If a drug therapy in the treatment of the main female organ has dried up and the result is zero, the doctor recommends doing supravaginal amputation of the uterus. Total hysterectomy and subtotal, is carried out after a thorough diagnosis of the woman, in the operating room and in the presence of various specialists.

Collapse

What it is?

Such a surgical intervention is performed for women who have the opportunity to save the cervix and remove only the body itself. Doctors check all organs to ensure they are free of malignant neoplasms.

The advantages of such an operation are that:

• reproductive organs do not lose their physiological abilities;
• there is no danger of prolapse in the future;
• complications are minimized.

When is the operation performed?

Supravaginal surgery on the uterus it is indicated for diseases that cannot be treated conservatively and if there is no cervical pathology. Sometimes such extirpation is urgently needed if a complication has arisen during another operation in the pelvic organs or during delivery. This is a consequence medical error due to their lack of qualifications and experience. The main indication is the presence malignant tumor in the uterus.

So, supravaginal amputation of the uterus is used for:

• myomatous nodes;
• malignant neoplasms in the area of \u200b\u200bthe ovaries, uterus;
• severe prolapse or prolapse of the organ;
• myoma, which is not the cervical canal or the organ itself;
• purulent-inflammatory processes in mature women (in age category after 50 years);
• severe damage to the ovaries or uterus with various formations, if drug therapy does not help;
• endometriosis and bleeding, which occur due to pathological changes;
• chronic erosions on the uterine walls;
• ruptures of the walls of the organ and their perforations;
• gender reassignment.

If in the midst of an infectious or inflammatory disease reproductive organs, it is first necessary to eliminate it and only then plan the operation.

How to prepare for supravaginal uterine amputation?

In order for the amputation of an organ to give positive results, special preparation must be carried out before it. The woman is obliged to undergo diagnostics. Required:

• general tests (blood and urine);
• cytological smears (from the cervix and vagina);
• blood tests (for rhesus and group).

Also, the doctor directs the patient to:

• colposcopy;
• ultrasound procedure;
• passing tests for STIs and HIV;
• an electrocardiogram (this is necessary in order to learn about the state of the heart, as it will be used general anesthesia Is a big load).

Prepare 500 ml of blood in advance in case of emergency transfusion. If necessary, prescribe a course of antibiotics and drugs that affect the tone of the veins and blood clotting.

Two weeks before the operation, the doctor sanitizes the vagina. Recommends not to eat foods that increase gas production. The menu should consist of light meals.

A couple of days before the scheduled surgery on the uterus, the patient is hospitalized. She already has test results and everything she needs.

7-9 hours before the hysterectomy, you should not eat anything and, if possible, you should drink less. In the evening, an enema is done to keep the intestines clean. Hair from the genitals is shaved off. Before sleep, the woman drinks a sedative.

On the operating table, a woman is catheterized, urine is removed. With varicose veins or thrombophlebitis, it is necessary to wear compression garments on the legs.

Types and technique of conducting

The operation is performed in several ways:

• laparotomic (abdominal, when an incision is made in the peritoneum);
• laparoscopic (punctures or small incisions are made in the peritoneum);
• vaginal (transvaginal, the surgeon makes an incision in the vaginal fornix).

In any case, general anesthesia is indicated, therefore, a conversation with an anesthesiologist is first needed to select the appropriate anesthesia. During organ amputation, the anesthesiologist is always present.

Often, doctors combine the techniques, which makes it possible to carry out an operation, remove the affected area and not greatly injure the patient.

The uterus can be amputated with and without appendages.

Supravaginal amputation of the uterus without appendages by the abdominal method is performed by dissecting the peritoneum. It can be median (starting from the epigastric zone and ending near the pubic part) or an incision is made across, over the pubic region. Depending on what will be removed, the operation technique is selected. Fallopian tubes, ligaments, arteries are fixed with two clamps. In order to correctly cut off the organ, it is taken to the other side, removed in a conical shape. With the help of catgut, then all the vessels are sutured. After that everything is processed with iodine.

In order not to damage the intestines, it is gently pushed to the side.

Such a hysterectomy lasts about an hour, sometimes more.

Supravaginal amputation of the uterus with appendages is similar to the above technique, but there are some additions. The appendages are distinguished with scissors and a tupfer. After this, the uterus is retracted into left side... The ovary, which is located on the right, together with the ampullar end of the tube, is grasped with fingers or tweezers, lifted and pulled, the field of which is pinched by two clamps and cut. All edges are ligated with catgut. In the future, all actions coincide with the above.

It is important for the surgeon not to damage the ureter, which is nearby. To exclude trauma, the ends of the clamps should be directed not inside the pelvis.

After all the manipulations to remove the uterus have been made, the doctor drains the peritoneum and examines everything, at the end he sutures the walls in layers.

The duration of the operation, in which the uterus with appendages is removed, is 2-3 hours.

You should be aware that the laparoscopic method is more loyal, since traumatism is minimal and the recovery period is short. After such an operation, adhesions and other complications do not appear so often. If the procedure is carried out by an experienced specialist, then there will not even be much blood loss. The only caveat is that such a hysterectomy is not permissible for everyone, especially those who have a large uterus, huge cysts in the ovaries, or severe prolapse. There are no big scars as only 4 punctures are made here.

If you want to study in detail the essence of the operation, watch the video on YouTube or any other search engine.

Recovery period

After surgical intervention the woman is in medical center, in the hospital. 3-5 days her lower limbs are wrapped with elastic bandages to prevent thrombosis.

Necessarily the appointment of funds that promote tissue regeneration, anticoagulants and infusion treatment. Every day, the medical staff processes the seams with brilliant green.

• After the woman is allowed to go home, it is necessary to wear for about two more months. compression stockings or tights. 2-3 months after the operation, examinations in the gynecological chair are not passed, sexual intercourse is unacceptable.
• You need to eat right. Products containing chocolate, confectionery and curd products, coffee will have a negative effect - they irritate the mucous membrane. You need to eat a little, but often.
• You can not lift heavy and engage in backbreaking work for the first months, so that the seams do not diverge.
• If a lady noticed profuse and prolonged blood loss, vomiting and nausea, the smell of pus from the genital tract or a wound on the abdomen, urinary incontinence, you need to rush every minute to consult a doctor.

In general, rehabilitation lasts three months.

Pregnancy after surgery, is it possible and when?

Subtotal hysterectomy will not prevent a woman from being sexually active, but she will never be able to get pregnant. The removed uterus is the main organ, without which it will not work to bear the baby. In such a situation, surrogacy is offered.

Sex life after surgery, when can you?

It is possible for a woman to have sex after removing the uterus after all the sutures have healed and the body has recovered. This will take about three months. Before the planned sexual intercourse, it is advisable to consult and be examined by a doctor.

Some ladies have pain during contact with a partner. But mainly those women who have partially removed the vagina experience discomfort.

Potential consequences and complications

The main complication is bleeding. They can occur due to improper suture, vascular injury during surgery.

In addition, there is:

• violation of the vaginal microflora, as a result of discharge;
• purulent inflammation in the seam area;
• thrombus formation on the legs;
• prolapse of the vagina, due to the fact that muscle tissue is injured;
• fecal and urinary incontinence because nerves have been damaged;
• diseases of the lymph nodes of an infectious and inflammatory nature;
• change in the position of the intestines or bladder;
• retention of urine, feces.

In order to prevent the above, a woman should carefully consider the choice of a doctor and the clinic itself, after surgery on the uterus, follow all the doctor's requirements.

The cost

We present to you for comparison 3 centers in Moscow. Here you can find the address of the clinic and the cost of the operation itself.

Output

The operation, in which supravaginal amputation of the uterus is performed, does not prevent a woman from further enjoying or having sex. But this manipulation will never again allow her to bear and give birth to a baby. It is done only in extreme cases: with uterine cancer or long-term ineffective therapy of diseases associated with the female organ.

Stages of supravaginal amputation of the uterus:

1.insection and ligation of the round ligaments;

2. mobilization or removal of appendages (transection and ligation of the uterine end of the tube, the ovarian's own ligament or the funnel ligament);

3. dissection of the plica vesicouterina and moderate mobilization (displacement) of the bladder. When performing supravaginal amputation, the uterus should not be displaced bladder more than is necessary to remove the body of the uterus;

4. transection of the vascular bundle. The transection and ligation of the vascular bundle during a typical operation of supravaginal amputation of the uterus is performed at or slightly above the internal os, i.e. only cross the ascending branches uterine arteries... At the same time, in contrast to the extirpation of the uterus, the vessels are only crossed to remove the uterus and are not further cut off from the cervix. For optimal placement of clamps on the vascular bundles at or slightly above the internal os, the posterior leaves of the broad ligaments are pre-dissected to the ribs of the uterus. Mikulich's clamps are applied perpendicular to the cervix so that the edge of the clamp captures the cervical tissue and, as it were, “slides off” from it, including the entire vascular bundle (this is especially important if varicose veins in this area). The uterine vessels are crossed to the border of the cervix, leaving the 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 a better subsequent comparison, the cervix is \u200b\u200bexcised in a wedge-shaped manner (with a wedge directed towards the internal pharynx). In the process of cutting off the body of the uterus, for convenience, the front and back lips are fixed with clamps (Kocher or Mikulich), after cutting off the uterus, the zone of the cervical canal is treated alcohol solution iodine or ethyl alcohol;

6. impose a suture on the cervical stump in the center, which is subsequently used as a holder. Suture material - vicryl (you cannot use non-absorbable sutures). Further, the ligation of the uterine vessels with vicryl or non-absorbable suture material is carried out, while, in contrast to the extirpation of the uterus (when during the operation, the vascular stump is "taken away" from the cervix when the cardinal ligaments are crossed), during the operation of supravaginal amputation of the cervix to achieve better hemostasis of the vascular stump sewn (fix) to the cervix. For this they sew thick fabric the cervix directly at the nose of the clamp applied to the uterine vessels and a ligature is tied behind the clamp. In the future, it is logical to impose a duplicate (safety) suture, when, when comparing (stitching) the anterior and posterior lips of the cervix in the area of \u200b\u200bthe 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 imposing separate catgut or better vicryl sutures, bringing the anterior and posterior lips of the cervix closer together (if the cervical stump is excised wedge-shaped, this is not difficult). It is advisable to use cutting needles, since the cervical tissue is dense, and to stitch both lips of the cervix below the level of amputation, then reliably ligate (the threads are cut);

8.peritonization is performed with a continuous catgut or vicryl suture: first, a purse-string suture is applied to the parametrium on the left: the posterior leaf of the broad ligament is stitched - the stump of the uterine appendages (or the stump of the funnel ligament) - the stump of the round ligament - the anterior leaf of the broad ligament. The suture is tied in such a way that the aforementioned stumps are immersed in the parametrium, then the suture is continued into a linear one - the vesicouterine fold is “covered” with the cervical stump as a result of stitching it with the posterior leaves of the wide ligaments of the uterus and the posterior surface of the cervix. Then the seam is continued into the purse-string suture on the right: the posterior leaf of the broad ligament is stitched - the stump of the uterine appendages (or the stump of the funnel ligament) - the stump of the round ligament - the anterior leaf of the broad ligament. The seam is also tied in such a way that all stumps are immersed in the parametrium;

9.check and drain the abdominal cavity, sew up the anterior abdominal wall... Operation of high supravaginal amputation of the uterus (when the body of the uterus is cut off significantly above the internal pharynx, which makes it possible to preserve part of the endometrium), the operation of defunding the uterus, and different kinds asymmetric supravaginal amputations of the uterus with the formation of endometrial cavities are currently practically not used. The place of these operations was deservedly taken by conservative myomectomy.

Complications of supravaginal amputation of the uterus

Intraoperative complications:

Damage to the bladder, ureters - exvisit cases during supravaginal amputation of the uterus, nevertheless, the course of the ureters should be monitored before the intersection of the voronic ligaments and uterine vessels.

Bleeding, the formation of hematomas is a more dangerous complication with supravaginal amputation of the uterus than, for example, with extirpation of the uterus (bleeding is intra-abdominal, not external), therefore, the thoroughness of hemostasis when performing supravaginal amputation of the uterus should be given special attention. Bleeding after the operation of 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, massive ligatures). If it is necessary to control hemostasis, drainage is mandatory abdominal cavity or expanding the scope of the operation before extirpation of the uterus.

Postoperative complications:

bleeding;

the formation of hematomas.

In the event of such complications after the operation of supravaginal amputation of the uterus, relaparomy is indicated. With late diagnosis, suppuration of hematomas - relaparotomy, extirpation of the cervical stump, sanitation and drainage of the small 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 intravenous drip.

In the presence of significant additional risk factors ( diabetes, violation of fat metabolism, anemia), it is advisable to use three times perioperative antibiotics. For example, the introduction of 1.2 g of amoxicillin + clavulanic acid intravenously during a 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 drip, then cefuroxime 0.75 g intramuscularly in combination with metronidazole 0.5 g intravenous drip after 8 and 16 hours.

FEATURES OF THE POSTOPERATIVE PERIOD MANAGEMENT

Postoperative management is the same as after uterine extirpation (see chapter "Uterine extirpation"). Features - no need to douch the vagina, an earlier discharge is possible (on the 5-6th day).

PATIENT INFORMATION

Wearing a bandage and compression garments for at least 2 months after surgery.

Exclusion of sexual intercourse within 6 weeks.

In the presence of any complications of supravaginal amputation of the uterus, an immediate appeal to the hospital where the operation was performed, if impossible - to any other gynecological hospital.

Chapter 22. TECHNIQUE OF TYPICAL OPERATIONS ON THE INTERNAL GENITAL ORGANS

Chapter 22. TECHNIQUE OF TYPICAL OPERATIONS ON THE INTERNAL GENITAL ORGANS

Surgical interventions on the internal genital organs can be performed both by laparotomy and laparoscopic access.

Before the operation, the operating field (the entire anterior abdominal wall) is treated with antiseptic solutions. The operating field is limited by sheets, leaving a free incision site.

With laparotomy access for surgical intervention on the pelvic organs, it is necessary to open the anterior abdominal wall. The most acceptable in gynecology are median gastrointestinal cuts and a cross section according to Pfannenstiel. With a midline incision, the anterior abdominal wall is opened in layers from the bosom (upper edge) to the navel.

When cutting along the Pfannenstiel, the skin, subcutaneous tissue is dissected with a transverse incision parallel to the bosom and 3-4 cm above it.The length of the incision is usually 10-12 cm.The aponeurosis is opened in the form of a horseshoe, the upper edges of the incisions on both sides should be at the level of the navel ... The intermuscular fascia (between the rectus abdominis muscles) is opened in an acute way at any incision. When opening the peritoneum, it is important to lift it with soft tweezers and carefully dissect it (in the middle between the bosom and the navel) so as not to damage the bowel loops and the bladder under the bosom. The peritoneum is fixed with clamps to napkins, which are placed along the incision on both sides. The anterior abdominal wall can be dissected with both a scalpel and an electric knife with coagulation or ligation of the vessels with suture material (silk, catgut, vicryl).

After dissection of the anterior abdominal wall, it is necessary to visually and palpate with a hand inserted into the abdominal cavity to revise the abdominal organs. Then the dilator is inserted, and the intestinal loops are carefully pushed back with a napkin into upper sections abdominal cavity, thereby providing visibility and accessibility of the pelvic organs.

When removing an organ or part of an organ, first of all, the vessels are clamped, and then they are crossed, followed by ligation. You can cut through the tissue with scissors. Silk, catgut, vicryl, etc. are used to suture the ligamentous apparatus, vessels, stumps of the cervix and the walls of the vagina.

Fallopian tube removal technique.To remove the fallopian tube, regardless of the nosological form of the disease on the mesosalpinx and the isthmus of the fallopian tube, in which the branches of the ovarian and uterine

arteries and veins, apply a clamp (Kocher). The tube is cut off above the clamps and removed from the abdominal cavity (the material is sent for histological examination). The mesosalpinx is stitched under the clamp and the ligature is tied, carefully removing the Kocher clamp. After cutting off the isthmus of the tube, 1-2 separate sutures are applied to the corner of the uterus.

Peritonization can be performed with a continuous suture, connecting the sheets of the peritoneum of the wide uterine ligament. The area of \u200b\u200bthe isthmus of the tube, as a rule, is peritonized by the round uterine ligament.

Technique for removing the uterine appendages.Operating clamps (Kocher) are applied to the funnel ligament, in which the ovarian artery passes; mesosalpinx; own ligament of the ovary with the branches of the ovarian and uterine vessels passing through it; isthmus of the pipe. The uterine appendages are cut off above the clamps. The stumps are ligated with separate sutures. Peritonization is carried out by the sheets of the peritoneum of the wide uterine ligaments and the round uterine ligament. The appendages of the uterus, after excision, are removed from the abdominal cavity and sent to histological examination (Fig.22.1, a, b).

Supravaginal amputation of the uterus (subtotal, supravaginal) without appendages.Surgical clamps (Kocher) are alternately placed on both sides of the uterine rib. The bottom edge of the clamp should be in line with the inner throat. In this case, the clamp contains the fallopian tube (isthmus), the round uterine ligament, the ovary's own ligament. At 0.5-1 cm lateral to the previous clamp, a separate clamp is applied to the round uterine ligament and a clamp to the fallopian tube and the ovarian's own ligament. The "noses" of the lateral clamps should be at the same level. The ligaments are crossed between the clamps. With scissors in front, a leaf of the peritoneum of the vesicouterine fold is opened, and the bladder is lowered downward. From behind, the posterior leaf of the wide uterine ligament is opened in the direction of the sacro-uterine ligaments (in order to avoid ligation and injury of the ureters). Round ligaments and stumps of the uterine appendages are separately stitched and ligated. Vascular clamps are applied perpendicularly to the uterine vessels at the level of the internal uterine os on both sides. The vessels are transected and sutured with separate ligatures. The body of the uterus is cut off at the level of the internal os above the ligatures of the uterine vessels and removed from the abdominal cavity. Separate ligatures are applied to the cervical stump. Peritonization of the stumps of the uterine appendages and its cervix is \u200b\u200bcarried out with a continuous suture due to the leaves of the wide uterine ligaments and the leaves of the vesicouterine fold (Fig. 22.2, a-g).

Supravaginal amputation of the uterus with appendages on one side, on both sides, with a fallopian tube on one side and on both sides is carried out by analogy with the above operations.

Extirpation of the uterus (total hysterectomy)can be without appendages, with the removal of the uterine appendages on one side, on both sides, with the fallopian tubes, with the removal of the fallopian tube on one side. In this operation, both the body and the cervix are removed. Before the stage of cutting off the body of the uterus and applying clamps to the uterine vessels, the operation is carried out in the same way as with supravaginal amputation of the uterus. Before applying hemostatic

Figure: 22.1.Adnexectomy. Laparotomy: a - the clamps are placed on the funnel ligament, the ovary's own ligament and the isthmus of the fallopian tube (right, back view); b - after cutting off the uterine appendages, ligation (right, side view)

clamps on the vessels, it is necessary to open the peritoneum of the vesicouterine fold and separate the bladder below the cervix. Behind the uterus, the posterior leaf of the wide uterine ligament is opened to the level of the external os of the cervix. Hemostatic clamps are placed on the uterine vessels parallel to and close to the uterine rib. Vessels cross

Figure: 22.2.Stages of supravaginal amputation of the uterus without appendages. Laparotomy (a-g): a - Kocher clamps are applied to the round, own ligament of the ovary and the isthmus of the fallopian tube (rear view). Artist A.V. Evseev

Figure: 22.2.Continuation.b - the round, own ligament of the ovary and the fallopian tube (rear view) are crossed between the clamps. Artist A.V. Evseev

Figure: 22.2.Continuation.c - opening of the vesicouterine fold (front view). Artist A.V. Evseev

Figure: 22.2.Continuation.d - vascular clamps are applied to the uterine vessels at the level of the internal os (rear view). Artist A.V. Evseev

Figure: 22.2.Continuation.e - cutting off the body of the uterus at the level of the internal os (front view). Suturing of the cervical stump. Artist A.V. Evseev

Figure: 22.2.Continuation.f - cervical stump after suturing (left view)

Figure: 22.2.Continuation.g - peritonization. Artist A.V. Evseev

and stitching. After the clamps are applied, the sacro-uterine ligaments are ligated and crossed, the utero-rectal fold of the peritoneum is opened between them, which should also be lowered below the cervix.

After mobilization of the cervix, the vagina is opened, preferably in front, below the cervix, controlling the localization of the bladder and ureters (they must be deflated). The cervix is \u200b\u200bcut off from the vaginal vaults with scissors, the walls of the vagina are fixed with clamps and additional hemostasis is performed, if necessary. The uterus is removed from the abdominal cavity, the walls of the vagina (front and back) are sewn together with separate sutures. Peritonization is carried out with a continuous suture due to the peritoneum of the wide uterine ligaments, vesicouterine fold. Control hemostasis. The abdominal cavity is sutured tightly in layers: a continuous catgut or vicryl suture is applied to the peritoneum and muscles, separate silk or vicryl ligatures are applied to the aponeurosis, tantalum staples or individual silk sutures or a subcutaneous cosmetic suture are applied to the skin (depending on the incision).

22.1. Operative technique of some laparoscopic operations

Surgical interventions by laparoscopic access on the genitals differ from celiac surgery.

The patient is placed on the operating table with reinforced leg holders (Fig. 22.3). Legs should be about 90 ° apart. It is important that the thighs are flush with the body without interfering with the movement of the outer parts of the instruments in the lateral trocars. Pro-

Figure: 22.3.Position of the patient on the operating table during laparoscopy

Figure: 22.4.Uterine probe Cohenduring laparoscopy

the interstitial space should be behind the edge of the table (it is better if the table has a recess for vaginal manipulation). This allows you to actively move the uterine probe (Cohen)(Fig. 22.4), inserted into the uterus and fixed with bullet forceps. For extirpation of the uterus, the Clermont uterine manipulator is most suitable, with the help of which it is possible to give the uterus a comfortable position for cutting off the vaginal vaults.

The operating field is treated with an antiseptic solution from the edge of the costal arch to the middle of the thighs, especially carefully - the perineum and vagina. The surgical field is delimited with sterile sheets on the left and right, fixed with a pin in the area xiphoid process... At the level of the bosom, the skin is covered with a film fixed to the sheets. Thus, the operating field has the shape of a triangle. A sterile film is placed under the perineal area. This allows the assistant to manipulate the uterine probe without disturbing asepsis.

Operations are performed under endotracheal anesthesia.

The location of the operating team.The surgeon is on the patient's left, the 1st assistant is on the right, the 2nd assistant is between the spread legs. The surgeon performs the main manipulations with his left hand, holding the camera with his right hand. The function of the assistants is to create optimal interposition and tension of tissues during the operation.

Trocars and instruments.The minimum set of instruments for all stages of the operation: trocar for a 10 mm telescope; 2 trocars 5 mm; forceps with fixing ratchets 5 mm, preferably one of the instruments with wide-grip traumatic jaws; dissector 5 mm; scissors 5 mm; bipolar forceps; aspirator-irrigator 5 mm; pliers 10 mm; uterine probe Cohen;morcellator; a needle for suturing the aponeurosis (Fig.22.5).

Equipment.Operations are performed using an endoscopic stand with conventional equipment. An electrosurgical unit with a power of at least 300 W is required.

Stages of laparoscopy

First step -imposition of pneumoperitoneum and introduction of the first trocar. The Veress needle (to create a pneumoperitoneum) and the 1st trocar are inserted along the edge of the umbilical ring according to the traditional technique. The place of choice is the area 2 cm to the left above the navel. In patients who underwent a laparotomy with a lower median incision and a Pfan incision

Figure: 22.5.Instruments for laparoscopy (a, b)

nestilyu, uterine myoma big size, in obese patients, the point of insertion of the Veress needle and 1st trocar is usually determined individually. The introduction of the 1st trocar in previously operated patients in the traditional place (along the edge of the umbilical ring) is impractical. In patients who have undergone operations on the abdominal organs, it is preferable to insert the 1st trocar on the left above the navel. This ensures that the telescope objective is located in the abdominal cavity outside of the adhesions.

Second phase -introduction of additional trocars. For the convenience of the surgeon during manipulations, as a rule, three counter-openings are needed: 1st and 2nd - on the right and left in the avascular zone medial to the anterior superior iliac spine, 3rd - in the center of the midline under the bosom (Fig.22.6).

Figure: 22.6.View of the operating field during laparoscopy

After the introduction of the telescope and instruments, the abdominal and pelvic organs are revised. The operating table is transformed to give the patient a Trendelenburg position. This allows you to move the bowel loops and the omentum to the upper abdominal cavity, creating conditions for manipulation of the pelvic organs.

Laparoscopic tubectomy

After tensioning with forceps, the fallopian tube is clamped with the branches of the dissector and mono or bipolar current is supplied to it in coagulation mode. In this case, the tube is cut off along the upper edge of the mesosalpinx with simultaneous hemostasis. The tube is removed from the abdominal cavity with a soft clamp through the extended counterperture on the left (Fig. 22.7, a, b).

Laparoscopic adnexectomy

The fallopian tube is removed in the manner indicated above. Ovarian tissue is grasped with forceps near its own ligament, coagulated and transected. Then, the ovarian tissue is grasped with forceps near the funnel ligament, and when it is pulled, the ovary is cut off from the meso-ovary with a monopolar coagulator. When using bipolar forceps, the separation of the tissues after coagulation is performed using endoscopic scissors. The ovary and tube are removed through an extended counter-opening. The abdominal cavity is washed with isotonic sodium chloride solution (Fig. 22.8, a-d).

Figure: 22.7.Stages (a, b) of tubectomy (rear view, left). Laparoscopy

Figure: 22.8.Stages of adnexectomy. Laparoscopy: a - the intersection of the own ligament of the ovary (rear view, left)

Figure: 22.8.Continuation.b - the own ligament of the ovary and the isthmus of the fallopian tube are crossed (rear view, left); c - the intersection of the funnel ligament (rear view, left); d - view of the stump after cutting off the uterine appendages (rear view)

Supravaginal amputation of the uterus without appendages

After revision of the pelvic organs and the abdominal cavity, a uterine probe (Cohen) is inserted into the uterine cavity. With a bipolar coagulator and scissors or a monopolar coagulator with simultaneous hemostasis, the round uterine ligaments are crossed alternately on both sides, the fallopian tubes, own ligaments of the ovaries. The vesicouterine fold of the peritoneum is opened and separated from top to bottom together with bladder... Close to the rib of the uterus, the posterior leaf of the wide uterine ligament is opened towards the sacro-uterine ligament. The uterine vessels can be coagulated and transected using mono- and bipolar coagulation, or sutured and tied with vicryl sutures. The body of the uterus is dissected from the cervix at the level of the internal os using monopolar coagulation. The body of the uterus is removed from the abdominal cavity using a morceller (a device for grinding tissue) or through the colpotomy opening. The vaginal wall in the area of \u200b\u200bthe colpotomy opening is restored by suturing laparoscopically or through the vagina. The appendages of the uterus, fallopian tubes (if necessary) are removed according to the method described above. After removing the body of the uterus, the abdominal cavity is sanitized and additional hemostasis (if necessary) is performed. Peritonization of the uterine stump is not performed (Fig. 22.9, ae; 22.10).

Extirpation of the uterus without appendages

Until the moment of cutting off the body of the uterus from the fornix of the vagina, the operation is performed in the same way as the above-described supravaginal amputation of the uterus. One of the most technically critical stages of uterine extirpation is cutting off the cervix from the vaginal vaults. At this stage, the Clermont uterine manipulator must be used. The probe is inserted into the uterine cavity through the cervical canal. The bladder and the posterior leaf of the wide uterine ligament are separated below the cervix. The latter is cut off from the vaults by a monopolar coagulator with simultaneous hemostasis. The uterus is removed through the vagina. To create the tightness of the abdominal cavity after removing the uterus (to complete the operation), a sterile medical rubber glove with a gauze pad inside is inserted into the vagina.

At the end of the operation, hemostasis is carefully controlled. For this purpose, an isotonic sodium chloride solution is introduced into the pelvic cavity and aspirated until it is completely transparent. The injected fluid allows you to clearly see even the smallest bleeding vessels, which are targeted coagulate with the branches of the dissector. The vagina is sutured from the abdominal side using an extracorporeal suture technique. At the end of the operation, a suture is applied to the aponeurosis after morcellation, even with small hole sizes (15-20 mm).

Figure: 22.9.Stages of supravaginal amputation of the uterus. Laparoscopy: a - the intersection of the fallopian tube in the isthmus (side view, right); b - the intersection of the own ligament of the ovary (rear view); c - opening the parametrium (rear view)

Gynecology: textbook / BI Baisov et al.; ed. G. M. Savelyeva, V. G. Breusenko. - 4th ed., Rev. and add. - 2011 .-- 432 p. : ill.

Subtotal hysterectomy (amputatio uteri supravaginalis s. Hysterectomia subtotalis) is an operation aimed at removing the body of the uterus while preserving its cervix. The following options for this operation are possible:

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 is most often performed in young women in the absence of pathology from the side of the uterine appendages.

Execution technique. The abdominal cavity is opened with a lower median or transverse incision. The right hand is used to audit the pelvic organs (uterus and appendages). The uterus is brought out to the incision and fixed with Musot forceps. The forceps are applied at the bottom of the uterus, symmetrically between its corners - the area of \u200b\u200bthe discharge of the tubes. If possible, the uterus is removed by hand from the abdominal cavity, and then fixed with Musot forceps. A mirror is inserted into the lower corner of the wound and with its help the anterior Douglas space is exposed, the lower edge of the wound and the bladder are moved downward. Napkins 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 with Musot forceps, and the lower mirror moves to the right and the right half of the surface of the uterus with the appendages and the 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 own ligament of the ovary in a direction perpendicular to the uterus at a distance of 3-4 cm from it, so that a duplication of the peritoneum (without vessels) is visible at the ends of the clamps. By pulling on 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 (counterclamp) is applied to the round ligament, the uterine end of the tube and the ovary's own ligament already 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.

Figure: 59.

: 1 - the application of a clamp on the round ligament of the uterus, the own ligament of the ovary 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 brychina; 5 - dissection of the peritoneum along the posterior surface of the uterus; 6 - clearing of uterine vessels.

Figure: 60.

: 1 - cutting off the uterus from the cervix along the posterior surface; 2 - cutting off the uterus from the cervix along the front 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 - the imposition of clamps on the funnel-pelvic (hanging the ovary) ligament during supravaginal amputation of the uterus with appendages.

In a state of slight tension of the tissues between the uterus with the Musot forceps and the clamps between the latter, the round ligaments of the uterus, the tube and the ovarian's own ligament are dissected (Fig. 59.2). Their dissection is performed along the lower edge of the common clamp, imposed closer to the uterus. Next, the peritoneum is dissected in front in the area of \u200b\u200bthe vesicouterine fold (Fig. 59,3,4) and the bladder is blunt and sharp way falls somewhat downward. The posterior leaflet of the broad ligament of the uterus is dissected posteriorly (Fig. 59.5), and then in the transverse direction the peritoneum above the projection of the internal os of the uterus is incised to the midline and is also somewhat bluntly and sharply freed downward. 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 is exposed with a translucent vascular uterine bundle. The stump of the round ligament of the uterus is tied, its ligature is held by a clamp. The ligature of the tied 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 turns to the right side, the mirror is transferred to the left of the midline, and the round ligament, the uterine end of the tube and the ovary's own ligament on the left are clamped and dissected in the same way. The peritoneum on the left is dissected anteriorly in the region of the vesicouterine fold in the horizontal direction and at the level of the internal pharynx from behind until it is connected with its incisions on the right. The uterus is lifted up with Musot forceps, the front mirror is set 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 the horizontal direction, so that their ends partially capture the tissues of the cervix (Fig. 59.6). Control clamps are applied 2 cm higher at an angle, already somewhat vertically. The vascular bundles are traversed at the lower edge of the upper clamps and tied 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 by an oblique direction of the scalpel (from top to outside downward to inside), the tissue is dissected in front and behind so that the cut off uterus below looks like a small cone, and top part stump of the cervix - 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 falls above the stump of the tied vascular bundles of the uterus on the right and left.

When cutting off the body of the uterus from the cervix, the stumps are applied to the front and back of its stump to hold the Kocher clamps.

Next, the stump of the cervix is \u200b\u200bsutured (Fig. 60.4). Separate ligatures are applied in such a way that the needle is pricked from the inside at the border of the mucous membrane and the wound, and outside by 1.5-2 cm from top to bottom of the wound. Usually 3-4 such ligatures are sufficient. For them, the stump of the cervix is \u200b\u200blifted upward and the stumps of the vascular uterine bundles are tied to it with additional ligatures (Fig. 60.3), and then the stump of the round ligaments of the uterus. If necessary, the stumps of the appendages of the uterus are additionally tied up and for these ligatures they are held for convenience during subsequent peritonization. In the future, the stumps of the uterine appendages should be attached to the stump of the uterus. Peritonization is performed by connecting the free edge of the peritoneum, separated from the lower surface of the uterus in the area of \u200b\u200bthe 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 along the edges - in the form of purse string sutures. We do this, starting with a purse-string suture on the right side, then in the center and ending with a purse-string suture on the left. As a result, the cervical stump looks like a "small uterus", to which the stumps of the round ligaments and the stump of the uterine appendages are attached. In the process of peritonization, if necessary, for the convenience of work, a direct mirror is inserted into the posterior Douglas space, which holds the intestinal loops. Before peritonization, hemostasis is monitored: with clamps, the sheets of the peritoneum are lifted in front and behind, the ligatures of the stumps of the round ligaments and the appendages of the uterus 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 the peritoneum, together with ligatures on the cervical stump, the second angle is the stump of the round ligament and the third angle is the stump of the uterine appendages. Then the stump of the cervix is \u200b\u200bfixed to the stump of the round ligaments of the uterine appendages.

After peritonization, a revision of the abdominal cavity is performed: kidneys, liver, omentum, stomach, intestines.

Suturing of the abdominal cavity is carried out in layers: the peritoneum - with a continuous suture, after fixing it at the bottom, the edges of the muscles of the abdominal wall are connected; the aponeurosis is sutured with separate silk sutures with a longitudinal section of the abdominal wall and a continuous suture with its transverse section; subcutaneous fatty tissue is connected by continuous or separate sutures. The skin edges of the incision are connected by various methods: cosmetic suture, separate sutures, etc. Aseptic dressing. Control procedures: drying the vagina with gauze tampons, removing urine from the bladder with a catheter. Extubation.

Brief description of the operation in the medical history Laparotomy (lower median, according to Pfannenstiel). It was found: the uterus was enlarged due to tumor formations up to 14-15 weeks of pregnancy, fixed with Musot forceps and removed from the abdominal cavity. The appendages of the uterus were normal. Alternately, on the right and on the left, clamps and counterclamps are imposed on the round ligaments of the uterus, the uterine ends of the tubes and the ovarian's own ligaments, the tissues between the clamps are dissected and the latter are replaced with ligatures. The sheets of the peritoneum are dissected in front and behind, the bladder is lowered downward. The vascular uterine bundles are exposed, clemmed, 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 fixed with additional sutures to the cervix. Control for hemostasis. Peritonization. Revision of the abdominal organs, her toilet. The abdominal cavity is sutured tightly in layers. Aseptic dressing. Urine excreted by a 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 the amputation of the uterus, clamps are applied (Fig. 60.6) to the funnel-pelvic ligament (on one or both sides).

Next to it, the ureter runs down along the posterior leaf of the broad ligament, which requires special care when applying clamps. Before this, the fallopian tube and ovary are raised and retracted to the side so that the ligament is well visible. The clamp is applied so that its end does not reach the edge of the uterus by 2-3 cm, passing slightly above the base of the broad ligament. The funnel-pelvic ligament is dissected between the clamps and ligated, the ligature on the stump is cut off and the latter is immersed in the abdominal cavity. The round ligament of the uterus was pre-cleared, dissected and ligated, as in the case of amputation of the uterus without appendages. Both sheets of the broad ligament are dissected closer to the ovary, in a horizontal direction, to the corner of the uterus, where the ovary's own ligament is attached, so as not to damage the ureter, which runs at the base of the broad ligament. Similarly, actions are performed on the other side when both uterine appendages are removed.

Amputation of the uterus with tubes (without ovaries) is possible. In this case, the clamps are applied to the ovarian's own ligament and the mesentery of the 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 according to Pfannenstiel). Revision of the pelvic organs: the uterus is enlarged up to 14-15 weeks of gestation with many myoma nodes. The ovaries are enlarged (up to 6x7 cm) due to cystic formations... The round ligaments, the uterine ends of the tubes and the own ligaments of the ovaries were cleared, dissected and ligated alternately on the right and left. The anterior and posterior sheets of the peritoneum are dissected in the front in the region of the vesicouterine fold, and behind - above the sacro-uterine ligaments. The bladder is somewhat deflated. The vascular uterine bundles at the level of the internal os are exposed, clemmed, dissected and ligated, with the seizure of 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. Her stump is sutured in with separate sutures. Control for hemostasis. Peritonization. Abdominal toilet, organ revision. The incision of the abdominal wall is sutured tightly in layers. Bandage. Urine excreted by a catheter - light, 100 ml. Extubation. Macro preparations (description).

Removal of the uterus is a difficult, crippling operation. The consequences of removing the uterus for a woman are irreversible and lead to the inability to have children. Therefore, this surgical intervention is carried out only when a woman is threatened with death without an operation. With the development of medicine, this surgical intervention is carried out less and less, but there are situations in which there is no alternative. There is also no specific age when it is best to have surgery to remove the uterus. The intervention is prescribed for health reasons and can be performed on a woman of any age category.

It can be done in three ways:

1. Supravaginal amputation of the uterus without appendages. It is carried out in the case of uterine fibroids, endometriosis, which leads to prolonged persistent bleeding, initial stages uterine cancer. A prerequisite for the operation is the presence of an unchanged cervix. This operation has the least invasiveness.
2. Supravaginal amputation of the uterus with appendages. The indication for surgery is a neoplasm of the ovaries, which is combined with the pathology of the accessory apparatus and the uterus itself. Also, for a successful operation, the cervix must be unchanged.
3. Extirpation of the uterus with appendages, the postoperative period and the consequences of which are the most severe. It differs from amputation in that during extirpation, the cervix is \u200b\u200bremoved along with its body. Indications for surgery are diseases of the uterus, which are combined with ovarian pathology (combination of uterine fibroids with ovarian endometriosis), uterine cancer. It is also performed if a woman decides to change sex.

Depending on the access that is performed to remove the uterus, the following operations are distinguished:

• Open, or laparotomy;
• Laparoscopic removal of the uterus, which is performed using instruments inserted into small incisions;
• Laparoscopic, conducted by the da Vinci robot;
• Removal of the uterus through the vagina;
• Transvaginal access, which is combined with laparotomy.

The operation begins with the introduction of the patient into anesthesia. Which anesthesia is better for removing the uterus is always decided by the anesthesiologist, depending on a number of factors:

1. The patient's body weight;
2. Woman's age;
3. The general condition of the patient and the presence of concomitant diseases;
4. Duration and volume of surgery.

Given that the removal of the uterus is a long-term operation, which consists of many stages, and the surgical field has a large area, all patients are given general anesthesia. If the operation is carried out by the method of laparoscopy, in which there is minimal trauma to the skin, the woman must also be injected into general anesthesia to achieve the greatest relaxation of the muscles of the anterior abdominal wall.

Endotracheal anesthesia is used, but an epidural or spinal anesthesiawhich also provide sufficient relaxation of the abdominal muscles.

Technique of supravaginal amputation of the uterus without appendages

The surgeon, having cut the anterior abdominal wall in layers, examines and palpates the pelvic cavity. Once the uterus has been found, it must be removed from the wound for ease of handling. If adhesions appear, they are dissected.

With the help of two clamps applied to the fallopian tubes and ligamentous apparatus, the appendages are ligated. The vesicouterine fold of the peritoneum is crossed.

To exclude trauma to the bladder, it is taken to the side along with its peritoneal leaf. Clamps are applied to the released vascular bundle in order to cross it. The vessels are cut off to the muscular layer of the cervix. For proper transection, the uterus is pulled in the opposite direction. Suturing of the cut vessels is performed with catgut.

The uterus from the cervix with a scalpel is cut 1 cm above the cut vascular bundle. Removal of the uterus is carried out in the form of a cone. After the uterus has been removed, the cervical stump is stitched with catgut, and the entire cervical canal is lubricated with iodine solution.

Before layer-by-layer suturing of the operating wound, it is necessary to conduct an audit, while evaluating the following indicators:

• Density of stitches on the cervical stump;
• No internal bleeding;
• Reliability of superimposed ligatures.

The total duration of the operation is 1 -1.5 hours.

Technique of supravaginal amputation of the uterus with appendages

Performing supravaginal amputation of the uterus with appendages differs from the same operation without removing the appendages with some additions:

1. Having applied two clamps on both sides of the supporting ligament, it is crossed, after which the stump is stitched and the clamps are removed;
2. Having cut the posterior leaf of the wide ligament of the uterus, it must be pushed downward;
3. The round ligament of the uterus and the vesicouterine fold of the peritoneum are dissected;
4. The vascular bundle is clamped, the vessels are crossed, after which they are stitched;
5. Allocate the uterus along with the appendages;
6. The cervical stump is stitched.

The posterior layer of the peritoneum and the anterior layer of the broad ligament of the uterus must be stitched with a continuous suture. The anterior abdominal wall is sutured in layers. The duration of this operation is on average about 1.5 hours.

Extirpation of the uterus with appendages - the course of the operation

If a woman is shown extirpation of the uterus, the course of the operation consists of several stages:

• The beginning of the operation coincides with the beginning of the supravaginal amputation of the uterus with the appendages until the separation of the bladder;
• Along the entire length of the cervix, the bladder is separated, after which it is pushed downward;
• After removal of the uterus, the stump of the cervix is \u200b\u200btied and stitched;
• Dissection of the wide ligament of the uterus (its posterior leaflet) is performed, but this stage is dangerous, since there is a possibility of injury to the ureter;
• The vessels are crossed between the clamps imposed on the vascular bundles, after which they are sutured.

Further actions are performed through the vagina, on the front wall of which an incision is made. Then the vaginal part of the cervix is \u200b\u200bbrought out through the wound. The vagina is dissected around the neck. The uterus and its appendages are removed from the small pelvis. The vagina is sutured with catgut. The operation ends with the imposition of layer-by-layer sutures on the ligaments and the anterior abdominal wall.

Extirpation of the uterus with appendages is the most traumatic and longest operation. The duration is 2 to 3 hours. Complications after removal of the uterus by extirpation are most common.

Management of the early postoperative period

After the end of the operation, the woman is transferred to the intensive care unit, where round-the-clock monitoring of the patient's condition is carried out and is on duty medical staffDeveloping First Aid Skills postoperative complications... The ward in which the woman is after the operation must contain:

1. Oxygen supply system;
2. Resuscitation kit;
3. A set of medicines in case of an emergency.

Within 6 hours after the completion of the operation, the woman is constantly measured arterial pressure, pulse and respiratory rate. Also within 3 hours you need to postoperative wound put a heavy object. This is done in order to restore blood circulation in the small pelvis as soon as possible. To prevent bleeding, an ice pack is applied to the abdomen.

After the operation, the woman has pain syndrome... To remove it, use non-steroidal anti-inflammatory drugs (baralgin, promedol), and if they are ineffective, narcotic analgesics. If necessary, the injections can be repeated at intervals of 4-6 hours. 9 hours after the operation, the bladder is completely emptied through a catheter or naturally.

During the first day, the doctor should regularly assess the woman's condition, palpate the abdomen and check the Shchetkin-Blumberg symptom, which should not be normal.

Diet after surgery to remove the uterus

The diet is followed from the first minutes after the end of the operation. In the first hours, it is forbidden to even drink water, and if a woman has a thirst, it is quenched by wetting her lips with wet gauze. You can drink only 12 hours after surgery. All fluid loss is replaced by infusion of infusion solutions.

Nutrition after surgery to remove the uterus is allowed only after two days. A woman can eat low-fat broth, chicken eggs, tea, crackers. Starting from the third day, the menu includes kefir, boiled chicken, and liquid soup. A week after the operation, you can return to your normal diet.

Management of the late postoperative period

In the late postoperative period regular monitoring of the seam on the anterior abdominal wall is necessary.

A woman should carefully monitor the state of her reproductive system and consult a doctor in case of minor violations. After removal of the uterus, all patients are subject to dispensary supervision and should visit a gynecologist regularly.

The appointment of hormones after the removal of the uterus and ovaries is a mandatory step, since when the uterus is removed, the hormonal balance in the woman's body is disturbed. Female sex hormones (estrogen, progesterone) are used. Hormone therapy after removal of the uterus and ovaries, it is appointed by the gynecologist at the place of residence after the woman is discharged from the hospital.

If the operation was performed for malignant neoplasm, the oncologist prescribes radiation to the woman after the removal of the uterus, which is aimed at preventing the recurrence of cancer. It is also possible to undergo a course of chemotherapy if the disease was in the third stage.

Rehabilitation after removal of the uterus should be carried out by a gynecologist in conjunction with a psychologist. Sexual rehabilitation is a separate item, since a woman during intercourse after complete removal The uterus can experience both physical and emotional discomfort. Labor rehabilitation consists in choosing a new professional field that is not associated with chemical hazards or heavy physical exertion.

Complications

The main complication is bleeding after removal of the uterus and ovaries, the cause of which is the leaky suture of the vessels during the intersection of the vascular bundle, or injury to other vessels if the operation technique is not followed. Other complications are:

• Discharge after removal of the uterus and ovaries, which arise from a violation of the microflora of the genital organs;
• Suppuration of the seams due to the ingress of an infectious agent into them;
• Vein thrombosis lower limbs, especially in women over 50;
• Vaginal prolapse due to injury to the muscles that support the genitals
• Incontinence of urine and feces due to damage to the pelvic nerves;
• Infectious and inflammatory diseases lymph nodes due to non-compliance with the conditions of sterility in the operating room.

If the uterus and cervix are removed, the consequences can be more serious than removing only the body of the uterus. They are associated with the fact that the intestines and bladder change their position, as a result, there is a violation of urination and defecation. These anomalies lead to retention of urine and feces, which are the cause of intoxication of the body, the development of infectious and inflammatory diseases genitourinary system... Gymnastics after surgery to remove the uterus () and playing sports helps to prevent these complications.