum, bladder).

Moreover, the use of a suturing device for fixing the tape to the sacrospinous ligaments requires a wider dissection in the area of the pararectal space, which can increase the amount of intraoperative blood loss and also poses a risk of damage to the pelvic organs.

Compared to the claimed method, the analogue solves other problems: the main goal of the analogous method is apical fixation, but the rectocele remains without correction.

There is a risk of infectious complications associated with significant trauma to the vaginal mucosa during the formation of a monoblock of ligaments, as well as with contact of the monoblock with the bacterial flora of the vagina.

There is a known method of combined laparoscopic hysteropexy or vaginopexy in combination with rectopexy, correction of “high” rectocele, enterocele (see RF patent for invention No. 2712006 dated 02/12/2019), which consists in performing laparoscopy with the installation of 2 lateral trocars: on 5 cm above the symphysis and 8 cm lateral to the midline, an arcuate incision is made along the parietal peritoneum of the uterosacral ligaments, with the apex facing the posterior wall of the vagina, followed by separation of the prerectal tissue between the rectum and the posterior wall of the vagina down to the level of the levators on both sides and subsequent by forming an extraperitoneal tunnel through the left lateral puncture from the side of the outer edge of the left external oblique muscle between the leaves of the left broad uterine ligament, the left and right sacrouterine ligaments, between the leaves of the right broad uterine ligament, the outer edge of the right external oblique muscle and the right lateral puncture, a synthetic T --shaped flap measuring 4x6 cm and the dimensions of two tapes 3x35 cm, the flap is fixed in two places: at the point of projection of the origin of the uterosacral ligaments from the uterus, with the uterus preserved, or to the posterior wall of the vagina, in the absence of the uterus, and to the levators with removal of the tapes on the aponeurosis on each side and leaving them free.

Disadvantages of analogue. The absence of rigid fixation of the distal end of the flap creates conditions for its displacement and, as a consequence, recurrence of genital prolapse.

To place a flap on the anterior abdominal wall, it is necessary to pass it through a long tunnel (from left to right, from the outer edge of the oblique muscle between the leaves of the broad uterine ligament, the uterosacral ligaments, to the outer edge of the oblique muscle at the aponeurosis), which is associated with the risk of vascular injury and bleeding and formation of hematomas. In this case, the advancement of the implant along the canal past the muscles of the anterior abdominal wall and the location of the ends of the implant on the aponeurosis of the abdominal muscles, subsequently, can lead to pain during active movements of the patient.

There is a known method for laparoscopic correction of prolapse of the walls of the vagina, uterus, bladder and rectum, adopted as a prototype (see RF patent for invention No. 2720081 dated July 15, 2019), which consists in isolating the pectineal ligaments (Cooper's ligaments, lig . Iliopectineum) for 3-4 cm lateral to the obliterated lateral umbilical arteries (a. umbilicalis lateralis) and medial to the obturator vessels and nerves (a. et v. Obturatoria, n. Obturatorius). To do this, using bipolar coagulation, the peritoneum is opened over the internal surfaces of the pubic bones at the level of the obliterated umbilical arteries with further dissection laterally and caudally, and two autonomous synthetic implants made of polypropylene mesh are installed. Moreover, the first implant, having a width of 5 cm and a length corresponding to the length from the point of fixation to the levator ani muscles to the point of fixation to the cervix, is installed longitudinally in the rectovaginal space between the posterior wall of the vagina and the rectum. To fix it to m. levator ani use synthetic absorbable suture material with a long absorption period; non-absorbable suture material is used for fixation to the posterior wall of the cervix. The second is the anterior implant, which has a length of 15 cm and a width that is determined by the degree of prolapse and corresponds to the distance from the point of upper fixation in the front - the cervix - to the point of lower fixation - the vagina, is placed in the transverse direction and installed in the utero-vaginal-vesical space between the urinary tract bladder and pubocervical fascia. The specified implant is evenly fixed to the anterior wall of the vagina from the internal opening of the urethra to the cervix with non-absorbable suture material.

After installing mesh implants in the indicated posterior and anterior spaces, the uterus is “exposed” to the correct position (level of entrance to the pelvis, S1-S2). The lateral sections of the anterior mesh implant are tightly fixed to the pectineal ligaments (Cooper's ligaments) with Z-shaped sutures using non-absorbable suture material (pectopexy is performed) so that the uterus is located in the pelvis freely, without tension. The final stage of the operation is peritonization of the mesh implants.

Disadvantages of the prototype. The method implemented in the prototype is intended to solve another problem: correction of the patient’s organ prolapse with a preserved uterus; this method corresponds to other indications for the operation and conditions for its implementation, compared to the claimed one (that is, a different group of patients for whom the specified method is intended ).

Each implant - anterior and posterior - is separately fixed to points of the pelvic tissue that differ from the points proposed in the claimed invention, also differing in sutures and suture material, which in the postoperative period can lead to deformation of the supporting structure, inflammatory processes and relapse of the disease ( In the claimed method, it is proposed to stitch the 1st and 2nd implants in the central area and to the dome of the vagina or cervix).

The objective of the invention is to create and implement a method for surgical correction of combined forms of genital prolapse using laparoscopic combined longitudinal-transverse fixation of the vaginal dome or cervix - laparoscopic combined MESH-pectovaginopexy (combined laparoscopic approach), including in case of relapse of genital prolapse.

As a result of using the method, the effectiveness of surgical treatment of genital prolapse is increased, the risk of damage to tissues and pelvic organs is reduced and, due to this, the possibility of subsequent relapse of the disease is reduced.

The work was carried out at the Obstetrics and Gynecology Clinic named after. V.F. Snegirev University Clinical Hospital No. 2 FSAOU HE First Moscow State Medical University named after. THEM. Sechenov (Sechenov University). Our study included patients ranging in age from 46 to 75 years. Their informed consent to participate in the study was obtained.

Based on the results of a comprehensive examination of patients who applied for recurrent pelvic organ prolapse, a group of patients was identified who needed to undergo the specified laparoscopic combined MESH-pectovaginopexy.

The criteria for not being included in the study are: refusal to participate in the study, contraindications to surgical treatment, malignant neoplasms of the female genital organs and confirmed oncological diseases, pregnancy and lactation, terminal stage of chronic diseases, acute phase and exacerbation of chronic infectious diseases. Patients can be excluded from the study at any stage of its implementation (the presence of general somatic concomitant chronic diseases in the decompensation phase).

In this case, patients who were indicated for hysterectomy additionally underwent a typical total or radical hysterectomy immediately before correction of prolapse.

For all patients in the group, the technical result was achieved through combined longitudinal-transverse fixation of the vaginal dome or cervical stump with two synthetic Mesh implants to the natural physiological supporting elements of the pelvis.

The need to use modern mesh prostheses to correct prolapse of the uterus and vaginal walls is justified by the fact that this prolapse is based on extensive defects in the supporting fascial structures, requiring neofasciogenesis.

The formation of the supporting structure is provided by two mesh implants. The first implant is longitudinally shaped with protrusions, which is attached longitudinally with a wide base into the rectovaginal space, with individual sutures fixing the non-absorbable ethylene terephthalate thread “Ethibond” to the bundles mm. Iliococcygeus on both sides, and with a narrow proximal base to the stump of the vagina or cervix.

The second transverse implant in the form of a 4 x 15 cm tape is fixed with the central part also to the stump of the vagina or cervix, and with the ends to the pectineal ligaments. Moreover, to ensure the normal physiological position of the vaginal stump or cervix, before the stage of securing the ends of the tape of the second implant, the assistant surgeon tightens the vaginal dome in the cephalic direction, by apical pressure and pushing using a forceps installed in the vagina.

In this case, the design of implants connected to fixation in the central region forms a reliable structure, and each of them performs its own function of supporting the pelvic organs: both along (1st implant) in the region of the longitudinal axis of the sagittal plane, and across (2nd implant) th implant) in the area of the transverse axis. Such actions of the surgeon and the proposed fixation of the implants help prevent their displacement, twisting and wrinkling, which increases the effectiveness of the pelvic support apparatus, improves the result of the operation to eliminate prolapse and ensures the long-term therapeutic effect.

The use of two simple-shaped implants (instead of one, for example, T-shaped or cross-shaped) allows, firstly, to reduce the time for their manufacture and, secondly, to carry out their careful, smooth delivery through trocars to the attachment sites.

The relatively free space in the area of the removed uterus provides the opportunity for optimal selection and formation of fixation points and placement of implants.

Preventive prevention of possible hyperplastic processes is carried out.

Changing the anatomy of the pelvis due to removal of the uterus leads to a change in the vector of intra-abdominal pressure, which is an additional anti-relapse factor.

Since during the operation there is no conflict with adjacent hollow organs and there is no damage to them, drainage of the abdominal cavity is not performed, and intraoperative bleeding is minimal.

Reducing the risk of damage to tissues or adjacent organs to a minimum is also ensured by the fact that the entire operation is carried out under strict laparoscopic and video-endoscopic control. As a result, the possibility of intraoperative bleeding is reduced and, with minimal intraoperative impact on the organs and tissues of the body, the possibility of postoperative complications and relapse of the disease is reduced.

The proposed method of treating patients with recurrent pelvic organ prolapse, ensuring their rapid activation and reliable rehabilitation, has not only medical, but also social significance - the health and quality of life of women improves.

All patients prescribed treatment according to the stated method receive informed consent for the operation and installation of implants.

They perform the operation under combined endotracheal anesthesia - ETN (it is possible to use other methods of pain relief).

Preparatory stage. Preoperative antibiotic prophylaxis is carried out half an hour before the start of the operation and prevention of venous thromboembolic complications - compression knitwear of the veins of the lower extremities. The operating team consists of a surgeon and first and second assistants. The patient is placed on the operating table in the lower lithotomy position with her legs widely apart. A Folley 16 indwelling urinary catheter, such as a Fhench with an inflatable cuff, is placed transurethrally into the bladder. The surgical field is treated: the anterior abdominal wall, external genitalia and vagina with an antiseptic solution. Carry out other known steps in preparation for the operation.

The solution to the above problem and the technical result are achieved in option 1 of the invention - a method of surgical correction of combined forms of genital prolapse using laparoscopic combined longitudinal-transverse fixation of the vaginal dome or cervix with synthetic mesh implants, performed as follows:

the peritoneum is opened over the internal surfaces of the pubic bones with further dissection laterally and caudally, the rectovaginal space is dissected, the pectineal ligaments, external iliac vessels - veins and arteries are isolated,

the first implant made of synthetic mesh material is longitudinally installed with one side into the rectovaginal space to the levator ani muscles and stitched, and the other side is attached in the area of ventral fixation and stitched with non-absorbable suture material,

the second implant, made of the same material as the first, in the form of a rectangular strip, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material,

at the same time, the operated tissues and organs are “exposed” to the correct physiological position corresponding to the landmarks of the pelvis,

after which the lateral sleeves of the second implant are fixed to the pectineal ligaments with non-absorbable suture material, without tension,

produce peritonization of the surgical field,

characterized in that a patient who has undergone a hysterectomy

after the preparatory stage of the operation

Stage 1: the vagina is additionally treated and, under aseptic conditions, the vaginal dome is fixed on a tupfer (Tupfer (German: Tupfer - tampon) - sterile probe-tampon. Wikipedia),

under aseptic conditions, CO2 pneumoperitoneum (4.5 l) is typically applied through a paraumbilical puncture with a Veress needle,

after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar in the midline and two 6 mm trocars in the right and left iliac regions are installed in the suprapubic region,

the patient is transferred to the Trendelenburg position and the abdominal cavity and pelvic organs are examined,

in order to improve the exposure of the pelvic organs, the sigmoid colon is fixed to the side wall of the pelvis by suturing the fat pads,

a forceps with a tampon soaked in an antiseptic solution is installed in the vagina to allow displacement and apical pushing of the vaginal stump in the cephalic direction,

after which the peritoneum is opened in the area of the vaginal stump 1 cm from the cervical stump or vaginal dome,

then dissection of the rectovaginal space is carried out sharp or blunt to the muscles that lift the ani - mm. levator ani, and their upper bundles mm. Iliococcygeus,

in parallel, mobilization of the rectum is carried out with sampling of the rectocele,

then the vesicouterine fold of the peritoneum is opened and the bladder is bluntly lowered with its maximum possible mobilization to the anterior wall of the vagina;

Stage 2: along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left,

on both sides, the descending branches of the pubic bones are identified to the pectineal ligaments, anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels - vein and artery (arteria, vena femoralis),

the first implant has an elongated shape with approximate dimensions in accordance with the anatomical features of the patient: length: 10-12 cm, upper base: width - 4 cm, the width of the lower base with protrusions on the sides for fixation is determined by location (guidelines are the size of the defect, the width of the straight intestines and the distance between the levator ani muscles),

the specified implant is fixed with a wide base with separate sutures with a non-absorbable thread to the bundles mm. Iliococcygeus on both sides, to the stump of the vagina or cervix, the first implant is fixed with a narrow proximal base with two sutures, also with a non-absorbable thread,

the second implant, which is placed in the transverse direction, is fixed in its central part to the stump of the vagina or cervix,

after this, both implants are sewn together with three separate sutures using a non-absorbable thread with stitching of the vaginal stump,

then the second assistant, by apical pressure and pushing with the help of a forceps previously installed in the vagina, pulls the vaginal stump in the cephalic direction to ensure its normal physiological position,

after which the ends of the second implant are fixed to the pectineal ligaments with separate sutures using a non-absorbable thread, 1 suture on each side,

remove the fixation of the sigmoid colon from the left side wall of the pelvis, return it to its previous physiological position,

peritonization is performed using a continuous suture with a monofilament absorbable thread, with all stumps and implant flaps located extraperitoneally,

perform sanitation of the pelvic cavity, complete hemostasis,

sutures are placed on the trocar wounds.

In particular, the length of the second implant is 15 cm and the width is 4 cm.

Drainage of the abdominal cavity is not performed, since during the operation there is no conflict with adjacent hollow organs.

Also, the solution to the above problem and the technical result are achieved in option 2 of the invention - a method of surgical correction of combined forms of genital prolapse using laparoscopic combined longitudinal-transverse fixation of the vaginal dome or cervix with synthetic mesh implants, performed as follows:

the peritoneum is opened over the internal surfaces of the pubic bones with further dissection laterally and caudally, the rectovaginal space is dissected, the pectineal ligaments, external iliac vessels - veins and arteries are isolated,

the first implant is made of synthetic mesh material, one side is longitudinally installed in the rectovaginal space to the muscles that lift the ani, and stitched, and the other side is attached in the area of ventral fixation and stitched with non-absorbable suture material,

the second implant, made of the same material as the first, in the form of a rectangular strip, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material,

at the same time, the operated tissues and organs are “exposed” to the correct physiological position corresponding to the landmarks of the pelvis,

after which the lateral sleeves of the second implant are fixed to the pectineal ligaments with non-absorbable suture material, without tension,

produce peritonization of the surgical field,

characterized in that the patient for whom a hysterectomy is recommended,

after the preparatory stage of the operation

Stage 1: the vagina is additionally processed and the cervix is fixed under aseptic conditions with bullet forceps,

preparing for a hysterectomy,

in this case, the length of the uterine cavity is measured using a probe,

after preliminary expansion of the cervical canal with Hegar dilators up to No. 9, a uterine manipulator is inserted transcervically into the uterus,

under aseptic conditions, CO2 pneumoperitoneum (4.5 l) is typically applied through a paraumbilical puncture with a Veress needle,

after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar in the midline and two 6 mm trocars in the right and left iliac regions are installed in the suprapubic region,

the patient is transferred to the Trendelenburg position and the abdominal cavity and pelvic organs are examined,

in order to improve the exposure of the pelvic organs, the sigmoid colon is fixed to the side wall of the pelvis by suturing the fatty pendants;

Stage 2: to form and visualize the surgical field, the second assistant performs an apical push of the uterus (in the cephalic direction) with a previously installed manipulator,

after which the peritoneum of the retrouterine space is opened 1 cm from the cervix,

then, using a sharp or blunt method, dissection of the rectovaginal space is performed to the muscles that lift the ani - mm. levator ani, and their upper bundles mm. Iliococcygeus,

in parallel, mobilization of the rectum is carried out with sampling of the rectocele;

Stage 3: Next, a typical hysterectomy is performed,

in this case, in the case of removal of the uterus with appendages, using a bipolar coagulator, the round uterine ligaments and infundibulopelvic ligaments are coagulated and crossed on both sides, as well as the uterine vessels, cardinal and uterosacral ligaments are coagulated and crossed on both sides,

or, in the case of removal of the uterus with fallopian tubes, after preliminary coagulation, they cross the round ligaments of the uterus, mesosalpinx, fallopian tubes on both sides and the proper ovarian ligaments on both sides, as well as coagulate and cross the uterine vessels, cardinal and uterosacral ligaments at both sides,

then the vesicouterine fold of the peritoneum is opened and the bladder is bluntly lowered with its maximum possible mobilization to the anterior wall of the vagina,

then the vaginal wall is cut off circularly along the edge of the isoelectric cap of the manipulator,

the second assistant removes the macro-preparation - the uterus with appendages or fallopian tubes - together with the manipulator from the pelvis through the vagina,

the vaginal dome is formed with separate sutures using a monofilament absorbable thread, with the stump of the uterosacral ligaments being fixed to the vaginal stump,

a forceps with a tampon soaked in an antiseptic solution is installed in the vagina to allow displacement and apical pushing of the vaginal stump;

Stage 4: along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left,

on both sides, the descending branches of the pubic bones are identified to the pectineal ligaments, anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels - vein and artery (arteria, vena femoralis),

the first implant has an elongated shape with approximate dimensions in accordance with the anatomical features of the patient: length: 10-12 cm, upper base: -4 cm wide, the width of the lower base with protrusions on the sides for fixation is determined by location (landmarks are the size of the defect, the width of the straight intestines and the distance between the levator ani muscles),

the specified implant is fixed with a wide base with separate sutures with a non-absorbable thread to the bundles mm. Iliococcygeus on both sides,

the first implant is fixed to the vaginal stump with a narrow proximal base using two sutures, also with a non-absorbable thread,

the second implant, which is placed in the transverse direction, is fixed in its central part to the vaginal stump,

after this, both implants are sewn together with three separate sutures using a non-absorbable thread with stitching of the vaginal stump,

then the second assistant, by apical pressure and pushing with the help of a forceps previously installed in the vagina, pulls the vaginal stump in the cephalic direction to ensure its normal physiological position,

after which the ends of the second implant are fixed to the pectineal ligaments with separate sutures using a non-absorbable thread, 1 suture on each side,

remove the fixation of the sigmoid colon from the left side wall of the pelvis, return it to its previous physiological position,

peritonization is performed using a continuous suture with a monofilament absorbable thread, with all stumps and implant flaps located extraperitoneally,

perform sanitation of the pelvic cavity, complete hemostasis,

sutures are placed on the trocar wounds.

In particular, the length of the second implant is 15 cm and the width is 4 cm.

Drainage of the abdominal cavity is not performed, since during the operation there is no conflict with adjacent hollow organs.

The proposed invention is illustrated by the following clinical examples.

Clinical example No. 1. Patient A., 68 years old, was admitted to the gynecological department of the Obstetrics and Gynecology Clinic (UCB No. 2) of the First Moscow State Medical University named after. THEM. Sechenov October 15, 2019

Complaints: Sensation of a foreign body in the perineal area, frequent urination. Blood transfusions: denies. Allergies and intolerances: Lidocaine - cough (vitamins B). Gynecological history: Menstruation: 5 days every 28 days, moderate, painless, last in 1999. In 1999 - laparoscopy, supravaginal amputation of the uterus without appendages. Pregnancies - 3. Childbirth 1 - 1974, spontaneous, timely birth, without complications. Gynecological diseases: cervical erosion, DEC. In 1999 - hysteroscopy, RDV, removal of the IUD. Since 1999 - uterine fibroids, in 1999 - laparoscopy, supravaginal amputation of the uterus without appendages. In 2003, there was bleeding from the cervical stump, cervicoscopy was performed, and endocervix curettage was performed. History: According to ultrasound of the pelvic organs (09.27.19): Cervical stump 25*16 mm. C-prolapse of 2 degrees, cystocele of 1-2 degrees, rectocele is not detectable echographically, the urethral sphincter is not changed. Conclusion: C-prolapse, 2nd degree. Considering the presence of prolapse of the cervical stump in the patient after a subtotal hysterectomy, leading to complaints and deterioration in the quality of life, the patient was recommended for surgical treatment and was hospitalized in the gynecological department with operating rooms of the obstetrics and gynecology clinic of the Clinical Clinical Hospital No. 2. According to the results of a general clinical examination (consultation with a cardiologist on 10/08/2019, a therapist on 10/08/2019): There are no contraindications for surgical treatment and endotracheal anesthesia. Clinical diagnosis: Prolapse of the vaginal dome. 2003 - laparoscopy, hysterectomy without appendages. Hypertension stage 2, grade 2, grade 3 risk. Varicose veins of the lower extremities. Obesity 1 tbsp.

Conclusion: Considering the presence of prolapse of the vaginal dome in the patient after a total hysterectomy, leading to complaints and deterioration in the quality of life, the patient is indicated for surgical treatment in the following volume: laparoscopy, longitudinal-transverse MESH-pectovaginopexy with two mesh synthetic implants. Consent for the operation has been received and the volume has been warned. The patient is prepared for surgery.

Progress of the operation. Preoperative preparation (known stages) is carried out - preoperative antibiotic prophylaxis half an hour before the start of the operation and prevention of venous thromboembolic complications - compression hosiery of the veins of the lower extremities. Anesthesia: Combined endotracheal anesthesia. The operating team consists of a surgeon and first and second assistants. The patient is placed on the operating table in the lower lithotomy position with her legs widely apart. A permanent urinary catheter Folley 16, Fhench type with an inflatable cuff, is installed transurethrally into the bladder. The surgical field is treated: the anterior abdominal wall, external genitalia and vagina with an antiseptic solution. Carry out other known steps in preparation for the operation. Additionally, the vagina is treated and, under aseptic conditions, the vaginal dome is fixed on a tupfer (Tupfer (German: Tupfer - tampon) - a sterile probe-tampon. Wikipedia). Under aseptic conditions, CO2 pneumoperitoneum (4.5 l) is typically applied through a paraumbilical puncture with a Veress needle, after which a central trocar with an internal lumen of 10 mm and a video camera are installed. In the suprapubic region, one 12 mm trocar is installed in the midline and two 6 mm trocars are installed in the right and left iliac regions, at the McBurney Point, the patient is transferred to the Trendelenburg position and the abdominal cavity and small organs are examined pelvis In order to improve the exposure of the pelvic organs, the sigmoid colon is fixed to the side wall of the pelvis by suturing the fat pads. A forceps with a tampon soaked in an antiseptic solution is installed in the vagina to allow displacement and apical pushing of the vaginal stump in the cephalic direction. After preliminary coagulation, the infundibulopelvic ligaments are crossed on both sides. The appendages are cut off. The drugs are removed from the abdominal cavity through a 12 mm trocar. After which the peritoneum is opened in the area of the vaginal stump 1 cm from the vaginal dome. Then dissection of the rectovaginal space is carried out sharp or blunt to the muscles that lift the ani - mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, mobilization of the rectum is carried out with selection of the rectocele. The vesicouterine fold of the peritoneum is opened and the bladder is bluntly lowered with its maximum possible mobilization to the anterior wall of the vagina. The dome of the vagina is exposed. Along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, and on both sides the descending branches of the pubic bones to the pectineal ligaments are isolated. Anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels - vein and artery (arteria and vena femoralis). The first mesh synthetic implant is cut out (use polypropylene mesh, 21 g/m2) of an elongated shape with dimensions in place: length: 11 cm, upper base: width - 4 cm, width of the lower base with protrusions on the sides for fixation - 6 cm (guideline: according to the distance between the muscles that lift the ani). The implant is fixed longitudinally with a wide base with separate sutures using a non-absorbable ethylene terephthalate thread (“Ethibond”) to the bundles mm. Iliococcygeus on both sides, with a narrow proximal base, the implant is fixed with two sutures with the same thread to the vaginal stump. A second implant is also cut out from the same material as the first; it has the shape of a rectangular strip with dimensions of 15 by 4 cm. The second implant is placed in the transverse direction and fixed in its central part to the dome of the vagina, after which both implants are stitched together with three separate sutures with non-absorbable ethylene terephthalate thread (“Ethibond”) with stitching of the vaginal dome. Next, the second assistant, by applying apical pressure and pushing with the help of a previously installed forceps, pulls the vaginal stump in the cephalic direction to ensure its normal physiological position corresponding to the pelvic landmarks. After that, the lateral sleeves of the second implant are fixed to the pectineal ligaments with the same non-absorbable thread (1 suture on each side), without tension. Peritonization of the surgical field with a continuous suture of monofilament absorbable suture polyglecaprone copolymer (“Monocryl”) with all stumps and implant flaps located extraperitoneally. The fixation of the sigmoid colon is removed from the left side wall of the pelvis and returned to its previous physiological position. Sanitation of the pelvic cavity. Additional hemostasis. Abdominal drainage is not performed. Sutures are placed on trocar wounds and sutures on the skin. Aseptic stickers. Blood loss 50 ml. Urine through a permanent catheter is 100 ml, light.

The postoperative period proceeded without complications. Antibacterial, analgesic, anticoagulant, infusion and anti-inflammatory therapy, and physiotherapy were carried out. Healing of sutures by primary intention. Routine examination (outpatient) after 6 months: complete correction of apical and posterior prolapse.

Clinical example No. 2. Patient N., 45 years old, was admitted to the gynecological department of the Clinic of Obstetrics and Gynecology of the First Moscow State Medical University named after. THEM. Sechenov 06/22/2021

Complaints: heavy menstruation, discomfort in the perineal area, difficulty urinating. Blood transfusions: denies. Gynecological history: Menstruation: 6-7 days every 28 days, heavy, painless. Mirena in the uterine cavity for 3.5 years (removed on January 15, 2021). Pregnancies - 5. Childbirth 3. In 2010 - caesarean section. Gynecological diseases: in 2009, laparoscopy, myomectomy; in 2015 - 2017 repeatedly: hysteroscopy, RDV for endometrial hyperplasia; uterine fibroids; adenomyosis. History: According to ultrasound of the pelvic organs dated June 17, 2021: Contours of the uterus: smooth. Myometrial structure: heterogeneous. Features: pronounced adenomyosis. The endometrium corresponds to: phase II. Cervix: elongation 65 mm. Right ovary: Structure: b\o. Left ovary: Structure: corpus luteum 16 mm. Features: urethra - moderate hypermobility. C - prolapse 1, cervical elongation, rectocele 1. Conclusion: Adenomyosis. Incompetence of the pelvic floor muscles. The patient was recommended for surgical treatment. Based on the results of the clinical examination: Therapist’s conclusion 06/11/2021: There are no contraindications for surgical treatment. Clinical diagnosis: Adenomyosis. With stage 2 prolapse, cervical elongation.

Conclusion: Considering the presence of pelvic floor muscle failure in the patient, which leads to complaints and a decrease in quality of life, the patient is indicated for surgical treatment in the amount of: Laparoscopy. Extirpation of the uterus with fallopian tubes. Longitudinal-transverse MESH pectovaginopexy with two mesh synthetic implants. Consent for the operation has been received and the volume has been warned. The patient is prepared for surgery. Progress of the operation. Preoperative preparation (known stages) is carried out - preoperative antibiotic prophylaxis half an hour before the start of the operation and prevention of venous thromboembolic complications - compression knitwear of the veins of the lower extremities. Anesthesia: Combined endotracheal anesthesia. The operating team consists of a surgeon, first and second assistants. The patient is placed on the operating table in the lower lithotomy position with her legs widely apart. A permanent urinary catheter Folley 16, Fhench type with an inflatable cuff, is installed transurethrally into the bladder. The surgical field is treated: the anterior abdominal wall, external genitalia and vagina with an antiseptic solution. Carry out other known steps in preparation for the operation.

Additionally, the vagina is treated and the cervix is fixed under aseptic conditions with bullet forceps, preparations are made for hysterectomy, while the length of the uterine cavity is measured using a probe, after preliminary expansion of the cervical canal with Hegar dilators to No. 9, a uterine manipulator is inserted transcervically into the uterus. Under aseptic conditions, CO2 pneumoperitoneum (4.5 l) is typically applied through a paraumbilical puncture with a Veress needle, after which a central trocar with an internal lumen of 10 mm and a video camera with rigid video recording are installed, one 12 mm trocar is installed in the suprapubic region along the midline and two 6 mm trocars in the right and left iliac regions, at the McBurney Point. The patient is transferred to the Trendelenburg position: 30-35°, and the abdominal cavity and pelvic organs are examined. Found: The body of the uterus is of normal size, pink in color, with a smooth surface. Right ovary 2*1.5*1 cm; folding is pronounced. The right fallopian tube is 7 cm long, pink, convoluted, fimbriae are pronounced. The left ovary is 2*2*1.5 cm, pronounced folding. The left fallopian tube is 7 cm long, tortuous, fimbriae are pronounced. Vesico-uterine and rectal-uterine spaces - without visible pathological changes. The greater omentum, edge of the liver, intestinal loops, peritoneum - without visible pathological changes. Surgical diagnosis: Adenomyosis. C - prolapse 2nd degree. In order to improve the exposure of the pelvic organs, the sigmoid colon is fixed to the left side wall of the pelvis by suturing the fat pads. To form and visualize the surgical field, the second assistant performs apical pushing of the uterus (in the cephalic direction) with a previously installed manipulator. After that, the peritoneum of the retrouterine space is opened 1 cm from the cervix, then the rectovaginal space is dissected sharply or bluntly to the muscles that lift the ani - mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, mobilization of the rectum is carried out with selection of the rectocele. A typical hysterectomy is performed - the uterus and fallopian tubes are removed. After preliminary coagulation, the round ligaments of the uterus, mesosalpinx, fallopian tubes on both sides and the proper ovarian ligaments on both sides are crossed, and the uterine vessels, cardinal and uterosacral ligaments on both sides are coagulated and crossed. Next, the vesico-uterine fold of the peritoneum is opened and the bladder is bluntly brought down with its maximum possible mobilization in place to the anterior wall of the vagina, the vaginal wall is cut off circularly along the edge of the isoelectric cap of the manipulator. The second assistant removes the macro-preparation - the uterus with the fallopian tubes - together with the manipulator from the pelvis through the vagina. The vaginal dome is formed with separate sutures using a monofilament absorbable thread, polyglecaprone copolymer “Monocryl” with fixation of the stump of the uterosacral ligaments to the vaginal stump. A forceps with a tampon soaked in an antiseptic solution is installed in the vagina to allow displacement and apical pushing of the vaginal stump. Along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, and on both sides the descending branches of the pubic bones to the pectineal ligaments are isolated. Anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels - vein and artery (arteria, vena femoralis). The first mesh synthetic implant (polypropylene) is cut out in an elongated shape with dimensions in place: length: 10.5 cm, upper base: width - 4 cm, width of the lower base with protrusions on the sides for fixation - 6 cm. The implant is fixed longitudinally with a wide base with separate sutures non-absorbable thread ethylene terephthalate (“Ethibond”) to the bundles mm. Iliococcygeus on both sides, with a narrow proximal base, the implant is fixed with two sutures with the same thread to the vaginal stump. The second implant is cut out from the same material as the first; it has the shape of a rectangular strip with dimensions of 15 by 4 cm. The second implant is placed in the transverse direction and fixed in its central part to the vaginal stump, after which both implants are sewn together with three separate sutures non-absorbable thread ethylene terephthalate (“Ethibond”) with stitching of the vaginal stump. Next, the second assistant, by applying apical pressure and pushing with the help of a previously installed forceps, pulls the vaginal stump in the cephalic direction to ensure its normal physiological position corresponding to the pelvic landmarks. After that, the lateral sleeves of the second implant are fixed to the pectineal ligaments with the same non-absorbable thread (1 suture on each side), without tension. Peritonization of the surgical field with a continuous suture of monofilament absorbable suture polyglecaprone copolymer (“Monocryl”) with all stumps and implant flaps located extraperitoneally. The fixation of the sigmoid colon is removed from the left side wall of the pelvis and returned to its previous physiological position. Sanitation of the pelvic cavity. Additional hemostasis. Abdominal drainage is not performed. Sutures are placed on the trocar wounds. Aseptic stickers. Blood loss 100 ml. The urine from the permanent catheter is light, 300 ml. Macro specimen: Uterus with fallopian tubes. Purpose: 1. stationary mode. 2. table 1 a/h. 3. cefotaxime 1 g IM 2 times a day. 4. appointments of the anesthesiologist.

The postoperative period proceeded without complications. Antibacterial, analgesic, anticoagulant, infusion and anti-inflammatory therapy, and physiotherapy were carried out. Healing of sutures by primary intention. Routine examination (outpatient) after 6 months: complete correction of apical and posterior prolapse.

Clinical example No. 3. Patient O., 64 years old. She entered the gynecological department of the Clinic of Obstetrics and Gynecology of the Perm State Medical University named after. THEM. Sechenov 08/29/2021 Operating room No. 3 (Gynecology).

Name of the operation: Laparoscopy. Extirpation of the uterus by appendages. MESH pectovaginopexy.

Complaints: sensation of a foreign body in the perineal area. Transfusion history: denies. Gynecological history: Menstruation: 3 days every 28 days, moderate, painless. Sexual life from the age of 22. Pregnancies - 4. Childbirth 1 in 1982, timely spontaneous birth, 3700 g, without complications. Induced abortions: 3, the last one in 1992. Gynecological diseases: Incompetence of the pelvic floor muscles, prolapse of the vaginal walls since 2003. In 2021, grade 1-2 cystocele and endometrial polyp were diagnosed, and on July 13, 2021, surgery was performed: Dilatation of the cervical canal. Hysteroscopy. Separate diagnostic curettage of the endocervix and endometrium. According to the results of histological examination: 1. In a scraping from the cervical canal there are small layers of stratified squamous epithelium without underlying tissues with some enlarged nuclei in the lower third of the layer. 2. In scrapings from the uterine cavity there are fragments of fibromuscular tissue with concentric structures (leiomyoma? basal layer?). There are small particles of fibrous tissue with cystically dilated glands (cystic endometrial atrophy? part of a polyp?). Therapist: There are no contraindications for surgery. Clinical diagnosis: C - 3rd degree prolapse. Cystocele 2.st. Incompetence of the pelvic floor muscles. Uterine fibroids. NCD of hypotonic type. Conclusion: The patient is indicated for surgical treatment in the following scope: Laparoscopy, hysterectomy with appendages, MESH-pectovaginopexy. Consent for the operation has been received and the volume has been warned. The patient is prepared for surgery.

On September 1, 2021, surgical treatment was carried out in the following scope: the indicated laparoscopy, extirpation of the uterus with appendages, longitudinal-transverse MESH pectovaginopexy with two mesh synthetic implants (preparatory stages, see previous examples).

At the stage of hysterectomy, the uterus and appendages are removed. Using a bipolar coagulator, the round uterine ligaments and infundibulopelvic ligaments are coagulated and crossed on both sides, as well as the uterine vessels, cardinal and uterosacral ligaments on both sides are coagulated and crossed. The macropreparation - the uterus with appendages - is removed through the vagina. The stages of implant installation repeat the steps from example No. 2 (dimensions of the 1st longitudinal implant: length: 12 cm, width of the narrow base: 5 cm, wide (in place) - 6.5 cm, dimensions of the 2nd transverse implant: 15x4 cm. ). Blood loss 120 ml. The urine from the permanent catheter is light, 350 ml. Macro specimen: Uterus with appendages.

The postoperative period was without complications. Antibacterial, analgesic, anticoagulant, infusion and anti-inflammatory therapy, and physiotherapy were carried out. Healing of sutures by primary intention. Routine examination (outpatient) after 6 months: complete correction of apical and posterior prolapse.

At the end of the observation period, all patients participating in the study noted an improvement in the quality of life, including normalization of the functions of the pelvic organs. Objective examination data indicate complete correction of posterior and apical prolapse.

Claims (8)

1. A method of surgical correction of combined forms of genital prolapse with synthetic mesh implants, including laparoscopic combined longitudinal-transverse fixation of the vaginal dome or cervix with the following steps: the peritoneum is opened over the internal surfaces of the pubic bones with further dissection laterally and caudally, the rectovaginal space is dissected, the pectineal ligaments, external iliac vessels - veins and arteries are isolated, the first implant made of synthetic mesh material is longitudinally installed with one side into the rectovaginal space to the muscles that lift the posterior passage, and stitched with non-absorbable suture material, the second implant, made of the same material as the first, in the form of a rectangular tape, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material, while the operated organs are provided with a physiological position, after which the lateral sleeves of the second the implant is fixed to the pectineal ligaments with non-absorbable suture material without tension, peritonization is performed, characterized in that the patient who has undergone a hysterectomy, after the preparatory stage of the operation, is treated with a vaginal dome, under aseptic conditions, the vaginal dome is fixed on a tupfer, under aseptic conditions, pneumoperitoneum CO ₂ - 4.5 l is applied through a paraumbilical puncture with a Veress needle, after which a central trocar with with an internal lumen of 10 mm and a video camera, one 12 mm trocar is installed in the suprapubic region along the midline and two 6 mm trocars in the right and left iliac regions, the patient is transferred to the Trendelenburg position and the abdominal cavity and pelvic organs are examined, fixation of the sigmoid colon to the left side wall of the pelvis by suturing the fat suspensions, a forceps with a tampon soaked in an antiseptic solution is installed in the vagina, after which the peritoneum is opened in the area of the vaginal stump, 1 cm away from the stump of the cervix or vaginal dome, then dissection is performed rectovaginal space to the levator ani muscles - mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, the rectum is mobilized, then the vesicouterine fold of the peritoneum is opened and the bladder is bluntly lowered with its maximum possible mobilization to the anterior wall of the vagina; then, along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, on both sides the descending branches of the pubic bones are isolated to the pectineal ligaments, anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels - femoral vein and artery, the first implant has an elongated shape with dimensions: length: 10-12 cm, the upper narrow base is 4 cm wide, the width of the lower wide base with protrusions on the sides for fixation is determined intraoperatively in accordance with the distance between the levator ani muscles, the specified first implant is fixed wide base with separate sutures with non-absorbable thread to the bundles mm. Iliococcygeus on both sides, and its narrow base is fixed to the stump of the vagina or cervix with two sutures, also with a non-absorbable thread, the second implant is placed in the transverse direction, fixed in its central part to the stump of the vagina or cervix, after which both implants are sewn together with three separate sutures with a non-absorbable thread with stitching of the vaginal stump, then the second assistant, by apical pressure using a forceps previously installed in the vagina, pushes the vaginal stump in the cephalic direction, after which the ends of the second implant are fixed to the pectineal ligaments with separate sutures using a non-absorbable thread, 1 suture for each sides, remove the fixation of the sigmoid colon from the left side wall of the pelvis, return it to its previous physiological position, perform peritonization with a continuous suture with a monofilament absorbable thread, with the stumps and implant flaps located extraperitoneally, perform sanitation of the pelvic cavity, hemostasis, and apply sutures to the trocar wounds. 2. The method according to claim 1, characterized in that the length of the second implant is 15 cm and the width is 4 cm. 3. A method of surgical correction of combined forms of genital prolapse with synthetic mesh implants, including laparoscopic combined longitudinal-transverse fixation of the vaginal dome with the following steps: the peritoneum is opened over the internal surfaces of the pubic bones with further dissection laterally and caudally, the rectovaginal space is dissected, the pectineal ligaments, external iliac vessels - veins and arteries are isolated, the first implant made of synthetic mesh material is longitudinally installed with one side into the rectovaginal space to the muscles that lift the posterior passage, and stitched with non-absorbable suture material, the second implant, made of the same material as the first, in the form of a rectangular tape, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material, while the operated organs are provided with a physiological position, after which the lateral sleeves of the second the implant is fixed to the pectineal ligaments with non-absorbable suture material without tension, peritonization is performed, characterized in that, in the presence of a uterus, the vagina is treated and the cervix is fixed under aseptic conditions with bullet forceps, preparations are made for hysterectomy, while the length of the uterine cavity is measured using a probe, after preliminary expansion of the cervical canal with Hegar dilators to No. 9, a uterine manipulator is inserted transcervically into the uterus, under aseptic conditions, through a paraumbilical puncture with a Veress needle, pneumoperitoneum CO ₂ is applied, 4.5 l, after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar in the midline and two 6 mm are installed in the suprapubic region trocar in the right and left iliac regions, the patient is transferred to the Trendelenburg position and the abdominal cavity and pelvic organs are examined, the sigmoid colon is fixed to the left side wall of the pelvis by suturing the fatty pendants; then the second assistant forms and visualizes the surgical field, for this he performs an apical push of the uterus in the cephalic direction with a previously installed manipulator, after which the peritoneum of the retrouterine space is opened, retreating 1 cm from the cervix, then the rectovaginal space is dissected to the levator ani muscles - mm . levator ani, and their upper bundles mm. Iliococcygeus, in parallel, mobilizes the rectum; then a hysterectomy is performed, and in case of removal of the uterus with appendages, using a bipolar coagulator, the round uterine ligaments and infundibulopelvic ligaments are coagulated and crossed on both sides, and the uterine vessels, cardinal and uterosacral ligaments are coagulated and crossed on both sides , or, in the case of removal of the uterus with fallopian tubes, after preliminary coagulation, cross the round ligaments of the uterus, mesosalpinxes, fallopian tubes and proper ovarian ligaments on both sides, and also coagulate and cross the uterine vessels, cardinal and uterosacral ligaments on both sides, then the vesico-uterine fold of the peritoneum is opened and the bladder is bluntly lowered with the maximum possible mobilization to the anterior wall of the vagina, then the uterus is cut off from the vaults of the vaginal wall circularly along the edge of the isoelectric cap of the manipulator, the second assistant removes the macro-preparation - the uterus with appendages or with fallopian tubes - together with a manipulator from the small pelvis through the vagina, the vaginal dome is formed with separate sutures of a monofilament absorbable thread, with the stump of the uterosacral ligaments being fixed to the vaginal stump, a forceps with a tampon soaked in an antiseptic solution is installed in the vagina; Along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, the descending branches of the pubic bones are isolated on both sides to the pectineal ligaments, anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vein and artery, femoral vein and artery , the first implant has an elongated shape with dimensions: length: 10-12 cm, upper narrow base width - 4 cm, the width of the lower wide base with protrusions on the sides for fixation is determined intraoperatively, in accordance with the distance between the levator ani muscles, said implant fixed with a wide base using separate sutures with non-absorbable thread to the bundles mm. Iliococcygeus on both sides, to the vaginal stump, the first implant is fixed with a narrow base with two sutures, also with a non-absorbable thread, the second implant, which is placed in the transverse direction, is fixed in its central part to the vaginal stump, after which both implants are sewn together with three separate sutures with a non-absorbable thread with stitching the vaginal stump, then the second assistant, by apical pressure using a forceps previously installed in the vagina, pushes the vaginal stump in the cephalic direction, after which the ends of the second implant are fixed to the pectineal ligaments with separate sutures with a non-absorbable thread, 1 suture on each side, the fixation is removed sigmoid colon from the left side wall of the pelvis, return it to its previous physiological position, peritonization is performed with a continuous suture with a monofilament absorbable thread, with the stumps and implant flaps located extraperitoneally, the pelvic cavity is sanitized, complete hemostasis is performed, and sutures are applied to the trocar wounds. 4. The method according to claim 3, characterized in that the length of the second implant is 15 cm and the width is 4 cm.