Abdominal wide uterus, total vagina, total urethra, cystectomy plus ileal bladder replacement

All vulvar, vagina, cervix and other cancers are committed to the bladder, the urethra and the whole vagina, but the main ligament, uterine ligament and vagina are not infiltrated into the pelvic wall. Treatment of diseases: vaginal cancer, cervical cancer Indication All vulvar, vagina, cervix and other cancers are committed to the bladder, the urethra and the whole vagina, but the main ligament, uterine ligament and vagina are not infiltrated into the pelvic wall. Preoperative preparation 1. The corresponding examination should be carried out to understand the entire urinary system. 2. Oral antibiotics for 3 to 5 days before surgery. Surgical procedure Total: Surgical sequence: extensive abdominal uterus, total cystectomy whole vagina, total urethral resection placement of hose drainage, vaseline gauze, iodoform yarn closure of the peritoneum ileal or colonic bladder fistula. First, abdominal wide uterus, total vaginal, total urethroplasty plus bladder flap urethral abdominal wall transplantation Surgical sequence: extensive uterus total vaginal, total urethral resection bladder flap urethral abdominal wall transplantation. 1. Abdominal incision: mid-lower incision in the middle and lower abdomen, from the upper edge of the pubic symphysis, up to 2 ~ 3cm around the umbilicus. 2. Extensive total uterine resection: See extensive hysterectomy and extensive uterine total vaginal resection. 3. Expose the anterior wall of the bladder: pull the uterus backwards and upwards, and cut the pelvic peritoneum at the bottom of the bladder. The peritoneum is separated to the pubis and the anterior wall of the bladder is free. 4. Expose the upper part of the anterior wall of the urethra: under the pubic symphysis, separate the loose connective tissue between the pubis and the bladder and the urethra, reveal the lower part of the bladder and the upper part of the urethra, continue to free the urethra under the shame, and release the upper and middle urethra. 5. Cut the upper urethra: cut the urethra along the lower edge of the pubis at the urethra. The urethral stump was continuously locked and sutured. 6. Perineal incision: an arc-shaped incision is made about 1 cm above the outer urethra, and the vaginal mucosa is formed along the left and right vestibules to form an elliptical incision. 7. Separation of the anterior segment of the anterior wall of the urethra: along the incision above the urethra, the connective tissue around the anterior wall of the urethra and the urogenital muscles are separated from the lower edge of the pubic symphysis, deep to the anterior wall of the lower bladder, and the entire urethra is free. 8. Separation of the vagina: separation of the posterior wall and lateral wall of the vagina, the method is the same as extensive uterine resection of the whole uterus (see extensive uterus plus total vaginal resection). At this point, the surgical specimen can be removed from the vaginal incision. In the abdominal surgery group, two hoses were placed for drainage Vaseline gauze applied to the wound surface all the iodoform yarn was clogged and then fixed by the vagina. Methods See extensive uterine total vaginal resection. 9. Close the pelvic peritoneum: The abdominal group surgery cooperated with the vaginal surgery group to close the pelvic peritoneum. 10. Bladder valve artificial urethra formation: a 9 cm × 5 cm bladder flap with a nearly trapezoidal shape on the anterior wall of the bladder. From the neck of the bladder, the base is at the base of the bladder. The bladder wall incision was sutured continuously with a 3-0 absorbable line and made into an artificial urethra. 11. Bladder valve artificial urethral abdominal wall transplantation: a 1.5-2 cm diameter circular incision was made in one side of the lower abdomen skin, and then the peritoneal surgical fascia was cut in a cross shape, and the end of the artificial urethra was taken out of the abdomen. , with no tension. 12. Fix the base of the artificial urethra: The artificial urethral adventitia and the external oblique muscle fascia are sutured for 4 to 5 needles at about 3 to 4 cm below the bladder fistula. 13. Stitching the artificial urethral opening: suture the artificial urethral opening and suture the skin. The suturing method is to take a needle from the muscular layer at the lower edge of the bladder fistula, and then the entire layer penetrates the bladder fistula and is ligated with the skin. 14. Fix the artificial urethral opening: make the bladder fistula nipple-like, retaining the suture. Place a small iodine imitation yarn around the mouth and fix it with the original suture. 15. Acupuncture: The abdominal wall is sutured in layers, and the right lower abdomen is the location of the bladder fistula. Second, abdominal wide uterus, cystectomy plus ileal bladder surgery Surgical sequence: extensive whole uterus, total cystectomy ileal bladder abdominal wall transplantation. 1. Incision: median incision in the middle and lower abdomen. 2. Exploring: To understand the degree of adhesion between the abdomen, pelvic organs and the pelvic wall, and the infiltration of the bladder into the bladder. 3. Cut the peritoneum of the pelvic funnel ligament surface. 4. Cut the pelvic funnel ligament: separate the pelvic funnel ligament to the level of the common iliac artery, and ligature and cut at high position. When the ligament is ligated, the lateral ureter should be revealed. 5. Cut the round ligament: cut and sew at 1/3 of the outer ligament. 6. Exposure of the anterior wall of the uterus to the bladder: Cut the peritoneum of the bladder bottom surface, push the anterior wall of the bladder after the pubic symphysis, reveal the lower part of the bladder and the upper part of the urethra (Fig. 7), and explore the extent of the lesion again. 7. Cut the urethra: Cut the upper urethra along the lower edge of the pubis. 8. Cut off the lower ureter: the lower middle segment of the ureter to the level intersecting the uterine artery, the ureter is cut off at this section, and the distal end is ligated. 9. Free ureteral surface peritoneal flap: a long peritoneal flap of the pelvic peritoneum on the proximal surface of the ureteral stump, slightly longer than the ureter retaining segment, to reduce the tension in the ureteral ileal anastomosis. 10. Treatment of the left ureter: The left mesenteric root should be cut open in the sigmoid (Figure 22), and the left ureteral peritoneal flap should be removed. 11. Separation of uterine rectal space: Lift the uterus in the direction of the pubic bone, press the rectum, cut the uterus and rectum to reflex, and separate the vaginal rectal space to the middle of the vagina. 12. Cut off the palpebral ligament: separate the rectal lateral fossa, reveal the uterine ligament ligament, and divide the deep and shallow layers into clamps and cut. Stitch the stump. 13. Cut the main ligament: separate the main ligament of the uterus, clamp the jaws 2 to 3 times, cut and sew the stump. 14. Cut the vagina: After the vaginal tissue is cut and the stump is sewed, the free vagina reaches a sufficient length to traverse it, and the whole surgical specimen is taken out. 15. Stitching the vaginal stump and reconstructing the pelvic peritoneum: the vaginal stump is continuously interlocked and sutured. Reconstruct the pelvic peritoneum. 16. Select the bladder of the intestine: 10 to 15 cm from the ileocecal area, cut a section of the ileum about 15 to 20 cm long, cut the corresponding mesenteric, and keep the arterial branch (Fig. 29). Intermittently suture the incision of the mesentery, end-to-end anastomosis of the proximal segment of the free intestine at both ends of the ileum. 17. Ileostomy: The free ileum is cleaned and cleaned with a 1:1000 cleanser. Two incisions about 1 cm long were made at the proximal end, and the ureteral port was cut into a bevel or a flap. 18. The ureter and the ileum end-to-side anastomosis: the ureters of both sides were anastomosed to the lateral side of the free ileum by absorbable lines. After anastomosis, the ileum muscle layer was freed and sutured with a full layer of the ureteral membrane for 5-6 needles. Before the anastomosis, the ureteral catheter was placed deep into the renal pelvis in the two ureters, and the catheter was built in the intestinal lumen. The three tubes were all taken out from the free ileum cavity. 19. Transureal bladder abdominal wall transplantation: Cut a circular skin of about 2 to 3 cm in diameter in the right lower quadrant, make a cross-shaped incision in the external oblique aponeurosis, and penetrate the corresponding peritoneum. The distal ostomy of the ileal bladder is combined with two ureteral catheters and catheters to extract from the right lower abdominal wall, and the length of the ileum is about 5 cm. The sarcoplasmic layer at the base of the ileum was sutured intermittently with the peritoneum and the external oblique aponeurosis. 20. Stitching the artificial bladder fistula: The mesentery at the end of the ileal bladder is cut longitudinally about 1 cm, and the intestine and the skin margin are valgus sutured to form a 2 cm long nipple that protrudes from the abdominal wall. The two ureteral catheters and catheters were properly fixed. 21. Fixed ileal bladder: suture the peritoneal incision on both sides, and fix the ileal bladder to the outside of the cecum. In addition to the ileal bladder after cystectomy, different procedures such as colonic bladder, colon or ileal bladder-rectal anastomosis may be used, and should be selected according to the specific circumstances of the operation. 22. Close the abdomen: close the abdominal cavity layer by layer. complication The common cause of poor drainage of the artificial urethra of the abdominal wall is clot blockage. It should be removed as soon as possible. If necessary, replace the mushroom tube to avoid leakage of the bladder wall due to water injection into the bladder. 1. Vaginal bleeding: postoperative vaginal drainage, color bright red, may have active bleeding, should use hemostatic drugs, if necessary, re-clogging the vaginal yarn. When conservative treatment is ineffective, it should be stopped in time to stop bleeding. 2. Postoperative infection: This operation has a large wound surface and is easy to be contaminated. Strong antibacterial drugs should be used after surgery. If the body temperature continues to be above 39 °C, vaginal secretions and blood samples should be taken for bacterial culture and drug susceptibility test in time, and the drug should be used under the guidance of drug susceptibility results.