Method for carrying out vaginal uterus extirpation

FIELD: medicine.

SUBSTANCE: method involves shortening and attaching round ligaments to vagina fornix and their suturing under the urethra as sling. Cardial ligaments are shortened and attached to the middle part of the vagina. Triangular flap is cut from posterior vaginal wall, sacrouterine ligaments are sutured. The posterior vaginal wall is separated from the rectum creating in this way duplicature from vaginal walls.

EFFECT: enhanced effectiveness of surgical treatment; eliminated urination disorders.

4 dwg

 

The present invention relates to gynecology, in particular for surgical treatment of genital prolapse stress urinary incontinence without it.

There are many operations in the treatment of genital prolapse, and these surgical procedures have many modifications. However, many types of surgical treatment of genital prolapse due to lack of effectiveness of treatment methods, a large number of relapses (see: S. Medvedev. Combined laparo-vaginal access in the treatment of patients with genital prolapse. Diss. candlenut. Moscow. 2000; 11-75).

The most well-known surgery vaginal hysterectomy includes the following steps of operation: the dissection of the anterior vaginal wall, the separation blunt and sharp through the wall of the vagina from the bladder. After the final separation from the fascia to the lateral edges of the produce of his separation from the cervix of the uterus and peritoneum upwards, cleaving preduzimaju tissue. Next, the cervix is pulled up, to fold, cut the back wall is brought to a place of discharge of the Sacro-uterine ligaments of the uterus. The walls of the vagina prepare the chin slightly upwards and sideways to expose the uterine vessels and cardinal ligaments. The uterus is taken out to the opening of the wound. Along the edges of the uterus impose a consistently strong C the presses, since cardinal ligaments, then put the clamps along the body of the uterus on each side. The uterus is cut off. Tissue taken in the clamps (ligaments, vessels, fallopian tube end), sheathe. The bladder is fixed with interrupted sutures placed in the transverse direction, the incision of the vaginal wall is superimposed continuous seam. Rear plastic vagina, levatorplasty (see Hirsch H., Kezer, O., Icle F. Operative gynecology. TRANS. from English. Moscow. GEOTAR medicine. 1999; 218-228, 243-252).

If the patient stress urinary incontinence vaginal hysterectomy combined with anti-stress operation. However, after conducting this activity, the percentage of development of relapses for up to 8%, which dictates the necessity of developing new methods of surgical treatment of these patients (O. Makarov, ilina IU, Schwartz p. g, the Russian Bulletin of the obstetrician - gynecologist, Moscow. 2002. Volume 2, No. 5, 61-63).

Also known vaginal hysterectomy in McCall, which consists in suturing the Sacro-uterine ligaments at a distance of 3-5 cm from the ends. In seam, you can enable the rear edge of the peritoneum between the Sacro-uterine ligaments. With a very wide divergence ligaments are excised between them a triangular wedge. McCall put three such seam. Tying seams lay before the end of surgery or prior to the execution of the back colporrhaphy. Sacral-matoon the e chords closer to the middle of premonicion-uterine cavities, move the vagina medially and fix it (see Hirsch H., Kezer, O., Icle F. Operative gynecology. TRANS. from English. Moscow. GEOTAR medicine. 1999; 233-235).

If the patient stress urinary incontinence surgery combined with anti-stress operation. The percentage of recurrences of the less after carrying out this treatment, however, is insufficient, because this operation is insufficient fixation of ligaments to the vaginal walls, which leads in some cases to the loss of the vaginal stump in the postoperative period.

Also known vaginal hysterectomy in the modification of Mayo, which consists in suturing the ligament of the uterus, to which is fixed to the wall of the vagina. Needle injected directly at the upper angle of the wound through the mucous membrane of the vagina, the fascia and the peritoneum of the bladder, the upper section of the United uterine ligaments and put through the layers described in the reverse direction opposite edge of the wound. The same thread make a second seam, grasping the edges only of the mucous membrane of the vagina, the more medially previous vcol for thicker edges of the mucous. Such joints impose few, retreating 1,5-2 cm down from the first. These seams vaginal wall is fixed to the coupled between the ligaments of the uterus. The latter strengthens the vaginal wall into the area and stump Sacro-uterine ligaments. This suturing stump ligaments are extraperitoneal (see Kulakov V.I., Selezneva N, V. Krasnopolsky Operative gynecology. Moscow. The honey. book. 1998; 315-319). If the patient stress urinary incontinence conduct this type of treatment combined with a stress relieving operation.

The percentage development of recurrence after surgery was significantly reduced, however, after vaginal surgery one of the complications is the occurrence of different types of urinary incontinence, which can even lead to the development of various psycho-emotional disorders in patients (Stanton 2000). If stress incontinence occurs after the operation, aimed at the correction of genital prolapse, there often arises the need for additional anti-stress operations. All this leads to the need to develop surgical treatment aimed not only at reducing the development of relapse, but also for the treatment and/or prevention of occurrence of stress urinary incontinence in the postoperative period.

The purpose of the invention is to improve the results of surgical treatment aimed at correction of genital prolapse in combination with stress incontinence and without it, but with the elimination of occurrence of urination disorders in the postoperative period.

This whole which is achieved by after vaginal removing the uterus produce shortening and fixation of the round ligaments to the vaginal vaults and their closure under the urethra in the form of a makeshift sling, shortening the cardinal ligaments and their fixation to the middle part of the vaginal wall, in all cases, the excised triangular flap from the posterior vaginal wall and sutured Sacro-uterine ligaments, and when the plastic back wall of the vagina maximum usepreview the rear wall of the rectum, creating duplicator the walls of the vagina, levatorplasty.

Figure 1 presents schematically the shortening and fixation of the round ligaments to the vaginal vaults and their closure under the urethra in the form of a sling (1st stage); figure 2 - the shortening of the cardinal ligaments and their fixation to the middle part of the vaginal wall (2nd stage); figure 3 - excision of a triangular flap from the posterior wall of the vagina and the closure of the Sacro-uterine ligaments (3rd stage); figure 4 - separation of the rear wall of the vagina from the rectum for the purpose of creating duplicatory the walls of the vagina, levatorplasty (4th stage).

The claimed method is illustrated with specific examples of its implementation.

Example 1.

Patient M 51 appealed with complaints about dropped uterus, unpleasant sensations in the lower abdomen, discomfort in the crotch area, leakage of urine when coughing, sneezing. Within 10 years of concern t nudie pain in the lower abdomen, the feeling of a foreign body in the vagina. The first episode of incontinence said about 5 years ago. Last year marked a significant deterioration in increasing urinary incontinence whenever you cough or sneeze. History of 6 pregnancies, two births, the first complicated by rupture of the perineum and cervix. Comorbidities: chronic bronchitis, varicose veins of the lower extremities. At vaginal examination sexual slit gaping, legs levatores are widely. Outside of the genital slit without natureline is the cervix, is determined cystocele, rectocele, elongation of the cervix, when the cough is determined by the leakage of urine (cough test positive), Q-type test is positive.

Thus, on the basis of complaints, anamnesis and physical examination on the gynecological chair has a preliminary diagnosis: partial prolapse of the uterus and vaginal walls, the elongation of cervix of the uterus, cystocele, rectocele, the failure of the pelvic floor muscles, stress urinary incontinence.

According to a comprehensive urodynamic studies sistematicheskaya capacity of the bladder was 205 ml, the first urge to urinate patient noted to 96 ml, maximum detrusor pressure of 34.5 cm aq. Art., detrusor pressure at maximum flow 14,8 cm aq. Art., average and maximum speeds mo is eemission amounted to 9.0 and 20.4 ml/s, respectively. Unstable contractions of the bladder and obstructive voiding, the patient no. Stress profile be pressure proved leak urine when you cough on programme observed negative pressure closing.

As a preoperative preparation of the patient was assigned to Ovestin” in the form of candles in the vagina for 3 weeks 3 times a week.

Was vaginal hysterectomy without adnexa with improvised sling.

Description of operation: the dissection of the anterior vaginal wall, the separation blunt and sharp through the wall of the vagina from the bladder. After the final separation from the fascia to the lateral edges of his separation from the cervix of the uterus and peritoneum upwards with dissection predposylki fiber. The cervix is pulled up to the bosom, made a slit in the rear wall to the place of discharge of the Sacro-uterine ligaments of the uterus. After peeling walls of the vagina naked uterine vessels and cardinal ligaments. The uterus is removed through the opening in the wound. Along the edges of the uterus imposed consistently clips, starting with the cardinal ligaments, then the clamps along the body of the uterus on each side. The uterus is cut off. Tissue taken in the clamps (ligaments, vessels, fallopian tube end), trimmed. The bladder is fixed interrupted sutures. Produced shortening and fixing all the misfits from the roof of the vagina (1.1) and their closure under the urethra (1.2) in the form of a makeshift sling (1.3), the shortening of the cardinal ligaments and their fixation to the middle part of the vagina (2.1), excision of a triangular flap from the posterior wall of the vagina (3.2) and the closure of the Sacro-uterine ligaments (3.1), incision of the vaginal wall superimposed continuous seam. Most tsepilova the back wall of the vagina from the rectum with the creation of duplicatory from the vaginal wall, levatorplasty.

The postoperative period was uneventful. Discharged on the 8th day in a satisfactory condition.

When coughing, sneezing patient leaks urine no notes.

At the control examination after 12 months of complaints and signs of prolapse of the vaginal walls no cough test is negative.

In complex urodynamic study, the patient M. pathological disorders are not detected.

Example 2.

Patient R. 54 years old was admitted with complaints of discomfort in the lower abdomen, discomfort in the crotch area. Within 15 years of concern the above complaints. History of 7 pregnancies, three genera, the first complicated by rupture of the perineum. Comorbidities: chronic pyelonephritis, ischemic heart disease, angina, FC I, HK 0, varicose veins of the lower extremities. At vaginal examination sexual slit gaping, legs levatores are widely. Outside of the genital slit without natureline is the cervix, is determined by qi tiele, rectocele, cough test is negative.

Thus, a preliminary diagnosis: partial prolapse of the uterus and vaginal walls, cystocele, rectocele, the failure of the pelvic floor muscles.

When conducting a comprehensive urodynamic studies in patients lesions were found.

As a preoperative preparation of the patient was assigned to Ovestin” in the form of candles in the vagina for 4 weeks before surgery 2 times a week.

Was vaginal hysterectomy without adnexa with improvised sling.

The description of the operation as in example 1.

The postoperative period was uneventful. Discharged on day 7 in a satisfactory condition.

At the control examination after 6, 12 months of complaints and signs of prolapse of the vaginal walls no cough test is negative.

In complex urodynamic study pathological changes it is not revealed.

Example 3.

Patient E. 45 years have complained of discomfort in the lower abdomen, leaking of urine when coughing, sneezing, sexual intercourse, physical activity. For 7 years bother dragging pain in the lower abdomen. The first episode of incontinence said about 2 years ago. In the last 6 months marks a significant deterioration in increasing urinary incontinence when everyone is coughing, the sneezing. Previously, for the treatment of urinary incontinence was not addressed. History of 6 pregnancies, one delivery without complications. Comorbidities: osteochondrosis of the lumbar spine, hypertension I-II. At vaginal examination sexual slit gaping, legs levatores are widely expressed prolapse of vaginal walls, cystocele, rectocele. When the cough is determined by the leakage of urine (cough test positive), Q-type test is positive.

Preliminary diagnosis: prolapse of vaginal walls, cystocele, rectocele, the failure of the pelvic floor muscles, stress urinary incontinence.

According to a comprehensive urodynamic studies unstable contractions of the bladder and obstructive voiding, the patient no. Stress profile be pressure proved leak urine when you cough on programme observed negative pressure closing.

Was vaginal hysterectomy with improvised sling, as described in example 1.

The postoperative period was uneventful. Discharged on the 8th day in a satisfactory condition.

When coughing, sneezing patient leaks urine no notes.

At the control examination after 12 months of complaints and signs of prolapse of the vaginal walls and cervix no cough test is negative.

When integrated ugly the systematic study of patient E. pathological changes were not found.

Despite its apparent simplicity, the claimed method of surgical intervention is not obvious for specialists working in this field, including for professionals with experience in operative gynecology.

We first performed an operation on a single technique in patients with genital prolapse stress urinary incontinence without it. The operation was developed based on years of practice and experience in operative gynecology with the analysis of outcomes and various modifications of the operation. Unexpected is that the seemingly simple technical solution to the problem proved to be the most effective method, as leading to the treatment and prevention of occurrence of stress urinary incontinence, decreased development of relapses in the immediate and long periods after the operation.

Developed technique of operation reduces the time for vaginal removing the uterus, eliminates the need for all cases, additional anti-stress operations, reducing bed-day, improves and shortens the recovery period. The method has important socio-economic value.

The way of the vaginal removing the uterus, including the fixation of ligaments, levatorplasty, characterized in that the produce of the criminal code shall enhance the fixation of the round ligaments to the vaginal vaults and their closure under the urethra in the form of a sling, the shortening of the cardinal ligaments and their fixation to the middle part of the vagina, excision of a triangular flap from the posterior wall of the vagina and the closure of the Sacro-uterine ligaments, then usepreview the back wall of the vagina from the rectum, creating dublicator the walls of the vagina.



 

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