Intrafascial hysterectomy

It refers to the hysterectomy performed in the cervical fascia after the uterus is removed and the uterine blood vessels are cut off. It can be done by abdominal transvaginal route or by laparoscopy (ie Semm procedure).

Treatment of diseases: cervicitis uterine fibroids

Indication

Suitable for uterine fibroids without chronic cervicitis, no pelvic malignant lesions, no pelvic adhesions.

Age 40 years old, requiring no postoperative vaginal length.

The uterus is enlarged in patients with uterine fibroids that are no more than 12 weeks pregnant uterus size.

Contraindications

Patients with uterine fibroids with chronic cervicitis should not use this procedure.

Preoperative preparation

Cervical smear and diagnostic curettage were performed before surgery to exclude cervical and uterine malignant tumors.

Surgical procedure

Surgical procedure: According to the traditional hysterectomy step, the ligament of the ligament, the ovary intrinsic ligament and the fallopian tube or the funnel ligament are cut off, the tissue between the broad ligament is separated and cut into the uterine isthmus, the peritoneal reflex is cut, the bladder is slightly pushed down, and the uterus is cut off. Arterial ascending branch. At the slightly higher margin, a circular incision of about 2 to 3 mm is made, and the uterus is pulled upward, and the blunt sharpness is combined with the separation of the cervical fascia to reach the cervicovaginal part. The uterus was removed along the vaginal dome. After routine disinfection, the vaginal stump is sutured with a No. 0 absorbable synthetic thread or intestinal line, and then the cervical fascia is continuously sutured with a No. 0 gut to embed the vaginal stump. The pelvic peritoneum was sutured as usual.

a. Abdominal intrafascial hysterectomy:

Advantages: The treatment of the uterine main ligament, patellar ligament and para-uterine and paravaginal tissues is reduced during surgery. Avoid ureteral injury, and do not need to fully separate the bladder, generally does not damage the bladder during surgery. Therefore, the surgical procedure is simplified, the operation time is shortened; the structural and functional integrity of the pelvic floor is maintained, and there is no vaginal relaxation and prolapse after surgery; the uterine artery descending branch is not cut, and the pelvic floor nerve plexus is small, which is beneficial to the stump. Healing, guarantee the complete supply of blood to the vagina; remove the endocervix of the cervix to avoid the occurrence of cervical stump cancer.

b. Yin intrafascial hysterectomy:

Advantages: Compared with abdominal intrafascial hysterectomy, vaginal fascia hysterectomy has the advantages of small trauma, no abdominal interference, rapid postoperative recovery, short hospital stay, no scar on the abdominal wall, low hospitalization cost, etc. The principle of surgery. Especially for patients with obesity, diabetes, coronary heart disease, high blood pressure and other medical complications can not tolerate open surgery, it is an ideal surgical procedure.

Surgical procedure: Inject oxytocin (oxytocin) into the connective tissue on both sides of the cervix 10 U; cut the posterior iliac mucosa between 3 to 9 o'clock at the junction of the posterior lip of the cervix and the vaginal wall, separate the uterus and rectum, open the abdomen, suture Marked; the cervical fascia was circumcised 0.5 cm outside the cervical transition zone, and the uterus was removed from the posterior peritoneum; the round ligament, the ovarian intrinsic ligament and the fallopian tube isthmus (not retaining the ovary-splitting funnel ligament) and the uterine arteries and veins were cut in close proximity to the uterus; After the uterus was removed, the cervical fascia was dissected with a rat tooth forceps and sutured with an absorbable thread. The stumps were sutured on both sides of the peritoneum; the peritoneal vaginal mucosa was sutured after the cervical reduction. The vagina was filled with Vaseline yarn for 24 hours, and the catheter was indwelled for 24 hours.

c. Laparoscopic intrafascial upper cervical hysterectomy (CISH):

Advantages: small trauma, less bleeding, quick recovery, while maintaining the integrity of the pelvic floor, vagina and cervical sheath to maximize the prevention of cervical stump cancer.

Surgical procedure: 1 to 4 steps with TLH; 5th step into the snare in the uterine isthmus; step 6 in the laparoscopic uterus correction rod through the cervix into the uterine cavity through the uterus; 7th cylindrical resection The center of the uterus is cut from the cervix with the correction rod as the center (the different sizes of the cervix are selected from different diameters of the cylindrical rectator); after the strip of uterus is removed in step 8, the snare is placed in the uterine isthmus Tightening, ligation, occlusion of the blood vessels; Step 9: Excision of the uterus above the uterine isthmus ligature; Step 10: Inserting a large grasping forceps through the abdominal wall puncture cannula, clamping the uterus, using a cylindrical circulator to smash the uterus Take out in strips; Step 11: Wash the pelvis to stop bleeding; Step 12 close the puncture.

d. Laparoscopic cervical intrafascial hysterectomy (TLIH): Also a new hysteroscopic hysterectomy procedure. The difference from CISH is that the cervix is completely removed and the vaginal stump is sutured under direct vision. The surgical procedure below the uterine isthmus is the same as the abdominal surgery.

complication

1. Bleeding: When dealing with uterine round ligament, ovarian intrinsic ligament, and fallopian tube, the end of the suture is not tight or the knot is slippery and causes bleeding, so double ligation is appropriate. When cutting the uterine arteries and veins, the tissue surrounding the uterine arteries and veins should be separated as much as possible, the blood vessels should be recognized, and the uterus should be clamped tightly and firmly ligated. When pushing down the bladder, it is necessary to distinguish the levels, too shallow or too deep will cause bleeding.

2. Adjacent organ injury: Because subtotal hysterectomy is often used for adhesion between uterus and pelvic organs, especially when the bladder, rectum and cervical adhesions are dense, the anatomical level is not clear, and bladder, rectum and ureteral damage are prone to occur. Once it appears, it should be patched immediately.

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