Surgery on the external genitalia and vagina

Opening of an abscess of the large gland of the vestibule of the vagina

Indications: acute inflammatory process.

Technique: a longitudinal incision is made inwards from the labia minora parallel to the latter, followed by drainage. In the postoperative period, it is washed daily with hydrogen peroxide until cleansing, then a gauze turunda is inserted.

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Removal of a cyst of the large gland of the vestibule of the vagina (enucleacio cystis glandulae vestibularis major)

Indications: recurrent abscess of the bortollin gland, fistula tract after opening of the abscess, cyst deforming the entrance to the vagina.

Technique: an oval skin incision 5-6 cm long is made above the tumor outside the labia minora. The cyst is separated from the surrounding tissue using sharp and blunt methods and removed. The cyst bed is sutured with immersion catgut sutures. Nodular silk sutures are applied to the skin incision.

Hymen surgeries

Indications: complete fusion or severe rigidity that prevents sexual intercourse or menstrual bleeding.

There are several options for the operation:

1. The hymen is incised with a scalpel in the lower outer section, extending the incision to the base of the hymen. The edges of the wound are stretched, the vessels are ligated. Separate catgut sutures are applied to the edges of the incision, stretched in the longitudinal direction;
2. excision of the hymen (hymenectomia) - a cross-shaped incision is made with excision of the edges of the wound between the corners. The edges of the excised hymen are sutured with separate catgut sutures;
3. an operation for the fusion of the hymen with the formation of hematocolpos (colpostomia). A cross-shaped incision is made in the protruding hymen with the edges of the incision being sutured with separate catgut sutures to prevent the exposed wound surfaces from sticking together.

Operations for prolapse and prolapse of the vaginal walls and abnormal positions of the uterus

Anterior colporrhaphy (colporrhaphia anterior)

Indications: prolapse of the anterior vaginal wall, prolapse of the anterior vaginal wall, cystocele.

Technique: the vaginal portion of the cervix is exposed using speculums. The anterior lip of the cervix is grasped with bullet or two-pronged forceps and brought down to the vaginal entrance (or the anterior vaginal wall is brought out of the genital slit - in case of prolapse). An incision is made between four Kocher clamps - 2 cm below the external opening of the urethra, 2 cm above the external os of the cervix and twice - on the sides of the cut oval-shaped flap to the depth of the underlying loose layer of cellular tissue. The mucous membrane is separated from the underlying vesical fascia by sharp and blunt means. Then the bed of the urinary bladder is strengthened - a continuous, interrupted or purse-string catgut suture is used to connect the paravesical tissues with immersion of the urinary bladder. The edges of the vaginal mucosa are connected with a continuous catgut suture in the longitudinal direction.

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Colpoperineorrhaphia. Colpoperineoplasty

Indications: prolapse and prolapse of the posterior vaginal wall, rectocele.

Technique: the vagina is exposed using speculums. A triangular flap of the mucous membrane of the posterior vaginal wall is cut out. The base is located along the posterior commissure at the border of the vaginal mucosa and the skin of the perineum, the apex is along the midline closer to the fornix (the size of the cut flap depends on the height of the perineum being restored and the severity of the prolapse). The entrance to the vagina should allow 2 fingers to pass through. After excising the flap of the mucous membrane, begin suturing the wound from the upper corner, connecting the edges of the mucosa with a continuous suture. Then proceed to levatoroplasty. Use a round thick needle, which is first inserted under the pedicle of the levator on one side, punctured and grasped from the inside outward of the pedicle of the levator on the other side. Apply 2-3 similar tightening sutures. Then continue connecting the edges of the vaginal wound with a continuous catgut suture to the border of the skin. The final stage is suturing the muscles and skin of the perineum with interrupted silk sutures.

Median colporrhaphia (colporrhaphia mediana)

Indications: complete prolapse of the uterus in old age, relapse of vaginal prolapse after vaginal extirpation of the uterus. The operation excludes the possibility of sexual activity in the future.

Technique: the cervix is grasped by both lips with bullet forceps, pulled down, and the vagina and uterus are brought out. Then the cervix is pulled down and a rectangular flap is excised from the anterior wall of the vagina with the borders - the upper one is 2 cm below the external opening of the urethra, the lower one - in the area of the vaginal fornix. The width of the flap depends on the width of the vagina, at the top the flap should be somewhat wider. A flap of the same size and shape is cut out along the posterior wall of the vagina. The flaps are separated sharply. Then the refreshed surfaces are connected to each other with separate catgut sutures sequentially, starting from the anterior and posterior fornix (the edges of the transverse incisions in front and behind the cervix), thus the wound surfaces are connected, turned inward, and the cervix goes deep into the vagina. On the right and left, lateral channels remain for the outflow of cervical discharge.

Ventrofixation of the uterus (ventrofixatio uteri)

Indications: prolapse and prolapse of the vaginal and uterine walls. Often complements vaginal and perineal surgeries. Indicated for elderly women.

Technique: lower midline laparotomy. The uterus is brought out of the abdominal cavity and pulled to the lower corner of the wound. The peritoneum is sutured with a continuous catgut suture from the upper corner with an introduction under the uterus. In the lower corner, the peritoneum is sutured to the outer surface of the uterus. Thus, the body of the uterus lies on the peritoneum parallel to the abdominal wall. The anterior surface of the uterus is attached to the rectus abdominis muscles with catgut sutures. The aponeurosis is sutured with interrupted silk sutures.

To increase the effectiveness of the operation and prevent relapses (since the peritoneum is stretched), the bottom of the uterus is stitched with 2-3 silk sutures, passing them through the peritoneum, muscles and aponeurosis, over which the sutures are tied. The peritoneum and aponeurosis are usually sutured.

Ventrosuspension (ventrosuspensio uteri) is an operation to suspend the uterus by the round ligaments according to Dolery-Gilliam.

Indications: prolapse and prolapse of the uterus, fixed retroflexion of the uterus.

Technique: The abdominal cavity is opened. The peritoneum together with the aponeurosis is grasped on both sides of the incision with Kocher clamps. Stepping back 2 cm from the edge of the incision, holes up to 1 cm in diameter are made in the aponeurosis with a scalpel. The round ligaments of the uterus are grasped one by one at a distance of 3-5 cm from the uterus and a loop of the ligament is brought out through the opening in the aponeurosis on the corresponding side. The loops of the ligaments are connected above the aponeurosis with a silk suture and attached to the aponeurosis with separate sutures. The peritoneum and aponeurosis are sutured as usual.

Operation Manchester

Indications: prolapse and partial prolapse of the uterus, especially with elongation of the cervix and the presence of cystocele.

Technique: the cervix is grasped with bullet forceps and brought down to the vaginal opening. An incision is made in the anterior vaginal wall to the fascia of the bladder, starting 1.5-2 cm below the external opening of the urethra. A triangular flap can be outlined on the anterior vaginal wall. Then a circular incision is made in the mucous membrane around the circumference of the cervix (in front - at the level of the last transverse fold). The mucous membrane of the anterior vaginal wall is separated from the bladder, the connective tissue strands running from the cervix to the bladder are incised with scissors, and the latter is retracted upward in a blunt and sharp manner, the bladder is transposed with 2-3 catgut sutures. Along the circular incision, the vaginal vaults are separated upward from the cervix in a blunt manner. The cardinal ligaments located on the lateral surfaces of the elongated cervix are exposed. The ligaments are grasped with clamps, dissected, and sutured together with the branch of the uterine artery passing through them. Cone-shaped amputation of the elongated part of the cervix and uterus is performed after preliminary bougienage of the cervical canal with Hegar dilators up to No. 10-11. The severed cardinal ligaments are pulled to the midline and sutured together under the bottom of the urinary bladder, providing additional support for it. Attachment of the vaginal vaults to the amputated cervix is performed with U-shaped sutures. The lateral parts of the cervix are sutured with separate catgut sutures, capturing the mucous and muscle tissue.

The final stage of the operation is colpoperineorrhaphy using the standard technique.

Vaginal extirpation of the uterus (extirpatio uteri per vaginam)

Indication: complete prolapse of the uterus.

Technique: the cervix is grasped with Musot forceps, the uterus is lowered to the entrance to the vagina. At the border of the anterior vaginal fornix and the mucous membrane covering the cervix, the vaginal wall is dissected with a circular or crescentic incision and separated in the form of a cuff in the direction of the cervical os. The urinary bladder is separated from the cervix with sharp and blunt means, reaching the vesicouterine fold, which is determined by its whitish color. The urinary bladder is pushed forward with a lift and the vesicouterine fold is opened (anterior colpotomy). The paracervical tissue and cardinal ligaments are grasped with clamps, crossed and ligated with catgut. The free edge of the vesicouterine fold is connected to the edge of the vaginal wound with catgut sutures. The body of the uterus is brought out through the anterior colpotome opening. After bringing it out, the uterus is retracted to the left, clamps are applied to the initial sections of the round, proper ligaments and fallopian tube. Between them, the formations are crossed and ligated with catgut. Similar actions are performed on the other side. The uterus is pulled to one side, the stumps of the appendages - to the other. The tissue of the lateral surface of the uterus is released, clamps are applied perpendicular to it on the uterine artery, which is crossed and ligated (the same is done on the other side). The body and cervix of the uterus are pulled towards themselves, the sacrouterine ligaments are exposed, which are clamped, crossed and ligated. The lateral fornices, peritoneum, posterior fornix of the vagina are crossed, which is pulled to the entrance to the vagina with clamps. The peritoneum is sutured with a purse-string suture. The stumps of the round ligaments and appendages are fixed extraperitoneally, connecting them on each side to each other and to the lateral edges of the vaginal incision. The cardinal ligaments are superimposed on each other and sutured. The vaginal wall incision is sutured with interrupted catgut sutures. It is advisable to supplement this operation with colpoperineorrhaphy to eliminate the insolvency of the pelvic floor muscles.