Extraperitoneal cesarean section

With the application of extraperitoneal cesarean section in obstetrics, the surgical procedures are diversified and the surgical indications tend to be relaxed. Extraperitoneal cesarean section was originally used in women with intrauterine infections or potential infections. Because the operation is more difficult and complicated than the intra-abdominal uterine cesarean section, the time required for the operation from the beginning of the operation to the delivery of the fetus is longer, especially the incomplete separation of the bladder from the peritoneum, so that the uterus is not cut enough, high or deep The fetal head is prone to difficulty in taking the fetal head, tearing the uterine incision, and damaging the bladder and ureter. This kind of surgery has not been advocated abroad, but the advantages of extra-abdominal operation, small postoperative reaction, rapid recovery of intestinal peristalsis and light abdominal pain are excellent for doctors and patients. If you take the abdominal wall and the transverse incision, it is more popular with the mother. Through a large number of clinical practice and accumulation of clinical data, as well as continuous improvement of the surgical procedure, the secondary damage of the operation is small and safe. However, strict control of indications, contraindications, and mastery of extra-abdominal cesarean section techniques can not be ignored. Treating diseases: dystocia Indication 1. Premature rupture of membranes, there may be intrauterine infection. 2. The lower part of the uterus is well formed, the fetal head has been connected, and the uterus opening is 2~3cm. Contraindications Absolute contraindication (1) Abdominal surgery for the abdominal cavity, such as pregnancy with uterine fibroids, malformation of uterine pregnancy, rupture or rupture of uterine aura, emergency laparotomy. (2) When the placenta previa and the placenta are attached to the anterior wall of the lower uterus. (3) When the fetus is distressed or needs to be delivered quickly. 2. Relative contraindications (1) huge children. (2) The fetal head is embedded too deeply. Preoperative preparation 1. The bladder does not require special preparation. 2. Continuous epidural anesthesia. Surgical procedure The technical point of extraperitoneal cesarean section is to correctly separate the bladder from the peritoneum. According to the way of separating the bladder to retract the peritoneum, it can be divided into the bladder side entry type, the bladder top type, the hydraulic type and the bladder top side joint type. At present, the top side joint type is adopted, and the surgical field is well exposed, which is advantageous for operation to reduce damage. (a) Latzko side entry (latzko cesarean section) 1. Features: Do not cut the anterior fascia of the bladder. 2. Surgical procedure (1) incision of the abdominal wall: the same as the intraperitoneal uterine segment of the cesarean section. (2) Separation of the posterior wall of the abdominal wall: the operator uses the finger to separate the posterior space of the abdominal wall along the left edge of the abdominal wall incision. The bladder is more right-handed with the right side of the uterus, and the bladder is more likely to be exposed on the left side. (3) Exposing the triangle area, separating the fat pile: the surgeon uses the right finger along the left edge of the abdominal wall incision to separate the posterior space of the abdominal wall, expose the anterior wall of the bladder and the left fossa, and the transverse fascia is weak, which can be pushed together with the lower adipose tissue. Open, if the transverse fascia is thickened, it is cut open, and the depth of separation is not limited to the lower abdominal artery. The assistant lifts the left abdominal wall cutting edge with the abdominal wall hook to expose the fat pile on the left side of the bladder. The surgeon pressed the peritoneum at the top of the bladder with his left hand, and pushed the yellow fat and connective tissue in the lateral fossa to the outside with his right hand to expose the peritoneal fold. The characteristics of the foldback are light, smooth and shiny. If the left hand is relaxed and pressed, sometimes the ascites is filled. The three sides of the triangle are composed of the inferior epigastric artery, the peritoneal reflex and the bladder side wall. The uterine muscle wall forms the base of the triangle, and the surface of the uterus is attached to the anterior fascia. Pushing away from the fat pile should start from the higher position near the top of the bladder, and gradually clear the field leading to the lower part of the bladder to prevent damage to the ureter and the iliac vessels. (4) Expose the lower part of the uterus, cut the anterior fascia of the uterus: After the boundary of the triangle is discriminated, the anterior cervix of the cervix is removed 1 cm below the edge of the peritoneum, and the transverse cervix is cut straight to the right edge of the uterus, and then from the cervix The posterior fascia of the bladder below the anterior fascia free incision, the right hand lifts the bladder, and the fascia between the bladder and the peritoneal retraction is tightened by both hands to identify the boundary of the top of the bladder, and the fascia is cut open until the lower uterus is fully exposed. (5) Cut the uterus transversely, deliver the fetus, and intraperitoneal cesarean section. It should be noted that this procedure does not open the anterior fascia of the bladder, and the exposure of the lower uterus is often unsatisfactory. There are more opportunities to pull out the fetal head with the forceps. Therefore, it is necessary to prepare a cesarean section with a small forceps before cutting the uterus. See the relevant contents of intraperitoneal cesarean section for the precautions for the difficulty of delivery of the fetal head. If the above treatment does not work, the fetus is extremely difficult to deliver, and the peritoneal sac can be cut from the center of the uterine wall under direct vision, and the uterine section of the lower uterus can be changed. (6) suture the uterine incision, confirm the absence of ureter and bladder injury, and close the uterine incision. The method is the same as the intraperitoneal uterus incision cesarean section, but it is necessary to ensure that the incision is completely closed, the abdomen bladder, the fascia without suturing, suture the abdominal wall layer by layer. (2) Waters cedar type (waters cesarean section) 1. Features: Free and push the bladder from the front and top of the bladder, expose the lower uterus, cut the uterus, and remove the extraperitoneal cesarean section. The free bladder area of this procedure is large, the separation is difficult, and the bladder is easily damaged, but the surgical field in the lower part of the uterus is fully exposed, and the tire is easy to take. 2. Surgical procedure (1) Incision of the abdominal wall: the operation is the same as the side entry type, but in order to fully expose the bladder and the lower uterus, the posterior space of the bilateral abdominal wall and the posterior pubic space should be separated, but not too deep. (2) Incision of the anterior fascia of the bladder: "disorder" is removed for the top of the free bladder and its posterior wall. The bladder fascial incision can be "T", "one" or curved. Most authors have an arcuate incision that corresponds to the top edge of the bladder, as the incision does not necessarily separate the anterior wall of the bladder. The surgeon touched the bladder to determine the bladder boundary, and cut the bladder fascia 2 cm below the top edge of the bladder. Then, the vascular clamp was inserted into the fascial incision to separate the layers, and the assistant edge was cut along the edge of the bladder until the middle of the side. The contralateral fascia was cut in the same way to complete the arc-shaped incision of equal length on both sides. (3) Free bladder: The bladder top is separated by a combination of blunt and sharp. Pinch the upper margin of the anterior fascial incision of the bladder and tighten it. The surgeon wraps the gauze with your fingers and gently presses down the bladder wall near the top of the bladder. If the bladder is tightly connected to the fascia, cut it gently with a cut. Separation. Directly to the bladder after the peritoneal fold. Push up the bladder to fold back, push down the bladder, and expose the lower uterus. (4) Incision of the anterior fascia of the uterus: upper and lower abdominal retraction and bladder, respectively, exposed the anterior fascia of the uterus, about 2cm below the peritoneal retraction, and use 2 hemostasis to lift the anterior fascia, from the middle of the second forceps The transverse incision was made, and the fascial incision was extended to the left and right by 10 cm. Stretch the finger in the fascial mouth, bluntly separating downward, the bladder will fall vertically into the posterior pubic space, and the lower part of the uterus will be exposed clearly. (5) Incision of the uterus, removal of the fetus, sutured uterine incision are the same as transabdominal uterine cesarean section. (6) Proper hemostasis: suture the bladder fascia with a small round needle and a thin thread to suture the bladder fascia 3 to 4 needles, and reset the bladder. Note that the suture does not penetrate the bladder wall. (7) suture the abdominal wall with the same intraperitoneal cesarean section. (3) Hydraulic type The procedure is the same as the top-in type. The difference is that the 0.5% procaine layer is injected into the interstitial space of the bladder peritoneal reflex, so that the loose connective tissue between the bladder and the peritoneum expands, the gap is widened, and the scissors are used for sharp separation. To avoid damage to blood vessels and reduce bleeding. The bladder is pushed back below the peritoneum to fully expose the lower uterus. (four) bladder top side joint The advantages of priming and lateral insertion are absorbed, and the surgical procedure is simplified and safe. Many obstetric units use this type of surgery. 1. Features: combined with the extraperitoneal cesarean section of the bladder, the bladder fascia is cut from the left side of the curve, and the blunt free bladder is started from the left side of the bladder. The bladder is pushed from the upper left to the lower right, and exposed. Lower uterus. 2. Surgical procedure (1) Incision of the abdominal wall: the operation is the same as the side entry type. (2) Separation of the anterior fascia of the bladder: about 2 cm below the top edge of the bladder, use the curved vascular clamp to lift the anterior bladder fascia, and cut it with the scissors to the left and right sides until the side edge of each side of the bladder. This method was repeated to separate the bladder fascia 3 to 4 times until the bladder muscle fiber tissue and the blood vessels in the bladder muscle wall were exposed. (3) free bladder cervical space: first free the top of the bladder, traction vascular clamp on the upper margin of the fascia, so that the fascia is stretched out, the operator's left hand pad gauze compression fixed peritoneum, right hand finger wrap gauze, gently push the bladder down the bladder, After being pushed back and forth between the umbilical ligaments 2 to 3 times, the bladder was pushed down about 3 to 4 cm. (4) Separation of the bladder uterus to retract the peritoneum: Insert the bladder fascia with a handle or finger and continue to free the bladder fascia from the top of the bladder. Use a curved vascular clamp to hold the fat and connective tissue close to the left edge of the bladder and cut it. After gently pushing the connective tissue and fat to the left side, a small part of the left anterior wall of the cervix can be exposed, where the outer edge is the open connective tissue, the upper edge is the posterior peritoneal fold, and the lower edge is The left side wall of the bladder. (5) Exposure of the lower part of the uterus: After the majority or complete separation of the peritoneum from the top of the bladder, the bladder is completely freed from the lower part of the uterus by a blunt dissection method, and the lower part of the uterus is exposed. (6) Cut the uterus and take out the fetus. The sutured uterine incision is the same as the intraperitoneal uterine cesarean section. (7) The extraperitoneal space was cleaned. After no hemorrhage, the bladder was removed by suturing the anterior fascia of the bladder with a No. 1 silk thread for 3 to 4 needles. (8) Layered suture of abdominal wall tissue.

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