Surgery to strengthen the pelvic floor muscles. Synthetic materials in pelvic floor surgery

Tuesday, March 12, 2019

Pelvic floor reconstruction with mesh prostheses

One of the most uncomfortable diseases that women suffer from is pelvic organ prolapse. The pelvic organs include the bladder, uterus, vagina, and rectum. They are all supported and held in place by a group of muscles and tissues. When these muscles weaken over time, the pelvic organs can droop or fall out. In such situations, doctors recommend pelvic floor reconstruction.

Symptoms and causes of the disease

Each of the 5 types of pelvic organ prolapse has its own symptoms, but in general the most common ones are:

1. Pressure, pain, or a feeling of fullness in the vagina or rectum, or both;
2. Feeling of "prolapse of internal organs", bulge of the vagina;
3. Fecal incontinence;
4. chronic constipation;
5. back/pelvic pain;
6. Lack of sexual sensations;
7. Urinary incontinence during intercourse.

There are many reasons for the manifestation of such an unpleasant pathology. Factors change with age and it is likely that most women have more than one underlying cause as well as additional factors. The most common causes of prolapse are:

1. Childbirth - complications in the birth of children with large weight, prolonged 2nd stage of labor, nerve damage, multiple births, improper rehabilitation. The impact of a difficult birth may be felt immediately, or it may take many years to show up;
2. Menopause is an age-related effect on pelvic floor muscle tone due to a decrease in estrogen levels; Menopause affects the strength, elasticity and density of muscle tissue;
3. Chronic constipation - irritable bowel syndrome, poor diet or lack of exercise may also be the cause;
4. chronic cough;
5. Intense physical activity - athletes, marathon runners, aerobics - repetitive downward movement of internal structures;
6. Genetics - there may be a predisposition to the disease;
7. Neuromuscular diseases - diabetic neuropathy, collagen deficiency, etc.;
8. Surgical intervention - .

An accurate diagnosis of the disease requires anamnesis, physical and instrumental examination. If you have symptoms of prolapse, you should make an appointment with a doctor who will conduct a thorough diagnosis, on the basis of which he will prescribe certain types of treatment.

Pelvic floor reconstruction

When making a diagnosis of pelvic organ prolapse, after consulting with the patient, he will prescribe one or another type of therapy, which will either involve the use of transplants of synthetic origin, or other options for solving the problem will be offered.

Surgical reconstruction of the pelvic floor using mesh prostheses allows artificial formation of the pelvic fascia instead of the destroyed endopelvic fascia. Thanks to this, a framework for the pelvic organs (bladder, rectum, vaginal walls) is recreated. This type of operation is not only surgically justified and allows you to create neofascia to replace the destroyed ones, but also allows you to restore reliable fixation of the fascia to the pelvic walls. Due to this, there is much less chance in the future to acquire a protrusion of the walls of the vagina of a pathological nature with increased intra-abdominal pressure.

It can be said that the reconstruction of the pelvic floor with mesh prostheses completely solves the problem, moreover, the implants are not felt, and the risk of recurrence is extremely low.

Pelvic floor reconstruction surgery lasts less than an hour and is performed under general anesthesia.

In our clinic, the operation is performed by experienced surgeons, using prolift and eleveit mesh implants. Polypropylene mesh material is absolutely adapted to various types of stress that occur in the body, it is not subject to decomposition and remains stable under the action of tissue enzymes.

The cost of a prolift or eleveit operation in our clinic is average in Moscow, but the quality is extremely high. Our specialists have the necessary skills and abilities to effectively solve this unpleasant problem.

FAQ

Hello, Vaginal prolapse question. I am 45 years old. The omission appeared after the first birth, at the age of 20. At that time, in a women's consultation, during the examination, they told me that everything would pass, do not strain, this is your prolapse of the anterior wall of the vagina. During the whole time it did not cause any disturbance. In the last month or two, from carrying bags with groceries from the store, lifting heavy things in front of me, skiing, I feel an increase in descent. In the absence of stress, the condition improves. Can you help me?

Yes, you can and should help. To date, the problem is effectively solved. However, in order to give effective recommendations and prescribe treatment, I need to examine you. What you can do yourself now is pelvic floor exercises, fight constipation (if any), not carry weights. These measures will not reduce the prolapse, but may partly reduce the rate of its progression.

Hello! I was at the gynecologist's appointment. Conclusion: cervical prolapse 1 tbsp. I am 36 years old, 2 children. Navy - 4 years. The doctor recommends removing the IUD. Is it really necessary? How to treat cervical prolapse?

- If there is no inflammation, then the IUD can stand for five years. Cervical prolapse can only be treated surgically.

Why does pelvic floor muscle weakness occur?

- Childbirth, especially complicated ones, lead to damage (stretching, tears, ruptures) of the pelvic floor muscles. At the same time, with age, the muscles of the pelvis, as well as the muscles of the whole body, weaken. All this together can lead to the emergence of various diseases associated with the prolapse of the pelvic organs, for example: prolapse of the uterus, anterior (cystocele) or posterior (rectocele) walls of the vagina. Another consequence may be stress incontinence.

What causes weakness in the pelvic floor muscles?

- Weakening of the pelvic floor muscles, as well as impaired contractility of these muscles, leads to conditions such as urinary incontinence, prolapse of the anterior and posterior walls of the vagina, prolapse of the uterus. In addition, this condition can cause chronic pelvic pain and tenderness in the vestibule.

Section 4. Operations on the walls of the vagina and pelvic floor

Surgery for the prolapse of the anterior wall of the vagina with the formation of a cystocele

After preparing the surgical field and conducting conduction and infiltration anesthesia with a 0.25% solution of novocaine with adrenaline of the entire Boulevard Ring, the labia minora is fixed to the inner surface of the thighs with interrupted sutures. The cervix is ​​exposed with Simps' speculums, after which a pair of bullet forceps is applied to her front lip. By gently sipping on them, the cervix is ​​brought down as much as possible. The vaginal walls are re-treated with iodonate, after which it is possible to start cutting out a mucosal flap from the anterior wall. The width of the flap is determined by the severity of the pathological process, the age of the patient and the state of her sexual function.

The incision should begin 2 cm from the external opening of the urethra and end 1.5-2 cm from the lower edge of the cervix. It must be remembered that only when cutting tissue with the belly of a scalpel is it possible to control the depth of the cut. It is impossible to make an incision with the tip of the instrument due to the risk of injuring the bladder. With a correctly made incision, the edges of the wound, as a result of contraction of the muscles of the vaginal tube, should diverge by 5-8 mm.

The upper edge of the cut mucosal flap is captured by a pair of Pean's clamps and supported from below by the second finger of the surgeon's left (right) hand. If the incision has reached the submucosal layer, then the separation of the flap is very easy and without significant bleeding. Only occasionally is the cutting of thin connective tissue fibers along the lateral edges of the incision required.

Strengthening the anterior wall of the vagina can be done in two ways:

1. The imposition of individual interrupted sutures of thin catgut or vicryl on the prevesical fascia in the transverse direction.

Rice. 18. Plastic surgery of the anterior wall of the vagina a-cutting and separation of the flap of the vaginal mucosa; b - dissection of connective tissue fibers between the cervix and bladder

In this case, a thin, steeply curved cutting needle should be used. The needle is injected approximately 5 mm from the edge of the vaginal mucosa and is held under the pre-vesical fascia for 4-5 mm, after which it is punctured and similarly done on the other side. It is better if 3-0 or 4-0 metric Vicryl with an atraumatic needle is used for these purposes. To prevent puncture of the bladder wall, we recommend a subfascial injection of 20-30 ml of novocaine solution before suturing. Sutures are placed at intervals of 8-10 mm. You can tie ligatures as you suture. However, we prefer to first put all the seams and only then proceed to tying. In the presence of vicryl a, suturing of the vaginal mucosa can be performed with a continuous suture according to the Riverden method, and if catgut is used for these purposes, interrupted sutures are considered more reliable.

2. In our work, we prefer the dissection of the prevesical fascia, followed by separation of the bladder and its displacement upwards. This makes it possible to create a duplication of the fascial sheet, which more reliably strengthens the anterior wall of the vagina. This is done as follows:

Rice. 19. Surgery for the prolapse of the anterior wall of the vagina and bladder

a - separation and upward displacement of the bladder; b - the imposition of a purse-string suture on the prevesical fascia (according to Martin); c, d. - the imposition of the second row of interrupted sutures on the prevesical fascia

a) 20-30 ml of novocaine is injected under the prevesical fascia, which ensures the removal of the bladder wall in the area of ​​the proposed incision;

b) the prevesical fascia should be dissected with the belly of the scalpel with light pressure on the instrument. An indicator of the correct dissection of the fascia is the appearance of a shiny surface of the bladder and the expiration of the injected novocaine;

c) 2 Pean clamps are placed on the edges of the fascia and handed over to the assistants;

d) with blunt scissors, the ends of which should be turned towards the fascia, the latter is cut off up and down. After that, the back side of the tweezers is inserted under the fascia, over which the fascia is dissected with scissors to the required level;

e) the connective tissue fibers between the fascia and the bladder are cut in a sharp way. The "legs" of the bladder in the lower corner of the wound should be dissected between the clamps and sheathed with catgut. Bleeding vessels are better to be immediately ligated with catgut or sheathed;

f) after crossing the "legs" of the bladder, the latter, as a rule, is easily displaced upwards with the first finger of the right (left) hand of the surgeon, wrapped in gauze. During this stage of the operation, the left hand of the surgeon should hold the cervix by the bullet forceps in the lower position. The finger that moves the bladder upwards should be firmly pressed against the cervix and move upwards with rolling movements. Failure to comply with this recommendation may lead to a violation of the integrity of the bladder wall;

g) after the separation of the bladder, it is fixed in the upper position using a purse-string Vicryl suture. During the application of a purse-string suture, one of the assistants, using a small gauze tupfer, holds the bladder in the upper position, and the surgeon applies stitch sutures from the inside of the prevesical fascia. Ligatures should be tied off immediately;

h) The next stage of the operation is the plasty of the prevesical fascia. It is performed in this way: the first nodal catgut suture is applied to the vaginal mucosa in the upper corner of the wound and tied behind the Kocher clamp, which limits the upper angle of the incision. The instrument is removed, and the ends of the ligatures are taken on the Pean clamp, and lifted up by the assistant. For the first row of sutures on the fascia, we

we use catgut or vicryl in the form of separate interrupted sutures,

which follow with an interval of 6-8 mm. Puncture of the fascia with a needle

Rice. 20. The scheme of suturing according to the method of Riverden

begins on the left side of the incision 3-5 mm from the edge of the vaginal mucosa and is punctured after 3-4 mm. After that, the right edge of the fascia is lifted with tweezers, and it is pierced at the base. Ligatures are immediately tied and cut off.

If Vicryl or Polysorb is used as suture material, then the second row of sutures can be continuous (according to Riverden). Using catgut, we prefer interrupted sutures. They are superimposed as follows: first, the vaginal mucosa is pierced on the left side, after which the thread is transferred to the right side, where the prevesical fascia is initially pierced with a puncture of 3-4 mm from the edge of the vaginal mucosa and only after that the edge of the mucosa. We do not excise excess prevesical fascia, and with the described method of applying the second row of sutures, they are immersed under the mucous membrane of the anterior wall of the vagina. This creates an almost insurmountable obstacle to the descent of the posterior wall of the bladder. The superimposed suture is treated with iodonate, after which, by pressing on the anterior lip of the cervix, it is immersed in the lumen of the vagina. Bladder catheterization, upon completion of the first stage of the operation, is mandatory! This allows you to make sure that there is no damage to it.

Rice. 21. Scheme of strengthening the prevesical fascia

Rice. 22. Scheme of suturing the second floor of the sutures on the anterior wall of the vagina

We believe that the prolapse of the anterior vaginal wall with the formation of a cystocele is possible only in the presence of partial or complete failure of the pelvic floor muscles and surrounding pelvic tissue.

Based on this, surgery without restoring the integrity of the pelvic floor may soon be complicated by a relapse of the disease and the progression of uterine prolapse. This complication can be prevented by obligatory pelvic floor muscle plastic surgery.

This stage of the operation begins with the instruments limiting the area of ​​the mucous membrane of the posterior wall of the vagina and the skin of the perineum to be removed. First, with a long Kocher clamp, the mucous membrane of the posterior wall of the vagina should be superficially captured in the center at a distance of 5-6 cm from the vestibule of the vagina, and then the same clamps should be applied to the skin at the base of the labia majora. After that, the side clamps should be brought together until they touch, which will enable the surgeon to determine the width of the Boulevard Ring with two fingers of the right hand. Don't forget to do this

Rice. Fig. 23. The initial stage of pelvic floor plasty a - dotted lines indicate the incision lines of the posterior wall of the vagina; b - limiting clamps are applied at the base of the labia minora

in women with preserved sexual function. This should not be forgotten in women of older age groups, since the narrowing of the entrance to the vagina can become an insurmountable obstacle to the continuation of sexual activity and even to the breakup of the family. Having carried out this technique and making sure that the flap of the mucous membrane of the posterior wall of the vagina is correctly limited, you can proceed to the hydropreparation of the surgical intervention zone with a 0.25% solution of novocaine (40-60 ml). Additionally, an anesthetic solution should be injected into the levator area on both sides. After a 2-3 minute wait, you can start cutting out a mucosal flap from the posterior vaginal wall. The assistant lifts the Kocher clamp applied to the vaginal wall, which leads to the formation of a pyramidal elevation. The mucosal incision is made with the belly of the scalpel in the direction from the side wall of the vagina to the top of the "pyramid". In this case, the end of the scalpel should be facing the side wall of the vagina. It is impossible to make a cut in the opposite direction, because the cutting part and the tool in g

Rice. 23. (Continued)

c, d. - variants of detachment of the flap of the mucous membrane of the posterior wall of the vagina

that in this embodiment will be the end of the scalpel. In this case, the surgeon loses a sense of the depth of the incision. The second half of the incision is made from the lower end of the first incision towards the Kocher clamp on the labia majora. After that, the assistants spread the clamps on the labia to the sides, and the surgeon dissects the skin of the perineum in the direction from the clamp to the clamp. The incision should have a slight curvature towards the anus. Separation of the mucous membrane of the posterior wall of the vagina can be successful only if the incision has reached the submucosal layer. It can be performed in two ways (Fig. 23.d.).

In the first variant, it can be started from the top of the mucosal flap. To do this, the edges of the mucosa of the removed flap are captured by two Pean forceps and slightly pulled down. In this case, the second finger of the left hand is placed under the clamps and squeezes up the wall of the vagina, which ensures the divergence of the edges of the incision and facilitates the work of the scalpel. Connective tissue fibers are cut along the lateral edges of the incision, and in the center of the flap, the mucosa is displaced by the edge of the scalpel. The tissue fibers stretching at the same time are cut with a scalpel in the direction of the finger. It is necessary to remember the thickness of the vaginal-rectal septum and use the instrument with the utmost care. Bleeding vessels are best ligated immediately by sheathing with thin catgut.

In the second variant, the separation of the flap can be performed with dissecting blunt scissors or a scalpel, starting from the skin incision of the perineum. To do this, the skin is lifted with surgical tweezers and the undercutting of the connective tissue fibers begins in the direction of the mucosal flap. With well-adjusted wound illumination, the border of the vaginal mucosa and the rectal wall is clearly visible. At the time of the extraction of the mucosal flap, assistants must constantly dry the wound from blood with gauze napkins. After the flap is removed, the wound is thoroughly dried, hemostasis is performed, and novocaine is additionally injected into the levator area on both sides.

We do not connect levators without first dissecting the fascia of the perineum. To perform this stage of the operation, it is necessary that the assistant lift the back wall of the vagina by the clamp to the limit. In this case, the border of the rectum is well marked at the side wall of the vagina, where the fascia is punctured with a scalpel. The end of the scalpel should be directed towards the side wall of the pelvis, and the tip of the blade should be pointing up. The immersion depth of the scalpel should not exceed 0.5-0.8 cm. Hemostatic clamps are inserted alternately from both sides into the hole formed and these holes are enlarged by spreading the jaws from top to bottom. Their further expansion, providing good access to the “legs” of the levators, is carried out with the help of the second finger of the right hand by pulling towards the anus.

To strengthen the anterior wall of the rectum, the medial edges of the dissected fascia are sutured together with 3-4 knots.

Rice. 23. (Continued)

e - dissection of the fascia of the perineum; e - the beginning of the connection of the muscles raising the anus; g - sutures on t. levator ani and vaginal mucosa; h - the final stage of the operation on the pelvic floor

catgut or vicryl sutures. After that, you should begin to sew the edges of the mucous membrane of the posterior wall of the vagina. For this, interrupted catgut sutures (through 0.5-0.8 cm) or a continuous suture according to Riverden with one of the absorbable suture materials (vicryl, polysorb) can be used. Due to insufficient reliability, we do not use catgut in a continuous seam. On the border of the upper fold of the dissected fascia, the last interrupted suture should be applied, but the ligature should not be temporarily cut off, but used as a holder. For stitching the “legs” of levators, it is better to use vicryl with a metric “O” or “1” on a strong, medium-sized, sharply curved cutting needle.

To prevent injury to the rectum before piercing the levator, it is advisable to insert the second finger of the left hand into the fascia incision to remove the intestinal wall.

Having flashed the levator, the needle is punctured, the thread is thrown through the rectum and the "leg" of the right levator is stitched in a similar manner. The suture should not be tied immediately, but it is better to take it on a clamp and moderately pull the threads down, which ensures better visibility of the overlying sections of the levators for the subsequent imposition of 2-3 more sutures.

After that, the assistant pulls the middle ligature down, and the surgeon, if the operation is performed under local anesthesia, asks the patient to relax as much as possible and proceeds to tying the ligatures. First, the top is tied, then the bottom, and the middle is tied last. The ends of the league tour are cut off 2-3 mm above the knot. The next step is the stitching of the lateral edges of the dissected fascia of the perineum, which ensures the immersion of the levators under the fascia. Vicryl dip sutures are placed over the fiber. The operation is completed by suturing the vaginal mucosa and perineal skin.

The correct connection of the hymenal fold is important, which ensures the symmetry of the external genital organs. The skin of the perineum is sutured with 2-3 nylon sutures, but a skin vicryl suture can be used inside. The vagina is treated with iodonate and filled for a day with a sterile gauze pad moistened with vaseline oil.

"Manchester" Operation (Donald's Operation)

The indication for its implementation is the omission of the internal genital organs of the II degree with lengthening of the cervix and partial failure of the pelvic floor muscles. It can only be performed in a patient who has completed her reproductive function or is in postmenopause. "Manchester surgery" includes plastic surgery of the walls of the vagina, high amputation of the cervix with transplantation of the vaginal fornix and plastic surgery of the pelvic floor muscles.

The operation can be performed under any type of anesthesia, but we prefer local infiltration and conduction anesthesia with 0.25% solution of novocaine with adrenaline. The latter is added at the rate of 8 drops per 200 ml of novocaine.

This not only prolongs the action of the anesthetic, but also significantly reduces tissue bleeding. The operation, as a rule, is attended by a surgeon, two assistants and an operating sister. During the operation, an intravenous infusion of saline sodium chloride solution is performed. Reliable connection with the vein allows, if necessary, to add intravenous anesthesia (ketamine).

It is performed as follows: the ischial tuberosity is felt and in the middle third between it and the anus an injection needle 6-8 cm long is injected and a "lemon crust" is created. After that, the needle moves in the direction under the ischial tubercle to the ischeorectal fossa to a depth of 4-5 cm. The advancement of the needle should be preceded by a jet of novocaine. Sufficient for anesthesia should be considered the introduction of 40 ml of a 0.25% novocaine solution at each point. Similarly, anesthesia is performed on the other side. The next stage of anesthesia is the infiltration of the labia minora and the clitoral area with novocaine. This is done mainly for a preventive purpose, ensuring the absence of pain in case of an accidental needle prick during the operation. After that, the labia minora is sutured to

Rice. 24. Scheme of pudendal anesthesia

the inner surface of the thighs with interrupted nylon seams. This greatly facilitates the work of assistants. However, when tying these sutures, it is necessary to remember the possibility of their eruption and calculate the tension force of the threads in such a way that damage to the tissue of the labia minora does not occur.

The cervix is ​​exposed by the Simps mirrors, fixed behind the anterior lip with a pair of bullet forceps, and brought down beyond the genital slit. The walls of the vagina are additionally treated with iodonate or chlorhexidine, after which circular infiltration anesthesia is performed at the level of the vaginal vaults. The final stage of anesthesia is the infiltration of the anterior wall of the vagina. The operation can be started after a 2-3 minute wait. It should begin with careful probing of the cervix and uterine cavity with a bellied probe in order to clarify the anatomical relationships.

The front wall of the vagina strictly in the center at a distance of 1.5-2 cm below the external opening of the urethra is captured by the Kocher forceps and slightly pulled up. The end of the scalpel marks a flap of mucous width, which depends on the degree of prolapse of the anterior wall of the vagina, the age of the patient and the state of her sexual function. It is possible to dissect the vaginal mucosa only with the abdomen

scalpel. If the incision is made with the end of the instrument, then control of the depth of the tissue incision is lost, which can lead to damage to the prevesical fascia and even injury to the bladder.

With a correctly made incision, the edges of the mucosa should diverge by 5-8 mm. At the level of the vaginal vaults, the lower ends of the incisions are connected to each other along the posterior wall. In this case, the depth of the transverse incision ranges from 0.8 to 1.0 cm. Often occurring bleeding has to be stopped with chipping sutures from catgut or vicryl.

The apex of the domed flap of the anterior vaginal wall is grasped by a pair of Pean's forceps and protruded with the second finger of the left hand. If the incision is made correctly, then the separation of the flap is very easy and without significant bleeding. Only occasionally do you have to hook the tissue fibers along the side incisions. The next step is the dissection of the prevesical fascia, as described in the previous operation, the bladder is shifted upward and fixed in this position with a purse-string vicryl suture. The first finger of the right hand, wrapped in a gauze napkin, with smooth but strong pressure on the cervix, the vaginal vaults are shifted upwards. If their displacement is difficult, then the incision should be deepened from the side of the posterior fornix of the vagina. After displacement of the vaults to the required distance, it is possible to dissect the prevesical fascia with scissors almost to the cervix along the border of the mucosal incision.

Bleeding, as a rule, does not occur. Clemming and dissection of the cardinal ligaments should be performed symmetrically on both sides. Clamps should be applied parallel to the cervix. After tissue dissection, the stumps of the cardinal ligaments move apart. It is better to dissect the cardinal ligaments in two steps. Their stumps are sheathed with catgut or vicryl, after which they are slightly shifted upwards by gently pressing the gauze pad. After that, the vascular bundles are clamped, dissected on both sides and sheathed with vicryl with a metric of "0".

Plastic surgery of the prevesical fascia and suturing of the vaginal mucosa is performed in the same way; as described in the previous operation. The next stage of the operation is high amputation of the cervix. The surgeon must have a clear idea of ​​​​where the internal cervical os is located, because. its clipping should not be closer than 1.5 cm to it. Initially, the cervical canal is re-probed with a nugged probe, after which it is dilated with Hegar dilators to number 10. The last dilator should not be removed. It is taken in the left hand of the surgeon, along with bullet tongs, and stretched downwards. The cervix is ​​cut off cone-shaped. After opening the anterior wall of the cervical canal, one bullet forceps should be transferred to the severed anterior lip and only then complete the amputation of the neck. Both stumps of the cardinal ligaments are sutured with catgut or vicryl to the anterior wall of the cervix. The final formation of the cervix can be performed according to Sturmdorf or in the modification of L. A. Nemtsova by applying 4 catgut or vicryl sutures (see Fig. 15).

For these purposes, it is better to use a strong cutting needle of medium size and bend.

The first injection is made 2 cm from the edge of the mucous membrane of the anterior vaginal fornix and 0.5 cm from the suture on the anterior wall of the vagina. The needle is passed through the entire thickness of the anterior wall of the cervix with a prick into the cervical canal. After that, the thread is pulled, and the needle is injected into the mucous membrane of the anterior fornix at a distance of 2-3 mm from the edge. Stitch seams (3-4) are directed towards the lateral arch. Then the needle is injected from the side of the cervical canal and punctured onto the cut-off surface 0.5 cm from the edge, after which the edge of the mucosa of the anterior vaginal fornix is ​​lifted with tweezers and the needle is punctured at the site of the first injection. The ends of the threads are taken on the clamp. Three more similar seams are sequentially superimposed, and only after that you can start tying the threads. To do this, the threads of the first suture are taken in hand and, by alternating sipping, contribute to the convergence of the mucosa of the vaginal fornix and the mucosa of the cervical canal. A single overlap of ligatures is made. Alternately, similar actions are performed with the rest of the sutures, and then both pairs of ligatures are connected to each other in the anterior and posterior fornix of the vagina.

The ligatures are cut off, the cervix is ​​immersed in the lumen of the vagina and treated with iodonate. Urine is removed by a catheter.

Plastic surgery of the pelvic floor muscles is performed according to the method described above.

Median colporrhaphy (Neugebauer operation)-Lefora)

This operation can be performed on older women who are not sexually active. Technically, median colporrhaphy does not present great difficulties. In terms of clinical examination, these patients, in addition to the standard laboratory examination, require endometrial aspiration biopsy. And this is especially necessary for patients with a history of postmenopausal bleeding from the vagina.

The operation is performed, as a rule, under local infiltration and conduction anesthesia with a 0.25% novocaine solution. As with all other vaginal surgeries, pain management should begin with a pudendal nerve block. After that, the cervix is ​​exposed by Simps mirrors, fixed with a pair of bullet forceps and, together with the walls of the vagina, is brought out of the genital slit. The walls of the vagina are re-treated with iodonate, after which the anterior and posterior walls are infiltrated with novocaine with adrenaline. In this case, the injection needle with its cut should be directed to the vaginal mucosa, and the depth of injection should not exceed 3 mm. Upon completion of anesthesia on the anterior wall of the vagina, 2 cm below the external opening of the urethra, a transverse incision of the vaginal mucosa 3-4 cm long is made. The second transverse incision is made 2 cm above the external opening of the cervical canal, and its length should not exceed 2 cm. Ends cross sections on both sides are interconnected, forming the figure of an overturned trapezoid. If the cuts are made correctly, then their edges should diverge from each other by 5-8 mm. The lower edge of the upper transverse incision of the vaginal mucosa is captured by a pair of Pean's clamps, pulled downwards on the second finger of the surgeon's left hand placed under the flap. In most cases, the flap is easily displaced downward without significant bleeding. In case of poor separation of the flap, it is necessary to undercut the connective tissue fibers with a scalpel.

Similarly, the flap on the back wall of the vagina is limited. The same size of the flaps is achieved by measuring with a scalpel handle. The symmetry of the wound surfaces facilitates their further stitching. Separation of the posterior flap of the vaginal mucosa is somewhat difficult because its implementation has to be started in an uncomfortable position - from the bottom up. The success of the operation and the smooth course of the postoperative period depend entirely on the thoroughness of hemostasis. Bleeding vessels are best immediately carefully sheathed with thin vicryl (4-0; 5-0). Upon completion of hemostasis, you can start stitching the wound surfaces of the vaginal walls. This stage of the operation should begin with the suturing of vicryl or polysorb (metric 4-5-0) on a thin atraumatic needle. In their absence, a thin catgut on a thin round needle can be used for this, which prevents the formation of cavities for wound secretion and blood.

We must not forget about the proximity of the bladder and rectum, so the connecting sutures should be applied very superficially. The last to be sutured are the upper transverse incisions; tied alternately, but the ligatures are not cut off, but are used as holders for some time. The catheterization of the bladder completes this stage of the operation. Our clinic considers it appropriate to supplement median colporrhaphy with pelvic floor muscle plasty according to the above method. As a result of this operation, two lateral channels about 1.5 cm wide are formed, which fully ensures the outflow of wound secretion. From the second day of the postoperative period, the lateral canals are treated once a day with a 5% solution of potassium permanganate.

Operation of vesico-vaginal interposition of the uterus (according to Alexandrov)

This operation can be performed in women of older reproductive age who have completed the generative function and in the premenopausal period with II degree of prolapse of the internal genital organs (according to M. S. Malinovsky), accompanied by a dysfunction of the bladder (partial urinary incontinence). The operation can be performed under any type of anesthesia, but we prefer endotracheal oxy-oxygen anesthesia. In order to reduce bleeding, the anterior wall of the vagina is infiltrated with an isotonic solution of sodium chloride with adrenaline.

After preparing the surgical field, the vaginal walls and external genitalia are treated with iodonate or an alcohol solution of chlorhexidine bigluconate.

The cervix is ​​exposed by the vaginal mirrors, fixed with a pair of bullet forceps on the anterior lip and gently pulled out of the genital slit. The walls of the vagina are re-treated with disinfectant solutions, after which the anterior wall of the vagina is infiltrated with a saline solution of sodium chloride with adrenaline (40-50 ml).

After that, 2 cm below the external opening of the urethra, the vaginal wall is captured with a Kocher forceps, an oblong-oval mucosal flap with a maximum width of 2.5-3.0 cm is cut out. In this case, the lower end of the incision ends 2 cm from the edge of the cervix. Los-cutmucosa is captured at the upper corner with a Pean clamp and is separated from top to bottom in a sharp way. Under the prevesical fascia, 20-30 ml of saline is injected, after which it is carefully dissected with a sliding movement of the scalpel abdomen. The reference point for a correctly made incision in front of the vesical fascia is the “brilliant” surface of the bladder wall and the outflow of the solution introduced under the fascia. Curved dissecting scissors are inserted into the resulting incision, and by alternately diluting them, the fascia is exfoliated towards the external opening of the urethra. The dissection of the fascia is carried out above the back side of the tweezers inserted under it. Similarly, the fascia is dissected in the lower direction. The edges of the fascia are grasped by two Pean forceps and passed into the hands of the assistants. By cutting the connective tissue fibers with scissors, the fascia is separated from the bladder to the sides. The vesicouterine ligaments are dissected between clamps and ligated with thin catgut or vicryl. The bladder is moved up by rolling movements of the first finger of the surgeon's right hand, wrapped in gauze, until the peritoneum of the vesicouterine fold is exposed. The latter is captured by surgical tweezers, lifted up and dissected with scissors in the transverse direction. The incision is extended in both directions to the rib of the uterus. The next stage of the operation is the removal of the uterus into the wound.

Rice. Fig. 27. Operation of vesico-vaginal interposition of the uterus a - the body of the uterus is brought out through the anterior colpotomy opening; b - the peritoneum of the vesicouterine fold is sutured to the posterior surface of the uterus at the level of the ovarian ligaments; c - the uterus is immersed in the colpotomy opening, and the bladder is at the bottom of the uterus; g. - suturing of the uterus to the anterior wall of the vagina

Through the hole in the peritoneum, the second finger of the surgeon's left hand is inserted into the abdominal cavity. This is done by sliding along the anterior surface of the uterus, which makes it possible to palpate not only the uterus, but also the region of its appendages. After that, the finger moves to the bottom of the uterus. A special hook is held under the finger towards the bottom of the uterus. Its head moves in a horizontal plane.

Having reached the bottom of the uterus, the head of the hook is transferred to a vertical plane and plunged into the myometrium with finger pressure. Before traction of the hook, the cervix is ​​immersed into the depth of the vagina by pressing on the bullet forceps, and the hook removes the body of the uterus into the wound.

If there is no special hook, then the extraction of the uterus can be done by alternately applying bullet forceps to the anterior surface of the uterus. The peritoneum of the vesicouterine fold is sutured to the posterior surface of the uterus at the level of attachment of the proper ovarian ligaments with interrupted vicryl sutures.

This operation in women of older reproductive age should be accompanied by sterilization, which is performed in our clinic by excision of the fallopian tubes. After completing the sterilization, pressing on the front wall of the uterus is immersed in the wound. In this case, the bladder rises to the bottom of the uterus. Lower suturing of the peritoneum to the posterior wall of the uterus in the postoperative period can lead not only to persistent dysuric disorders, but even to malnutrition of the bladder wall. Before plastic surgery of the prevesical fascia, it is necessary to carry out a thorough hemostasis, after which the anterior wall of the uterus must be treated with iodonate or alcohol, which ensures a stronger adhesive process between the uterus and the prevesical fascia.

The anterior wall of the uterus is deeply, but without entering the cavity, stitched with catgut or vicryl, starting from its bottom, after which the ends of the ligatures are passed through the prevesical fascia and are punctured onto the vaginal mucosa 0.5 cm from the edge. In total, 4-6 sutures are applied, but the ligatures of the right and left sides are not tied, but are taken with clamps. Plastic surgery of the prevesical fascia is performed according to the type of duplication. As a result of this, the edges of the vaginal mucosa come together and are sutured with interrupted vicryl sutures. Upon completion of the suturing of the mucosa, one should proceed to alternately tying the sutures through the wall of the uterus. This allows you to firmly fix the uterus to the prevesical fascia. The ends of the ligatures are cut off 3-5 mm above the knot. The suture area is treated with iodonate followed by bladder catheterization. The final stage of this operation in our clinic is the plasty of the pelvic floor muscles.

Operation Dolery - jilliama

This operation is performed in addition to plastic surgery of the walls of the vagina and the pelvic floor in young patients with prolapse of the internal genital organs of the II-III degree. It allows the uterus to maintain some mobility and does not always prevent the development of the onset of pregnancy. In our clinic, uterine ventrosuspension is performed under endotracheal anesthesia in women who have completed their reproductive function, and is accompanied by sterilization. Plastic surgery of the vaginal walls and pelvic floor muscles is performed according to the method adopted in the clinic, after which the patient is transferred on the operating table to the position for abdominal dissection. An inferomedian laparotomy or a Pfannenstiel incision can be used to access the abdominal cavity. If a transverse incision is chosen, then only the skin and subcutaneous fat are dissected. After that, the upper edge of the skin incision is captured with a Kocher forceps and pulled up. The subcutaneous fat is separated with a scalpel from the aponeurosis towards the navel for 7-8 cm.

Bleeding branches of perforating arteries are ligated by sheathing.

The upper edge of the skin is fixed to the anterior abdominal wall with a nylon suture, and the edges of the wound are sheathed with gauze napkins. Further dissection of the abdominal wall is performed, as in the case of median abdominal dissection.

A retractor is inserted into the wound, the intestines are fenced off

Rice. 28. Suspension of the uterus to the anterior abdominal wall by round ligaments of the uterus

a - pulling the loop of the round ligament of the uterus through the peritoneum, muscles and aponeurosis; b - round uterine ligaments are brought out under the aponeurosis; c - the abdominal wall is sutured in layers; round ligaments of the uterus are sewn together and fixed to the aponeurosis

is applied with gauze napkins, after which the surgeon enters the small pelvis with his right hand, grabs and brings the uterus to the wound, examines the condition of its appendages. After that, round ligaments of the uterus are grasped alternately with surgical tweezers at a distance of 4-5 cm from their attachment to the uterus; they rise up and with the help of a needle a strong nylon thread is passed under them, the ends of which are captured by Pean's clamps. The uterus sinks into the abdominal cavity.

The aponeurosis of the rectus abdominis muscles is incised with a scalpel 2 cm from the edge of the incision and 5-6 cm above the pubic symphysis. Using a hemostatic forceps, the rectus abdominis muscles and peritoneum are perforated on both sides. The ends of the ligatures are captured by clamps and through the formed channels are removed above the aponeurosis. The next stage of the operation is the closure of the vesicouterine cavity by applying 2-3 nylon sutures.

This serves to prevent strangulation of intestinal loops after suspension of the uterus. Sterilization is performed by excision of the fallopian tubes. Before the aponeurosis, the abdominal wall is sutured according to the generally accepted method. After that, by pulling on the ligatures-holders, the round ligaments of the uterus are removed from the abdominal cavity and sewn together with nylon sutures. The ligaments are fixed to the aponeurosis with the same sutures (4 sutures on each side). The subcutaneous fat is fixed to the aponeurosis with separate catgut or vicryl sutures. A vicryl suture is most often applied to the skin.

Operation isthmic hysteropexy

This operation can be performed when the internal genital organs are prolapsed in a young woman who is interested in maintaining reproductive function. It is performed in combination with plastic surgery of the vaginal walls and pelvic floor muscles.

The essence of the second stage of the operation is as follows:

1. Inferior transection is performed according to the generally accepted method;

2. The surgeon enters the abdominal cavity with his right hand, grabs the uterus, pulls it up to the surgical wound and fixes it in the bottom area with a strong catgut ligature:

3. directly above the vesicouterine fold of the peritoneum, the isthmus is sutured with a strong nylon ligature, the ends of which are brought to the aponeurosis of the anterior abdominal wall. The second ligature is superimposed 2 cm above the first, and its ends are also displayed on the aponeurosis.

Rice. 29. a - isthmic hysteropexy; b - obliteration of the posterior Douglas pocket with purse-string sutures (from the lower median incision)

In the presence of a deep uterine-rectal recess, it is advisable to combine this operation with the imposition of a series of purse-string sutures made of thin nylon or vicryl. It is better to first put all the seams and only then tie them. In this case, it is necessary to remember the proximity of the rectum and ureters. The needle should pierce only the peritoneum; and its progress is well controlled by sight. After obliteration of the posterior Douglas space, the anterior abdominal wall can be sutured. Before complete closure of the peritoneum, the assistant must insert a finger between the uterus and the anterior abdominal wall, while the surgeon, meanwhile, ties the first ligature on the aponeurosis. This is the prevention of infringement of the intestinal loop.

The second ligature can be tied after complete suturing of the peritoneum and connection of the rectus muscles. The postoperative period is carried out as in any operation on the walls of the vagina and pelvic floor.

Rice. 30. Scheme of isthmic hysteropexy cut by Pfan-Nenstiel in the modification of N. P. Romanovskaya 1 - body of the uterus; 2 - the lower edge of the aponeurosis of the anterior abdominal wall; 3 - sutures in the isthmus of the uterus

Operation of ventricular fixation of the uterus

a) Modified by N. P. Romanovskaya.

The operation is performed under endotracheal anesthesia. It cannot be considered an independent surgical intervention, because. does not eliminate the underlying pathology - failure of the pelvic floor muscles; performed only in patients of older age groups (65 years and older) with preserved sexual function. An indication for its implementation is the omission of the internal genital organs of the II and III degrees (according to M. S. Malinovsky). This operation can be performed in two modifications: according to N. P. Romanovskaya and according to Kocher. Our clinic prefers the first of them. The essence of the modification by N. P. Romanovskaya is as follows: entry into the abdominal cavity is carried out by a cut along the Pfan Nenshtil. The upper edge of the skin is captured by the surgical

Rice. 31. Ventrofixation of the uterus according to N. P. Romanovskaya (cut according to Pfannenstiel)

1 - sutures are passed through the upper edge of the aponeurosis of the anterior abdominal wall and the anterior wall of the uterus; 2 - the upper edge of the aponeurosis of the anterior abdominal wall; 3 - subcutaneous fat of the lower edge of the incision

with tweezers and lift up. The subcutaneous fat is separated from the aponeurosis with a scalpel towards the navel by 7-8 cm. The upper edge of the skin is fixed to the anterior abdominal wall with an interrupted nylon suture. The aponeurosis is dissected in the transverse direction and sharply cut off towards the navel. Bleeding perforating arteries should be ligated immediately by suturing. The muscles in the midline are bred stupidly, the peritoneum is dissected in the longitudinal direction. The surgeon with his right hand enters the cavity of the small pelvis, grabs the uterus and brings it into the wound, after which the appendages and the upper abdominal cavity are carefully examined.

In the absence of pathology, the body of the uterus is sutured with nylon sutures. The sutures should penetrate deeply into the myometrium, but not into the uterine cavity. The first fixation suture is applied in the bottom area, after which each of the threads is passed through the peritoneum, muscles and is punctured 1.5-2 cm apart on the aponeurosis closer to the navel. Subsequent sutures are carried out through the anterior wall of the uterus with an interval of 1.0-1.5 cm and are brought to the aponeurosis at a distance of 2 cm from the first of them (4-5 sutures in total).

Sewing of the peritoneum starts from the upper corner of the incision and after 2-3 continuous sutures the first fixation suture is tied. Before tightening it, the assistant places his finger between the body of the uterus and the peritoneum, which prevents the intestinal loop or omentum from being pinched. The last suture is placed on the peritoneum after the last fixation suture is tied. Unlike the Kocher modification, the uterus remains in the abdominal cavity. Subsequent suturing of the abdominal wall is performed according to the generally accepted method. If the general somatic status allows, then the first stage of this operation is the plastic surgery of the walls of the vagina and the muscles of the pelvic floor. Usually, the total duration of the combined operation does not exceed 1.5 hours and is relatively easily tolerated by most patients. If the somatic condition does not allow performing surgery on the walls of the vagina and pelvic floor at the same time, then we tried to delay the second stage of surgery for 4-6 months, but most patients refused to be rehospitalized and surgically treated.

Kocher modification

Ventrofixation of the uterus according to Kocher is practically not used by anyone. In our country, a modification of the Kocher-Leopold-Czerny operation is more often performed. This operation is performed as an addition to the plasty of the walls of the vagina and the muscles of the pelvic floor from the lower median incision. The surgeon enters the abdominal cavity with his right hand, grabs the uterus and brings it out into the wound. A nylon ligature is applied to the bottom of the uterus - a holder, after which an examination of the uterine appendages and the upper abdominal cavity is carried out.

In the absence of pathology, suturing of the peritoneum begins from the upper corner of the incision. The assistant holds the uterus in a raised state, and the surgeon continues to sew the peritoneum with a continuous catgut suture. The peritoneum is sutured to the uterus at the level of the ovarian ligaments and this suture is completed in the lower corner of the wound. On the other hand, the peritoneum is fixed to the uterus with interrupted catgut sutures. On the aponeurosis overlays -

Rice. 32. Combination of ventricular fixation methods according to Kocher-Leo-pold-Czerny

durable nodal nylon seams are sewn. First, the aponeurosis is stitched on one side, then the body of the uterus without capturing the endometrium and the aponeurosis of the opposite side. In total, 4-5 such sutures are applied. The remaining areas of the aponeurosis can be sutured with interrupted catgut sutures, but we prefer stronger suture materials (vicryl with a metric “O” or capron). An indispensable condition for the second stage of the operation is careful hemostasis.

Operations for excision of the longitudinal and transverse septa of the vagina

The longitudinal septum of the vagina often accompanies the doubling of the uterus. The greatest complications in this pathology can occur during the birth act and especially if the doubled uterus has a common neck or one of them opens into a partially aplastic vagina. The operation is performed under local anesthesia or in combination with ketamine

Rice. 33. Excision of the longitudinal septum of the vagina in case of developmental anomalies

a - view of the vagina before surgery; b - view of the vagina after removal of the septum

you anesthesia. Upon completion of anesthesia, spoon-shaped mirrors are inserted into both vaginas and pulled down. Excision of the septum should begin from the back wall. Two straight strong clamps are applied to the septum at a distance of 0.8-1.0 cm from the vaginal wall. A closer application of the clamps represents a significant dangerous injury to adjacent organs during suturing. Bleeding areas are sheathed with eight-shaped catgut or vicryl sutures with a 3-0 metric. Alternately shifting the clamps and pulling them towards the vestibule of the vagina facilitates the excision of the septum in the depths of the vagina. Similarly, the septum is excised from the anterior wall of the vaginal cavity.

The transverse septum of the vagina is most often located on the border of the lower and middle thirds of the organ. The presence of a septum prevents normal sexual activity and the outflow of menstrual blood. With a complete transverse septum, hematocolpos, hematometra, and even hematosalpinx may occur. Excision of the septum is carried out by a circular incision along its lower edge. Facilitation of the operation can be achieved by preliminary dissection of the septum at 14, 16, 20 and 22 hours (on the dial). As the septum is excised, eight-shaped catgut sutures are applied. A possible complication after this operation may be stenosing scarring. In order to prevent this complication, it is recommended to start a regular sexual life two weeks after the operation.

Extirpation of the uterus by vaginal access

The indication for surgery is the complete prolapse of the internal genital organs in elderly women in the presence of pathology in the uterus (uterine fibroids, recurrent hyperplastic processes in the endometrium).

The operation can be performed under any type of anesthesia (local infiltration and conduction anesthesia, endotracheal oxygen-nitrous anesthesia, epidural anesthesia). The choice of anesthesia method depends not only on the tolerance of painkillers, but also on the patient's consent to one or another method of anesthesia, preoperative preparation is no different from other operations on the walls of the vagina and pelvic floor.

The operation is attended by: a surgeon, two assistants, an operating nurse and an anesthesiological team. A strong connection with one of the peripheral veins is carried out before the start of the operation, and during it, a slow infusion of crystalloid solutions is performed.

After treating the external genitalia and vaginal walls with one of the disinfectant solutions, the surgical field is protected with sterile linen, after which anesthesia can be started. If the patient is operated on under endotracheal anesthesia or epidural anesthesia, then the initial stage of the operation is the fixation of the labia minora to the inner surface of the thighs with interrupted nylon sutures. This greatly facilitates the further work of assistants and reduces trauma to the external genital organs. After applying a pair of bullet forceps to the cervix, the vaginal walls must be treated again with disinfectant solutions. By smooth pulling on the bullet forceps, the vaginal walls are removed outside the genital slit, after which the instrument is transferred to the hands of the assistants, and the surgeon proceeds to infiltrate the vaginal walls with saline sodium chloride solution with the addition of 8 drops of adrenaline for every 200 ml of solution. This is done to reduce tissue bleeding. If the operation is performed under local anesthesia, then adrenaline is added to novocaine not only to reduce bleeding, but also to prolong the action of the anesthetic.

Along with the use of local anesthesia, we often combine it with intravenous ketamine anesthesia.

The initial stage of the operation itself is no different from Donald's operation (Manchester operation). After the bladder is displaced upward, the lower section of the cardinal ligaments is dissected and ligated, the latter are slightly displaced upward by smooth pressure of the gauze tupfer, which makes clamping and dissection of the uterine artery and veins more accessible. In contrast to the Manchester operation, the clamps on the vascular bundles should be applied parallel to the cervix in such a way that their ends slide off its lateral surface. The dissected vessels are ligated with vicryl with a metricity of "O" or "1" or capron. If the operation is performed under infiltration anesthesia, then before dissection of the peritoneum of the vesicouterine fold, it is necessary to anesthetize it with the introduction of 20-40 ml of novocaine. The injection of the needle should be very superficial, and the cut of the needle should be facing the peritoneum. Novocaine is additionally injected along the large vessels and under the bladder. The peritoneum of the vesicouterine fold is then grasped and lifted with surgical forceps. The peritoneum is dissected with scissors in the transverse direction. In this case, the ends of the blunt scissors should be directed to the body of the uterus. The upper edge of the peritoneum is stitched with a capron ligature-holder and lifted up, after which the peritoneum is dissected laterally to the uterine rib. Through the resulting hole, the second finger of the surgeon's left hand is inserted into the abdominal cavity and held to the bottom of the uterus. The uterus can be removed from the abdominal cavity using a special hook or by alternate gripping with bullet forceps, as described in the section “Uterine interposition according to Alexandrov”.

To facilitate the removal of the uterus into the wound, the cervix with bullet forceps applied to it is immersed in the lumen of the vagina. If infiltration anesthesia with novocaine is used, then after removing the uterus into the wound, novocaine must be injected along the wide and round ligaments of the uterus, along the own ligaments of the ovaries and fallopian tubes. Holding the body of the uterus with an instrument, the cervix is ​​again lowered outside the vagina and an anesthetic is injected under the peritoneum of the posterior Douglas space. After that, a thorough palpation of the area of ​​​​the uterine appendages is carried out on both sides. The final step in the removal of the uterus is the clamping, dissection and ligation of the ligamentous apparatus of the organ and the supply vessels. For clamping, it is better to use strong hemostatic clamps. Initially, the terminal is applied from the side of the posterior Douglas space. This is done under the control of the second finger of the surgeon's left hand, inserted into the retrouterine cavity.

The open jaw of the clamp pierces the peritoneum behind the uterine cavity, after which the clamp advances

Fig. 35. Vaginal extirpation of the uterus (according to V. I. Kulakov)

a - posterior colpotomy; b - the uterus is brought out through the anterior thoracic foramen; c - clamping of the own ligament of the ovary, fallopian tube and round ligament of the uterus on the left side; g. - klemirovan formations are dissected. Crossed a large vascular bundle on the left; d - the cresto-uterine ligaments are clamped, the stumps of the ligaments are fixed to the walls of the vagina; e - peritonization with extraperitoneal abandonment of the stumps; g - connection of the mee / sdu with a stump of the cardinal ligaments and sutures on the vaginal mucosa

up and snaps into place at the rib of the uterus. The second clamp is applied towards the first and captures the previously listed ligaments. It is better if the ends of the clamps come one after the other, which ensures reliable clamping of the vessels. At the same time, clamps should be applied on the other side, and only after that proceed with cutting off the uterus. In the process of its removal, do not pull on the applied clamps, because. their slippage can lead to bleeding into the abdominal cavity and the need for abdominoplasty. For ligation of dissected tissues, we prefer to use the method of sheathing tissues with nylon or vicryl with a metric of "0" or "1". It must be remembered that when sheathing the stumps of the ligaments and fallopian tubes, each of them must be picked up by a needle. When tightening the ligatures, the assistants should not sharply open the terminal due to the risk of tissue slipping and subsequent bleeding.

The terminal should open slowly as the ligature is tightened. After tying, the ligatures are not cut off, but are taken on Pean's clamps and fixed to the linen of the surgical field. Small bleeding vessels should be sheathed with thin vicryl or catgut. The course of the postoperative period and the success of the operation as a whole largely depend on the reliability of hemostasis. Peritonization of the abdominal cavity is carried out by applying a purse-string catgut suture. To do this, the assistants pull the ligatures of the stumps of the ligaments down, and the surgeon applies a purse-string suture so that the stumps of the ligaments are outside the abdominal cavity. When applying a peritoneal suture, the surgeon must clearly see the needle under the peritoneum, which is the prevention of injury to adjacent organs and vessels of the ligamentous apparatus. After tying the peritonization suture, the ligatures are not cut off, and their ends are brought out to the mucous membrane of the vagina of the posterior fornix and captured by the Pean forceps. The stumps of the dissected ligamentous apparatus of the right and left sides are sutured together with 2-3 sutures from strong catgut. To do this, the assistants, by sipping on the ends of the ligatures, move the ligaments downward; and the surgeon applies the indicated seams.

After tying the ligatures, their ends are brought out to the vaginal mucosa and taken to the clamps.

The next stage of the operation is the plasty of the prevesical fascia according to the previously described method. The vaginal mucosa can be sutured with interrupted catgut (vicryl) sutures or a continuous Riverden vicryl suture. At the end of the first stage of the operation, the surgeon ties the ligatures that were previously placed on the vaginal mucosa. The threads from the peritoneal suture are tied first, which makes it possible to eliminate the free space between the peritoneum and the stumps of the ligaments. Tying the rest of the ligatures, brought to the vaginal mucosa, leads to the pulling of the vaginal stump to the ligamentous apparatus. The ligatures are cut 3-4 mm above the knot, after which the suture line is processed with a iodon-tome. With smooth pressure of the gauze tupfer, the vaginal stump is immersed in its lumen, and then the bladder is catheterized. Plastic surgery of the pelvic floor muscles is carried out according to the previously described method (see the section "Plastic surgery of the walls of the vagina and muscles of the gas bottom").

Vaginal extirpation of the uterus in combination with median colporrhaphy

In patients of older age groups who are not sexually active and have a history of repeated uterine bleeding in the premenopausal period, we recommend combining transvaginal hysterectomy with subsequent median colporrhaphy. The technique of this operation has some fundamental differences, which are as follows:

1. trapezoidal mucosal flaps are cut out from the anterior wall of the vagina, as in normal median colporrhaphy;

2. prevesical fascia is not dissected;

3. The lower transverse incisions of the mucosa are interconnected by deep circular incisions along the vaginal fornix, after which, by smooth pressure of the gauze tupfer or the first finger of the surgeon's right hand, wrapped in a gauze napkin, the latter are displaced upward to the level of attachment of the peritoneum of the vesicouterine fold.

The peritoneum is cut with scissors in the transverse direction, and its upper edge is stitched with a nylon ligature, the ends of which are fixed with a Pean clamp.

In order to facilitate the removal of the uterus, we recommend the dissection of the cardinal and sacro-uterine ligaments, which ensures the free lowering of the uterus outside the genital gap. After that, the peritoneum of the posterior Douglas space is dissected. This facilitates not only the subsequent clamping of the ligamentous apparatus, but also facilitates palpation of the uterine appendages. It is easier to remove the uterus through an incision in the peritoneum of the vesicouterine cavity. The next stage of removal of the uterus is performed as described in the previous operation. When applying a peritonization suture, the ligamentous apparatus should not be deeply pierced because of the risk of damage to the vessels and the occurrence of a dissecting hematoma. The stumps of the ligaments of the right and left sides are fixed with catgut sutures to the lateral fornix of the vagina, and the ends of the ligatures are brought out to the mucosa of the lateral fornix. After that, the imposition of connecting sutures on the scalped surfaces of the anterior and posterior walls of the vagina begins. Thin catgut or 3-0 metric Vicryl can be used as suture material. Interrupted sutures are alternately applied to the vaginal mucosa. Upon completion of suturing, two lateral canals remain, passable only for a thin tupfer. Plastic surgery of the pelvic floor muscles is the last and final stage of this operation in all patients.

Elimination of cervical or vaginal stump prolapse after previous radical operations on the pelvic organs

Prolapse of the cervical or vaginal stump after previous radical operations on the pelvic organs is not uncommon, and the treatment of this pathology presents significant difficulties and is performed only surgically. The cause of the pathology is not only the dissection of the ligamentous apparatus of the uterus during a radical operation, but also connective tissue dysplasia, congenital pathology of the pelvic floor muscles and birth injuries.

Plastic surgery of the walls of the vagina and the muscles of the pelvic floor does not guarantee against the onset of relapse. Most often, such a complication occurs within the first year after radical surgery.

In the gynecological clinic of the Russian State Medical University. acad. IP Pavlova, in order to correct this pathology, two methods are used. They combine the plasticity of the walls of the vagina and the muscles of the pelvic floor in our modification, followed by fixation of the stump by abdominal access. The operation is performed under general anesthesia.

A). Suspension of the stump of the cervix or vagina to the aponeurotic-muscular flap. This stage of the operation is performed after plastic surgery on the walls of the vagina and pelvic floor. The skin and subcutaneous fat is dissected along the scar after the previous operation. With a lower median scar, the latter is excised to the aponeurosis, and after that, the fatty tissue with a scalpel is separated from the aponeurosis by 2-

3 cm to the sides of the midline. The assistant spreads the edges of the wound with Farabef's hooks, and the surgeon, meanwhile, cuts out a dome-shaped aponeurotic-muscular flap, facing the apex towards the navel. The length of the flap should be at least 8 cm with a width of 2 cm. The top of the cut flap is captured by the Kocher forceps and pulled towards the pubic symphysis. The aponeurosis of the white line of the abdomen with a thin layer of rectus and pyramidal muscles is cut with a scalpel. The bleeding vessels of the muscles are immediately sheathed with a thin catgut. The selected flap is wrapped in a gauze napkin soaked in physiological sodium chloride solution, and placed on the enclosing linen at the pubic joint. Further entry into the abdominal cavity is carried out as standard. The wound is covered with wet gauze pads.

With the instrument inserted into the vagina at the end of the first stage of the operation, the stump is fed up and forward, stitched along the back wall with a strong nylon ligature.

The peritoneum covering the stump is carefully dissected in the transverse direction by 4-5 cm. The bladder is separated with dissecting scissors and shifted down. After that, the peritoneum is separated towards the sacro-uterine ligaments and also shifted down. The stumps of the round ligaments of the uterus are determined and taken on ligatures-holders. After that, the selected aponeurotic-muscular flap is lowered into the abdominal cavity, its end is immersed in the peritoneal "pocket" between the sacro-uterine ligaments (in the presence of a cervical stump) and sutured with prolene or nylon sutures. Additionally, this flap is sutured to the anterior wall of the stump, after which 3-4 interrupted nylon sutures are applied to the sacro-uterine ligaments, and the stumps of the round ligaments of the uterus are sutured to the stump of the cervix or vagina.

The anterior abdominal wall is sutured according to the generally accepted technique. The domed shape of the aponeurotic-muscular flap facilitates the suturing of the aponeurosis at the final stage of the operation. If there is a difficulty in tightening the edges of the aponeurosis, longitudinal notches of 1-1.5 cm can be applied to the latter at a distance of 2 cm from the edge of the aponeurosis.

According to the described technique, 29 patients were operated on in our clinic with a favorable outcome. The follow-up period ranged from 3 to 10 years. A recurrence of the disease was noted in one patient due to complete lysis of the aponeurotic-muscular flap due to impaired blood supply. Another 4 patients had di.zu-

Rice. 37. Scheme of fixation of the stump of the cervix on the aponeurotic-muscular flap

1 - aponeurotic-muscular flap; 2 - pubic articulation; 3-bladder; 4 - stump of the cervix; 5 - vagina; 6 - rectum

richeskie phenomena (frequent urination and a feeling of incomplete emptying of the bladder). During the control catheterization of the bladder, residual urine was not detected. In all likelihood, these phenomena were due to a decrease in the capacity of the bladder due to its compression by the aponeurotic-muscular flap. Sexual function was preserved in all patients.

b). Fixation of the stump of the cervix (vagina) to the promontorium using a polypropylene mesh.

The operation is performed under endotracheal anesthesia. The first step is plastic surgery of the vaginal walls and pelvic floor muscles according to the method adopted in the clinic, after which the patient is transferred to the operating table in the position for abdominal dissection. Entry into the abdominal cavity is carried out by

Rice. 38. Scheme of fixing the stump of the cervix (or vagina) to the promontorium using a polypropylene mesh 1 - promontorium; 2 - polypropylene mesh; 3 - cervical stump; 4 - bladder; 5 - pubic articulation; 6 - vagina; 7 - rectum

Xia with excision of the scar after a previous operation. After the revision of the upper abdominal cavity, the stump of the cervix (vagina) is lifted up with an instrument inserted into the vagina at the end of the first stage of the operation, stitched with a strong nylon ligature and pulled up to the wound of the abdominal wall. The peritoneum covering the stump is dissected with scissors between the sacro-uterine ligaments in the transverse direction. With the help of blunt scissors, it exfoliates from the posterior surface of the cervix or vagina by 2-2.5 cm. After that, by pulling on the ligature-holder, the stump is shifted towards the left wall of the pelvis. To the right of the rectum in the promontorium zone, 30-50 ml of a 0.25% novocaine solution or saline sodium chloride solution is injected under the peritoneum. In this place, the peritoneum captures

Xia surgical tweezers, rises up and dissected with scissors parallel to the rectum. The incision is extended towards the stump, its length is 6-7 cm. The subperitoneal tissue in the area of ​​the promontorium is displaced with a gauze tupfer, after which it is necessary to palpate the area of ​​fixation of the polypropylene mesh to exclude the presence of large vessels there. A polypropylene mesh 8 cm long and 1.0-1.5 cm wide is first immersed in the formed "pocket" between the sacro-uterine ligaments and fixed there with prolene sutures (4-5).

The second end of the mesh is sutured to the transverse ligament of the sacrum also with prolene sutures. For these purposes, it is better to use a medium-sized, strong, sharply curved cutting needle. A total of 4 stitches are applied. Excessive mesh tension should not be achieved. The free end of the mesh is immersed between the sheets of the dissected peritoneum and covered with interrupted catgut sutures.

As in the first version of the operation, the round ligaments of the uterus are fixed to the stump, and the sacro-uterine ligaments are sutured together. The recto-uterine recess is sutured with 2-3 purse-string sutures made of vicryl or capron. The abdominal wall is sutured in layers according to the generally accepted technique.

Surgery for rectocele and complete failure of the pelvic floor muscles

The appearance of a rectocele and the rapid progression of the process, as a rule, is due to the complete failure of the pelvic floor muscles after a perineal injury during childbirth. In some observations, the rectocele can reach large sizes with complete prolapse of the posterior vaginal wall, while the cystocele is absent or there is a slight prolapse of the anterior vaginal wall. These patients have impaired bowel function due to the involvement of the rectum in the pathological process.

Surgical correction of this pathology presents great difficulties due to the sharp thinning of the rectovaginal septum and the danger of injuring the rectum during the separation of the vaginal mucosal flap. If the rectocele is combined with the prolapse of the posterior wall of the bladder, then this pathology should first be eliminated and only then work on the posterior wall of the vagina should be started.

In persons with preserved sexual function, an additional difficulty is the correct determination of the area of ​​the removed mucosal flap.

The traditional instrumental restriction of the flap with a large rectocele does not make it possible to clearly determine the width of the vaginal tube after suturing. In our clinic, this operation is performed in the following sequence. After preparing the surgical field, a pair of bullet forceps is applied to the cervix. With gentle pressure, the cervix, and then the back wall of the vagina, is immersed in the depths of the small pelvis. After that, Kocher clamps are applied closer to the base on the skin of the labia majora. The subsequent convergence of these clamps between themselves allows you to determine the width of the vestibule of the vagina, for which two fingers of the surgeon must be inserted into the vulvar ring. The clamp should not be applied to the back wall of the vagina, because. it is all clearly visible with a slight pull on the bullet tongs and lifting them up. Unlike the classic variant of the plasty of the posterior wall of the vagina, the mucosal incision is made not triangular, but domed, and it should begin 2 cm from the external os of the cervix.

In this case, the lateral branches of the incisions should have an arcuate shape with a bulge to the sides and end at the clamps on the labia majora. The width of the cut out flap depends on the size of the rectocele. Separation of the mucosal flap is performed in a sharp way under the control of the fingers of the left hand, placed under the exfoliated mucosa. Separation should always start from the top. Bleeding vessels should be immediately sheathed with thin catgut or vicryl. The skin of the perineum is dissected with an arc-shaped incision, facing the bulge towards the anus. To do this, the assistants stretch the Kocher clamps to the sides, which makes it possible to perform a symmetrical incision. After removal of the mucosal flap

Rice. 39. Scheme of the incision of the posterior wall of the vagina with a "giant" rectocele

1 - clitoris; 2 - urethra; 3 - cervix; 4 - posterior commissure; 5 - anus; 6-cut line of the vaginal mucosa; 7 - a thick line indicates a rectocele

Rice. 40. Scheme of suturing the mucous membrane of the vagina with a "giant" rectocele

1 - clitoris; 2 - urethra; 3

Cervix; 4 - scalped surface of the posterior wall of the vagina with sutures; 5

anus

the fascia of the perineum is dissected. To do this, it is better to use a spear-shaped scalpel, the end of which should be directed towards the pelvic wall. A hemostatic clamp is inserted into the resulting hole, and its branches are bred in a vertical plane. At the completion phase of this action, the first phalanx of the second finger of the surgeon's right hand is inserted into the hole and the dissection of the fascia is completed by gentle pressure towards the anus. This creates favorable conditions for free access to the "legs" of the muscles that lift the anus.

The medial edges of the dissected fascia are sutured over the rectum with interrupted catgut or vicryl sutures. With a sharp thinning of the fascia of the perineum, a prolene mesh can be used as a plastic material. When suturing the fascia, it is also necessary to lift the intestinal wall, as shown in the figure. To do this, it is better to use a standard atraumatic needle of medium size.

The vaginal mucosa should be sutured with interrupted vicryl sutures, starting from the cervix, and be sure to carefully pick up the intestinal wall in 2-3 places in such a way that a bulge is turned downwards. The imposition of each subsequent suture allows you to remove the protruding wall of the rectum. The connection of the edges of the domed incision makes it possible to create a semblance of the posterior fornix of the vagina. The connection of longitudinal incisions of the vaginal wall should also be accompanied by superficial stitching of the rectal wall. First, the vaginal mucosa is pierced on the left side, then the intestinal wall and the right wall.

The sutures are tied at the same time, which makes it possible to remove the protruding wall of the rectum with each subsequent suture. The distance between the stitches should not exceed 0.8 cm. Three vicryl sutures with a metric of "1" are usually applied to the "legs" of levators. Tying ligatures should not be very tight, which can lead to malnutrition of tissues and eruption of sutures. The ligatures are tied in the following sequence: the assistant lifts the middle ligature and keeps it in tension, and the surgeon first ties the top seam, then the bottom one, and the middle one is tied last. Above the connected muscles, the lateral edges of the perineal fascia are sutured with interrupted vicryl sutures, and only after that the suturing of the vaginal mucosa and fiber is completed. 3-4 nylon sutures are applied to the skin of the perineum, and a gauze swab is inserted into the vagina for a day. In obtaining favorable long-term results, an important role belongs not only to high-quality surgical intervention, but also to careful care in the postoperative period.

Levatoroplasty- an operation performed on the muscles of the pelvic floor (circular muscles of the anus, vaginal ring). The main function of these muscles is to maintain the pelvic organs in the correct position.

When the muscles of the pelvic floor are weakened, such unpleasant problems arise as the prolapse of the uterus and bladder, dysfunction of urination and defecation, gaping of the vaginal lumen, which leads to constant inflammation. The pelvic floor muscles play an important role in labor and are responsible for a woman's sex life.

Causes of muscle weakness

• Overweight, obesity.
• Traumatic childbirth with lacerations of the perineum and vagina.
• Sports loads that can indirectly lead to weakening of the pelvic floor muscles.
• Frequent constipation.
• Connective tissue dysplasia.

Treating weakened pelvic floor muscles

The pelvic floor muscles need to be strengthened. As a rule, preventive correction of the condition of the pelvic floor muscles includes the use of special exercises (Kegel exercises), vaginal balls, and exercises on special simulators. In case of severe weakening of the pelvic floor muscles, as well as in case of ineffectiveness of conservative methods, surgical correction of the weakening of the pelvic floor muscles is performed.

Levatoroplasty

Levatoroplasty- a surgical operation designed to correct the position of weakened pelvic floor muscles - is used in the following cases:

• Rectocele (prolapse of the mucous membrane of the anterior wall of the rectum into the lumen of the anal canal).
• Vaginal prolapse.
• Discomfort in the perineum with or without defecation.

In some cases, levatoroplasty can be performed without these indications, at the request of a woman who seeks to narrow the entrance to the vagina and improve her sex life, however, initially, experts recommend, due to their high efficiency, still try conservative methods for correcting the function of the pelvic floor muscles, and then , with their inefficiency, resort to surgical intervention.

Levatoroplasty at GUTA CLINIC

Levatoroplasty at GUTA CLINIC is performed in a specialized gynecological hospital equipped with the latest medical, diagnostic and operating equipment from leading manufacturers (USA, UK, Italy, France, Germany, Japan, etc.).

Levatoroplasty is performed under general anesthesia or epidural (spinal) anesthesia (the latter is the most preferable, because the relaxation of the muscles of the perineum is achieved). In levatoroplasty with perineal access, the rectovaginal septum is dissected, the anterior portions of the pubococcygeal muscle are isolated, they are stitched over the rectal wall, thorough hemostasis is performed, followed by suturing of the perineal wound in the transverse direction.

With levatoroplasty by vaginal access (otherwise the operation is called "posterior colporrhaphy" and it almost always accompanies levatoroplasty), an incision is created along the posterior wall of the vagina, a triangular flap is excised, then the edges of the incision are sutured. Fixed sutures are placed in the vagina, which gradually dissolve on their own.

Perineal sutures are removed on the 5th day after the operation, within 2 weeks the patient is recommended to refrain from sitting. Pregnancy planning should be carried out no earlier than a year later. Levatoroplasty is not a contraindication for independent childbirth, however, the obstetrician-gynecologist should be informed about the operation performed by the patient, because. during childbirth, ruptures of the vagina or perineum along the scar are not excluded.

In the postoperative period, the patient is given recommendations for conservative correction of the state of the pelvic floor muscles (Kegel exercises, etc.), and rehabilitation measures are prescribed.

Levatoroplasty Currently, it is the operation of choice for surgical correction of the function of the pelvic floor muscles. However, in the postpartum period, if levatoroplasty was performed at the request of the patient before delivery, the effect may be lost, especially without appropriate conservative treatment.

Complicated childbirth, overweight, heavy physical activities, age-related changes can cause pelvic floor muscle failure in women. Such a pathology occurs when the pelvic floor muscles cannot hold the pelvic organs in a physiological position. Omission of organs entails unpleasant consequences: pain, chronic inflammation of the genitourinary system, disorders of urination and defecation. The operation to strengthen the pelvic floor muscles in women allows you to restore their functions, eliminate symptoms and return the internal organs to their normal position.

Benefits of operative pelvic floor muscle strengthening in women

Degrees of failure of the muscles of the pelvic floor

Reconstructive surgery of the pelvic floor muscles is indicated in the case when conservative correction methods have exhausted themselves without bringing the desired effect. As a rule, when lowering the pelvic organs of 3 and 4 degrees of severity, the operation becomes the only way to return them to the correct, physiological position. During the operation, the integrity of the ligaments and muscles is restored using the patient's tissues and/or mesh graft.

Advantages of the surgical method of treatment: high efficiency even in relation to severe pathology, minimal risk of recurrence.

Indications and contraindications for surgery

Indications for pelvic floor plasty in women are:

• tears and other injuries of the perineum,
• omission and prolapse of the uterus or dome of the vagina,
• urinary incontinence,
• rectocele (prolapse of the rectal mucosa).

In some cases, an operation to restore the muscles of the pelvic floor is performed if a woman wants to restore the lost sensitivity of the walls of the vagina.

Contraindications to the operation are:

• acute infectious diseases,
• chronic diseases in the acute stage,
• lung failure,
• cardiovascular pathologies in the stage of decompensation,
• varicose veins of the lower extremities in the acute stage,
• blood diseases associated with a violation of its coagulability,
• the presence of malignant neoplasms in the patient.

Relative contraindications include some chronic diseases, such as diabetes mellitus. In this case, the decision to operate is made on an individual basis.

Types of surgical reconstruction of the pelvic floor muscles

For the reconstruction of the pelvic muscles in women, the methods of levatoroplasty and colpoperineoplasty are used.

Levatoroplasty

Levatoroplasty - strengthening the muscular base of the pelvic floor

The operation is aimed at strengthening the muscular base of the pelvic floor. It is carried out with the prolapse and prolapse of the pelvic organs through the vaginal ring. It is performed under general anesthesia or with the use of epidural anesthesia.

Operation progress:

• dissect the vaginal-rectal septum;
• allocate the anterior bundles of the paired pubic-coccygeal muscle;
• the edges of the bundles are sutured over the wall of the rectum;
• after careful hemostasis, the edges of the wound are sutured.

Postoperative sutures are removed on the fifth day after levatoroplasty, the patient cannot sit for two weeks. Pregnancy during the first year is undesirable.

Colpoperineoplasty

Indications for colpoperineoplasty are prolapse of the dome of the vagina, uterus, bladder and associated urinary incontinence. Like levatoroplasty, the operation is performed under general anesthesia or with the use of epidural anesthesia.

The course of the procedure:

• conduct a longitudinal incision of the rectovaginal septum;
• a diamond-shaped flap is cut out from the mucous membrane of the posterior wall of the vagina and the skin of the perineum;
• the edges of the incision are connected at an obtuse angle in the posterior third of the perineum above the anus;
• in case of prolapse of the rectum, isolated suturing of the muscles that lift the anus is also performed.

The first 7-8 days after surgery, patients are shown bed rest. In the absence of complications, discharge from the hospital occurs on the 10-12th day.

Preparing for the operation

Before surgery, patients need to undergo a complete examination in order to identify diseases that can cause postoperative complications. An electrocardiogram is mandatory. Laboratory blood and urine tests are also needed.

A prerequisite is the absence of inflammatory processes in the vagina. If colpitis is detected, mandatory antimicrobial therapy is performed before surgery.

Before the procedure, the intestines are cleaned, a urinal catheter is inserted into the ureter, and compression stockings are put on the patient's legs.

Features of the postoperative period

The rehabilitation period after surgical restoration of the pelvic floor muscles usually takes 2-3 weeks. During this period, it is recommended to observe the following rules:

• avoid excessive loads, do not lift heavy objects;
• do not ride a bike;
• refuse to visit the sauna, bath, solarium;
• refuse to take baths in favor of the shower;
• daily treat the vagina with an antiseptic solution;
• do not sit down for the first 10-14 days;
• within one and a half to two months it is necessary to refrain from sexual activity.

Laser correction of the pelvic floor muscles

Laser vaginal rejuvenation is indicated for mild pathology

An alternative to surgery is laser correction of the pelvic floor muscles. The procedure is indicated for mild pathologies, stress urinary incontinence and decreased vaginal sensitivity.

As a rule, 2 treatments are needed, spaced 1 month apart, but in some cases up to 4 treatments may be required. The use of a high-frequency laser allows:

• reduce the connective tissues of the vagina, creating a stronger support for the uterus when it is lowered;
• stimulate the production of collagen, which is responsible for the firmness and elasticity of tissues;
• accelerate the formation of new capillaries, improve blood circulation and blood supply to the vaginal mucosa.

Contraindications for surgery:

• the presence of inflammatory processes in the vagina, urinary tract, pelvic organs;
• pregnancy;
• malignant neoplasms;
• blood diseases associated with impaired coagulation function.

• abstain from sexual intercourse for a month;
• within two weeks, change your diet in such a way as to avoid constipation;
• within a month, do not visit the pool, solarium, bath, sauna, do not take a bath;
• do not insert tampons and suppositories into the vagina for 3-4 weeks;
• avoid heavy physical exertion and heavy lifting for one and a half months.

Operative and non-surgical plasty of the pelvic floor muscles in women allows restoring reproductive health and improving the quality of life, including in the intimate area.

Moscow Regional Research Institute of Obstetrics and Gynecology
Director - Corresponding Member RAMN, prof. IN AND. Krasnopolsky

Thanks to the scientific research of Frencis C. Usher in the middle of the last century, the history of surgery has taken a step from various biological materials used in tissue replacement to synthetic ones. This was facilitated by the extensive experience gained in the use of the wide fascia of the thigh, plantar tendon, periosteum, dura mater, etc. as a plastic material. In his work, Usher (1959) presented data on the use of high-density polyethylene in the closure of defects in the chest and abdominal walls.

Since 1959, several dozen polypropylenes have been synthesized for these purposes, collectively called MESH. Later, thanks to the work of Lichtenstein (1989), tension-free laparoscopic MESH hernioplasty became the operation of choice in the surgical treatment of inguinal hernias.

Today, synthetic materials are also widely used in operative gynecology, especially in pelvic floor surgery. It is known that the basis of prolapse and prolapse of the internal genital organs (OiVVPO) in women is a defect in the connective tissue, leading to failure of the ligamentous apparatus of the uterus and vaginal walls. Using only one's own tissues to reposition uterine position abnormalities increases the risk of recurrence. So, after anterior colporrhaphy, the recurrence rate reaches 24-31%, after posterior colporrhaphy - 25-35%. After vaginal hysterectomy for prolapse, recurrence in the form of vaginal dome prolapse is observed with a frequency of up to 43%.

To systematize the information about the difference between synthetic materials used today in pelvic floor surgery, the following is the MESH classification (the accepted abbreviation for synthetic mesh), proposed in 1997 by Amid P.K.

: synthetic mesh contains only macropores larger than 75 µ (GyneMesh soft, Marlex, Prolene). The mesh cell size is optimal for infiltration by macrophages, fibroblasts, germination by blood vessels and collagen fibers, while being permeable to bacteria. The use of a monofilament thread significantly reduces the wick properties of the prosthesis and, accordingly, the risk of infectious complications (photo 1).

: synthetic mesh contains micropores less than 10 µ (Gore-Tex). Such a prosthesis is impenetrable both for macrophages and fibroblasts, and for bacteria, which slows down the formation of its own collagen, increases the risk of developing infectious complications (Photo 2).

: synthetic mesh of multifilament thread with macro- or micropores (Mersutures, Micromesh, Parietex, Surgipro, Teflon). The main disadvantage of such prostheses is the high wicking ability of the material, which significantly increases the risk of developing infectious complications (Photo 3).

: synthetic network with submicron pore size (less than 1 µ). These materials (Silastic, Cellguard) are used with the first type of materials to replace the peritoneum when the mesh is implanted into the abdominal cavity.

Modern MESH must meet the following requirements:

• resistant to infection (monofilament materials)
• the ability to germinate with surrounding tissues (pore size more than 75 µ)
• histologically inert (quality and minimal amount of material limit fibrosis)
• maintain softness and elasticity (positively affects the quality of sexual life)
• should not shrink during the healing process (shrinkage can be minimized by reducing the inflammatory response when using an inert macroporous material).

It is also necessary to know about some technical parameters of modern mesh prostheses.

Of great importance are also elasticity, transparency, resistance to mechanical stress, biological compatibility, ease of use of the material and its cost.

An important condition for the use of synthetic mesh prostheses in pelvic floor surgery is the need not only to provide mechanical support, but also to "adjust" to the work of the pelvic organs, providing good functional results, namely, the storage and evacuation functions of the rectum, bladder and urethra, sexual function.

Studies have shown that polypropylene MESH from a monofilament thread, produced under the brand name Prolene?, has the best properties. Since 2004, GyneMESH soft has been widely used in pelvic floor surgery - a specially woven polypropylene with maximum elasticity, easily adapts to the surface to be coated.

Now, after receiving information about modern MESH, it becomes clear the reasons for using synthetic material as an alternative to plastics with their own fabrics. The following are the necessary information about the size of the prosthesis used, as well as the principles of pelvic floor surgery using synthetic materials.

Initially, the size of the MESH corresponded to the size of the fascia defect. However, experience has shown that the small size of the MESH led to its displacement, as well as the formation of lateral defects.

Today it is generally accepted that the size of the prosthesis should exceed the size of the fascia defect by 2-4 cm. This allows you to securely fix it, prevent displacement, use the universal technique of the operation, regardless of the location of the defect (central or lateral).

It became possible to fix a larger MESH not to the edges of the fascia defect, but to the bone structures of the pelvis or to use large tissue arrays, the preserved ligamentous apparatus of the small pelvis (obturator window, sacrospinal ligaments).

The basic principles of pelvic floor surgery using synthetic prostheses should be further noted.

1. The prosthesis should be located under the fascia of the anterior or posterior walls of the vagina, which significantly reduces the risk of mucosal erosion.
2. When placing MESH on the surface of a fascia defect, the mesh should overlap the defect by more than 2 cm and be placed without any tension. This casts doubt on the need to excise excess vaginal mucosa, since after this tension is inevitably created, which increases the risk of erosion.
3. The use of antibiotics and drainage remain controversial.

MONIIAG has accumulated extensive experience in the use of MESH for the surgical correction of OiVVPO. It should be emphasized that the use of synthetic materials made it possible not only to adapt the well-known abdominal surgery to the conditions of laparoscopy (Ls), but also to use vaginal or combined (vaginolaparoscopic) approaches more widely. Today, original methods of synthetic loop urethropexy (TVT/TVT obt), vaginopexy using transvaginal MESH (TVM) have also been developed and applied.

The technique of laparoscopic MESH vaginopexy to the aponeurosis of the external oblique abdominal muscle consists in retroperitoneal insertion of a 15X300 mm Prolene flap fixed to the vaginal dome or sacro-uterine ligaments (in case of preservation of the uterus). Next, the flap is fixed to the anterior abdominal wall in a state of moderate tension, which creates reliable support for the pelvic floor.

Vaginopexy with a prolene tape was used in 18 patients during abdominal surgery, when there were unfavorable conditions for performing aponeurotic vaginopexy, among which it is necessary to highlight a history of abdominal surgery (lower median laparotomy, Pfannenstiel incision). The aponeurotic flap was replaced with a prolene one, and then the operation proceeded normally.

This type of fixation of the dome of the vagina to the aponeurosis has its drawbacks, namely, the non-physiological displacement of the vaginal tube from the front, which in some cases caused the development of dyspareunia.

Photo 4. Transobturator route of insertion of the prosthesis in the plastic of the anterior wall of the vagina and a set of tools for the prosthesis (PROLIFT).

MONIIAG has developed a method of sacrovaginopexy with a combined (vaginolaparoscopic) approach, which achieves a more physiological displacement of the vagina. At the vaginal stage, the prolene flap is fixed to the rectovaginal septum, retroperitoneally carried out to the sacrum under the control of the laparoscope, and fixed to the transverse presacral ligament.

It is well known that the prolapse and prolapse of the uterus is accompanied by the formation of cysto- and / or rectocele, often combined with functional disorders of the lower urinary tract and rectum. Surgical treatment of genital prolapse involves the correction of the position of the walls of the vagina. The methods of cystocele plasty proposed earlier involve suturing the defect of the urogenital diaphragm using one's own tissues. Often this procedure is accompanied by excessive tension, which inevitably leads to a relapse. With the use of Gyne-MESH soft, it became possible to eliminate the defect without tension, which is consistent with the principles of plastic surgery.

Pre-cut spindle-shaped prosthesis is placed in paravesical tissues, replacing the defect f. antevesicale. In 2002, B. Jacquetin and M. Cosson proposed a transobturator way of inserting an original form prosthesis using special perforators (photo 4).

Photo 5. A set of tools for conducting TVT has been developed.

In 1995, U. Ulmsten proposed the TVT operation, a new treatment for stress urinary incontinence using a tension-free prolene loop passed retropubically under the urethra. The author has developed a set of tools that greatly simplifies the intervention (photo 5). A prolene tape placed in a polyethylene cover with the help of special perforators is carried out retropubically from the side of the vagina under the urethra, after positioning the tape, the protective cover is removed, the free sections of the prosthesis are cut off and immersed under the skin, the wounds of the vagina and skin are sutured.

Since 2002, the TVT obt method has been widely used. - transobturator access to urethropexy with a synthetic loop. Having results similar to TVT, the operation is distinguished by a minimal risk of intraoperative complications: bladder perforation, infectious and hemorrhagic complications.

Synthetic materials have ushered in a new era in OIVVPO surgery. However, with the accumulation of experience in their use, specific complications began to occur. These include infiltrates, rejection reaction, erosion, ligature fistulas. According to Slack (2002), the complication rate for MESH from 1955 to 1997 was amounted to 5-30%. The frequency and nature of complications was largely determined by the choice of synthetic material.

For 704 operations using MESH Prolene, performed since 1994 at MORIAH (all types of surgical correction of genital prolapse and/or urinary incontinence using synthetic materials from polypropylene are included), 9 specific complications were noted.

These are two cases of vaginal erosion after TVT surgery, erosion of the vaginal wall after cysto/rectocele plasty using Gyne-MESH - in 5 patients, bladder erosion after TVT - in two patients.

Only in two cases of erosion of the vaginal wall after plasty of a cystocele with a MESH prosthesis, the latter was removed. In three patients, the synthetic mesh was re-immersed under the vaginal mucosa with satisfactory long-term results. The reason for the formation of erosion was the excessive tension of the tissues after excision of a part of the mucous wall of the vagina.

Patient A., 38 years old, was operated on in 2001 for stress urinary incontinence, a typical TVT operation was performed, in which no damage to the bladder wall was detected during the control cystoscopy. The course of the postoperative period is smooth, noted the retention of urine. After 6 months, she noted leakage of urine from the vagina, not associated with physical exertion. A vesico-vaginal microfistula was found. Cystoscopy revealed a fragment of TVT in the lumen of the bladder. Transvaginally part of the tape is excised with suturing of the fistula. The outcome of the reoperation is favorable, urine is retained.

In another case, erosion of the anterior vaginal wall was noted 1 month after cystocele plasty using GyneMESH. After the application of secondary sutures, the wound healed.

In conclusion, it should be noted that the use of synthetic materials in the treatment of prolapse and prolapse of the internal genital organs made it possible to change the principles of pelvic floor surgery, the main of which can be considered the absence of tension in the compared tissues.

Modern GyneMESH soft prostheses have all the necessary physical (elasticity, transparency, strength and ease of use) and biological properties (reactivity, biological comparability, bacterial permeability).

ABSTRACT

The article presents the results of treatment of 704 patients operated on for prolapse and prolapse of the internal genital organs, stress urinary incontinence using various synthetic materials. Modern polypropylene GyneMESH soft has the best properties, among which the most important are elasticity, transparency, strength, ease of use, as well as unreactivity, biological comparability, bacterial permeability.