Amputation of the uterus (hysterectomy) is a gynecological operation that is performed only when absolutely necessary, when the question arises of saving the patient’s life.
If severe pain and bleeding are the consequences of endometriosis and fibroids, the patient is asked to choose whether to continue living with such torment or agree to amputation.
Depending on the degree of organ damage and the reasons for the need for surgery, the type of amputation is selected.
Laparoscopic. The operation is performed using several small incisions in the anterior abdominal wall.
Laparotomy. One incision is made abdominal cavity required size. Typically used for very large lesions.
Hysteroscopic. Performed by making an incision back wall vagina. The method is used in cases where there is no need to remove appendages or for small tumors. Applies only to women who have given birth.
After the period necessary for recovery after the operation, the woman returns to normal life.
But there are a number of problems that she may encounter.
Very often, a hysterectomy causes the patient to feel inferior. She feels unwanted, unloved and unhappy. Such emotional problems are not difficult to deal with as a family. It is very important to surround your loved one with love, attention and care. Pity will be unnecessary and can only cause new problems. Better than everyone possible ways show how dear and loved a person is. However, in some cases it may be necessary psychological assistance. This is especially important if a woman is lonely and is unable to get rid of depression on her own.
Some time after the operation, a woman can return to her usual lifestyle - go to work, do her favorite things and hobbies.
Many patients experience increased libido due to lack of anxiety about unwanted pregnancy. Supravaginal amputation of the uterus without appendages does not reduce sexual desire, since it does not affect the main erogenous zones. A decrease in sexual activity can only occur if the ovaries are removed, which causes a change in hormonal levels.
This is one of the main problems for patients, especially those without children. The only solution in such a situation is surrogacy or adoption. It is worth remembering that the consequences of refusing surgery can be more serious. After all, it is prescribed only in case of emergency to save the patient’s life.
Hysterectomy leads to a complete cessation of menstruation, and this eliminates PMS, which causes more and more discomfort over the years. And also, when sexual relations are resumed, there is no need for contraception.
Usually there are no health problems after surgery. The woman can continue to lead her usual lifestyle. But sometimes consequences such as discomfort and pain during sexual intercourse may occur. This usually happens in cases where intimate relationships are resumed too early. It is necessary to follow the doctor's recommendations and abstain for the required time.
Some women complain of vaginal prolapse, this is due to a violation of the location internal organs. Kegel exercises can help in such a situation. If appendages were removed during surgery, this may lead to the development of osteoporosis as a symptom. early menopause.
If during the operation only the uterus was removed, then hormonal background remains normal. But if the appendages are removed, menopause quickly sets in, as estrogen production stops completely.
In this case, menopause is very difficult, especially in young women. After the operation, they are prescribed hormonal drugs, which reduce unpleasant symptoms and allow the body to gradually adapt to a new way.
Undoubtedly, amputation of the uterus is a serious stress for the body, and especially for the psycho-emotional state of a woman. To recovery period passed as soon as possible, you need to follow some recommendations.
Doctor of Medical Sciences, Professor Afanasyev Maxim Stanislavovich, oncologist, surgeon, oncogynecologist, expert in the treatment of dysplasia and cervical cancerHistorically, medicine has established the opinion that the uterus is needed only for bearing a child. Therefore, if a woman does not plan to give birth, she can safely resort to surgery.
Is this really true or not? Why, for example, in March 2015, Angelina Jolie had both ovaries removed from her fallopian tubes, but left an “unnecessary” uterus? Let's find out together whether hysterectomy is dangerous. And if it’s dangerous, then with what.
From a surgeon's point of view, radical surgery solves the issue “at its root”: no organ – no problem. But in fact, surgeons’ recommendations cannot always be perceived as objective. They often do not follow up with patients after discharge, do not conduct examinations six months, a year, 2 years after removal of the uterus, and do not record complaints. Surgeons only operate and rarely face the consequences of the operation, so they often have a false idea about the safety of this operation.
Meanwhile, scientists different countries independently conducted a series of observations. They found that within five years after hysterectomy, most women developed:
1. (previously absent) pelvic pain of varying intensity,
2. problems with the intestines,
3. urinary incontinence,
4. vaginal prolapse and prolapse,
5. depression and depression, up to serious mental disorders,
6. emotional and physiological problems in a relationship with a spouse,
7. Some women who were operated on for severe dysplasia or in situ cancer experienced a recurrence of the disease - damage to the stump area and vaginal vault.
8. fatigue,
9. steady increase blood pressure and other serious cardiovascular problems.
The problem is not invented, because according to the data Science Center obstetrics, gynecology and perinatology of the Russian Academy of Medical Sciences, various operations for hysterectomy make up from 32 to 38.2% of all abdominal gynecological operations. In Russia, this is about 1,000,000 uterus removed annually!
The problem also has another side. Since all of these complications develop gradually, over the course of a year or several years after surgical intervention, women do not associate the deterioration in their quality of life with the previous operation.
I am writing this material so that you can evaluate for yourselfall the pros and cons of the operation, weigh the pros and cons,and make your choice consciously.
My practice shows that there are no extra organs. Even in older women, removal of the uterus carries negative consequences for health, and in the second part of the article I will dwell on them in detail.
Thanks to the introduction of high-tech methods, some of the indications for genital removal have ceased to be absolute indications. Here is a list of diagnoses for which removal of the uterus in women can be replaced by other treatment methods and the organ can be saved.
1. Symptomatic, enlarged, rapidly growing uterine fibroids are today treated by embolization of the uterine arteries: the vessels feeding the fibroids are blocked. Subsequently, the fibroid gradually resolves.
2. Adenomyosis, or internal endometriosis, can be eliminated using a therapeutic method (PDT).
Endometriosis causes cell proliferation inner shell uterus in atypical places. PDT specifically destroys these cells without affecting healthy tissue.
Photodynamic therapy is an organ-preserving treatment method that is part of federal standard providing medical care(see).
3. Precancerous condition of the endometrium -, – are also treatable using PDT. To date, I have successfully treated 2 patients with this pathology.
In cases where hyperplasia is predominantly viral in nature, treatment with PDT can eliminate the cause of the disease. In the treatment of cervical pathologies, the complete destruction of the human papillomavirus after one PDT session is confirmed in 94% of patients, and in 100% of patients after a second PDT session.
4. Precancerous conditions and oncological formations in the cervix. , and even microinvasive cancer can be completely cured using photodynamic therapy in 1 or 2 sessions.
The PDT method eliminates not only the disease itself, but also its cause – the human papillomavirus.
That's why correctly and completely performed photodynamic therapy is the only method that ensures lifelong recovery and minimal risk relapses (reinfection is possible only if reinfection HPV).
There is one more good news. Previously, a combination of age and several gynecological diagnoses was a compelling reason for organ removal. For example, a combination of cervical condylomas and uterine fibroids, or cervical dysplasia with adenomyosis against the background of a completed labor function.
To justify the removal of an organ, the surgeon usually does not give rational arguments, but refers to own experience or established opinion. But today (even if the attending physician tells you otherwise) a combination of several diagnoses is no longer a direct indication for removal of the uterus. Modern medicine considers each diagnosis as independent, and for each treatment tactics is determined individually.
For example, dysplasia and adenomyosis regress after photodynamic therapy. And the presence of multiple fibroids is not a reason for oncological alertness. Numerous observations recent years show that fibroids are in no way associated with cancer and do not degenerate into cancerous tumor and is not even a risk factor.
In surgery, there is a concept of risks of therapeutic effects. The task of a good doctor is to minimize risks. When a doctor decides on treatment tactics, he is obliged to evaluate the indications, weigh the possible negative consequences of different treatment methods, and choose the most gentle and effective one.
By law, doctors must inform everyone possible methods treatment, but in practice this does not happen. Therefore, against the backdrop of the surgeon’s urgent recommendations for organ removal, I strongly advise you to consult several specialists or write to me to evaluate the possibility of performing organ-conserving treatment that is suitable for you.
Unfortunately, not all diseases of the uterus can be treated with minimally invasive and therapeutic methods, and in some cases it is still better to remove the uterus. Such indications for removal are called absolute - that is, not requiring discussion.
1. Uterine fibroids with necrotic changes in the node. Preservation of an organ with such a diagnosis poses a threat to life.
2. Long lasting uterine bleeding that cannot be stopped by any other means. This condition is fraught with the loss of a large volume of blood and poses a serious danger to life.
3. Combination of large uterine fibroids and cicatricial deformation of the cervix.
4. Uterine prolapse.
5. Cancer, starting from stage I.
6. Giant size of tumors.
Depending on the indications, operations on the uterus are performed different methods and in different volumes. First, we will get acquainted with the types of surgical interventions. Then I will dwell in detail on the consequences that every woman will experience to one degree or another after the removal of this organ.
IN medical practice abdominal and endoscopic removal uterus.
Abdominal surgery to remove the uterus through a large incision is one of the most traumatic procedures. In addition to the complications caused directly by the removal of the uterus, such an operation has other negative consequences.
1. After the operation, a noticeable scar remains.
2. High probability of hernia formation in the scar area.
3. Open surgery usually leads to the development of extensive adhesions in the pelvic area.
4. Rehabilitation and restoration (including performance) requires a lot of time, in some cases up to 45 days.
Whether the cervix is left or removed during a hysterectomy depends on the condition of the cervix and the risks associated with retaining it.
If the cervix is left, this is the most favorable situation possible.
On the one hand, due to the preserved ovaries hormonal system continues to function more or less normally. But why do they leave the cervix when removing the uterus? Preserving the cervix allows you to maintain the length of the vagina, and after restoration the woman will be able to lead a full sex life.
Removal of the uterus without appendages, but with the cervix, is a more traumatic operation.
By leaving the ovaries, the surgeon allows the woman to maintain normal hormonal levels. If the operation is performed at a young age, the ovaries can avoid menopause and all associated health consequences.
But even after removal of the uterus without appendages, the anatomical relationship of the organs is disrupted. As a result, their function is impaired.
Besides, complete removal of the uterus, even with preservation of the ovaries, leads to shortening of the vagina. In many cases, this is not critical for sex life. But the anatomy of the organ is different for everyone, and not all women manage to adapt.
This is the most traumatic operation that requires a lot of recovery time.
She needs serious hormonal correction and usually causes all the most severe consequences, especially if performed at the age of 40-50 years - that is, before the onset of natural menopause.
I will tell you more about the most common consequences of hysterectomy below. The most unpleasant thing is that all these consequences are irreversible and practically impossible to correct.
Meanwhile, a series of recent scientific research in this area says the opposite. Even if the ovaries are preserved, removal of the uterus is an operation With high risk endocrine disorders.
The reason is simple. The uterus is connected to the ovaries and tubes by a system of ligaments, nerve fibers and blood vessels. Any operation on the uterus leads to serious disruption of the blood supply to the ovaries, up to partial necrosis. Needless to say, in literally suffocating ovaries, the production of hormones is disrupted.
Hormonal imbalances manifest themselves in a whole string unpleasant symptoms, the most harmless of which is a decrease in libido.
In the vast majority of cases, the ovaries are not able to completely restore or compensate for normal blood supply. Accordingly, it is not restored and hormonal balance female body.
This is a fairly common complication in cases where the ovaries are preserved after removal of the uterus. This is how it manifests itself negative influence the operation itself.
To understand the nature of the cyst, you must first understand how the ovaries work.
In fact, a cyst is a natural process that occurs every month in the ovary under the influence of hormones and is called follicular cyst. If the egg is not fertilized, the cyst bursts and menstruation begins.
Now let's see what happens to the ovaries after removal of the uterus.
The uterus itself does not produce hormones. And many surgeons assure that after its removal the hormonal levels will not change. But they forget to say how closely the uterus is connected to other organs. When separating the ovaries from the uterus, the surgeon inevitably disrupts the blood supply and injures them. As a result, the functioning of the ovaries is disrupted, and their hormonal activity decreases.
Unlike the uterus, the ovaries produce hormones. Disturbances in the functioning of the ovaries lead to disruption of hormonal levels and the process of follicle maturation. The cyst does not resolve, but continues to grow.
It takes about 6 months to restore full functioning of the ovaries and level out hormonal levels. But not always everything ends well, and the enlarged cyst resolves. Often, to remove an overgrown cyst, it is necessary reoperation– with large tumors there is a risk of rupture and bleeding.
If, several months after removal of the uterus, pain appears in the lower abdomen, which increases over time, you should visit a gynecologist. The most probable cause, why does the ovary hurt, it’s an overgrown cyst.
The likelihood of developing this complication is only 50% dependent on the skill of the surgeon. Every woman's anatomy is unique. It is not possible to predict the location of the ovaries and their behavior before surgery, so no one can predict the development of a cyst after removal of the uterus.
Extensive adhesions after removal of the uterus often lead to the development of chronic pelvic pain. Characteristic symptoms these pains - they intensify with bloating, indigestion, peristalsis, sudden movements, long walking.
Adhesions after surgery to remove the uterus form gradually. Accordingly, pain appears only after some time.
On initial stage postoperative adhesions in the small pelvis are treated conservatively; if ineffective, they resort to laparoscopic excision of adhesions.
Body weight after surgery can behave differently: some women gain weight, sometimes even gain weight, while others manage to lose weight.
The most common scenario after removal of reproductive organs is rapid weight gain, or a woman’s belly grows.
1. One of the reasons why women gain weight is due to violation metabolic processes and the fluid retention it causes in the body. Therefore, strictly monitor how much water you drink and how much you excrete.
2. After removal of the uterus and ovaries, the hormonal levels change, which leads to a slowdown in the breakdown of fat, and the woman begins to gain excess weight.
In this case, a gentle diet will help to remove belly fat. Meals should be fractional, small portions 6-7 times a day.
Should you worry if you have lost weight after having your hysterectomy? If the reason for the operation was a giant tumor or fibroid, there is no need to worry, you lost weight after removing the uterus.
If there was no mass formation, but you are losing weight, most likely it is a hormonal imbalance. To return your weight to normal, you will need hormone therapy.
Women who have undergone vaginal hysterectomy should observe sexual rest for at least 2 months until they heal. internal seams. In all other cases, sex can be had 1-1.5 months after the operation.
Sex life after removal of the uterus undergoes changes.
In general, women are concerned about vaginal dryness, burning after intercourse, discomfort, painful sensations. This occurs due to a drop in estrogen levels, which causes the genital mucosa to become thinner and begin to produce less lubricant. Hormonal imbalance reduces libido, decreases interest in sex life.
Does a woman have an orgasm after a hysterectomy?
On the one hand, all sensitive points - the G-spot and the clitoris - are preserved, and theoretically a woman retains the ability to experience orgasm even after removal of the organ.
But in reality, not every woman gets an orgasm after surgery.
Thus, when the ovaries are removed, the content of sex hormones in the body drops sharply, and many develop sexual coldness. A decrease in the production of sex hormones occurs even if the ovaries are preserved - for many reasons, after surgery, their activity is disrupted.
The best prognosis for orgasms is for those who still have a cervix.
The consequences after removal of the uterus and cervix are manifested in a shortening of the vagina by about a third. Full sexual intercourse often becomes impossible. Studies carried out in this area have shown that the cervix has great importance in achieving vaginal orgasms, and when the cervix is removed, its achievement becomes extremely difficult.
Pain is one of the main complaints after surgery.
1. In the postoperative period, pain in the lower abdomen may indicate a problem in the suture area or inflammation. In the first case, the stomach hurts along the seam. In the second case, the main symptom is joined high temperature.
2. If the lower abdomen hurts and swelling appears, you can suspect a hernia - a defect through which the peritoneum and intestinal loops extend under the skin.
3. Severe pain after surgery to remove the uterus, high temperature and poor health indicate pelvioperitonitis, hematoma or bleeding. Repeat surgery may be required to resolve the situation.
4. Pain in the heart indicates the possibility of development cardiovascular diseases.
A large Swedish study of 180,000 women found that hysterectomy significantly increases the risk of cardiovascular disease. coronary disease and stroke. Removing the ovaries further aggravates the situation.
5. If you are concerned about swelling of the legs, an increase in local skin temperature, you need to exclude thrombophlebitis of the pelvic veins or lower limbs.
6. Pain in the back, lower back, right side or left can be a symptom adhesive disease, cysts on the ovary and much more - it is better to consult a doctor.
After removal of the uterus, the anatomical location of organs is disrupted, muscles, nerves and blood vessels are injured, and the blood supply to the pelvic area is disrupted. The frame that supports the organs in a certain position ceases to perform its functions.
All this leads to displacement and prolapse of internal organs - primarily the intestines and bladder. Extensive adhesions aggravate the problem.
This is manifested by numerous increasing problems with the intestines and urinary incontinence during physical activity and coughing.
The same mechanisms cause the so-called genital prolapse - drooping of the vaginal walls and even their loss.
If in the postoperative period a woman begins to lift weights without waiting full recovery, then the situation gets worse. Intra-abdominal pressure increases, the walls of the vagina are “pushed” out. For this reason, lifting weights is contraindicated even for healthy women.
When lowering, a woman has a feeling foreign object in the perineal area. Pain bothers me. Sex life becomes painful.
To reduce the symptoms of prolapse of the vaginal walls after removal of the uterus, it is indicated special gymnastics. For example, Kegel exercises. Constipation also increases intra-abdominal pressure, so to prevent the process you will have to learn to monitor bowel function: bowel movements should be daily, and feces– soft.
Unfortunately, vaginal prolapse after hysterectomy cannot be treated.
Intestinal problems after surgery are affected not only by the changed anatomy of the pelvis, but also by a massive adhesive process.
Intestinal function is disrupted, constipation, flatulence, various defecation disorders, and pain in the lower abdomen occur. To avoid intestinal problems, you must follow a diet.
You will have to learn to eat often, 6 - 8 times a day, in small portions.
What can you eat? Everything, with the exception of heavy foods, foods that cause bloating, and stool retention.
Improves the condition of the pelvic organs and regular exercise.
This syndrome develops in almost 100% of cases as a consequence of a violation of the integrity of the ligamentous and muscular framework during surgery. The bladder prolapses and the woman loses control of urination.
To restore bladder function, doctors recommend performing Kegel exercises, but even with exercise, the condition usually progresses.
Uterine surgery is performed for various indications.
Unfortunately, the operation does not protect against relapse if the uterus was removed for one of those diseases that are caused by the human papillomavirus, namely:
Regardless of the technique of execution, surgery does not guarantee 100% recovery, it only removes the outbreak. Traces of the human papillomavirus, which is the cause of all these diseases, remain in the vaginal mucosa. Once activated, the virus causes a relapse.
Of course, if there is no organ, then a relapse of the disease cannot occur either in the uterus or in its cervix. The cervical stump and the mucous membrane of the vaginal vault undergo relapses - dysplasia of the vaginal stump develops.
Unfortunately, relapses are very difficult to treat with classical methods. Medicine can only offer such patients traumatic methods. Removing the vagina is an extremely complex and traumatic operation, and the risks of radiation therapy are comparable to the risks of the disease itself.
According to various sources, relapses after surgery occur in 30–70% of cases. That is why, for the purpose of prevention, the Herzen Institute recommends performing photodynamic therapy of the vagina and cervical stump even after surgical removal uterus. Only eliminating the papilloma virus protects against the return of the disease.
This is the story of my patient Natalya, who faced a relapse of cancer of the vaginal stump after removal of the uterus.
“Well, I’ll start my sad story in order, with happy ending. After giving birth at 38 years old and my daughter turning 1.5 years old, I had to go to work and I decided to see a gynecologist. In September 2012, there were no signs of sadness, but the tests were not reassuring - stage 1 cervical cancer. It was of course shock, panic, tears, sleepless nights. In oncology I passed all the tests, where the human papillomavirus genotype 16.18 was discovered.
The only thing our doctors offered me was expiration of the cervix and uterus, but I asked to leave the ovaries.
The postoperative period was very difficult both physically and mentally. In general, a vaginal stump remained, no matter how sad it may sound. In 2014, after 2 years, tests again show a not very good picture - then after six months, grade 2. They treated her with everything - all kinds of suppositories, antivirals, ointments.
In short, a lot of money was spent, and after a year and a half of treatment for this dysplasia, it went into the third stage and again cancer. What did our doctors offer me this time: photodynamics.
After reading about her, I was delighted and gave myself into their hands. And what do you think, what was the result of them? innovative technologies? And things are still there! Everything remained in its place. But I read so much about this method, studied various articles, I was especially attracted to the photodynamic method of Dr. Afanasyev M.S., and having compared the method and technology of treatment, I was surprised that everything that this doctor writes and tells was significantly different from how they did it me in our clinic. Starting from the ratio of the drug per kilogram of my weight, the methodology itself, the questions they asked me. After photodynamics, I was forced to wear glasses for almost a month, sit at home with the curtains closed, and not lean out into the street. I had no doubt that they simply did not know how to do this procedure! I contacted Dr. Afanasyev M.S., bombarded him with questions, told my story and he offered his help. I thought and doubted for a long time.
My doctor suggested me radiation therapy, but knowing its consequences and the quality of life after this therapy, I still chose photodynamics again, but that Maxim Stanislavovich would give it to me.
Having gathered new strength, I flew to Moscow. The first impression of the clinic was, of course, pleasant, you feel like a person whom everyone cares about, attentiveness and responsiveness are the main qualities of these employees.
About the PDT procedure and recovery
The procedure itself took place under anesthesia, went away quickly, and in the evening I went to see my sister who was staying with me. I only wore glasses for three days. After 40 days I went for an initial examination to my clinic, but I had an eroded spot, apparently the healing was slow, but despite everything this - tests were good! The doctor prescribed healing suppositories. And when I came back after 3 weeks, the doctor gave me…….., everything healed, and I was very surprised - how did that happen! After all, during the entire practice of conducting photodynamics using their technology, there was not a single positive result! Now I will go for another examination in April. I am sure that everything will always be fine for me now!
This is my story. And I’m telling it to you so that you don’t give up, and during treatment choose the most gentle method of treatment, and not remove everything at once, apparently this is easier for our doctors. If I had found out about Maxim Stanislavovich earlier, I would have avoided these tears, a terrible operation, the consequences of which will strain my whole life! So think about it! No amount of money is worth our health! And most importantly, if you have the human papillomavirus of this particular genotype, which provokes cervical cancer under certain circumstances, you need to remove this cause. This is exactly what photodynamics does, but the technology and the doctor who does it must be masters of their craft. who have extensive experience, scientific works And positive results in this area. And I think the only doctor who observes all this is Maxim Stanislavovich. Thank you very much Maxim Stanislavovich!!!”
The consequences described above after removal of the uterus concern different women to varying degrees. Young women of childbearing age have the hardest time undergoing hysterectomy.
Surgery during menopause also does not greatly affect the health and well-being of a woman.
And if the operation was performed according to indications, then you made the right choice.
If a woman did not have menopause before the operation, then during the recovery period it will be very difficult for her. The consequences of surgery during active childbearing years are experienced much more acutely than at the age of natural menopause.
If the operation was caused by a huge fibroid or bleeding, removal of the uterus provides significant relief. Unfortunately, almost everything develops over time. long-term consequences, which we talked about above.
On medical language this condition is called post-hysterectomy and post-variectomy syndrome. It manifests itself as mood swings, hot flashes, arrhythmia, dizziness, weakness, and headache. The woman does not tolerate stress well and begins to get tired.
Within just a few months, sexual desire decreases and pain develops in the pelvic area. Suffering skeletal system– the level drops minerals, osteoporosis develops.
If hormonal levels are not corrected, aging will begin immediately after surgery: 5 years after hysterectomy, 55–69% of women operated on at the age of 39–46 years have a hormonal profile consistent with the postmenopausal one.
Uterine cancer is adenocarcinoma and carcinoma is a malignant process. The choice of treatment method and extent of intervention depends on the stage of the disease.
Earlier initial stages cancer (, microinvasive cancer) and precancerous diseases (,) were indications for removal of the uterus. Unfortunately, oncological surgery does not eliminate the cause of the disease - the human papillomavirus - and therefore has a high rate of relapses.
The uterus is one of the most important organs female reproductive system. The significance of this anatomical education difficult to overestimate. However, under the influence of many unfavorable factors, pathological conditions can form in a woman’s body, for the treatment of which complete removal or extirpation of the uterus is prescribed.
The division of methods of surgical intervention takes into account such criteria as the scale of the surgical intervention and the method of its management. According to the scale of the intervention, hysterectomy is divided into the following types:
Each of the above interventions can be performed through the following approaches:
The selection of the necessary technique is carried out by the attending physician. Its choice depends on laboratory data and instrumental examination, the nature of the disease and the severity of the pathological process. Before the operation, the consequences of hysterectomy without appendages are assessed, since there is a risk of complications.
The main indications for intervention are conditions in which conservative therapy doesn't give positive effect. Also, it is advisable to use the intervention for malignant neoplasms that have large size or having rapid growth.
The main indications include:
Hysterectomy, like all other types of surgical intervention, has a number of specific contraindications that are important to consider before choosing a method.
Such contraindications include:
It is strictly prohibited to perform extended extirpation of the uterus with appendages if there is a significant increase in the size of the uterus, as well as with large ovarian tumors. The vaginal extirpation technique is contraindicated in the presence of multiple adhesions, after cesarean section, inflammatory diseases vagina and cervix, as well as if you suspect cancer of the body and cervix.
The success of surgical intervention directly depends on the quality of preliminary diagnosis and preparation of the patient. In the preparatory period, each woman must undergo a series of laboratory tests:
In addition, each woman needs to complete a number of such preparatory measures:
The primary stage of surgery is putting the patient under anesthesia. The type of anesthesia is selected by an anesthesiologist. His choice is influenced by the following factors:
Considering the large scale of the operation, before performing it the woman is given general anesthesia. The surgical technique will be presented using the example of supravaginal amputation of the uterus without appendages.
The standard course of a hysterectomy operation includes the following stages:
Before suturing the surgical wound, a medical specialist inspects it. The following indicators are taken into account:
The average duration of surgery is from 60 to 90 minutes.
Most serious complication after amputation and hysterectomy is internal bleeding, which can have varying degrees of intensity. The cause of this complication is poor-quality application of vascular sutures during surgery.
Other complications may include:
In the postoperative period after extirpation of the uterus and appendages, women often experience painful sensations, the intensity of which depends on the scale of the intervention. For the first few days after surgery, the woman is recommended to perform elastic bandaging of the lower extremities. This event is aimed at preventing blood clots.
In addition, the woman is prescribed anticoagulants, medications that improve tissue regeneration, as well as infusion therapy. Postoperative sutures are treated with a solution of brilliant green once a day.
After discharge from the hospital, the woman is recommended to wear compression garments for the first 2 months after surgery. Within 6–8 weeks, in order to improve the condition after extirpation of the uterus and appendages, it is strictly prohibited gynecological examinations and sexual contacts. When bloody discharge a woman should immediately seek medical help.
In some cases, a woman who has had a hysterectomy may experience pain during intercourse. Most often this happens when part of the vagina has been removed along with the uterus.
If extirpation of the uterus and appendages was performed, the consequence may be early menopause, since the ovaries are responsible for the production of estrogens. In order to eliminate the signs of early menopause, the woman undergoes replacement therapy hormone therapy(HRT). The appointment of HRT after extirpation of the uterus and appendages is carried out by the attending physician.
General rehabilitation period after extirpation of the uterus and appendages is several months. Removal of the uterus is not a death sentence for a woman, since after the operation she remains healthy and can continue to lead her usual lifestyle. This intervention also does not affect sex life. The only disadvantage of the operation is the loss of reproductive function.
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Subtotal hysterectomy (amputatio uteri supravaginalis s. Hysterectomia subtotalis) is a surgical intervention aimed at removing the body of the uterus while preserving its cervix. Possible the following options this operation:Typical amputation without appendages (Fig. 59-60);
Typical amputation of the uterus with appendages (Fig. 60, 6);
Atypical variants of supravaginal amputation of the uterus.
Typical supravaginal amputation of the uterus without appendages (amputatio uteri supravaginalis sine adnexis per abdomen). This operation most often performed in young women in the absence of pathology from the uterine appendages.
Execution technique. The abdominal cavity is opened with a lower median or transverse incision. Right hand an audit of the pelvic organs (uterus and appendages) is performed. The uterus is brought out to the incision and fixed with Museau forceps. The forceps are applied at the bottom of the uterus, symmetrically between its corners - the area where the tubes originate. If possible, the uterus is removed from the abdominal cavity by hand and then fixed with Museau forceps. A mirror is inserted into the lower corner of the wound and with its help the anterior pouch of Douglas is exposed, the lower edge of the wound and the bladder are moved downwards. Wipes are inserted posterior to the uterus, with the help of which the abdominal cavity is fenced off and the posterior surface of the uterus is exposed.
After a thorough examination and assessment of the situation, the uterus is retracted to the left using Museau forceps, and the lower mirror is moved to the right and the right half of the surface of the uterus with the appendages and round ligament of the uterus is exposed. Clamps (clamps) are applied to the round ligament of the uterus, the uterine end of the tube and the proper ligament of the ovary in a direction perpendicular to the uterus at a distance of 3-4 cm from it, so that the duplication of the peritoneum (without vessels) is visible at the tips of the clamps. By pulling the clamps, the loop of the round ligament and the uterine appendages are retracted to the right of it and closer to the uterus, a common clamp (counter-clamp) is applied to the round ligament, the uterine end of the tube and the own ligament of the ovary in the vertical direction, parallel to the rib of the uterus so that at the end of the clamp, which should be above the vesicouterine fold, a duplication of the peritoneum (without vessels) was also visible.
Rice. 59.
: 1 - applying a clamp to the round ligament of the uterus, the proper ovarian ligament and the uterine end of the tube; 2 - cutting off the uterus from the appendages and dissecting the round ligament; 3 - peeling of the peritoneum between the round ligaments; 4 - dissection of the vesicouterine fold of the peritoneum; 5 - dissection of the peritoneum along the posterior surface of the uterus; 6 - clamping of the uterine vessels.
Rice. 60.
: 1 - cutting off the uterus from the cervix along the posterior surface; 2 - cutting off the uterus from the cervix along the anterior surface; 3 - the stumps of the vascular bundles are tied with additional ligatures to the stump of the cervix; 4 - suturing the cervical stump; 5 - peritonization; 6 - application of clamps to the infundibulopelvic (suspensory ovary) ligament during supravaginal amputation of the uterus and appendages.
In a state of slight tension of the tissues between the uterus with Musot forceps and the clamps between the latter, the round ligaments of the uterus, the tube and the proper ligament of the ovary are dissected (Fig. 59.2). Their dissection is carried out according to bottom edge a common clamp placed closer to the uterus. Next, the peritoneum is dissected from the front in the area of the vesicouterine fold (Fig. 59, 3, 4) and the bladder is lowered somewhat downwards in a blunt and sharp way. The posterior leaf of the broad ligament of the uterus is dissected posteriorly (Fig. 59.5), and further in the transverse direction the peritoneum above the projection of the internal os of the uterus is incised to the midline and, also in a blunt and sharp way, is somewhat released downwards. After separation of the round ligament of the uterus and its appendages on the right, the right half of the lower part of the uterus with a translucent vascular uterine bundle is exposed. The stump of the round ligament of the uterus is ligated, its ligature is held with a clamp. The ligature of the bandaged stump of the appendages is cut off and the latter is immersed in the abdominal cavity to avoid tension and slipping of the ligature from the stump. Then the uterus is turned to the right side, the mirror is moved to the left of the midline and the round ligament, the uterine end of the tube and the proper ovarian ligament on the left are clamped and dissected in the same way. The peritoneum on the left is dissected anteriorly in the area of the vesico-uterine fold in the horizontal direction and at the level of the internal pharynx at the back until connected to the incisions already made on the right. The uterus is lifted upward with Museau forceps, the anterior mirror is installed in the middle, the bladder is lowered down and captured by the mirror. On the exposed vascular uterine bundles, alternately on the right and left at the level of the internal uterine pharynx, clamps are applied in a horizontal direction, so that their ends partially capture the tissue of the cervix (Fig. 59.6). 2 cm higher, control clamps are applied at an angle, already somewhat vertically. The vascular bundles are crossed along the lower edge of the upper clamps and ligated under the lower clamps. The uterus is cut off above the ligatures on the vascular bundles: first, small incisions are made on the uterus on both sides, then with an oblique direction of the scalpel (from top to bottom to inside) in front and behind, the tissue is dissected so that the cut off uterus at the bottom looks like a small cone, and upper part cervical stump - boat-shaped depression (Fig. 60,1,2).
The direction of the oblique incision when cutting off the uterus should be such that its lower inner edge is above the stump of the ligated vascular bundles of the uterus on the right and left.
When cutting off the body of the uterus from the cervix, Kocher clamps are applied to the anterior and posterior parts of its stump to hold it.
Next, the cervical stump is sutured (Fig. 60.4). Separate ligatures are applied in such a way that the needle prick from the inside passes at the border of the mucous membrane and the wound, and from the outside 1.5-2 cm downwards from the upper edge of the wound. Usually it is enough to apply 3-4 such ligatures. For them, the stump of the cervix is lifted upward and the stumps of the vascular uterine bundles are tied to it with additional ligatures (Fig. 60.3), and then the stumps of the round ligaments of the uterus. If necessary, the stumps of the uterine appendages are additionally tied up and they are held by these ligatures for convenience during subsequent peritonization. In the future, the stumps of the uterine appendages should be attached to the uterine stump. Peritonization is performed by connecting the free edge of the peritoneum, separated from bottom surface the uterus in the area of the vesicouterine fold, with the edge of the peritoneum along the posterior surface of the cervical stump (Fig. 60.5). The connection of these edges of the peritoneum is made in such a way that in the center they are connected above the stump of the cervix and are fixed to it, and at the edges - in the form of purse-string sutures. We do this starting from the purse string suture with right side, then in the center and finish with a purse-string stitch on the left. As a result, the cervical stump looks like a “small uterus”, to which the stumps of the round ligaments and the stumps of the uterine appendages are attached. During the process of peritonization, if necessary, for ease of work, a direct mirror is inserted into the posterior Douglas pouch to hold the intestinal loops. Before peritonization, hemostasis is monitored: with clamps, the sheets of the peritoneum are lifted in front and behind, ligatures of the stumps of the round ligaments and uterine appendages on the right and left alternately, and the cervical stump is held by the ligatures - while the wound surfaces are clearly defined in the form of a triangle on both sides: one corner - clamps on the sheets of peritoneum along with ligatures on the stump of the cervix, the second corner is the stump of the round ligament and the third corner is the stump of the uterine appendages. Then the cervical stump is fixed to the stump of the round ligaments of the uterine appendages.
After peritonization, an inspection of the abdominal cavity is performed: kidneys, liver, omentum, stomach, intestines.
Suturing of the abdominal cavity is done in layers: the peritoneum - with a continuous suture, which, after fastening below, connects the edges of the muscles of the abdominal wall; the aponeurosis is sutured with separate silk sutures for a longitudinal incision of the abdominal wall and with a continuous suture for a transverse incision; subcutaneous fatty tissue connected with continuous or separate seams. The edges of the skin incision are connected using various methods: cosmetic suture, separate sutures, etc. Aseptic dressing. Control procedures: drying the vagina using gauze swabs, removing urine with a catheter from the bladder. Extubation.
Brief description of the operation in the medical history Laparotomy (lower middle, according to Pfannenstiel). Found: the uterus is enlarged due to tumor formations up to 14-15 weeks of pregnancy, fixed with Musot forceps and removed from the abdominal cavity. The uterine appendages are without features. Alternately, on the right and left, clamps and counter-clamps are applied to the round ligaments of the uterus, the uterine ends of the tubes and the proper ligaments of the ovaries, the tissue between the clamps is dissected and the latter are replaced with ligatures. The leaves of the peritoneum are dissected in front and behind, the bladder is lowered downwards. The vascular uterine bundles are exposed, clamped, dissected and ligated; at the level of the internal os, the body of the uterus is cut off from the cervix. The stump of the latter is sutured with three separate sutures. The stumps of the vascular bundles are secured with additional sutures to the cervix. Hemostasis control. Peritonization. Inspection of the abdominal organs, its toilet. The abdominal cavity is sutured tightly in layers. Aseptic dressing. Urine was removed by catheter, 200 ml, light. Extubation.
Supravaginal amputation of the uterus with appendages (amputatio uteri cum adnexis per abdomen) is one of the most common operations in gynecological practice.
Execution technique. When removing the appendages, simultaneously with amputation of the uterus, clamps (Fig. 60.6) are applied to the infundibulopelvic ligament (on one or both sides).
Next to it, the ureter passes below along the posterior leaf of the broad ligament, which requires special care when applying clamps. Before this, the fallopian tube and ovary are lifted and retracted to the side so that the ligament is clearly visible. The clamp is applied so that its end does not reach the rib of the uterus by 2-3 cm, passing slightly above the base of the broad ligament. The infundibulopelvic ligament is cut between the clamps and ligated, the ligature on its stump is cut off and the latter is immersed in the abdominal cavity. The round ligament of the uterus was first clamped, cut and ligated, as in the case of amputation of the uterus without appendages. Both leaves of the broad ligament are dissected closer to the ovary, in a horizontal direction, to the angle of the uterus, where the own ovarian ligament is attached, so as not to damage the ureter, which runs at the base of the broad ligament. In a similar way, actions are performed on the other side when removing both appendages of the uterus.
Amputation of the uterus with tubes (without ovaries) is possible. In this case, the clamps are applied to the ovarian ligament and mesentery. fallopian tube, the tissues between them are dissected and ligated. If necessary, this is done on both sides. Subsequently, the operation is performed as when removing the uterus without appendages.
Brief description of the operation in the medical history Lower median laparotomy (or Pfannenstiel). Revision of the pelvic organs: the uterus is enlarged to 14-15 weeks of pregnancy with many myomatous nodes. The ovaries are increased in size (up to 6x7 cm) due to cystic formations. The round ligaments, the uterine ends of the tubes and the proper ovarian ligaments were clamped, dissected and ligated alternately on the right and left. The anterior and posterior layers of the peritoneum are dissected anteriorly in the area of the vesicouterine fold, and posteriorly above the uterosacral ligaments. The bladder is slightly lowered downwards. The vascular uterine bundles at the level of the internal os are exposed, clamped, dissected and ligated, capturing the cervical tissue on the right and left alternately. The body of the uterus was cut off at the level of the internal os from the cervix. Its stump is sutured with separate sutures. Hemostasis control. Peritonization. Abdominal toilet, organ inspection. The abdominal wall incision is sutured tightly in layers. Bandage. Urine was removed by catheter - light, 100 ml. Extubation. Macropreparations (description).
Stages of supravaginal uterine amputation:
1. intersection and ligation of round ligaments;
2. mobilization or removal of the appendages (crossing and ligation of the uterine end of the tube, own ligament ovary or infundibulopelvic ligament);
3. dissection of the plica vesicouterina and moderate mobilization (displacement) of the bladder. When performing supravaginal amputation of the uterus, you should not displace the bladder more than is necessary to remove the body of the uterus;
4. intersection of the vascular bundle. The intersection and ligation of the vascular bundle when performing a typical operation of supravaginal amputation of the uterus is carried out at the level of or slightly above the internal pharynx, i.e. only the ascending branches of the uterine arteries cross. In this case, unlike hysterectomy, the vessels are only crossed to remove the uterus and are not subsequently cut off from the cervix. For optimal application of clamps to the vascular bundles at the level or just above the internal os, the posterior layers of the broad ligaments are first dissected to the ribs of the uterus. Mikulicz clamps are applied perpendicular to the cervix so that the edge of the clamp grabs the tissue of the cervix and, as it were, “slides” from it, including the entire vascular bundle (this is especially important if there is varicose veins veins of this area). The uterine vessels are crossed to the border of the cervix, leaving a stump of the uterine vessels above the clamp of sufficient length (at least 1 cm);
5. cutting off the cervix. The body of the uterus is cut off from the cervix with a scalpel. For better subsequent comparison, the cervix is excised wedge-shaped (with the wedge directed towards the internal pharynx). In the process of cutting off the body of the uterus, for convenience, the anterior and posterior lips are fixed with clamps (Kocher or Mikulicz); after cutting off the uterus, the area of the cervical canal is treated alcohol solution iodine or ethyl alcohol;
6. Place a suture on the cervical stump in the center, which is subsequently used as a holder. The suture material is vicryl (non-absorbable threads cannot be used). Next, ligation of the uterine vessels is carried out with vicryl or non-absorbable suture material, and, in contrast to hysterectomy (when during the operation the vascular stump is “retracted” from the cervix when crossing the cardinal ligaments), during the operation of supravaginal amputation of the cervix to achieve better hemostasis of the vascular stump sewn (fixed) to the cervix. To do this, the dense tissue of the cervix is stitched directly at the spout of the clamp applied to the uterine vessels and the ligature is tied behind the clamp. In the future, it is logical to apply a backup (safety) suture, when, when matching (suturing) the anterior and posterior lips of the cervix in the area of the corners (lateral surfaces), the uterine vessels are once again fixed to the cervical stump;
7. The final formation of the cervical stump is carried out by applying separate catgut or, better yet, vicryl sutures, bringing the anterior and posterior lips of the cervix closer together (if the cervical stump is excised wedge-shaped, this does not present any difficulties). It is advisable to use cutting needles, since the tissue of the cervix is dense, and stitch both lips of the cervix below the level of amputation, then securely ligate (the threads are cut);
8. Peritonization is carried out with a continuous catgut or vicryl suture: first, a purse-string suture is placed on the parametrium on the left: the posterior leaf of the broad ligament is sutured - the stump of the uterine appendages (or the stump of the infundibulopelvic ligament) - the stump of the round ligament - the anterior leaf of the broad ligament. The suture is tied in such a way that the above stumps are immersed in the parametrium, then the suture is continued into a linear one - the cervical stump is “covered” with a vesicouterine fold as a result of suturing it with the posterior leaves of the broad ligaments of the uterus and back surface cervix. Next, the suture is continued into a purse-string suture on the right: the posterior leaf of the broad ligament is sutured - the stump of the uterine appendages (or the stump of the infundibulopelvic ligament) - the stump of the round ligament - the anterior leaf of the broad ligament. The suture is also tied in such a way that all stumps are immersed in the parametrium;
9. The abdominal cavity is checked and drained, and the anterior abdominal wall is sutured. The operation of high supravaginal amputation of the uterus (when the body of the uterus is cut off significantly above the internal os, which makes it possible to preserve part of the endometrium), the operation of defundation of the uterus, as well as various types Asymmetrical supravaginal amputations of the uterus with the formation of endometrial cavities are practically not used at present. Conservative myomectomy deservedly took the place of these operations.
COMPLICATIONS OF SUPRAVAGINAL AMPUTATION OF THE UTERUS
Intraoperative complications:
Damage to the bladder and ureters are emergency cases during supravaginal amputation of the uterus; however, the course of the ureters should be monitored before crossing the infundibulopelvic ligaments and uterine vessels.
Bleeding, hematoma formation - more dangerous complication with supravaginal amputation of the uterus than, for example, with extirpation of the uterus (bleeding is intra-abdominal, not external), therefore care should be taken in hemostasis when performing supravaginal amputation of the uterus special attention. Bleeding after surgery for supravaginal amputation of the uterus is more difficult to diagnose and eliminate, since it occurs in a closed cavity - the parametrium and then into the abdominal cavity or directly into the abdominal cavity. In this regard, at the stage of peritonization, the stump of all ligaments and vessels must be examined again and, if necessary, additionally bandaged (especially in the presence of varicose vessels and massive ligatures). If it is necessary to control hemostasis, it is necessary to drain the abdominal cavity or expand the scope of the operation before extirpation of the uterus.
Postoperative complications:
bleeding;
formation of hematomas.
If such complications occur after supravaginal amputation of the uterus, relaparomy is indicated. In case of late diagnosis, suppuration of hematomas - relaparotomy, extirpation of the cervical stump, sanitation and drainage of the pelvis.
Infectious postoperative complications:
wound infection;
peritonitis and sepsis;
thromboembolic complications (described in the relevant sections of the manual).
In the absence of contraindications (intolerance to antibiotics or the presence of polyvalent allergies), antibiotic prophylaxis of infectious postoperative complications is necessary. It is advisable to use protected penicillins, for example amoxicillin + clavulanic acid at a dose of 1.2 g intravenously during induction of anesthesia. Options: cefuroxime 1.5 g intravenously during a skin incision in combination with metronidazole 0.5 g intravenously.
If there are significant additional risk factors ( diabetes mellitus, violation fat metabolism, anemia), triple perioperative use of antibiotics is advisable. For example, administering 1.2 g amoxicillin + clavulanic acid intravenously at the time of skin incision and an additional 1.2 g intravenously after 8 and 16 hours.
Options: cefuroxime 1.5 g intravenously during a skin incision in combination with metronidazole 0.5 g intravenously, then cefuroxime 0.75 g intramuscularly in combination with metronidazole 0.5 g intravenously after 8 and 16 hours.
FEATURES OF MANAGEMENT IN THE POSTOPERATIVE PERIOD
Maintaining postoperative period the same as after hysterectomy (see chapter “Hysterectomy”). Features - there is no need to douche the vagina, earlier discharge is possible (on the 5th–6th day).
INFORMATION FOR THE PATIENT
Wearing a bandage and compression garments for at least 2 months after surgery.
Avoid sexual intercourse for 6 weeks.
If there are any complications of supravaginal amputation of the uterus, immediately go to the hospital where the operation was performed, or, if impossible, to any other gynecological hospital.
