Surgery on the external genitalia and vagina

An opening of the abscess of the large gland of the vestibule

Indications: acute inflammatory process.

Technique: a longitudinal section is made to the inside of the small labia parallel to the latter, followed by drainage. In the postoperative period, hydrogen peroxide is washed daily before purification, then gauze turunda is injected.

[1], [2], [3], [4]

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

Indications: recurrent abscess of bortolin gland, fistulous course after opening of abscess, cyst, deforming entrance to vagina.

Technique: an oval cut of skin 5-6 cm long above the tumor outside of the labia minora. In a sharp and blunt way, the cyst is excreted from the surrounding tissue and removed. The bed of the cyst is sutured with submerged catgut sutures. On a cut of a skin nodal silk seams are imposed.

Operations on the hymen

Indications: complete infection or severe stiffness, preventing sexual intercourse or the flow of menstrual blood.

There are several options for the operation:

1. the dissection of the hymenotomy is made with a scalpel in the lower-external section, leading the incision to the base of the hymen. The edges of the wound are stretched, the vessels are ligated. On the edges of the cut, stretched in the longitudinal direction, separate catgut stitches are placed;
2. excision of the hymenectomy (hymenectomy) - a cross-sectional incision is made with excision of the edges of the wound between the corners. The edges of the excised hymen are covered with separate catgut sutures;
3. operation in the process of hymen replacement with the formation of hematocolpos (colpostomia). A cruciform incision is made of the protruding hymen with the sheathing of the edges of the incision with separate catgut sutures in order to prevent the naked wound surfaces from sticking together.

Surgery for ovulation and prolapse of the vaginal wall and abnormal position of the uterus

Anterior colporaphhasia (colporrhaphia anterior)

Indications: omission of the anterior wall of the vagina, prolapse of the anterior wall of the vagina, cystocele.

Technique: the vaginal part of the cervix is exposed by mirrors. The anterior lip of the cervix is captured by bullet or two-prong forceps and is reduced to the entrance to the vagina (or the removal of the anterior wall of the vagina from the genital gaps - in the fall). The incision is made between the four clamps of Kocher - 2 cm below the outer opening of the urethra, 2 cm above the outer cervical cervix and twice - along the sides of the oval shaped patch, to a depth up to the underlying loose fiber. The mucous membrane is separated in an acute and blunt manner from the underlying ventricular fascia. Then, the bed of the bladder is strengthened-a continuous, nodal or cetacean catgut suture connects the paravezic tissues with the immersion of the bladder. The edges of the vaginal mucosa are connected by a continuous catgut joint in the longitudinal direction.

[5], [6], [7], [8], [9], [10]

Colpoperineorrhaphia. Colpoperineoplastica

Indications: ovulation and prolapse of the posterior wall of the vagina, rectocele.

Technique: the vagina is exposed through mirrors. A patch of the mucous membrane of the posterior wall of the vagina is triangular. The base is located on the back spike on the border of the mucous membrane of the vagina and the skin of the perineum, the vertex - along the middle line closer to the vault (the size of the cut flap depends on the height of the recovered perineum and the severity of the ptosis). The entrance to the vagina must pass 2 fingers. After excision of the mucosal flap, the wound is wound from the upper corner, connecting the mucosal edges with a continuous suture. Then proceed to levatoroplasty. Use a round thick needle, which is first brought under the leg of the left-hand side of one side, punctures and grasps the inside of the left leg of the other side from the outside. Apply 2-3 of these tightening seams. Then, the connection of the edges of the vaginal wound is continued by a continuous catgut suture to the border of the skin. The last stage is suturing the muscles and skin of the perineum with nodal silk sutures.

Median colporaphasia (colporrhaphia mediana)

Indications: complete loss of the uterus in old age, recurrence 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 bullet forceps for both lips, pulled downward, and the vagina and uterus are ejected outward. Then the neck is taken down and a rectangular flap is cut from the anterior wall of the vagina with the borders - the upper 2 cm below the outer opening of the urethra, the lower one - in the vaginal vault. The width of the flap depends on the width of the vagina, at the top the flap should be somewhat wider. The same size and shape of a flap is cut along the back wall of the vagina. The grafts are separated by a sharp path. Then, the refreshed surfaces are joined together by separate catgut seams in sequence, beginning with the anterior and posterior arches (the edges of the transverse incisions in front and behind the cervix), thus the wound surfaces are joined, screwed inward, and the neck extends into the vagina. Left and right side channels remain for the outflow of cervical excretions.

Ventrophy of uterus (ventrofixatio uteri)

Indication: the descending and prolapse of the walls of the vagina and uterus. Often complements operations on the vagina and perineum. It is shown in elderly women.

Technique: lower middle laparotomy. The uterus is removed from the abdominal cavity and pulled up to the lower corner of the wound. The peritoneum is sewn with a continuous catgut suture from the upper corner with placement under the uterus. In the lower corner of 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. With the catgut sutures, the anterior surface of the uterus attaches to the abdominal muscles. Aponeurosis is sutured with nodal silk sutures.

To increase the effectiveness of the operation and prevent relapses (since the peritoneum is stretched), the stitching of the uterine fundus is performed by 2-3 silk sutures, passing them through the peritoneum, muscles and aponeurosis, over which the sutures are tied. Peritoneum and aponeurosis are usually sutured.

Ventrosuspension (ventrosuspensio uteri) is the operation of hanging the uterus for round ligaments according to Doleri-Gilliam.

Indications: omission and prolapse of the uterus, fixed retroflexia of the uterus.

Technique: the abdominal cavity is opened. The peritoneum, together with the aponeurosis, is grasped on both sides of the incision by the clamps of Kocher. Stepping back 2 cm from the edge of the incision, the hole in the aponeurosis is formed with a scalpel in diameter up to 1 cm. The round ligament of the uterus is alternately seized at a distance of 3-5 cm from the uterus and the loop of the ligament is withdrawn through the hole in the aponeurosis from the corresponding side. Above the aponeurosis, the ligament loops are connected by a silk suture and attached to the aponeurosis by separate sutures. Peritoneum and aponeurosis are usually sutured.

Manchester Operation (operatio Manchester)

Indication: omission and partial prolapse of the uterus, especially when elongation of the cervix and the presence of cystocele.

Technique: the cervix is captured by bullet forceps and is reduced to the entrance to the vagina. The incision is made of the anterior wall of the vagina to the fascia of the bladder, starting 1.5-2 cm below the outer orifice of the urethra. You can delineate a triangular flap on the front wall of the vagina. Then a circular incision of the mucosa along the circumference of the cervix is done (in front - at the level of the last transverse fold). The mucous membrane of the anterior wall of the vagina is cut off from the bladder, the connective tissue strands that run from the neck to the bladder are cut by scissors, and the last blunt and acute way is removed upward, with 2-3 catgut sutures, the bladder is transposed. Along the circular incision, the vaginal vaults are separated from the cervix by a blunt way. Cardinal ligaments located on the lateral surfaces of the elongated neck are exposed. Ligaments are grasped by clamps, dissected, sewed together with the branch of the uterine artery passing through them. A conical amputation of the elongated part of the cervix and uterus is made after the pre-bougie of the cervical canal by Gegar dilators to No. 10-11. The severed cardinal ligaments are pulled to the middle line and sewed together under the bottom of the bladder, making for it an additional support. Attachment of the vaginal vaults to the amputated neck is made by U-shaped sutures. The lateral parts of the neck are sutured with separate catgut sutures with the capture of the mucosa and muscle tissue.

The last stage of the operation is colpoperineorafia according to the usual method.

Vaginal extirpation of the uterus (extirpatio uteri per vaginam)

Indications: complete prolapse of the uterus.

Technique: the cervix is grasped by Myso forceps, the uterus is reduced to the entrance to the vagina. On the border of the anterior vault of the vagina and mucous membrane covering the cervix, a circular or semilunar incision is dissected into the vaginal wall and is cut off in the form of a cuff towards the uterine pharynx. The bladder is separated in an acute and blunt way from the cervix, reaching the vesicle-uterine fold, which is determined by a whitish color. The bladder is pushed to the front by a lift and a vestibular fold is opened (anterior colpotomy). Paracervical fiber, cardinal ligaments are grasped by the clamps, intersect and ligated with catgut. The free edge of the vesicle-uterine fold connects with the edge of the vaginal wound with catgut sutures. The body of the uterus is led out through the anterior colpotomy. After excretion, the uterus is removed to the left, clamps are placed on the initial sections of the circular, own ligaments and the fallopian tube. Between them, these formations intersect and are ligated with catgut. Similar actions are performed on the other side. The uterus is pulled in one direction, the stump of the appendages in the other. Fiber of the lateral surface of the uterus is liberated, perpendicular to it clamps are placed on the uterine artery, which intersects and ligates (the same is done on the other side). The body and cervix are pulled toward themselves, the sacro-uterine ligaments are exposed, which are pinched, crossed and ligated. The intersection of lateral arches, peritoneum, posterior vaginal fornix, which is tightened at the terminals to the entrance to the vagina, is made. The peritoneum is sutured with a sutured suture. The cults of the round ligaments and appendages are fixed extraperitoneally, connecting them on each side with each other and with the lateral edges of the vaginal incision. Cardinal ligaments are superimposed on each other and stitched together. The incision of the vaginal wall is sutured with nodal catgut sutures. It is advisable to eliminate the incompetence of the pelvic floor muscles to supplement this operation with colpoperineoraphy.