Uterine surgeries

A distinction is made between radical and conservative-plastic (with preservation of menstrual and possibly generative function) operations. Radical operations include supravaginal amputation of the uterus with or without appendages and extirpation of the uterus with or without appendages.

Conservative surgeries include removal of a subserous myomatous node on a pedicle, enucleation of interstitial or subserous nodes, removal of a developing submucous myomatous node through the vagina, excision of the fundus of the uterus (defundation), and 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 of uterine fibroids: large tumor size (over 13 weeks of pregnancy), especially in the postmenopausal period; rapid tumor growth (over 5 weeks in 1 year); suspicion of malignancy; cervical fibroids, submucous fibroids, subserous node on a long stalk, uterine bleeding such as meno- and metrorrhagia with posthemorrhagic anemia, pain syndrome, dysfunction of adjacent organs, torsion of the stalk of the fibroid node, necrosis or rupture of the node capsule, infertility or habitual miscarriages caused by the presence of uterine fibroids. Indications for developmental anomalies: any developmental anomaly of the uterus that causes a violation of the menstrual and generative function.

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

Technique for removing a subserous myomatous node (myomectomia conservativa per abdomen): the anterior abdominal wall is opened by a lower midline or suprapubic incision. The uterus is brought out into the surgical wound. An incision is made at the base of the tumor so that its line passes 1.5 cm higher and has a circular direction. The node is grasped with bullet forceps, lifted and isolated with the capsule by blunt dissection. Then clamps are applied to the stretched muscle fibers of the uterus, and the node is finally removed. Hemostasis is performed, since the vessels feeding the tumor are located at the base of the pedicle. Wound closure is performed simultaneously with peritonization due to the serous cover isolated from the base during the first incision.

Technique for removing a submucous node through the vagina (myomectomia conservatia transvaginalis): the operation is performed when the node is born in young women in the presence of a thin long stalk of the node and the absence of myomatous nodes in other locations.

The anterior lip of the cervix is fixed with bullet forceps. The size of the node, the length and width of the pedicle are assessed using a digital examination. The node is grasped with bullet or two-pronged forceps, and rotational movements are made in one direction with simultaneous gentle pulling down. After the node is removed, an instrumental examination of the uterine cavity is performed to exclude damage to the wall, the presence of other nodes, and for the purpose of diagnostic curettage. A mandatory condition for performing this operation is the availability of a ready operating room.

Technique of interstitial node enucleation (myomectomia conservative per abdomen - enucleatio): laparotomy is performed by lower midline laparotomy or according to Pfannenstiel. The uterus is brought out into the wound, carefully examined, palpated to clarify the localization, number and size of the nodes. Above the tumor, at the site of the greatest protrusion of the uterine wall, a small incision is made through the peritoneum, uterine muscle, and tumor capsule. Incisions in the area of the fundus and tubal angles should be made transversely in the body of the uterus - oblique from bottom to top, in the area of the lower segment - transverse, i.e. taking into account the architectonics of the uterine vessels associated with the course of muscle and nerve fibers. The part of the node exposed from tissue is grasped with bullet forceps and the tumor is enucleated in a blunt and sharp way using scissors, pulling the node and rotating it from side to side. After enucleation of the node, careful hemostasis is performed. The wound bed is sutured with separate muscular-muscular nodes, in case of a deep wound - in 2 rows, so that there are no dead spaces that contribute to 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 uterus has been brought out into the wound, the separation of the appendages from it begins, having first applied clamps to the ascending branches of the uterine vessels above the level of the intended excision. The vessels are intersected and ligated. Clamps are applied to the uterine ends of the tubes and the proper ligaments of the ovaries. The appendages are cut away from the uterus, their stumps are ligated with catgut. Defundation is performed by excising a small wedge with its apex toward the uterine cavity above the stumps of the ascending branches of the uterine vessels. In case of high amputation of the uterus, the wedge is excised from the lower segment or above it from the body of the uterus. The edges of the ruptures are grasped with bullet forceps, the mucous membrane of the opened uterine cavity is lubricated with 5% iodine tincture. The edges of the incisions of the stump are sutured with separate catgut sutures. The stumps of the appendages are fixed at the corners of the incision. Peritonization is achieved through the peritoneum of the vesicouterine fold or by loops of the round ligaments.

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

Technique of supravaginal amputation of the uterus without appendages (sine adnexix): the abdominal cavity is opened by a lower midline or suprapubic incision. After bringing the uterus into the wound and delimiting the abdominal organs, the uterus and appendages are examined. The uterus is brought into the wound by grasping it by the bottom with Musot forceps. The round ligaments are intersected after applying clamps, stepping back 2-3 cm from the uterus, and counter clamps at the level of the uterus. The proper ligament of the ovary and the fallopian tube are pulled aside, to which clamps are similarly applied. Between the clamps, the above formations are intersected. The same is done on the other side. Between the stumps of the round ligaments, the vesicouterine fold is dissected transversely, followed by separation of its peritoneum from the uterus by a sharp or blunt method. The fold is lowered towards the cervix below the level of the internal os.

The vessels are clamped at the level of the internal os by applying clamps perpendicular to the uterine rib, intersected and ligated with catgut, capturing the tissue of the cervix (the vascular bundle is, as it were, tied to the uterine rib). The body of the uterus is cut off in the form of a cone, which makes it possible to well match the edges of the remaining stump of the cervix. The lumen of the cervical canal is lubricated with iodine. Separate catgut sutures are applied to the stump, connecting the anterior and posterior parts of the cervix. Peritonization is carried out due to the peritoneum of the broad ligament of the vesicouterine fold, capturing the posterior surface of the cervix, the peritoneum of the fallopian tube and the proper ligament of the ovary and the round ligament with a continuous catgut suture. In this case, the sections of the peritoneum located distal to the stumps of the round ligament, fallopian tube and proper ligament of the ovary are connected with a half-purse-string, then the posterior and anterior sheets of the broad ligament are connected, the vesicouterine fold of the peritoneum is sutured with the posterior sheet of the peritoneum of the supravaginal part of the cervix. Peritonization is performed similarly on the other side.

Technique of supravaginal amputation of the uterus with appendages (cum adnexix): to remove the appendages, clamps are applied to the infundibulopelvic ligament, for which the tube should be lifted with tweezers and one should protect oneself from possible capture of the ureter.

The clamps are applied closer to the appendages. The ligament is crossed between the clamps and ligated with catgut. The further course of the operation is the same.

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

Technique of hysterectomy without appendages (sine adnexix): the first stages (removal of the uterus, clamping, dissection and ligation of the round ligaments, tubes, proper ovarian ligaments) are performed as in supravaginal amputation of the uterus. Subsequently, after crossing the vesicouterine fold, the urinary bladder is separated to the level of the anterior vaginal fornix, mainly by blunt means. The uterus is lifted anteriorly and the peritoneum is dissected along the posterior surface of the cervix above the attachment site of the uterosacral ligaments. The peritoneum is bluntly peeled back to the border of the vaginal part of the cervix. Then clamps are applied to the uterosacral ligaments on both sides, the latter are crossed and ligated with catgut. To ligate the uterine arteries, the peritoneum is retracted downwards along the ribs of the uterus to the level of the vaginal fornix. At the level of the internal os, a clamp is applied to the trunk of the uterine artery, and below that, a counter clamp. The vessels are intersected between them. The distal sections of the vascular bundle with adjacent tissue are moved downwards and laterally and ligated with catgut. The lower sections of the uterus are freed from surrounding tissues by peeling them off in clamps beyond the cervix. Then the anterior fornix is grasped with a clamp, lifted and opened with scissors. A gauze strip moistened with alcohol is inserted into the incision and passed into the vagina. Kocher clamps are applied to the vaginal fornices through the resulting opening parallel to the incision, after which the uterus is cut off from the vaginal fornices above the clamps under visual control. The vagina is closed with interrupted catgut sutures as the clamps are removed. Peritonization is performed with a continuous catgut suture of the anterior and posterior sheets of the peritoneum. The stumps of the appendages are closed on both sides with a purse-string suture.

After suturing the anterior abdominal wall, a gauze strip is removed from the vagina and the vagina is treated with alcohol.

Technique of extirpation of the uterus with appendages (cum adnexix): to remove the appendages, it is necessary to apply clamps to the infundibular pelvic ligament on one or both sides.

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