extensive 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. Treatment of diseases: uterine sarcoma endometrial cancer Indication 1. Cervical cancer ia or above. 2. Endometrial cancer. 3. Malignant trophoblastic tumor, chemotherapy effect is not good, uterine lesions persist. 4. Uterine sarcoma. Contraindications 1. Those who are over 65 years old and have other adverse factors. 2. Debilitating or accompanied by organ diseases such as heart and lung, liver and kidney. 3. The pelvic cavity has inflammation or endometriosis, and there are a wide range of adhesions. 4. Patients with stage IIa or above who have obvious infiltration around the cervix or have metastases in the bladder and rectum. 5. Excessive obesity. Preoperative preparation Extensive hysterectomy is a large and complex procedure. Preoperative preparation, postoperative management, and surgical procedures are equally important for surgical outcomes. The following preparations must be made before surgery. Ideological 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, the family members are confessed to the possible consequences to obtain 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. 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; excessive obesity 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 fast; 2 enema: clean hen 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: pre-operative 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 thigh of the thigh, soapy water brushing, shaving, pay special attention to cleaning the dirt in the umbilicus; 6 preparation of blood; 7 preoperative application of atropine or scopolamine, Rumina. Surgical procedure 1. Incision: a straight incision in the lower abdomen. 2. Exploration: For endometrial cancer, first take ascites or peritoneal washings after laparotomy, and send cytology. Then explore the abdominal cavity and pelvic conditions from top to bottom. 3. Treatment of the pelvic funnel ligament: at the entrance of the pelvic funnel ligament at the entrance of the pelvis, open the pelvic peritoneum, cut it forward along the psoas muscle, and reach the outer 1/4 of the round ligament, and cut the ligament. Then along the anterior lobe of the broad ligament, continue to cut to the midline, reaching the bladder side socket. In addition, the pelvic entrance is 1 cm away from the ureter along the ureter, and the pelvic peritoneum is cut inward and downward to the outside of the patellofemoral ligament. Sharply separate the lateral rectal fossa of the ureter to the entrance of the tunnel between the ureter and the uterine artery. Note that when the ureter is separated, the inner side of the ureter is not attached to the pelvic membrane to ensure blood supply to the ureter. Free pelvic funnel ligament, double ligation or suture at high position, and detached to the ovary root after cutting. 4. Treatment of uterine ligament: the uterus is lifted to the pubic symphysis, and the rectum is pushed upwards and backwards to expose and open the peritoneum of the uterus rectal fossa. Separate the rectal vaginal septum to the level of 4 to 5 cm below the external cervix. Before the ureter enters the tunnel, it is released 5 to 6 cm and pulled to the outside to expose the uterine ligament. The appropriate length of the uterine ligament is removed according to the disease period, generally not less than 2 cm. 5. Incision of the ureteral tunnel: open the bladder peritoneal reflex, sharply separate the bladder and vaginal septum to the level of 4 to 5 cm below the external cervix, pull the bladder to the pubic symphysis, expose and cut the cervix bladder ligament. Pull the uterus toward the cephalad, gently press the bladder against the pubic symphysis with the intestine plate, expose the entrance of the ureteral tunnel, and use the vascular clamp to pass in and out from the tunnel opening. Clamp and cut the anterior leaf of the bladder ligament. At this time, the inside of the ureter has been exposed, and the anterior lobe of the bladder ligament is cut open in stages according to the law, and the ureter enters the bladder directly. Sharply separate the posterior lobe of the bladder ligament, so that the ureteral tunnel segment is completely free. 6. Resection of the main ligament: the ureter is removed to the side wall of the basin, and the main ligament is removed and sutured to the level of vaginal fistula. The length of the main ligament removed depends on the stage of disease or the degree of infiltration, and should usually be above 2.5 cm. 7. Excision of the paravaginal tissue and vagina: remove the paravaginal tissue along both sides of the vaginal wall. Free vagina until 4 ~ 5cm below the cervix, closed the vagina. 8. Stitching the vaginal stump: suture the vaginal stump with a retractable line of continuous locking. One or two drainage hoses are placed in the central perforation and are taken out from the vaginal opening. 9. Acupuncture: Wash the field, take measures to prevent intestinal adhesions, and close the abdomen layer by layer. complication 1. Ureteral injury: usually when the pelvic funnel is ligated in the high position of the ureter in three places, it is easy to mistake the ureter as the ovarian blood vessel, and ligature and cut together. The ureter straddles the common iliac artery and walks on the inner side of the ovarian blood vessel. The method of avoiding accidental injury to the ureter is to open the pelvic peritoneum when ligating the ligament, dissociate and identify the ureter, and treat the ovarian blood vessels. 2 When treating the uterine ligament, it is possible to damage the ureter that is walking on the outside. The method of prevention is that when the ligament is treated, the uterus rectal fossa and the rectal side fossa should be fully dissipated, and the uterus, rectum, and ureteral end segments are respectively pulled forward, rearward, and lateral, respectively, to fully expose the entire segment of the ligament, under direct vision. deal with. 3 Separation of the ureteral tunnel segment is the most common site of ureteral injury. When separating, pay attention to the anatomical level. Pull the uterus, bladder and ureter to the contralateral side, the front side and the outer side respectively, so that the entrance of the tunnel is clearly exposed. The tunnel is separated along the path in front of the ureter, and the tunnel can be opened safely. Ureteral injury can be divided into complete transection, broken holes, fistula formation. If the ureter crosses or the hole is more than 1/3 of the lumen, the end of the ureteral anastomosis should be performed. Before the anastomosis, the damaged tissue of the ureteral end should be cut off, and the broken end should be cut into a slope to enlarge the anastomosis area and prevent the anastomotic stenosis. At the same time, the length should be freely above and below the broken end (about 2~4cm). Reduce the tension of the anastomosis. A catheter stent was placed in the ureteral cavity, the renal pelvis was placed in the lower end, and the lower end was inserted into the bladder. A 3-0 or 4-0 gut was used, and about 6 needles were sutured intermittently. If necessary, use 3-0 gut, strengthen the suture ureteral sheath 6-8 needles, the alignment direction must be accurate when suturing, avoid the lumen torsion. After the operation, a hose or a cigarette is placed around the anastomosis and is drawn from the vagina or the abdominal wall. The drainage strip can be removed about 1 week after surgery or when the drainage fluid is small. The ureteral catheter stent can be removed 2 weeks after surgery. For ureteral rupture less than 1/3 of the diameter of the tube, suture repair is feasible. The ureteral muscle layer and fascia needles can be sutured with 3-0 gut longitudinally. To prevent postoperative ureteral stricture or spasm, ureteral catheter and drainage strip should also be placed. Ureteral ureteral bladder anastomosis or ureteral bladder valve implantation is feasible in the proximal ureteral injury. Most of the ureteral fistula appears 3 to 14 days after surgery, and can be treated with anti-inflammatory and nutrient-enhancing treatments. Small pupils are expected to heal themselves after the above treatment. If it still does not heal, under the premise that the tumor is completely controlled, ureteral anastomosis can be performed after 3 months. 2. Bladder urinary retention: urinary retention refers to those who can not urinate on their own 10 days after surgery, or can urinate themselves but residual urine >100ml. This is one of the most common complications of extensive hysterectomy. The main reason is 1 urinary tract infection. 2 surgical damage to pelvic sympathetic and parasympathetic nerve fibers. 3 After the hysterectomy, the bladder is over-positioned and the urination is poor. Measures to prevent urinary retention: 1 Strictly perform aseptic procedures to prevent and actively treat urinary tract infections. 2 The uterine ligament, main ligament and vaginal resection are closely related to the recovery of postoperative bladder function. Based on the principle of maximally resecting the tumor and maximizing organ function, the scope of surgical resection can be appropriately narrowed for early cancer. In order to achieve the purpose of radical treatment and reduce postoperative complications. 3 intraoperatively fix the bladder to the anterior abdominal wall and correct the bladder. Treatment of bladder urinary retention: first is to prevent and treat urinary tract infections, systemic antibiotics, and flush the bladder with 1/4000 nitrofurazone solution; secondly, various measures are taken to promote the recovery of bladder function, such as staying catheters regularly open to train the bladder Contraction function, or acupuncture acupuncture, physiotherapy, laser treatment.