hysterectomy

Extensive hysterectomy for surgical treatment of cervical cancer. The basic procedure for surgical treatment of cervical cancer is to remove all regional lymph nodes and to perform extensive hysterectomy. The pelvic lymph nodes must be thoroughly and carefully removed, including the total iliac crest, the external iliac crest, the internal iliac crest, the obturator, and the main ligament group. If necessary, the para-aortic, lumbosacral, and deep groin groups should be removed. Extensive hysterectomy must open the lateral fossa of the bladder, separate and cut the ligament and connective tissue of the uterus before and after the bilateral uterus, remove the adipose tissue around the main ligament, cut off near the wall of the pelvis, after all the connective tissue of the vagina is removed. , the vagina is removed, and the margin is generally 3 to 4 cm from the lesion. Subtotal hysterectomy can be used for the surgical treatment of uterine fibroids. Subtotal hysterectomy, also known as partial hysterectomy or vaginal hysterectomy, surgical removal of the uterus and preservation of the cervix. Indication Extensive hysterectomy: 1, for cervical cancer Ib ~ IIa (including pregnancy or postpartum). 2. There is vascular infiltration and fusion infiltration in stage Ia. Subtotal hysterectomy: 1, uterine fibroids or other uterine benign diseases such as functional uterine bleeding, uterine adenomyosis (disease), etc., young women who need to remove the uterus and normal cervix, can retain the cervix. 2, the cervix has no serious lesions, and the patient's general condition is not good, or there are systemic serious complications, can not support more complicated hysterectomy surgery, or have a wide range of adhesions, difficult to perform total uterine surgery. Contraindications Extensive hysterectomy 1. Those who are over 65 years old and have other adverse factors. 2, weak constitution or accompanied by heart, lung, liver, kidney and other organ diseases. 3, pelvic inflammation or endometriosis, and a wide range of adhesions. 4, there is obvious infiltration around the cervix, or patients with stage IIa or above who have metastasized in the bladder and rectum. 5. Excessive obesity. Subtotal hysterectomy 1, the cervix has serious lesions, such as atypical hyperplasia, severe erosion or cervical smear cytology examination suspicious, should not retain the cervix. 2, uterine fibroids have malignant changes. 3, the endometrium has malignant lesions. 4, combined with patients with malignant lesions. 5, acute pelvic inflammation. Preoperative preparation Extensive hysterectomy 1, mental preparation The operator must fully consider the surgical procedure, the problems that may occur during the operation, and the methods to be solved. Serious preoperative discussions are also required to complete the major surgery declaration form. The patient and his family are introduced separately to the condition and the operation. On the one hand, the patient's enthusiasm is mobilized and the treatment is actively coordinated. On the other hand, explain the possible consequences to the family to gain understanding and cooperation. 2. Detailed medical history and examination Understand the current medical history and past medical history, whether there are diseases in important organs, whether there is bleeding tendency and inflammation history. Routine examination of patients with heart, lung, liver, kidney and other organ functions, chest X-ray, ECG, B-ultrasound, if necessary, cystoscopy and intravenous pyelography. If there is a suspected transfer, CT examination can be further performed. 3, the treatment of complications before and after surgery Anemia should be corrected, bleeding should be treated effectively, infected lesions should be controlled, malnutrition and metabolic disorders should be positively corrected, blood pressure of hypertensive patients should be properly controlled, but should not be lowered too low, too obese And the elderly and infirm, the surgery should be particularly meticulous, stop bleeding to be sure, to prevent infection. 4, preparation before surgery 1 diet: 3d before surgery, less slag diet, from semi-liquid to fluid, 1d before surgery should be fasted. 2 enema: clean enema on the eve of surgery. 3 vaginal preparation: 3 days before surgery, wash the vagina with potassium permanganate solution, or scrub the vagina with Xinjieer, once a day. 4 sleep: preoperative night safety. 5 skin preparation: 1 day before surgery, the patient first shower. From the abdomen to the xiphoid, down to the pubic symphysis, the vulva and the upper third of the thigh, the soapy water is brushed and shaved, paying special attention to cleaning the dirt in the umbilicus. 6 preparation for blood. 7 preoperative application of atropine or scopolamine, luminal. Subtotal hysterectomy 1, with the general gynecological abdominal preparation before surgery. 2, cervical scrapings to check cancer cells. 3, menstrual disorders and patients under the age of 50, should be diagnosed curettage before surgery, a comprehensive understanding of the uterus, except for endometrial lesions to determine the ovarian retention. Surgical procedure Extensive hysterectomy An important component of extensive hysterectomy is the removal of lymph nodes, which have recently been advocated for the removal of large-scale resections of the carpet, including lymph nodes, lymphatic vessels, and surrounding adipose tissue. For the sake of clarity, it is still explained by decomposition surgery. 1. Incision Generally, the abdominal longitudinal incision is used, and the left umbilicus is extended by 3 to 5 cm to release the pubic symphysis. The layers of the abdominal wall are cut in turn, and the fascia below it must also be cut to the pubic bone to facilitate the expansion of the surgical field and facilitate the operation. It has also been advocated to take a transverse incision in the abdomen, but the rectus abdominis must be severed, the tissue damage is large, and the surgical field is not exposed to the longitudinal incision. After opening the abdominal cavity, first explore the uterine activity, the attachments on both sides are free of adhesions and lesions, the parametrial tissue, bladder, rectum with or without infiltration, hypertrophy or adhesion; check pelvic lymph nodes, abdominal aortic lymph nodes, with or without swelling and induration Explore the liver, gallbladder, spleen, kidney, diaphragm and omentum. If there is extensive adhesion or existing cancer metastasis, it is estimated that surgical resection is difficult, surgery should be stopped, the abdominal cavity should be closed, and radiotherapy should be changed. Otherwise, the surgery continues. 2, clamp the two corners of the uterus Two long curved vascular clamps were used to clamp the bilateral ligaments, ovarian uterine ligaments and fallopian tubes to pull the uterus. Gently lift the uterus, push the gut tube up with a large cotton pad, so that it completely leaves the surgical field, and place the automatic hook to fully expose the surgical field. In the past, conventionally used double-jaw forceps or single-jaw forceps pulled the uterus, which was hanged for patients with malignant tumors. The main consideration was that if the uterus had cancer infiltration, clamping the uterus would inevitably promote the spread of cancer cells, and must be prevented in advance. 3, cut open pelvic funnel ligament Starting from the right side, in order to avoid damage to the ureter, the position of the ureter across the common iliac artery must be ascertained. After the lateral side is lifted, the peritoneum is incision, first cut 3 to 4 cm, and then cut down along the ureter. Here, the peritoneum is thin, and the position of the ureter is superficial, which is often seen through the peritoneum. Can not confirm, you can gently stimulate the device, you can see ureteral peristalsis. 4, pinching, cutting, sewing ovarian blood vessels Because the posterior peritoneum is opened, it is easy to identify the ovarian movements and veins in a bundle shape, and it is blunt or sharply separated, fully exposing its direction of travel, clamping, cutting and suturing near the wall of the basin, and doing double suture. Some people do not advocate opening the posterior peritoneum and free ovarian blood vessels, but taking direct clamping, cutting, and suturing will increase the chance of damaging the ureter. 5, pinch, cut, and sew the right round ligament In the right round ligament, the middle and outer 1/3 junctions are clamped and cut, the No. 7 silk thread is sewn, and the long end is left for traction. The left round ligament is treated in the same way. 6, cut the anterior lobe of the broad ligament The anterior lobe of the broad ligament was cut along the outside of the pelvic leaky ligament and reached the end of the left round ligament. 7, cut the bladder peritoneal reflex Starting from the broken end of the right round ligament, the curve is cut open forward and downward, and reaches the broken end of the left round ligament. 8, push the bladder down Push the bladder directly to the external cervix. According to the anatomical structure, there are 3 wrinkles between the bladder and the cervix. Use your fingers for blunt separation. If necessary, use scissors to push down and push down. Start from the middle, then separate to the left and finally to the right. If the anatomical level is clear, pushing the bladder is easy and there is no bleeding. If the adhesion is very tight, it can be used for sharp incision, and the bleeding is ligated to stop bleeding. Due to the rich blood vessels on both sides of the cervix and vagina, it is advisable to push the vasculature to the sides while pushing the bladder, so as not to damage the venous plexus on both sides and ooze blood. After the bladder is pushed open, it can be pressed here with saline gauze. 9. Exposing the common iliac artery and ureter The cut posterior peritoneum was sutured with silk sutures, or the small vascular clamp was used for traction to fully expose the common iliac artery and its bifurcation. The external iliac artery and the internal iliac artery were seen in the field of view. The ureter crossed the front of the common iliac artery and went to the medial side. 10, exposure of the external iliac artery, reproductive femoral nerve The cellulite before the external iliac artery is separated, and the external iliac artery, the psoas muscle, and the reproductive femoral nerve between the two are exposed. The femoral nerve can be protected from injury by a little attention. 11. Exposing the external iliac vein and the deep iliac vein The fibrous fat mass in front of the iliac vessels was separated, and the external iliac vein was seen behind the external iliac artery. Separate down to the iliac artery and see the deep iliac vein. 12, clear the total lymph node Pulling the hook in the upper right side of the incision, it can expose the common lymph nodes in front of and inside the common iliac artery. When the lymph nodes are swept, the anatomical features are removed from the outside to the inside, from far to near, and surrounded by the surrounding. Lymph node and fat separation have many advantages for sharp separation, which can accurately remove the relevant tissues and overcome the shortcomings of cancer cells caused by the blunt separation of the surrounding tissue. When the lymphatic tissue is removed, according to the direction of the lymphatic vessels, the lymphatic vessels are cut at a small number, and at the upper and lower ends, the upper and lower ends are to be ligated. According to pathological studies, cancer metastasis is generally limited to the lower part of the common iliac artery, so it is removed from the lower segment. Pay attention to protecting the ureter. 13, ligation of the small branch of the common vein The common iliac vein is located behind the common iliac artery. There is a small vein branch at the bifurcation of the common iliac artery. It must be clamped, cut, and sutured to avoid injury and affect the whole operation. 14. Exposure of extra-orbital lymph nodes The outer sheath of the external iliac artery was cut longitudinally along the external iliac artery, and the lymph nodes and adipose tissue around the blood vessel were removed from the top to the bottom. Be careful not to damage the reproductive femoral nerve on the inside of the psoas muscle and close to the blood vessel. 15, clear the deep lymph nodes of the inguinal There is a large deep inguinal lymph node below the inferior inguinal ligament in the lowermost part of the external iliac artery, and the deep venous venous venous sinus is underneath, and the lymph node is removed to protect against damage. Because the lymphatic vessels are thicker at the site, the distal end is ligated with a thin wire to reduce the formation of postoperative lymphocytic cysts. 16, clear the intraorbital lymph nodes This group of lymph nodes is small, along the internal iliac vein, and the site is deep. The fat and lymph nodes on the inner side of the external iliac vein were freed by hemostatic forceps or curved scissors, and the fat and lymphoid tissues were pulled to the outside to expose the internal iliac artery, and the fat and lymphoid tissues above and outside were separated and removed. Be careful not to damage nearby veins. Clear lymph nodes and adipose tissue should be removed as much as possible. At this point, the fatty lymphoid tissue between the internal and external vessels of the iliac crest was completely removed. 17, ligation of the small branch of the external vein After the fat and lymphatic tissue between the internal and external iliac vessels are removed, a small branch of the lower iliac vein can be seen. At this time, ligation should be performed to prevent bleeding and affect the surgical field. 18. Exposure of closed pores Pull the bladder inward, use a small hook to gently pull the external iliac vein to the outside, and continue to separate with the scissors or fingers with the small outside of the internal iliac artery. The closed hole is located between the external iliac vein and the pelvic wall. 19. Separation of obturator lymph nodes Use a finger or a curved vascular clamp to separate the fat in the closed hole, revealing a closed-cell lymph node, and behind it is a closed-cell nerve parallel to the left pelvic wall. The vascular clamp used for separation should not be rough, and should not be inserted too deeply to prevent damage to the obturator, vein, obturator nerve and pelvic venous plexus. 20, clear closed-cell lymph nodes Because closed-cell lymph nodes sometimes cling to the anterior and obturator nerves, special care must be taken to clear the lymph nodes and prevent damage to blood vessels and nerves. If the small blood vessels in the deep hole of the closed hole are damaged, there will be a lot of bleeding. If necessary, ligation or hemostasis will be performed. Because the lymphatics are thicker, they should be ligated when the lymph nodes are removed. 21, separation of uterine artery Both the uterine artery and the superior bladder artery are separated from the internal iliac artery. Before the uterine artery is ligated, the two must be identified to prevent the upper bladder from being mistaken. After the uterine artery is separated, it goes down to the inside, and enters the uterus at the inner cervix; while the superior bladder is on the outside and continues to the bladder. The uterine artery is slender and curly, with a diameter of no more than 2 mm; while the superior bladder artery is relatively straight and has no curl. The uterine artery is separated from the internal iliac artery, so be careful not to damage the uterine vein. 22, clamping the uterine artery After identifying the uterine artery, 1 cm away from the internal iliac artery, the clamp 2 clamped the vascular to the uterine artery. Under normal circumstances, the uterine vein is not parallel, but the ureter should be recognized, clamped on the outside of the ureter, a few centimeters apart. If you do not leave the uterine artery, do not clamp at the proximal iliac artery, but clamp in front of the ureter, it is likely to damage the ureter. 23, cut and ligation of the uterine artery After cutting the uterine artery, the distal end is double-ligated, and the proximal uterine end of the line is left in a line for traction. 24, separation of uterine veins It is not difficult to identify the uterine vein. The uterine vein has a certain distance from the uterine artery. The deeper part of the uterine artery enters the internal iliac vein. It walks behind the ureter and has an acute angle near the uterus. Therefore, when separating the uterine vein, care should be taken not to damage the ureter and adjacent blood vessels. 25, clamping, cutting, ligation of the uterine vein The purpose of ligating the uterine vein is to create conditions for proper control of bleeding when separating the ureteral tunnel. Generally, it is not ligated with the uterine artery. On the one hand, the distance between the uterus and the vein is long, and the ureter is easily damaged. On the other hand, if the ureter is ligated together, the vein is easily broken and the bleeding is caused during the operation, which increases the difficulty of surgery. 26. Free upper bladder artery The superior bladder artery is separated from the internal iliac artery and finally distributed on the surface of the bladder. It is located outside the ureter and is freed from injury during the next operation. However, some people advocate that there is no need to separate and raise vigilance. At this point, the right side is all over, and the left side is also treated in the same way. 27, free ureter In order to meet the requirements of extensive hysterectomy, free ureter is an important step. The blood supply of the ureter comes from the blood vessels of the accessory. In order to prevent the occurrence of ureteral fistula, the blood supply of the ureter should be preserved as much as possible. Therefore, it is advisable to start the ureter from the uterine artery 2 to 3 cm above the ureter, and it should not exceed the internal iliac artery. Ureteral nutrition branch. Free ureter from the posterior peritoneum, first lift the posterior peritoneum, then use scissors to cut loose connective tissue 1cm away from the ureter, the scissors face up, gently release the ureter until the uterine artery. 28, continue to push the bladder The bladder has reached the external cervix. In order to extensively remove the vagina and adjacent tissues, the bladder is separated by scissors or fingers, and the position of the ureters entering the tunnel is clearly indicated. 29. Separate and cut off the anterior lobe of the bladder ligament (ie, the anterior ureteral tunnel) In order to adequately remove the cervix and paravaginal tissue and lymph nodes, the bladder, cervical ligament, and free ureter must be opened. Here, the ureter travels inward and forward. When clamping the bladder and anterior cervix of the cervix, use a curved vascular clamp to extend into the tunnel. The concave surface is facing forward. In this direction, gently separate the ureter and press the ureter to the rear. When it is confirmed that the ureter is not clamped, it can be cut and sutured. Treatment of ureteral tunnel should be bold and decisive, and be careful and careful; prevent coarse and large block clamps, damage the ureter, and can not be timid, so that the anterior leaves are separated too shallow, the residual treatment is insufficient, the ureter is not fully free, and the ureter is treated again. It is bound to encounter difficulties. If the anterior layer is completely cut, it can be seen that all the ureters are running and there is less bleeding. On the contrary, the anatomy is unclear and there is a lot of bleeding. It has also been suggested that the finger is used for blunt separation here to avoid bleeding and damage to the ureter. However, this method is progressing very slowly. If it is stuck, it is more difficult. Since the vaginal venous plexus is distributed above and below the tunnel, and the ureter is in between, care must be taken during the separation to avoid bleeding. 30, separation, cutting the bladder, the posterior lobe of the cervix (ie the posterior ureteral tunnel) Carefully separate the posterior ligament of the ligament to prevent bleeding and damage to the ureter. 31, incision of the posterior lobe of the broad ligament and uterus, rectal peritoneal reflex The uterus is pulled toward the pubic symphysis, and the uterus and the rectum are resected with a pair of scissors. The two sides extend to the posterior lobe of the broad ligament and reach the free ureter. If the position of the incision is too high, it is difficult to separate the peritoneal reflex and it is easy to damage the ureter. 32, push open the rectum Lift the cut posterior peritoneum and use the curved scissors or fingers to separate the rectum from the posterior wall of the vagina. 33, continue to push the rectum Along the sides of the uterosacral ligament, the two sides of the rectum are pushed away, and the middle part continues to separate the rectum from the vaginal wall, reaching 2/3 of the vagina. 34. Exposing the rectal side fossa On the outside of the uterosacral ligament, use loose scissors or fingers to push open the loose honeycomb tissue to fully expose the rectal fossa. At the same time, the humeral ligament of the uterus is mostly free. 35. Cut and sew the shallow layer of the right tibiofibular ligament Use the hook to gently pull the right ankle vasculature and ureter to the outside, push the rectum to the opposite side, fully expose the patellofemoral ligament, clamp the superficial layer of the patellofemoral ligament with a curved vascular clamp, cut it, and suture the No. 7 silk thread. 36. Cut and sew the deep layer of the right tibia ligament Because the patient takes the supine position in the supine position, the lower rectum is lifted higher. When the ligament of the uterus and tibia is clamped to the deep layer, the curvature of the humerus and the direction of the rectum along which the bending is performed must be noted. Failure to pay attention to this feature of anatomy may damage the rectal wall. The deeper the depth, the more attention should be paid to the operation of the vascular clamp and scissors with large curvature. 37, cut and suture the right cervix ligament The superior bladder artery was pushed open to avoid injury, and the bladder side socket was separated along the bladder side wall with the indicator. Use a hook to gently pull the ureter outward to expose the main ligament. Use a long curved vascular clamp at the wall of the basin to make a clamp or a cut twice, and use a 10 thread to sew. When the main ligament is separated, pelvic venous hemorrhage often occurs, and the treatment is difficult. The movement should be gentle during surgery to prevent bleeding. The steps from the treatment of the left pelvic funnel ligament to the treatment of the left main ligament are the same as on the right side. 38, separation of the left adjacent vagina tissue The uterus is separated from the posterior wall of the pelvis. The paracervical and paravaginal lymph nodes are completely free. The tissues around the iliac vessels are separated. The rectum is separated from the vagina. The uterus is only associated with the vagina and the front wall. At this time, the bladder and the ureter were pulled apart by a hook, and the tip of the curved scissors was separated to the side of the bladder by more than 3 cm. There is more oozing here, which prevents damage to the bladder and ureters when ligation and hemostasis. The depth of the separation of the paravaginal tissue should be consistent with the level of the isolated rectum, that is, the plane from which the vagina is intended to be removed. The opposite side is treated in the same way. 39. Clamping, cutting, and sewing the paravaginal tissue Use a long curved vascular clamp to clamp the paravaginal tissue. The tip of the forceps should reach the lower part of the vaginal plane that is expected to be removed, and the posterior end of the ligament of the uterus. Before clamping, cutting and suturing, it is necessary to check whether there is any damage to the bladder and ureter. If the examination is correct, the cutting can be performed. If the paravaginal tissue can not be completely removed at one time, it can be carried out in several stages. 40, clamp, circular cut vaginal wall Pull the uterus upwards to fully reveal the vaginal part. Use two right angle vascular clamps to clamp the vaginal wall 3 to 4 cm below the cervix, one on each side, to prevent cancer cells from falling out of the pelvic cavity, cut the vaginal wall under the right angle vascular clamp, and remove the entire specimen. 41, suture the vaginal wall After circumcision of the vagina, use the rat tooth forceps to lift the front, back, left and right sides of the cutting edge. After the traditional end of the broken end, fill the dry gauze in the vagina, and push all the pollutants to the pelvis to the vagina. Remove the gauze. However, some people do not advocate blocking gauze and think that the possibility of pollution is not great. The treatment of vaginal stumps is different. The common use is the continuous locking of the vaginal wall, the closure of the vagina, and the placement of two extraperitoneal drainage tubes in the pelvis, which are extended from both sides of the lower abdomen, so that the pelvic cavity can be extraperitoneally Blood seepage and lymph drainage. Another method is to suture the vaginal wall with continuous seaming, open the vagina, and place 2 pelvic extraperitoneal drainage tubes to the vaginal drainage. Both have their own advantages and disadvantages. The former has left scars on the abdominal wall, and the drainage is not as smooth as the vaginal drainage. However, the latter has a higher chance of vaginal ascending infection than the abdominal wall. Another method is to intermittently suture the vaginal wall. After placing a cigarette drainage tube into the pelvic peritoneum, the method is simple and the oozing is not used much. However, when the vaginal wall is bleeding, the effect of intermittent suture is less than the first two. After placing the drainage tube, observe how much the exudate determines the time to take out, and usually take it out at 3 to 5 days. There were not many bleedings during the operation, and there was little exudation. Some people advocated that the vaginal wall should be continuously locked or sutured, all closed and not drained. In short, suture the vaginal wall and related drainage problems, a variety of, can be combined with their own experience. After the suture of the vaginal wall is finished, some people advocate suturing the anterior wall of the rectum and the posterior wall of the vagina to prevent premature healing of the open vaginal wall; suspending the bladder to prevent urinary retention, suturing the bladder and reversing the anterior wall of the vagina to prevent bladder Back tilt; urinary retention to strengthen the bladder. But some people do not advocate such surgery. In this regard, more experience is needed. 42. Stitching the pelvic peritoneum Check the surgical field before suturing, whether there is bleeding, if bleeding, you must stop bleeding; pay attention to the ureter, bladder, rectum or not; whether the ureter is ectopic or distorted, should be kept in place. The pelvic peritoneum was sutured continuously or intermittently with a No. 0 gut or a No. 4 silk thread, and the round ligament was fixed thereon. It is not too tight when suturing the pelvic peritoneum. Be careful not to damage the ureter. Subtotal hysterectomy 1. The abdominal wall is cut open. 2, explore the pelvic cavity Understand the uterus, attachments and their lesions, and determine the size, location, presence or absence of adhesions, and the relationship with the surrounding organs. When suspected tumor malignancy, it should also explore the diaphragm, liver, spleen, stomach, kidney, intestine, omentum and lymph node metastasis. After the investigation was completed, the intestine tube was opened with a large gauze cloth and placed in a puller to fully expose the surgical field. If there is adhesion, it should be separated sharply or bluntly. 3, lifting the uterus Use 2 toothed vascular clamps to hold the sides of the uterus under the ovary ligament directly along the uterine horn for traction. It is also possible to carry out the operation of the uterus from the abdominal cavity according to the size of the uterus and personal operation habits. Generally, if the uterus is not large, it is convenient to operate in the abdominal cavity, and it also reduces the chance of contamination of the operation outside the abdominal cavity. 4, processing round ligaments The round ligament was lifted with tissue forceps, and clamped at 3 cm from the point of attachment of the uterus, and clamped with a mid-bend vascular clamp, and the distal end was ligated through a suture with a 7-gauge wire or a 1-0 chrome gut. 5, processing accessories According to the condition and the age of the patient, and whether the ovaries are normal or not, the ovarian retention is determined. If the ovaries are not preserved, the uterus and the fallopian tubes and ovaries are pulled up to the side. The surgeon uses the fingers or vascular clamps to lift the broad ligament forward, avoiding the blood vessels, and clamping the three thick and medium curved vessels from the outside to the inside. The pelvic funnel ligament is clamped by the side-by-side forceps. To prevent slippage, the clamp slightly exceeds the blood vessel, and the clamp should be placed close to the ovarian side of the fallopian tube to prevent the short-term vascular slippage or accidental injury to the ureter. After clamping, no other tissue was observed. The hopper ligament was cut between the pliers on the 2nd and 3rd, and the ligament was sewed through the 10th and 7th wires or nylon thread. The opposite side is treated in the same way. If the ovary is preserved, the mesenteric mesangial is clamped with a mid-bend vascular clamp, and the No. 7 silk thread is sewn. The thick and medium curved vascular clamp clamped the ovarian ligament, cut off, and the 10th thread penetrated through the suture. When the ovaries were preserved while the fallopian tubes were preserved, the isthmus and ovarian ligaments of the fallopian tubes were clamped with a thick curved clamp, cut off, and the sutures were sewed through the 10 and 7 silk threads. 6, cut the bladder peritoneal reflex, push open the bladder From the end of the uterine lateral round ligament, between the two lobe of the broad ligament, insert a blunt-head scissors, along the edge of the attached uterus, separate and cut the anterior lobe of the broad ligament and the peritoneal reflex of the bladder, directly below the broken end of the contralateral round ligament. The loose free part of the center of the bladder peritoneal reflex can also be lifted with a toothless forceps, cut open, and cut to the sides to the end of the bilateral round ligament. Use the vascular clamp to lift the edge of the bladder peritoneal reflex, use the finger or the shank, along the loose tissue between the bladder fascia and the cervix fascia, and bluntly peel off the bladder downwards and on both sides to push the bladder away. The uterus is slightly under the mouth, and the side reaches 1cm beside the cervix. When the bladder is re-folded, the depth should be moderate, too deep and easy to bleed, and it is not easy to peel. If it is too shallow, it will be easily peeled off. For example, the thickness of the incision is appropriate, the level is clear, and the bladder can be pushed smoothly, and there is little bleeding. When it is firmly connected to the cervix, it can be cut with scissors. If there is bleeding, you can use a silk thread to ligation or electrocoagulation to stop bleeding. After the separation is completed, the free edge of the bladder peritoneum is fixed at the lower end of the incision to better expose the surgical field. 7. Isolation and cutting of the posterior lobe of the broad ligament The assistant pulls the uterus forward, closes the uterus and cuts the posterior lobe of the ligament to the vicinity of the ligament of the uterus, and gently pushes open the loose tissue inside the broad ligament to expose the uterine arteries and veins. Here is the avascular zone, the tissue is loose, easy to separate, and if there are small blood vessels, it can be ligated. 8, treatment of uterine blood vessels After the anterior and posterior lobes of the broad ligament are opened, the uterine arteries and veins are clearly exposed. It can be seen that the blood vessels are beating, and the blood vessels can be touched by hand. A few patients are not easy to touch. Lift the uterus up to one side, pliers with 3 thick and curved vessels, at the level of the uterine isthmus, perpendicular to the lateral edge of the uterus, and clamp the clamps sideways. Push the bladder open again before clamping. If the uterine artery clamp is too high, it will increase the difficulty of surgery, and the clamp will be too low to easily cause excessive bleeding. The tip of the forceps should be close to the uterus to prevent the blood vessels from leaking. Here, the ureter is closer to the uterus, so the clamp should not be too large to avoid damage to the ureter and bladder. After the clamp is exact, it is cut between the upper and middle pliers, and the end of the pliers is slightly extended downward to facilitate the sewing. The broken ends are stitched together by a 10th wire and a 7th wire. The opposite side is treated in the same way. 9, remove the uterus How much to remove the uterus depends on the specific situation. If a young patient needs to have a menstrual cramp, the scope of resection can be above the uterus (the uterine fibroids are low, except for surgery). Generally, the uterus can be removed from the flat mouth. The left hand lifts the uterus, exposes the incision site, and pads the wet pad around it to prevent the secretion from the neck tube from contaminating the surgical field. The oblique blade is used for wedge resection, and the assistant lifts the cervical stump with tissue forceps. If the uterine vascular suture is completely complete, the cervical end is white, there is active bleeding should be sutured to stop bleeding, the cervical end is disinfected with 2, 5% iodine and 75% ethanol, and the cervix is used to wear the No. 1 chrome gut. Or nylon thread for 8 or intermittent stitching. 10, fixed round ligament Some scholars are accustomed to stitching the end of the round ligament to the end of the cervix to prevent the cervix from sagging. 11. Suture the pelvic peritoneum: check and clean the wound of the cervix. After the hemostasis, the pelvic peritoneum is sutured continuously with 4-0 silk thread. Starting from the end of the pelvic funnel ligament, the peritoneum is lifted and the suture is continuously sutured to the contralateral pelvis funnel. The ligament is broken, and when the suture is sutured, the broken ends are turned into the peritoneum, and the pelvic cavity is peritoneally formed to form a smooth pelvic surface. 12, suture the abdominal wall See the abdominal wall incision and suture. complication Extensive hysterectomy 1, bladder and ureteral injury Bladder vaginal fistula and ureterovaginal fistula are the main causes of direct injury and ischemic injury. Direct injury is caused by accidental injury caused by unfamiliar anatomical location or anatomical variation. Ischemic injury is caused by ischemic necrosis due to local blood circulation obstruction. If urinary fistula has occurred and the cavity is not large, the time for placing the catheter can be extended for 4 to 6 weeks, and the buttocks are raised to make the bladder and ureter end fully rest, in order to obtain self-healing. If conservative treatment is not effective, surgery should be performed as soon as possible. 2, bleeding In the extensive hysterectomy, when the main ligament and ureteral tunnel are separated, pelvic venous hemorrhage often occurs. At this time, temporary internal iliac artery or common iliac artery can be used to control local bleeding, find bleeding point and then sew. Stop bleeding; or use compression to stop bleeding (at least 7min), and add vasoconstrictor drugs, to find the bleeding point and then sew, avoid blind clamping. If the large blood vessels are damaged, non-invasive suture or anastomosis is required. Anticoagulation and anti-infection treatment must be performed during and after surgery. The recent bleeding after surgery is mostly due to ineffective hemostasis or loosening of the ligature. Such as in the vagina can be clamped, sutured to stop bleeding, such as in the pelvic cavity, and more bleeding, should immediately open the abdomen to stop bleeding. If it occurs several days after the operation, it is mostly caused by secondary infection, and a large amount of antibiotics can be used to control the infection. Such as vaginal bleeding, local antibiotics, vasoconstrictors, clotting agents can be used to stop bleeding; if pelvic hemorrhage, it should be opened in time for vascular occlusion or tamponade, drainage, plus large doses of antibiotics. Regardless of the method used to stop bleeding, blood volume must be replenished in time to correct complications caused by blood loss and prevent infection. If there is a tendency to hemorrhage, the cause should be identified and corrective actions taken. 3, infection The cause is a potential infection or co-infection before surgery, or inadvertent contamination during surgery, or secondary infection after surgery. Prophylactic or therapeutic anti-infective measures should be adopted according to the situation. Prophylactic measures should use broad-spectrum antibiotics; therapeutic anti-infection, timely use of antibiotics sensitive to pathogenic bacteria, such as pelvic abscess, lymphatic cyst should be drained in time. 4, dysfunction 1 bladder paralysis: due to pelvic visceral nerves and blood vessels damaged during surgery, resulting in weakened bladder detrusor function, the formation of urinary retention. The measures to prevent bladder paralysis mainly preserve the pelvic nerve plexus and its accessory branches, preserve the upper and lower bladder arteries and ganglia, and avoid urinary retention and infection after operation. 2 rectal anesthesia, less frequent. During the operation, the blood vessels, nerves and other tissues inside the humeral ligament of the uterus should be preserved as much as possible to prevent the occurrence of rectal paralysis. 3 vaginal shortening, removal of most of the vagina, will affect sexual life. It can be solved by prolonging the vagina. The bladder peritoneum is creased to the anterior wall of the vaginal stump, and the rectal peritoneum is re-folded to the posterior wall of the vaginal stump. Finally, the posterior wall of the bladder and the anterior wall of the rectum are continuously sutured at an appropriate height to make the vaginal depth. Can be extended. 4 artificial menopause, young women undergoing extensive hysterectomy while double attachment resection, can form artificial menopause. In particular, the lack of estrogen can also cause osteoporosis. According to statistics, patients with fractures who died of osteoporosis were 9 times more likely to have cervical cancer. Therefore, in recent years, it has been emphasized that the scope of surgery depends on the stage of cervical cancer, and the normal ovaries can be retained in young patients before Ib. In order to prevent the recurrence of recurrence, the ovary can be moved to the peritoneum of the abdominal cavity, or the ovary can be transplanted to the abdominal wall, under the armpits, and the like. 5 pelvic retroperitoneal lymphocyst, mainly due to lymphatic tissue clearance, there is a dead space behind the peritoneum; reflux of lymph fluid retention, the formation of cysts, cysts gradually increase can produce compression symptoms; secondary infection fibrosis, the formation of lumps, often Misdiagnosed as recurrent cancer. The precautionary measure consists in carefully ligating the lymphatic stump, especially if the lymphatics are thicker, and should be ligated. The drainage tube was placed behind the pelvic peritoneum and removed from 3 to 5 days. No dead space was left to avoid the formation of lymphatic cysts. If it has occurred and the symptoms of compression have occurred, topical application of Glauber's salt can be applied; in patients with secondary infection, incision and drainage can be performed extraperitoneally; if fibrotic cysts are formed and symptomatic, extraperitoneal resection can be performed. Extensive hysterectomy: 1, to avoid damage to the ureter 1 should be familiar with the anatomical relationship of the ureter, should pay attention to protect the ureter from beginning to end to avoid accidental injury. Especially in the free, ligation of ovarian motion, veins, treatment of the patellofemoral ligament, separation of the ureteral tunnel and suturing the pelvic peritoneum should pay special attention. 2 Avoid using surgical instruments to clamp the ureter, or excessive traction for a long time. 3 free ureter should not be too long to avoid damage to the ureteral sheath and ureteral nutrient vessels to protect their blood supply. 4 If there is bleeding around the ureter, avoid thick wire ligation or excessive knots. 2, clear lymph nodes must pay attention 1 When clearing the lymph nodes, according to the anatomical features from the outside to the inside, from far and near, try to do a large block, because the lymph nodes and lymphatic vessels are embedded in the surrounding cellulite and adipose tissue. 2 Because the lymph nodes travel along the blood vessels, and the lymphatic vessels are often accompanied by small blood vessels, care must be taken not to injure the accompanying blood vessels. 3 in the removal of lymphoid tissue according to the direction of the lymphatic vessels, in the thicker lymphatic vessels, should be carefully ligated to prevent the formation of lymphocysts, especially in the external group, the inguinal deep lymphoid group, the obturator group. 3, prevent bleeding 1 The wall of the vein is thin and easy to be damaged, especially at the intersection of the internal and external iliac veins. When the lymph nodes are cleared, it can be damaged with carelessness, and there is a large bleeding that is difficult to control. 2 When the pelvic deep ligation and hemostasis, it is very important to accurately knot the knot. If the ligature is loose, the vascular end is indented, and then clamping can easily cause injury or hemorrhage. 3 Note that the anatomy and operational points of each step in the operation are important to prevent bleeding. For example, when clearing the closed-cell lymph nodes, it is not allowed to pull from the pelvic wall. It should not involve the deep layer of the obturator nerve. When freeing the uterus and veins, pay special attention to its anatomical position and direction, and ligature separately to treat the anterior and posterior walls of the ureteral tunnel. To stop the blood to be exact, suture the vaginal tissue, avoid excessive traction of the uterus, to prevent bleeding between the posterior wall of the vagina and the pelvic floor, the anterior venous plexus is generally not easy to damage, if there is adhesion, bruises during separation, then Big bleeding is not limited. At this time, do not clamp, so as not to cause more tears, but can only stop bleeding, and then suture to stop bleeding when the bleeding point is found. Subtotal hysterectomy: 1, bleeding The site where hysterectomy is prone to bleeding is when the pelvic funnel ligament, uterine blood vessels, and pushdown bladder are treated. When the fibroids are too large and too wide, when the special position is low, it is easy to bleed and increase the difficulty of surgery. In this case, we must first identify the anatomical relationship and accurately treat the large blood vessels. The operation is generally performed on the easy-to-operate side. The assistant tries to pull the uterus to the opposite side, so that the blood vessel is exposed clearly, the clamp is complete, the ligation is firm, and the hysterectomy is performed once or the suture is strengthened to prevent the tissue tension. Reduce the bleeding after the knot is loose. Cut the ligaments to leave enough tissue to avoid slipping. Handle the bleeding points of the abdominal wall, especially the muscle layer, so as not to cause abdominal wall hematoma. 2, adhesion When uterine fibroids are associated with endometriosis or inflammation, there may be varying degrees of adhesion, often resulting in surgical difficulties. Adhesives can be separated by light and blunt fingers or handles. Dense adhesions, especially adhesions that are widely or located in the rectal fossa or uterus. If the treatment is not proper, it will cause bleeding. First, the organ should be damaged. The operation should be extra careful. Try to separate sharply under direct vision. Sexual separation. When separating, try to be close to the tumor. Sometimes a benign disease will leave some of the tumor wall on the organ. 3, organ damage The uterus is located in the pelvis, adjacent to the bladder, rectum, and ureter, and is easily accessible to hysterectomy. When the adhesion is severe or the tumor is large and the anatomical part is changed, the operation may cause organ damage without paying attention. Generally, the most common injuries include bladder damage, ureteral injury, and rectal injury. Bladder injury often occurs when the peritoneum is incision. When the bladder is pushed down, it should be repaired immediately after the injury. Ureteral lesions occur in large uterine fibroids, especially in broad ligaments or cervical fibroids. The ureters are often displaced and easily injured. Patients with extensive adhesions or bleeding can also easily cause ureteral injury. In this case, the anatomy is discriminated. First, the operation is meticulous, and the tissue is clamped or cut blindly without stopping the bleeding. You can use your finger to touch the ureter to the direction of the ureter. If necessary, open the pelvic funnel ligament and operate under direct vision. Rectal injury occurs in patients with adhesions in the uterus rectal fossa. It should be light and delicate during operation. If there is dense adhesion, it should not be forced to be blunt.

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