RU2848252C1 - Method for sacrospinal hysterovaginopexy - Google Patents

Abstract

FIELD: medicine; operative gynaecology.

SUBSTANCE: transvaginal access is achieved through a longitudinal incision in the anterior wall of the vagina. After that, the posterior wall of the bladder is separated from the anterior wall of the vagina to its middle third and the cervix, and channels are formed to the left and right of the cervix towards the sacrospinous ligaments. Then, alternately on the left and right sides, the sacrospinous ligaments are sutured with a suturing device at a distance of 1.5 cm from the ischial spine. A polypropylene mesh implant 1 cm wide and with a length corresponding to the distance from the cervix to the sacrospinous ligament is used. The central part of the implant is fixed with three knotted sutures to the anterior surface of the cervix with non-absorbable thread, placing the sutures at a distance of 1.0 cm from each other. The free ends of the implant are fixed to the sutures that were previously used to suture the sacrospinous ligaments on the left and right sides, respectively. By traction on the sutures, the ends of the mesh implant are passed through the sacrospinous ligaments on the left and right sides, and the colpotomised wound is sutured with two rows of sutures: a Holsted corset suture is applied to the pubocervical fascia, the incision in the vaginal mucosa is sutured with a Reverden suture, the anatomical position of the cervix is restored by traction on the free ends of the threads fixed to the mesh implant, after which the threads are cut off at the level of the wound of the mucous membrane of the anterior vaginal wall.

EFFECT: fixation of the uterus and vaginal vault, reduction of the trauma of the intervention and the risk of damage to adjacent organs.

1 cl, 1 ex

Description

The invention relates to medicine, namely to surgical gynecology.

The prevalence of pelvic organ prolapse (POP) in the population reaches 41-50%, with only up to 10% of patients seeking medical attention [1]. This indicates that the disease is asymptomatic in its early stages. POP combined with pelvic organ dysfunction in its later stages is the reason for seeking medical attention.

Most often, POP occurs in women aged 50-79 years: in 34% of cases, POP manifests as cystocele formation, in 19% - rectocele, and in 14% - uterine prolapse [2]. Recently, an increase in the proportion of POP in patients of reproductive age has been noted [3].

A special group of patients is made up of posthysterectomy prolapsed women, the incidence of which reaches 7.9-15% [4, 5, 6, 7]. Posthysterectomy prolapse is caused by disruption of the paracervical fibrous ring due to severance of the uterosacral and cardinal ligaments [4, 5, 6, 7]. All of this leads to an increase in the number of surgeries, which, combined with a high recurrence rate, prompts the search for new and reliable surgical treatment methods.

Vaginal sacrospinal fixation was proposed by K. Richter in 1968 [8]. In 1971, S. Randall and D. Nichols began using it in combination with vaginal hysterectomy, and later this operation began to be used as an independent method of treating POP [9, 10, 11]. Subsequently, the development of the method went in different directions.

Currently, sacrospinal colpopexy is one of the most popular and well-studied methods for correcting POP. This approach fits in with the increasing trend toward organ-preserving surgeries.

The main disadvantage of this operation is the wide access to the pararectal tissue with the isolation of ligaments under visual control, which can be performed in the presence of sufficient severity of the prolapse of the posterior vaginal wall, as well as the high recurrence rate of POP - up to 70% with a five-year observation period [12].

An alternative direction in the treatment of POP is reconstructive surgery using a mesh implant. In 1997, P. Petros proposed “replacing” defective ligaments with a synthetic mesh implant [13].

With the beginning of the use of mesh implants in the correction of POP, doctors were faced with the emergence of new specific complications; however, due to the ability of the prostheses to replace their own incompetent fascial tissues, this type of intervention made it possible to reduce the frequency of relapses and increase the effectiveness of these interventions [14].

During observations, researchers confirmed a direct relationship between the size of endoprostheses and the likelihood of complications, such as erosion of the vaginal mucosa, which leads to a desire to reduce the volume of implanted material [15, 16].

A method of surgical reconstruction of the pelvic floor is known, which consists of transvaginal sacrospinal hysteropexy using the UroSling-1 mesh implant (RU 2661042 C1 2018).

The disadvantages of this method are:

- passing the Urofix PL conductor from the outside to the inside through the sacrospinous ligaments using this technique is only possible with extensive experience from the surgeon due to the lack of the ability to palpate the direction of the Urofix PL conductor in the outside-in modification, which is accompanied by an increased risk of injury to blood vessels, nerve trunks and adjacent organs.

- when installing an endoprosthesis through the posterior wall of the vagina, the endoprosthesis is fixed to the cervix using sutures to its posterior surface, which creates a critical point of increased load, in which area the likelihood of suture cut-through is higher.

As a basic method, we have chosen the method of surgical correction of uterine prolapse using a mesh implant (RU 2766667, C1 2022).

A known technique includes vaginal placement of a polypropylene mesh endoprosthesis tape with atraumatic edges of a macroporous structure through a longitudinal incision in the anterior vaginal wall by passing it through the sacrospinous ligaments on both sides with fixation to the cervix after separating the posterior wall of the bladder from the anterior vaginal wall and cervix and mobilizing the sacrospinous ligaments on both sides. In this case, the endoprosthesis tape is installed by perforating the sacrospinous ligament at a distance of 1.5-2.0 cm from the sciatic spine at an angle of 20° to the median sagittal plane with a perforator guide fixed to the free end of the endoprosthesis tape, after which it is passed "from the inside to the outside" to the skin and the free end of the endoprosthesis tape is brought out through a skin incision in the gluteal region, formed in the projection of the passed end of the perforator guide; Then, from the other side, using a perforator guide with the other free end of the endoprosthesis tape, the other sacrospinous ligament is perforated at a distance of 1.5-2.0 cm from the sciatic spine at an angle of 20° to the median sagittal plane; then, without changing the direction of the perforator guide, it is passed "from the inside to the outside" to the skin and the other free end of the endoprosthesis tape is brought out through another incision in the gluteal region, formed in the projection of the passed end of the perforator guide; the central part of the endoprosthesis tape is fixed with two interrupted sutures to the anterior surface of the cervix using non-absorbable threads, placing the sutures at a distance of 1.5 cm from each other; the colpotome wound is sutured with a continuous suture, the free ends of the endoprosthesis tape are pulled up, restoring the normal anatomical position of the cervix, and cut off at the level of the skin incisions in the gluteal regions, which are sutured with interrupted sutures.

The disadvantages of this method are:

- the difficulty of passing a perforator guide through the sacrospinous ligaments using the "inside-out" technique is only possible if the surgeon has experience and knowledge of the anatomical relationships of organs, nerves and vessels, due to the lack of the ability to fully manually control the perforator's progress, as well as the presence of skills to correct possible complications (injury to vessels, adjacent organs and nerve trunks).

The objective of the invention is to reduce tissue trauma and increase the safety of inserting a mesh implant through the sacrospinous ligament during correction of apical prolapse, while maintaining the effectiveness of the method.

The technical result achieved by implementing the invention consists in preventing relapse and reducing the trauma of the intervention due to:

- the use of a non-absorbable polypropylene implant as a fixing element, which ensures more reliable fixation of the cervix compared to the use of suture material;

- insertion of the implant through the anterior vaginal access, horseshoe-shaped placement of the tape and uniform distribution of the static load;

- insertion of the implant through the sacrospinous ligament, which eliminates the need to fix the implant to the ligament using suture material;

- modification of the stage of the operation by “blind” perforation of the sacrospinous ligament and the lower gluteal region with a perforator guide, which helps prevent injury to adjacent organs, nerve trunks and/or vascular bundles, thereby reducing the degree of tissue damage, and shortening the duration of the operation;

- formation of the physiological position of the cervix not only due to the actions of the surgeon, but also through the patient’s motor activity in the early postoperative period;

- the absence of direct contact between the vaginal mucosa and the colpotome wound with the mesh implant, which eliminates the risk of vaginal mucosal erosion and mesh implant protrusion.

The proposed method also allows for the combination of apical prolapse correction with the simultaneous possibility of cystocele correction; provides the possibility of multifactorial adjustment of the degree of prosthesis tension; allows for the standardization of the pelvic floor reconstruction technique at all stages of the operation, minimizing the risk of trauma and reducing the duration of the operation;

Manual control of the perforation point when using a ligature carrier of the sacrospinous ligament and a 1.5 cm distance from the sciatic spine eliminates the need for a perforator guide, minimizing the risk of damage to anatomical structures such as the rectum, pudendal nerve, and blood vessels, and also eliminates contact of the implant with these structures.

The essence of the invention is as follows.

The patient is placed on the operating table in the lithotomy position with her legs maximally flexed and abducted at the hip joints. After anesthesia is administered, the bladder is catheterized with a Foley catheter connected to a urine collection bag. Hydropreparation is performed with 60 ml of 0.9% sodium chloride solution, which is injected subfascially into the anterior vaginal wall. A 4-5 cm longitudinal incision is made on the anterior vaginal wall with a scalpel. The edges of the vaginal mucosa are grasped with Allis clamps, and the posterior wall of the bladder is separated from the anterior vaginal wall to the middle third and cervix. Channels are created in the direction of the sacrospinous ligaments on the left and right lateral sides of the cervix. Then, alternately on the left and right sides, the sacrospinous ligaments are stitched with a thread using a stapling apparatus at a distance of 1.5 cm from the sciatic spine on the left and right sides, respectively.

Next, a polypropylene mesh implant is taken, 1 cm wide and the length corresponding to the distance from the cervix to the sacrospinous ligament. The central portion of the mesh implant is secured to the anterior surface of the cervix with three interrupted sutures using non-absorbable sutures, spaced 1.0 cm apart. Etibond polyester suture can be used as a non-absorbable suture material.

The free ends of the mesh implant are secured to the sutures previously used to pierce the sacrospinous ligaments on the left and right sides, respectively. Using traction on the sutures, the ends of the mesh implant are passed through the sacrospinous ligaments, after which the sutures are not cut. A Halsted corset suture is placed on the pubocervical fascia using absorbable #1 Vicryl suture material, after which the vaginal mucosal wound is closed with a continuous Reverdin suture using absorbable #2-0 Vicryl suture. Traction is applied to the free ends of the sutures secured to the mesh implant (without extending beyond the mucosal wound), restoring the normal anatomical position of the cervix, and the sutures are cut off at the level of the anterior vaginal mucosal wound.

The vagina is cleaned with an aqueous antiseptic solution and tightly packed with a gauze pad soaked in iodopyrone, which remains in place for 24 hours. The urinary catheter is removed the morning after surgery.

To prove the possibility of implementing the stated purpose and achieving the specified technical result, we provide the following data.

The method is carried out as follows.

A sacrospinal hysterovaginopexy technique involving a transvaginal approach and the implantation of a polypropylene mesh implant by passing it through the sacrospinous ligaments on both sides and fixing it to the cervix. A transvaginal approach is performed by making a longitudinal incision in the anterior vaginal wall, after which the posterior wall of the bladder is separated from the anterior vaginal wall down to the middle third and cervix. A channel is created toward the sacrospinous ligaments on the left and right sides of the cervix. The sacrospinous ligaments are then alternately sutured on the left and right sides with a stapler, 1.5 cm from the sciatic spine. A polypropylene mesh implant, 1 cm wide and of a length corresponding to the distance from the cervix to the sacrospinous ligament, is then inserted. The central portion of the implant is secured to the anterior cervical surface with three interrupted sutures using non-absorbable sutures, spaced 1.0 cm apart. The free ends of the mesh implant are secured to the sutures previously used to suture the sacrospinous ligaments on the left and right sides, respectively. Using traction on the sutures, the ends of the mesh implant are passed through the sacrospinous ligaments. The colpotome wound is closed with two rows of sutures: a Halsted suture is placed on the pubocervical fascia, and the vaginal mucosal wound is closed with a Reverdin suture. Traction on the free ends of the sutures secured to the mesh implant restores the normal anatomical position of the cervix, after which the sutures are cut at the level of the wound in the anterior vaginal wall.

Clinical example.

Patient S., 67, was referred to the surgical department with complaints of a foreign body sensation in the vagina, difficulty urinating, and a feeling of incomplete bladder emptying. These complaints had persisted for five years. Based on the patient's history, complaints, and bimanual vaginal examination, a clinical diagnosis was established: pelvic floor muscle insufficiency. Incomplete prolapse of the uterus and vaginal walls (grade III apical prolapse according to the POP-Q system).

Vaginal examination reveals a gaping genital slit. During straining, the cervix prolapses beyond the genital slit (C+2, Bp -2, Ba +1, TV1 8).

Considering the presence of apical and anterior prolapse, surgical correction of prolapse was performed by hysteropexy and anterior colporrhaphy using a synthetic mesh implant according to the proposed method.

The surgical procedure lasted 40 minutes. Intraoperative blood loss was 30 ml. No damage to adjacent organs, vessels, or nerves was observed. The postoperative period was uneventful. The patient had no complaints. No urinary or defecation problems were observed. Healing occurred by primary intention. The patient was discharged to the obstetrician-gynecologist at the antenatal clinic 3 days after the surgery. She had no complaints at follow-up examinations 2 and 6 months after the surgery. No recurrence of postoperative pelvic inflammatory disease was detected. The patient subjectively reports a significant improvement in her quality of life.

The proposed installation technique and the selected prosthesis made it possible to eliminate prolapse of the uterine body and minimize the risk of intraoperative complications in the form of perforation of adjacent organs, nerve trunks and vessels, as well as postoperative complications in the form of pain syndrome, erosion of the vaginal mucosa, dyspareunia, and also maintain a low risk of recurrence of POP.

The proposed method was successfully tested on 34 patients. Thus, the claimed method of surgical correction of uterine prolapse through a vaginal approach allows:

- combine correction of apical prolapse with the simultaneous possibility of correction of cystocele;

- multifactorial regulation of the degree of tension of the prosthesis;

- standardize the technique of pelvic floor reconstruction at all stages of the operation, minimizing the risk of injury to adjacent structures and reducing the duration of the operation.

Claims (1)

A method of sacrospinal hysterovaginopexy, including performing transvaginal access, implanting a polypropylene mesh implant by passing it through the sacrospinous ligaments on both sides with fixation to the cervix, characterized in that the transvaginal access is carried out through a longitudinal incision in the anterior wall of the vagina, after which the posterior wall of the bladder is separated from the anterior wall of the vagina to its middle third and the cervix, channels are formed on the left and right of the cervix in the direction of the sacrospinous ligaments, then the sacrospinous ligaments are stitched alternately on the left and right sides with a stapler at a distance of 1.5 cm from the sciatic spine, a polypropylene mesh implant 1 cm wide and of a length corresponding to the distance from the cervix to the sacrospinous ligament is used, the central part of the implant is fixed with three interrupted sutures to the anterior surface of the cervix with a non-absorbable thread, placing the sutures at a distance of 1.0 cm from each other; the free ends of the implant are fixed to the threads that were previously used to suture the sacrospinous ligaments on the left and right sides, respectively, by traction on the threads, the ends of the mesh implant are passed through the sacrospinous ligaments on the left and right sides, the colpotome wound is sutured with two rows of sutures: a Halsted corset suture is applied to the pubocervical fascia, the incision in the vaginal mucosa is sutured with a Reverdin suture, the anatomical position of the cervix is restored by traction on the free ends of the threads fixed to the mesh implant, after which the threads are cut off at the level of the wound in the mucosa of the anterior vaginal wall.