RU2304937C1 - Method for laparoscopic hysteropexy and vaginopexy - Google Patents

Abstract

FIELD: medicine, operative gynecology.

SUBSTANCE: one should introduce and install 2 lateral trocars into abdominal cavity, extraperitoneally apply a synthetic fragment to be fixed towards the site of sacro-uterine ligaments branching against the isthmus, extraperitoneally form a tunnel at withdrawing the fragment's ends onto anterior-abdominal wall. Moreover, simultaneously with forming the tunnel through left lateral paracentesis from the side of external edge of external oblique muscle extraperitoneally between the leaves of the left and the right sacro-uterine ligaments, between the leaves of the right broad ligament of uterus it is necessary to apply a synthetic fragment of 2x35 cm size to fix its central part to the site of sacro-uterine ligaments branching against the isthmus. Fragment's free ends should be withdrawn onto aponeurosis to leave free. The innovation enables to provide uterine physiological position, decrease traumatism of operation and decrease the quantity of synthetic materials in the wound.

EFFECT: higher efficiency.

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Description

The present invention relates to medicine, in particular to operative gynecology, and may find application in practical health care.

There is a method of open aponeurotic hysteropathy, vaginopexy, which consists in the fact that by open access after an incision according to Pfannenstiel, two flaps 12 cm long, 2.5 cm wide with a wider base at the edge of the oblique abdominal muscles are cut out from the aponeurosis of the oblique muscles of the abdomen. Between the round ligament of the uterus and the ovarian's own ligament for 2-2.5 cm alternately open parametrium. Stupidly exfoliate the parietal peritoneum in the direction of the projection of the base of the cut flaps. Captured by the clamp, the free ends of the flaps, under the control of a finger, are carried out extraperitoneally from each side between the leaves of the wide uterine ligament through preformed tunnels. Spend flaps. Under the control of vision, the posterior leaf of the wide uterine ligament is perforated with a clamp at the level of attachment of the sacro-uterine ligaments to the uterus, departing 1-1.5 cm from its rib. Aponeurotic flaps from the parametrium are removed into the abdominal cavity, fixed by nylon ligatures to the sacro-uterine ligaments of the same name with two nylon seams. At the same time, the degree of tension of the aponeurotic flaps is controlled (Krasnopolsky V.I., Radzinsky V.E., Buyanova S.N., Manukhin IB, Kondrikov NI Pathology of the vagina and cervix. M: Medicine, 1997, p. 211-225.). The disadvantage of this method is that the method is limited to 1) the use of laparotomic access, which is undesirable in patients planning a pregnancy because of the high risk of developing tubal-peritoneal infertility and adhesions; 2) is limited in patients with previous surgical interventions due to the inability to carve out an adequate aponeurotic flap of the required shape and size.

There is a method of shortening the round ligaments of the uterus by fixing them to the sacro-uterine ligaments of opposite sides, which consists in creating “windows” in the avascular zone of the wide uterine ligaments, lowering the ligaments to the area of the isthmus, fixing them to the place of attachment of the sacro-uterine ligaments of opposite sides (Adamyan L .V., Blinova MA, Sashina BE Modern concepts of surgical treatment of prolapse and prolapse of the female genital organs: Endoscopy in the diagnosis, treatment and monitoring of female diseases: Collected scientific works / Ed. ulakova VI, Adamyan LV - M., 2000, s.622). The disadvantages of this method are: 1) the opening of the posterior angle, the sacral cavity, which requires additional technology; 2) the use of the patient’s own tissues, which is not always justified in case of systemic connective tissue pathology.

A known method of laparoscopic colpofixation, including entering the abdominal cavity through a laparoscope, using merselen or prolene flaps 2 × 30 cm, fixing the center of the flap to the sacro-uterine ligaments with non-absorbable suture material, holding the flaps extraperitoneally and fixing the flaps, with the criss-cross ligature they seize the front wall of the rectum into the sutures, form tunnels extraperitoneally from the aponeurosis of the external oblique muscle of the abdomen to the sacro-uterine ligaments and through them free segments of the flap lead to the anterior abdominal wall, then form a tunnel over the aponeurosis of the external oblique muscle of the abdomen, through which the ligature is made of non-absorbable material, and they connect both segments in a state of moderate tension, the excess part of the mesh is cut off (Pat. No. 2182470 RF. IPC 7. A61B 17/42 Method for laparoscopic colposification. Popov AA, Gorsky SL, Shaginyan GG / Moscow Regional Research Institute of Obstetrics and Gynecology, 2002, bull. No. 14). This method is selected for the prototype. The disadvantages of the method include:

1) the peritoneal location of the synthetic flap in the region of the sacro-uterine ligaments, which requires its peritonization using serosa of the rectum;

2) the presence of two synthetic flaps of 2 × 30 cm, which increases the amount of foreign material in the wound;

3) the need to create a transverse subcutaneous tunnel in the aponeurosis of the anteritoneal wall along the entire length according to the position of two lateral trocars for ligature, which increases the risk of hematomas, infectious complications, increases the time and volume of the operation;

4) in addition, this type of operation has limitations in patients who underwent surgical interventions on the anterior abdominal wall and organs of the abdominal cavity, and is also limited in women who, due to concomitant extragenital indications in the future, delivery by cesarean section is possible.

The objective of the invention is to ensure the physiological position of the organ through the use of minimally invasive technology, reducing the invasiveness of the intervention, the risk of intraoperative and infectious complications, reducing synthetic materials in the wound, the possibility of subsequent surgical interventions on the organs of the abdominal cavity and pelvis, including in patients planning a pregnancy .

This is achieved due to the fact that simultaneously with the formation of a tunnel through the left lateral puncture from the side of the outer edge of the external oblique muscle extraperitoneally between the leaves of the left wide uterine ligament, subperitoneally above the left and right sacro-uterine ligaments, between the leaves of the right wide uterine ligament, a synthetic flap is performed 2 × 35 cm in size with fixation of its center to the place of discharge of the sacro-uterine ligaments, the free ends of the flap are brought to the aponeurosis and left free.

The formation of the tunnel with simultaneous simultaneous flap reduction reduces the time and invasiveness of the operation. The extraperitoneal flap with a safe uterus in young patients prevents the development of adhesions in the abdominal cavity and does not require peritonization due to the rectum, which reduces the risk of infectious complications. Using a single flap facilitates its fixation to the place of departure from the isthmus of the sacro-uterine ligaments, reduces the amount of foreign synthetic material in the body. The presence of only a posterior synthetic half-ring (“posterior sling”) does not prevent entry into the abdominal cavity during possible subsequent surgical interventions. In addition, the “rear sling” ensures the free physiological position of the organ, the lateral location of the synthetic flap is projected onto the natural location of the cardinal ligaments, which does not contribute to opening the angle of the anterior or posterior fornix, which reduces the risk of relapse of genital prolapse in the future. In addition, this method does not prevent the simultaneous execution of a hysterectomy (according to indications), a vaginal hysterectomy with laparoscopic assistance, as well as the use of other combined technologies for the correction of genital prolapse and simultaneous operations on the pelvic and abdominal organs with concomitant pathology.

The method is as follows.

Carry out the usual entry into the abdominal cavity with the installation of two lateral trocars in a typical place, simultaneously with the formation of a tunnel through the left lateral puncture from the outer edge of the external oblique muscle extraperitoneally between the leaves of the left broad uterine ligament, then extraperitoneally above the left and right sacro-uterine ligaments, between with leaves of the right wide uterine ligament, a synthetic flap 2 × 35 cm in size is carried out, the center of the flap is fixed to the place of discharge of the sacro-uterine ligaments, free the ends of the flap are left free, which in combination with the rear half ring forms a “rear sling”.

The method is based on a standard laparoscopic technique. A typical laparoscopy is performed (with the installation of two lateral trocars in a typical location 5 cm above the symphysis and 8 cm lateral midline). After revision of the abdominal organs through the left lateral puncture under the control of a laparoscope from the side of the outer edge of the external oblique muscle of the abdomen, an extraperitoneal laparoscopic clamp makes a tunnel between the leaves of the left wide uterine ligament. Then extraperitoneally tunnel the space above the left and right sacro-uterine ligaments and between the leaves of the wide right uterine ligament - to the outer edge of the right external oblique muscle of the abdomen. Through a tunnel made using a laparoscopic clamp, a 2 × 35 cm mercilene or prolene flap is passed, the ends of which extend onto the aponeurosis from the left and right sides of the outer edge of the external oblique muscles of the abdominal wall. Excess ends of the flap are cut off. The ends of the flap are left free. The flap is fixed only in one place - in the area of the sacro-uterine ligaments (with a preserved uterus) and in the area of the posterior wall of the vagina (in the absence of the uterus) with 2-3 interrupted sutures using non-absorbable suture material. The so-called extraperitoneal posterior sling is formed. Mobile fixation of the vagina allows the body to "pick up" the symmetry of the flap tension, which is a warning of the development of persistent pain after surgery, posterior sling does not interfere with subsequent surgical interventions on the anteroperitoneal wall.

Clinical example.

Example No. 1. Patient X. 37 years old was admitted to the clinic with complaints of sensations of a foreign body in the vagina, the appearance of pain in the vagina by the end of the working day. In connection with the diagnosis: incomplete prolapse of the uterus and the walls of the vagina, the operation was performed laparoscopic hysteropexy with a prolene flap. The main stage is complemented by plication of the sacro-uterine ligaments and obliteration of the Douglas space. The duration of the operation was 35 minutes.

Discharged on the 5th day. Duration of observation is 1.5 years. The uterus in anteversio-flexio, moderately mobile, painless. No relapse.

Example No. 2. Patient P. 49 years. Was admitted to the hospital with complaints of menorrhagia for 7-8 days, leading to a decrease in hemoglobin to 98 g / l, a foreign body sensation in the vagina. Operated with a diagnosis of Interstitial uterine fibroids of small size with centripetal node growth, prolapse of the uterus and vaginal walls of 3 degrees. Anemia 2 tbsp. A laparoscopic hysterectomy without appendages was operated on. Vaginopexy with a prone flap, plication of the sacro-uterine ligaments, obliteration of the Douglas space. The duration of the operation is 1 hour and 50 minutes. Duration of observation 11 months. No relapse.

Example No. 3. Patient K., 64 years old. Was admitted to the clinic with complaints of prolapse of the walls of the vagina. A history of vaginal hysterectomy due to complete prolapse of the uterus and vaginal walls. At admission: there is a complete loss of the vaginal stump. The contents of the hernial sac are loops of the small intestine, partly the bladder. In connection with the diagnosis: relapse of complete prolapse of the vaginal stump, entero-, cystocele, laparoscopic vaginopexy was performed with a prolen flap, supplemented with correction of paravaginal defects, plication of the sacro-uterine ligaments, obliteration of the Douglas space. The duration of the operation is 1.5 hours. Duration of observation is 9 months. No relapse.

In total, 19 women were operated on using this method (on the basis of the Main Clinical Hospital of the Ministry of Internal Affairs and the Main Hospital of the Space Forces of Russia). The average age was 49 ± 3.9 years. The duration of the disease is 9 years.

Examination of patients included: general clinical research methods (o.an. blood, urine, blood biochemistry, ultrasound of the pelvic organs, etc.), as well as special research methods necessary to address the causes of prolapse (urodynamic study, electromyography pelvic floor muscles, echocardiography, etc.).

The leading criteria for the selection and justification of the method of surgical correction of genital prolapse were: age, parity, concomitant extragenital pathology, type and degree of genital prolapse, form of involvement of adjacent organs, concomitant gynecological pathology, previous operations.

A relatively satisfactory effect was objectively observed in 1 patient (5.2%) in the form of a 2-3-degree cystocele, which was not regarded as a relapse of the disease. The situation is regarded as insufficient correction of the paravaginal defect with the help of assistive technology in conditions of relapse of the complete loss of the vaginal walls after a previous vaginal hysterectomy.

Claims (1)

The method of laparoscopic hystero-vaginopexy, including entering the abdominal cavity with the installation of two lateral trocars, extraperitoneal administration of a synthetic flap, fixed to the place of departure from the isthmus of the sacro-uterine ligaments, extraperitoneal tunnel formation with the removal of the ends of the flap on the anteritoneal wall, which is different, with the formation of a tunnel through the left lateral puncture from the side of the outer edge of the external oblique muscle extraperitoneally between the leaves of the left shea an uterine ligament eye, extraperitoneally above the left and right sacro-uterine ligaments, between the leaves of the right wide uterine ligament, a synthetic flap 2 × 35 cm in size is fixed with its center fixed to the place of departure from the sacro-uterine ligament isthmus, the free ends of the flap are brought to aponeurosis and left free.