Operations on the uterus

Distinguish radical and conservative-plastic (with the preservation of menstrual, and possibly generative function) surgery. The radicals include supravaginal amputation of the uterus with or without appendages and extirpation of the uterus with appendages and without them.

Conservative operations include removal of the subserous myomatous node on the pedicle, enucleation of the interstitial or subserous nodes, removal of the born submucous myomatous node through the vagina, excision of the uterine fundus (defundation), high amputation of the uterus.

Indications: uterine myoma, adenomyosis, malignant neoplasms of the uterus and cervix, malignant ovarian tumors, developmental anomalies.

Indications for surgical treatment for uterine myomas: large tumor sizes (over 13 weeks of pregnancy), especially in the postmenopausal period; rapid growth of the tumor (more than 5 weeks for 1 year); suspected malignancy; cervical myoma, submucous myoma, subserious knot on the long leg, uterine bleeding such as menopausal and metrorrhagia with posthemorrhagic anemia, pain syndrome, impaired function of neighboring organs, torsion of the leg of the myomatous node, necrosis or rupture of the capsule of the node, infertility or habitual miscarriages due to the presence of fibroids the uterus. Indications for developmental abnormalities: any abnormality of the development of the uterus, which is the cause of the violation of menstrual and generative function.

Indications for adenomyosis: adenomyosis of I-II degree in the absence of the effect of complex therapy; adenomyosis of the third degree; contraindications for hormonal therapy; relapse of adenomyosis, combined uterine lesion (endometriosis and myoma), endometriosis of the additional horn of the uterus.

Technique for removal of the subserous myomatous node (myomectomia conservativa per abdomen): the anterior abdominal wall is opened by a lower-median or suprapubic incision. The uterus is excreted into the surgical wound. A cut is made at the base of the tumor, so that its line passes 1.5 cm higher and has a circular direction. The knot is grasped by bullet forceps, raised and released with a capsule in a blunt way. Then the clamps are placed on the stretched muscular fibers of the uterus, and the node is finally removed. Hemostasis is performed, as the vessels feeding the tumor are at the base of the leg. Closure of the wound is carried out simultaneously with peritonization due to the serous cover, isolated from the base during the first incision.

The technique of removal of the submucous node through the vagina (myomectomia conservatia transvaginalis): the operation is performed at the birth of the node in young women with a thin long knot of the node and the absence of myoma nodes of other localization.

The front lip of the cervix is fixed with bullet forceps. With the help of finger research, the size of the knot, the length and width of the leg are evaluated. The knot is grasped by bullet or two-prong tongs, and rotational movements are made in one direction while simultaneously being carefully pulled down. After removal of the node, instrumental examination of the uterine cavity is performed to exclude damage to the wall, the presence of other nodes, and also for the purpose of diagnostic scraping. A prerequisite for performing this operation is the availability of a finished operating room.

Technique of enucleation of the interstitial node (myomectomia conservative per abdomen - enucleatio): abdominal incision is performed by lower-median laparotomy or Pfanenstil. The uterus is excreted into the wound, carefully inspected, palpated to determine the localization, number and size of the nodes. Above the tumor, in the place of the largest protrusion of the uterine wall, a small incision is made through the peritoneum, the uterus muscle, the tumor capsule. Incisions in the region of the bottom and tube angles should be made in the transverse direction in the body of the uterus - oblique from the bottom up, in the lower segment - transverse, i.e. Taking into account the architectonics of the vessels of the uterus, associated with the course of muscle and nerve fibers. Naked tissue from the site is captured with bullet forceps and the tumor is blunt blunt and sharp with scissors, pulling the knot and rotating it from side to side. After the node is harvested, thorough hemostasis is performed. The wound bed is sewn up by separate muscular-muscular nodes, with a deep wound - in 2 rads, so that no dead spaces remain that promote the formation of hematomas and poor healing. Then a serous-muscular continuous catgut suture is applied.

Defundation and high amputation of the uterus (defundatio et amputatio uteri alta): after the removal of the uterus into the wound, the appendages begin to separate from it, having previously clamped the ascending branches of the uterine vessels above the level of the intended cutoff. Vessels intersect and are ligated. The clamps are superimposed on the uterine ends of the tubes and the ovaries' own ligaments. Attachments are cut off from the uterus, their stumps are ligated with catgut. Defundation is performed by excision of a small wedge with a vertex to the uterine cavity above the stump of the ascending branches of the uterine vessels. With high amputation of the uterus, the wedge is excised from the lower segment or above it from the uterus body. The edges of the ruptures are captured by bullet forceps, the mucous membrane of the open uterine cavity is lubricated with 5% tincture of iodine. The edges of the incisions of the stump are sewn by separate catgut sutures. The appendages are attached to the corners of the incision. Peritonization is carried out at the expense of the peritoneum of the vesicle-uterine fold or the loops of the round ligaments.

Supravaginal amputation of the uterus (removal of the uterus body at the level of the internal pharynx, amputatio uteri supravaginal).

Technique of supravaginal amputation of the uterus without appendages (sine adnexix): the abdominal cavity is opened by the lower-median or suprapubic incision. After removing the uterus into the wound and delimiting the organs of the abdominal cavity, examine the uterus and appendages. The uterus is excreted into the wound by grasping Myso with forceps. The circular ligaments are crossed after the application of the clamps, having receded 2-3 cm from the uterus, and the counter-terminal at the level of the uterus. In the direction of their own ligament ovaries and the fallopian tube, on which the clamps are likewise drawn, are retracted. Between the clamps, these formations intersect. The same is true on the other hand. Between the stems of the circular ligaments in the transverse direction, a vesicle-uterine fold is dissected, followed by the separation of her peritoneum from the uterus in a sharp or blunt way. The fold is lowered towards the neck below the level of the inner throat.

Vessels are terminated at the level of the internal pharynx by superimposing the terminals perpendicular to the uterine rib, they are crossed and tied with a catgut with the capture of the neck tissue (the vascular bundle is attached to the uterine rib). The body of the uterus is cut off in the form of a cone, which makes it possible to compare the edges of the remaining stump of the neck well. The lumen of the cervical canal is smeared with iodine. On the stump separate catgut stitches are connected, connecting the front and back parts of the neck. Peritonization is carried out at the expense of the peritoneum of the broad ligament of the vesicle-uterine fold, with the capture of the posterior surface of the cervix, the peritoneum of the uterine tube and its own ligament of the ovary and the circular ligament with a continuous catgut suture. At the same time, the peritoneal regions connect distal parts of the peritoneum, located distally to the stems of the circular ligament, the fallopian tube and its own ovary ligament, then connect the posterior and anterior sheets of the broad ligament, the vestibular fold of the peritoneum stitches together with the posterior leaf of the peritoneum of the supraaginous part of the cervix. Similarly, peritonization is performed from the other side.

Technique of supravaginal amputation of the uterus with appendages (cum adnexix): to remove the appendages, the clamps are superimposed on the voronkotazovuyu bunch, which should be raised with a tweezers tube and protect yourself from possible capture of the ureter.

The clamps are superimposed closer to the appendages. The ligament is crossed between the clamps and ligated by the catgut. Later the course of the operation is the same.

Extirpation of the uterus (removal of the body and cervix, extirpatio uteri).

Technique of extirpation of the uterus without appendages (sine adnexix): the first stages (excision of the uterus, clamping, dissection and dressing of the round ligaments, tubes, ovaries' own ligaments) are performed, as with supravaginal amputation of the uterus. Subsequently, after the intersection of the vesicle-uterine fold, a blunt way of separation of the bladder to the level of the anterior vaginal fornix is performed. The uterus is raised anteriorly and the peritoneum is dissected along the posterior surface of the cervix above the attachment site of the sacro-uterine ligaments. The peritoneum is bluntly exfoliated to the border of the vaginal part of the cervix. Then, the clamps are placed on the sacro-uterine ligaments from both sides, the latter are crossed and ligated with catgut. For ligation of the uterine arteries, the peritoneum is led down the ribs of the uterus to the level of the vaginal vaults. At the level of the internal pharynx, a clamp is placed on the trunk of the uterine artery, below is the counter-cell. Between them intersect the vessels. The distal sections of the vascular bundle with the adjacent tissue are moved downwards and laterally and are bandaged with catgut. The lower parts of the uterus are released from the surrounding tissues by peeling them in the terminals beyond the neck. Then the front arch is gripped by a clamp, raised and opened with scissors. In the incision, a gauze strip moistened with alcohol is introduced and carried into the vagina. Through the formed opening on the vaginal vaults, Kocher's clamps are placed parallel to the incision, after which the uterus from the vaginal vaults above the clamps is cut off under the vision control. Nodal catgut sutures as the clips are removed, the vagina is closed. Peritonization is performed by the anterior and posterior leaves of the peritoneum with a continuous catgut suture. The stump of the appendages is closed on both sides with a suture seam.

From the vagina after suturing the anterior abdominal wall, a gauze strip is removed, the vagina is treated with alcohol.

Technique of extirpation of the uterus with appendages (cum adnexix): to remove the appendages it is necessary to attach the clamps to the voronkotazovuyu bunch from one or both sides.

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