Surgical interventions on the female genitalia

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

Methods of surgical approaches in gynecology

Transabdominal (abdominal wall)		Transvaginal (vaginal)
Laparotomy	Laparocentesis
Lower median Transverse suprapubic (according to Pfannenstiel) Transverse interiliac (according to Cherny)	Laparoscopy Open laparoscopy	Anterior colpotomy Posterior colpotomy hysteroscopy

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

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Inferomedian laparotomy

The incision runs along the midline from the pubis towards the navel. In some cases, for ease of manipulation and revision of the abdominal cavity, the incision is extended to the left, bypassing the navel.

After cutting the skin and subcutaneous fat, the surgeon applies clamps to the bleeding vessels and ligates or, more rationally, coagulates them. After exposing the aponeurosis, it is cut with a scalpel in the longitudinal direction 1 cm long, then completely along the entire length of the cut - with scissors. The rectus muscles are spread with fingers along the entire cut or one of the sheaths of the rectus muscle is cut.

Then the transverse fascia is opened and the preperitoneal tissue is retracted, exposing the parietal peritoneum, which is opened between two tweezers. It is important not to grab the adjacent intestinal loops and omentum with the tweezers. After dissecting the peritoneum along the entire length of the incision, the abdominal cavity is delimited.

After opening the abdominal cavity, the pelvic organs are examined and separated from the intestinal loops and omentum by inserting a napkin (towel) soaked in isotonic sodium chloride solution into the abdominal cavity.

After the operation is completed, the dissected abdominal wall is sutured layer by layer. The peritoneum is sutured with a continuous suture of absorbable suture material, starting from the upper corner.

The right and left rectus muscles are aligned using the same or separate sutures.

The suturing of the aponeurosis during longitudinal incisions is of particular importance, since the healing and the possibility of a postoperative hernia depend on its thoroughness. The aponeurosis is restored with separate sutures using synthetic non-absorbable threads. The subcutaneous fat is brought together with separate sutures using absorbable suture material. Separate silk sutures are applied to the skin.

Pfannenstiel laparotomy (transverse suprapubic laparotomy)

The abdominal wall is dissected along the suprapubic skin fold. After exposure, the aponeurosis is dissected in the middle in a transverse direction with a scalpel so that the incision to the right and left of the midline does not exceed 2 cm. Then, the aponeurosis is separated bluntly first to the right and then to the left from the underlying rectus muscles. The dissection of the aponeurosis to the right and left should be extended with a crescent-shaped incision, the direction of which should be steep, which allows for maximum surgical access to the pelvic organs in the future. The aponeurosis should be cut off along the midline only by a sharp method. The aponeurosis cut off in this way should have the shape of a wedge with a base located 2–3 cm from the umbilical ring.

The rectus muscles are separated by blunt or sharp dissection, then the transverse fascia is opened and the parietal peritoneum is exposed. The abdominal cavity is opened and delimited in the same way as in the lower median laparotomy.

When performing a Pfannenstiel incision, it is necessary to remember the anatomy and location of the superficial epigastric artery and the superficial circumflex iliac artery, which are located in the intervention area and require particularly careful hemostasis, preferably with suturing and ligation.

The anterior abdominal wall is restored as follows. The peritoneum is sutured in the same way as in the lower median laparotomy, continuous twisted or knotted sutures are applied to the rectus muscles, and in order to avoid injury to the inferior epigastric artery, the needle should not be inserted deep under the muscles. When suturing the aponeurosis incision, all four fascia sheets are necessarily captured. The rectus and oblique muscles located in the lateral parts of the wound. The subcutaneous fatty tissue is connected with separate sutures using absorbable suture material. The skin is restored by applying an intradermal continuous suture or separate silk sutures.

A correctly performed Pfannenstiel incision allows for sufficient access to the pelvic organs to perform virtually any volume of intervention and has undoubted advantages over others: it allows for active management of the patient in the postoperative period, postoperative hernias and intestinal eventration are not observed. Currently, this type of laparotomy in operative gynecology is preferable and is performed in virtually all medical institutions.

This method of laparotomy is not recommended in cases of genital cancer and purulent inflammatory processes with pronounced cicatricial-adhesive changes. In case of repeated laparotomy, the incision is usually made along the old scar.

Cherny laparotomy (transverse interiliac laparotomy)

The advantage of this incision over the Pfannenstiel incision is that it allows for wide access to the pelvic organs even with excessive development of subcutaneous fat.

The skin and subcutaneous fat are dissected transversely 4-6 cm above the pubis. The aponeurosis is dissected in the same direction, with its edges rounded outward. The inferior epigastric arteries are transected and ligated on both sides, then both rectus muscles are transected. After opening the transverse fascia, the peritoneum is opened transversely. The incision is sutured as follows:

• the peritoneum is restored with continuous suturing using absorbable suture material from right to left;
• individual U-shaped sutures are applied to the rectus muscles using absorbable suture material;
• The suturing of the aponeurosis, subcutaneous fat and skin is performed in the same way as with the Pfannenstiel incision.

Complications of laparotomy and their prevention

All types of laparotomy carry the risk of injury to the apex of the bladder. This complication can be prevented by mandatory urine drainage before the operation and careful visual control during dissection of the parietal peritoneum.

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. The vessels occupy the outer two-thirds of the lacuna, the inner third is called the femoral ring, filled with fatty tissue and lymphatic vessels. Prevention of these complications is an incision always made above the inguinal ligament.

One of the complications of transverse incisions is the formation of hematomas. Insufficient ligation of the inferior epigastric artery or injury to its branches is very dangerous, especially with a Cherny incision. In such cases, the leaking blood easily spreads along the preperitoneal tissue, meeting virtually no resistance. In this regard, the volume of hematomas can be quite significant. Only the correct surgical technique and the most thorough hemostasis of the vessels with their suturing and ligation allow us to avoid this complication.

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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 location;
• features of the blood supply to the anatomical areas within which the intervention is performed.

When performing abdominal operations for tumors of the uterus and appendages, injuries to the ureters may occur, which intersect with the uterine arteries at the base of the broad ligament; the urinary bladder, when it is separated, especially when myomatous nodes are located on the anterior surface of the uterus; hematomas of the parametria with inadequate hemostasis during operations.

In the postoperative period, internal bleeding may develop when the ligature slips off large vessels in the early postoperative period; vesicovaginal, ureterovaginal fistulas when the above organs of the urinary system are injured or when they get caught in a suture, especially with synthetic non-absorbable sutures. A pronounced adhesive process in the small pelvis and abdominal cavity may become a condition for inflicting a wound to the intestine when separating adhesions and adhesions.

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

New medical technologies that have appeared in recent years make it possible to perform abdominal gynecological operations using endovideo technology. The stages of performing laparoscopic operations in gynecological practice are fundamentally the same as those of operations performed by laparotomy access.

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