Name of gynecological operations. Types of gynecological operations, technique, consequences
Gynecological surgery is a radical, and in some cases the only possible method treatment of pathologies of the reproductive system in women. Surgical interventions are performed in the gynecology department of the MLC of varying complexity using new, low-traumatic techniques and expert-class medical equipment.
The cost of services at the Women's Medical Center does not exceed the average price range in Moscow. At the same time, it is the base clinic of the First Moscow State Medical University named after. Sechenov, and the staff of the center consists of the best obstetricians and gynecologists of the city.
Prices for surgical gynecology
- from 96 000 R Supravaginal amputation and hysterectomy (2-3 degree of complexity)
- from 32 000 R Surgery to remove gynecomastia
- 3 500 R Initial consultation with an obstetrician-gynecologist + ultrasound
- 7 000 R Diagnostic vacuum aspiration of the endometrium with histological examination
- 5 000 R Vacuum aspiration of the endometrium
- 7 000 R Polypectomy with curettage of the central canal, with histological examination (Surgitron)
- 35 000 R Tracheloplasty
- 35 000 R Colporrhaphy
- 35 000 R Vaginoplasty
- 35 000 R Operative hysteroscopy
- 15 000 R Resection of cervical fibroids
- 138 000 R Operative laparoscopy + emergency hysteroscopy
- 23 000 R Using gel to prevent adhesions
- 35 000 R Plastic surgery of the external genitalia
- 30 000 R Removal of Bartholin's gland
- 25 000 R Marsupialization of Bartholin's gland
- 25 000 R Vaginal cyst removal
- 5 000 R Defloration
- 12 000 R Complicated removal of an IUD under general anesthesia
- 20 000 R Suturing for isthmic-cervical insufficiency
- 5 000 R Bougienage of the cervical canal during fusion
- 2 000 R Intravenous anesthesia (routine)
- 4 000 R Intravenous anesthesia (hematometra)
- 4 000 R Intravenous anesthesia with extragenital pathology
- 35 000 R Levatoroplasty
- 12 000 R Defloration (operating room), intravenous anesthesia
- 50 000 R Operation Sturmdorf
- 7 500 R Immunohistochemistry
- 4 000 R Emergency intravenous anesthesia
- 6 000 R Emergency intravenous pain relief with extragenital pathology
- 35 000 R Surgical treatment of the vagina
What operations are performed in the gynecology department of the MLC?
The Women's Medical Center performs minor and major gynecological surgeries. For surgical interventions, the gynecology department has 2 operating rooms with autonomous air conditioning systems, air sterilization and modern anesthesia stations. There is a one-day and day hospital with comfortable wards for procedures in the postoperative period.
Specialists
Small operations
Most minor gynecological operations are performed vaginally: the cervix is secured with forceps, treated with a disinfectant solution, and the pathological focus is removed under the control of a hysteroscope or ultrasound sensor. The biopsy obtained during the operation is sent for histological examination - analysis for the presence of cancer cells.
For minor surgical interventions, the MLC uses modern minimally invasive techniques:
- radio wave therapy Surgitron - exposure of pathological areas to high frequency radio waves. Allows you to excise soft fabrics and, at the same time, coagulate bleeding vessels. Used in MLC for the treatment of polyposis, dysplasia and erosion of the cervix, cystic formations of the Bartholin glands;
- vacuum aspiration of the endometrium - obtaining a biopsy sample of the pathologically altered mucous layer of the uterus without dilating the cervix and administering intravenous anesthesia. Used for inflammatory diseases of the internal mucous membrane of the uterine body, frozen pregnancy and postpartum complications;
- hysteroscopic sterilization ESSURE - installation of microimplants in the fallopian tubes for irreversible contraception if there are medical indications. The effectiveness of the method is 99%.
All abdominal operations - polypectomy with curettage of the cervical canal, complicated removal of the IUD, bougienage of the cervical canal during fusion and others, are performed after intravenous anesthesia.
Large operations
For major gynecological operations, an incision is made in the anterior abdominal wall (laparotomy) or vaginal vault (colpotomy). In this way, the MLC performs supravaginal amputation and extirpation of the uterus, plastic surgery of the vagina, cervix and external genitalia, and also removes the Bartholin gland in case of recurrent abscesses or cysts. Such surgical interventions are performed in a large operating room under general anesthesia.
Laparoscopy
The clinic also practices organ-preserving and endoscopic operations - diagnostic and therapeutic laparoscopy. Typical laparoscopic interventions are:
- myomectomy - removal of uterine fibroids;
- tubal plastic surgery;
- separation of adhesions in the pelvic area;
- resection of cervical fibroids;
- biopsy and enucleation of ovarian cysts;
- removal of tubal pregnancy.
During laparoscopy, video equipment with 40x magnification power is used, which guarantees high accuracy of all manipulations.
Operative hysteroscopy
Another type of organ-preserving intervention that is practiced at the MLC is operative hysteroscopy. The essence of the technique is the excision of neoplasms inside the uterine cavity (polyps, submucosal nodes, synechiae) using a hysteroscope, an endoscopic medical device.
Laparoscopy and hysteroscopy allow you to restore and preserve fertility; their main advantages are a short rehabilitation period and the absence of postoperative scars.
Tests before gynecological surgery
Before any gynecological operation, blood tests are carried out: general, group and Rh factor, coagulogram. The condition of the genitourinary system is examined to exclude complications from the kidneys, and the function of the heart is to choose a method of pain relief.
Our center has its own express laboratory, where you can undergo all the necessary tests. Test results will be ready in 1-2 business days.
Advantages of surgical gynecology at the MLC
Surgical treatment in the gynecological department of the Medical Women's Center is carried out by doctors of the highest qualification category. Most of the gynecologists at our clinic have academic degree and more than 15 years of experience. By choosing MLC for planned surgical intervention, you can be sure of the absence of disease relapses and postoperative complications.
Don’t put off your visit to a gynecologist until later, sign up for a consultation at the Women’s Medical Center today!
One has to agree to surgery when there are no other treatment methods. Every operation is associated with risk.
Nodules may form in the thyroid gland. They synthesize hormones that make the gland overactive or turn into malignant formations. During surgery, part or all of the gland is removed. The operation lasts 40-90 minutes. Recovery time is 10 days or more.
The gallbladder fails due to poor nutrition, vitamin deficiency, stress, medications, and diets. As a result, stones are formed from calcium and cholesterol. Hiccups and severe pain indicate the need for surgery. Using the traditional method, an incision is made under the breastbone; with laparoscopy, three small scars will remain on the abdomen. Depending on the method, the operation lasts 1-2 hours and is discharged on days 3-7.
They recover with the laparoscopic method in a couple of days, with the traditional method - more than 10 days. Caesarean section is performed if a woman cannot push due to myopia, heart disease, high blood pressure, narrow pelvis or the need for quick action. To prevent a blood clot from forming after the operation and getting blood into the lungs, the patient’s legs are raised. The operation lasts a few minutes and is discharged after a week if there are no complications.
An ectopic pregnancy occurs when a slow sperm meets an egg outside the uterus in the oviduct or ovary. If it develops slowly and is detected in a timely manner, it is removed laparoscopically. When a woman starts bleeding and loses consciousness due to a burst oviduct, surgery is necessary. After opening the abdominal cavity blindly, the surgeon needs to find the cause of the bleeding, since the abdominal cavity is filled with blood. The operation lasts 30 minutes. Discharged in a week.
Fibroids can appear in women due to hormonal imbalance and excess estrogen. The tumors are scraped out. More often the uterus is completely removed. The operation is performed in 1-1.5 hours. The patient remains in the hospital for about a week before being discharged. After the wound has healed, women can live peacefully, but under the care of a doctor.
Benign and small ovarian tumors are curable medicines. Large ones may burst. The surgeon, based on the gynecological results, decides on the radicality of the operation. The non-cancerous tumor and part of the ovary are removed so that the woman can have a child in the future. The operation lasts about an hour. Discharged in a week.
Hemorrhoids in women appear more often during pregnancy, also from chronic constipation and a sedentary lifestyle. During the operation, the hemorrhoidal node is grabbed with forceps and tied up so that it dies. The operation lasts 1-2 hours, and the patient is discharged from the hospital after 7-10 days. During recovery, general weakness is observed.
Varicose veins can be hereditary, acquired during pregnancy, or an occupational disease. When performing an operation, precision is required. The surgeon energetically and quickly pulls out the main vein from the side branches. The operation may take several hours. Discharged after 3-5 days. After a couple of days, some patients are already walking, while others have difficulty walking for several weeks.
A painful bunion is caused by long-term pressure from shoes with narrow toes and high heels. A bone growth appears at the base of the finger. The surgeon chips it off piece by piece. On average, the operation lasts 40 minutes. They are discharged in a few days.
TYPICAL GYNECOLOGICAL OPERATIONS
ACCESS TO THE PELVIC ORGANS
Surgical interventions on the female genital organs are carried out mainly in two ways - transabdominal or transvaginal.
Methods of surgical approaches in gynecology
Inferomedian laparotomy
An incision is made along the midline of the abdomen from the upper edge of the symphysis pubis to the navel. In some cases, for ease of manipulation and revision of the abdominal cavity, the incision is extended upward, bypassing the navel on the left. After cutting the skin and subcutaneous fat, the bleeding vessels are ligated or coagulated. The aponeurosis is dissected with a scalpel or scissors in the longitudinal direction, retreating to the left from the midline by 0.5-1 cm. In this case, the anterior layer of the sheath of the left rectus abdominis muscle is usually opened. After retracting the rectus muscle and spreading the pyramidal muscles, the transversalis fascia is opened and the preperitoneal tissue is displaced, exposing the parietal peritoneum.
The peritoneum is opened closer to the navel, stretching it between two tweezers. It is important not to grab the adjacent intestinal loops and omentum with tweezers. Then, not forgetting the danger of injury Bladder, the peritoneum is cut downwards with scissors along the entire length of the incision, after which the abdominal cavity is delimited from the muscles, tissue and skin.
After opening the abdominal cavity, the pelvic organs are inspected and separated from the omentum and intestinal loops with a napkin (towel) moistened with an isotonic sodium chloride solution inserted into the abdominal cavity.
Upon completion of the operation, the abdominal cavity is again inspected and the integrity of the anterior abdominal wall is restored layer by layer. A continuous suture is placed on the peritoneal incision using absorbable suture material, starting from the upper corner. The edges of the right and left rectus muscles are compared with the same or separate sutures; however, the needle should not be inserted deep under the muscles to avoid injury to the inferior epigastric artery. Restoring the aponeurosis during longitudinal incisions is given particular importance, since healing depends on its thoroughness, as well as the possibility of the formation of a postoperative hernia. The edges of the aponeurosis are connected with separate sutures using non-absorbable synthetic threads. The subcutaneous fatty tissue is brought together with separate sutures. The skin wound is sutured with separate sutures or a continuous intradermal suture.
Due to its technical simplicity, lower median laparotomy has become widespread in emergency gynecology. Preference should also be given to this access in cases where technical difficulties are expected during the operation (the presence of adhesions, surgery for a tubo-ovarian abscess or cancer).
Pfannenstiel laparotomy (transverse suprapubic transection)
The skin and subcutaneous fatty tissue are dissected along the suprapubic skin fold 2-3 cm above the symphysis pubis, after which thorough hemostasis is performed. The aponeurosis is incised with a scalpel in the transverse direction 2 cm to the right and left of the linea alba and bluntly separated from the underlying rectus muscles. Then, placing Kocher clamps on the edges of the aponeurosis incisions, use curved scissors to extend the incisions to the right and left along the entire length of the skin wound. Along the white line, the aponeurosis is cut off only sharply. When separating the aponeurosis from the abdominal muscles, special attention is paid to careful hemostasis, since an intraoperatively unrecognized injury to the inferior epigastric artery or one of its branches can cause the formation of an extensive subaponeurotic hematoma in the postoperative period. Retraction of the left rectus muscle, opening of the transverse fascia, exposure of the parietal peritoneum, opening and delimitation of the abdominal cavity are performed in the same way as with inferomedian transection.
Restoration of the anterior abdominal wall to the aponeurosis is performed in the same way as with median transection. When suturing the aponeurosis incision, be sure to capture all four layers of fascia of the rectus and oblique muscles located in the lateral sections of the wound. Suturing the subcutaneous tissue and skin incision is no different from lower-median laparotomy.
The Pfannenstiel incision provides fairly good access to the pelvic organs. Its advantages are the possibility of active management of the patient in the postoperative period, the absence of postoperative hernias and a reduced risk of intestinal eventration during inflammatory complications, and the cosmetic appearance of the postoperative suture.
Transection using this method is not recommended for oncological pathology, purulent-inflammatory diseases, or the presence of a pronounced cicatricial adhesive process in the abdominal cavity. For repeated abdominal surgeries, the incision is usually made along the old scar.
Laparotomy according to Cherny (transverse interiliac transection)
The skin and subcutaneous fatty tissue are dissected in the transverse direction 4-6 cm above the pubis. After careful hemostasis, the aponeurosis is dissected in the same direction. The aponeurosis is separated upward and downward by 1.5-2 cm, exposing the pyramidal and rectus abdominis muscles. The rectus muscles are crossed alternately in the transverse direction, which contract well and, as a rule, there is no bleeding. The lower epigastric vessels are divided and ligated. After opening the transversalis fascia and displacing the preperitoneal fatty tissue, the peritoneum is opened in the transverse direction.
Suturing of the peritoneum, aponeurosis, subcutaneous fatty tissue and skin is carried out in the same way as with a Pfannenstiel incision. The peculiarities of restoration of the anterior abdominal wall is the application of 2-3 separate U-shaped sutures to the rectus abdominis muscles with absorbable suture material on a round atraumatic needle.
The advantage of this incision over Pfannenstiel laparotomy is the possibility of wider access to the pelvic organs.
Complications of abdominal surgery and their prevention
With all types of transection there is a danger of injury to the top of the bladder. In order to prevent this complication, urine is excreted before surgery, bladder catheterization is performed during surgery, and careful visual control is performed during dissection of the parietal peritoneum and at other stages of the operation.
A dangerous complication that can occur with a transverse suprapubic incision is injury to large blood vessels located at the base of the femoral triangle. The femoral artery and vein with the lumboinguinal nerve pass through the vascular lacuna located here, occupying the outer two-thirds of the lacuna. The inner third of the lacuna is filled with adipose tissue and lymphatic vessels. To prevent bleeding, make an incision above the inguinal ligament.
One of the complications of transverse incisions is the formation of hematomas due to insufficient ligation of the inferior epigastric artery or injury to its branches, especially when incision according to Cherny. In such cases, the leaking blood easily spreads through the preperitoneal tissue, encountering virtually no resistance, and therefore the volume of hematomas can be quite significant. Correct surgical technique and the most thorough hemostasis with suturing and ligation of vessels can avoid this complication.
Laparoscopy
The laparoscopy operation consists of inserting a Veress needle into the abdominal cavity, followed by the application of pneumoperitoneum and insertion of the first trocar. When choosing the point of insertion of the Veress needle, the location of the epigastric vessels, aorta, and inferior vena cava is taken into account. The safest and most optimal area for this is the area surrounding the umbilical ring within a radius of 2 cm. A feature of the Veress needle, which is used to insufflate gas into the abdominal cavity, is the presence of a blunt spring mandrel protruding beyond the needle in the absence of external resistance. This design protects the abdominal organs from damage by the needle tip after the needle passes through the peritoneum. Gas is pumped into the abdominal cavity using an insufflator, which provides control of the pressure and gas flow rate.
Carbon dioxide or nitrous oxide is usually used to create pneumoperitoneum. These chemical compounds are quickly resorbed by the peritoneum; unlike oxygen and air, they do not cause pain or discomfort and do not form emboli.
“Blind” insertion of the first main trocar, intended for insertion into the abdominal cavity of the laparoscope, is the most critical stage during the operation, since this instrument with a sharp end can cause serious damage. The current level of development of laparoscopic technology provides for the use of two types of trocars that ensure the safety of “blind” insertion:
1)trocars with defense mechanism, in design reminiscent of a Veress needle, - in the absence of external resistance, the tip of the trocar is blocked by a blunt fuse;
2) “visual” trocars - the advancement of the trocar through all layers of the anterior abdominal wall is controlled using the optical system of the laparoscope.
During open laparoscopy, a trocar using special equipment is inserted through a small incision in the anterior abdominal wall without first introducing gas into the abdominal cavity. This method avoids complications associated with “blind” entry into the abdominal cavity.
The introduction of additional trocars necessary to perform surgical laparoscopy is carried out strictly under visual control to avoid injury to internal organs and epigastric vessels. The location of additional trocars for manipulators and their number are determined by the anatomical features of the patient, as well as the nature of the intended intervention. The decision on the extent of the operation and the method of completion (in some cases, taking into account anatomical changes, it becomes necessary to proceed to laparotomy) is made after a thorough examination of the abdominal and pelvic organs.
Cryo- or laser destruction of cervical erosion. In gynecological hospitals, artificial termination of pregnancy is also carried out for up to 12 weeks. All minor gynecological operations are performed vaginally.
Diagnostic curettage of the mucous membrane of the uterine body is performed to determine the histological structure of the endometrium during uterine bleeding, hyperplastic processes of the endometrium and to monitor ongoing hormonal therapy. Set of instruments: vaginal speculum and lift, set of Hegar dilators, bullet and two-pronged forceps, uterine probe, set of curettes (No. 2 and No. 4), forceps, sterile cotton balls, napkins.
Operation technique: the cervix is exposed in the speculum, the vagina and cervix are treated first with a dry sterile swab, and then with a swab soaked in 96% ethyl alcohol or iodonate solution. The cervix is fixed with bullet or two-pronged forceps, after which the lift is removed. Nurse holds the vaginal speculum during the procedure. A uterine probe is carefully inserted through the cervical canal into the uterine cavity and the location of the uterus and the length of its cavity are determined. Typically, in a healthy woman who has given birth, the length of the uterus along the probe is 7-8 cm.
Then the cervical canal is expanded using Hegar dilators. The curette is carefully inserted without effort through the cervical canal into the uterine cavity and the mucous membrane of the uterine body is scraped in a certain order: first the anterior wall, then the posterior wall, and finally the angles are checked. The scraping is collected into a small container and sent for histological examination. In the direction indicate the last name, first name, patronymic and age of the patient, medical history number, day menstrual cycle, diagnosis, nature of hormonal treatment.
During separate diagnostic curettage of the endometrium and the mucous membrane of the cervical canal in case of suspected uterine cancer, initially, before the expansion of the cervical canal, scraping of its mucous membrane is carried out, and then all stages of curettage of the mucous membrane of the uterine body are performed. Scrapings of the endometrium and mucous membrane of the cervix are always placed in different containers and sent for histological examination with separate directions.
Endometrial aspiration allows you to obtain a biopsy of the endometrium without dilating the cervical canal and performing anesthesia. Preparation for surgery is no different from that for minor surgical interventions. After fixation and treatment of the cervix, a narrow metal tip on a special syringe is inserted through the cervical canal, through which endometrial fragments are obtained. The biopsy specimen is placed in containers with 10% formaldehyde solution and sent for histological examination.
Artificial termination of pregnancy (artificial abortion) can be performed in a short time, from 2-3 days to 21 days of delay of the next menstruation (mini-abortion) and more late dates(up to 12 weeks of pregnancy).
Mini abortion can be carried out in a hospital and in a antenatal clinic. The possibility of carrying it out is determined only by a doctor after confirming the presence of pregnancy and its duration (ultrasound examination).
Set of instruments: vaginal speculum, bullet forceps, uterine probe, Hegar dilators, forceps, vacuum aspirator and tips for it. The aspiration apparatus consists of an electric pump, a container, tips and a connecting tube that combines all these parts into one apparatus. The pump has a vacuum gauge with a scale from 0 to 760 mmHg. Art. Depending on the duration of pregnancy and the clinical situation, a vacuum in the range of 0.5-1 atm is selected. The suction tip has two side holes located near its end.
Operation technique: The operation usually does not require pain relief. After exposure in the speculum, treatment and fixation of the cervix, probing of the uterine cavity is carried out. Without dilating the cervical canal, the tip is inserted into the uterine cavity (for mini-abortion, flexible plastic cannulas with holes are used). The apparatus is turned on and the contents of the uterus are aspirated. The operation is considered complete if the contents do not enter the tank.
Induced abortion within a period of 6 to 12 weeks, it can be carried out using the vacuum aspiration method and the uterine curettage method.
Set of instruments: vaginal speculum, Hegar dilators up to No. 12, uterine probe, long tweezers, curettes different sizes, abortion forceps, vacuum aspirator and tips for it, bullet and two-pronged forceps, forceps (Fig. 74).
Surgery technique: the operation is performed under anesthesia in compliance with the rules of asepsis and antiseptics.
The cervix is exposed in the speculum, the vagina and cervix are treated with a disinfectant solution, the anterior lip of the cervix is taken with bullet forceps and brought down to the area of the entrance to the vagina, while the angle between the body and the cervix is significantly reduced. Then, using a uterine probe, determine the length of the uterine cavity and the direction for introducing dilators. The lift is removed, and the lower mirror is held by a nurse during the operation. Hegar dilators are introduced sequentially to the required number. Then the tip of the vacuum apparatus is inserted into the uterine cavity, the latter is turned on and the process of destruction and removal of the elements of the fertilized egg from the uterine cavity is monitored, observing the filling of the vacuum apparatus reservoir. Then the tip is removed, and if necessary, curettes No. 3 and No. 2 are used to inspect the uterine walls and tubal angles.
After making sure that there are no parts of the fertilized egg and bleeding, remove the bullet forceps, treat the cervix and vagina with a disinfectant solution and remove the vaginal speculum. This is how an induced abortion is performed after 6 weeks of pregnancy using vacuum aspiration. Artificial abortion by curettage of the uterus consists of widening the cervical canal, removing large parts of the fetus with a blunt curette or abortion forceps, scraping out the remnants of the fertilized egg and decidua with a sharp curette.
After surgery, a woman is transported on a gurney to the ward, and an ice pack is placed on her lower abdomen. The nurse monitors the well-being and condition of the patient, the nature and quantity bloody discharge from the genital tract.
Polypectomy - removal of cervical polyp.
Operation technique: after treating the vagina and cervix with disinfectant solutions, the cervix is fixed with bullet or two-pronged forceps. The polyp's stalk is grasped with a forceps and the polyp is removed using rotating movements (for a thin stalk) or a scalpel (for a wide stalk). Then separate curettage of the mucous membrane of the cervix and uterine body is performed. The resulting material is placed in different containers and sent to the histology laboratory. The cervix is treated with a disinfectant solution and the speculum is removed. The woman is transported to the ward on a gurney.
Removal of the born submucosal myomatous node.
Preparation for surgery is similar to that for all gynecological operations.
Operation technique: expose the cervix with the help of a gynecological speculum and a lift, treat it, the vagina and the newly born myomatous node with a disinfectant solution. The cervix and the born myomatous node are grasped with two-pronged forceps. By pulling the born knot down with forceps, its stem is exposed. If the leg is thin, then the knot is removed by unscrewing. If the leg is wide, then first the capsule of the node is cut with scissors at the point where it transitions into the leg, then the node is unscrewed. The removed node is placed in a special container and sent for histological examination. The cervix and vagina are treated with a disinfectant solution and the vaginal speculum is removed.
The operation to remove a born myomatous node is always performed in a large operating room. If an attempt to remove the node vaginally fails, then laparotomy and removal of the uterus are performed.
Endoscopic operations. Thanks to the development of general endoscopy, it has become possible to perform gynecological diagnostic and therapeutic procedures during laparoscopy. Laparoscopy is performed under conditions of pneumoperitoneum - the introduction of gas or air into the abdominal cavity.
The gas supply (at a rate of 4.5 liters of gas per minute) is controlled automatically using an electronic unit. This allows you to maintain constant pressure in the abdominal cavity during manipulation.
Preparing the patient for surgical laparoscopy is the same as for transection. Pain relief should be general, since in this way it is possible to achieve mobilization and revision of the pelvic organs, and perform diagnostic and therapeutic manipulations.
Typical laparoscopic procedures include separation of adhesions in the pelvic area, biopsy of the gonads, puncture biopsy and enucleation of ovarian cysts, partial resection or removal of the ovaries and uterine appendages. In pathological processes, removal of the fertilized egg during tubal pregnancy, tubal plastic surgery, sterilization, conservative myomectomy, and coagulation of foci of endometriosis are performed.
Major gynecological operations are performed by abdominal section (laparotomy) and vaginal section (colpotomy). Such operations include interventions on the uterine appendages and removal of the uterine appendages (tubectomy, oophorectomy, adnexectomy, supravaginal amputation of the uterus, hysterectomy, panhysterectomy). The most commonly performed vaginal routes are anterior, middle and posterior vaginal plasty, enucleation of vaginal cysts and cysts of the large gland of the vestibule, as well as vaginal hysterectomy.
Major gynecological operations are performed in a large operating room and under general anesthesia. Before the operation, the operating nurse places a set of instruments on the table in a certain order: scalpels with replaceable blades; scissors - straight and curved, long and short, blunt and sharp; tweezers - surgical and anatomical, short and long; Kocher, Mikulicz, Billroth clamps; bullet forceps and two-pronged Musée forceps; retractors; Reverden blade; clothes clips; needle holders - long and short; surgical needles - cutting and round of different sizes, as well as a metal catheter, syringes with needles, abortion tools, a tip for a vacuum device.
On the operating nurse’s table, closer to the surgeon, there are groups of hemostatic clamps, scalpels, scissors, forceps with gauze tuffs clamped in them. In the next row, closer to the operating nurse, there are needle holders and needles, suture material, mirrors, and spare instruments. In the “pocket” from the fold of the sterile sheet with which the table is covered, gauze napkins and balls are placed.
During the operation, the surgeon is located to the left of the patient, the assistant surgeon is to the right, the second assistant is next to the first assistant, closer to the foot end of the table. The operating nurse stands facing the surgical field, having in front of her a table with instruments and sterile material. The set of instruments is determined by the nature and extent of the surgical intervention. During the operation, the nurse carefully monitors the progress of the intervention in order to promptly inform the surgeon and his assistants necessary tools and sterile material.
At the head end of the operating table there is an anesthesiologist, anesthesia and monitoring equipment. At the table on which the patient’s right hand lies, there is an assistant anesthesiologist - a nurse anesthetist. She prepares the system for infusion therapy, punctures the vein, carries out all the doctor’s orders during the operation, and fills out the anesthesia card.
When a doctor pronounces a verdict: “The uterus must be removed,” many women perceive this as a death sentence. Undoubtedly, surgery is a violent intervention in the human body, and removal of the uterus can be said to be personal. But not everything is so scary, and many patients, after surgery, begin a new life, both literally and figuratively.
Indications determining the operation
Hysterectomy – this is the scientific name for removing the uterus, is never performed just like that, “for prevention.” Both removal of the uterus with and without appendages is carried out strictly according to indications. And if the doctor/doctors insist on carrying it out, then you should agree with their opinion. A woman is recommended to have surgery if:
- malignant tumor of the uterus
- malignant lesion of the cervix
- symptomatic uterine fibroids
- size of uterine fibroids exceeding 12 weeks of pregnancy
- rapid growth of fibroids (the size of the uterus increases in 12 months at 4 weeks of pregnancy)
- necrosis of the uterine fibroid node
- submucosal uterine fibroids
- menorrhagia complicated by anemia
- adenomyosis grade 3-4
- gender change
- chronic pain syndrome in the pelvis
- uterine prolapse
- endometrial diseases without improvement from conservative therapy and curettage
Is it really necessary?
The doctor insists on a hysterectomy, but the patient is categorically against it, what should I do?
- First, you should consult with another doctor, a third, a tenth. It is possible that the patient’s attending physician is sincerely mistaken.
- Second, consider other options that replace hysterectomy, such as conservative myomectomy and uterine artery embolization.
- Thirdly, consider all the positive and negative aspects of the upcoming hysterectomy.
Conservative myomectomy is good because it allows you to preserve the organ intended by nature to bear a child and is therefore performed on women of childbearing age. Negative aspects include the possibility of the growth of new myomatous nodes and almost lifelong (at least until menopause) dispensary observation at the gynecologist. Who undergoes conservative myomectomy:
- the presence of a pedunculated myomatous node (i.e. its location outside the uterus) or subserous nodes
- (2 or more cases of spontaneous abortion) and infertility (if other causes are excluded and there is at least 1 node, the size of which exceeds 4 cm)
- menstrual irregularities accompanied by bleeding and anemia of the patient
- big sizes fibroid nodes (exceed 10 cm)
- dysfunction of the bladder and/or intestines due to compression of the fibroid node
Uterine artery embolization surgery
She is considered innovative technology, although it began to be used back in the 70s of the 20th century. The essence of embolization is to catheterize the femoral artery, then the catheter reaches the uterine artery (under X-ray control), and then the places where the vessels branch from it, which supply blood to the fibroid nodes.
The introduction of special drugs through a catheter creates a block in small vessels leading to myomatous nodes and disrupts blood circulation in them. Uterine artery embolization is an excellent alternative to surgery to remove uterine fibroids, as it helps stop the growth of nodes, and even their reduction or disappearance.
This operation is performed in the presence of growing uterine fibroids up to 20 weeks, but if there are no diseases of the ovaries and cervix, and in women whose condition is caused by fibroids. In addition, uterine artery embolization is indicated for uterine bleeding, life-threatening. However, there are situations when hysterectomy for fibroids cannot be replaced with something else:
- submucosal uterine fibroids
- large size uterine fibroids
- combination of fibroids with internal endometriosis and ovarian tumors
- constant bleeding that leads to anemia
- growing tumor
Positive aspects of hysterectomy surgery
Before deciding to have a hysterectomy with or without appendages, you should weigh all the pros and cons. TO positive aspects Hysterectomy may include:
- absence of menstruation and problems arising with them
- no need for contraception
- disappearance of pain and bleeding, which greatly complicated life
- protection against uterine cancer (no organ - no problem)
- weight loss, waist narrowing
Negative points include
- psychoemotional disorders
- scar in the lower abdomen
- Duration of pain after surgery is 3 – 6 – 12 months
- maintaining sexual rest for 1.5 - 2 months
- earlier onset of menopause
- risk of developing osteoporosis and heart disease 5 years earlier
Case study: I had one patient of childbearing age who endlessly performed abortions on me (see). She had been registered with uterine fibroids for several years. And after the next termination of pregnancy, the situation became very complicated: there was an interstitial node in the uterus, which grew and practically blocked the lumen in the isthmus area. It had to be scraped out with great difficulty and risk. I confronted the patient with the fact that she needed amputation of the uterus, which was performed at the regional hospital. After hospitalization, she calls: “They offer me a conservative myomectomy, but you said that I need to do a supravaginal amputation of the uterus, what should I do?” Of course, as a doctor, I should advocate for the preservation of the organ, but as an attending physician, I was categorically against it. Who will perform abortions on this woman and how will she continue in the same spirit? But the doctors at the regional hospital decided to preserve the patient’s reproductive function and left the uterus, cutting out the nodes. Yes, well done, yes, smart guys. But here’s the question: if a woman wanted to give birth, would she really have a dozen abortions? Well, she doesn't need a uterus. And by the way, she already had a child, about 15 years old. Fortunately for me, she moved to another city and disappeared from my field of vision.
Pain relief for hysterectomy
Removal of the uterus is performed under general anesthesia. There are 2 methods of pain relief:
- intravenous anesthesia (with tracheal intubation and absence of spontaneous breathing)
- and regional anesthesia (spinal and epidural anesthesia).
Intravenous anesthesia is more often used during abdominal surgery (when the uterus is removed by making an incision in the anterior abdominal wall). The advantages of such anesthesia are the patient’s deep sleep, absence of pain and good control of the patient’s condition.
For laparoscopic hysterectomy and vaginal hysterectomy, preference is given to regional anesthesia, which is performed in two ways. Spinal anesthesia causes rapid pain relief in the lower part of the patient’s torso and maximum relaxation of the abdominal muscles; with epidural anesthesia, pain relief occurs after some time, but this method allows you to treat pain after surgery. The patient is conscious during regional anesthesia, but does not feel pain.
Of course, when choosing anesthesia, they are guided by the patient’s condition, the urgency of the situation, the expected scope of the intervention and its duration. The operation time varies and can range from 40 minutes to 3 hours.
Types of hysterectomy
Removal of the uterus is not just the elimination of a diseased organ, since hysterectomy is often combined with excision of other anatomical formations. Depending on the scope of the operation, Hysterectomy is divided into:
- subtotal – uterine amputation (the cervix is preserved)
- total - surgery to remove the cervix and the uterus itself (extirpation)
- hysterosalpigno-oophorectomy or panhysterectomy - removal of the uterus and ovaries with appendages, cervix
- radical - extirpation of the uterus with appendages, the upper third of the vagina, pelvic tissue that surrounds the uterus and regional lymph nodes
Depending on the method of access, the following types of hysterectomy are distinguished:
- laparotomy hysterectomy (the uterus is removed through a longitudinal or transverse incision in the abdominal wall)
- removal of the uterus laparoscopically (several punctures, from 2 to 4, in the abdominal wall, through which the laparoscope and instruments are inserted)
- vaginal hysterectomy – access to the affected organ is through the vagina
- vaginal hysterectomy with laparoscopic assistance
Radical hysterectomy is performed in case of malignant lesion of the uterus with transition to the cervix or in case of a malignant process of the cervix. Total hysterectomy is necessary for significant size of uterine fibroids, widespread endometriosis, combined diseases (tumors) of the uterus and cervix, as well as for women over 45. In other cases, amputation of the uterus is performed. Whether to remove the appendages or not - this issue is often decided during surgery, when the ovaries and tubes are visible to the naked eye.
How access will be achieved largely depends on the operating physician. But sometimes a woman is asked to make her own choice.
The advantages of abdominal hysterectomy are low cost, reliability, low risk of intraoperative complications, and the ability to perform it in almost any gynecological department. Disadvantages include: a large scar on the abdomen, length of stay in the hospital (10 days), a long recovery period (4 - 6 weeks).
The advantages of laparoscopic hysterectomy include: discharge after 5 days, a short recovery period (2 - 4 weeks), no cosmetic effect (no scar), low risk of formation of adhesions in the abdomen, and, therefore, a lower likelihood of adhesive disease with severe pain. Disadvantages include: high cost, likelihood of switching to laparotomy, performed only in large hospitals (medical centers and institutes).
Vaginal hysterectomy is easier to tolerate, there are no scars on the abdomen, recovery period in short, 3 – 4 weeks, there is practically no pain after surgery. The disadvantages include: complex technique and high risk of intraoperative complications.
Contraindications for hysterectomy
Removal of the uterus, ovaries, and tubes, just like all other surgical operations, has contraindications. The list of general contraindications includes any acute and chronic infectious processes in the acute stage, inflammatory diseases of the genital organs (vagina, cervix, appendages and uterus), severe chronic extragenital diseases (cardiovascular pathology, pathology of the bronchopulmonary system, and others), pregnancy .
Laparoscopic hysterectomy cannot be performed if the uterus or ovarian tumors are very large, with multiple adhesions in the abdominal cavity, or in case of uterine prolapse. Vaginal removal of the uterus is contraindicated in case of adhesive disease, after cesarean section, with existing large uterine fibroids, with inflammation of the vagina and cervix, as well as if there is a suspicion of cervical or if it is present.
Preparing for surgery
Before undergoing a hysterectomy, you must undergo an examination, which includes:
- clinical urine and blood tests
- blood for clotting
- biochemical blood test (cholesterol, total protein, glucose, AST, ALT, creatinine and other indicators)
- ECG, consultation with a therapist
- smear from the vagina, urethra and cervix for microflora (see)
- testing for sexually transmitted infections using PCR (chlamydia, ureaplasma, HPV, herpetic infection and others)
- smear for cytology from the cervix and cervical canal
- colposcopy (for cervical pathology)
- blood for group and Rh factor (the department must have at least 1 liter of blood of the required group)
- histological examination of the endometrium (after diagnostic curettage)
- chest x-ray
- visiting the dentist and cleaning carious teeth
- Gynecological ultrasound
In some cases (with significant size of uterine fibroids or severe endometriosis), the patient is prescribed hormonal treatment for a period of 3 or more months in order to stabilize the growth of nodes and the progression of the disease.
If appropriate treatment is prescribed several months in advance, if the patient is taking antiplatelet drugs, they are canceled 10 days before surgery.
The day before the operation, the patient is prescribed table No. 1 (liquid and pureed food), in the evening a cleansing enema, which is repeated in the morning. On the day of surgery, food and water intake is prohibited. After premedication, the patient is taken to the operating room (a urinary catheter is inserted in advance and the legs are bandaged with elastic bandages).
How is a hysterectomy performed?
How the hysterectomy operation goes is of interest to all patients, without exception. To dispel doubts and clarify any questions that have arisen, you should communicate with the surgeon on the eve of the intervention.
After the woman has been transported to the operating room, she is placed on the operating table and her limbs are fixed.
- In the case of vaginal hysterectomy, the patient's legs are bent at the knees and hip joints (as on a gynecological chair) and spread apart.
- During laparotomy or laparoscopic access, the anterior abdominal wall is treated with antiseptic solutions, while the patient is under anesthesia or regional anesthesia.
A layer-by-layer incision of the abdominal wall is made, then the situation of the organs in the pelvis is assessed (the size of the uterus, the location of nodes, the condition of the appendages; if a malignant process is suspected, the periuterine tissue and neighboring organs are examined for metastases).
The final decision on the extent of the operation is made by surgeons after opening the abdomen. The uterus and/or appendages are cut off, hemostasis is performed and the abdominal wall is sutured in layers. If necessary, the abdominal cavity is drained (risk of bleeding, peritonitis and other circumstances). If hysterectomy was planned in advance, then on the operating table the vagina is sanitized with antiseptic solutions and tamponed with a sterile napkin.
During laparoscopic removal of the uterus, after treating the anterior abdominal wall with antiseptics, 3 (on average) small incisions, 1.5–2 cm long, are made in it. Through one, a laparoscope with a microvideo camera is inserted, which feeds an image of the internal organs onto a large monitor (the operating surgeon is guided by it), and through the remaining 2, air is pumped into the abdominal cavity and special laparoscopic surgical instruments are inserted. The course of the operation in the future is no different from abdominal hysterectomy.
A vaginal hysterectomy is the removal of the uterus through the vagina. After aseptic treatment of the vagina, a speculum and a lift are inserted into it, and an incision is made in the upper third. Technically, this operation is more complex and requires a certain skill of the surgeon.
Case study:
When I first had a supravaginal (laparotomy) amputation of the uterus, I experienced my first shock when I cut open my stomach and saw the uterus, all in knots. I just wanted to give up everything and leave, as in the joke: “nothing works out anyway.” In principle, amputation of the uterus is a simple operation, but pitfalls lurk in the capture of the uterine arteries (they run along the ribs - the sides of the uterus, but of course they are not visible to the eye). 2 clamps are applied to the uterine arteries at the place of their intended course on each side (at a distance from each other). After which the uterus is cut off, the arterial stumps are ligated, the uterine stump is sutured with suturing of the appendages, it is peritonized and the anterior abdominal wall is sutured tightly. And so, after the uterus was cut off, blood gushed out from one side and instantly flooded the entire stomach. This means that the artery was not intercepted. But the surgeon (very experienced) was not at a loss and blindly intercepted the pulsating vessel (it happened on his part). This was my second shock during the operation. The further course of the operation was without complications, the postoperative period was smooth. The patient was discharged with gratitude for the operation and for the fact that she did not have to go to the regional hospital.
Duration and cost of the operation
An important question: “Operation to remove the uterus: how much does it cost” also faces a woman. It is difficult to give a definite cost for the operation.
- Firstly, it is determined by the region in which the future patient lives, the level of equipment of the hospital, the qualifications of the doctor, the suture material used during the operation, the volume of intervention and the conditions of stay in the postoperative period.
- Secondly, the price depends on the surgical approach and type of operation.
- For example, embolization of the uterine arteries costs about 100,000 rubles,
- Laparoscopic extirpation or amputation of the uterus from 16,000 to 90,000,
- Removal of the uterus via the vaginal route ranges from 20,000 to 80,000 rubles.
- Hysterectomy performed through laparotomy should be free in the hospital at the place of registration or in the regional center, but private clinics carry out such interventions for money. The price ranges from 9,000 to 70,000 rubles.
Removal of the uterus: how long does the operation last?
It is impossible to answer this question unequivocally. The duration of a hysterectomy depends, again, on the extent of the operation, its complexity, complications during surgery and access.
- On average, laparotomy hysterectomy lasts from 40 minutes to 2.5 hours
- laparoscopic lasts 2.5 – 3.5 hours,
- vaginal 2 – 2.5 hours.
After operation
Bed rest after removal of the uterus and/or appendages by abdominal route should continue for 24 hours. At the end of the first day, the woman is allowed to get up and move carefully. Early physical activity activates intestinal motility and prevents the development of paresis. Since pain after surgery, especially on the first day, is severe, analgesics are prescribed.
For prophylactic purposes, the administration of antibiotics and anticoagulants is indicated. The stitches are removed on the 8th day, and discharge is carried out after 8 – 10 days. After laparoscopy, the patient gets up within 5–6 hours and is allowed to go home after 3–5 days. Elastic leg bandaging is mandatory on the first day after surgery, but is desirable throughout the early postoperative period. Before bowel movement, the patient is prescribed table No. 1a (mashed and liquid food), and after bowel movement, a general diet.
Possible early complications:
- internal bleeding of varying intensity
- bleeding from the postoperative suture and hematoma formation
- injury to neighboring organs (undetected damage to the intestines and bladder during surgery)
- thrombophlebitis of the veins of the lower extremities
- suppuration of the suture
- vaginal prolapse
- infection of the urethra and bladder (consequence of prolonged catheterization)
- peritonitis (inflammation of the peritoneum)
- thromboembolism
Obstetrician-gynecologist Anna Sozinova
Content
Hysterectomy is a fairly common operation in women over 40 years of age. Scientifically, the operation that involves removing the uterus is called a hysterectomy.
Hysterectomy is a surgical operation, the duration of which and rehabilitation after it depend on many factors. It is difficult to answer the question of how many factors influence the duration of the procedure. It is of great importance how old the patient is, as well as the characteristics of her medical history. The type of surgical method affects how long the operation takes.
Removal of the uterus is a fairly serious operation, which is carried out after a detailed examination. There are strict indications for surgery in patients both after 40 years of age and for certain gynecological diseases.
- malignant tumors of the uterus or its cervix;
- uterine fibroids of large and giant sizes;
- rapidly growing fibroids;
- necrosis of the node after its torsion;
- internal endometriosis in the last stages;
- gender change;
- uterine prolapse.
Some doctors recommend removal of the uterus for most women after fifty years of age as a preventive measure against cancer of the reproductive system. The decision in favor of hysterectomy is influenced by how many nodes are diagnosed in the patient and what location they are.
Pros and cons of hysterectomy
After removal of the uterus, a woman is unable to become pregnant, no matter how old she is. In addition, hysterectomy is often characterized by a difficult rehabilitation period. How many complications occurred during the procedure also affects the rehabilitation period.
However, there are also a number of advantages after the manipulation, especially in women after forty to fifty years. The positive aspects after removal of the uterus include:
- absence of critical days, need for contraception;
- disappearance of the clinical picture of many gynecological diseases;
- prevention of cancer.
Like any surgical procedure, hysterectomy is associated with certain risks both during removal and during the recovery period.
The disadvantages of a hysterectomy include:
- psychoemotional disorders;
- scar after surgery in the lower abdomen;
- pain that lasts for some time after surgical treatment;
- early onset of menopause;
- development of cardiovascular pathologies and osteoporosis;
- obligatory sexual rest.
How long sexual rest lasts is determined by the doctor based on the type, volume of the operation and the characteristics of the rehabilitation period.
Pain relief during hysterectomy
The choice of anesthesia method depends on how long the hysterectomy will take. The type of hysterectomy and the patient’s medical history are also essential.
The operation must be performed under anesthesia. In modern gynecology, two types of anesthesia are used.
- Intravenous. Doctors perform tracheal intubation, in which the patient does not breathe independently while the operation is underway.
- Regional. The operation is performed under spinal or epidural anesthesia.
Intravenous anesthesia is indicated for procedures during which a muscular organ is removed through a traditional incision.
Among the advantages of intravenous anesthesia are:
- the patient's immersion in deep sleep;
- no pain;
- the ability to control a woman’s condition.
Regional anesthesia is recommended for laparoscopy as well as vaginal hysterectomy. The patient is conscious and does not feel pain. Spinal pain relief works quickly, also relaxing the abdominal muscles. During epidural anesthesia, the loss of sensation occurs later, and therefore this method is often used after surgery to relieve pain.
The choice of anesthesia method depends on the type of hysterectomy, as well as on the woman’s medical history. When choosing pain relief, doctors take into account how long the operation will take. Surgery to remove the uterus usually lasts up to three hours.
Types of hysterectomy
There are various options for hysterectomy surgery, which differ in the method of execution and the duration of the intervention. Of great importance is how many organs should be amputated.
According to the volume of amputation, there is a hysterectomy.
- Subtotal. This surgical treatment involves removing only the uterine body.
- Total. During the operation, the uterus and cervix are removed. In another way, such amputation is called extirpation.
- Hysterosalpigno-oophorectomy. The operation involves removal of the uterine body, ovaries, appendages and cervical part of the uterus.
- Radical. Amputation is otherwise called extirpation, which includes the uterus, appendages, as well as the upper vaginal third, tissue around the uterus and lymph nodes.
Hysterectomy varies depending on the access to the organs being amputated.
- Laparotomy. Surgery is performed by making a traditional horizontal or vertical incision in the abdomen.
- Laparoscopy. It lasts about an hour and is performed through small holes in the abdomen that provide access to the laparoscope.
- Vaginal hysterectomy. The method is performed using access through the vagina.
- removal through the vagina using laparoscopy.
Radical removal is recommended for oncological tumors, while total intervention is performed for myomatous nodes and various forms of endometriosis. Often, the issue of amputation of appendages is decided by the doctor during the operation.
Abdominal surgery has a number of advantages, among which are:
- affordability;
- reliability;
- low risk of complications after removal;
The disadvantages of laparotomy include:
- scar after removal;
- the duration of inpatient treatment is about ten days;
- long-term rehabilitation.
Laparoscopy is one of the more modern surgical methods of treatment. This type of removal takes less time.
The laparoscopic method has many positive aspects:
- the duration of rehabilitation is insignificant;
- absence of scar and adhesions after surgery;
- The length of hospital stay is about five days.
The disadvantages of laparoscopy are as follows:
- relative high cost;
- risk of using abdominal surgery.
Many representatives are interested in how long it takes to recover after a vaginal hysterectomy. In general, this type of removal is a fairly gentle procedure. In addition, after the operation there are no scars on the abdomen or pain, and rehabilitation is about four weeks. However, no matter how many advantages this technique has, it is necessary to note its complexity and high risk of complications after manipulation.
Contraindications to hysterectomy surgery
In some cases, hysterectomy is contraindicated.
Contraindications to this type of surgical intervention include:
- exacerbation of any chronic diseases;
- inflammatory processes in the reproductive sphere;
- severe pathologies not related to the field of gynecology;
- pregnancy period.
- large volume of the uterus;
- extensive adhesive process.
Vaginal uterine removal is not performed if:
- adhesions;
- presence of a scar after cesarean section;
- large fibroids;
- inflammatory processes and cancer alertness.
The duration of the operation depends on its type.
The clinical picture of the pathology that necessitated surgical treatment is essential.
Hysterectomy is a common, but at the same time complex surgical tactic. Before it is carried out, careful preparation is necessary, during which the patient undergoes the necessary examination.
Women are interested in what procedures need to be performed before amputation. As a rule, preparation for surgery includes performing:
- urine and blood tests;
- vaginal smears for flora, bacterial culture, STIs, oncocytology;
- colposcopy;
- Ultrasound of the pelvic organs;
- fluorography.
Before hospitalization, a woman also needs to consult a therapist, phlebologist and dentist.
Often, before manipulation, hormonal treatment is prescribed, which helps stabilize the pathological condition. The woman is hospitalized in the hospital at least one day before the operation. Before the operation, a diet and a cleansing enema are indicated. On the operating day, eating and drinking any liquid is prohibited.
How long the operation lasts depends on many factors. In general, the duration of the manipulation depends on the type of removal and the clinical picture of the pathology. It is also important how the removal process itself proceeds, since various complications cannot be excluded during and after the operation.
In gynecological practice, surgery to remove the uterus lasts from forty minutes to two to three hours. If unforeseen situations arise, the duration of the intervention increases.
Surgical interventions on the external genitalia, vagina, artificial termination of pregnancy (abortions and various invasive examination methods) are considered minor gynecological operations (Fig. 53-54).
These include:
- probing the uterus (Fig. 53.1);
- expansion of the cervical canal (Fig. 53.2);
- curettage of the uterine mucosa (Fig. 53.3);
- puncture of the abdominal cavity through the posterior fornix (Fig. 53.4);
- cervical biopsy and removal of polyps (Fig. 53.5);
- surgeries for tumors of the external genitalia;
- operations for kraurosis and leukoplakia of the vulva;
- operations for diseases of the large gland of the vaginal vestibule (Fig. 54,1,2)
- removal of condylomas (Fig. 54.3);
- operations for tumors and cysts of the vagina (Gartner's ducts) (Fig.
- dissection of the cervix;
- operations for termination of pregnancy (Fig. 54, 5,6).
Fig. 53. Minor gynecological operations 1 - probing the uterus, 2 - dilatation of the cervical canal, 3 - curettage of the uterine mucosa (polyp removal), 4 - puncture of the abdominal cavity through the posterior fornix, 5 
abortion (removal of the fertilized egg using a vacuum extractor).
- Probing of the uterus
Execution technique. The cervix is exposed with speculum and fixed with bullet forceps by the anterior lip. With her left hand she holds the bullet forceps, and with her right hand she holds the probe between her thumb and forefinger by the handle. This important point should be observed so that if there are obstacles, the probe can be placed between the fingers. It is important to know the location of the uterus: when it is positioned in anteversio-flexio, the concave surface of the probe turns upward, and in retroversio-flexio, it turns downward. Then, with slow movements, the fundus of the uterus is reached, after which all its walls are examined.
- Expansion of the cervical canal
Execution technique. The cervix is exposed with speculum and fixed with bullet forceps (or Museau) by the anterior lip. The expansion of its canal is carried out using metal bougies (Gegard expanders) from No. 1 to No. 16 (and more), differing from one another by 0.5-1.0 mm. One end of the expander is rounded, the other has a plane with a number. The bougies have a curvature, the direction of which is taken into account when inserting them into the cervical canal, depending on the position of the uterus, as with the insertion of a probe (anteflexio-versio, retroflexio-versio).
The expansion of the cervical canal is always preceded by probing of the uterus. Depending on the purpose, the canal is expanded to 0.5-2.0 cm or more (abortions at different stages of pregnancy, curettage of the uterine mucosa, etc.). In some situations, the cervical canal is opened by dissection.
- Curettage of the uterine mucosa
Therefore, this operation should be treated with great responsibility and with knowledge of all the conditions and rules for its implementation.
Before the operation, a vaginal examination is required with a clear assessment of the anatomical and functional state of the female genital organs.
Execution technique. The cervix is exposed with mirrors and grabbed with Musot forceps (or two bullet ones) behind upper lip. After proper treatment with disinfectants, the vaginal speculum is changed. The external pharynx and cervix are treated with a swab moistened with alcohol. The latter is pulled downwards and towards itself using Musot forceps (if the uterus is positioned in retroflexio-versio, upwards and towards itself in order to avoid its perforation). The length of the uterine cavity is measured with a probe. It should be inserted easily and freely, without significant effort. The cervical canal is opened with Gegard dilators (one from the other through a full size) up to No. 10 (for gynecological curettage) or large sizes (for abortions). Dilatation of the cervical canal should be carried out without violence. If it is difficult to insert the dilator, you should return to the previous smaller size. It is necessary to remember the direction of the cervical canal when inserting dilators: the concavity of the dilator is upward when the uterus is positioned in anteflexio-versio and downward when it is retroflexio-versio.
Taking this into account, after opening the cervical canal, a curette is inserted into the uterine cavity. The movements of the curette should be such that the insertion is slow and the withdrawal is faster. The curette does not move out with each movement. First, the back wall of the uterus is scraped, then the front and sides. There must be curettes, the operation begins with a larger curette and ends with a smaller one. At the end of the operation, a specific sound of a scraping curette on a hard object (the dense wall of the uterus) is heard along all walls of the uterus. In places where it is absent, scraping is carried out. At the end of curettage, the forceps are removed and the cervix is treated with 5% tincture of iodine or alcohol.
- Abdominal puncture through the posterior fornix
Puncture technique. The cervix is exposed with mirrors, fixed with Musot forceps by the posterior lip and retracted upward. In this case, the posterior arch is stretched, which is pierced with a special long needle with a diameter of up to
- mm. A puncture through the peritoneum is felt as a soft crunch and gentle movements (turns) of the needle up and down and left and right are detected. The advancement of the needle beyond the wall of the fornix should not be more than 1.0-1.5 cm. After this, if fluid does not flow through the needle from the abdominal cavity, an attempt is made to suck it out with a syringe. Usually, after inserting a needle into the abdominal cavity, if there is liquid in it, the latter flows through the needle dropwise or even in a stream. In complicated situations, the needle may enter the wall of the uterus, the rectum, or other formations of the pelvic cavity. In special situations, it is possible to perform this manipulation without mirrors and fixation of the cervix. To do this, the index and middle fingers of the left hand are inserted into the vagina, they press upward on the area of the uterosacral ligaments, and a needle is passed between the fingers with the right hand, which pierces the wall of the posterior fornix.
- Surgeries for tumors of the external genitalia
Execution technique. If there is a pedicle, the latter is intersected between the clamps, and the tumor is removed. Tumors located deep in the tissue are removed through incisions made over the tumor. Tumors are removed by cutting within healthy tissue. In this case, the surgeon should be careful, especially when localizing tumors near the urethra, clitoris and rectum, in order to avoid their damage. Hemostasis is carefully performed, since there is a high probability of hematoma formation. The wound is sutured in layers.
- Operations for kraurosis and leukoplakia of the vulva
Execution technique. If the pathological process is limited, its excision is carried out, followed by suturing of the wound. However, with kraurosis, the process most often involves the tissue of the vulva over a significant extent, i.e. the process is common. Therefore, surgical treatment in such situations consists of vulvectomy. Incisions are made along the outer edge of the labia majora, which connect above the ulitorum, and at the bottom they rise vertically along the inner edge of the labia minora and end above the urethra. Between the incisions on the right and left, the skin and fatty tissue are removed. Careful hemostasis is performed. Edges of skin tears and
The mucous membranes are connected with separate sutures.
- Surgeries for diseases of the large gland of the vaginal vestibule
Execution technique. The incision is made longitudinally outward from the gland. Blunt enucleation of the cyst usually fails; it is excised with a scalpel. It is advisable to remove the cyst without damaging its capsule, although this is not always possible. Hemostasis is performed in the area of the cyst bed, followed by layer-by-layer suturing. When the cyst capsule is opened, its bed is drained.
8. Opening the abscess of the large gland of the vestibule of the vagina.
A number of techniques for this operation are used.
Execution technique. An incision is made in the area of greatest convexity (fluctuation) of the formation. The second incision is made at the bottom of the abscess. Gauze drainage is passed through both holes. It is possible to open with a longitudinal or transverse incision with subsequent suturing of the edges (marsupialization). If abscess formation recurs, the entire gland is removed.
- Removal of condylomas
Execution technique. Condylomas are excised at the base with a scalpel. The wound surface is subjected to local treatment, which is combined with etiotropic therapy. Currently, condylomas are often removed using diathermocoagulation, diathermoexcision, laser therapy, and cryoexcision.
- Surgeries for tumors and cysts of the vagina
Execution technique. The vaginal mucosa above the formation is incised and the tumor or cyst is removed. This does not represent a technical difficulty when localizing formations in the area of the vestibule of the vagina and in its lower parts. But since Gartner’s ducts usually end in the area of the vaginal vault along the outer walls, the cysts from them are located higher. In such situations, when the cyst is removed, there is a risk of damage to the bladder, urethra, or even the ureter. Therefore, during the operation, control is carried out using a catheter. If necessary, the upper pole of the cyst or tumor capsule is cut off or left. Identification during pregnancy and childbirth of a cyst that impedes the advancement of the fetus is the basis for puncture and evacuation of the liquid contents of the cyst without removing the capsule. Subsequently, in such cases, recurrences of the cyst occur, which will require radical surgical intervention.
- Cervical dissection
Execution technique. It is exposed in the mirrors and fixed with bullet forceps by the anterior and posterior lips of the cervix. The outer edges of the external pharynx or in the area of the posterior lip are incised. Dissection of the walls of the cervix should not be carried out high (up to the fornix) in order to avoid damage to the vessels or ureters. Suturing of wound surfaces is carried out upon achieving the set goals.
- Biopsy and removal of cervical polyps
Execution technique. The cervix is exposed with mirrors and fixed with bullet forceps. The sites to be excised (usually identified by previous colposcopy) should be free of bullet forceps. They are grabbed with tweezers and excised in the form of a cone within the healthy tissue.
Depending on the size of the excised part of the cervix and the degree of bleeding, the wound is electrocoagulated or a suture is placed on it. In a similar way, polyps are removed, followed by separate curettage of the mucous membrane of the cervical canal and the uterine cavity.
13. Scarification of the cervix is puncturing cysts in the cervical area in order to empty them of their contents. This is done 2-3 times daily or every other day. Anesthetics are injected into the cervix. This method of treating cystic changes in the cervix is currently used extremely rarely. Instead, diathermoexcision or diathermoconization is performed.
- Abortion surgery
Artificial termination of pregnancy (abortus artificialis). Induced abortion is performed up to 21 weeks of pregnancy (previously up to 27 weeks). In the early stages (up to 12 weeks), termination of pregnancy is carried out using a curette, vacuum aspiration and other methods.
Curettage of the uterus for the purpose of termination of pregnancy is performed according to the same principles as diagnostic, but with certain differences.
Execution technique. The cervix is exposed in the mirrors and fixed with Musot forceps by the upper lip. All further manipulations are carried out taking into account the location of the uterus: when inserted into the uterus, curved instruments are directed upward with the concave surface positioned upward when the uterus is located in anteflexio-versio, and vice versa - with the concave surface downward with the instrument directed downward when it is located in retroflexio-versio.
When probing the uterus, its location is clarified, the patency of the cervical canal and the length of the uterus are determined.
The cervical canal of the cervix is expanded with the help of Hegar dilators from No. 1 to No. 12 (for a pregnancy of 10-12 weeks), to No. 9-10 (for a pregnancy of up to 8-9 weeks).
Curette No. 6 destroys and removes the fertilized egg. An abort tang is also used for this purpose. The mucous membrane (decidua) of the uterus is removed from all its walls using a curette located in right hand between the index and thumb when inserting into the uterus and in the palm of the hand when withdrawing. The area of the uterine walls where the fertilized egg was attached is especially carefully checked.
The feeling of a specific “crunch” when moving the curette along the walls of the uterus indicates that the fertilized egg and the uterine mucosa have been removed.
Artificial termination of pregnancy using vacuum aspiration has been carried out in the world since the early 20s, and in Belarus in all antenatal clinics - since the late 70s of the 20th century. For this purpose, a number of devices have been created, the essence of which is that the fertilized egg is removed using vacuum aspiration through special tubes with tips inserted into the uterus.
Execution technique. The cervical canal is expanded 1-2 mm larger than the thickness of the tip inserted into the uterus (its diameter is 5-8 mm), the latter at the end has one or two holes on the side walls. The end of the tip has a rounded shape. It is connected through a rubber or polyethylene tube to a vacuum device with negative pressure up to 1 atm. The absence of aspirate from the uterus and the appearance of air bubbles indicate removal of the fertilized egg.
Termination of pregnancy using vacuum aspiration is performed during pregnancy up to 5 weeks on an outpatient basis. The duration of such an intervention is 2-5 minutes and can be performed without anesthesia.
There are a number of other methods using hormonal, medication and physiotherapeutic agents to terminate pregnancy.
In our clinic (I.V. Duda, O.K. Kulaga, V.I. Duda) a method of terminating pregnancy in the early stages (up to 3-4 weeks) has been developed using UTI (pulse magnetic field). This is carried out as physiotherapeutic procedures (lasting 10-15 minutes) for 1 to 4 days on an outpatient basis.
For spontaneous miscarriages surgical interventions are performed in the following situations: an abortion that has begun (abortus imminens), in which all manipulations are actually carried out, as with an artificial abortion, but more often without pre-expansion cervical canal (usually it is already open); abortion in progress (abortus protragens), when the fertilized egg has separated from the walls of the uterus and is located in the birth canal (cervical canal, vagina) and must be removed, often with an abortionist, with subsequent monitoring of the cavity and walls of the uterus; incomplete abortion (abortus incompletus), when the remnants of the fertilized egg and uterine mucosa are removed using a curette and abortionist; complete abortion (abortus completus), in which only a control examination of the uterine cavity is carried out.
With an infected abortion, the same actions are actually carried out as with a spontaneous abortion. The differences are that an infected abortion is most often a consequence of criminal intervention, during which the genitals and even abdominal organs could be damaged.
With an infected abortion, there is usually endometritis, in which intrauterine intervention has an increased risk of uterine perforation and other damage.
Cervical pregnancy is a condition when the fertilized egg is localized in the cervical canal. A radical surgical intervention is indicated - hysterectomy. Only in some cases is it possible to remove the fertilized egg, scrape the walls of the uterus and cervical canal, followed by its tamponade. Sometimes it is possible to preserve the uterus in this way, which, however, is associated with a high risk of massive blood loss.
- Features of hemostasis during gynecological operations
To understand how much an operation to remove uterine fibroids costs in a clinic, you need to understand what types of interventions there are and how they differ. One of the most common diseases of the female reproductive system in our country is uterine fibroids. This is one of the types of benign neoplasms in women. It can develop both in the wall and on the inner or outer surface of the mucous membrane. To treat this disease, gynecologists offer women two classical methods– hormonal and operational. Each method has its own contraindications and recommendations.
What is taken into account during treatment?
The nature of treatment directly depends on the type, size and growth rate of the tumor. It can be represented by a nodule several millimeters in size, or a formation weighing about 1 kg.
There is a group of indications for which surgical intervention is extremely necessary, and hormone therapy is dangerous and ineffective.
Surgery
Removal surgery is necessary in cases where:
- The growth rate of the tumor is too rapid;
- The tumor puts pressure on other internal organs;
- The disease is accompanied by severe painful sensations;
- Provokes frequent and fairly heavy bleeding;
- The disease at the thermal stage cannot be treated with hormonal therapy;
- There is a risk of cancer due to the tumor;
- Significant size and weight of the formation.
Selecting a method
Modern medicine offers women several methods of surgical intervention. The method is selected individually for each case and depends on many factors, including:
- Patient's age;
- Tumor size;
- Stage of the disease;
- The presence or absence of extensive fibroids, consisting of several nodes;
- Can the patient conceive and carry a child? does she plan to do this in the future?
Surgery to remove uterine fibroids: types
Today, doctors offer several options for removing fibroids, depending on the stage of the disease and other important factors.
This method includes several subtypes. After the operation, the woman retains the ability to produce offspring. Only nodes, that is, foci of tumor occurrence and growth, are eliminated surgically.
- Laparoscopic. A special instrument is used for this – a laparoscope. She prescribes it for those patients whose tumor is represented by many nodes of varying degrees of localization. The operation is extremely complex, there are many contraindications, and complications often occur after it.
Contraindications include:
- Diseases of the cardiovascular system;
- Chronic liver failure;
- Increased blood sugar levels;
- Severe chronic diseases of the body's respiratory system;
- Blood coagulation disorder;
- Possible presence of cancer;
- Dimensions too large (from 0.1 m).
- Laparotomy. This subtype entails a long rehabilitation period, but the results are reliable. Just like laparoscopy, it is performed through an incision or puncture in the abdominal cavity.
- Hysteroscopic. Unlike previous methods, hysteroscopic myomectomy involves the insertion of instruments so that the operation is performed through the vaginal opening into the uterus without damaging the skin. This method is used mainly for fibroids with a subcumatous tumor location.
It is an artificial blockage of blood vessels, as a result of which the flow of blood to the myomatous nodes is suspended, as a result of which their growth stops and the tumor cells gradually die. It is performed under local anesthesia. An embolization drug is injected into the femoral artery through a catheter. Elements of the drug provoke the death of tumor cells, but do not cause any harm to healthy cells of internal organs. Embolization treatment guarantees complete recovery and makes it impossible for the disease to return after some time.
The implantation is absolutely painless and does not entail any harm to the reproductive organs, which means that the woman’s body will be able to perform reproductive functions in the future.
There should be no side effects or complications, but doctors do not exclude the possibility of an allergy to certain components of the drug.
Radical surgery
In advanced forms of this disease, hysterectomy, or removal of the uterus, is used. Afterwards, the possibility of having children is completely excluded, as a result of which hysterectomy is prescribed for patients who do not plan to give birth in the future or when there is no other cure, and alternative surgical methods are not applicable to this case for one reason or another.
An organ is removed in cases where:
- Rapid trends in the development of nodes;
- Large amount of education;
- Thermal stage of the disease.
Hysterectomies are performed by cutting into the abdomen or laparoscopic incisions and punctures.
Rehabilitation after intervention
After intervention using any of the proposed methods, rehabilitation is prescribed. This appointment is especially important in severe cases. Rehabilitation must be carried out in several stages, one after another in a clear sequence, and it is imperative to carefully follow all the instructions of the attending physician and lead a correct, healthy lifestyle. What are the main recommendations that doctors give to their patients?
The formation is eliminated using the methods described above; the organ is removed only in the most serious and dangerous cases, and if other methods of combating nodes and tumors are useless. This happens especially often when the disease becomes malignant or threatens to become so.
Before performing this kind of surgical intervention, the patient is prescribed an ultrasound examination, EEG, blood test, ECG and scraping. You should also undergo a thorough examination by a gynecologist. This is important, since for surgery it is necessary to know the type of tumor based on its location relative to the organ. It is also necessary to understand that such an operation can have serious consequences and lead to complications. The smallest consequence is a scar from the intervention.
If surgery cannot be avoided, it is extremely important to follow the doctor’s advice during the rehabilitation period. Psychological rehabilitation after the intervention is no less important.
The patient needs support and attention, and a person who will let the woman understand that after the intervention her life does not end, and there is no less bright colors than it was before. But you will still need to take some things for granted. You will have to monitor your health more carefully.
Even if the formation was eliminated in another way, the patient in any case will face dramatic changes in life, constant vigilance of her health and self-care.
Factors influencing recovery
After laparoscopic myomectomy, it is recommended to return to normal work within 15-25 days after the intervention.
Absolute restoration of performance largely depends on whether the patient had concomitant diseases, such as:
- Diabetes.
- Kidney or liver failure;
- Problems with the cardiovascular system;
- Musculoskeletal system;
- Nervous system;
- Violation of blood coagulation (clotting);
- Severity of anemia before surgery.
Sexual activity is possible about a month after laparoscopic myomectomy. In the future, you should regularly (at least 2 times a year) be examined by a gynecologist to prevent relapse.
Often the solution to “women’s” health problems is gynecological surgery. They have many types - we will tell you about each of them.
Operations in gynecology are of great importance. They make it possible to cope with diseases that were previously considered incurable. But a woman’s reproductive function is very delicate, and therefore the decision on surgical intervention is made by the doctor only in exceptional cases when conservative treatment does not help. The gynecologist analyzes the positive effect and the risk of possible complications. Women's health is important. Contraindications to a particular gynecological operation have a priority role. Severe damage to the cardiovascular system, liver disease, kidney disease, etc. this is an argument for continuing conservative treatment.
Minor gynecological operations
These include: early induced abortion, separate therapeutic and diagnostic curettage, knife biopsy and conization of the cervix, diathermocoagulation, cervicoscopy, hysteroscopy.
Early abortion is considered before 12 weeks of pregnancy. According to the legislation of the Russian Federation, it can be performed at the request of the woman. There are three methods of such an abortion: medication, vacuum, and surgery. We are interested in the latter: it is the most dangerous. The consequences of such an operation may be removal of the uterus and, accordingly, infertility. Complications in the urinary system are also possible, which will be very difficult to cure. Gynecologists resort to this method as a last resort.
Separate diagnostic curettage is an operation performed to diagnose pathologies of the uterine mucosa and cervical canal. This is actually a type of biopsy, i.e. collection of tissues and sending them for research. The operation is performed with a special instrument - a curette using a hysteroscope (a device equipped with optical system to examine the uterine cavity).
An indicator for this procedure may be uterine fibroids, endometriosis, endometrial pathologies, uterine bleeding, etc. It is performed in the first phase of the menstrual cycle under anesthesia. The entire operation takes approximately 20 minutes, but then you need to spend several hours in the hospital under the supervision of a doctor. The patient must first undergo a general examination.
We have already talked about what a biopsy is. It is prescribed for suspected cervical dysplasia or cancer. Based on the results of the analysis, we can talk about the benignity or malignancy of the cells.
The procedure is prescribed if poor cytology smear results are obtained, suspicious changes have appeared in the cervix, or polyps. To exclude possible complications, give up sex, tampons and any medications other than those mentioned by your doctor for 2 days. Do not eat 8 hours before the procedure.
Conization of the cervix is used not only for diagnostic, but also for therapeutic purposes. It is prescribed for pathologies of the cervical canal mucosa, positive cytology results, dysplasia, ruptures, etc. There are three methods of conization: knife, laser and loop. The latter is the most common and effective.
Preparation for surgery consists of a blood test, bacteriological smear, biopsy and colposcopy. The procedure is carried out in the first days after menstruation and lasts no more than fifteen minutes. Complications may include mild pain, discharge, and heavy periods. 2 weeks after the operation, you must come for a follow-up appointment with the doctor.
Diathermocoagulation is a popular method of treating cervical erosion. This is cauterization with electric current. The procedure is quite unpleasant, but does not bring any particular painful sensations. But it is publicly available and cheap. It is performed within 20 minutes without anesthesia. Until the evening, the patient remains in the ward under the supervision of a doctor. In the evening he goes home if there are no complaints or complications. The disadvantages of the procedure include pain, prolonged healing, the likelihood of needing a repeat procedure, and the inability to use nulliparous women.
Cervicoscopy is another examination method. It examines the mucous membrane of the cervical canal using a hysteroscope. Indications for cervicoscopy are bleeding, hyperplasia, polyps, endometriosis, etc.
Hysteroscopy allows you to examine the canal and cavity of the uterus, the mouth of the fallopian tubes. A hysteroscope is inserted and the condition of the organs is assessed through the image on the monitor. This helps to identify endometriosis, uterine fibroids, etc. It is most often performed under anesthesia. After surgery, there may be some mild pain and discharge.
Cervicoscopy, laparoscopy, colposcopy, hysteroscopy, culdoscopy – these are. Endoscopy is a visualization method that is based on the introduction of special optical devices into the body.
Major gynecological operations
They involve a large volume of surgical intervention and, as a result, a longer hospital stay.
Types of large operations:
- Laparoscopic. Entry into the abdominal cavity through 3 small incisions in the navel and iliac regions.
- Laparotomy. Entry through a transverse or longitudinal incision.
- Vaginal. Passed through the vagina, without an incision.
The most dangerous operation is considered to be a hysterectomy, or removal of the uterus. It is performed for a malignant tumor of the uterus, cervix or ovary. Can also be prescribed for fibroids or endometriosis, if conservative treatment Does not help. The uterus can be removed completely, including the cervix and appendages, or partially. This operation deprives a woman of the opportunity to become a mother. Sex life you can continue, but neither menstruation nor pregnancy will occur. The operation can have many consequences: bleeding, damage to neighboring organs, infections, emotional disturbances, osteoporosis, loss of libido, pain, vaginal prolapse, etc. Of course, it will not be possible to return everything back. They resort to this operation only when there is an exceptional threat to the health and life of a woman.
Myomectomy is another dangerous operation on the uterus, but it leaves the main thing - the woman’s reproductive function. The procedure is performed in the presence of a benign tumor. Only fibromatous nodes are removed, preserving the body of the uterus. This operation is also carried out in at a young age. Preliminary tests are taken. At the time of the procedure, the patient is immersed in anesthesia, after which she is placed in a ward under the supervision of a doctor.
A clinical and biochemical analysis is performed, an AIDS examination, urine and stool analysis, colposcopy, ultrasound, chest x-ray, and ECG are performed. For certain operations, additional examinations are prescribed. it cannot be - there is a minimum of necessary tests. Training can take place in a hospital setting. Gynecology at the modern level can guarantee the patient complete monitoring, from diagnosis to recovery.