METHOD OF SURGICAL CORRECTION OF COMBINED FORMS OF GENITAL PROLAPSE USING LAPAROSCOPIC COMBINED LONGITUDINAL-TRANSVERSE FIXATION OF VAGINAL DOME OR CERVIX (OPTIONS) Russian patent published in 2023 - IPC A61B17/42 A61B17/34 A61F2/04 

FIELD: gynecology.

SUBSTANCE: inventions relate to the surgical treatment of genital prolapse, including relapse of genital prolapse. Laparoscopic combined longitudinal-transverse fixation of the vaginal dome or cervix is performed with the following steps. The peritoneum is opened over the inner surfaces of the pubic bones with further lateral and caudal dissection. The rectovaginal space is dissected, the pectineal ligaments and external iliac vessels — veins and arteries — are isolated. The first implant, made of synthetic mesh material, is placed longitudinally on one side into the rectovaginal space towards the levator ani muscles and sutured with non-absorbable suture material. The second implant, made of the same material as the first, in the form of a rectangular strip, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material. The operated organs are provided with a physiological position, after which the lateral sleeves of the second implant are fixed to the pectineal ligaments with non-absorbable suture material without any tension, and then peritonization is performed. For a patient who has undergone a hysterectomy, after the preparatory stage of the operation, the vagina is treated, and the dome of the vagina is fixed on a pad under aseptic conditions. Under aseptic conditions, pneumoperitoneum CO₂ — 4.5 l is applied through a paraumbilical puncture with a Veress needle, after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar in the midline and two 6 mm trocars are installed in the suprapubic region trocar in the right and left iliac regions. The patient is placed in the Trendelenburg position and the abdominal cavity and pelvic organs are examined. The sigmoid colon is fixed to the left side wall of the pelvis by suturing the fat suspensions, a forceps with a tampon soaked in an antiseptic solution is installed in the vagina, after which the peritoneum is opened in the area of the vaginal stump, 1 cm away from the cervical stump or vaginal dome. Then the rectovaginal space is dissected to the levator ani muscles — mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, the rectum is mobilized. Next, the vesicouterine fold of the peritoneum is opened and the bladder is bluntly brought down with its maximum possible mobilization to the anterior wall of the vagina. Then, along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, and on both sides the descending branches of the pubic bones are isolated to the pectineal ligaments. Anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vessels — femoral vein and artery, the first implant has an elongated shape with the following dimensions: length: 10–12 cm, the upper narrow base is 4 cm wide, the width of the lower wide base with protrusions on the sides for fixation is determined intraoperatively in accordance with the distance between the levator ani muscles. The specified first implant is fixed with a wide base using separate sutures with a non-absorbable thread to the bundles mm. Iliococcygeus on both sides, and its narrow base is fixed to the stump of the vagina or cervix with two sutures, also with a non-absorbable thread. The second implant is placed in the transverse direction, fixed in its central part to the vaginal stump or cervix, after which both implants are sewn together with three separate sutures with a non-absorbable thread with stitching of the vaginal stump. Next, the second assistant, by apical pressure using a forceps previously installed in the vagina, pushes the vaginal stump in the cephalic direction, after which the ends of the second implant are fixed to the pectineal ligaments with separate sutures with a non-absorbable thread, 1 suture on each side, remove the fixation of the sigmoid colon from the left side wall of the pelvis, return it to its previous physiological position, perform peritonization with a continuous suture of a monofilament absorbable thread, with the stumps and implant flaps located extraperitoneally, perform sanitation of the pelvic cavity, hemostasis, and apply sutures to trocar wounds. Alternatively, the invention is used for surgical correction of combined forms of genital prolapse with synthetic mesh implants, including laparoscopic combined longitudinal-transverse fixation of the vaginal dome with the following steps. The peritoneum is opened over the inner surfaces of the pubic bones with further lateral and caudal dissection. The rectovaginal space is dissected, the pectineal ligaments and external iliac vessels — veins and arteries — are isolated. The first implant, made of synthetic mesh material, is placed longitudinally on one side into the rectovaginal space towards the levator ani muscles and sutured with non-absorbable suture material. The second implant, made of the same material as the first, in the form of a rectangular strip, is placed in the transverse direction and fixed to the vagina with non-absorbable suture material. The operated organs are provided with a physiological position, after which the lateral sleeves of the second implant are fixed to the pectineal ligaments with non-absorbable suture material without any tension, and then peritonization is performed. If a uterus is present, the vagina is treated and the cervix is fixed under aseptic conditions with bullet forceps, and preparations are made for hysterectomy. The length of the uterine cavity is measured using a probe, after preliminary expansion of the cervical canal with Hegar dilators to N9, a uterine manipulator is transcervically inserted into the uterus, under aseptic conditions, pneumoperitoneum CO₂, 4.5 l, is applied through a paraumbilical puncture with a Veress needle, after which a central trocar with an internal lumen of 10 mm and a video camera are installed, one 12 mm trocar is installed in the suprapubic region along the midline and two 6 mm trocars are installed in the right and left iliac regions. The patient is placed in the Trendelenburg position and the abdominal cavity and pelvic organs are examined. The sigmoid colon is fixed to the left side wall of the pelvis by suturing the fat pads. Then the second assistant forms and visualizes the surgical field performing an apical push of the uterus in the cephalic direction with a previously installed manipulator, after which the peritoneum of the retrouterine space is opened, retreating 1 cm from the cervix. Then the rectovaginal space is dissected to the levator ani muscles — mm. levator ani, and their upper bundles mm. Iliococcygeus, in parallel, the rectum is mobilized. Next, a hysterectomy is performed. In the case of removal of the uterus with appendages, using a bipolar coagulator, the round uterine ligaments and infundibulopelvic ligaments are coagulated and crossed on both sides, and the uterine vessels, cardinal and uterosacral ligaments are coagulated and crossed on both sides, or, in case of removal of the uterus with fallopian tubes, after preliminary coagulation, the round ligaments of the uterus, mesosalpinxes, fallopian tubes and proper ovarian ligaments are crossed on both sides, and the uterine vessels, cardinal and uterosacral ligaments are coagulated and crossed on both sides. Next, the vesicouterine fold of the peritoneum is opened and the bladder is bluntly brought down with the maximum possible mobilization to the anterior wall of the vagina. Then the uterus is cut off from the vaults of the vaginal wall circularly along the edge of the isoelectric cap of the manipulator. The second assistant removes the macro-preparation — the uterus with appendages or fallopian tubes — together with the manipulator from the small pelvis through the vagina, the vaginal dome is formed with separate sutures using a monofilament absorbable thread, with the stumps of the uterosacral ligaments being fixed to the vaginal stump, a forceps with a tampon soaked in an antiseptic solution is installed in the vagina. Along the stumps of the round ligaments of the uterus, the layers of the peritoneum are opened paravesically to the ileo-obturator region on the right and left, the descending branches of the pubic bones are isolated on both sides to the pectineal ligaments, anatomical landmarks are visualized on both sides: pectineal ligaments, external iliac vein and artery, femoral vein and artery. The first implant has an elongated shape with the following dimensions: length: 10–12 cm, the upper narrow base is 4 cm wide, the width of the lower wide base with protrusions on the sides for fixation is determined intraoperatively, in accordance with the distance between the levator ani muscles. The specified implant is fixed with a wide base using separate sutures with a non-absorbable thread to the bundles mm. Iliococcygeus on both sides, to the vaginal stump. The first implant is fixed with a narrow base with two sutures, also with a non-absorbable thread, the second implant, which is placed in the transverse direction, is fixed in its central part to the vaginal stump. After this, both implants are sewn together with three separate sutures using a non-absorbable thread and stitching the vaginal stump. Next, the second assistant, by apical pressure using a forceps previously installed in the vagina, pushes the vaginal stump in the cephalic direction. After which, the ends of the second implant are fixed to the pectineal ligaments with separate sutures using a non-absorbable thread, 1 suture on each side, the fixation of the sigmoid colon is removed from the left side wall of the pelvis, and it is returned to its previous physiological position. Peritonization is carried out using a continuous suture with a monofilament absorbable thread, with the stumps and implant flaps located extraperitoneally, the pelvic cavity is sanitized, complete hemostasis is performed, and trocar wounds are sutured.

EFFECT: methods increase the effectiveness of surgical treatment of genital prolapse, reduce the risk of damage to tissues and pelvic organs, thereby reducing the possibility of subsequent relapse of the disease, and improve the quality of life, including normalization of the functions of the pelvic organs.

4 cl, 3 ex