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Optimization of surgical correction of genital prolapse with subsequent tubal sterilization
8. Simbirtsev AS Cytokines - a new system of regulation of defense reactions.//Cytokines and inflam-mation. - 2002. -№ 1. - P. 9-1
Nasimova Nigina Rustamovna, assistant Samarkand State Medical Institute E-ma: [email protected]
Optimization of surgical correction of genital prolapse with subsequent tubal sterilization
Abstract: Currently, pelvic organ prolapse is the most common pathology among women of reproductive age. For these patients it is relevant not only the correction of pelvic organ prolapse but also the search for the most effective contraceptive methods. Treatment of prolapse with simultaneous contraception for these patients is an actual problem of modern gynecology. This paper proposes a method of transvaginal voluntary surgical contraception, produced in conjunction with surgery descent and prolapse of the vaginal walls. We studied the nearest and long-term results of surgery in women during the surgical treatment of genital prolapse at the same time was performed transvaginal tubal ligation.
Keywords: Transvaginal voluntary surgical contraception, descent and prolapse of internal genital organs.
One of the urgent problems of modern gynecology is genital prolapse in women of reproductive age. This is due to the fact that descent and prolapse of internal genital organs remains in the spotlight of gynecologists, not only because of the tendency to increase the frequency and severity of this disease, but also the fact that intervention for prolapse in the structure of gynecological operations in frequency rank third place, but also by the tendency to increase the frequency of this pathology.
In the structure of gynecological morbidity the descent and prolapse of internal genital organs makes 1,7-28% [1; 8]. Despite the improving the quality of obstetric care, approximately 50% of all women giving birth in term observed genital prolapse of varying severity, the disease has a wide age range, in addition, in recent years there has been a noticeable "rejuvenation" of this disease and the increasing number of complicated and recurrent forms [1; 2; 3; 6]. Problem of genital prolapse is becoming increasingly important for women of reproductive age. Insolvency of the pelvic floor, including the omission of sexual organs, is extremely frequent pathologies observed in almost a third of women of reproductive age [5; 7]. In the treatment of prolapse and internal genital prolapse the surgery plays a leading role. In literature described in detail more than 300 ways of surgical treatment of descent and prolapse of internal genitals by vaginal, abdominal, laparo-scopic or combined access, which indicates a certain degree of imperfection of each. However, the high rate of recurrence of the disease (16 to 43%) indicates a lack of efficacy of currently used surgical techniques [1; 3]. In modern conditions, given the trend toward "rejuvenation" of the disease, genital prolapse seems not only medical but also personal, family, social issues affecting sexual, professional and many other areas of life of patients. Reasons for the high incidence among women of reproductive age — one-third of all patients on
given nosology — lie in the general deterioration in the health of women in the population.
The most important factor in maintaining the health of women who have undergone surgery for prolapse is a solution to the problem of unwanted pregnancy. It is believed that carried plastic surgery on the genitals is an absolute indication for cesarean section [7]. Thus, women operated on for prolapse of the vaginal walls need to be informed and make a choice about their reproductive goals, i. e. they need the highly effective methods of contraception, such as voluntary surgical contraception. In this regard, the use of contraception is considered as one of the most important trends in the rehabilitation of women in the process of complex treatment of genital prolapse. It is known that when choosing a method of contraception should be considered reproductive intentions and experiences of patients, which is the driving factor of contraceptive behavior [5]. Researchers did not study these issues in women with genital prolapse.
The purpose of this study was to develop recommendations for optimizing the surgical correction of genital prolapse and choosing an effective method of contraception for women of reproductive age.
Materials and methods
Under the observation were 105 women of reproductive age with genital prolapse. A survey of women began with the study of history. From history we found out the age of the transferred gynecologic and extra genital diseases, surgery. The focus was on duration of the disease, the nature and effectiveness of the remedial measures earlier. In the study of menstrual function was paid attention to the age of menarche, menstrual function (duration of menstruation, the intensity, the presence of pain), the rhythm of the cycle. Also was noted the age of onset of sexual activity, contraceptive methods used previously. In the analysis of reproductive function was drawn
Section 7. Medical science
attention to the number of pregnancies, births, abortions, especially their current complications. Especially we paid attention to obstetric trauma of soft tissues of the birth canal and the effectiveness of their recovery. Were excluded chronic inflammatory diseases of the pelvic organs, complications of pregnancy and childbirth, vaginal operative delivery methods, benefits and other conditions of the body, which could lead to obstetric injury of the cervix and vaginal walls. Additionally were examined: occupation, place of residence, professional activity, especially working and living conditions, availability of physical activity, the types of additional loads (work in the garden and suburban areas, the content of the farm cattle and small livestock). Hereditary predisposition was emerged from history. The age range is 20-45 years. Basically, it was a woman's age group 31-40 years (52%). The average age of patients was 37,3±2,5 years.
Of the total number of examined patients residents of the city were 66 (62.5%), of village — 35 (37.5%). The genetic predisposition for genital prolapse was indicated 60 women (57.5%). Most of the patients had 2-3 childbirths (48.7%). 28 of (27.5%) women had a history of one childbirth, and 24 (23.8%) — 4 or more. Parity was 2,52±0,7, ie per a woman was by 2,52 ± 0,7 childbirths. Reproductive function was characterized by a large number of births, which were accompanied by high perineal injuries (64%) (the weight of a newborn 4000gr was in 28%), high frequency of abortion. Gynecological inflammatory diseases identified in 100% of cases. Out of 80 women who had a history of childbirth, all 80 linked their disease to childbirth. Almost half of the patients — 55 (52.5%) had a history of 1 to 4 artificial and spontaneous abortion.
In 15 (18.6%) diagnosed cervical elongation in combination with the old perineal, in 45 (56.3%) — elongation cervix in combination with the old perineal, 12 (15.0%) — ptosis walls vaginal cervical elongation, cystocele, 8 (10.0%) — pto-sis cervix in combination with the old discontinuity.
All patients in the scheduled order underwent surgical treatment. As the table shows, the predominant method of surgical treatment of genital prolapse in women of reproductive age is a front and rear-Colpe perineorraphy. Restoration of the pelvic floor was performed in all women using their own tissues. All patients used vaginal access.
Our proposed technique of colpoperineolevatoroplas-tics strengthening of vesicovaginal fascia and sterilization by Pomeroy transvaginal access:
Stage I — bares vagina using mirrors, grab a cervix vul-sella and reducing it. Making the front vaginal vault incision 2-3 cm long and penetrate into the abdominal cavity.
• Stage II — using pipe hook Ramathibodi grab the fallopian tube and reducing it in the vagina. Examining Division ampullar and fimbriae, we see that relegated pipe and choose avascular area.
• Stage III — in the avascular portion of the pipe creating a loop of 1-2 cm, impose a stranglehold free chromic catgut (simple O-shaped ligature) around the pipe and tight-
en a square knot. Loop tube is cut off, holding the ligature stretched. Inspect the stump tubes for the absence of bleeding, cut the ligature 1 sm from the tube and immerse the tube into the peritoneal cavity. Perform the same procedure on the other side of the wound and sutured anterior vaginal vault continuous catgut suture.
• Stage IV — cervix send down to the entrance of the vagina, in the midline, at some distance from the outer 1.5-2 cm opening of the urethra and toward the cervical os before reaching the border of cervical and vaginal vault, cut the vaginal wall to be loose layer of fiber. Blunt and sharp by exfoliate vaginal wall from the underlying fascia gallbladder. Separation area depends on the flap of the vaginal wall, which will be deleted as redundant.
• Stage V — purse-string catgut suture connect midline perivesical tissue, piercing the fascia and muscle layer, thereby provided "strengthening" of the bladder and hemostasis simultaneously.
• Stage VI — remove redundant tissue of the vaginal wall, the wound edges combine continuous catgut suture. Evaluation of hemostasis, removal of bullet forceps.
• Stage VII — define the boundaries of the triangular flap removed posterior vaginal wall with clamps Kocher two clips at the outer corners of the triangle imposed on the lower sections of the labia minora, above the boundaries of posterior commissure, at the level where the future will be re-formed back spike. The vertex of the triangle is located to the rear vaginal wall along the midline. Reducing bottom clips together, define the width of the resulting postoperative vaginal entrance.
• Stage VIII — stretching the clamps base of a triangle with a scalpel make a thin cut along the junction of the vaginal mucosa and perineal skin. Impose on the resulting flaps clips, stretch injury, and penetrate into the rectovaginal tissue and blunt and sharp separation through the vaginal wall of the rectum. The flap is cut off with scissors, starting from the top corner, then moving to the side corners.
• Stage IX — continuous catgut suture to sew up the wound resulting from its upper corner, connecting only the edges of the mucosa. After a few — 4-5 — pass the end of the thread stitches with needle holder assistant and proceed to levatoroplastics.
• Stage X — levatoroplastics performed in two ways, depending on the muscle. If at a palpation determined that the leg muscles are not broken, they were isolated from the fascia. If at a palpation the abdomen muscles, lifting the anus, poorly defined, the remaining parts of the muscle were ligated together with the fascia covering. In the first case from the vaginal wound over the abdomen muscles (determined by palpation) cut tissue and fascia. Found on both sides of the levator under them carried a thick ligature and pulled up into the wound of the vagina, while freeing them from the fascia prerectal parts into which imposed tightening 2-3 main seam. In the second case, not separating the muscles using steep thick needle, a first summing it with one hand muscle, gouged
