RU2281705C1 - Method for surgical treatment fo vaginal enterocele - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should dissect mucosa of posterior vaginal wall along middle line up to the border of the middle and the upper third to exfoliate it bluntly, separate and withdraw hernial sac into the wound by lancing its top and setting its content into abdominal cavity and tighten at the bottom. Posterior vaginal arch should be strengthen due to implanting a synthetic netting, the size being 5x10 cm, not more. It should be fixed submucosally as a cupola with separate interrupted sutures. Vaginal wound should be sutured in with interrupted catgut sutures. The innovation enables to decrease technical difficulties on removing anatomic defects of pelvic bottom, shorten the duration and increase reliability of operation and, also, achieve high functional results.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to surgery.

There is a method for transvaginal correction of enterocele, which includes an incision of the mucous membrane of the posterior vaginal wall along the midline to the apex of the posterior fornix, dissection and removal of the hernial sac into the wound, opening of its apex, its contents into the abdominal cavity, bandaging at the base, cutting off and directing the stump into the abdominal a cavity followed by suturing of the sacro-uterine ligaments and vaginal wounds with nodal catgut sutures, proposed by GGWard in 1922 (Ward GG JAMA, 1922, V.79, P.709). However, according to various authors, relapses range from 5 to 12%, due to the weakness of the ligamentous apparatus of the pelvis, which is used to strengthen the pelvic floor, the gradual extension of the pelvic peritoneum under the influence of increased intra-abdominal pressure, and technical difficulties in identifying the utero-sacroiliac ligaments used to strengthening the pelvic floor, especially with post-hysterectomy enterocele. When suturing the uterine-sacral ligaments from the vaginal access, there is also a high risk of entrapment of the ureters into the suture (Uiliss K.P. Atlas of pelvic surgery. M.: Medical literature, 1999, pp. 56-61; Hirsch H.A., Keser O. , Ikle F.A. Operational Gynecology: Atlas: Translated from English Edited by V.I. Kulakov, I.V. Fedorov, M .: GEOTAR MEDICINE, 1999, S.263-265; Breen JL, Florio PL Critique to: Repair ofenterocele - posterior vaginal wall hernia. In: Tovell HMM, Dank LD et al. Gynecological Operations. New York: Har-per &Row; 1978: P.239; Phaneuf LE Am. J. Obstet. Gynec., 1943, V.45, P.490-496; Webb MJ Gynäkologe, 1981, V.14, P.187; Zacharin RF Obstet. Gynecol, 1980, V.55, P.135-140, etc.).

The task of the invention is to reduce technical difficulties during surgery and reduce the percentage of relapses.

To solve this problem, it is proposed to dissect the vaginal mucosa not to the top of the posterior fornix, but to the border of the middle and upper third, and then exfoliate in a blunt way. After the hernial sac is removed and removed into the wound, its apex is opened, the contents of the hernial sac are inserted into the abdominal cavity, the bandage at the base of the hernial sac is ligated, it is cut off and its stump is inserted into the abdominal cavity, the posterior vaginal fornix (Douglas pocket) is strengthened using a mesh from marlex or mercilene with dimensions not exceeding 5 × 10 cm, which is placed in the posterior vaginal fornix in the form of a dome and fixed with separate interrupted sutures under the mucosa of the posterior vaginal fornix.

Distinctive features of the claimed invention, giving reason to consider it appropriate signs of novelty and inventive step, are the following:

- the vaginal mucosa is not dissected to the top of the posterior fornix, but to the border of the middle and upper third, and then exfoliates in a blunt way,

- reinforcement of the posterior vaginal fornix (Douglas pocket) is carried out by implantation into the posterior fornix of a synthetic mesh with dimensions of no more than 5 × 10 cm, which is fixed under the mucosa in the form of a dome by separate interrupted sutures, and not by local tissues.

The method is presented in the drawings:

Figure 1 shows a dissection of the vaginal mucosa 1 along the midline from the vestibule to the border of the upper and middle third;

Figure 2 shows the hernial sac 2 brought to the wound, opened along the top 3, as well as the base 4 of the hernial sac,

Figure 3 - shows a view in the frontal plane of the vaginal fornix 1, reinforced with a mesh 5 under the separated mucosa 6;

Figure 4 - shows a view in the sagittal plane of the arch of the vagina 1, reinforced with a grid 5 in the form of a dome 7

Figure 5 - shows a wired section of the posterior wall of the vagina.

The method is as follows, In a patient in a position as for perineal lithotomy, the mucosa of the posterior wall of the vagina 1 is dissected in the traditional way to the level of the border of its middle and upper third (Fig. 1). Further, in contrast to the prototype, in the area of the vaginal fornix, it exfoliates in a blunt way. Then, in the generally accepted way, the hernial sac 2 is removed and removed into the wound, its apex 3 is opened, the contents of the hernial sac 2 are sent to the abdominal cavity. The hernial sac 2 is bandaged at the base 4, cut off, its stump is set into the abdominal cavity (figure 2). A mesh 5 of marlex or merceline 5 × 10 cm in size is placed in the posterior fornix of the vagina 1 under the separated mucous membrane 6 (Fig. 3) in the form of a dome 7 and fixed with separate nodular submucosal sutures in the required position (Fig. 4). Depending on the depth of the vaginal fornix, the mesh size may decrease by 1 - 1.5 cm on each side. Then, according to the generally accepted method, the pelvic floor is strengthened by anterior levatoroplasty and suturing of the vaginal mucosa with catgut sutures 8 (Fig. 5).

Example. Patient A., 45 years old, was admitted to the hospital on November 17, 02, complaining of a foreign body feeling in the perineum, aggravated by standing and during physical exertion, constipation. Sick for about six months. A history of a year ago hysterectomy for fibromyoma and polycystic ovary. A general clinical examination, ultrasound of the pelvic organs, a study of the passage of barium through the colon, proctography. Sonography and x-ray studies were performed in a standing position at rest and with straining. Anorectal manometry and electromyography of the pelvic floor were also performed. The diagnosis of enterocele, rectocele II degree. The contents of the hernial sac are loops of the small intestine. November 21, 02 the operation was performed: in the position, as for perineal lithotomy, the mucous membrane of the posterior wall of the vagina was cut along the midline from its vestibule to the border of its middle and upper third. The mucous membrane is separated to the sides and deep in the arch area with the transition to the front wall of the vagina to the border of the upper and middle third. The hernial sac was separated and removed into the wound, its apex was opened, the contents (loops of the small intestine) were inserted into the abdominal cavity. The hernial sac is bandaged at the base, cut off, the stump is immersed in the abdominal cavity. In the area of the posterior arch with the transition to the posterior and anterior walls of the vagina, a 5 × 10 cm marlex mesh is placed in the form of a dome, which is reinforced with separate nodular non-absorbable sutures in the area of the stump of the hernial sac, anterior wall of the vagina with a submucosal suture, in the region of the posterior wall to the rectovaginal fascia. The muscles that raise the anus are isolated and sutured. The section of the vaginal mucosa is sutured with nodal catgut sutures after excision of its excess on both sides. The postoperative period was uneventful. The patient was discharged on the 8th day in a satisfactory condition. The patient was examined 3, 6 and 12 months after surgery using ultrasound and x-ray methods. There is no data for relapse. Dyspareunia and constipation are not noted. The patient does not present any other complaints and is completely satisfied with the result of the operation.

Thus, the proposed technique can reduce technical difficulties in eliminating anatomical defects of the pelvic floor, reduce the duration and increase the reliability of the operation, achieve good functional results, and reduce the percentage of relapses.

Claims (1)

A method for surgical treatment of a vaginal enterocele, including a midline incision of the mucous membrane of the posterior wall of the vagina, dissection and removal of the hernial sac into the wound, opening of its apex, its contents into the abdominal cavity, dressing at the base, excision and reduction of the stump into the abdominal cavity, followed by suturing of the vaginal wounds with nodal catgut sutures, characterized in that the vaginal mucosa is dissected to the border of the middle and upper third, peeled off in a blunt way, and the posterior vaginal arch is strengthened by implant tation synthetic mesh size not exceeding 5 × 10 cm, which is fixed under the mucous domed separate interrupted sutures.

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