Surgery on the uterine appendages

Indications: tubal pregnancy, hydro- and pyosalpinx, sterilization, benign and malignant ovarian neoplasms, ovarian apoplexy, sclerocystic ovary syndrome, infertility.

Technically, surgery on the uterine appendages can be simple, but in some cases it is complicated by numerous adhesions.

If it is difficult to remove the ovarian tumor into the wound, two swabs on a forceps can be used and, having placed them under the tumor, carefully remove it from the abdominal cavity. A very large tumor can be reduced in size by puncturing it with a trocar connected to an electric suction device. A purse-string suture must be applied beforehand to tighten it after the trocar is removed.

The ovarian tumor should be opened in the operating room after removal to examine the inner surface of the capsule, since in some cases there are papillary growths on the inner surface of the capsule of smooth-walled mobile tumors. The presence of fragile, easily bleeding papillae is suspicious for a malignant neoplasm.

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Ovarian resection

After the ovary is brought out into the wound, it is held either by the operator's hand or by a gauze strip around the ovarian hilum. The ovarian tissue is excised in a wedge shape almost to its hilum. 2/3 of the ovary volume is removed. Its integrity is restored by suturing with absorbable suture material using a round, steep needle. The first injection is made with the bottom of the wound captured, the second superficially; when tying the suture, the edges of the ovary are well aligned. The threads should be tied after all the sutures have been applied. It is possible to suture the ovary with a continuous furrier's suture. It is permissible to use biological glue to form the ovary.

Technique of surgery for a tumor or rupture of the ovary: the ovary must be lifted, the stalk wrapped with a wide gauze loop. An incision line is marked slightly above the level of the tumor or rupture site. The pathologically altered tissue is removed tangentially with a scalpel. The ovarian wound is sutured with a continuous or interrupted catgut suture on a thin round needle.

The technique of wedge resection of the ovaries in case of sclerocystic ovary syndrome: the ovarian pedicle is grasped with a gauze loop. A wedge-shaped area located between the ovarian poles is excised from the ovarian tissue on the side facing the abdominal cavity, so that after its removal the ovary acquires approximately normal dimensions. The edges of the resulting wound are sutured with interrupted catgut sutures on a round thin needle. In case of sclerocystic ovaries, at least 2/3 of the ovarian tissue is removed.

Technique of surgery for interligamentous location of tumor (enucleatio cystis intralegamentaris): after opening the abdominal cavity and careful orientation in anatomical and topographic relationships, the anterior leaflet of the mesosalpinx (broad ligament) between the tube and the round ligament of the uterus is dissected. The incision is made along the anterior surface of the tumor to avoid injury to the ureter. After the incision, the peritoneum is peeled away from the tumor capsule with closed scissors. The cyst is carefully enucleated from the interligamentous space, while it is necessary to stay as close to the tumor capsule as possible at all times. After removal of the cyst, hemostasis is performed and the leaves of the broad ligament in the area of the incision are sutured with a continuous catgut suture.

Technique for removing a pedunculated ovarian tumor (ovarioectomia): after laparotomy, the tumor is removed by hand or with a swab on forceps, placed under the lower pole. Two clamps are applied to the tumor pedicle - one at the uterine edge on the proper ligament of the ovary, the other on the suspensory ligament and mesovarium. When removing a tumor with a tube (adnexectomia), the second clamp is applied to the infundibulopelvic ligament.

Above the clamps, the pedicle is crossed and ligated with catgut. Peritonization in case of removal of the uterine appendages is performed with the round ligament of the uterus and the posterior leaf of the broad ligament. It is possible to apply a purse-string suture, passed through the round ligament, the angle of the uterus and the posterior leaf of the peritoneum of the broad ligament.

Technique of surgery for torsion of the ovarian tumor stalk: untwisting the stalk before ligation is dangerous, as there is a risk of rupture of blood vessels, risk of bleeding and thromboembolism. Therefore, without untwisting the stalk, a clamp is applied to its entire thickness above the torsion site. The tumor is cut off. The stump is sutured with a catgut suture. Peritonization is performed as usual.

Ovarian cyst enucleation

After the ovary with the tumor is removed into the wound, it is separated from the abdominal cavity with gauze napkins. Then, along the edge of the healthy ovarian tissue, an incision (crescentic or circular) is made with a scalpel so as not to injure the tumor capsule. The edges of the incision are taken with clamps. The tumor is enucleated using a sharp and blunt method. The sutures are applied in the same way as during ovarian resection, or first immersion sutures are applied, and the ovary is formed with a second row of sutures. It is very important to leave the ovarian tissue unchanged, even if there is only a small area of the cortex at the ovarian hilum.

Removal of uterine appendages

After the tumor has been removed from the wound, clamps are applied to the infundibulopelvic ligament. Before applying the clamps, the fallopian tube and ovary are lifted so that the ligament is taut and clearly visible in the light. Then, in the direction of the angle of the uterus, the upper part of the broad ligament is grasped together with the fallopian tube and the proper ligament of the ovary. The ligaments are crossed, stitched and tied. Peritonization is performed using the round or broad ligament.

When the ovarian tumor stalk is twisted, the clamp is applied below the torsion site. It is not recommended to untwist the tumor stalk, since blood clots, which are usually present in the lumen of twisted vessels, can enter the bloodstream.

Removal of the fallopian tube (salpingectomy, salpingo seu tubectomia)

Technique: after opening the abdominal cavity, a hand is inserted into the small pelvis, the altered tube is found, which is brought out into the wound. The tube is lifted, stretching its mesentery, on which a clamp is applied from the ampullar end to the corner of the uterus (the clamps should lie parallel to the course of the tube), the second clamp is applied towards the first. The tube is cut off above the clamps and sutured with catgut. Peritonization is performed using the round uterine ligament, which is sutured to the back surface of the uterus with several catgut sutures, covering the stump of the tube.

Sterilization (sterilisatio chirurgica)

The technique of the Madlener operation: the tube with a small section of the mesosalpinx is pulled into a loop using a clamp, and the base of the loop is crushed by the clamp. A silk ligature is applied at the site of compression. For greater reliability, the loop is excised.

Technique of the Hunter operation: the middle part of the tube is pulled upward with two soft clamps placed at a distance of 2-3 cm. The peritoneum is stretched between the clamps and dissected longitudinally above the tube, which is isolated along the peritoneal incision using tweezers or a scalpel. The freed area at the peripheral ends is tied with silk ligatures and removed. Both ends of the transected tube are immersed in the mesosalpinx, the wound of which is closed with a continuous catgut suture.

During laparotomy, simple tubal ligation, tubal crushing with ligation, tubal dissection between two ligatures, segmental tubal resection with treatment of the remaining ends, and tubal ring placement can be performed.

Ovarian resection (removal of part of the ovary, resectio ovarii)