total abdominal hysterectomy

Abdominal hysterectomy for the surgical treatment of uterine fibroids. Treatment of diseases: uterine fibroids Indication 1. Benign diseases such as uterine fibroids require removal of the uterus, severe lesions in the cervix, or older women. 2. Early uterine malignancies, such as endometrial cancer, cervical carcinoma in situ, and accessory malignancies. 3. Pelvic inflammatory mass, tuberculous mass and other conservative treatment is invalid. Contraindications 1. Uterine fibroids with accessory malignant tumors, endometrial cancer above stage II or cervical cancer Ib stage or above should not be a simple hysterectomy. 2. Acute pelvic inflammation. Preoperative preparation 1. Prepare with the general gynecological abdominal surgery. 2. Cervical scraping 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. 4. On the 3rd day before surgery, the vagina was perfused with disinfectant (1:1000 benzalkonium chloride or 1:5000 furancillin solution) daily. Make a vaginal swab culture if necessary. Surgical procedure 1. The abdominal wall is cut. 2. Exploring 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. Treatment of 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 attachments 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 pliers. To prevent slippage, the clamp slightly exceeds the blood vessel, and the clamp should be placed close to the oviduct side of the fallopian tube to avoid 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 and 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. Treatment of uterine fibular ligament The assistant pulls the uterus toward the premise, and then can see two uterine humerus ligaments in the shape of a dovetail. The middle ventricle is clamped at the inner cervix, and the jaws are cut and cut with a 7-gauge thread. The position of the uterine fibular ligament should not be too high to avoid increasing the difficulty of surgical separation. Between the two broken ends, the peritoneum of the posterior wall of the uterus is opened, and the rectum is bluntly separated and pushed open to the outside of the cervix. With two fingers, it can meet before and under the cervix. In some patients, the patellofemoral ligament is narrow. It can also be treated together with the main ligament without separate treatment. 10. Treatment of the main ligament After the bladder rectum is fully pushed open, the uterus is pulled up and to the side, and tightened, with a vascular clamp, slided from the anterior and posterior sides of the cervix, and clamped to the cervix for clamping, paying attention to the end of the vaginal side. If the clamp is too high, it may cause difficulty in hysterectomy. If it is too low, it may cause tearing of the paravaginal tissue. Depending on the width and thickness of the main ligament, the clamp can be clamped once or twice. The bilateral clamps are completed, close to the cervix, leaving enough tissue to prevent slipping, and the 10th thread is sewn. The opposite side is treated in the same way. 11. Cut the anterior vaginal wall and remove the uterus Exposing the uterus to the cervix and vaginal connection area, pulling the bladder downward, and then checking to confirm that the tissue around the uterus has been fully peeled off, and then use a small gauze pad to surround the posterior wall of the uterus to prevent secretion from flowing into the abdominal cavity, in the vagina. The anterior iliac crest is cut across the small mouth. After entering the vagina, the vaginal cutting edge is clamped with tissue clamps, the scissors are inserted, the vagina is cut along the ankle ring, and the uterus is removed. In order to prevent the vaginal secretion from overflowing and contaminating the abdominal cavity, after cutting the anterior wall of the vagina, a piece of gauze is inserted into the vagina, and is taken out from the vagina at the end of the operation. The vaginal stump was pulled with 4 tissue clamps. 12. Stitching the vaginal end The vaginal stump is disinfected with 2.5% iodine and 75% ethanol. After being rubbed with saline, it is sutured continuously with 1-0 chrome gut or nylon thread or sutured with 8 words. There are branch vessels at both ends of the vagina. The semi-powder is sutured to prevent bleeding. To reduce bleeding at the end of the fracture, the posterior peritoneum and the anterior wall of the vagina can be sutured together. Infected patients can be sutured by vaginal seams and not closed, which is good for drainage. 13. Stitching the pelvic peritoneum 14. Suture the abdominal wall. Remove the vaginal gauze after surgery. complication Vaginal bleeding: 2d after total hysterectomy, there may be a small amount of vaginal bleeding, mostly residual vaginal blood during surgery, no need to deal with. About 7 days after surgery, due to suture absorption and shedding, local small amount of oozing may occur, mostly reddish or serous exudation, which gradually decreases and disappears after 2 to 3 weeks. If the bleeding lasts for a long time, you should pay attention to whether there is any infection, check it, and handle it according to the situation. If vaginal bleeding occurs within a short period of time after surgery, it should be checked immediately to find out the cause. If the bleeding is broken, gauze can be used for compression. If it is active bleeding, it should be immediately localized or clamped to stop bleeding or electrocoagulation to stop bleeding. Many should reopen the abdominal cavity to stop bleeding. Sudden massive hemorrhage 2 weeks after the operation, mostly due to detachment or infection of the knot, and the infection of the broken end can be suppressed by iodoform gauze, such as pelvic hematoma, if necessary, open bleeding to stop bleeding.