HYSTERECTOMY (Latin exstirpatio eradication, removal with a root; synonym hysterectomy) — operation of removal of a uterus.
The hysterectomy can be made without adnexectomy or with their removal (panhysterectomy). Removal of a uterus with cellulose of a small pelvis and prisoners in it limf. nodes is called an expanded hysterectomy.
The hysterectomy through a vagina was for the first time executed in 1821 by Saufer. The vulval hysterectomy at cancer is for the first time manufactured in Russia in 1846 by A. A. Kitter. In 1878 W. A. Freund suggested to make a hysterectomy through an abdominal wall. The big contribution to improvement of operation was made by domestic obstetricians-gynecologists D. O. Ott, A. P. Gubarev, E. M. Schwarzman, V. S. Frinovsky, L. S. Lersianinov, etc.
Indications to the emergency hysterectomy are diffuse peritonitis after the delivery and abortion, a necrosis of a myomatous node, the born myoma, twisting of a leg of a node of subserous myoma.
Serve as indications to a planned hysterectomy without adnexectomy a hysteromyoma at an arrangement of nodes in the field of an isthmus and a neck of uterus, a fast-growing hysteromyoma, a combination of a hysteromyoma to an erosion and deformation of a neck of uterus, cancer of a neck of uterus of a zero stage at women aged start of 40 years, a hysterocarcinoma of 1 stage at young women.
Indications to a panhysterectomy are malignant tumors of ovaries, widespread inflammatory processes of internal generative organs with damage of ovaries, and also patol. processes, at to-rykh the hysterectomy without adnexectomy (see above), in combination with pathology of ovaries is shown. Quite often the question of need of an adnexectomy arises only during operation, often later strong gistol. researches of remote bodies.
The expanded hysterectomy is made at cancer of a neck of uterus of Ib and the II stage as one of stages of the combined treatment. There is an opinion on expediency of an expanded hysterectomy and at a hysterocarcinoma, the exception is made by patients of advanced age, the Crimea prefer to make a panhysterectomy.
Preoperative preparation depends on age, the general condition of the patient, the basic and associated diseases (see. Preoperative period ). Before operation release a catheter urine, process a vagina and a neck of uterus alcohol and 5% spirit solution of iodine (at virgins the vagina and a neck of uterus are not dezinfntsirut). An optimum method of anesthesia is the anesthesia with muscular relaxants (see. Muscle relaxants ).
carry out the Hysterectomy belly stenochnym or a vulval way. The hysterectomy is more often applied belly stenochnaya. The hysterectomy is made in the vulval way at a hysteromyoma of the small sizes, the submucosal born myoma on the wide basis, sharply gross obesity of a front abdominal wall, and also at a full prolapse of the uterus, having the extended and hypertrophied neck. An indispensable condition of a vulval extirpation is the sufficient mobility of a neck of uterus allowing to reduce se to an entrance to a vagina.
Belly stenochnaya a hysterectomy
At a hysterectomy belly stenochnym in the way as access to a thicket apply the lower median laparotomy (see), at tumors of a uterus of the small sizes — a cross suprapubic section across Pfannenshtil (see. Pfannenshtilya section ). After opening of an abdominal cavity delimit intestines sterile napkins and carefully examine bodies of a small pelvis (if necessary make audit of all abdominal organs). In the presence of commissural process make division of commissures. The uterus is removed in a wound. Consistently cross and alloy round ligaments of a uterus, uterine parts of uterine tubes and own ligaments of ovaries. Having tightened for ligatures of a stump of round ligaments of uterus, dugoobrazno cut a front leaf of a wide ligament of uterus and a vesicouterine fold of a peritoneum in the place where iod to it is the loose coating of cellulose located between a bladder and a neck of uterus. The bladder together with vesical edge of a peritoneum is otseparovyvat in the stupid way down to a vault of the vagina. Having tightened a peritoneum, make an incision a back leaf of a wide ligament of uterus along edge of a uterus to the level of an internal pharynx. Lateralno and down is removed by appendages of a uterus, baring vascular bundles. Not to injure an ureter, the clip on a vascular bundle is imposed perpendicular to an artery at edge of a neck of uterus where the main trunk of a uterine artery is divided into the ascending and descending branches. The counterterminal is imposed much above on edge of a uterus. The vascular bundle is crossed on both sides and tied up. The uterus is delayed to a pubic symphysis, crossed and tie up sacrouterine sheaves in the place of an otkhozhdeniye them from a uterus. If necessary otseparovyvat a bladder. Tie up and cross a vulval branch of a uterine artery with the cellulose located around it. The neck of uterus is covered in front and behind big and index fingers to define whether the neck of uterus to vaults of the vagina is allocated (at the time of delivery and in a puerperal period this reception is not informative owing to a softening of a neck of uterus). The front wall of a vagina is cut in transverse direction. For an otgranicheniye of an abdominal cavity enter a gauze tampon into a vagina, cut a vulval part of a neck of uterus from the arches. Edges of a vagina sheathe eight-figurative catgut seams, connecting a front wall of a vagina to a peritoneum of a bladder, and back — to a peritoneum of a rectum. Thus, the stump of a vagina remains open, and conditions for a natural drainage are created. In the absence of bleeding of fabrics the stump of a vagina is sewn up tightly. Peritonization is made leaves of wide ligaments of uterus with use of a purse-string seam, immersing in them stumps of uterine tubes, round ligaments of a uterus and own ligaments of ovaries. At E. m concerning peritonitis for the prevention of a pyosalpinx (see. Adnexitis ) delete uterine tubes (not ovaries!), and also make drainage of an abdominal cavity. Drainage tubes place in lateral canals and remove through an abdominal wall (in ileal areas), carry out drainage of a cavity of a small pelvis by means of the drainage tube removed through a vagina. At purulent peritonitis and need of carrying out peritoneal dialysis the drainage is entered also into the epigastric area.
There is a number of modifications belly stenochnoy E. m. By a method of the Dean open the back arch (the tail of the arch, T.) vaginas together with a peritoneum, increase an opening in transverse direction nippers to Myuza take a vulval part of a neck of uterus and bring her in this opening, cut a neck of uterus from the vulval arches and only after that cross and tie up vascular bundles and sacrouterine sheaves; the neck of uterus is strongly pulled, and it separates from friable cellulose.
V. S. Frinovsky (1958) offered modification of operation, at a cut low otseparovyvat a bladder, open the front arch (the forefront of the arch, T.) vaginas, through an educated opening take and remove a vulval part of a neck of uterus and cut it from the arches; then tie up and cross vascular bundles and, pulling a neck of uterus forward and up, delete a uterus.
During opening of a peritoneum at the shift of a bladder there is a danger of its damage up. In this regard the peritoneum should be opened closer to a navel and it is careful under kontrolen sight to continue a section to a pubic symphysis. The possibility of wound of a bladder increases also at disturbances of the topografo-anatomic ratios observed at big tumors, commissural process of a pla insufficient separation of a bladder from a neck of uterus and a vagina. Therefore the peritoneum of vesicouterine deepening needs to be cut closer to a neck of uterus in that place where it is mobile. It is necessary to separate a bladder at the neck of uterus and a vagina. At identification of injury of a bladder the otseparovyvaniye is stopped and make layer-by-layer mending of an opening.
At operation damage of ureters that is usually observed at shift them towards a uterus, to its side edge and a sacrouterine sheaf is possible (is more often at allocation of a tumor of a uterus). (E.g., at the expressed commissural process) at first it is necessary to find an ureter in nek-ry cases (since the place of its excess at an ambit of a basin), and then to allocate a tumor. It is possible to damage an ureter also during the imposing of clips on vessels of a uterus. For the prevention of this complication it is necessary to allocate well a vascular bundle from friable cellulose before imposing of a clip. A serious complication of E. M. is injury of intestines, a cut can happen at division of commissures. For providing a hemostasis the obshivaniye of a stump of a vagina is recommended to be begun with its side walls.
The vulval hysterectomy
the Vulval hysterectomy without adnexectomy is made after careful disinfection of a vagina and a vulval part of a neck of uterus. The neck of uterus slowly, but is vigorously reduced to an entrance of a vagina. As a result of gradual (not rough) pulling up of a neck of uterus sacrouterine sheaves and cardinal sheaves are extended and approach an entrance to a vagina, and uterine arteries, ureters and a bladder are displaced up, bare a front vault of the vagina. In the place where the front vault of the vagina passes into a vulval part of a neck of uterus, make semi-lunar cross section, connective tissue fibers between a bladder and a neck of uterus make cuts. Then otseparovyvat a bladder and take away it up, exempt a neck of uterus from cellulose to the level of an internal pharynx. After opening of a peritoneum palpatorno define a condition of bodies of a small pelvis then under control of sight the section in a peritoneum is expanded in both parties. The first line of a section of a peritoneum is hemmed to edge of a vulval wound. In an abdominal cavity remove the elevator. The body of the womb is tightened to a kolpotomny opening and enter it through a kolpotomny opening. After removal of a uterus the body it is delayed aside. The round ligament of a uterus, a uterine tube and own ligament of an ovary are tied up and crossed. Then tie up a uterine artery. The same is made on the other hand then cross and tie up kresttsovomatochny sheaves and a back leaf of a peritoneum. After removal of a uterus make peritonization so that stumps of sheaves and uterine arteries were located ekstraperitonealno.
At a prolapse of the uterus the extirpation it through a vagina is made along with colporrhaphy (see). From a front wall of a vagina the big rag of triangular shape, top find to-rogo is in 2 cm from an outside opening of an urethra; otseparovyvat a rag to the place of transition of a vault of the vagina to a neck of uterus, cut a vaginovesical partition and connective tissue fibers at the lower bound of a bladder, after that remove a bladder up. After detection and opening of puzyrnomatochny deepening of a peritoneum operation is made in the usual way as it is described above. After that carry out a back colporrhaphy (see. Colpoperineoplasty ).
the Panhysterectomy is made belly stenochnym in the way. At the same time cross and alloy the sheaves suspending ovaries (voronkotazovy sheaves), and round ligaments of a uterus. Then cut wide sheaves at edge of a uterus; dugoobrazno cut a peritoneum of vesicouterine deepening and otseparovyvat a bladder. After cutting off of a neck of uterus from the arches the uterus is deleted together with appendages. Then operation is carried out the same as a hysterectomy without adnexectomy.
The expanded hysterectomy
the Expanded hysterectomy is carried out belly stenochnym and a vulval way. Expanded belly stenochnaya the hysterectomy carries the name of operation of Vertgeym by name the Austrian obstetrician-gynecologist E. Vertgeym who in detail described it in 1902. It is made at cancer of a neck of uterus or a body of the womb. During the carrying out operation neob hodimo respect for the sequence of the moments of operation, the maximum removal in the acute way of pelvic cellulose one block together with located in it limf. nodes, and also removal of an upper third of a vagina.
At operation use two accesses. Make the lower median laparotomy more often. After a section of an abdominal wall make careful audit of abdominal organs: examine a parietal peritoneum, a stomach, a big epiploon, a liver, a gall bladder, kidneys, pelvic and paraortalny limf, nodes, a parametrium. At detection in an abdominal cavity of liquid its urgent cytologic research is necessary. Cross and alloy the round and wide ligaments of a uterus and a sheaf suspending ovaries. Throughout between round ligaments of a uterus cut a peritoneum of puzyrnomatochny deepening. In the acute way otseparovyvat a bladder from top to bottom. Delete cellulose and limf. nodes from ileal vessels. The thin fascia covering an outside ileal artery throughout is cut therefore surrounding cellulose to the level of an inguinal (pupartovy) sheaf and the place of entry of an upper vesical artery into a wall of a bladder easily departs from vessels and muscles of a sidewall of a basin together with limf, nodes. On the basis of rags of cellulose for the purpose of the prevention of a lymphorrhea and bleeding from small vessels impose thin catgut ligatures. The outside ileal vein is taken away by knaruzh and make cuts a leaf of her fascial vagina. Cellulose is separated, tied up and cut uterine vessels of a knaruzha from an ureter. Otslaivat a bladder from a front wall of a vagina then otseparovyvat ureters to the place of their entry into a bladder. The back leaf of a wide ligament of uterus is in addition cut over an ureter, cut a peritoneum of rectouterine deepening, the rectum is pushed aside from top to bottom. Cut and alloy a sacrouterine linking, layers of a paravaginal fat and the remains of cardinal sheaves. An upper third of a vagina together with a uterus is cut. On walls of a vagina put knotty catgut stitches. The edge of a peritoneum of vesicouterine deepening is hemmed to a front wall of a vagina, and the back leaf of a peritoneum is fixed seams to its back wall. As the gleam of a stump of a vagina remains open, the wound secret from a parametrium flows freely. Peritonization of stumps of sheaves a wasp is shchestvlyat by means of leaves of wide ligaments of uterus and a vesicouterine fold. The abdominal wall is sewn up layer-by-layer.
During operation also complications as injuries of ileal veins, a bladder, an ureter, a rectum are possible. At their emergence carry out the corresponding additional interventions.
At cancer of a neck of uterus the expanded hysterectomy can be made in also vulval way (Shauta's operation — Shtekkelya), however in connection with impossibility of removal of lymph nodes on the course of large vessels of a basin this operation is applied seldom.
At expanded the hysterectomy feature of the postoperative period is the big frequency of complications (urinogenital fistulas, shock, peritonitis, secondary bleeding from vessels, cystitis, pyelonephritis, pneumonia, a deep vein thrombosis of the lower extremities and a small pelvis). In this regard in the postoperative period careful control of a condition of the patient is necessary.
After operation by the patient recommend the early movements in a bed, LFK; allow to rise on 2 — the 3rd days. Write out patients at an uncomplicated current of the period, postoperative on the 10th — the 12th days.
The postoperative lethality at a hysterectomy considerably decreased in recent years. At the Expanded hysterectomy, according to foreign researchers, the lethality averages 1-2%.
Bibliography: Gubarev A. P. Operational gynecology and fundamentals of abdominal surgery, page 628, M. — L., 1928; Davydov S. N., Khromov B. M. and Sheyko V. 3. Atlas of gynecologic operations, L., 1982; Clinical gynecology, under the editorship of N. N. Blochin and B. E. Peterson, t. 2. M, 1979; Makarov R. R. and Gabelov A. A. Operational gynecology. L., 1977; Ott D. O. Operational gynecology, SPb., 1914; Persianinov L. S. Operational gynecology. M, 1976; Serebrov A. I. Operational onko-gynecology, L., 1965; Frinovsky V. S. Modification of a panhysterectomy at malignant new growths of appendages of a uterus, Akush. and ginek., No. 5, page 99, 1958; Ginekologia, pod red. R. Klimka, s. 539. Warszawa, 1982; gynecologic oncology, ed. by M. Coppleson, Edinburgh — N. Y., 1981; Aktuelle Probleme und Tendenden in der operativen Gynakologie, Zbl. Gynak., Bd 103, S. 657, 1981; Markus G. Operative gynecology, Stuttgart — N. Y., 1982; Novak F. Gynacologische Operationstechnik, S. 229, 2 m. a., 1978; Wertheim E. Ein Beitrag zur Frage der Radlkaloperatium beim Uteruskrebs, Arch. Gynak., B. 65. S. 1, 1902.
T. A. Starostina; V. P. Kozachenko (expanded hysterectomy).