Surgical method for treating the cases of chronic pelvic pains

FIELD: medicine.

SUBSTANCE: method involves carrying out double-sided transverse nerve vaporization at the places the sacrouterine ligaments fuse with inferior uterine segment. Ablation is additionally applied all along the whole length between the transverse ablations along the inferior uterine segment.

EFFECT: enhanced effectiveness of treatment.

1 dwg

 

The present invention relates to medicine, in particular for surgical gynecology.

Surgical treatment of chronic pelvic pain based on the interruption of pain impulses coming from the uterus and proximal fallopian tubes through paracervical plexus of Frankenhauser and Sacro-uterine ligament to the lower and upper hypogastric plexus by denervation.

There is a method of treatment of chronic pelvic pain by excision sites Sacro-uterine ligaments within 1 cm from both sides of the electrocoagulation at the confluence of the Sacro-uterine ligaments from the lower uterine segment with the aim of denervation (Savitsky GA and other "Surgical treatment of pelvic pain syndrome in gynecologic clinic", SPB, ZAO ALBI" 2000, str).

Another well-known method of surgical treatment of chronic pelvic pain is ablation of the Sacro-uterine nerves laser, includes two-way cross vaporization nerves laser (Ishchenko A.I., Abdullayev L.A "Tactics of treatment of patients with chronic pelvic pain in gynaecological practice", Zh. Questions of gynecology, obstetrics and Perinatology, 2003, Vol.2, No.1, p.53-56).

The disadvantage of this method is its relatively low efficiency (33-63%), probably due to incomplete denervation due to the variability nanotopography and the possible regeneration of nerve fibers and the many of the plexus nerve fibers penetrate into the lower uterine segment together with blood vessels.

The objective of the invention is a more effective method for the treatment of chronic pelvic pain.

The problem is solved by the method lies in the fact that in addition to bilateral transverse vaporization nerves Ho-YAG laser at the confluence of the Sacro-uterine ligaments from the lower uterine segment perform ablation on the whole stretch between the cross alazemi in domed direction of the lower uterine segment.

Practically the method performs as follows. Under aseptic conditions produce entering the Central trocar in the paraumbilical area using equipment produced by Karl Storz Lawton (Germany) according to traditional methods using a 10 mm laparoscope "Storz" with 30° or 0° optical system, create pneumoperitoneum CO2- 4.5 l with insufflator firm "Lawton" and introduce additional manipulators in the suprapubic area under the control of the laparoscope (5 mm). Next, the uterus reject anteriorly by means of a manipulator, visualize the Sacro-uterine ligaments and produce laser vaporization of nerve fibers passing in the Sacro-uterine ligaments on both sides in the transverse direction at the confluence of the Sacro-uterine ligaments with the lower metaclassement over 1 cm Ho-YAG laser noncontact technique with a capacity of 15 watts. Then, on the whole stretch between the cross alazemi perform additional ablation for contactless technique with a capacity of 15-20 watts on the lower uterine segment (see drawing).

Laser vaporization perform pulsed Ho : YAG laser with a wavelength of 2.09 μm and penetrating power of 0.2-0.4 mm Laser energy, which was obtained by setting "STN-10" (Russia), was delivered on a flexible quartz laser fibers with a diameter of 400 μm. The laser fiber was introduced through the working channel of insufflator and brought directly to the Sacro-uterine ligaments. The laser fiber was positioned at a distance of 1-2 mm from the surface and slowly moved over her. The parameters of laser irradiation: the output power of 15 W to 20 W, pulse frequency 10-16 Hz, the pulse time is 300-400 μs.

Clinical example.

Patient Z., 38 years old, he enrolled in the operational Department of the clinic of obstetrics and gynecology MMA. Sechenov with complaints about the constant nagging pain in the lower abdomen, pain during sexual intercourse, painful menstruation.

From the anamnesis: the pain of worry for 7 years. Repeatedly received anti-inflammatory and antibiotic therapy without effect. The last few years, notes the intensity of pain. In 2003, he referred to the clinic of obstetrics and gynecology, inspection of suspected outside of genitally the endometriosis, ultrasound of the pelvic organs revealed adenomyosis "(diffuse form), endometrioid ovarian cysts.

The patient was examined by a neurologist, focal neurological pathologies it is not revealed, there is a chronic pain syndrome, anxiety-depressive syndrome.

Preliminary diagnosis: chronic pelvic pain. Adenomyosis (diffuse form). Suspicion of external genital endometriosis (endometrial ovarian cysts on ultrasound).

Recommended surgical treatment.

Made surgery: laparoscopy. Division of adhesions in the pelvis. Adnexectomy right. Resection of the left ovary. Drilling of the uterus But-YAG laser. Lazarovici foci of endometriosis. Conducted by moving the laser guide (parameters of laser irradiation: the output power of 15 W to 20 W, pulse frequency 10-16 Hz, the pulse time is 300-400 μs) cross-bilateral vaporization of nerves at the confluence of the Sacro-uterine ligaments from the lower uterine segment and on the whole stretch between the cross alazemi in domed direction of the lower uterine segment.

Clinical diagnosis: chronic pelvic pain. External genital endometriosis (endometriosis of pelvic peritoneum, endometrioid ovarian cysts). Adenomyosis (diffuse form). Adhesions in the pelvis.

Polioptera the ion period was uneventful, received an anesthetic, symptomatic and antibiotic therapy.

Discharged from the hospital on the 5th day after surgery in satisfactory condition. Pain decreased significantly.

Dynamic observation of the patient revealed a significant improvement in the reduction of pain and improved quality of life.

The method of surgical treatment of chronic pelvic pain, including bilateral transverse vaporization nerves Ho-YAG laser at the confluence of the Sacro-uterine ligaments from the lower uterine segment, characterized in that it further perform ablation on the whole stretch between the cross alazemi on the lower uterine segment.



 

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