Vaginal hysterectomy - indications and consequences. Vaginal hysterectomy Contraindications for surgery

This operation is very good in cases where complete removal of the uterus is indicated due to its benign pathology or cancer in situ of the cervix. The technique described here is very simple and easy, so the operation takes little time. The operation consists of four main stages: 1) opening the anterior and posterior pouches of Douglas to expose the broad ligaments; 2) sequential clamping of the broad ligament from the uterosacral and cardinal ligaments to the fallopian tube, the ovarian ligament and the round ligament; 3) suspending the vaginal stump by suturing the uterosacral and cardinal ligaments to it; 4) creating a duplication of the uterosacral ligaments in the midline to close the pouch of Douglas and eliminate the possibility of developing enterocele. It is better to suspend the vaginal stump directly during the operation, rather than as a separate step at the end. When performing this manipulation, 4 types of sutures are applied: 1) initial suture on the uterosacral and cardinal ligaments; 2) a purse-string peritonic suture, which complements the sutures on the uterosacral, cardinal ligaments and vaginal stump; 3) an entwining suture along the edge of the vaginal stump; 4) sutures that complete the operation, connecting the sacrouterine ligaments across the midline.

The purpose of the operation is to remove the uterus through the vagina.

Physiological consequences. Removal of the uterus leads to the cessation of menstruation and the onset of sterility. At the same time, all existing pathological changes in the uterus are eliminated.

Warning. Care should be taken to open the anterior pouch of Douglas to avoid injury to the bladder.

After opening the anterior and posterior pouches of Douglas, the broad ligaments should be securely clipped to reduce bleeding.

Before applying a blanket suture to the edge of the vagina, the stumps of the broad ligament should be retroperitoneized.

The vagina should not be completely sutured. A continuous enveloping suture should be placed on its edges with a synthetic absorbable thread 0 and the vagina should be left open for the free outflow of secretions.

METHOD:

The patient lies supine in the stone cutting position, moving forward as much as possible so that her buttocks protrude over the edge of the table. Appropriate general anesthesia is administered. Before the operation, a thorough bimanual examination is performed. The vulva and vagina are prepared for surgery. A wide posterior speculum is inserted into the vagina to expose the cervix. For a better view, you can use retractors that retract the front and side walls of the vagina. The cervix is ​​grabbed by the anterior and posterior lips with two forceps and brought down to the entrance to the vagina.

To reduce bleeding, 10 ml of Pitressin solution is injected into the area of ​​the transitional fold (10 IU of Pitressin is diluted in 25 ml of isotonic sodium chloride solution). This method should not be used in patients with hypertension or cardiac arrhythmia, but in healthy premenopausal patients it can be very effective.

After injection of Pitressin, the mucous membrane is cut with a scalpel around the entire cervix. The depth of the incision should be such as not to touch the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly.

The cervix is ​​pulled down with forceps, and the bladder is separated from the anterior surface of the lower uterine segment with the handle of a scalpel.

Using a finger, the bladder is separated completely to the very peritoneum of the uterovesical space. Often this stage of the operation is not performed completely enough for fear of injury to the bladder. If the tissues are not separated all the way to the peritoneum, opening the anterior pouch of Douglas is difficult.

A retractor is inserted under the vaginal mucosa and bladder, with which the bladder is retracted back and up. In this case, it is easier to find the uterovesical fold of the peritoneum. It appears as a white stripe across the lower segment. The cervix is ​​strongly pulled downwards, the fold of the peritoneum is grabbed with a thin clamp and cut with sharp curved scissors.

If you lift the fold of the peritoneum using thin clamps, a hole is formed leading into the abdominal cavity. You should insert a finger into this hole and examine the opened area to: 1) make sure that this is really the abdominal cavity and not the bladder, and 2) perhaps detect some pathological changes that were not found during the examination before surgery. A retractor is inserted into this hole below the finger.

The cervix is ​​now retracted to the symphysis pubis, opening the posterior pouch of Douglas. The peritoneum of this space is stretched using thin clamps and then opened with curved scissors.

A finger is inserted into the resulting hole and a study similar to the previous one is carried out. After opening the posterior pouch of Douglas, approximately 75-100 ml of peritoneal fluid may be released. A second retractor is inserted into this space.

The wide vaginal speculum is removed. Using two retractors, the broad ligament (from the sacrouterine ligament to the ovarian and round ligaments and the fallopian tube) is widely exposed. Using a finger inserted into the posterior pouch of Douglas, the site of attachment of the uterosacral ligament to the lower uterine segment is found.

The cervix is ​​retracted forward and to the side, and a curved clamp is inserted into the posterior pouch of Douglas and the uterosacral ligament is compressed. The clamp must be applied in close proximity to the cervix so that some of the cervical tissue is also caught in the clamp. This is done to prevent possible injury to the ureters when the clamp is applied too laterally.

The uterosacral ligament is divided with curved scissors.

A fixing ligature suture is applied to the ligament stump using a synthetic absorbable thread 0. This is the first of 4 types of sutures used to suspend the vaginal stump. In Fig. And it is shown that the first injection is performed at the end of the clamp and the thread is passed through the thickness of the uterosacral ligament and the edge of the vaginal mucosa. In Fig. B shows that the second injection is made under a clamp at the level of the middle of the ligament and the thread passes through the vaginal mucosa and the thickness of the ligament. In this case, the ligament stump is connected to the vaginal stump, promoting better hemostasis and performing a suspensory function.

The ends of the ligature are held on a clamp and pulled tight. This suture not only ligates the stump, but also fixes the pedicle of the ligament to the vaginal stump.

While maintaining traction on the cervix, the cardinal ligaments are clamped and divided in close proximity to the lower uterine segment.

The stumps of the cardinal ligaments are ligated with a synthetic absorbable thread 0. Here, a fixing ligature suture is not used for fear of causing the development of a hematoma in this abundantly supplied area. Before ligating the broad ligament upward, ligation of the uterosacral and cardinal ligaments is performed on the opposite side.

After clipping, dissection and ligation of the uterosacral and cardinal ligaments on both sides, a portion of the broad ligament remains, attaching to the lower uterine segment and bearing the lower uterine artery. A clamp is placed on it near the cervix. When applying one clamp, the risk of damage to the ureter is less than when applying two, since the second, lateral, clamp may touch the ureter.

The uterosacral and cardinal ligaments and uterine arteries on both sides are grasped with clamps, cut and ligated. The cervix is ​​pulled forward and upward along the midline. The posterior wall of the uterus is grasped with long-toothed forceps (as for the thyroid gland) and the fundus of the uterus is gradually, without much effort, removed.

The forceps are held on the cervix and wall of the uterus with one hand, and a finger of the other hand is inserted under the bundle of round and ovarian ligaments and the fallopian tube to the previously ligated lower portion of the broad ligament.

Two large curved clamps are applied to the bundle consisting of the fallopian tube, round and ovarian ligaments; the bundle is crossed near the fundus of the uterus.

The resulting stump is ligated twice. In Fig. And it is shown that the first ligature is a simple tying of the stump with a synthetic absorbable thread 0. The ligature is applied immediately behind the second clamp, which is removed before tying; The ligature is located on the clamped area. The remaining first clamp, at the moment of tying the ligature, is opened for a short time and then closed again, which makes it possible to tightly tie all the structures included in this stump.

In Fig. B shows the application of a second fixing ligature with suturing of the stump in its middle part. In Fig. C shows that the ligature is tied on both sides of the stump until the remaining clamp is removed. In Fig. D the stump is completely ligated and the ends of the second ligature are clamped.

The anterior and posterior retractors are removed, and a wide posterior speculum is inserted into the vagina. The anterior wall of the vagina is lifted with a short retractor; in this case, the edges of the vaginal stump are better visible. At the same time, the entire ligated broad ligament becomes visible - from the stump of the fallopian tube, round and ovarian ligaments in front, to the stump of the uterosacral ligament in the back. A gauze swab is inserted into the abdominal cavity, which is used to divert the ovaries, fallopian tubes and intestines, which improves visibility of the structures of the broad ligament. The stumps of all the above structures are examined again to assess hemostasis. If a bleeding stump or part of it is detected, a hemostatic clamp is applied to the bleeding site, and then a ligature suture is applied. It is better if this suture captures the tissue at the end of the clamp and the edge of the vaginal mucosa. If the bleeding area is large enough, the entire stump of the broad ligament can be sutured with a running suture of synthetic absorbable suture 0, simultaneously connecting it to the edge of the vaginal mucosa. The hemostatic suture must be applied with caution, not deeper than the primary sutures, so as not to damage the ureter.

The edge of the peritoneum covering the bladder is found by grasping the anterior vaginal wall with a clamp and gradually pulling the bladder wall down into the vagina.

Peritonization of the pelvis by applying a circular purse-string suture is the second step in suspending the vaginal stump. The suture begins at the anterior edge of the peritoneum and the stump of the fallopian tube, round and ovarian ligaments. After suturing this stump to the edge of the vagina, the stay suture on it can be cut off. The suture is then continued down to the stumps of the cardinal and uterosacral ligaments, which are connected to the edge of the vagina to provide additional support. Next, the seam passes to the peritoneum of the posterior pouch of Douglas, which is sutured with one or two stitches. Now the suture goes to the opposite side, and the thread is passed from the inner surface of the stump of the uterosacral ligament to the outside through the vaginal mucosa. The stay sutures on the stumps of the uterosacral ligaments are not cut, as they will be needed in the future. The suture continues to be applied upward, capturing the stump of the fallopian tube, round and ovarian ligaments. The seam-stay on it is cut off. The last turns of the suture are placed on the edge of the peritoneum covering the bladder. After tightening the purse-string suture, the entire small pelvis turns out to be peritonized, and the stumps of the broad ligament are retroperitoneized.

The lumen of the vaginal stump is left open to drain secretions and prevent postoperative abscess formation in the pelvis. Closing the edge of the vaginal stump, a continuous wrapping suture with a synthetic absorbable thread 0 begins to be applied from the position corresponding to 12 o'clock, and continues along the edge of the vagina to the stumps of the uterosacral and cardinal ligaments, which are once again stitched and fixed to the vaginal stump (this is the third stage of hanging the stump) . The same actions are performed on the opposite side. Next, the suture is continued upward, to the point where it begins, completing the closure of the edge of the stump. Two stitches on the stumps of the uterosacral ligaments are tied together, thereby closing the posterior pouch of Douglas and reducing the likelihood of enterocele.

Upon completion of the operation, the upper parts of the vagina should be examined to assess hemostasis. We prefer to catheterize the bladder at the end of the operation rather than at the beginning, since a full bladder is easier to see and less likely to be injured. The catheter should not be left in the bladder, nor should any tampons be inserted into the vagina. Antibiotic therapy must be started before surgery.

Women who have been diagnosed with a condition that requires removal of the uterus and appendages feel like their world is collapsing. Depression sets in and fears appear. How will life change? What will happen to the appearance? How will the operation affect your sex life? Let's try to understand this situation.

What is hysterectomy

In gynecology, such surgical intervention is prescribed to save a woman’s life when serious diagnoses are made. Before making a decision, doctors weigh the pros and cons. Hysterectomy with appendages is an operation to remove the uterus along with the cervix, fallopian tubes and ovaries. After it, a hormonal imbalance occurs, the woman is deprived of childbearing function. She receives psychological trauma, which she cannot always cope with.

Indications for removal of the uterus and appendages

Gynecologists, when prescribing an operation, pay close attention to the woman. Removal of the uterus after 50 years, from a psychological point of view, is less traumatic. The woman is past childbearing age. Until menopause has occurred, they try not to remove the ovaries. Operation is necessary when its cost is life. The indications are:

  • prolonged uterine bleeding;
  • cancer of the female genital organs;
  • endometriosis;
  • large uterine fibroids;
  • uterine injuries;
  • prolapse, loss of genitalia;
  • active growth of fibroids during menopause.

Preparing for uterine amputation surgery

It all starts with collecting tests and examinations. When planning to remove the ovaries and uterus, they do:

  • general tests;
  • checking blood for the presence of venous diseases;
  • colonoscopy – examination of the cervix and vaginal walls for the presence of tumors and cysts;
  • biopsy and smear taken;
  • cytological and biopsy examination of tissues;
  • examinations to rule out inflammation in the body.

After it becomes clear that the woman is ready for extirpation of the uterus and appendages, the following procedures are performed:

  • prepare donor blood;
  • give an enema to cleanse the intestines;
  • install a catheter to remove urine;
  • consult a vascular surgeon;
  • if there is a likelihood of blood clots forming in the veins of the lower extremities, apply a tight bandage with an elastic bandage;
  • give medications.

How is hysterectomy performed and how long does it last?

Surgery is performed using full anesthesia. The process is complex and takes several hours to complete. Depending on the volume of intervention, they differ:

  • extirpation - removal of the uterus and cervix;
  • supravaginal amputation of the uterus - removal without the cervix;
  • panhysterectomy – removal of the uterus and appendages;
  • extended operation of extirpation of the uterus with appendages - lymph nodes and pelvic tissue are additionally removed.

Depending on the complexity of the situation and diagnosis, the operation is performed in various ways. There are different types of surgical intervention:

  • Laparoscopic extirpation. It is performed for small fibroids. Removal of the uterus using the laparoscopic method is carried out using special equipment. Several holes are made in the abdominal wall through which instruments are inserted. Laparoscopy allows for quick recovery after surgery.
  • Vaginal hysterectomy is performed externally, through the vagina.
  • Laparotomy - abdominal surgery - is performed in difficult cases. The cause may be a large fibroid or a cancerous tumor. It is indicated in situations where it is necessary to remove not only the uterus, adnexal organs, but also lymph nodes. The operation is performed through an incision in the anterior abdominal wall. This gives you a complete overview of the organs. This is important for cancer symptoms to find out the area affected. Look at the photo to see how the female reproductive organs are located.

Consequences

The operation of removing the uterus leads to hormonal imbalance in the body. Young women are especially sensitive to it, because menopause occurs abruptly.

The post-castration period is characterized by symptoms:

  • change of mood;
  • increased fatigue;
  • chronic fatigue syndrome;
  • tides;
  • anxiety;
  • suspiciousness;
  • depression.

After extirpation of the uterus, menstruation ceases and reproductive function is excluded. For young women this is a huge psychological problem; they begin to feel inferior. There is a decrease in sexual desire, pain appears during sex. In the absence of psychological support, serious problems in relationships are possible. After operations related to cancerous lesions, disability is not excluded.

The operation is very serious, so complications are likely to occur in the post-hysterectomy period. Problems with blood vessels arise - blood clots may form. In addition, there may be:

  • bleeding;
  • suppuration;
  • peritonitis;
  • formation of hematomas;
  • adhesions after surgery;
  • sepsis;
  • injuries to neighboring organs during surgery.

Life after hysterectomy

To prevent a woman from feeling depressed, she needs the support of loved ones. Sometimes you need to see a psychologist. It is important to remember that life does not end after amputation of the uterus. The recovery period will pass, it is necessary to undergo periodic examinations by a gynecologist. To eliminate problems associated with menopause, he will prescribe hormone replacement therapy (HRT). These may be new generation products - a gel or patch containing estradiol. The cost of the drugs is reasonable.

Postoperative period

It is very important to begin treatment immediately after surgery. Prescribe pain relief, use of vaginal suppositories, infusion therapy - droppers with special solutions. In addition, there are recommendations:

  • start early activation;
  • treat seams daily;
  • be sure to wear a bandage;
  • perform physical therapy exercises.

Discharge

Often after surgery, discharge is observed for several weeks. These phenomena are not dangerous and are considered normal. Inflammatory processes may be occurring. You should consult a doctor if the discharge:

  • with pus, have an unpleasant odor;
  • profuse, as with menstruation, bright red in color;
  • bloody, with clots;
  • Brown color.

What can you eat after surgery?

Immediately after surgery, a diet is prescribed that starts bowel function. After the operation, hormonal levels change, and women begin to gain excess weight. You need to watch your diet:

  • eat more fruits and vegetables;
  • main meal before lunch;
  • exclude flour and sweets;
  • spend fasting days;
  • drink more water.

Rehabilitation

To recover faster after surgery, you should take a number of measures. You need to rest more and not overload yourself with work. Long sleep and walks in the air are encouraged. In addition, rehabilitation includes:

  • physiotherapy;
  • psychological recovery;
  • therapeutic exercises;
  • prevention of inflammatory processes.

Sex

An important issue remains sexual life after removal of the uterus. It is recommended to stop it after surgery for 8 weeks. After this period, sex depends on your partner's attentive attitude towards you. Some problems are possible:

  • decreased sex drive;
  • pain during intercourse;
  • difficulty relaxing;
  • depression;
  • lack of orgasm;
  • hyperexcitability.

Climax

Hysterectomy surgery has less discomfort if it occurs at the time of menopause. A woman already knows what menopause is and how to survive it. It’s worse for young people, because very drastic changes occur in the body. Sudden menopause causes:

  • tides;
  • emotional instability;
  • osteoporosis;
  • depression;
  • disruption of the heart and blood vessels.

Radiation after hysterectomy

In order to prevent further formation of cancer cells, radiation therapy is prescribed after cancer surgery. It is combined with droppers - exposure of cells to chemicals. Irradiation can be internal or external. In the first case, a catheter with a radiation source is inserted. External – carried out from the outside, through healthy tissue. The procedures have unpleasant side effects - nausea, vomiting, hair loss.

Initial stages operations of vaginal hysterectomy without appendages exactly the same as during supracervical amputation: a tongue-shaped incision in the anterior vaginal wall, separation of the flap (consisting of the vaginal wall and bladder) from the cervix, detection and dissection of the vesicouterine fold of the peritoneum. You can also use a technique consisting of a circular intersection of the vaginal vaults around the circumference of the cervix. This makes it easier to subsequently cut off the uterus from the posterior vaginal wall and intersect the peritoneum of the rectouterine cavity.

Free edge of the vesicouterine fold of the peritoneum catgut ligatures are connected to the edge of the vaginal wound and marked with an instrument.

If the uterus turns out to be large and it cannot be removed through the colpotomy opening, then the uterus can be cut in half along the midline from the external cervical os to the fundus, first along the anterior and then along the posterior surface and extract each half separately (except for cases of tumor lesion, when this technique is contraindicated ,.

After removal of the uterine body, the assistant, using hooks or a ligature, vigorously retracts the uterus to the left side, and then the upper part of the right broad ligament becomes visible. Clamps are applied to the initial sections of the round, proper ovarian ligament and tube, and between them the indicated formations are intersected and tied with catgut.

To avoid when dressing the ligature slips It is recommended to thread at least one of the listed formations.
The left side is processed similarly.

Pulling the uterus to one side, and severed appendages for ligature to the other and slightly moving the appendages into the depths of the pelvis, they release the tissue of the lateral surfaces of the uterus, in which the uterine artery passes. Clamps are applied to the uterine artery perpendicular to the uterus, then the vessels are divided and ligated with catgut. Vessels on the other side are similarly intersected and ligated.

Having produced simultaneous pulling of the body and neck towards themselves and somewhat to the side, the uterosacral ligaments are exposed and made accessible for inspection, which are compressed, intersected and ligated with catgut. The uterus now appears connected only with the peritoneum of the rectouterine space and the vaginal vaults. The lateral fornix, peritoneum and posterior vaginal fornix are intersected. As these formations are crossed, clamps are applied, with which the edges of the wound are pulled towards the entrance to the vagina.

After removal of the uterus, the rectouterine peritoneum connected to the edge of the posterior vaginal vault with several sutures. Then the stumps of the appendages are fixed extraperitoneally, connecting on each side with each other: the edge of the vagina in front, the edge of the vesicouterine fold, the peritoneum covering the stumps of the appendages above the ligatures, the peritoneum of the rectal-uterine space and the edge of the posterior wall of the vagina.

Vaginal hysterectomy without appendages

Thanks to this technique, the wound narrows, and the stumps of the appendages appear to lie extraperitoneally and are securely connected to the vaginal wall. The abdominal cavity is then closed by joining the edges of the peritoneum.

To prevent possible formation of hernial protrusion in the area of ​​the rectal-uterine space, over the sutured peritoneum, the stumps of the uterosacral ligaments and, if possible, cardinal ligaments are sutured together, which will then serve as a support for the pelvic organs. The last stage: the vaginal wound is closed with a continuous catgut suture.

Vaginal extirpation of the uterus with appendages

Operation of vaginal extirpation of the uterus with appendages is carried out according to the same plan as hysterectomy without appendages until the uterus is removed into the vagina. From this stage, the uterus is sharply lowered and at the same time taken somewhat to the side. The ovary and tube are grabbed with soft clamps, and after they are removed into the wound, the suspensory ligament becomes visible, on which two clamps are applied; between them the ligament is crossed and ligated with catgut. After this, the round uterine ligament is clamped, cut and ligated. Otherwise, the operation continues as described above.

A vaginal hysterectomy is a surgical procedure that sometimes involves the ovaries and tubes. Recently, this operation has been used very often, but some doctors are still against it. Their opinion is based on the fact that if a woman’s life is not in danger, then a hysterectomy is unnecessary. Another group of doctors assures that upon reaching a certain age, the uterus ceases to be a useful and necessary organ, but only becomes a source for the spread of infections.

Vaginal hysterectomy of the uterus is the so-called golden mean among all other types of this surgical intervention. During the operation, an incision is made in the upper part of the vagina, through which the uterus is removed. As a rule, it is performed only on women who have given birth. Mainly due to the fact that their vagina is already dilated and the removal of the uterus will be easier.

Vaginal hysterectomy. Indications for use

pros

  • After this operation, there are no scars left on the patient’s body.
  • Blood loss is minimal.
  • There is a rapid recovery of physical condition.
  • Low number of complications and minimal number of deaths.

Contraindications

  • Inflammatory diseases of any organ throughout the body system.
  • Large size of the uterus.
  • A history of cesarean section and subsequent adhesions.
  • A disease that requires examination of the organs of the entire abdominal cavity.

But, despite the fact that vaginal hysterectomy has so many positive aspects compared to other types of hysterectomy, only a third of the operations are performed using this method.

Vaginal hysterectomy is performed only if all the necessary conditions are present, namely: absence of cancer, size, and flexible vaginal walls.

Vaginal hysterectomy. Consequences

  • Postoperative fever.
  • Bleeding.
  • Peritonitis.
  • Development of purulent processes in hematomas.
  • Vaginal prolapse.
  • Formation of adhesions.
  • Backache.
  • Urinary incontinence.
  • Possible appearance
  • Infection on the wound surface.
  • Thromboembolism.
  • Bowel prolapse through the vagina.
  • Nausea.
  • Development of osteoporosis.
  • Libido disturbance.
  • Joint pain.
  • Declining ovarian function.

After the operation, the woman must visit the doctor for an examination for several weeks. As a rule, recovery of the body occurs after 1.5-2 months.

Most doctors recommend performing it only after the onset of menopause, since if it is performed at an earlier time, serious complications may arise. In addition to mental disorders that women experience even before menopause, they experience a loss of desire for sex. Many people fear that a vaginal hysterectomy will make them sexually unattractive.

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