Vaginal uterine extirpation.

Vaginal hysterectomy can be simple and quite complex if it is performed without prolapse of the vaginal walls and in the absence of pelvic floor muscle failure. The postoperative course after vaginal surgery is usually easier than after abdominal wall laparotomy.

There are the following contraindications for vaginal extirpation of the uterus:

1. the size of the uterine tumor corresponding to a pregnancy of more than 2 weeks;
2. repeat laparotomy in cases where significant adhesions in the abdominal cavity can be expected;
3. the need for revision of the abdominal cavity;
4. combined pathology, i.e. the presence, in addition to a uterine tumor, of an ovarian tumor of significant size.

After appropriate treatment, a speculum and a lift are inserted into the vagina. The cervix is grasped with two prongs in such a way that the clamp simultaneously catches the anterior and posterior lips. Then the spoon-shaped speculum is replaced with a Doyen-type speculum. Lateral lifters are inserted into the vagina.

A circular incision is made in the vagina at the border of its transition to the cervix and it is separated upwards using blunt and sharp methods. Clamps are applied to the cardinal ligaments, they are crossed and ligated. The ligatures are taken on holders. After the cardinal ligaments are crossed, the uterus becomes more pliable. By pulling it down by the cervix, the urinary bladder is separated down to the vesicouterine fold. The posterior vaginal fornix is opened. After the posterior vaginal fornix is opened, with constant downward tension on the uterus, the tissues are successively crossed directly at the lateral surfaces of the uterus and the uterus is gradually removed from the abdominal cavity. Upon achieving sufficient mobility of the uterus, the vesicouterine fold is opened, a suture is applied and taken on a keeper. The bottom of the uterus is grasped with bullet forceps and dislocated into the wound, after which the round ligaments of the uterus, the proper ligaments of the ovaries and the fallopian tubes become accessible. Clamps are applied to them, they are cut and ligated. When pulling the uterus towards itself and downwards, clamps are applied to the uterine vessels. The vessels are cut and ligated. The uterus is removed.

If it is necessary to remove the uterine appendages, long mirrors are inserted into the abdominal cavity. This makes the infundibulopelvic ligaments accessible, to which clamps are applied. The ligaments are crossed and ligated. The ligatures are taken on clamps.

After the uterus is removed, the wound is sutured in such a way that the ligament stumps remain outside the peritoneum. To do this, the first suture is applied on the left in such a way that the needle passes through the vaginal wall, the peritoneum, the ligament stumps and vascular bundle, the peritoneum of the rectouterine pouch and the posterior vaginal wall. Then, the same suture is applied to capture only the vaginal walls. The thread should not be tied so as not to complicate the application of the suture on the other side. After the threads are pulled through on both sides, the knots should be tied. If the sutures are applied correctly, the vaginal walls are connected. The ligament stumps remain between the peritoneum and the vaginal wall, i.e. they are reliably peritonized. If necessary, an additional suture can be applied to the vaginal wall. It is not necessary to achieve complete hermeticity of the abdominal cavity, since if there is wound discharge, it is brought out.