Update: October 2018

Hysterectomy or removal of the uterus is a fairly common operation that is performed for certain indications. According to statistics, approximately a third of women who have crossed the 45-year mark have undergone this operation.

And, of course, the main question that concerns patients who have undergone surgery or are preparing for surgery is: “What consequences can there be after removal of the uterus”?

Postoperative period

As you know, the period of time that lasts from the date of surgical intervention to restoration of ability to work and good health is called the postoperative period. Hysterectomy is no exception. The period after surgery is divided into 2 “sub-periods”:

• early
• late postoperative periods

During the early postoperative period, the patient is in the hospital under the supervision of doctors. Its duration depends on the surgical approach and the general condition of the patient after surgery.

• After surgery to remove the uterus and/or appendages, which was carried out either vaginally or through an incision in the anterior wall of the abdomen, the patient remains in the gynecological department for 8 - 10 days, and it is at the end of the agreed period that the sutures are removed.
• After laparoscopic hysterectomy the patient is discharged after 3–5 days.

The first day after surgery

The first postoperative days are especially difficult.

Pain - during this period, the woman feels significant pain both inside the abdomen and in the area of ​​the sutures, which is not surprising, since there is a wound both outside and inside (just remember how painful it is when you accidentally cut your finger). To relieve pain, non-narcotic and narcotic painkillers are prescribed.

Lower limbs remain, as before the operation, in or bandaged with elastic bandages (prevention of thrombophlebitis).

Activity - surgeons adhere to active management of the patient after surgery, which means getting out of bed early (after laparoscopy in a few hours, after laparotomy in a day). Physical activity “accelerates the blood” and stimulates intestinal function.

Diet - the first day after a hysterectomy, a gentle diet is prescribed, which contains broths, pureed food and liquids (weak tea, still mineral water, fruit drinks). Such a treatment table gently stimulates intestinal motility and promotes early (1–2 days) spontaneous bowel movement. Independent stool indicates the normalization of intestinal function, which requires a transition to regular food.

Belly after hysterectomy remains painful or sensitive for 3–10 days, which depends on the patient’s pain sensitivity threshold. It should be noted that the more active the patient is after surgery, the faster her condition recovers and the lower the risk of possible complications.

Treatment after surgery

• Antibiotics - usually antibacterial therapy is prescribed for prophylactic purposes, since the patient’s internal organs came into contact with air during the operation, and therefore with various infectious agents. The course of antibiotics lasts an average of 7 days.
• Anticoagulants - also in the first 2 - 3 days, anticoagulants (blood thinning drugs) are prescribed, which are designed to protect against thrombosis and the development of thrombophlebitis.
• Intravenous infusions- in the first 24 hours after hysterectomy, infusion therapy (intravenous drip infusion of solutions) is carried out in order to replenish the volume of circulating blood, since the operation is almost always accompanied by significant blood loss (the volume of blood loss during an uncomplicated hysterectomy is 400 - 500 ml).

The course of the early postoperative period is considered smooth if there are no complications.

Early postoperative complications include:

• inflammation of the postoperative scar on the skin (redness, swelling, purulent discharge from the wound and even dehiscence);
• problems with urination(pain or pain when urinating) caused by traumatic urethritis (damage to the mucous membrane of the urethra);
• bleeding of varying intensity, both external (from the genital tract) and internal, which indicates insufficiently well-performed hemostasis during surgery (discharge may be dark or scarlet, blood clots are present);
• pulmonary embolism- a dangerous complication that leads to blockage of the branches or the pulmonary artery itself, which is fraught with pulmonary hypertension in the future, the development of pneumonia and even death;
• peritonitis - inflammation of the peritoneum, which spreads to other internal organs, dangerous for the development of sepsis;
• hematomas (bruises) in the area of ​​the sutures.

Bloody discharge after removal of the uterus, like a “daub,” is always observed, especially in the first 10–14 days after the operation. This symptom is explained by the healing of sutures in the area of ​​the uterine stump or in the vaginal area. If a woman’s discharge pattern changes after surgery:

• accompanied by an unpleasant, putrid odor
• the color resembles meat slop

You should consult a doctor immediately. It is possible that inflammation of the sutures in the vagina has occurred (after hysterectomy or vaginal hysterectomy), which is fraught with the development of peritonitis and sepsis. Bleeding from the genital tract after surgery is a very alarming signal and requires repeat laparotomy.

Suture infection

If a postoperative suture becomes infected, the general body temperature rises, usually not higher than 38 degrees. The patient’s condition, as a rule, does not suffer. Prescribed antibiotics and treatment of sutures are quite enough to relieve this complication. The first time the postoperative dressing is changed and the wound is treated the next day after the operation, then the dressing is carried out every other day. It is advisable to treat the sutures with a solution of Curiosin (10 ml, 350-500 rubles), which ensures gentle healing and prevents the formation of a keloid scar.

Peritonitis

The development of peritonitis more often occurs after a hysterectomy performed for emergency reasons, for example, necrosis of a myomatous node.

• The patient's condition deteriorates sharply
• The temperature “jumps” to 39 – 40 degrees
• Pronounced pain syndrome
• Signs of peritoneal irritation are positive
• In this situation, massive antibiotic therapy is carried out (prescription of 2–3 drugs) and infusion of saline and colloid solutions
• If there is no effect from conservative treatment, surgeons perform relaparotomy, remove the uterine stump (in case of uterine amputation), wash the abdominal cavity with antiseptic solutions and install drainages

The hysterectomy slightly changes the patient’s usual lifestyle. For a quick and successful recovery after surgery, doctors give patients a number of specific recommendations. If the early postoperative period proceeded smoothly, then after the woman’s stay in the hospital expires, she should immediately take care of her health and the prevention of long-term consequences.

• Bandage

A good help in the late postoperative period is wearing a bandage. It is especially recommended for premenopausal women who have had a history of multiple births or for patients with weakened abdominal muscles. There are several models of such a supportive corset; you should choose the model in which the woman does not feel discomfort. The main condition when choosing a bandage is that its width must exceed the scar by at least 1 cm above and below (if an inferomedial laparotomy was performed).

• Sex life, weight lifting

Discharge after surgery continues for 4 to 6 weeks. For one and a half, and preferably two months after a hysterectomy, a woman should not lift weights of more than 3 kg and perform heavy physical work, otherwise this could lead to the rupture of internal sutures and abdominal bleeding. Sexual activity during the specified period is also prohibited.

• Special exercises and sports

To strengthen the vaginal and pelvic muscles, it is recommended to perform special exercises using an appropriate simulator (perineal gauge). It is the simulator that creates resistance and ensures the effectiveness of such intimate gymnastics.

The described exercises (Kegel exercises) got their name from a gynecologist and developer of intimate gymnastics. You must perform at least 300 exercises per day. Good tone of the vaginal and pelvic floor muscles prevents prolapse of the vaginal walls, prolapse of the uterine stump in the future, as well as the occurrence of such an unpleasant condition as urinary incontinence, which almost all women in menopause face.

Sports after a hysterectomy are easy physical activity in the form of yoga, Bodyflex, Pilates, shaping, dancing, swimming. You can start classes only 3 months after the operation (if it was successful, without complications). It is important that physical education during the recovery period brings pleasure and does not exhaust the woman.

• About baths, saunas, and the use of tampons

For 1.5 months after surgery, it is prohibited to take baths, visit saunas, steam baths and swim in open water. While there is spotting, you should use sanitary pads, but not tampons.

• Nutrition, diet

Proper nutrition is of no small importance in the postoperative period. To prevent constipation and gas formation, you should consume more liquid and fiber (vegetables, fruits in any form, wholemeal bread). It is recommended to give up coffee and strong tea, and, of course, alcohol. Food should not only be fortified, but contain the required amount of proteins, fats and carbohydrates. A woman should consume most of her calories in the first half of the day. You will have to give up your favorite fried, fatty and smoked foods.

• Sick leave

The total period of incapacity for work (counting the time spent in the hospital) ranges from 30 to 45 days. If any complications arise, the sick leave is naturally extended.

Hysterectomy: what then?

In most cases, women after surgery face psycho-emotional problems. This is due to the existing stereotype: there is no uterus, which means there is no main female distinctive feature, and accordingly, I am not a woman.

In reality, this is not the case. After all, it is not only the presence of a uterus that determines a woman’s essence. To prevent the development of depression after surgery, you should study the issue regarding removal of the uterus and life after it as carefully as possible. After the operation, the husband can provide significant support, because outwardly the woman has not changed.

Fears regarding changes in appearance:

• increased facial hair growth
• decreased sex drive
• weight gain
• changing voice timbre, etc.

are far-fetched and therefore easily overcome.

Sex after hysterectomy

Sexual intercourse will give the woman the same pleasures as before, since all sensitive areas are located not in the uterus, but in the vagina and external genitalia. If the ovaries are preserved, then they continue to function as before, that is, they secrete the necessary hormones, especially testosterone, which is responsible for sexual desire.

In some cases, women even note an increase in libido, which is facilitated by relief from pain and other problems associated with the uterus, as well as a psychological moment - the fear of unwanted pregnancy disappears. Orgasm will not disappear after amputation of the uterus, and some patients experience it more vividly. But the occurrence of discomfort and even...

This point applies to those women who have had a hysterectomy (a scar in the vagina) or a radical hysterectomy (Wertheim operation), in which part of the vagina is excised. But this problem is completely solvable and depends on the degree of trust and mutual understanding of the partners.

One of the positive aspects of the operation is the absence of menstruation: no uterus - no endometrium - no menstruation. This means goodbye to critical days and the troubles associated with them. But it’s worth mentioning that, rarely, women who have undergone uterine amputation while preserving the ovaries may experience slight spotting on menstruation. This fact is explained simply: after amputation, a uterine stump remains, and therefore a little endometrium. Therefore, you should not be afraid of such discharges.

Loss of fertility

The issue of loss of reproductive function deserves special attention. Naturally, since there is no uterus - the place of fruit, pregnancy is impossible. Many women list this fact as a plus for having a hysterectomy, but if the woman is young, this is definitely a minus. Before suggesting removal of the uterus, doctors carefully assess all risk factors, study the medical history (in particular the presence of children) and, if possible, try to preserve the organ.

If the situation allows, the woman either has myomatous nodes excised (conservative myomectomy) or the ovaries are left. Even with an absent uterus, but preserved ovaries, a woman can become a mother. IVF and surrogacy are a real way to solve the problem.

Suture after hysterectomy

The suture on the anterior abdominal wall worries women no less than other problems associated with hysterectomy. Laparoscopic surgery or a transverse incision in the lower abdomen will help to avoid this cosmetic defect.

Adhesive process

Any surgical intervention in the abdominal cavity is accompanied by the formation of adhesions. Adhesions are connective tissue cords that form between the peritoneum and internal organs, or between organs. Almost 90% of women suffer from adhesive disease after a hysterectomy.

Forced penetration into the abdominal cavity is accompanied by damage (dissection of the peritoneum), which has fibrinolytic activity and ensures lysis of fibrinous exudate, gluing the edges of the dissected peritoneum.

An attempt to close the area of ​​the peritoneal wound (suturing) disrupts the process of melting of early fibrinous deposits and promotes increased adhesions. The process of formation of adhesions after surgery depends on many factors:

• duration of the operation;
• volume of surgical intervention (the more traumatic the operation, the higher the risk of adhesions);
• blood loss;
• internal bleeding, even leakage of blood after surgery (resorption of blood provokes adhesions);
• infection (development of infectious complications in the postoperative period);
• genetic predisposition (the more the genetically determined enzyme N-acetyltransferase, which dissolves fibrin deposits, is produced, the lower the risk of adhesive disease);
• asthenic physique.

• pain (constant or intermittent)
• urination and defecation disorders
• , dyspeptic symptoms.

To prevent the formation of adhesions in the early postoperative period, the following are prescribed:

• antibiotics (suppress inflammatory reactions in the abdominal cavity)
• anticoagulants (thin the blood and prevent the formation of adhesions)
• motor activity already on the first day (turning on its side)
• early start of physiotherapy (ultrasound or, Hyaluronidase, and others).

Properly carried out rehabilitation after a hysterectomy will prevent not only the formation of adhesions, but also other consequences of the operation.

Menopause after hysterectomy

One of the long-term consequences of hysterectomy surgery is menopause. Although, of course, any woman sooner or later approaches this milestone. If during the operation only the uterus was removed, but the appendages (tubes with ovaries) were preserved, then the onset of menopause will occur naturally, that is, at the age for which the woman’s body is “programmed” genetically.

However, many doctors are of the opinion that after surgical menopause, menopausal symptoms develop on average 5 years earlier than expected. There are no exact explanations for this phenomenon yet; it is believed that the blood supply to the ovaries after a hysterectomy somewhat deteriorates, which affects their hormonal function.

Indeed, if we recall the anatomy of the female reproductive system, the ovaries are mostly supplied with blood from the uterine vessels (and, as is known, quite large vessels pass through the uterus - the uterine arteries).

To understand the problems of menopause after surgery, it is worth defining the medical terms:

• natural menopause - cessation of menstruation due to the gradual fading of the hormonal function of the gonads (see)
• artificial menopause - cessation of menstruation (surgical - removal of the uterus, medication - suppression of ovarian function with hormonal drugs, radiation)
• surgical menopause – removal of both the uterus and ovaries

Women endure surgical menopause more severely than natural menopause, this is due to the fact that when natural menopause occurs, the ovaries do not immediately stop producing hormones; their production decreases gradually, over several years, and eventually stops.

After removal of the uterus and appendages, the body undergoes a sharp hormonal change, since the synthesis of sex hormones suddenly stopped. Therefore, surgical menopause is much more difficult, especially if a woman is of childbearing age.

Symptoms of surgical menopause appear within 2–3 weeks after surgery and are not much different from the signs of natural menopause. Women are concerned about:

• tides (see)
• sweating ()
• emotional lability
• Depressive states often occur (see and)
• later dryness and aging of the skin occur
• brittleness of hair and nails ()
• urinary incontinence when coughing or laughing ()
• Vaginal dryness and related sexual problems
• decreased sex drive

In case of removal of both the uterus and ovaries, hormone replacement therapy is necessary, especially for women under 50 years of age. For this purpose, both gestagens and testosterone are used, which is mostly produced in the ovaries and a decrease in its level leads to a weakening of libido.

If the uterus and appendages were removed due to large myomatous nodes, then the following is prescribed:

• continuous estrogen monotherapy, used as oral tablets (Ovestin, Livial, Proginova and others),
• products in the form of suppositories and ointments for the treatment of atrophic colpitis (Ovestin),
• as well as preparations for external use (Estrogel, Divigel).

If a hysterectomy with adnexa was performed for internal endometriosis:

• treatment with estrogens (Kliane, Progynova)
• together with gestagens (suppression of the activity of dormant foci of endometriosis)

Hormone replacement therapy should be started as early as possible, 1 to 2 months after the hysterectomy. Hormone treatment significantly reduces the risk of cardiovascular disease, osteoporosis and Alzheimer's disease. However, hormone replacement therapy may not be prescribed in all cases.

Contraindications to treatment with hormones are:

• surgery for ;
• pathology of the veins of the lower extremities (thrombophlebitis, thromboembolism);
• severe pathology of the liver and kidneys;
• meningioma.

The duration of treatment ranges from 2 to 5 or more years. You should not expect immediate improvement and disappearance of menopausal symptoms immediately after starting treatment. The longer hormone replacement therapy is carried out, the less pronounced the clinical manifestations are.

Other long-term consequences

One of the long-term consequences of hysterovariectomy is the development of osteoporosis. Men are also susceptible to this disease, but the fairer sex suffers from it more often (see). This pathology is associated with a decrease in estrogen production, so in women osteoporosis is more often diagnosed during pre- and postmenopausal periods (see).

Osteoporosis is a chronic disease that is prone to progression and is caused by a metabolic disorder of the skeleton such as the leaching of calcium from the bones. As a result, the bones become thinner and brittle, which increases the risk of fractures. Osteoporosis is a very insidious disease; it occurs latently for a long time and is detected in an advanced stage.

The most common fractures occur in the vertebral bodies. Moreover, if one vertebra is damaged, there is no pain as such; severe pain is typical for simultaneous fractures of several vertebrae. Spinal compression and increased bone fragility lead to spinal curvature, changes in posture and decreased height. Women with osteoporosis are susceptible to traumatic fractures.

The disease is easier to prevent than to treat (see), therefore, after amputation of the uterus and ovaries, hormone replacement therapy is prescribed, which inhibits the leaching of calcium salts from the bones.

Nutrition and exercise

You also need to follow a certain diet. The diet should contain:

• dairy products
• all varieties of cabbage, nuts, dried fruits (dried apricots, prunes)
• legumes, fresh vegetables and fruits, greens
• You should limit your salt intake (promotes the excretion of calcium by the kidneys), caffeine (coffee, Coca-Cola, strong tea) and avoid alcoholic beverages.

To prevent osteoporosis, it is useful to exercise. Physical exercise improves muscle tone and increases joint mobility, which reduces the risk of fractures. Vitamin D plays an important role in the prevention of osteoporosis. Consuming fish oil and ultraviolet irradiation will help compensate for its deficiency. The use of calcium-D3 Nycomed in courses of 4 to 6 weeks replenishes the lack of calcium and vitamin D3 and increases bone density.

Vaginal prolapse

Another long-term consequence of hysterectomy is prolapse of the vagina.

• Firstly, prolapse is associated with trauma to the pelvic tissue and supporting (ligament) apparatus of the uterus. Moreover, the wider the scope of the operation, the higher the risk of prolapse of the vaginal walls.
• Secondly, prolapse of the vaginal canal is caused by the prolapse of neighboring organs into the freed pelvis, which leads to cystocele (prolapse of the bladder) and rectocele (prolapse of the rectum).

To prevent this complication, women are advised to perform Kegel exercises and limit heavy lifting, especially in the first 2 months after hysterectomy. In advanced cases, surgery is performed (vaginoplasty and its fixation in the pelvis by strengthening the ligamentous apparatus).

Forecast

Hysterectomy not only does not affect life expectancy, but even improves its quality. Having gotten rid of the problems associated with diseases of the uterus and/or appendages, forever forgetting about the issues of contraception, many women literally blossom. More than half of the patients note liberation and increased libido.

Disability after removal of the uterus is not granted, since the operation does not reduce the woman’s ability to work. A disability group is assigned only in cases of severe uterine pathology, when hysterectomy entailed radiation or chemotherapy, which significantly affected not only the ability to work, but also the patient’s health.

Before such a complex operation that can lead to serious complications, it is necessary to perform a certain set of examinations. Among the mandatory diagnostic techniques used today are:

• • hysteroscopy with curettage;
  • colposcopy with biopsy and further cytological examination;
  • ultrasound examination of the uterus and its appendages;
  • determining the level of vaginal cleanliness;
  • general blood analysis;
  • general urine analysis;
  • blood chemistry;
  • coagulogram;
  • blood test for glucose levels;
  • determination of blood group;
  • determination of the Rh factor.

In cases where the presence of a malignant neoplasm is suspected, the examination can be significantly expanded through ultrasound, chest x-ray, fibrogastroduadenoscopy, fecal occult blood analysis, as well as some other diagnostic techniques.

Features of surgery

Extirpation of the uterus and appendages is a serious surgical intervention that can bring a large number of complications. Its implementation involves the removal of the body and cervix, as well as the fallopian tubes and ovaries. This operation is performed under general anesthesia. This intervention is performed by gynecologists.

Before performing an operation to remove the uterus and appendages, it is necessary to carry out some preparation. First of all, doctors prepare the required amount of donor blood, identical in type and Rh factor. In addition, the intestines are emptied (most often with an enema), and the bladder is catheterized.

Removal of the uterus and appendages begins with preoperative preparation. Doctors pay especially great attention to disinfection of the vaginal cavity.

The fact is that this organ is often the source of infection. In the future, the course of the operation involves the sequential performance of the following manipulations by specialists:

1. 1. A laparotomy or incision in the vaginal wall is performed.
   
   
   2. An audit of internal organs is being carried out.
   3. A retractor is inserted into the incision.
   4. Intestinal loops and other structures that impede access to the organs of the female reproductive system are moved back and fixed with napkins or a sterile diaper.
   5. The large ligaments that hold the uterus and fallopian tubes in place are ligated and divided.
   6. They are attached with special clamps to the ribs or moved to the side.
   7. Absolutely all untied ligaments are tightened in those places where the vessels do not pass. This approach is used to avoid unnecessary tissue bleeding in the future.
   8. A perpendicular incision is made into the tightened ligaments.
   9. An incision is made in the fold located between the bladder and the uterine section, in the place between the appendages and the round ligament.
   10. Curved scissors are inserted under the abdominal cavity.
   11. With its help, moving tissues are raised. The result is the formation of a kind of tunnel.
   12. The ligaments of the ovaries and the ends of the fallopian tubes are ligated.
   13. Subsequently, the appendages are separated from the uterus.
   14. A reverse seam is made.
   15. The direction of the ureters is determined.
   16. 2 layers of peritoneum and testicular ligament are sutured. Such events are carried out on both sides.
   17. The bladder is mobilized. It is moved back until it no longer impairs access to the uterus and its cervix (this stage is not carried out if surgery is performed for a malignant neoplasm).
   
   
   18. The vessels are intersected at the level of the uterine os.
   19. The uterine fascia is incised.
   20. The sacral and uterine ligaments are intersected.
   21. Subsequently, the so-called cardinal ligaments are doped.
   22. The vaginal vault is opened.
   23. The vaginal vault is fixed with special clamps.
   24. The cervical region is cut off.
   25. A tampon with antiseptics is inserted into the vagina.
   26. The vagina is drained.
   27. Applying sutures to the vaginal walls.
   28. Peritonization is performed and the edges of the postoperative wound are sutured.

This operation is more complicated than supravaginal amputation of the uterus and appendages. That is why there must be quite serious indications for it to be carried out.

The main indications for such an operation

Radical hysterectomy is performed only when other surgical methods are not effective enough. We are talking about the following pathology:

• • malignant neoplasm of the uterus or its appendages;
  • benign tumors exceeding 12 weeks of pregnancy or corresponding to them in the presence of symptoms of compression of surrounding organs and tissues;
  • uterine prolapse;
  • adenomyosis (due to the development of debilitating bleeding);
  • with some serious obstetric pathology (uterine rupture, Cuveler's uterus and some others).

For less dangerous diseases, removal of the uterine appendages along with it is practically not performed.

About contraindications to extirpation of the uterus and appendages

There are a number of conditions in which it is impossible to remove the uterine organ by extirpating it along with the appendages. We are talking about the following cases:

1. 1. General serious condition of the patient.
   2. The presence of serious, disabling diseases of the cardiovascular system.
   3. Severe renal failure.
   4. Serious disorders of the respiratory system.
   5. Acute diseases of the female reproductive system.
   6. Pustular diseases.

After eliminating these limiting factors, it becomes possible to perform this type of surgical intervention.

Possible complications after hysterectomy

Such a serious surgical intervention can often have negative consequences. In this case, complications are divided into intra- and postoperative. The first group includes the following consequences:

• • bleeding;
  • infectious lesions of the operating area;
  • thromboembolism;
  • damage to nearby organs and tissues;
  • negative effects of anesthesia.

Such consequences of hysterectomy can be extremely life-threatening. That is why operating doctors carry out the most serious training before performing surgery, and are also always concentrated as much as possible while performing basic manipulations.

Life after hysterectomy may be accompanied by some long-term complications that develop as a result of major surgery. The most common consequences are the following:

• • infertility;
  • vaginal prolapse;
  • chronic pain syndrome;
  • urinary incontinence;
  • depression and psychosis (less often).

Also, after removal of the uterus and appendages, a woman experiences hormonal disorders. It is for this reason that gynecologists prescribe replacement therapy to patients. Such women have to live constantly taking medications. In addition, after such an intervention, patients have an increased risk of developing cardiovascular diseases.

With regard to the prevention of psychosis and depressive conditions, the presence of children and relatives who can support the woman is very important. If everything is fine in the family, then specialists often do not prescribe medications to women for preventive purposes that correct their mental state.

Classification of extirpation methods

The division of methods of surgical intervention takes into account such criteria as the scale of the surgical intervention and the method of its management. According to the scale of intervention, hysterectomy is divided into the following types:

• • Supravaginal hysterectomy - subtotal hysterectomy. During vaginal hysterectomy without appendages, the body of the uterus is primarily removed.
  • Hysterectomy - total hysterectomy. This type of intervention involves the complete removal of the uterus along with the cervix.
  • Hysterosalpingo-oophorectomy . During the operation, the ovaries, fallopian tubes and body of the cervix are removed. The indications for this type of intervention are neoplasms that tend to spread to surrounding organs and tissues.
  • Radical hysterectomy . The operation involves the removal of the ovaries, fallopian tubes, cervix and body of the uterus, the upper third of the vagina, as well as the tissue surrounding the pelvic organs. Indications for intervention are neoplasms that tend to spread in the pelvic area.

Each of the above interventions can be performed through the following approaches:

• • Abdominal laparoscopic extirpation of the uterus and appendages through the abdominal wall.
  • Open access, involving extirpation of the uterus and appendages through Pfannenstiel laparotomy, followed by suturing.
  • Laparoscopic hysterectomy through the vagina.
  • Robotic surgery using a laparoscope.
  • Standard vaginal hysterectomy without laparoscope.

The selection of the necessary technique is carried out by the attending physician. Its choice depends on laboratory and instrumental examination data, the nature of the disease and the severity of the pathological process. Before the operation, the consequences of hysterectomy without appendages are assessed, since there is a risk of complications.

Indications and contraindications

The main indications for intervention are conditions in which conservative therapy does not produce a positive effect. Also, it is advisable to use the intervention for malignant neoplasms that are large in size or have rapid growth.

The main indications include:

• • malignant neoplasms in the body and cervix;
  • significant prolapse or prolapse of the uterus;
  • malignant neoplasms of the ovaries;
  • pedunculated myomatous nodes;
  • uterine fibroids located on the cervix or retroperitoneum;
  • purulent-inflammatory diseases of the ovaries in women over 42 years of age;
  • multiple benign neoplasms of the ovaries and uterus:
  • internal endometriosis, as well as bleeding associated with pathological changes in the endometrium;
  • chronically erosive changes in the uterine wall;
  • perforations and ruptures of the uterine wall;
  • multiple cysts;
  • as part of a series of sex reassignment operations.

Hysterectomy, like all other types of surgical intervention, has a number of specific contraindications that are important to consider before choosing a method.

Such contraindications include:

• • acute and chronic diseases in the acute stage;
  • the presence of an infectious-inflammatory focus in the body;
  • inflammatory diseases of the reproductive system;
  • severe extragenital pathology - diseases of the blood, cardiovascular system, pathology of the respiratory system;
  • period of bearing a child.

It is strictly prohibited to perform extended extirpation of the uterus with appendages if there is a significant increase in the size of the uterus, as well as with large ovarian tumors. The vaginal extirpation technique is contraindicated in the presence of multiple adhesions, after a cesarean section, in inflammatory diseases of the vagina and cervix, as well as in cases of suspected cancer of the body and cervix.

Preparing for surgery

The success of surgical intervention directly depends on the quality of preliminary diagnosis and preparation of the patient. In the preparatory period, each woman must undergo a series of laboratory tests:

• • clinical blood test;
  • general urine analysis;
  • a smear from the vaginal area and cervical canal for subsequent cytological examination (assessment of cellular composition);
  • blood test to determine the group and Rhesus affiliation.

In addition, each woman needs to complete a number of such preparatory measures:

• • Undergo a colposcopy procedure. This is necessary in order to detect the atrophic form of colpitis. If the diagnosis has been confirmed, the woman is recommended to undergo a course of treatment with drugs containing estriol. The duration of treatment is 1 month.
  • Take a blood test for HIV infection and other sexually transmitted diseases.
  • Pre-prepare at least 0.5 liters of blood. If a woman’s body is prone to developing anemia, then before surgery she is given a transfusion of stored blood.
  • If there is a tendency to form blood clots, the woman is advised to start taking medications that affect blood clotting and venous tone in advance.
  • Undergo an electrocardiographic study to assess the state of the cardiovascular system.
  • To prevent infection during surgery, the woman is given antibiotic therapy before surgery. This stage is not carried out in women who have individual intolerance to antibacterial drugs.

Technique of the operation

The primary stage of surgery is putting the patient under anesthesia. The type of anesthesia is selected by an anesthesiologist. His choice is influenced by the following factors:

• • patient's age;
  • body mass;
  • volume and duration of surgical intervention;
  • the presence of concomitant diseases in a woman, as well as her general condition.

Given the large scale of the operation, the woman is given general anesthesia before performing it. The surgical technique will be presented using the example of supravaginal amputation of the uterus without appendages.

The standard course of a hysterectomy operation includes the following stages:

1. 1. The surgeon performs a layer-by-layer dissection of the anterior abdominal wall, after which he performs an inspection of the pelvic area. After identifying the uterus, the doctor brings it to the wound area. When adhesions are detected, they are dissected.
   2. 2 clamps are applied to the area of ​​the uterine ligaments and tubes and the appendages are bandaged. Next, the uterovesical fold is crossed.
   3. To prevent trauma to the bladder, the surgeon moves it to the side. Clamps are applied to the vascular bundle, after which it is intersected. During the operation of extirpation of the uterus and appendages, the uterus is retracted in the opposite direction. Previously crossed vessels are sutured with catgut threads.
   4. The uterus is transected using a scalpel, 1 cm above the previously transected choroid plexus. It is important to remember that during extirpation of the uterus and appendages, the uterine wall is not crossed at the level of the vascular bundle. When the uterus is removed, a cone-shaped incision is made. After removal, the stump is sutured with catgut threads. The cervical canal is treated with iodine solution.

Before suturing the surgical wound, a medical specialist inspects it. The following indicators are taken into account:

• • no internal bleeding;
  • density of surgical sutures on the uterine stump;
  • strength of fixation of previously applied ligatures.

The average duration of surgery is from 60 to 90 minutes.

Complications

The most serious complication after amputation and hysterectomy is internal bleeding, which can have varying degrees of intensity. The cause of this complication is poor-quality application of vascular sutures during surgery.

Other complications may include:

• • suppuration of postoperative sutures;
  • the appearance of vaginal discharge after extirpation of the uterus and appendages, associated with postoperative disturbance of the microflora;
  • thrombosis of the veins of the lower extremities;
  • prolapse and prolapse of the vagina, which is associated with trauma to the muscles that support the internal genital organs;
  • infectious and inflammatory process in the lymph nodes associated with non-compliance with the rules of asepsis and antisepsis;
  • fecal and urinary incontinence, which is associated with damage to the nerve trunks in the pelvic area.

Postoperative period

In the postoperative period after extirpation of the uterus and appendages, women often experience pain, the intensity of which depends on the scale of the intervention performed. The first few days after surgery, the woman is recommended to perform elastic bandaging of the lower extremities. This event is aimed at preventing blood clots.

In addition, the woman is prescribed anticoagulants, medications that improve tissue regeneration, as well as infusion therapy. Postoperative sutures are treated with a solution of brilliant green once a day.

After discharge from the hospital, the woman is recommended to wear compression garments for the first 2 months after surgery. For 6–8 weeks, in order to improve the condition after extirpation of the uterus and appendages, gynecological examinations and sexual intercourse are strictly prohibited. If bloody discharge appears, a woman should immediately seek medical help.

In some cases, a woman who has had a hysterectomy may experience pain during intercourse. Most often this happens when part of the vagina has been removed along with the uterus.

If extirpation of the uterus and appendages was performed, the consequence may be early menopause, since the ovaries are responsible for the production of estrogens. In order to eliminate the signs of early menopause, the woman undergoes hormone replacement therapy (HRT). The appointment of HRT after extirpation of the uterus and appendages is carried out by the attending physician.

The general rehabilitation period after extirpation of the uterus and appendages is several months. Removal of the uterus is not a death sentence for a woman, since after the operation she remains healthy and can continue to lead her usual lifestyle. This intervention also does not affect sex life. The only disadvantage of the operation is the loss of reproductive function.

Types of hysterectomy operations

When prescribing surgery to remove the uterus (hysterectomy), doctors take into account not only the nature of the disease, but also the woman’s age. If she is young, then they try to preserve at least the ovaries so that the hormonal levels in the body are not disrupted and the patient’s life is not further complicated by the consequences of a lack of estrogen.

There are several options for performing a hysterectomy. One of them is amputation of the uterine body (subtotal hysterectomy) with preservation of the cervix, tubes and ovaries.

Extirpation of the uterus (total hysterectomy) is an operation in which the organ is cut out along with the cervix. There are 2 types of operation:

1. 1. Removal of the uterus and cervix without appendages. If a woman manages to save her ovaries, her quality of life does not deteriorate, since the production of sex hormones continues. If she wants to have a child, she can use the services of a surrogate mother, who will be implanted with the patient’s own eggs.
   2. Removal of the organ along with the cervix and appendages - fallopian tubes and ovaries (hysterosalpingo-oophorectomy).

Note: Surgeons, taking into account the nuances of the operation, also distinguish intrafascial, extrafascial and extended extirpation.

The most difficult option is the so-called radical hysterectomy, that is, removal of the uterus, cervix, appendages, upper part of the vagina and nearby lymph nodes.

Video: Indications and contraindications for hysterectomy. Possible consequences

Indications and contraindications for

Extirpation of the uterus is performed in extreme cases when its preservation is impossible due to the increased risk of developing severe and life-threatening complications.

Indications for such an operation are:

1. 1. The presence of numerous rapidly growing fibroids in the cavity or on its outer surface. Twisting of tumors that have a long thin stalk leads to tissue necrosis, peritonitis and sepsis.
   2. Uterine prolapse (a problem that occurs in older women);
   3. Heavy uterine bleeding that cannot be eliminated by conservative methods.
   4. Endometriosis in severe form.
   5. The formation of numerous polyps in the organ cavity.
   6. Detection of malignant tumors of the body of the uterus or its cervix. In this case, a radical hysterectomy is often performed.

The ovaries are removed if cysts or tumors are found in them.

A contraindication to extirpation is the presence of infectious diseases and inflammatory processes in the woman in the vagina, cervix, and other organs (for example, in the respiratory tract, bladder). Extirpation is not performed on patients with severe cardiac, respiratory or renal failure.

Extirpation methods

Removal of the uterus, cervix and possibly the appendages is done in three main ways: through an incision in the peritoneum (laparotomy), punctures in the abdomen (laparoscopy) or through the vagina (vaginal hysterectomy).

Laparotomy

More often, a horizontal incision is made below the navel, and the suture is less noticeable. Less commonly, a vertical incision is made.

Open access to the abdominal cavity allows for a thorough examination. If during the operation it is discovered that the lesion is more extensive than expected, then not only the appendages, but also the lymph nodes can be immediately removed.

Typically, extirpation is performed using this method if the uterus is large, as well as if there is advanced endometritis. Careful removal of the uterus will avoid the spread of the inflammatory process to other organs.

Laparotomy is performed for endometriosis, cancer, in the presence of constant uterine bleeding and pain of unknown origin.

The advantage of this operation is good access to the abdominal organs and the use of cheaper equipment. There are many disadvantages: a high probability of complications during and after surgery, a long recovery period. There is a stitch left on the stomach.

Laparoscopy

Hysterectomy is performed through several small incisions in the abdomen into which a video camera and surgical instruments are inserted.

The advantages of this technique are that punctures heal approximately 2 times faster than large incisions, and there are practically no traces of surgical intervention left. The use of optics gives the doctor the opportunity to clearly control the manipulation during the operation, since the image is displayed on the monitor screen. Possible use of robotics.

The disadvantage is the limited use of the technique: it is not suitable if the organ is large, there are adhesions in the abdominal cavity, if the patient has poor blood clotting.

Vaginal extirpation

The operation is mainly performed for complete or incomplete prolapse of the uterus in combination with weakening of the pelvic floor muscles, urinary retention, the formation of fibroids, ovarian cysts, and endometriosis.

There are contraindications to the use of this method. Extirpation through the vagina is impossible if the patient has malignant tumors of the genitourinary organs, as well as sexually transmitted diseases. The technique is not used in the presence of large benign tumors of the uterus and ovaries, or the formation of adhesions between the uterus, ovaries and neighboring organs.

The advantage is the absence of a postoperative suture on the abdomen.

Preparation for the operation

Special preparation is required for hysterectomy. Preliminary examination includes:

• • general blood and urine tests;
  • blood clotting test (coagulogram);
  • biochemical blood test for sugar, proteins, fats;
  • analysis for Rh factor and blood group;
  • blood test for sexually transmitted infections, hepatitis C and B, as well as HIV;
  • vaginal smear for microflora;
  • Pap test (to detect abnormal cells in the cervix);
  • Ultrasound of the pelvic organs;
  • CT scan of the abdomen.

If necessary, diagnostic curettage is performed using a hysteroscope, as well as examination of the vagina using colposcopy. A biopsy may be performed to perform a cytological examination of the sample and detect abnormal cells.

The operation is not performed during menstruation.

During extirpation, the intestines should be completely empty, so within 2-3 days the woman should switch to a diet with a predominant intake of liquid light foods. Avoid the consumption of gas-forming products and those containing fiber. In the last 8-10 hours before the operation, you should not eat at all; it is advisable to drink as little as possible. This will avoid vomiting after general anesthesia.

Before the operation, a cleansing enema is performed, the pubic and vaginal area is shaved. A catheter is installed in the bladder, which is not removed in the first days after the operation.

Even before the operation, the anesthesiologist finds out whether the patient is allergic to medications and selects a combination of anesthetics taking into account the individual characteristics of the patient’s body. Various types of anesthesia are used: endotracheal (deep narcotic sleep), spinal and epidural anesthesia (through the spine).

How is the operation performed?

During laparotomy the surgeon dissects the peritoneum, examines the abdominal cavity and assesses the condition of the uterus and ovaries, and outlines the scope of the operation. The intestinal loops are fixed with special devices to prevent accidental damage.

After cutting the ligaments holding the uterus, it is removed and the vaginal vault is tightly sutured. During the operation, measures are taken to prevent bleeding and damage to the ureters. While suturing the wound, drainage is left to prevent fluid from accumulating in the abdominal cavity and to avoid the occurrence of an inflammatory process.

With such an operation, the risk of complications is quite high, including infection in the peritoneal cavity, large blood loss, damage to the bladder and intestines, blood clots in the vessels, and inflammation of the suture. Possible suture dehiscence and formation of keloid scars (sutures growing into adjacent tissues). Such neoplasms create not only a cosmetic problem, but in rare cases they can degenerate into malignant tumors.

Laparoscopy. A catheter is inserted into one of the punctures, through which the abdominal cavity is filled with carbon dioxide to facilitate access to the organs. Using instruments inserted through additional holes in the peritoneum, the uterus is cut off and removed in parts through an incision in the vagina. Complications may include accidental damage to neighboring organs or large vessels, thromboembolism.

Vaginal extirpation carried out by cutting the walls of the vagina, dissecting the ligaments, removing the uterus, and ligating the blood vessels. Then the remaining part of the vagina is fixed to the muscle fibers. Special threads are used that dissolve within 2-4 weeks. The operation lasts 1-1.5 hours. The patient is in the hospital for 3 days. Over the next 10 days, slight bleeding, mild pain in the perineum, and a slight increase in temperature may appear. Full recovery occurs after 4 weeks.

The long-term consequence of hysterectomy by any method is the inability to give birth to children. In addition, urinary incontinence often occurs, vaginal prolapse occurs, and intestinal dysfunction occurs. Nagging pain in the lower abdomen may persist. Removal of appendages is fraught with the occurrence of depression, mental disorders, and other signs of hypoestrogenism.

Video: Methods of extirpation

Recovery period after extirpation

Restorative treatment includes pain relief and the administration of antibiotics to prevent inflammatory processes. Sedatives and vitamins are also prescribed. Intravenous infusions of saline solution with glucose are carried out to eliminate the consequences of blood loss and disturbances in the water-salt balance in the body. The patient should drink a lot and often to replenish fluid loss by the body.

Sutures or punctures are treated daily with antiseptic solutions, lubricated with synthomycin ointment or levomekol, and sterile napkins are applied.

For 6 to 8 weeks after surgery, women should wear compression stockings or wrap their legs with elastic bandages to prevent blood clots.

Within a few hours after laparoscopy and the next day after laparotomy, it is necessary to get up, change body position, and walk so that adhesions do not form in the abdominal cavity and the organs take a normal position. After laparotomy, the woman must wear a bandage that tightens the abdomen for 1 month. This prevents seams from coming apart and reduces pain.

It is necessary to regulate intestinal function through diet and prevent constipation.

You can resume sexual activity no earlier than the doctor confirms that the stitches have completely healed and your general health has been restored.

The female reproductive system consists of very delicate organs that are susceptible to various types of diseases. Chronic and complex pathologies sometimes have to be treated through surgical procedures, one of which is hysterectomy with.

Such operations are a last resort, which doctors decide to do when no other methods give the desired effect.

In contact with

Features of the technique

Extirpation of the uterine organ is one of the surgical interventions performed only in critical cases. In medical terminology, there is another name for it - hysterectomy.

Hysterectomy or extirpation is a gynecological operation aimed at removal of a woman's uterus with or without appendage organs.

This method of treatment is usually used for extremely complex diseases, when it comes to saving the life of the woman herself.

Hysterectomy is divided into several types, which are used when removing a certain amount of tissue.

Among the varieties:

• subtotal - only the body of the uterus is amputated;
• total – the organ itself and the neck are completely removed;
• hysterosalpingo-oophorectomy – the uterus with all its appendages is subject to amputation;
• radical - all accessory organs, the cervix, part of the vagina, lymph nodes, and adjacent pelvic tissues are amputated.

According to the method of operation there are:

• open extirpation done by laparotomy;
• robotic amputation, which involves an operating robot;
• vaginal removal – surgery through the vagina;
• laparoscopic removal.

What is a uterine stump - what is it. This is what doctors call the remnant of an organ that remains after its removal. The cervical stump is a consequence of the operation to remove the uterus.

Indications

Indications for hysterectomy in patients exist with the following diseases:

• uterine fibrosis;
• malignant lesions of the cervix, ovaries or uterine organ;
• adenomyosis;
• extensive fibroids;
• pathologies of the female reproductive organs, which are accompanied by serious menstrual irregularities, heavy bleeding, pain, and severe inflammatory processes.

Uterine fibrosis

The decision to perform this operation should be made exclusively by the attending gynecologist after thorough examinations and many necessary tests.

Preparing the patient

Preparation for surgery to remove the uterus must be thorough and carried out with the utmost seriousness. The effectiveness of the operation and the rehabilitation period depend on how carefully the patient is prepared.

Before starting the procedure, the patient must undergo general clinical diagnostics, cytological analysis from the vaginal segment of the cervix and cervical canal for the presence of atypical cells, extended colposcopy, and a procedure for identifying sexually transmitted diseases.

If infection is present, the necessary treatment is carried out. Patients who are at high risk of developing thromboembolic complications require close attention.

Preoperative preparation of such women should consist of taking vasoactive, antiplatelet and antispasmodic drugs and agents that stabilize the rheological characteristics of the blood.

Besides all this, you need use shapewear. If necessary, the patient can be referred to a vascular surgeon for a consultation and undergo duplex ultrasound of the veins of both legs.

Before the operation, the following anesthesia methods can be used:

• endotracheal anesthesia;
• epidural pain relief;
• combined anesthesia.

Stages of a hysterectomy

First, the surgeon opens the abdominal cavity. After this, specialists examine the internal organs and confirm or refute the diagnosis.

Progress of the operation

The flow of the operation is as follows:

1. During laparoscopic surgery, minor incisions are made in the abdominal cavity, through which surgical manipulations are performed. If laparotomy is indicated, a large incision is made across the lower abdomen. After this, the ligaments are cut, vascular bleeding is stopped, the uterus itself is separated from the vaginal walls, and removed. Extirpation of the uterus with appendagesoccurs under general anesthesia.
2. If the doctor uses vaginal extirpation, then first of all they disinfect the vagina, make a deep incision in its upper third, retract the uterine organ and cut off what is necessary. After these manipulations, the incisions are sutured except for a small drainage hole.

Laparoscopic amputation

It is carried out using laparoscopic access. The operating doctor makes the required number of small incisions in the abdomen and inserts a laparoscope, an operating optical tube, into them.

The laparoscope is equipped with a light source. Thanks to this tube, the surgeon can carefully examine the internal organs, the image of which is displayed on a special monitor. Additional incisions for inserting operating instruments allow for surgical interventions.

Important! Laparoscopic extirpation is a minimally invasive method of surgery.

It has no serious consequences and does not cause complications. The patient feels minimal pain and does not need much time to rehabilitate and restore her body.

During amputation, minimal blood loss may occur and there are no hematomas. Most women who undergo laparoscopic hysterectomy stay in the hospital for only four days.

Despite all the advantages, laparoscopy also has a number of disadvantages.

Among them are:

• the need to use expensive equipment, which entails an increased cost of the operation;
• Carbon dioxide is used and injected into the lower abdomen. Gas is strictly contraindicated in severe pathologies of the cardiovascular system and lungs.

Rehabilitation period

It is important to begin the postoperative period immediately after surgery. Medical orders include use of vaginal suppositories, painkillers, droppers with solutions.

Seams need to be treated

• early activation;
• regular (daily) treatment of seams;
• wearing bandages;

Important! After surgery, compression garments and a bandage must be worn for at least 2 months. You should abstain from sexual intercourse for 8 weeks. If infections, bleeding or other complications occur, you must urgently contact the gynecological hospital where the operation was performed. If this is not possible, you need to contact any nearest station.

Removal

Amputation of the uterus with appendages called total extirpation. It is prescribed strictly according to doctors' indications. Preparation for surgery to remove the uterus using a total hysterectomy is similar to other types of surgery.

Reasons for amputation of the uterus along with appendages may be:

• malignant lesions of the body of the uterus and appendages;
• a large number of benign formations;
• fibroids of the uterine body with obvious compression of adjacent organs;
• chronic heavy bleeding;
• relapses of hyperplastic processes in the uterine tissue;
• subserous and submucosal formations on the knife;
• death of the myomatous node, which resulted in peritonitis.
• As a rule, amputation is performed by laparotomy.

Indications for surgery

It is prohibited to use this type of extirpation when:

• the presence of infectious processes;
• cardiovascular problems;
• impaired lung and kidney function.

Vaginal hysterectomy

Vaginal hysterectomy and appendages is much easier to tolerate than other types of this operation.

The advantages include:

• no scars on the abdomen;
• short recovery period - only a few weeks;
• minimal pain during surgery.

But there are also disadvantages: complexity of implementation, increased likelihood of intraoperative complications.

Consequences of intervention

The main negative consequence – loss of reproductive ability. In addition, the woman suffers mental trauma, develops a chronic stress state, and disrupts her hormonal levels.

Possible consequences

As a result, the following quite serious problems may appear:

• vegetative-vascular failures;
• impaired function of the excretory organs;
• the occurrence of internal hematomas;
• prolapse of the vaginal walls;
• high blood glucose levels;
• development of overhydration;
• state of depression;
• high risk of heart disease and vascular problems;
• back pain.

It is very difficult for a woman to decide on such a specific operation. Especially if the patient has not yet had time to experience the joy of motherhood.

Video: Extirpation of the uterus with appendages

It is for this reason that a patient should carefully consider the pros and cons of a hysterectomy. It is advisable to get advice from different specialists, but you should not hesitate to make a decision.

Uterine amputation is a major intervention that is quite difficult to tolerate, but, unfortunately, is sometimes necessary. It can be carried out using different methods and have different volumes. Depending on this, the duration of the recovery period and the nature of the patient’s experience of the consequences of the intervention also differ. Total hysterectomy is one of the largest interventions, which leads to the greatest negative consequences for the body and severe complications (sometimes).

Collapse

Definition

Total hysterectomy or vaginal hysterectomy is, as mentioned above, the most extensive intervention in gynecology, during which almost all components of the reproductive system are removed, with the exception of the genitals. During the intervention, the uterine cavity itself is removed, as well as its cervix, fallopian tubes on both sides and the ovaries, also on both sides.

What is hysterectomy with appendages? This phrase is synonymous with what is described above, since hysterectomy without appendages is a completely different procedure in which only the organ cavity and its cervix are removed. It has a separate name - radical hysterectomy.

Access to the operated system during such an intervention can be carried out in different ways. With laparotomy access, an incision is made in the abdominal wall, and then the entire intervention takes place in the operating pit. During laparoscopic intervention, vascular ligation and sometimes the installation of clamps are performed using a laparoscope, but in the future it is still necessary to dissect the abdominal wall, since it is impossible to remove the severed tissue through the laparoscope. Another method is access through the vagina and cervix. It is not always convenient and not always feasible, therefore most often the intervention is performed laparotomically.

Indications

In what cases is extirpation of the uterus and appendages indicated? Since this is a fairly serious operation, doctors try to avoid it until the last minute, especially in women of reproductive age who have not yet given birth. Therefore, such intervention is prescribed only in the presence of very serious, and sometimes life-threatening, indications. The operation is performed in the following cases:

• Cancer of the uterus or other organ of the reproductive system in a sufficiently developed state;
• A precancerous process, but not amenable to conservative treatment, actively spreading and aggressive;
• Dysplasia, leukoplakia, which are difficult to treat or do not respond to it at all, often recur (since horses pose a danger from the point of view of transformation into an oncological process);
• Adenomyosis, endometriosis, which are difficult to respond to or do not respond to conservative treatment at all, recur and cause very severe symptoms;
• The presence of multiple cysts, polyps, papillomas that cannot be removed accurately;
• A serious hormonal imbalance that cannot be corrected by conservative means, as a result of which benign neoplasms constantly recur.

There may be other indications at the discretion of the doctor. For women after menopause, total hysterectomy with appendages is more often prescribed, since there is no need to preserve reproductive function. And, in addition, they tolerate it more easily, since the ovaries are no longer functioning, and therefore a global restructuring of the body due to the disappearance of estrogen does not occur in it.

Is it possible to remove the uterus at will?

Is it possible to remove the uterus at will? The legislation in Russia is such that this operation is not carried out legally. To avoid pregnancy, tubal ligation and voluntary sterilization are performed, but the uterus is not removed. If the pathological processes in it cause discomfort, then you can discuss this issue with your doctor, and he will describe the pros and cons of removal in a particular case.

Contraindications

Strictly speaking, if there are vital indications, minor and relative contraindications are not taken into account. Therefore, if the potential benefit from an intervention is higher than the potential harm from it, then the intervention is carried out. Contraindications to such therapy are:

• The presence of an inflammatory or infectious process in the reproductive system;
• The presence of a systemic inflammatory or infectious process in the body, including respiratory diseases;
• Decreased local tissue and general organic immunity, for example, during extensive surgical interventions or serious diseases;
• Presence of bleeding from the vagina of unknown origin;
• Poor blood clotting;
• Intolerance to anesthesia.

Some other contraindications may also exist. However, most of them, like those listed above, are relative in nature, that is, they do not cancel the operation, but postpone it. In most cases, laparotomy can still be performed, but after adequate drug preparation (for example, with poor blood clotting) or after treatment (for example, with inflammatory processes).

Preparation

Before cutting out this organ, a woman must undergo certain training, which will confirm that she has no contraindications for the intervention. The following diagnostic procedures are carried out:

1. General and biochemical blood test;
2. General clinical urine analysis;
3. Coagulogram;
4. Blood test for HIV, hepatitis, syphilis;
5. Vaginal microflora smear;
6. Consultations with a therapist and gynecologist.

Of course, in some cases such studies are neglected, for example, when intervention is urgently needed. But if the operation is carried out as planned, then such preparation is necessary.

Order of conduct

The operation is performed under general anesthesia. With laparotomy access, an incision is made in the peritoneum, clamps are applied, and the ligaments of the uterus are dissected. After this, the appendages are cut off and the body of the organ is removed. After the uterus has been removed, the appendages and fallopian tubes are cut off, the vessels are alloyed and the clamps are removed. The cervix and the upper third of the vagina are excised, and the vessels are also alloyed.

After this, the vagina is sutured, and then the peritoneum is sutured in layers. You can watch the progress of the operation in more detail in the video in the material.

Recovery

The postoperative period, depending on the characteristics of the body, lasts from two to three months. Rehabilitation treatment after total hysterectomy involves taking broad-spectrum antibiotics for 10 days after the procedure, as well as using anti-inflammatory drugs. Also, combined oral contraceptives are prescribed for a period of two months, which help the body smoothly adjust to the absence of estrogen, partially replacing it at first.

During this period, you should avoid overheating, excessive physical activity and sexual intercourse. It is important to eat right and give up bad habits.

Consequences

There are two main consequences of such an intervention, which always occur and are associated with the very nature of the procedure - infertility, associated with the inability to become pregnant and bear a child, and early menopause, which occurs as a result of the removal of the ovaries and, therefore, the cessation of estrogen production. This condition can be quite poorly tolerated by young women from a psychological point of view, which can lead to depression, depression, etc. Mood swings, insomnia, depression, touchiness, tearfulness, etc. may occur.

Pregnancy

Obviously, pregnancy after such an intervention is impossible for several reasons. Firstly, there are no ovaries, which means that eggs are not formed and the normal hormonal balance necessary for conception is not maintained. In addition, there is no cervix, which means sperm cannot penetrate beyond the vagina. And finally, there is no uterus itself in which fertilization would occur and the embryo would attach. Thus, the only way for a woman to have children after such an intervention is to resort to the services of a surrogate mother.

Price

The cost of such an intervention can vary significantly depending on the region in which it is performed, the degree of popularity of the medical center, and whether the price includes anesthesia and consumables. The price comparison is shown in the table.

When planning expenses, it is important to take into account that a significant amount will have to be spent on diagnostic tests in preparation for the intervention, as well as on hospital stay after surgery.

Conclusion

Although the operation is quite difficult, in general it can be said that all women , Those who have had their uterus removed live a normal, full life after this procedure. If the recovery period was completed correctly, and there were no contraindications to the intervention, then the state of health should remain good.

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

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

Surgical interventions on the internal genital organs can be performed using both laparotomy and laparoscopic approaches.

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

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 transections and a transverse incision according to Pfannenstiel. With a midline incision, the anterior abdominal wall is opened layer by layer from the pubis (upper edge) to the navel.

When making a Pfannenstiel incision, the skin and subcutaneous tissue are dissected with a transverse incision parallel to the pubis 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 sharply during any incision. When opening the peritoneum, it is important to lift it with soft tweezers and carefully dissect it (in the middle between the pubis and the navel) so as not to damage the intestinal loops and bladder under the pubis. The peritoneum is fixed with clamps to napkins, which are placed along the incision on both sides. The anterior abdominal wall can be dissected either with a scalpel or with an electric knife with coagulation or ligation of vessels with suture material (silk, catgut, vicryl).

After dissection of the anterior abdominal wall, it is necessary to visually and palpate the abdominal organs with a hand inserted into the abdominal cavity. Then the dilator is inserted, and the intestinal loops are carefully moved with a napkin into the upper abdominal cavity, thereby ensuring 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 fabrics with scissors. To apply sutures to the ligamentous apparatus, vessels, cervical stumps and vaginal walls, silk, catgut, vicryl, etc. are used.

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

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 sutured under the clamp and a ligature is tied, carefully removing the Kocher clamp. After cutting off the isthmus of the tube, 1-2 separate sutures are applied to the angle of the uterus.

Peritonization can be performed with a continuous suture, connecting the layers of the peritoneum of the broad uterine ligament. The area of ​​the isthmus of the tube is usually peritonized by the round uterine ligament.

Technique for removing the uterine appendages. Operating clamps (Kocher) are applied to the infundibulopelvic ligament, in which the ovarian artery passes; mesosalpinx; the 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 leaves of the peritoneum of the broad uterine ligaments and the round uterine ligament. After cutting, the uterine appendages are removed from the abdominal cavity and sent for histological examination (Fig. 22.1, a, b).

Supravaginal amputation of the uterus (subtotal, supravaginal) without appendages. Surgical clamps (Kocher) are applied alternately on both sides to the rib of the uterus. The lower edge of the clamp should be at the level of the internal pharynx. In this case, the clamp contains the fallopian tube (isthmus), round uterine ligament, and the ovarian ligament. 0.5-1 cm lateral to the previous clamp, apply a separate clamp to the round uterine ligament and a clamp to the fallopian tube and the proper ovarian ligament. The "noses" of the lateral clamps should be at the same level. The ligaments are crossed between the clamps. Using scissors, a piece of the peritoneum of the vesicouterine fold is opened from the front, and the bladder is lowered downwards. From behind, the posterior leaf of the broad uterine ligament is opened in the direction of the uterosacral ligaments (to avoid ligation and injury to the ureters). The round ligaments and stumps of the uterine appendages are separately sutured and bandaged. Vascular clamps are applied perpendicularly to the uterine vessels at the level of the internal os on both sides. The vessels are crossed 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 ​​carried out with a continuous suture using the leaves of the broad 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 the 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 removal of the uterine appendages on one side, on both sides, with fallopian tubes, with 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

Rice. 22.1. Adnexectomy. Laparotomy: a - clamps are applied to the infundibulopelvic ligament, the proper ovarian ligament and the isthmus of the fallopian tube (right, posterior view); b - after cutting off the uterine appendages, ligation (right side view)

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

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

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

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

Rice. 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

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

Rice. 22.2.Continuation. e - cervical stump after suturing (left view)

Rice. 22.2.Continuation. g - peritonization. Artist A.V. Evseev

and stitch it. After applying the clamps, the uterosacral ligaments are ligated and crossed, and the uterorectal 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 location of the bladder and ureters (they must be deflated). The cervix is ​​cut off from the vaginal fornix with scissors, the vaginal walls are fixed with clamps and additional hemostasis is carried out if necessary. The uterus is removed from the abdominal cavity, the vaginal walls (anterior and posterior) are sewn together with separate sutures. Peritonization is carried out using a continuous suture using the peritoneum of the broad uterine ligaments and the 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 separate 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 using laparoscopic access on the genital organs differ from abdominal surgery.

The patient is placed on the operating table with reinforced leg holders (Fig. 22.3). The legs should be spread approximately 90°. It is important that the thighs are aligned with the body without impeding the movement of the outer parts of the instruments in the lateral trocars. Pro-

Rice. 22.3. Position of the patient on the operating table during laparoscopy

Rice. 22.4. Uterine probe Cohen during laparoscopy

The perineum should be behind the edge of the table (it is better if the table has a recess for vaginal manipulation). This allows active movement of the uterine probe (Cohen)(Fig. 22.4), inserted into the uterus and fixed with bullet forceps. For hysterectomy, 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 vault.

The surgical 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 by sterile sheets on the left and right, fixed with a pin in the area of ​​the xiphoid process. At the level of the pubis, the skin is covered with a film fixed to the sheets. Thus, the surgical 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 violating asepsis.

Operations are performed under endotracheal anesthesia.

Location of the operating team. The surgeon is located to the left of the patient, 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 assistants is to create optimal positioning 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 5 mm locking ratchets, preferably one of the instruments has wide-grip traumatic jaws; dissector 5 mm; scissors 5 mm; bipolar forceps; aspirator-irrigator 5 mm; forceps 10 mm; uterine probe Cohen; morcelator; 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 stage - application of pneumoperitoneum and insertion of the first trocar. A Veress needle (to create pneumoperitoneum) and the 1st trocar are inserted along the edge of the umbilical ring according to the traditional method. The location of choice is the area 2 cm to the left above the navel. In patients who underwent laparotomy with an inferomedian incision and a Pfan incision,

Rice. 22.5. Instruments for laparoscopy (a, b)

nenstil, large uterine fibroids, in obese patients the point of insertion of the Veress needle and the 1st trocar is usually determined individually. Inserting the first trocar in previously operated patients in the traditional place (along the edge of the umbilical ring) is impractical. In patients who have undergone surgery on the abdominal organs, it is preferable to insert the 1st trocar on the left above the navel. This ensures that the telescope lens is located in the abdominal cavity outside the adhesions.

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

Rice. 22.6. Type of surgical field during laparoscopy

After introducing the telescope and instruments, an inspection of the abdominal and pelvic organs is carried out. The operating table is transformed to place the patient in a Trendelenburg position. This allows the intestinal loops and omentum to be moved to the upper abdominal cavity, creating conditions for manipulation of the pelvic organs.

Laparoscopic tubectomy

After tension with forceps, the fallopian tube is clamped with dissector jaws and a mono or bipolar current is applied 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 using a soft clamp through the extended contra-aperture on the left (Fig. 22.7, a, b).

Laparoscopic adnexectomy

The fallopian tube is removed in the manner described above. The ovarian tissue is grabbed with forceps near its own ligament, coagulated and cut. Then, forceps are used to grab the ovarian tissue near the infundibulopelvic ligament and, with its tension, complete the cutting of the ovary from the mesoovary with a monopolar coagulator. When using bipolar forceps, tissue separation after coagulation is performed using endoscopic scissors. The ovary and tube are removed through an expanded contraperture. The abdominal cavity is washed with isotonic sodium chloride solution (Fig. 22.8, a-d).

Rice. 22.7. Stages (a, b) of tubectomia (rear view, left). Laparoscopy

Rice. 22.8. Stages of adnexectomy. Laparoscopy: a - intersection of the ovarian ligament (rear view, left)

Rice. 22.8.Continuation. b - the proper ligament of the ovary and the isthmus of the fallopian tube are crossed (rear view, left); c - intersection of the infundibulopelvic 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 inspection of the pelvic and abdominal organs, a uterine probe (Cohen) is inserted into the uterine cavity. Using a bipolar coagulator and scissors or a monopolar coagulator with simultaneous hemostasis, the round uterine ligaments, fallopian tubes, and ovarian ligaments are alternately crossed on both sides. The vesicouterine fold of the peritoneum is opened and separated downwards along with the bladder. Close to the uterine rib, the posterior layer of the broad uterine ligament is opened towards the uterosacral ligament. The uterine vessels can be coagulated and divided using mono- and bipolar coagulation or sutured and ligated with vicryl sutures. The body of the uterus is cut off from the cervix at the level of the internal os using monopolar coagulation. The uterine body is removed from the abdominal cavity using a morcelator (a device for grinding tissue) or through a colpotome opening. The vaginal wall in the area of ​​the colpotome opening is restored by suturing laparoscopically or through the vagina. The uterine appendages and fallopian tubes (if necessary) are removed according to the method described above. After removing the uterine body, sanitation of the abdominal cavity and additional hemostasis (if necessary) are performed. Peritonization of the uterine stump is not performed (Fig. 22.9, a-e; 22.10).

Extirpation of the uterus without appendages

Until the body of the uterus is cut off from the vaginal vaults, the operation is performed in the same way as the supravaginal amputation of the uterus described above. One of the most technically responsible stages of hysterectomy is cutting off the cervix from the vaginal vault. The Clermont uterine manipulator must be used at this stage. The probe is inserted into the uterine cavity through the cervical canal. The bladder and posterior layer of the broad uterine ligament are dissected below the cervix. The latter is cut off from the fornix with a monopolar coagulator with simultaneous hemostasis. The uterus is removed through the vagina. To create a seal in the abdominal cavity after removing the uterus (to complete the operation), a sterile medical rubber glove with a gauze swab inside is inserted into the vagina.

When completing the operation, careful control of hemostasis is performed. For this purpose, an isotonic sodium chloride solution is injected into the pelvic cavity and sucked out until it is completely transparent. The injected liquid allows you to clearly see even the smallest bleeding vessels, which are precisely coagulated with the dissector jaws. The vagina is sutured from the abdominal side using the extracorporeal suture technique. At the end of the operation, a suture is placed on the aponeurosis after morcellation, even with small opening sizes (15-20 mm).

Rice. 22.9. Stages of supravaginal uterine amputation. Laparoscopy: a - intersection of the fallopian tube in the isthmus region (side view, right); b - intersection of the ovarian ligament (posterior view); c - dissection of the parametrium (rear view)

Gynecology: textbook / B. I. Baisova et al.; edited by G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.