Uterine vaginal amputation.

After opening the abdominal cavity, the uterus should be brought out into the wound as far as possible.

Clamps are applied to the round ligaments of the uterus, the proper ligaments of the ovaries, and the fallopian tubes in such a way that the first of them is located close to the uterus, and then, stepping back 1-1.5 cm from the lateral surface of the uterus, the clamps grasp the round ligament, the proper ligament of the ovaries, and the fallopian tube. If the fallopian tubes are removed, the clamps are applied to the mesosalpinx. The ligaments are crossed and ligated.

The ovarian ligament and fallopian tube are transected. After the said formations are transected, they are ligated using synthetic threads and the ligature is clamped.

The vesicouterine fold is opened from one round ligament to the other. After opening, the vesicouterine fold is separated downwards by blunt and sharp means together with the urinary bladder. Vascular bundles are isolated on both sides, clamps are applied to them in such a way that the edge of the clamp grasps the tissue of the cervix and seems to slide off it. Vascular bundles are crossed, stitched, ligated with synthetic threads. The body of the uterus is cut off from the cervix with a scalpel. When cutting off the cervix, the scalpel should be directed so as to form a triangular incision with the apex at the internal os. The edges of such an incision close well when sutures are applied.

When cutting off the cervix after cutting its anterior part, the stump is taken with a clamp. After cutting off, the stump of the cervix is treated with an alcohol solution of iodine or ethyl alcohol with one touch of a tampon. Three or four sutures are applied to the cervix with a synthetic absorbable material to avoid the formation of abscesses around the ligatures on the cervix.

Then peritonization is performed with the leaves of the broad ligament of the uterus and the peritoneum of the vesicouterine fold, applying a linear or purse-string suture, with the stumps of the round ligaments and appendages immersed in the suture.

The abdominal cavity is checked and dried. The anterior abdominal wall is sutured.

Extirpation of the uterus

Before the patient is taken to the operating room, the vagina and cervix are treated with a brilliant green solution. A permanent catheter is left in the bladder for the duration of the operation.

After opening the abdominal cavity, the uterus should be brought out into the wound as far as possible.

Clamps are applied to the round ligaments of the uterus, the proper ligaments of the ovaries and the fallopian tubes in such a way that the first of them is located close to the uterus, and then, stepping back 1-1.5 cm from the edge of the uterus, the clamps are grasped by the round ligament, the proper ligament of the ovaries and the fallopian tube. If the fallopian tubes are removed, then the clamps are applied to the mesosalpinx.

When leaving the uterine appendages, separate clamps are applied to the round ligament, fallopian tube, and proper ovarian ligament. The ligaments are dissected and ligated. When removing the appendages, clamps are applied to the infundibulopelvic and round ligaments. After applying clamps to the lateral surfaces of the uterus, the sheets of the broad ligaments are dissected, then the peritoneum of the vesicouterine recess at the transitional fold. The urinary bladder is separated from the cervix and moved to the area of the vaginal fornix.

The uterus is pulled to the left and, if possible, the vascular bundle is isolated from the tissue in the direction of its lateral surface, having previously dissected the posterior leaflet of the broad ligament to the level of the internal os. A clamp is applied to the vascular bundle perpendicular to the artery at the cervix. A counter clamp is applied to the vessels 0.5 cm above the first clamp. The vascular bundle is dissected and ligated, the ends of the ligatures are cut off. Then the same manipulation is performed on the other side.

After ligation and transection of the vessels, the uterus is pulled toward the pubis and clamps are applied to the uterosacral ligaments near their origin perpendicular to the uterus (so as not to capture the ureter). The uterosacral ligaments are transected and ligated.

Having ensured that the cervix has been sufficiently exposed, the uterus is pulled upwards, and the separated urinary bladder is moved downwards with a speculum, exposing the vaginal wall in the area of the anterior fornix. The anterior vaginal fornix is grasped with a clamp and opened with scissors or a scalpel. A gauze swab soaked in an antiseptic solution is inserted into the vagina (it is removed on the operating table after the operation is completed). Then the uterus is cut away from the vaginal fornices. The edges of the incision of the vaginal fornices are grasped with long clamps. The anterior wall of the vagina is sutured with a leaf of the vesicouterine fold with separate sutures. The posterior wall of the vagina is sutured, connecting it to the peritoneum of the rectouterine pouch. The stumps of the ligaments on both sides are immersed in the parametrium with purse-string sutures. In this case, the vagina remains open and acts as a natural drainage. It is not possible to count on this drainage to continue for a long time, since the vaginal walls will stick together in 12 hours at the most. You can tightly suture the vagina and connect the peritoneum of the vesicouterine fold and the rectouterine pouch above this suture.

The abdominal cavity is checked and dried. The anterior abdominal wall is sutured.

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