RU2839964C1 - Method of treating high rectocele using proper tissues - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical urogynaecology. A transverse incision is made along the posterior wall of vagina 1 cm below the posterior fornix. Areas of separation of rectovaginal fascia from uterine neck are detected by blunt dissection. Method includes mobilizing free flap of rectovaginal fascia, performing pararectal dissection from 2 sides in direction S2-S4, sacro-uterine ligaments are sutured in their middle one-third, provisional ligatures are applied by retroperitoneal access with a polyester non-absorbable suture 2-0 by 1 suture on each side, left on "holders" for further use, fixing a non-absorbable monofilament ligature 3-0 of the edge of the rectovaginal fascia to the stroma of the cervix from behind with a continuous suture with spreading the fascia, then the cervix is sutured in the centre with the sutures used to sew the sacro-uterine ligaments, as well as a rectovaginal fascia with a reverse (immersion) suture bilaterally so that the sacro-uterine ligaments in the form of a duplication are fixed to the posterior surface of the cervix and rectovaginal fascia, then the defect of the mucous membrane of the posterior vaginal wall is closed with the absorbable suture PGA 2-0.

EFFECT: method provides higher clinical effectiveness of treatment with simultaneous reduction of its injuries.

1 cl, 2 ex

Description

The invention relates to medicine, surgical urogynecology. The method includes correction of high rectocele with own (native) tissues. The present invention relates to urogynecology, in particular to surgical treatment of high rectocele.

It is estimated that pelvic organ prolapse occurs in approximately 40-60% of women who have given birth. The incidence of isolated posterior prolapse, or rectocele, is 7%, and in combination with other defects - 39%.

Rectocele is a type of urogenital prolapse, which is a prolapse of the posterior vaginal wall. Women with rectocele usually complain of a feeling of a foreign body in the perineum and vagina, difficult defecation, constipation or the need for manual assistance to empty the bowels, a feeling of incomplete bowel emptying. In addition, symptoms of overactive bladder, difficulty urinating, chronic pelvic pain within the framework of the posterior fornix symptom and sexual dysfunction are not uncommon.

The risk of developing rectocele increases with age and parity and occurs due to stretching and rupture of the rectovaginal fascia. During the 2nd stage of labor, with full dilation of the cervix, in particular, with rotation of the head and its flexion, there is a pronounced pressure of the head on the structures of the small pelvis, especially on the arch of the uterosacral ligaments and the upper part of the rectovaginal septum; this mechanism is responsible for the overwhelming majority of cases of rectocele formation, as well as enterocele, sigmoidocele, perineal descent, and even anterior apical prolapse. The authors are convinced that the uterosacral ligament is a key structure in adequate support of all parts of the small pelvis and its defect can cause a wide range of pelvic dysfunctions. Over the last 20 years, an in-depth study of the anatomy of the pelvic floor, and in particular its posterior section, has revealed some peculiarities: firstly, embryologically, the posterior wall of the vagina differs from the anterior wall in thickness, as well as in direction: it is located more vertically and has a greater length compared to the anterior wall. Defects of the rectovaginal fascia can be determined during examination as follows:

1. The absence of transverse striations on the posterior wall of the vagina indicates the dislocation of the underlying fascia from this part of the vagina.

2. Rectal examination: by palpating the anterior surface of the rectum from the posterior fornix to the perineal body, the defect can be easily identified.

The most effective method of treating pelvic prolapse is surgery.

Currently, almost all surgical methods for rectocele correction include levatoroplasty. However, it is the reduction of the abdominal clefts (levatoroplasty) that causes postoperative pain and dyspareunia in half of the cases. In this regard, a search for new effective pathogenetic techniques that will be free from the disadvantages of levatoroplasty suggests itself. At the same time, the technique for reconstructing the posterior section should be aimed at restoring all structures of the posterior section: the sacrouterine ligaments, the rectovaginal septum and the perineal body.

A method for surgical treatment of rectocele is known (RU, patent 2678185, published 23.01.2019), including punctures of the anterior abdominal wall in the paraumbilical region and in the iliac regions, an incision of the parietal peritoneum, introduction of a prolene mesh into the abdominal cavity, peritonization of the implant after fixation with peritoneal sheets, wherein the parietal peritoneum is dissected in the region of the medial inguinal fossa, the pectineal ligament is visualized, the paravesical space is opened in the avascular zone, dissection is performed up to the middle third of the anterolateral wall of the vagina and then a rectangular prolene mesh is fixed to the vagina at the lower level of dissection with absorbable sutures, to the uterus in the area of attachment of the cardinal ligaments and to the pectineal ligament with non-absorbable sutures, peritonization of the mesh is performed after fixation with peritoneal sheets, after which transperineal The access is used to perform microsurgical reconstruction of the rectovaginal fascia, levatoroplasty followed by posterior colporrhaphy.

The disadvantage of this known method is its traumatic nature.

Known (RU, patent 2212860, published 27.09.2003) is a method for treating rectocele and vaginal prolapse by performing a posterior colpotomy, which consists of excising the posterior wall of the vagina in the form of a triangular flap with the apex facing into the depth, isolating the muscles that lift the anus, posterior colporrhaphy and anterior sphincter levatorplasty, and after performing the posterior colpotomy, the sacrouterine ligaments are exposed, a trapezoidal polypropylene artificial surgical mesh is inserted, the size of which is selected individually, with the large base in depth, it is fixed with non-absorbable ligatures to the sacrouterine ligaments at the site of their origin and along the anterior wall of the rectum, on the sides to the muscles that lift the anus, to the anterior semicircle of the sphincter, the mesh is sutured to the mobilized edges the posterior wall of the vagina with single sutures in the longitudinal direction at a distance of 10 mm from each other and at a distance of 6-7 mm from the edge of the mesh, the excess vagina is resected.

The disadvantages of this method include the need for extensive tissue dissection and high trauma, the possibility of damage to nerve endings leading to dysfunction of the pelvic organs, possible disruption of sphincter function, a high risk of mesh-associated complications, as well as dyspareunia due to the levatorplasty performed.

Also known (RU, patent 2603290, published 27.11.2016) is a method for treating rectocele, consisting of performing a posterior colpotomy, excising excess mucous membrane of the posterior vaginal wall, isolating the muscles that lift the anus, and anterior sphincter levator plasty, wherein after performing a posterior colpotomy, isolating the muscles that lift the anus, with provisional sutures applied to them, a speculum is inserted into the wound and the vagina is maximally lifted upward, immersing the cervix into the abdominal cavity, then through two additional incisions on the lateral walls of the vagina in the projection of the cervix, the sacrouterine ligaments are pulled together and sutured with a U-shaped suture, placing the suture submucosally and transposing it to the posterior wall of the cervix, after which the muscles that lift the anus are sutured in the same projection.

Another method for treating rectocele is known (RU, patent 2251985, published 20.05.2005), including suturing defects of the anterior wall of the rectum, the posterior wall of the vagina, the anterior portion of the muscle levating the anus and plastic surgery of the rectovaginal septum, wherein the fascial-muscular graft, including the distal end, with a sheet of the broad fascia of the thigh located above it, is cut out based on the thin muscle of the thigh, the proximal end of the muscle is isolated while leaving the vascular-nerve bundle intact, the muscle is cut off from the pubic bone, then the graft is turned at an angle of 140-150 ° in the frontal plane in the area of the vascular-nerve pedicle and the proximal end is passed through a tunnel between the anterior wall of the rectum and the posterior wall of the vagina, then the muscular part of the graft is fixed to the anterior semicircle of the external sphincter of the rectum, and The fascial part of the transplant is fixed through a laparoscopic approach to the fascial sheath of the rectum above the suture line and in a taut state.

Also known (RU, patent 2196518, published 20.01.2003) is a method for treating rectocele performed in several stages. The first stage is cutting out an autodermal flap from the medial surface of the thigh. The flap is processed according to Yanov V.N. Next, the rectovaginal septum is split, the levator muscles are isolated. The anterior wall of the rectum is corrugated transversely with separate catgut sutures without puncturing the intestinal mucosa. The second row, with vicryl sutures, is used to suture the muscles that lift the anus, having previously been sharply isolated from the surrounding tissues. An autodermal flap of the required size is cut out and its ends are fixed over the vicryl sutures. The levator muscles are placed over the transplant.

The disadvantage of the method is the use of levatorplasty, which increases the risk of chronic pelvic pain and dyspareunia after surgery.

The technical task that the developed method is aimed at solving is to restore the anatomy of the pelvic floor, adequate defecation, improve the quality of life of patients and restore sexual life.

The technical result achieved by implementing the developed method consists in increasing the effectiveness of treatment while simultaneously reducing its trauma.

To achieve the specified technical result, it is proposed to use the developed method for treating high rectocele. According to the developed method for treating high rectocele using the patient’s own tissues, a transverse incision is made along the posterior wall of the vagina 1 cm below the posterior fornix, the areas of rectovaginal fascia detachment from the cervix are identified by blunt dissection, a free flap of the rectovaginal fascia is mobilized, pararectal dissection is performed on both sides in the direction of S2-S4, the sacrouterine ligaments are sutured in their middle third, provisional ligatures are applied to the ligaments via a retroperitoneal approach using 2-0 polyester non-absorbable thread, 1 suture on each side, they are left on “holders” for further use, the edges of the rectovaginal fascia are fixed to the cervical stroma from behind with a continuous suture using a 3-0 non-absorbable monofilament ligature with straightening of the fascia, then with the sutures that were used to suture the sacrouterine ligaments, The cervix is sutured in the center, as well as the rectovaginal fascia with a reverse (immersion) suture bilaterally in such a way that the sacrouterine ligaments in the form of a duplication are fixed to the posterior surface of the cervix and rectovaginal fascia, then the defect of the mucous membrane of the posterior vaginal wall is sutured with absorbable PGA 2-0 thread.

Preferably, the developed method is implemented as follows.

Transverse incision along the posterior vaginal wall 1 cm below the posterior fornix. Detection of the area of rectovaginal fascia detachment from the cervix using blunt dissection, mobilization of the free flap of rectovaginal fascia. Pararectal dissection on both sides in the direction of S2-S4. Detection of the uterosacral ligaments in their middle third, application of provisional ligatures to the ligaments through a retroperitoneal approach using 2-0 polyester non-absorbable suture (1 suture on each side), leaving them on "holders" for further use. Fixation of the edge of the rectovaginal fascia to the stroma of the cervix from behind with a continuous suture using a 3-0 non-absorbable monofilament ligature with straightening of the fascia. Next, the sutures that were used to sew the sacrouterine ligaments are used to sew the cervix in the center and the rectovaginal fascia with a reverse (immersion) suture bilaterally so that the sacrouterine ligaments are fixed in the form of a duplication to the posterior surface of the cervix and the rectovaginal fascia. Suturing the defect of the mucous membrane of the posterior vaginal wall with absorbable thread PGA 2-0.

The method reduces the risk of damage to tissues and organs of the small pelvis during surgery, intraoperative complications, reduces technical difficulties in eliminating anatomical defects of the pelvic floor, and allows achieving good functional and anatomical results. Retroperitoneal suturing of the sacrouterine ligaments allows minimizing the risk of impaired passage of urine through the ureters and damage to the hypogastric nerve. Refusal of a wider dissection of the pelvic muscles with the capture of the "bellies" of the levator muscle allows avoiding pain syndrome and dyspareunia in the future. Refusal to excise the "excess" vaginal mucosa or suturing the rectovaginal fascia allows preserving the length of the vagina.

Below are specific examples of the implementation of the claimed method for treating high rectocele.

1) Patient G., 70 years old

Admitted to the Urology Clinic of the First Moscow State Medical University named after I.M. Sechenov with the diagnosis: urogenital prolapse stage III. according to POP - Q: high rectocele stage III.

Complaints of a sensation of a foreign body in the vagina, difficult defecation

Medical history

Over the past 7 years, she began to notice the above complaints. She was consulted at LDO No. 4 of the UKB No. 2. During the examination, a high rectocele was detected. She was hospitalized on a planned basis for surgical treatment.

Obstetric and gynecological history: pregnancies - 3, births - 2 (term, spontaneous, second pregnancy - multiple). Menopause since 53 years.

Local status. The lumbar region is visually unchanged. The symptom of tapping on the lumbar region is negative on both sides. The kidneys are not palpated. The urinary bladder is not determined by palpation and percussion. The external genitalia are formed correctly. Urination is not frequent, painless, not difficult, urine is visually unchanged.

Vaginal examination: the external genitalia are developed correctly. The anterior vaginal wall is sound, not prolapsed. The cervix is normal. The body of the uterus is tilted forward, not enlarged, mobile, painless upon palpation and displacement. The posterior wall is prolapsed, 1 cm above the hymen (Ap-2; Bp - 1) - high rectocele. The appendages on both sides are not palpated, their area is painless.

Survey data:

PISQ 12: 12 points

PFDI-20: 123 points

PFIQ-7: 118 points

Diagnostic examination data

Ultrasound of the pelvic organs: the uterus, ovaries, and cervix are unremarkable; no free fluid is detected in the pelvis. No volumetric pathology of the pelvis was detected. Ultrasound of the kidneys and bladder: the right kidney is 10.0 x 5.0 cm in size, with clear, even contours, the parenchyma is homogeneous, up to 1.9 cm thick. No dilation of the renal pelvis and calyceal system was detected. Kidney mobility is within normal limits. The left kidney is 10.0 x 5.0 cm in size, with clear, even contours, the parenchyma is homogeneous, up to 1.9 cm thick. No dilation of the renal pelvis and calyceal system was detected. Kidney mobility is within normal limits. The urinary bladder has clear, even contours, and a volume of 230 ml. Wall thickness is 3 mm. Residual urine volume is 18 ml.

In order to correct the prolapse, the patient underwent surgical treatment using our method.

Progress of the operation:

The duration of the operation is 28 minutes.

Blood loss - 20 ml.

The vaginal tampon and urethral catheter were removed on the 1st day after the operation.

Ultrasound: no residual urine. The renal pelvis is not dilated on either side.

The patient was discharged on the 3rd day.

At examination 1 month after surgery:

The patient has no complaints. Vaginal examination reveals normal external genitalia, no prolapse of vaginal walls observed during cough test and straining. The body of the uterus is tilted forward, not enlarged, mobile, painless on palpation. The appendages on both sides are not palpated, their areas are painless. No pain observed on palpation. Ultrasound examination of the pelvis and perineum reveals normal results.

Survey data:

PISQ 12: 32 points

PFDI - 20: 0 points

PFIQ - 7:0 points

Ultrasound: no residual urine. The renal pelvis is not dilated on either side.

At the 6 month follow-up:

The patient has no complaints. The patient has no complaints. Vaginal examination: external genitalia are normal, no prolapse of the vaginal walls is observed during cough test and straining. The body of the uterus is tilted forward, not enlarged, mobile, painless on palpation. The appendages on both sides are not palpated, their areas are painless. No pain is observed during palpation. Ultrasound examination of the pelvis and perineum is normal.

Survey data:

PISQ 12: 33 points

PFDI - 20: 0 points

PFIQ - 7:0 points

At the 1 year follow-up:

The patient has no complaints. The patient has no complaints. Vaginal examination: external genitalia are normal, no prolapse of the vaginal walls is observed during cough test and straining. The body of the uterus is tilted forward, not enlarged, mobile, painless on palpation. The appendages on both sides are not palpated, their areas are painless. No pain is observed during palpation. Ultrasound examination of the pelvis and perineum is normal.

Survey data:

PISQ 12: 34 points

PFDI - 20: 0 points

PFIQ - 7: 0 points

2) Patient F., 60 years old

Admitted to the Urology Clinic of the First Moscow State Medical University named after I.M. Sechenov with the diagnosis: urogenital prolapse stage III. according to POP - Q: high rectocele stage III.

Complaints of a sensation of a foreign body in the vagina, difficult defecation

Medical history

Over the past 6 months, she began to notice the above complaints. She was consulted at LDO No. 4 at Clinical Hospital No. 2. During the examination, a high rectocele was detected. She was hospitalized on a planned basis for surgical treatment.

Obstetric and gynecological history: pregnancies - 4, births - 4 (term, spontaneous, episiotomy, 4 births - surgical). Menopause since 50 years.

Local status. The lumbar region is visually unchanged. The symptom of tapping on the lumbar region is negative on both sides. The kidneys are not palpated. The urinary bladder is not determined by palpation and percussion. The external genitalia are formed correctly. Urination is not frequent, painless, not difficult, urine is visually unchanged.

Vaginal examination: the external genitalia are developed correctly. The anterior vaginal wall is sound, not prolapsed. The cervix is normal. The body of the uterus is tilted forward, not enlarged, mobile, painless on palpation and displacement. The posterior wall is prolapsed, 0.5 cm above the hymen (Ap-2; Bp -0.5) - high rectocele. The appendages on both sides are not palpated, their area is painless.

Survey data:

PISQ 12: does not have a sex life

PFDI - 20: 108 points

PFIQ - 7: 132 points

Diagnostic examination data

Ultrasound of the pelvic organs: the uterus, ovaries, and cervix are unremarkable; no free fluid is detected in the pelvis. No volumetric pathology of the pelvis was detected. Ultrasound of the kidneys and bladder: the right kidney measures 11.0 × 5.0 cm, with clear, even contours, the parenchyma is homogeneous, up to 1.8 cm thick. No dilation of the renal pelvis and calyceal system was detected. Kidney mobility is within normal limits. The left kidney measures 11.0 × 5.0 cm, with clear, even contours, the parenchyma is homogeneous, up to 1.9 cm thick. No dilation of the renal pelvis and calyceal system was detected. Kidney mobility is within normal limits. The urinary bladder has clear, even contours, a volume of 280 ml. Wall thickness is 4.5 mm. Residual urine volume is 10 ml.

In order to correct the prolapse, the patient underwent surgical treatment using our method.

Progress of the operation:

The duration of the operation is 34 minutes.

Blood loss - 55 ml.

The vaginal tampon and urethral catheter were removed on the 1st day after the operation.

Ultrasound: no residual urine. The renal pelvis is not dilated on either side.

The patient was discharged on the 3rd day.

At examination 1 month after surgery:

The patient has no complaints. Vaginal examination reveals normal external genitalia, no prolapse of vaginal walls observed during cough test and straining. The body of the uterus is tilted forward, not enlarged, mobile, painless on palpation. The appendages on both sides are not palpated, their areas are painless. No pain observed on palpation. Ultrasound examination of the pelvis and perineum reveals normal results.

Survey data:

PISQ 12: does not have a sex life

PFDI - 20: 0 points

PFIQ - 7:0 points

Ultrasound: no residual urine. The renal pelvis is not dilated on either side.

At the 6 month follow-up:

The patient has no complaints. The patient has no complaints. Vaginal examination: external genitalia are normal, no prolapse of the vaginal walls is observed during cough test and straining. The body of the uterus is tilted forward, not enlarged, mobile, painless on palpation. The appendages on both sides are not palpated, their areas are painless. No pain is observed during palpation. Ultrasound examination of the pelvis and perineum is normal.

Survey data:

PISQ 12: does not have a sex life

PFDI - 20: 0 points

PFIQ - 7: 0 points

Claims (1)

A method for treating high rectocele using one's own tissues, characterized in that a transverse incision is made along the posterior wall of the vagina 1 cm below the posterior fornix, areas of rectovaginal fascia detachment from the cervix are identified by blunt dissection, a free flap of the rectovaginal fascia is mobilized, pararectal dissection is performed on both sides in the direction of S2-S4, the uterosacral ligaments are sutured in their middle third, provisional ligatures are applied to the ligaments via a retroperitoneal approach using 2-0 polyester non-absorbable thread, 1 suture on each side, they are left on "holders" for further use, the edges of the rectovaginal fascia are fixed to the cervical stroma from behind with a continuous suture using a 3-0 non-absorbable monofilament ligature with straightening of the fascia, then with the sutures that were used to suture the uterosacral ligaments, The cervix is sutured in the center, as well as the rectovaginal fascia bilaterally with a reverse suture so that the sacrouterine ligaments in the form of a duplication are fixed to the posterior surface of the cervix and rectovaginal fascia, then the defect of the mucous membrane of the posterior vaginal wall is sutured with absorbable PGA 2-0 thread.