tubal anastomosis

Fallopian tube anastomosis for the treatment of fallopian tube recanalization. Fallopian tube recanalization is an infertility caused by the fallopian tube factor, and the purpose of gestation is achieved through repair surgery. It is not only to make the lumen unobstructed, but also to consider the functional state of the organ. Therefore, the choice of the case before surgery and the fineness of the surgical technique, as well as careful postoperative treatment are the factors that determine the success or failure of the operation. The cases of recanalization were followed by tubal ligation and tubal obstruction infertility. The recanalization after tubal ligation is different depending on the original ligation procedure. The original ligation is performed by isthoracic entrapment or double-fold ligation, and the site of the ligation is in the fallopian tube. /3 segments for easy anastomosis. Due to the advancement of microscopy technology, the success rate of surgery has been improved. A large number of clinical data have reported that the success rate of microsurgical tubal anastomosis after sterilization is more than 90%. Microsurgery for fallopian tube recanalization, surgeons and assistants must first carry out basic training, familiar with the structure, performance and use of the operating microscope, training the uniformity of eye movements, and the cooperation between the surgeon and the assistant is also successful. The essential. The anastomosis operation is simple, the success rate of surgery and the postoperative pregnancy rate are much higher than those of ostomy and transplantation. Of course, in some cases, when the tube is ligated too much, the tube core is too much or the diameters of the two ends are very different, which will affect the effect of the operation. Infertility caused by obstruction of the fallopian tube accounts for 30% to 40% of infertility cases. Different pathological types have different success rates. Different surgical methods must be chosen depending on the location of the fallopian tube obstruction. The obstructive segment is at the distal end of the isthmus or the ampulla. The obstructive segment can be removed for anastomosis. The obstruction can be used for tubal ostomy in the umbrella or ampulla. The uterine horn (interstitial) or the proximal isthmus is used as the fallopian tube. Intrauterine transplantation, can also be based on the extent of bilateral fallopian tube lesions for their own fallopian tube transplantation. The fallopian tube obstruction caused by infection not only obstructs the lumen but also has inflammatory adhesions around the fallopian tube. The normal anatomy and physiological functions of the fallopian tube are destroyed. The success rate of recanalization is very low, and there is the possibility of ectopic pregnancy. Due to the interference of surgery, re-adhesion and infection can affect the effect of rehabilitation. In recent years, the development of IVF-ET has solved the surgical problem of partial fallopian tube infertility. The value of tubal recanalization is getting smaller and smaller. Curing disease: Indication 1. Fallopian tube anastomosis is suitable for those who require re-fertility for some reasons after tubal sterilization and meet the following conditions. (1) Women of childbearing age. (2) Good health. (3) Regular menstruation after sterilization, normal ovarian function. (4) There are no obvious lesions in the genitals, including inflammation and tumors. 2, the diagnosis of infertility caused by tubal obstruction without contraindications. Contraindications 1. When the age is over 40 years old, the reproductive ability is reduced. There is less chance of conception after reopening. It is generally not suitable for anastomosis. 2, genital tube disease gynecological tumors, genital inflammation, endometriosis and pelvic tuberculous inflammation adhesions are more serious. 3, ovarian dysfunction, no normal ovulation function. 4, the previous surgery for tubal resection or major resection, unipolar electrocoagulation sterilization and drug blocking sterilization, the extent of tubal damage and the previous failure of fallopian tubeplasty caused by the fallopian tube is too short, it is not appropriate to do anastomosis. 5. History of tuberculous salpingitis or history of diffuse tuberculous peritonitis. 6, multiple obstruction of bilateral fallopian tubes, history of bilateral salpingectomy or history of tubal pregnancy. 7, male infertility. 8. Suffering from a serious illness that cannot afford pregnancy or an acute phase of various diseases. 9, the abdominal skin infection should be suspended. 10. There is a small cesarean section or two cesarean section history as a relative contraindication. Preoperative preparation 1. Inquire about the medical history and physical examination in detail, understand the general medical history and methods of previous sterilization, whether there is any infection after surgery, and do the whole body and gynecological examination and necessary laboratory tests. 2. Explain the success rate of the operation and possible complications to the subject and family members. Both husband and wife are informed and sign the consent form. 3, uterine tubal iodine oil angiography before surgery to clarify the location of the fallopian tube obstruction and the presence or absence of lesions in the uterine cavity. The operation time should be performed after 3 months of angiography. It has been clarified that no angiography can be performed after sterilization. 4, endoscopy examination suspected pelvic adhesions, endometriosis, tuberculosis or tumors, should be done laparoscopic or posterior sputum examination, suspected uterine lesions should be done hysteroscopy. 5, the husband's semen routine examination. 6, 3 ~ 7d after menstruation, the fallopian tube mucosa is thin, the broken end is easy to match, so early proliferation is the best operation time. There are also advocated oral estrogen to prolong the proliferative phase and increase the chance of fluid. 7, antibiotics 3d before surgery, vaginal washing 3d. 8. Perform an anesthesia allergy test if necessary. 9. Prepare the skin in the abdomen. 10. Prepare surgical instruments for microsurgery (1) Zoom in 3 to 5 times of binocular magnifying glasses or magnify 6 to 30 times of binocular surgery microscope. (2) Microsurgical instruments. 7-0 or 8-0 non-invasive sutures, microsurgical surgical instruments, 1 to 1.2 mm diameter plastic tubes or catheters for epidural anesthesia as a stent for intraoperative use. Surgical procedure 1, preparation Abdominal routine disinfection, drape, remove the median longitudinal incision, about 8 ~ 10cm long, if you do a transverse incision, you need to cut the rectus abdominis, in order to fully expose the surgical field, cover the skin towel. 2, check the pelvic organs Enter the abdominal cavity, use a large gauze pad to wrap around the intestine to the upper abdomen, and then use a large gauze pad to block the uterine rectal fossa, so that the uterus and fallopian tube are exposed to the surgical field. Check the degree of adhesion between the fallopian tube and the surrounding tissue. If there is adhesion, carefully separate the sharp separation with small anatomical scissors to correct the abnormal bending of the fallopian tube. The fine adhesion can also be separated under the microscope. If there is bleeding, use electrocoagulation to stop bleeding. 3, check the obstruction of the fallopian tube Use a venous incision needle or a thin plastic tube or a silicone tube to insert the mound of the fallopian tube into the diluted methylene blue saline to determine the blockage, or use the Shirodhar forceps to clamp the uterine neck to make it locked. Use a 21-gauge needle to puncture the bottom of the palace. Injecting the dye into the uterine cavity, so that the lower end of the most venous part of the fallopian tube is used as the obstruction part. After the injection, remove the needle and do not pull out the needle, in order to use it again, avoid multiple times of acupuncture. Causes pinhole bleeding, localized electrocoagulation can be used to stop bleeding after the needle is pulled out. If there is no Shirodhar forceps, the operator or assistant can use your fingers to pinch the uterine isthmus from the bottom of the palace. 4, resection of the fallopian tube scar Use two microvascular clamps to lift the ends of the fallopian tube scar, inject saline or 0, 5% procaine into the serosal membrane to separate the serosa layer from the die, and cut the serosa in parallel or perpendicular with a sharp knife No. 11. Layer, free resection of the fallopian tube scar to the normal tissue at both ends, free should not be too long, so as not to affect the blood supply. The scar was removed and the normal mucosa was exposed. The normal needle was injected into the two ends with a 6-pin needle. 5, put into the bracket The material selected for the stent is required to be slender, smooth, and not easily broken, such as ponytail wire, nylon wire, epidural anesthesia catheter for children, chrome II gut, etc., and the stent is inserted from the two end nozzles. If the stent is not retained, the proximal uterus should not be inserted too deeply, and the end of the uterus should only be used as a guide anastomosis during surgery. If the stent needs to be preserved after surgery, the proximal end should be inserted into the uterine cavity. When inserting, the fallopian tube should be leveled at the same level as the uterine horn, and inserted slowly, and the distal end is taken out from the umbrella. 6, anastomosis of the fallopian tube Under the double binocular surgery microscope (can be placed 10 to 16 times), suture the oviduct muscle layer with 7-0 to 9-0 non-invasive nylon thread, and stitch one needle at 12, 6, 3, and 9 points respectively. The thickness of the lumen determines the number of sutures. The suture does not penetrate the mucosa, and the knot is not knotted. After the muscle layer is completely sewn, the knot is knotted together to keep the anastomosis flat. In order to make the lumen enlargement and easy to fit, you can also use the No. 1 silk thread to sew a needle pull line in the muscle layer of the 6 and 12 o'clock of the fallopian tube. Pull the lumen as far as possible to facilitate the anastomosis. After the muscle layer is finished, the traction line will be pulled. After extraction, the suture layer was sutured intermittently with 6-0~5-0 nylon thread. After the anastomosis was completed, the stent was removed from the umbrella end, and another fluid test was performed to check whether the anastomosis leaked. If there is leakage Supplemental sutures. Different methods of anastomosis are adopted according to the location of the fallopian tube lesion. Commonly used is the isthmic-isthmic anastomosis; Isthmic-ampullary anastomosis; Ampullary-ampullary anastomosis; Amphora canal and interstitial Anastomosis. End-to-hip anastomosis of the isthmus; suitable for the recanalization of the tubal isthmus after ligation, the diameter of the two ends of the site is the same, and the method of end-to-end anastomosis is used. Generally, 3 to 4 needles are sutured. The fallopian tube has sufficient length, the umbrella end is complete, and the rate of re-pregnancy is high. The isthmus is used for anastomosis of the ampulla: since the distal diameter is slightly larger than the proximal side, the distal end is a flat cut surface, and the proximal end is a chamfered surface, so that the diameters of the distal and the proximal ends are equal. Or at the time of suture, the needle spacing on the gorge is small, the needle distance on the ampulla side is slightly larger, and the needle spacing on the same side is equal. The margin should not be too wide. If the diameter difference between the two ends is large, the closed end end can be partially anastomosed, and the posterior side of the lumen can be sutured to suture the muscle layer 2 to 3 needles, so that the caliber of the two can be consistent. Or funnel-like anastomosis, that is, after the free scar tissue, the ampulla end has become a blind end, and the needle is inserted from the umbrella portion by a venous incision needle, and a small opening is cut at the blind end of the needle to make it conform to the isthmus. Abdominal anastomosis of the ampulla: the diameter of the two ends is approximately equal, and the end-end anastomosis is adopted. Because the lumen is large, a support line can be lifted at the back side of the fallopian tube at both ends, so that the edge of the mucosa is turned to the inside, and the suture is generally sutured. 6 stitches, many can be sewn 8 to 10 stitches. The isthmus and interstitial anastomosis, also known as hysterosalping anastomosis, is only suitable for proximal obstruction of the fallopian tube isthmus, and the interstitial and other parts are normal. Because the isthmus and interstitial anastomosis maintain a sufficient length of the fallopian tube, and better maintain the normal anatomical relationship between the fallopian tube and the ovary, less bleeding, the rate of re-pregnancy is much higher than that of uterine transplantation, the wound of the serosa is close to the uterine horn The chance of adhesion is also small. Because the lumens are roughly equal, the anastomosis of the anastomosis is not easy to form new scars. After the scar is removed, a support line is first sewed, and the stent is placed as a guide from the two ends, and the end-to-end anastomosis is performed. After the muscle layer is sutured, the support line is removed, and then the serosa layer is sutured, the stent is removed, and the fluid is not leaked until it is leaked. . 7, suture mesangium The oviduct mesangium was sutured with 5-0 nylon interlining. The mesenteric incision should be perpendicular to the long axis of the fallopian tube to prevent the scar after suturing from compressing the fallopian tube and affecting the smooth and normal peristaltic flow. 8, retaining the bracket The proximal end is curved in the uterine cavity, and the distal end is taken out from the abdominal wall, and is sutured to the abdominal wall with a silk thread to prevent slipping. 9, prevent adhesion In order to prevent the formation of new adhesions, 32% dextran-7 anhydride-70 300-500 ml, gentamicin 80,000-160,000 U, dexamethasone 10 mg, heparin 25 mg, phenacetin 25 mg were placed in the abdominal cavity before abdominal closure. . The drug solution is distributed in the pelvic cavity. 10. Stitch the layers of the abdominal wall. complication There is no major complication of tubal anastomosis, and ectopic pregnancy may occur in the long term.

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