COMBINED METHOD FOR SURGICAL CORRECTION OF PELVIC DESCENT COMBINED WITH UTERINE DISEASES IN ELDERLY AND SENILE WOMEN Russian patent published in 2024 - IPC A61B17/42 

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical gynaecology. Circular dissection of the vaginal wall mucosa and its separation, opening of rectal-uterine cavity, ligaments and uterine vessels ligation, opening of vesicouterine cavity, ligation of the remaining ligamentous apparatus and uterine appendages, restoring the integrity of the peritoneum, connecting the anterior and posterior walls of the vagina in the transverse direction, cutting out the flaps from the mucous membrane of the anterior and posterior walls of the vagina, immersing the vaginal stump into the pelvic cavity, wherein after the vaginal hysterectomy, the anterior and posterior walls of the vagina are connected in the transverse direction, sutures are fixed with clamps, flaps are cut out from vaginal mucosa, the distal edges of which are located directly in the area of vaginal fornix. Urethropexy of the middle third of the urethra is performed with a free synthetic loop – the first clamp is applied 1 cm below the external opening of the urethra and the second clamp is applied 1.5 cm below the first one, between the clamps, a longitudinal incision of the vaginal mucosa is made, the canals are formed by dissecting tissues with dissecting scissors at angle of 45° from the middle line. Then, using the guides with the synthetic prosthesis, the obturator membrane is perforated along the guide channel, and the ends of the synthetic prosthesis are brought out onto the hip skin so that the exit points are located symmetrically 2 cm lateral to the hip flexure and 2 cm above the external urethral opening. Vaginal mucosa is repaired with a continuous vicryl suture in the transverse direction; the cervix is fixed with bullet forceps and brought down. On the vaginal mucosa, Kocher clamps are applied in the form of a cone, the upper one – along middle line 3-4 cm above the external orifice of the uterus, and lateral clamps – on the mucous membrane at distance of 2-3 cm from the uterine cervix. Then, a scalpel is used to cut out a flap from the mucous membrane of the anterior vaginal wall in the form of a triangle, with transition into a circular incision on the posterior wall, at the level of the last transverse fold of the vaginal mucosa; the mucosa is separated from the front of the pre-bladder fascia and the posterior wall of the bladder. Uterine cervix is pulled down and connective tissue fibres between bladder, neck and vesicovaginal septum are sharply transected, with the help of a lifter, the bladder is taken upwards, the sacrouterine, cardinal ligaments and vascular bundles of the uterus are crossed, stitched and ligated in stages on both sides, in the transverse direction, the peritoneum of the posterior fornix of the vagina is sharply opened and separate sutures are applied on the mucous wall of the vagina with the peritoneum of the posterior vault, after which a peritoneum of an anterior fornix is sharply opened in a transverse direction. Then the uterine body is brought out through the anterior colpotomy opening and brought down with the bullet forceps; the uterine ribs are clamped with the proper ovarian ligaments, uterine tubes and round ligaments of the uterus on both sides, the uterine body is dissected away. Stumps of the proper ovarian ligaments, fallopian tubes and round ligaments of the uterus are transected, sutured and ligatured on both sides, and the abdominal cavity is inspected. Stumps of the sacrouterine, cardinal ligaments, vascular bundles of the uterus, proper ligaments of the ovaries, fallopian tubes and round ligaments of the uterus are brought out from both sides extraperitoneally, the abdominal cavity is tightly closed with a continuous peritoneal circular suture. Stump of the right round ligament of the uterus is sutured and ligated with separate sutures with the stumps of the proper ligament of the ovary and the uterine tube on the left, and similarly the stump of the left round ligament of the uterus is sutured and ligated with separate sutures with the stumps of the proper ligament of the ovary and the uterine tube on the right, and haemostasis is achieved. Further, on the upper one-third of the anterior and posterior walls of the vaginal mucosa, clamps are applied: the upper anterior clamps are applied 0.5 cm below the ligatures applied to the mucous membrane of the anterior vaginal wall after urethropexy, lower anterior clamps are also applied symmetrically on both sides on the lower remaining unseparated edge of vaginal mucosa 1.0-1.5 cm above the previously applied ligatures after the second stage of the operation. Posterior wall of the vagina is also clamped on both sides symmetrically; the upper posterior clamps are applied along the last transverse fold of the vaginal mucosa, taking into account the relationship with the upper anterior clamps at distance of 1.0-1.5 cm. Lower posterior clamps are also applied symmetrically on both sides similarly to the front lower clamps, the rectangular flaps are separated in a sharp way, a lateral canal is formed, for this purpose, a prick is made from the mucous membrane of the anterior wall of the vagina with the wound surface sequentially of the anterior and posterior walls with a prick out from the mucous membrane of the vagina of the posterior wall, wherein said nodes face the lateral canal and similarly form the lateral canal of the other side. Tissues of the wound surfaces of the anterior and posterior walls are matched with separate sutures of the absorbable suture material in the transverse direction. Stage of formation of the lateral canals is alternated with the stage of wound surfaces closure until reaching an intact mucous membrane, suturing the mucous membrane of the anterior and posterior walls of the vagina with separate sutures; openings of the lateral canals are formed on the right and on the left. Then colpoperineosphincterolevatoroplasty is performed – clamps are applied in the form of a triangle so that its apex is located along the middle line of the posterior wall of vagina at 1.0 cm below the ligatures after the median colporrhaphy, two lateral clamps are applied on the base of the labia minora; a triangular flap is cut out. Edges of the dispersed sphincter are separated in a sharp way, a pararectal lance-like motion of a scalpel is used to dissect a cellular tissue, the anal sphincter tissue is clamped and pulled upwards. Sphincter edges are visualized, the anus is closed, the sphincter edges are aligned with the U-shaped vicryl suture, at m. levator ani, 3-4 vicryl sutures are applied, a continuous Reverden suture is applied on the mucous membrane of the posterior wall of the vagina, and an intradermal cosmetic suture is applied on the skin.

EFFECT: method makes it possible to significantly minimize the risks of purulent-septic complications and development of oncopathology, to exclude the probability of repeated operations and provision of anaesthetic aids, which is an important factor for elderly and senile patients, burdened with severe combined extragenital pathology, which also improves quality of life.

1 cl, 14 dwg, 2 ex