Surgical interventions on female genital organs

Surgical interventions on female genitalia are carried out mainly in two ways - transabdominal (abdominal) or transvaginal.

Methods of surgical access in gynecology

Transabdominal (abdominal)		Transvaginal (vaginal)
laparotomy	laparocentesis
Lower-median Transverse suprapubic (according to Pfannensthil) Transverse interiliacal (according to Czerny)	Laparoscopy Open laparoscopy	Anterior colpotomy Posterior colpotomy hysteroscopy

There is extraperitoneal access to the lower segment of the uterus, which is performed during the operation of caesarean section with a high risk of purulent-septic complications.

[1], [2], [3],

Lower-midline laparotomy

The incision runs along the middle line from the bosom towards the navel. In some cases, for convenience of manipulation and revision of the abdominal cavity, the incision is prolonged to the left bypassing the navel.

After cutting the skin and subcutaneous fat tissue, the surgeon applies clamps to the bleeding vessels and binds or, more rationally, coagulates them. After exposure of the aponeurosis, it is dissected with a scalpel in the longitudinal direction 1 cm long, then completely for the entire length of the incision with scissors. Straight muscles are diluted with fingers along the entire cut or dissected one of the vagina of the rectus muscle.

Then the transverse fascia is opened and the preperitoneal tissue is removed, exposing the parietal peritoneum, which is opened between two tweezers. In this case, it is important not to grasp with the forceps the adjacent intestinal loops and the omentum. After dissecting the peritoneum on the entire length of the incision, the abdominal cavity is delimited.

After opening the abdominal cavity, a revision of the pelvic organs is performed and their delimitation from the intestine and gland loops is introduced by insertion into the abdominal cavity of a napkin (towel) moistened with an isotonic sodium chloride solution.

After the operation is completed, seams are layerwise layered on the dissected abdominal wall. The peritoneum is sewn with a continuous suture with resorbable suture material starting from the upper corner.

The same or separate sutures are compared with the right and left rectus muscles.

Suturing the aponeurosis with longitudinal incisions is given special importance, since healing depends on its thoroughness, as well as the possibility of forming a postoperative hernia. Aponeurosis is restored by separate sutures with synthetic non-absorbable threads. Subcutaneous adipose tissue is brought together by separate sutures by absorbable suture material. On the skin, separate silk sutures are applied.

Laparotomy according to Pfannenstil (transverse suprapubic abdominal incision)

Produce a dissection of the abdominal wall along the suprapubic skin fold. After exposure, the aponeurosis is cut in the middle in the transverse direction with a scalpel in such a way that the cut does not exceed 2 cm to the right and to the left of the midline. Then the aponeurosis is firstly removed to the right and then to the left by the obtuse path from the underlying muscles. To prolong the dissection of the aponeurosis to the right and to the left follows a semilunar incision, the direction of which should be steep, which allows further creating maximum surgical access to the pelvic organs. On the middle line, aponeurosis should be cut only by a sharp path. The aponeurosis cut in this way should have a wedge shape with a base located 2-3 cm from the umbilical ring.

Straight muscles are separated by a blunt or acute route, then the transverse fascia is opened and the parietal peritoneum is exposed. Opening of the abdominal cavity and delimitation are performed in the same way as in the lower middle abdominal cavity.

When performing the Pfannenstil incision, it is necessary to remember the anatomy and location of the superficial epigastric artery and the superficial artery surrounding the ileum that are in the zone of intervention and require particularly careful hemostasis, preferably with stitching and ligation.

Restoration of the anterior abdominal wall is performed as follows. The peritoneum is sewn in the same way as in the lower middle abdomen, the straight muscles are superimposed with continuous knitting or knotty sutures, and to avoid injury of the lower epigastric artery, one should not hold the needle deep under the muscles. Sewing the incision of the aponeurosis, necessarily capture all four sheets of fascia. Straight and oblique muscles, located in the lateral sections of the wound. Subcutaneous adipose tissue is connected with separate sutures by absorbable suture material. The skin is restored by the imposition of an intracutaneous continuous suture or individual silk sutures.

Correctly executed section on Pfannenstil allows to provide sufficient access to the organs of the small pelvis practically for performing any in terms of the volume of the intervention and has undoubted advantages over the others: it allows to actively guide the patient in the postoperative period, postoperative hernia and intestinal event are not observed. At present, this type of abdominal surgery in operative gynecology is preferable and is performed in almost all medical institutions.

Trenching in this way is not recommended for cases of genital cancers and purulent inflammatory processes with marked cicatricial-adhesive changes. With repeated intubation, the incision is usually done using the old scar.

Laparotomy for Czerny (transverse intra-laculatory incision)

The advantage of this section in front of the Pfannenstiel cut is that it allows for a wide access to the pelvic organs even with excessive development of subcutaneous fat.

Cutting of the skin and subcutaneous fat tissue is made transversely at 4-6 cm above the womb. In the same direction, the aponeurosis is dissected, with its edges rounded outward. Both sides intersect and ligate the epigastric lower artery, then cross both straight muscles. After opening the transverse fascia, the peritoneum is opened in the transverse direction. The incision is sewn as follows:

• the peritoneum is reconstituted with a continuous suture with resorbable suture material from right to left;
• on the straight muscles impose individual U-shaped seams with a resorbable suture material;
• stitching of aponeurosis, subcutaneous fat and skin are performed in the same way as in the Pfannenstil section.

Complications of intubation and prevention

At all kinds of the abdominal cavity there is a risk of injury to the tip of the bladder. Preventive maintenance of this complication can serve as obligatory deducing of urine before operation and careful visual control at dissection of a parietal peritoneum.

A dangerous complication that can occur with a transverse suprapubic incision is the wounding of large blood vessels localized at the base of the femoral triangle. Through the vascular lacuna located here pass the femoral artery and the vein with the lumbar-inguinal nerve. Vessels occupy the outer two-thirds of the gap, the inner third is called the femoral ring, is made with fat tissue and lymphatic vessels. Prevention of these complications is the incision, always performed above the inguinal ligament.

One of the complications of transverse incisions is the formation of hematomas. Very dangerous is the insufficient ligation of the lower epigastric artery or the injury of its branches, especially in the case of the Cherni incision. In such cases, the resulting blood easily spreads through the preperitoneal tissue, practically without encountering resistance. In this regard, the volume of hematomas can be very significant. Only the correct technique of surgery and the most thorough hemostasis of vessels with the piercing and ligation of them make it possible to avoid this complication.

[4], [5], [6], [7],

Complications arising during gynecological operations

The nature of complications arising during surgical treatment of gynecological patients is determined by:

• type of operation;
• the size of the tumor, its localization;
• a feature of the blood supply to the anatomical areas within which the intervention is performed.

When performing cavitary operations for tumors of the uterus and appendages, ureteral injuries can occur that cross the uterine arteries at the base of the broad ligament; the bladder, when it is removed, especially when the myomatous nodes are located on the anterior surface of the uterus; hematoma of parameters with inadequately performed hemostasis during operations.

In the postoperative period, internal bleeding may develop with slippage of ligature from large vessels in the early postoperative period; vesical-vaginal, ureteral-vaginal fistulas when traumas of these organs of the urinary system or getting them into the seam, especially synthetic non-absorbable threads. The pronounced adhesion process of the small pelvis and abdominal cavity may become a condition for inflicting a wound of the intestine when the adhesions and adhesions are severed.

During vaginal operations, there is a risk of injury to the bladder and rectal wall, as well as the development in the postoperative period of hematoma of the vaginal wall and / or perineum with poorly performed hemostasis during the intervention.

Emerged in recent years, new medical technologies allow performing cavitary gynecological operations using endovideo technology. The stages of performing laparoscopic operations in gynecological practice essentially coincide with those in operations performed by laparotomy.

[8], [9], [10]