Transabdominal myomectomy

Especially suitable for uterine wall fibroids, can avoid the pain of removing the uterus. Treatment of diseases: uterine fibroids Indication Patients under the age of 35 who are eager to have uterine fibroids; those who are 40 years of age or older are strongly urged to retain the uterus; need to correct symptoms such as menstrual disorders and pain caused by fibroids; submucosal fibroids, subserosal fibroids and single or less than 3 Conservative surgery is better for interstitial fibroids. Contraindications Pelvic malignant lesions (except early onset carcinoma in situ), endometriosis and pelvic inflammatory disease with extensive pelvic adhesions, larger and lower cervical fibroids, broad ligament fibroids, with larger and cohesive Attachment mass (>6cm diameter), the height of the fundus exceeds the umbilicus, and the extremely narrow vaginal is still recognized as a contraindication for TVH. Preoperative preparation Cervical smear and diagnostic curettage were performed before surgery to exclude cervical and uterine malignant tumors. Surgical procedure Surgical steps: One of the procedures: to understand the location, number, size and attachment of fibroids. Exploration of uterine fibroids removal: Injecting uterine contraction medicine: Before cutting the myometrial muscle layer, 0.2mg of ergometrine can be injected around the tumor to reduce uterine contraction and reduce bleeding. After the muscle layer is cut, the fibroids often protrude from the incision surface, and the bleeding is convenient. Also less. Peeling fibroids: If the fibroid is located at or at the top of the uterus, the bottom is wide and the diameter is greater than 5 cm, an elliptical incision is made on the surface of the fibroid, or a "envelope" is cut around the tumor. If the fibroids are less than 5 cm in diameter, a longitudinal incision is made in the serosa layer. Two rat tooth clips were clamped to the edge of the incision and pulled outward to expose the subserosal fibroids. Then, the vascular clamp or finger or the shank was inserted into the serosa layer for blunt separation, and the fibroids were gradually separated. In the process of separation, if bleeding occurs, it should be clamped and ligated to stop bleeding. When there is bleeding, it can be stopped by saline gauze. When peeling off the bottom of the tumor or near the uterine cavity, try not to break into the uterine cavity and retain the muscle layer. To avoid postoperative infection or endometriosis. In order to prevent intraoperative hemorrhage, the larger fibroids can be used to pass through the circumference from the base of the broad ligaments on both sides of the broad ligament, which is equivalent to the level of the isthmus. After tightening, the vascular clamp is clamped. Stitching the residual cavity: suture the residual cavity with 0~1 chrome gut, and suture l~2 layers according to the size of the residual cavity. Do not leave the invalid cavity, and the suture should not pass through the mucosal layer. Stitching the myometrial muscle layer: suture the myometrial muscle layer with No. 00 gut nodule or sputum. Stitching the abdominal wall: After cleaning the abdominal cavity, the abdominal wall is sutured layer by layer. When the pedicled subdural myomectomy is performed, a longitudinal fusiform incision is made along the pedicle root along the pedicle, and the uterine surface is sutured by the same method after the tumor pedicle is removed. The second type of surgery: cervical fibroids removal surgery. Peeling fibroids: If the fibroids originate from the anterior cervical cervix, the bladder peritoneal reflex should be found on it, and the hemostatic forceps clamp the center, cut open, push the bladder open, and pull the uterus toward the patient's head. Pull, expose the fibroids, use a finger or a shank for blunt separation, and expand the incision to the sides while separating, until the fibroids are completely stripped. For the larger fibroids during the stripping process, clamp the fibroids with a rat tooth clamp. And pull up, which is good for the removal of fibroids. Be careful not to damage the bladder and ureters. After the uterine wall fibroids are pushed open, the uterus is pulled toward the front of the pubic symphysis, and a curved transverse incision is made slightly below the dividing line between the fibroids and the posterior wall of the uterus to reach the surface of the muscle layer and the fibroids. The tumor was peeled off in the same manner. Close the residual cavity: use the 01 gut line for l or 2 layers of longitudinal discontinuity 8 to suture the residual cavity to avoid bleeding and exudation. Suture the bladder to reverse the peritoneum. Suture the layers of the abdominal wall. Third of the procedure: Wide ligament fibroids removal: The vast majority of broad ligament fibroids are formed by the uterus or cervical wall fibroids growing outward, but also from the broad ligament muscle components. As the fibroids grow, the anatomical relationship of the surrounding tissue also changes. The uterus is often squeezed to the opposite side or stretched and flattened, and the ureter and blood vessels may be squeezed and displaced. If the fibroids originate from the side wall of the uterine isthmus or slightly behind, it is possible to squeeze the ureter into the deep pelvic cavity or the side wall. When the compression is too tight, it can cause hydronephrosis on the side of the kidney. When the lymphatic and venous return is blocked, swelling of the lower extremities and leg pain will occur. Exploration: After the opening of the abdomen, the location and size of the tumor, the relationship with the uterus and the cervix, the location of the fallopian tube and the round ligament, and the adhesion of the fibroids to the bladder and intestines were identified. Pay attention to changes in the position of the ureter and uterus. Sometimes the ureter is attached to the wall of the fibroid by the fibroids or between the side wall of the fibroid and the wall of the pelvis. Sometimes the ureter is pressed behind the fibroid. The ureter becomes thick or small due to compression, and the uterus moves and veins often become thick and ectopic. Cut the round ligament: open the anterior lobe of the broad ligament covering the surface of the fibroid, and then cut the myometrium to the surface of the fibroid, insert it with your finger and release it from the wall of the tumor. If the giant ligament fibroids are large, the posterior lobe of the broad ligament can be resected, and the fibroids can be peeled off from the back in the same way. Be careful not to damage the ureter that is deformed or displaced on the wall of the tumor. The highest part of the fibroids is clamped by a rat tooth clamp, and the traction is attempted. If the traction is loose, the uterus direction or the pelvic side wall can be further peeled off. Try to maintain the integrity of the ovaries and fallopian tubes during stripping. Do not damage or ligature the blood vessels in the funnel ligament and the ascending branch of the uterine artery to preserve the integrity of the ovaries and fallopian tubes. If the fibroids protrude forward and downward, the bladder should be reflexed and the peritoneum opened, pushing away from the bladder, still with blunt separation. It is generally difficult to separate to the bottom of the broad ligament or near the uterine side wall. It is necessary to peel off and pay attention to identify the ureter and blood vessels. If you encounter a cord-like structure, you should track its direction, soft and hard, identify clearly and then deal with it. Because the ureter above the fibroids may be stretched into a thin and thin fiber rope, if not carefully identified, it may be accidentally injured. After stripping the anterior, posterior and lateral wall of the fibroids, the top of the fibroids can be clamped with a double-toothed forceps and the pelvic cavity is presented, and the bottom of the pelvis is again examined to reveal the ureter. Then peel the fibroids and the uterus at the junction from top to bottom, and should be as close as possible to the fibroid side. Since the ascending branch of the uterine artery has many small branches distributed laterally on the side wall of the uterus, when the fibroids are large, the blood vessels may also be correspondingly thickened. Therefore, be sure to pull, move, side clamp, and ligation to avoid bleeding. Close the residual cavity, suture the round ligament fibroids, and then carefully check the important organs again, pay attention to whether the wound surface is oozing, cut the extra anterior and posterior lobe of the broad ligament as appropriate, and use the 00 chrome gut for intermittent or purse-string suture Promycoma residual cavity. Try to put the ovarian fallopian tube back to the original place and suture the cut round ligament. Stitching the abdominal wall: After cleaning the abdominal cavity, the abdominal wall is sutured layer by layer. The fourth type of surgery: submucosal myomectomy. Cut the layers of the abdominal wall in turn and expose the uterus. Injection of uterine contraction drugs, before cutting the myometrium, first injection of 0.2mg of ergometrine in the anterior wall of the uterus to contract the uterus to reduce intraoperative bleeding. The anterior wall myometrium was dissected longitudinally, the fibroids were removed and the tumor pedicle was sutured. Stitching the myometrium: suture the uterine incision in two layers with 0 to 1 absorbable gut. Avoid suturing the intima when suturing the first layer. This is a traditional submucosal fibroid surgery method. In recent years, due to the advent of intrauterine resectoscope, it has replaced the method of cesarean section. complication Treatment of fibroids and treatment of residual cavities: Large intermuscular fibroids should be carefully treated during the stripping operation. When approaching the uterine mucosa, try not to break into the uterine cavity. When suturing the residual cavity, the suture should be close to the mucosa. Lower layer, avoid entering the uterine cavity. To prevent postoperative infection or endometriosis. Injury: The damage of fibroid resection is more common in cervical fibroids and broad ligament fibroids. As the tumor is gradually enlarged here, the uterine blood vessels and ureters can be displaced. According to the location of the tumor and its growth direction, the ureter can be pushed to the caudal side, the lateral side, or even the cephalad, and is elongated and flat, which is very different from the normal ureter. If it is not noticed, it is easy to be injured. Special attention should be paid to this. Bleeding: There is a blood vessel that nourishes the fibroids in the connective tissue in the pseudocapsular of the fibroid. After the fibroids are removed, the bleeding points in the pseudocapsule are carefully sewed. If the wound surface oozes, you can use the hot saline gauze to stop bleeding, or the muscle wall to inject oxytocin (oxytocin) 10U to reduce bleeding.