RU2804447C1 - Method of surgical treatment of apical prolapse of the genitals - Google Patents

Abstract

FIELD: medicine, operative urogynecology.

SUBSTANCE: laparoscopic access is provided. A mesh implant measuring 20 cm by 2 cm is introduced into the abdominal cavity, followed by fixation of its central part to the cervix and distal parts to the Cooper's ligaments both on the right and left. Peritonization of the mesh implant and suturing are performed. After providing laparoscopic access, a subtotal hysterectomy with appendages is performed while maintaining the maximum length of the stumps of the round uterine ligaments and sacro-uterine ligaments. Cooper's ligaments are accessed, for which purpose a dissection is performed in the direction of the superior branch of the pubic bone and they are exposed laterally. A mesh implant is introduced into the abdominal cavity, the round uterine and sacro-uterine ligaments are fixed to the cervical stump. Then, the central part of the mesh implant is fixed to the cervical stump, the optimal lengths of the distal parts of the mesh implant are provided, and they are fixed to the Cooper's ligaments both on the right and left. After that, linear peritonization of the mesh implant and suturing are performed.

EFFECT: method makes it possible to increase the effectiveness of treatment and reduce the probability of prolapse recurrence by ensuring the optimal anatomical position of the cervical stump with its more reliable fixation with the optimal tension of the mesh implant.

3 cl, 2 dwg, 2 ex

Description

The invention relates to medicine, in particular to surgical gynecology, and can be used for surgical treatment of apical genital prolapse.

There is a known method of laparoscopic promontofixation, which includes providing laparoscopic access, introducing a mesh implant into the abdominal cavity with subsequent fixation of one of its narrowed ends to the presacral fascia, and fixation of the U-shaped split end to the uterosacral ligaments on both sides and to the isthmus of the uterus, peritonization of the mesh implant and suturing (see RF patent No. 2612518, IPC A61B 17/42, A61F 2/00, publication date 03/09/2017).

The disadvantages of this method are:

- anatomically complex spaces for dissection with a risk of injury to the area of the rectal vascular venous plexuses, including impaired blood supply to the rectum;

- risk of injury to the lower hypogastric nerve plexus, which can lead to intestinal dysfunction;

- risk of developing stress urinary incontinence;

- long duration of the operation, which limits its use in somatically burdened patients;

- a long period of training for surgeons due to the complexity of the surgical technique, which limits the widespread use of this type of intervention;

- dissection of the retroperitoneal space is a technically challenging task due to the high risk of bleeding from this area;

- the risk of developing spondylitis in the case of purulent-septic complications of an installed mesh implant and further difficulty in isolating the latter;

- in the presented method of laparoscopic promontofixation, the anterior angle between the uterus and the bladder opens, which can lead to increased anterior prolapse;

- due to the peculiarities of dissection of the paravesical space, the risk of developing urge urinary incontinence increases.

As the closest analogue (prototype), a method of surgical treatment of apical genital prolapse is adopted, including providing laparoscopic access, introducing a mesh implant measuring 20 cm by 2 cm into the abdominal cavity, followed by fixation of its distal parts to the Cooper ligaments on the right and left and with slight tension to the neck uterus, peritonization of the mesh implant and suturing (https://www.uroweb.ru/article/pektopeksiya-kak-sposob-korrektsii-apikalnogo-prolapsa-genitaliy).

The disadvantage of the closest analogue is that it does not have the ability to determine the required tension of the mesh implant.

The problem to be solved by the invention is the development of an effective and safest method of surgical treatment of apical genital prolapse with low labor intensity and minimal risk of complications, including relapses.

The technical result achieved in solving the problem is expressed in increasing the effectiveness of treatment and reducing the recurrence of prolapse by ensuring the optimal anatomical position of the cervical stump with its more reliable fixation with optimal tension of the mesh implant.

The problem is solved by the fact that the method of surgical treatment of apical genital prolapse, including providing laparoscopic access, introducing a mesh implant measuring 20 cm by 2 cm into the abdominal cavity, followed by fixing its central part to the cervix and distal parts to the Cooper ligaments on the right and left with insignificant tension, peritonization of the mesh implant and suturing differs in that after providing laparoscopic access, a typical subtotal hysterectomy with appendages is performed while maintaining the maximum length of the stumps of the round uterine ligaments and sacrouterine ligaments, access to Cooper's ligaments is performed, for which dissection is carried out in the direction of the upper branch pubic bone and expose them laterally, a mesh implant is inserted into the abdominal cavity, the round uterine and sacrouterine ligaments are fixed to the cervical stump, then the central part of the mesh implant is fixed to the cervical stump, the optimal lengths of the distal parts of the mesh implant are ensured and they are fixed to the ligaments Cooper on the right and left, after which typical linear peritonization of the mesh implant and suturing are performed.

In addition, the central part of the mesh implant is fixed in the area of attachment of the ligaments to the cervical stump.

In addition, the distal parts of the mesh implant are additionally fixed to the round uterine ligaments along the length of these ligaments to the pelvic wall.

A comparative (comparative) analysis of the essential features of analogues and the prototype indicates its compliance with the “novelty” criterion.

In this case, the distinctive features of the invention formula solve the following functional problems.

The signs “after providing laparoscopic access, a typical subtotal hysterectomy with appendages is performed” allows the formation of a base in the form of a cervical stump for fixation of the mesh implant.

Signs indicating that a typical subtotal hysterectomy is carried out “while maintaining the maximum length of the stumps of the round uterine ligaments and uterosacral ligaments”, “fixing the round uterine and sacrouterine ligaments to the cervical stump” make it possible to determine the degree of tension of these ligaments and the location of the cervical stump in the small pelvis.

The signs “access the Cooper's ligaments by dissecting in the direction of the superior ramus of the pubis and exposing them laterally” to enable fixation of the mesh implant to the Cooper's ligaments.

The signs “a mesh implant is inserted into the abdominal cavity” provide the possibility of forming a support system for the cervical stump with the vagina with a minimal risk of developing apical prolapse.

The signs indicating that “the central part of the mesh implant is fixed to the cervical stump, and the distal parts to the Cooper ligaments on the right and left,” as well as the signs of the first dependent claim of the formula, determine the placement of the mesh implant in the abdominal cavity in the form of a “hammock.”

The features “provide optimal lengths for the distal parts of the mesh implant” allow the tension of the mesh implant to be adjusted.

The sequence in which the distal parts of the mesh implant are fixed to the Cooper ligaments after fixing the ligaments and the central part of the mesh implant to the cervical stump ensures an anatomically correct ratio of the lengths of these elements of the cervical stump support system to the vagina.

Signs “carry out typical linear peritonization of the mesh implant and suturing” ensure closure of the visceral peritoneum defect while preventing infectious complications.

The signs of the second dependent claim of the formula allow you to organize a better support system for the cervical stump with the vagina and ensure an anatomically correct position of the cervical stump, corresponding to the functions of the round uterine ligaments in the support system.

In fig. Figure 1 shows the stage of fixation of the central part of the mesh implant to the cervical stump.

In fig. Figure 2 shows the formed system for supporting the cervical stump with the vagina after peritonization of the mesh implant.

The inventive method is carried out using standard equipment in several stages.

1. Preoperative preparation of the patient and provision of laparoscopic access.

The operation is performed under endotracheal anesthesia. Preoperative antibiotic prophylaxis and prevention of venous thromboembolic complications are carried out.

The patient is placed on the operating table on her back with her legs spread as far apart as possible and the knee joints bent. A Foley urethral catheter is inserted into the bladder cavity.

The laparoscope is inserted through the paraumbilical incision and three punctures are made in the anterior abdominal wall to install ports and instruments. After examining the internal organs, the patient is transferred to the 30° Trendelenburg position and the pelvic organs are examined.

2. Carrying out a typical subtotal hysterectomy with adnexa while maintaining the maximum length of the stumps of the round uterine ligaments and the uterosacral ligaments.

3. Providing access to Cooper's ligaments, for which dissection is carried out in the direction of the superior branch of the pubic bone and Cooper's ligaments are exposed laterally, 1.5 cm in the direction of the pubic bone.

4. Insertion of a mesh implant into the abdominal cavity.

To prevent microbial contamination, surgeons' gloves are changed.

A mesh implant in the form of a tape measuring 20 cm by 2 cm is inserted into the abdominal cavity in a plastic bag, from which it is then removed.

5. Immersion in a plastic bag from point 4 of the uterine body for its further morcellation.

6. Fixation of the round uterine and uterosacral ligaments to the cervical stump with V-loc 180 thread.

7. Fixation of the central part of the mesh implant to the cervical stump (in the area of attachment of the ligaments to it) with a non-absorbable twisted thread 2.0 with a 35 mm needle using five interrupted sutures.

8. Ensuring optimal lengths of the distal parts of the mesh implant.

The optimal length of the distal parts of the mesh implant is selected in such a way that contact of each of them is ensured with the nearest Cooper ligament and they are located freely without tension, while the excess edge of these distal parts is cut off.

9. Fixation of the distal parts of the mesh implant to the Cooper ligaments once or twice on the right and left with a 1-0 non-absorbable twisted thread with a 21 mm needle, while the distance between the injection and puncture of the Cooper ligament should be at least 5 mm.

10. Additional fixation of the distal parts of the mesh implant to the round uterine ligaments along the length of these ligaments to the pelvic wall.

11. Typical linear peritonization of a mesh implant and suturing with absorbable suture material.

In the presence of apical prolapse in combination with anterior and posterior genital prolapse, anterior-posterior colporrhaphy, levatoroplasty, and perineoraffy are performed before implementing the proposed method.

It is possible to perform laparoscopic dissection of the anterior and posterior vaginal walls with installation of mesh prostheses along the walls (similar to sacrovaginopexy); the disadvantages include the fact that this stage of the operation is more labor-intensive and technically complex.

The inventive method is illustrated by the following clinical examples.

Example 1. Patient D., 67 years old, was admitted to the gynecological department with complaints of a feeling of a foreign body inside the abdomen and difficulty urinating.

From the anamnesis it was established: pregnancies - 4; births - 2, on time, second-hand; abortion - 2 within 12 weeks, non-stop.

During a gynecological examination: the cervix and part of the uterine body protrude from the vagina at rest. When straining - complete loss. When repositioning the uterine body, latent urinary incontinence was revealed.

After examination, the patient was diagnosed with pelvic floor muscle failure. Apical prolapse grade 4 Neurogenic bladder. Obstructive type of urination. Postmenopausal period.

The operation was performed according to the claimed method. A subtotal hysterectomy with adnexa was performed.

The postoperative period proceeded without complications. The duration of the operation was 120 minutes, blood loss was minimal. The patient was discharged from the hospital on the 4th day in satisfactory condition.

Follow-up examinations were carried out 6 and 12 months after surgery. No recurrence of displacement of the internal genital organs was detected.

Example 2. Patient D., 61 years old, was admitted to the gynecological department with complaints of discomfort in the perineum and vagina, and frequent urination.

From the anamnesis it was established: pregnancies - 2; births - 2, in 1979, at 35 weeks, untreated, in 1994, at term, untreated.

During a gynecological examination: the cervix and the body of the uterus completely extend beyond the genital slit. When the uterine body is repositioned, the cough test is negative.

After examination, the patient was diagnosed with pelvic floor muscle failure. Incompetence of the pelvic floor muscles. Apical prolapse grade 4

The operation was performed according to the claimed method. A subtotal hysterectomy with adnexa was performed.

The postoperative period proceeded without complications. The duration of the operation was 200 minutes, blood loss was minimal. The patient was discharged from the hospital on the 6th day in satisfactory condition.

Follow-up examinations were carried out 6 and 12 months after surgery. No recurrence of displacement of the internal genital organs was detected.

Claims (3)

1. A method of surgical treatment of apical genital prolapse, including providing laparoscopic access, introducing a mesh implant measuring 20 cm by 2 cm into the abdominal cavity with subsequent fixation of its central part to the cervix and distal parts to the Cooper ligaments on the right and left, peritonization of the mesh implant and application sutures, characterized in that, after providing laparoscopic access, a subtotal hysterectomy with appendages is carried out while maintaining the maximum length of the stumps of the round uterine ligaments and the uterosacral ligaments, access to Cooper's ligaments is carried out, for which a dissection is carried out in the direction of the upper branch of the pubic bone and they are exposed laterally, a mesh implant is inserted into the abdominal cavity, the round uterine and sacrouterine ligaments are fixed to the cervical stump, then the central part of the mesh implant is fixed to the cervical stump, the optimal lengths of the distal parts of the mesh implant are ensured and they are fixed to the Cooper ligaments on the right and left, after which carry out linear peritonization of the mesh implant and suturing. 2. The method of surgical treatment of apical genital prolapse according to claim 1, characterized in that the central part of the mesh implant is fixed in the area of attachment of the ligaments to the cervical stump. 3. The method of surgical treatment of apical genital prolapse according to claim 1, characterized in that the distal parts of the mesh implant are additionally fixed to the round uterine ligaments along the length of these ligaments to the pelvic wall.