High cervical amputation surgical technique. Removal of the cervix

An operation to remove the cervix (trachelectomy) is a low-traumatic surgical intervention aimed at treating serious diseases of the organ while preserving the possibility of childbearing. The article provides information about the course, duration and methods of carrying out this manipulation. You can also learn about preparation for it and features of the postoperative period.

Trachelectomy consists of excision of the cervix, 2 cm of the upper part of the vagina and surrounding tissue. Opening access to surgical manipulations is carried out in 2 ways: vaginal and laparoscopic (through punctures in the abdominal cavity). Surgery is performed under local or general anesthesia. Sometimes an epidural is used, which numbs the entire lower body. Incisions are made both with a scalpel and with modern equipment (laser, ultrasound, cryodestruction, radio waves, electric current). Most of these techniques eliminate the appearance of scars on the operated epithelium. Most often, trachelectomy is performed vaginally, in which the cervix is ​​pulled towards the vagina and the necessary incisions are made. Using this method does not leave scars on the abdominal wall.

Surgery to remove the cervix is ​​prescribed in cases where other treatment methods do not produce results and there is a threat to the life and health of the patient.

Main indications for surgery:

Important! Amputation of the cervix for fibroids is practiced only if a malignant process is suspected and other treatment methods are ineffective. If the doctor insists on removing a benign tumor along with the organ, it makes sense to consult with other specialists. You can get rid of cervical fibroids in less radical ways.

Types of trachelectomy

According to the degree of complexity, trachelectomy is divided into simple, during which the cervix and part of the vagina are cut off, and radical, when the pelvic lymph nodes and tissue surrounding the uterus are additionally removed.

According to the technique of execution, wedge-shaped, cone-shaped and high amputation are distinguished. Wedge trachelectomy consists of cutting out tissue in a wedge shape from the anterior and posterior lips of the cervix and then suturing the remaining epithelium. This technique is used to eliminate hypertrophied and cystic glands of the submucosal epithelium. Cone amputation involves the removal of funnel-shaped tissue that captures the mucous membrane of the cervical canal. Performed for chronic inflammation of the mucous membrane of the cervix, trauma during childbirth, and dysplasia. With high amputation, the entire cervix is ​​cut off along with the internal os. This manipulation is used in cases of cancer, deep organ ruptures, and follicular hypertrophy.

Before trachelectomy, the patient is prescribed the following examinations and tests:

48 hours before trachelectomy, it is necessary to begin cleansing the intestines with laxatives. 8 hours before the procedure, you are prohibited from eating or drinking. On the day of surgery, pubic and perineal hair is removed and an enema is administered.

Operation duration

Depending on the type of manipulation, removal of the affected areas and reconstruction of the organ can take from 30 minutes to several hours. The scale of the intervention, the severity of the disease and the qualifications of the doctor also determine how long the operation will take. Removing the cervix through the vagina usually takes up to 60 minutes, using the laparoscopic method – up to 2 hours. In case of malignant tumors, amputation of the uterine cervix can take more than 2.5 hours. If it is necessary to collect tissue for histological analysis and in case of complications, the duration of the operation increases. The simplest manipulation of the cervix is ​​considered to be conization, during which the surgeon removes a cone-shaped area of ​​the affected tissue. This intervention does not involve cutting off the entire neck, but only part of it, and lasts 15-40 minutes.

A more complex type of surgical manipulation is in which the cervix is ​​removed along with the body of the uterus, while the fallopian tubes and ovaries remain. The operation is performed for cancer, rapid growth of benign tumors, complicated endometriosis, and polyposis. A hysterectomy can last from 40 minutes to 4 hours (in later stages of cancer).

Rehabilitation period

The woman spends the first day after trachelectomy in the recovery room under the supervision of doctors. She remains in the hospital for 7-10 days, where she takes painkillers and antibiotics to prevent infection.

Within 1.5-2 months after removal of the cervix, a woman is prohibited from:

• be sexually active;
• insert tampons and douche;
• train intensively and lift weights of more than 3 kg;
• take baths, use the sauna and swimming pool.

Planning a pregnancy is allowed at least six months after surgery.

Recovery after abdominal surgery to remove the cervix can take up to 3 months.

2 weeks after trachelectomy, an examination by a gynecologist is required. In the first 5 years after surgery, you should definitely undergo colposcopy and have a smear every 3 months.

What to expect after cervical removal?

The consequences of trachelectomy are, which are normal and can last up to 6 weeks. If purulent discharge with an unpleasant odor or high temperature appears, you should immediately consult a doctor.

Rarely, complications may occur in the form of suture infection, vein thrombosis, bleeding, lack of menstruation, and bladder damage. If the vagina is shortened during surgery, sexual intercourse may be accompanied by pain.

Sometimes, after surgery, scars remain on the organ. This can pose a health risk to the woman if she gives birth, as there is an increased risk of rupture and bleeding. Scar tissue is easily removed using radio wave surgery. The procedure is painless, does not leave wounds or burns, and is performed with the Surgitron device.

Pregnancy after trachelectomy is possible, but in some cases there may be problems. Narrowing or closure of the cervical canal and decreased mucous production can interfere with conception. Sometimes difficulties arise with pregnancy due to the loss of the optimal position of the uterus. The installation of pessaries - special supporting devices - will help to avoid this.

Partial or complete amputation of the cervix makes natural childbirth impossible. After manipulation, the cervix remains in place, unable to ripen, i.e. shorten and expand to accommodate the passage of the child. A woman can give birth only through.

They are increasingly diagnosed in patients of reproductive age. But gynecology does not stand still and new treatment methods are emerging that preserve a woman’s ability to give birth to a child. Regular monitoring of the health of the reproductive system and timely detection of diseases are important. After all, the sooner you start treating the disease, the greater the chances of preserving the organ and not losing the opportunity to become a mother.

Treatment of cervical diseases is often carried out surgically - using a scalpel, electric knife or laser. Amputations of the cervix (high, wedge-shaped, cone-shaped, dilated) are performed with a scalpel. The operation of partial excision of part of an organ is called resection, while cutting off its peripheral part is called amputation.

To understand how the cervix is ​​removed, you need to know its anatomical structure. This organ consists of smooth muscle fibers, a canal (endocervix), and two parts: one is located in the vagina, the second is above it. The vaginal part of the cervix is ​​covered with multilayered squamous epithelium, the cervical canal is covered with single-row cylindrical epithelium.

Malignant neoplasms of the cervix are localized in the transition zone, at the border of these two epithelia. Precancerous diseases include ectropion, leukoplakia, erythroplakia, and dysplasia. Cervical cancer can be primary or secondary (spreads from a primary tumor located in the uterus).

At the zero stage of cancer in women of fertile age, a cone-shaped conization of the cervix is ​​performed with an emergency histological examination by layer, which makes it possible to determine the spread of the invasion and preserve its healthy part.

At stage Ia1 - high knife cervixectomy, Ia2 - trachelectomy (removal of the cervix, pelvic lymph nodes and tissue, suturing the vaginal walls to the internal os of the preserved uterus).

Trachelectomy

Cervixectomy and amputation of the cervix are synonyms for trachelectomy. The operation is performed in Japan, the USA, and Eastern Europe. During amputation, the cervix is ​​removed, but the uterus itself, fallopian tubes and ovaries are not removed. The intervention is performed via vaginal access (radical vaginal trachelectomy) and abdominal access (radical abdominal trachelectomy).

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Indications:

• Squamous cell carcinoma of the cervix.
• Adenocarcinoma.
• The desire of a woman with cervical cancer to preserve reproductive function.

The operation is carried out under the following conditions:

• The upper third of the endocervix is ​​not involved in the tumor process (confirmed by MRI and cervicoscopy).
• There are no metastases to the pelvic lymph nodes and tissue.
• The tumor size is no more than 20 mm.
• Disease stage: IA2, IB1, germination depth no more than 1 cm.
• The patient is of reproductive age, fertile function is not realized.

Before the intervention, a standard preoperative examination, colposcopy, cervicohysteroscopy, MRI, biopsy, and sonography are performed. 12 hours before surgery, it is recommended to stop eating, cleanse the intestines with an enema, take a shower, and remove pubic and external genital hair. At night they give medicated sleep.

Radical vaginal trachelectomy is performed in large medical centers by experienced surgeons who are proficient in the technique of vaginal laparoscopy. The complexity of the intervention limits its application.

Abdominal

More often, women are operated on through an abdominal approach; a histological examination of the lymph nodes is performed on the operating table; in the presence of micrometastases, the scope of surgical intervention is expanded (the uterus and appendages are removed). The stages of cervixectomy are:

• Inferomedian laparotomy (longitudinal incision of the abdominal cavity from the pubis to the navel).
• Examination of the abdominal organs, retroperitoneal space, and small pelvis.
• Removal of pelvic lymph nodes.
• Creation of free space in the area of ​​the isthmus between the side wall of the uterus and the vessels supplying it with blood.
• Ligation and cutting of the uterine arteries.
• Perpendicular cutting of the cervix from the body of the uterus at a distance of 10 mm from the internal os, but not less than 5 mm from the edge of the tumor.
• Biopsy and emergency histology of the cervical resection margin.
• Isolation of the ureters.
• Severing the bladder bluntly to the border of the junction of the upper and middle third of the vagina.
• Creating access to the vaginal-rectal space.
• Ligation and cutting of the uterosacral ligaments.
• Resection of cardinal ligaments.
• Applying clamps to the paravaginal tissue and lateral sections of the vagina.
• Crossing the vaginal walls, ligating bleeding vessels.
• Sending the removed specimen (cervical cavity, part of the vagina with tissue, ligaments) for emergency histological examination.
• Formation of the connection between the cervical stump and the vagina.
  Drainage of the pelvis through the abdominal wall.
• Suturing the postoperative wound, applying an aseptic dressing.

The duration of amputation is about 3.5-4 hours, the average hospital stay is fifteen days. Postoperative complications develop in 25% of patients, these include hematomas, lymphocysts, inflammatory processes, and bleeding. For two postoperative months, the patient is recommended to exclude sexual activity, lifting heavy objects, and visiting open water bodies. For the first two years after the intervention, examinations are carried out every three months - colposcopy, Pap test, sonography of the pelvic organs.

Vaginal

Cervixectomy can be performed through a vaginal approach using microsurgical instruments for laparoscopy. Before performing the vaginal stages of the operation, abdominal laparoscopy is performed, pelvic lymph nodes are removed, examined and a decision is made on the extent of surgical intervention in favor of vaginal trachelectomy in the absence of metastases.

The surgical field is treated, anesthesia is administered and speculum is inserted into the vagina, a clockwise incision is made 20 mm below the cervical cavity, after which the tissue between the uterus, bladder, and rectum is separated. The ureters are isolated, the fiber is removed, the uterine artery and cervix are ligated and cut off. All other stages are identical to those for abdominal amputation.

Consequences

After such operations, menstrual function is preserved, more than half of women become pregnant on their own within a year, 60% of them give birth on time. Only 10% of pregnancies are terminated before thirty-two weeks. To prevent isthmic-cervical insufficiency, a circular silk suture is placed on the pseudocervix of the uterus, which is removed before childbirth. Delivery is carried out by caesarean section.

High

Indications for this operation are follicular hypertrophy and elongation of the cervix, ectropion. For the purpose of examination, patients are prescribed general clinical blood and urine tests and a coagulogram. They determine RV, hepatitis, HIV, perform sonography, FLG, colposcopy, cervical biopsy, Pap test, examine vaginal smears for the purity of the flora, and, if necessary, conduct an examination by other specialists.

The woman is placed on a special table with footrests, like on a gynecological chair. The surgical field is treated. The intervention consists of several stages:

• Spreading the vagina using speculum.
• CMM fixation.
• Probing of the uterine cavity.
• Expansion of the cervical canal.
• A vaginal incision is made in a circle at the level of the vaults.
• Sloughing of the bladder.
• Applying clamps, stitching, cutting off fiber, uterosacral ligaments and blood vessels.
• Dissection of the cervix with lateral incisions into the anterior and posterior halves to the intended level of amputation.
• Cutting off the anterior part at an acute angle from the endocervix.
• Separating the incised edge of the anterior vaginal wall, connecting the anterior edge of the vaginal wound with the anterior edge of the mucous membrane of the cervical canal using separate sutures. This manipulation is carried out with the back of the cervix and the back wall of the vagina.
• Stitching the sides of the cut.
• Checking the patency of the cervical canal.
• Postoperative treatment of cervix.
• Inserting a catheter into the bladder.
• Vaginal tamponade for 24 hours.

In the first few days after surgery there are no restrictions on food intake or movement. From the second day, the seams are treated daily.

Wedge-shaped

This surgical intervention is performed for moderate follicular hypertrophy, deformation, cervical prolapse, ectropion, and chronic endocervicosis. Amputation is performed under conduction and infiltration anesthesia.

The first four stages of the operation are performed as in the previous intervention. Then an incision is made along the side walls of the cervical cavity, the posterior lip is cut off from the side of the mucous membrane of the cervical canal in the form of a wedge. Sutures are applied, similar actions are performed with the front lip, the side surfaces of the wound are stitched separately. The wound is treated with antiseptics and urine is released using a catheter. Management of the postoperative period, as with high cervixectomy.

Cone-shaped

The operation is indicated for women suffering from chronic complicated endocervicitis with degeneration of the cervical muscle tissue into connective tissue, with frequent recurrences of polyps, long-term non-healing erosion, leukoplakia, erythroplakia, dysplasia, and cancer in situ.

The first four stages of amputation are performed as in the previous intervention, after which a circular incision is made in the exocervix mucosa one centimeter above the affected area, it is shifted upward 2 cm from the edge of the incision. One suture is placed on the lateral surfaces of the cervix.

Using a double-edged scalpel directed towards the endocervix and upward, tissue is excised in the form of a cone and removed from the surgical wound. Bleeding vessels are stitched. The separated part of the vaginal mucosa of the cervix is ​​sutured to the mucosa of the cervical canal. The wound is treated and the bladder is catheterized.

Currently, this operation is rarely performed due to its high morbidity and the availability of new alternative methods for resection of the cervix. Preference is given to radio wave (Surgitron device) and laser surgery. Using these methods, conization of the cervix is ​​performed with the least trauma to surrounding tissues and rapid subsequent restoration of the wound surface.

Extirpation, or trachelectomy, is an operation to remove the cervix, which is a low-traumatic surgical procedure and is prescribed for a number of pathologies of the genital organs.

Amputation of the cervix is ​​carried out in the following cases:

• in the early stages of cancer (only the cervix is ​​damaged, and the surrounding organs are completely healthy);
• with cervical hypertrophy - it occurs in the presence of pathological processes of the reproductive system (prolapse of the uterus, inflammatory processes);
• with chronic endocervicitis;
• with ectropion - uterine rupture during difficult childbirth or late abortion;
• in the presence of erosions that cannot be treated;
• if there are cervical deformities, for example, scars, congenital anomalies.

Preparing for surgery to remove the cervix involves taking tests (blood, urine). If there is a suspicion that a malignant tumor has formed on the cervix, then you need to undergo magnetic resonance and computed tomography, as well as a biopsy. The blood will also be checked for the presence of tumor markers. If there are inflammatory processes in the body, then surgery is possible only after they are completely cured.

1-2 days before surgery you need to take a laxative to cleanse your intestines. You can also do a cleansing enema. You also need to remove pubic and perineal hair.

Types and procedure for cervical amputation surgery

Amputation of the cervix is ​​carried out in two ways:

• laparoscopically;
• through the vagina.

Laser, electric current, ultrasound, radio rays, and cold can also be additionally used. The average duration of the operation is about half an hour. If there are any complications (such as bleeding), it may take longer.

General and local anesthesia is used. Regional anesthesia has recently become very popular: an injection is given into the spinal canal, as a result of which the sensitivity of the entire lower part of the body is turned off. After the patient has fallen asleep under anesthesia, doctors begin the operation.

Removal of the cervix can be carried out using three methods:

• according to Schroeder, when the tissues of the anterior and posterior lips of the neck are excised with a wedge;
• according to Sturmdorf - the remote part is a funnel (cone) that goes deep into the neck;
• high amputation - complete removal of the cervix, while the surgeon makes incisions on the vaginal mucosa.

During the operation, depending on the complexity of the pathology, only the cervix or the cervix along with part of the vagina can be removed. Then the doctor puts stitches. In most cases, self-absorbing threads are used, less often - nylon threads.

All other organs are preserved, which in the future allows the woman to become pregnant and give birth to a healthy baby.

Even with a properly performed operation, the following complications can occur:

• relapse – after some time the disease may form again;
• damage to the bladder - most often occurs if it was not emptied before surgery;
• slipping of ligatures, which can subsequently cause bleeding;
• high risk of infection (sepsis, suppuration, peritonitis);
• prolapse of intestinal loops through the vagina;
• necrosis of the vaginal dome.

If such consequences cannot be treated conservatively, additional surgical intervention will be required.

Recovery after cervical amputation

The patient remains in hospital for approximately one to two weeks under the supervision of a physician. Among the symptoms that a woman experiences after surgery are drowsiness, lethargy, apathy, and fatigue. During the first few days, you will experience pain in the lower abdomen, so painkillers are prescribed. Dark brown discharge may also appear. The patient will also take antibacterial drugs to eliminate the possibility of infection. For the first time, she is fitted with a urinary catheter.

After discharge, rehabilitation does not end, but continues for about 1-1.5 months at home. During this time you must adhere to the following rules:

• You cannot swim in open reservoirs, pools, or visit a sauna or bathhouse.
• Refrain from sexual relations.
• Tampons should not be used if there is any kind of discharge.
• You need to protect yourself from possible pregnancy for at least six months.
• Do not lift weights weighing more than 4-5 kg.
• Walk often, but walks should not be too long.
• From about 3-4 weeks you should do light yoga and Pilates exercises.
• Two weeks after cervical amputation, you should definitely visit a doctor.
• Further examinations and tests by a gynecologist are carried out in the following sequence:
  • 1.5 months after surgery, gynecological examination, smear for cytological analysis, colposcopy, MRI (if necessary):
  • every three months for a year, a smear for cytology;
  • If the indication for surgery was an oncological tumor, then the examination must be completed every quarter for 5 years.

Is it possible to have a baby after removing the cervix?

All cervical amputation operations are aimed at stopping the pathological process in the reproductive system and preserving reproductive function. If the disease was detected early, then in most cases this is exactly what happens. If the pathology is very complex, then, naturally, the percentage of the probability of becoming pregnant and giving birth to a child is much lower.

Infertility can be one of the consequences of the operation if the cervical canal narrows, and this in turn affects the decrease in the amount of cervical mucus. Obstruction of the fallopian tubes may also be the cause. If these pathologies cannot be cured, in the absence of contraindications, you can become pregnant using in vitro fertilization or artificial insemination.

There are also cases when a woman becomes pregnant without difficulty, but cannot bear a child, since the cervix is ​​very weak and cannot support the fetus. In such cases, special sutures are placed on the cervix and pessaries (special devices for supporting the uterus) are used.

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There are various methods of cervical amputation surgery; the choice of method depends on the nature and spread of the pathological process in the cervix, causing the need for surgical intervention. So, for example, with follicular hypertrophy, you can limit yourself to amputation of the vaginal part of the uterus by wedge-shaped excisions (excisions) from both lips of the uterine pharynx. In case of chronic endocervicitis, accompanied by the formation of recurrent cervical polyps, it is advisable to perform a cone-shaped amputation of the cervix.

With significant hypertrophy and elongation of the cervix, protruding from the genital slit and causing the sensation of uterine prolapse, so-called high amputation of the cervix may be necessary. In case of a high-growing old cervical rupture, accompanied by ectropion and causing painful sensations, high amputation of the cervix can also be used, especially if the patient is past childbearing age.

High amputation of the cervix can also be indicated in cases of significant follicular hypertrophy of the cervix, when not only the vaginal, but also the supravaginal part is riddled with many retention cysts, giving the cervix an adenomatous character.

Wedge amputation, a relatively simple technical operation, can be performed by a doctor who is not yet a complete specialist. As for the other two methods of surgery, especially cone-shaped amputation, these operations are not only technically more difficult, but bleeding is often observed during their production and in the postoperative period. Therefore, they are beyond the power of a novice surgeon. Novice surgeons can perform these operations only as part of their studies, with the indispensable guidance of an experienced surgeon.

Preparation for cervical amputation surgery, usual for vaginal operations. If surgery is undertaken for chronic endocervicitis, then the presence of an acute and subacute process is a contraindication to surgery; if there is increased or purulent secretion from the cervical canal, then preparation for the operation should begin several days in advance, during which conservative treatment of existing chronic endocervicitis is carried out - vaginal douching with medicinal solutions, medicinal vaginal baths, tampons, etc.

Immediately before the operation, in addition to the usual preparation for vaginal operations, it is also necessary to remove mucus from the cervical canal with a probe wrapped in a thin layer of sterile cotton wool or gauze moistened with a 10% soda solution. After removing the mucus, the cervical canal is lubricated with iodine tincture.

Technique of wedge amputation of the vaginal part of the cervix . Preparation for surgery, usual for vaginal operations. After disinfection of the external genitalia, vagina and cervix, the vaginal part of the uterus is exposed with speculum and the lips of the os are each separately grasped with strong bullet forceps or four-pronged forceps. In order to bring the cervix well down to the entrance to the vagina, the posterior speculum is replaced with a short operating speculum. After lowering the cervix, the uterus is probed, the cervical canal is expanded with the first numbers of metal dilators. The surgeon takes the bullet forceps with which the posterior lip of the uterine pharynx is grasped with his left hand, and the forceps with which the anterior lip is grasped is held by an assistant. With his free right hand, the operator takes straight scissors, one branch of which he inserts into the cervical canal and sequentially, first on one side, then on the other side, dissects the vaginal part of the uterus symmetrically from the sides, not reaching the vaginal fornix. The depth of the incision should correspond to the size of the vaginal part to be removed. After the hypertrophied vaginal part is cut horizontally into two equal halves, the anterior half of the cervix is ​​usually cut off (amputated) first in the vertical direction, but not in a straight plane, but in the form of a wedge. Immediately after wedge-shaped excision of the anterior half of the cervix, sutures are applied, which simultaneously achieve hemostasis and form the anterior lip of the uterine pharynx. To do this, we use strong catgut ligatures and correspondingly large and strong needles (the cervix in these cases is thick and significantly dense). For the most part, three stitches are sufficient. Sutures should be placed so as to grasp the entire wound bed. When all the sutures have been made and the surgeon begins to tie each of them, starting with the middle one, the assistant, using two surgical tweezers, tries to fit together the edges of the mucous membrane covering the vaginal part to the mucous membrane of the cervical canal. The applied ligatures are not cut off; they serve as a “holder” until the amputation of the posterior half of the vaginal part of the uterus is completed. It is produced using the same method as the front one. After both lips of the new uterine os are formed, two sutures are placed on the sides of the incision. When all this is completed, the first thing to check is hemostasis. To do this, they stop tensioning the neck with the ligature that served as a “holder” and look to see if blood is leaking somewhere between the ligatures. If necessary, additional ligatures are applied. If hemostasis is complete, then cut off the ligatures, but not too short, so that, if necessary, if bleeding is still detected after a few hours, pull up the neck using them and apply a suture to the bleeding area. A gauze swab sprinkled with white streptocide is inserted into the vagina and left until the next day.

With significant hypertrophy of the cervix and its excessive elongation, wedge-shaped amputation of the cervix, as already indicated, is not sufficient to eliminate the symptoms caused by hypertrophy; in such cases it is necessary to resort to high amputation.

High cervical amputation technique. Preparation for surgery and reduction of the vaginal part of the uterus are carried out in the same way as for wedge-shaped amputation. A flap or cuff is cut out from the mucous membrane of the vaginal fornix, as surgeons do from the skin of a limb during amputation, in order to then cover the wound surface of the amputation stump. To do this, at the level of the transition of the vaginal vault to the cervix, a circular incision is made with a scalpel through the thickness of the vaginal wall. The bladder is separated from the cervix slightly above the level at which the cervix is ​​supposed to be amputated. In order to reach the muscular wall of the uterine cervix from the side, it is necessary to cut the tissue lying at the base of the broad ligament; in this tissue passes the descending branch of the uterine artery, which must first be ligated. To do this, after the lateral vaginal fornix is ​​cut, they cut off the layer of fiber lying directly under the vaginal wall with a catgut ligature, find the descending branch of the uterine artery, tie it with a separate catgut ligature and cut it. Then the vaginal vault is moved away from the side wall of the cervix. The posterior vaginal fornix is ​​also separated from the cervix, which is gradually completely separated from the vaginal fornix. When the entire cervix is ​​completely isolated to the required level and bleeding from the tissue has stopped, they begin to cut off the cervix itself. To do this, the cut-off part of the cervix is ​​first cut in half horizontally with side cuts, starting from the external uterine os to the intended level of amputation, and then the anterior half of the cervix is ​​cut off. When it is cut off, three strong catgut ligatures on large and strong needles connect the anterior edge of the vagina to the edge of the mucous membrane of the cervical canal. Ligatures need to be passed under the entire wound bed and tied one after another, starting from the middle one. In this case, it is necessary to ensure that the ligature does not pass through the mucous membrane of the posterior wall of the cervical canal, as this may lead to the closure of the cervical canal. This results in a newly formed anterior lip of the uterine os. Then they begin to form the posterior lip of the pharynx: the posterior half of the neck is cut off and sutures are applied to the stump in the same way as after cutting off the anterior half, after which the side sutures are applied. Hemostasis must be complete. If necessary, additional stitches are applied.

Technique of cone amputation of the cervix. This method, used to treat old, chronic inflammation of the mucous membrane of the cervical canal that is not amenable to conservative treatment, is more technically complex and more dangerous in terms of possible complications than simple amputation of the cervix. Therefore, we consider such an operation accessible only to an experienced specialist. The operation consists of excision, together with a cone from the muscular wall, of a significant part of the mucous membrane of the cervical canal, without reaching the internal uterine os. The original and important part of the operation is the method of suturing.

After preparing for the operation and removing the cervix with forceps into the vestibule of the vagina or even outward, a circular incision is made on the vaginal part of the uterus, at the site of attachment of the vaginal vaults to it. From this incision, the vaginal wall is separated 1.5-2 cm from the cervix. This will be the base of the cone, which gradually deepens into the thickness of the muscular wall of the cervix. The excised cone also captures a significant part of the pathologically altered mucous membrane of the cervical canal. To hold the cervix in place until the cone is completely removed, you need to grab the edges of the vaginal wound with forceps in front and behind. After removing the cone, they begin to stop the bleeding (a very important point, since with this method the sutures are not inserted under the entire wound bed). As soon as the bleeding has stopped, the clamps are replaced with ligatures. Then they move on to suturing. Many people use silk ligatures; we prefer strong catgut. The first suture is passed through the anterior edge of the vaginal wall, 1 cm away from it; both ends of the ligature are punctured from the cervical canal through the thickness of the funnel formed in the cervix and out through the vaginal wall, retreating 2-2.5 cm from the edge of the incision. In this case, care must be taken not to puncture the wall of the bladder, as this can lead to the formation of a urinary fistula. The risk of a fistula increases when a cone of significant size is excised from the cervix. If this is necessary, we recommend that before making a suture, separate the bladder from the anterior wall of the cervix for a short distance, and only after that, pushing the bladder upward, pass this suture through the thickness of the cervix and the anterior wall of the vagina. When tying a suture, the edge of the separated vaginal wall will automatically retract into the funnel and completely cover the wound surface of the stump from the front. This is made easier if an assistant uses two surgical tweezers to screw the edge of the vaginal wall into the funnel while the surgeon ties the knot. The same seam is carried out at the back. After the two main sutures are tied in front and behind, they begin to apply lateral sutures, just as with wedge-shaped amputation of the neck, but these sutures must be passed through the entire thickness of the stump, under the entire wound bed. As a result of suturing, the vaginal mucosa, screwed into the funnel, lines the new cervical canal.

With strict adherence to the indications for surgery and good technique, cone-shaped amputation of the cervix gives good results and relieves the patient of the painful symptoms that accompany chronic endocervicitis and cervicitis that are not amenable to conservative treatment methods. With some skill in performing this operation, its implementation is not difficult for a qualified surgeon. At the same time, it is necessary to point out the complications that sometimes accompany this operation. First of all, these are postoperative bleeding, which in some cases was of a threatening nature. That is why it is necessary to emphasize once again the importance of careful hemostasis. The reason for the unsuccessful outcome of the operation may be the occurrence of strictures in the cervical canal, which are formed when the cone of the cervix is ​​excised too deeply, reaching the internal uterine os, as well as when the flap of the separated vaginal mucosa is insufficient, which may not be enough to replace the excised mucosa of the cervical canal.

The development and introduction into gynecological practice of a safer method - diathermocoagulation - further limits the use of this method of operation.

Management of the postoperative period for all methods of cervical amputation is simple: no local procedures, except for the usual toilet of the external genitalia. We allow the patient to get out of bed and walk no earlier than the 7-8th day in order to avoid bleeding, which can occur with rapid resorption of the catgut ligature. We discharge the patient from the clinic no earlier than the 10th day after the operation. Unless there are special indications, we do not examine the patient through the vagina either at discharge or in the postoperative period. After discharge, if the patient has discharge, careful (low pressure) douching with a lukewarm solution (37-38°) of potassium permanganate can be used. Sexual activity after cervical amputation surgery is permitted no earlier than one and a half months later and after menstruation has passed. After menstruation, the patient can be examined through the vagina.

Anesthesia during amputation of the cervix is ​​necessary because this operation requires complete retraction of the vaginal part of the uterus into the vestibule of the vagina, which, with the exception of cases of uterine prolapse, is always accompanied by pain.

During the operation, various methods of pain relief can be used: general anesthesia, spinal anesthesia and local anesthesia. Since the operation is small and short, we use either inhalation ether anesthesia or local infiltration anesthesia with a 0.5% novocaine solution. With the latter method, in order to achieve a good effect, it is necessary to generously soak the area of ​​parametric fiber enclosed between the layers of the peritoneum with novocaine solution.

Collapse

To eliminate this or that problem in gynecology, surgical interventions may be prescribed. They are diverse in nature, differ greatly in severity, specificity and nature of implementation. Removal of the cervix alone can be performed in three different ways, one of which, Sturmdorff cervical amputation, will be discussed in this article. In what cases is this method indicated, what is its essence and how is such intervention carried out? All this is described in this material.

Definition

Cervical amputation is a process of surgical removal of cervical tissue, which can be performed using various methods. The Sturmdorff method involves excision of a cone-shaped area of ​​tissue of one size or another, followed by the formation and restoration of the cervix. This method is preferred by many doctors, since it is quite highly effective, but at the same time it is easily tolerated by patients and preserves their reproductive function.

Depending on the nature and extent of the pathological process, different amounts of tissue can be removed. In this regard, low, medium and high cervical amputations are distinguished.

Indications

Such intervention is indicated in the following cases:

• Cervical cancer;
• Recurrent erosion that cannot be treated and causes discomfort;
• Leukoplakia, dysplasia that cannot be treated;
• Multiple papillomas and/or cysts, which are impossible or impractical to remove one by one;
• Some types of organ hypertrophy;
• Organ deformities, congenital or acquired.

There are also some other individual indications.

Contraindications

But sometimes it is prohibited to carry out this intervention. For example, in the following cases:

1. The presence of an infectious or inflammatory process, both systemic and in the reproductive organs;
2. Significant weakening of the immune system;
3. Bleeding from the uterus, the cause of which has not been established;
4. Poor blood clotting;
5. Intolerance to anesthesia.

Often, treatment or other medication preparation is needed before surgery.

Preparation

In order for the operation to take place without any significant complications for the body, it is necessary to carefully prepare for it. To do this, a number of diagnostic procedures are carried out aimed at establishing the absence or presence of contraindications for intervention. The following studies are being carried out:

• Blood tests: general and biochemical tests to confirm or refute the presence of any hidden inflammatory process in the body, analysis for HIV, syphilis, hepatitis - a standard procedure in preparation for surgery, coagulogram to determine the degree of blood clotting;
• A vaginal smear and examination by a gynecologist will determine the presence of hidden or obvious infectious and/or inflammatory processes in the reproductive system in order to avoid infection during the operation. A pelvic ultrasound is also prescribed;
• An electrocardiogram and examination by a therapist are carried out to determine the degree of tolerability of general or epidural anesthesia.

In the absence of contraindications, the intervention is well tolerated.

If surgery is performed urgently, some of these tests may be skipped. But if the order is planned, then it is necessary to go through all the studies.

Progress of the intervention

The entire operation takes about 40 minutes and is performed under epidural and, in some cases, local anesthesia. Hospitalization is short - only a few days. At its core, such an intervention is a cone-shaped truncation, high or medium, depending on the volume of tissue removed. This manipulation is carried out in several stages:

1. Administration of anesthesia and sanitation of the vagina and cervix, exposure of the cervix by using speculum;
2. Using a special probe, the length of the cervix to the pharynx is determined, since the intervention should not affect it;
3. Anesthesia with novocaine is carried out in the area of ​​the vaginal vault, as soon as it begins to take effect, dilators are installed on the cervical canal;
4. A circular incision is made at one and a half centimeters, with the edges of the neck diverging by 6-7 mm;
5. One suture is placed on the lateral surfaces of the neck to ensure high-quality hemostasis;
6. The tip of the scalpel is directed upward towards the cervical canal, amputation is carried out by performing circular movements;
7. Immediately after cutting the cervix, clamps are placed on its proximal lip;
8. Tissue truncation is completed;
9. A clamp is also applied to the second lip;
10. Hemostasis and suturing of blood vessels are performed;
11. Specific sutures are placed on the anterior and posterior hips to restore the shortened neck;
12. The cervix and vagina are treated with an antiseptic and gynecological instruments are removed.

Additionally, it is necessary to install a catheter in the urethra in order to accurately avoid urine entering the operated area. This catheter remains in the urethra for several days after the procedure.

Technically, high amputation of the cervix according to Sturmdorf differs from low amputation only in the volume of tissue removed and the degree of shortening of the cervix as a result of such an intervention.

Recovery

The patient spends the first day in the recovery room, then another 5-6 days in the normal room. Physical inactivity is contraindicated - you must start walking on the first day after the intervention. The diet should be normal, but natural and not cause increased gas formation and constipation, which can negatively affect the condition of the sutures. During the early recovery period, the seams should be treated daily (starting from the second day) with potassium permanganate.

The entire rehabilitation period lasts from a month to a month and a half, depending on the nature of the intervention and the individual characteristics of the body, such as the speed of recovery. For this entire period, sexual activity, the use of tampons and vaginal suppositories, douching, and vaginal application of drugs not prescribed by a doctor are prohibited. You should also not swim, overheat on beaches or in solariums, or take baths. It is necessary to carefully observe hygiene, but only with the help of a shower and without the use of chemicals, especially at an early stage.

Physical inactivity is prohibited, but you should not overexert yourself significantly. You can't lift weights. Nutrition should be healthy and proper, easy to digest.

Consequences

The intervention potentially has both general operational and specific implications. General operating procedures include such possible complications as:

• Bleeding;
• Inflammation and infection of the suture;
• Infection of neighboring organs during this intervention;
• Complications after anesthesia, up to respiratory arrest;
• Development of inflammation;
• Adhesions and/or deformations as a result of scar formation.

A specific feature of such an intervention is that the adhesive process and the process of scar formation can affect reproductive function, significantly impairing it. In rare cases, even infertility develops.

Pregnancy

The operation is specially designed in such a way that reproductive function is preserved. In this case, the features of the course of pregnancy will differ depending on what kind of amputation was performed - medium, low or high. If, as a result of the intervention, little tissue is removed and the cervix is ​​shortened slightly, then, in most cases, it is able to bear the load of the weight of the fetus during pregnancy and there is no danger of premature birth.

If the shortening is severe, then the cervix often cannot withstand the pressure of the fetus and there is a possibility of early birth as a result of this. In this case, a suture is placed on the cervix or a gynecological pessary is installed. The birth proceeds, in general, favorably.

If the intervention is performed correctly, and the recovery period has passed with the implementation of all recommendations, then there are usually no obstacles to conception after such an intervention. The exception is cases of individual tendency to form adhesions and scars that may block the cervical canal. In this case, artificial insemination or in vitro fertilization is recommended. You can start planning a pregnancy in consultation with your doctor, no earlier than six months after the intervention.

Price

Several factors influence the cost of such an intervention. First of all, this is the region and the composition of services, that is, whether the price includes only the operation, or subsequent hospitalization and the upcoming examination, too. Approximate prices for this service by region are shown in the table.

The price may also be influenced by the level of fame and status of the medical center.

Conclusion

Despite the rather high invasiveness of the intervention, it is still more gentle than some other methods of surgical treatment of the cervix. It should be understood that the doctor prescribes surgical intervention only when other methods are not available, and the least traumatic method is selected that will be effective in this situation. Therefore, there is no point in refusing to intervene. His appointment often indicates that there is no other choice.

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