Yin hysterectomy includes Yin surgery for prolapsed uterus and non-prolapsed uterus, which can be further divided into Yin surgery for benign and malignant lesions. The main procedures include: total hysterectomy, subtotal hysterectomy, myomectomy, triangular hysterectomy, subtotal hysterectomy, extensive hysterectomy, extensive cervical hysterectomy, and removal of combined ovarian cysts or adnexal resection.
The negative hysterectomy is an ancient procedure that preceded the transabdominal hysterectomy. langebeck in Germany performed the world’s first total negative hysterectomy (cervical cancer combined with uterine prolapse) in 1813 and the patient survived for 26 years after the operation. In the following era, when sterilization and antimicrobial techniques were not well developed, the negative hysterectomy was the main type of uterine surgery. By the mid-twentieth century, with the development of sterile and antimicrobial techniques, open surgery gradually became dominant, such that the open route was the mainstay of uterine surgery in most hospitals. In the last decade or so, minimally invasive surgery, represented by laparoscopy, has become mainstream. However, laparoscopic surgery has certain limitations. It usually requires higher cost, longer operation time, more bleeding, greater surgical risk, and expensive equipment investment. In contrast, the negative uterine surgery not only conforms to the principle of “minimally invasive”, but also has its more outstanding advantages: less damage, faster recovery, no scars on the abdominal wall, shorter hospital stay, lower medical costs, no need for expensive surgical instruments, simple anesthesia requirements, and easy to master surgical methods. Therefore, in the last decade, the negative uterine surgery has been reintroduced to an important position, and more and more scholars are more enthusiastic to carry out various types of negative surgeries. This type of surgery is especially suitable for the people in the less economically developed areas of China, and can be considered as an inexpensive and ultra-minimally invasive gynecological surgery.
In this article, we will discuss the three types of procedures for total hysterectomy, subtotal hysterectomy, and myomectomy for non-prolapsed uterus due to benign lesions, including some precancerous lesions and carcinoma in situ, and their complication prevention and control.
I. Instruments
Conventional instruments include: anterior vaginal wall puller, posterior vaginal wall puller, vaginal pressure plate, cervical pressure plate, fibroid remover, double-jawed forceps, single-jawed forceps, intrinsic ligament hooked forceps, spiral fibroid drill, light source and light source puller. Yin uterine surgical instruments: intrinsic ligament hook clamp, spiral myoma drill, vaginal pulling hook with light source.
Indications and contraindications
There are four main criteria for the selection of a negative surgery: first, the surgeon’s proficiency in this type of surgery, and also the availability of a competent assistant. If the surgeon and assistant are skilled and experienced, the indications can be relaxed, and vice versa, they should be more strict. The second is the size of the uterus. In recent years, with the improvement of surgical skills and surgical instruments, there have been reports from abroad of a uterus of 24 weeks of gestation weighing 1290 grams undergoing a cervical resection, while the largest reported uterus in China is 22 weeks of gestation weighing 1150 grams. In fact, a large uterus can be fragmented, such as by taking out the uterus in pieces, cutting it in half, and stripping out the fibroids, and then completing the surgery. The third is the mobility of the uterus. Poor mobility of the uterus, even if the volume is not large, often increases the difficulty of surgery. Attention should be paid to preoperative, especially post-anesthesia gynecological examination, and operators who are not very experienced should try to avoid doing negative uterine surgery with poor mobility. In case of no certainty, laparoscopic assistance is feasible. Fourth is the degree of vaginal laxity. This is also relative; most vaginas with a history of vaginal delivery are more relaxed and suitable for a vaginal procedure. However, practice shows that if the size of the uterus does not exceed 12 gestational weeks, even if there is no history of vaginal delivery, the vaginal surgery can be successfully completed.
To sum up, the indications for negative uterine surgery are relative, and different hospitals, different operators, and even different stages may have different indications. The current indications in our hospital are: benign uterine lesions with uterine size up to 14 gestational weeks, CIN III, cervical carcinoma in situ, stage Ia1 cervical cancer, and severe atypical hyperplasia of the endometrium. For uterus larger than 14 gestational weeks, combined laparoscopic and cathodic surgery is chosen.
Contraindications: severe endometriosis, or pelvic inflammatory disease causing extensive pelvic adhesions; heart, lung, liver, kidney and other important organ diseases that make it difficult to tolerate anesthesia and surgery; advanced malignant lesions of the reproductive system requiring extensive excision and exploration; vaginal contracture caused by congenital or acquired diseases.
III. Preoperative preparation
Basically, it is the same as open surgery. The vaginal environment is more demanding. Before surgery, vaginal discharge examination is routinely done to exclude inflammatory diseases, and the vagina is routinely douched with 0.25% iodophor solution once a day for 3 days, paying special attention to cleaning the deep vaginal area and the anterior and posterior domes. The night before surgery and early morning of the day of surgery, a clean enema is given and the pubic hair is shaved. The disinfection of the surgical field is also required to be stricter, with the disinfection covering the lower abdomen up to the level of the umbilicus and down to the upper 1/3 of the thigh, and the anus is isolated with sterile towel sutures.
IV. Anesthesia
Most of them use continuous epidural anesthesia. If the combined epidural-lumbar anesthesia or general anesthesia is used, the effect is better. If there is sufficient certainty about the operation, lumbar anesthesia can also be used directly according to the situation.
V. Position
Take the bladder truncated position, with the head low and hips high at 15°; pay special attention to the hips beyond the edge of the surgical bed for 15 cm, so as to facilitate the placement of the posterior vaginal wall hook; fully abduct the legs; fix the two labia minora sutures on the lateral skin.
VI. Surgical steps
(A) Yin total hysterectomy
1. The anterior and posterior vaginal wall pulling hooks are used to pull open the anterior and posterior vaginal walls, the vaginal pressure plate assists in pulling open the lateral vaginal walls, and the cervical forceps hold the cervix and pull it outward to fully expose the cervix and vagina. The anterior vaginal wall puller with light source can increase the illumination of the surgical field.
2. 1:200,000 epinephrine saline solution is injected at 3, 6, 9 and 12 points under the vaginal mucosa at the level of the bladder sulcus at the cervical-vaginal junction, or in the case of hypertension, epinephrine solution (20 u in 100 ml of saline). This step is commonly known as the “water pad”. Its function is to separate the cervical-bladder gap and the cervical-rectal gap by water pressure, and also to constrict blood vessels and reduce intraoperative bleeding. The water pad should be injected just under the vaginal mucosa, so that it is “bulging” but not “white”, i.e. the water pad should make the vaginal mucosa bulge slightly, but not make it white, as it may be too deep if it does not bulge and too shallow if it is white.
3. The vaginal wall is cut off circumferentially at the vaginal-cervical junction. The anterior wall is at the level of the bladder sulcus, with 0.5 cm upward on both sides, and the posterior
It is important to determine the correct location of the bladder sulcus, as the incision is often too close to the cervix (too low), where the tissue is dense and tough, making it difficult to separate into the bladder-cervical space, and too high, which can injure the bladder. In fact, before “hitting the water pad”, the cervix is pulled downwards, when the mucosa is stretched tight and the bladder sulcus is not identified. The depth of incision through the vaginal wall is also important, to cut through it just right. This again depends on the water pad, which, when done well, will naturally cut the vaginal wall well. Conversely, it may be too deep or too shallow, both of which will affect the separation gap in the next step.
4. Separate the anterior and posterior cervical gaps sharply plus bluntly with tissue scissors. To boldly use scissors, play the water pad of the cervical bladder gap is very clear, use tissue scissors while cutting and pushing upward, to a certain height, the fingers can be used close to the cervix upward blunt separation, until touching the two layers of peritoneum between the sliding sensation, that is, to the peritoneal reflex above, not eager to cut the peritoneal reflex, can wait for the separation of the sacral and main ligaments before cutting. The posterior wall is advocated to cut the peritoneum directly in one step, excessive separation of the vaginal-rectal gap can increase the unnecessary stripping surface, resulting in excessive blood leakage from the surgical wound, affecting the surgical field, or postoperative stump hematoma.
5.Clamp cut sacral and main ligaments. Some operators do not suture, and when the vaginal stump is sutured together, but the author believes that it is better to suture, which can reduce intraoperative blood leakage and help to keep the surgical field fresh, and this process usually includes the treatment of the cervical ligament of the bladder. If the cervix is long, cutting the sacral and main ligaments can also be handled in two sessions.
6.Cutting the bladder-cervical regurgitant peritoneum. After dealing with the above ligaments, the cervical cervix is pulled outward and the anterior vaginal wall is pulled upward to clearly expose the retroperitoneum, which is boldly cut with scissors and the incision is extended to both sides.
7.Cut the uterine vessels by clamping. Leave a little more stump as possible to avoid the ligature line slipping. The ligature strives to be in place in one step, it is sutured once, in fact, the double suture is not only time-consuming, and does not play much effect.
8.Use the intrinsic ligament hook clamp to hook the ovarian intrinsic ligament, fallopian tube isthmus and round ligament at one time, clamp, cut and suture the stump, this time suture more tissue, to “8” suture. There is a hole at the front of the hook clamp, which can be pierced with a silk thread, after hooking out the ligaments, first ligated once, this ligament may not play a complete ligature to stop bleeding, but can ensure that there will be no tissue slippage in the next step of clamping.
9, fragmentation to remove the uterus. The small uterus can be pulled out directly, while the large uterus should be removed gradually after fragmentation. The cervix can be cut first, and then the uterus will be rolled, while half folded open, in the case of fibroids can be picked out first. In case of large adenomyosis, the tissue can be removed in pieces. To avoid violent pulling, which may make the ligature line already ligated slip off.
10. Carefully examine each stump and bilateral adnexa. In case of combined ovarian cysts, cyst debridement or ovariectomy is feasible at this time.
11.Suture the anterior and posterior vaginal walls and the anterior and posterior peritoneum at one time. The sequence of stitches is: anterior vaginal wall mucosa, anterior wall peritoneum, posterior wall peritoneum, and posterior vaginal wall mucosa. The sutures are divided into two parts from both sides, and the central intersection is perforated to place the pelvic drainage tube. Special attention should be paid to the sutures on both sides, as improper treatment here may result in postoperative bleeding. There are operators who do not place drains, but the author strongly advocates the placement of drains, even if there is full assurance that there is no bleeding, drains can also play a role in reducing the rate of postoperative disease and infection, after all, negative surgery is a relatively sterile surgery. Moreover, an extra drainage tube does not increase the patient’s discomfort much.
(ii) Subtotal hysterectomy in the negative mode
There is an anterior and a posterior approach, i.e., through the anterior and posterior domes to complete the procedure. Generally speaking, the anterior approach is more common for those with tumors in the anterior wall, and conversely, the posterior approach is also possible. Depending on personal habits, the author is more likely to perform the procedure via the anterior approach, even for those with tumors in the posterior wall, which is usually more lenient.
In the anterior approach, only the anterior wall water pad is used, that is, the vagina is injected with epinephrine saline solution or epinephrine solution at 3, 9 and 12 points, the anterior vaginal wall mucosa is incised at the level of the bladder sulcus from 3 to 9 points, the anterior cervical space is separated sharply and bluntly with tissue scissors to reach the anterior peritoneal fold, the peritoneal reflex is cut, the uterus is turned out from the incision, and then the ligaments, the innominate ligaments, and the round ligaments are clamped, cut and sutured one by one according to the steps of abdominal subtotal hysterectomy. The uterus was cut at the isthmus, the cervical stump was sutured, the cervical fascia was sutured, and the vaginal mucosal incision and the anterior peritoneum were sutured.
In the posterior approach, the posterior wall water pad is played, the posterior vaginal mucosa is incised, and the posterior vault of the uterus is turned out. The rest of the steps are the same as above.
It is more convenient to use a spiral myoma drill when turning out the uterus, and 2-3 myoma drills can be used to alternately drill into the myoma or the uterine body and gradually pull outward, and the myoma can be peeled off first when it is present.
(C) Yin-type myomectomy
The method of turning out the uterus is the same as that of subtotal hysterectomy. There is also a difference between anterior and posterior approach. Anterior wall fibroids are removed via the anterior route, posterior wall fibroids via the posterior route, and bottom fibroids via the anterior route. After turning out the uterus, the fibroids are removed and the cavity is sutured. Large fibroids can be removed while turning. The myoma drill is preferred to the claw forceps when turning out the uterus. Depending on the situation, the cervical ligament of the bladder or sacral ligament can be cut, or the vaginal wall can be cut in the middle of the “T” shape longitudinally to enlarge the incision.
The advantages of the negative myomectomy are: minimally invasive, manual, low possibility of missing myomas, and even submucosal myoma removal when hysteroscopic surgery is not available. There are also disadvantages: it turns aseptic surgery into sterile surgery, it is not easy to turn out the fibroids when they are too large, it increases the trauma of the uterus when turning out the uterus, and it may lead to “a thousand holes” in the uterus if it is not mastered well.
Seven, the main points of negative surgery
1.Find the right bladder sulcus. 2.Play a good water pad. 3.Appropriately circumcise the vaginal wall at the cervical-vaginal junction. 4.Properly
4.Push the scissors into the bladder-cervical space and separate it. 5.Take care of the ligation of the cervical ligament of the bladder to stop bleeding. 6.Treat the bleeding from the incisional margin of the posterior vaginal wall. 7.Treat the uterine vessels. 8.Treat the adnexa. 9.Crumble, remove or turn out the uterus.
VIII. Common misunderstandings of the negative surgery
1. For fear of damaging the bladder, the vaginal mucosa is too close to the cervix during circumcision, resulting in difficult separation and small surgical field.
2. The vaginal mucosa is too shallow when cervical mucosa is circumcised, which results in difficulty in separating the bladder and cervical space and increases the chance of bladder injury.
3. The vaginal mucosa is too deep when cricothyroidotomy is performed, entering the cervical muscle layer and sometimes even separating directly into the tumor cavity, making it impossible to find the bladder-cervical space.
The cysto-cervical space cannot be found.
4. When separating the bladder-cervical space, the patient does not dare to use scissors to push it, thinking that blunt separation is more reliable, so he or she uses his or her fingers blindly.
The result is an increased chance of bladder injury.
5. In order to expand the surgical field of view, the bladder and cervical space is separated by cutting too much to both sides, which damages the bladder and cervical ligaments and does not suture to stop bleeding in time.
No timely suturing to stop bleeding, resulting in more bleeding and affecting the surgical field.
6.The uterus is not sufficiently fragmented, and the uterus is forcibly drawn out, which may result in the ligature of the already treated stump slipping out.
7.No drainage tube is placed without active bleeding, with the result that some patients have long postoperative fever and even pelvic abscesses.
IX. Our lessons
From July 2004 to June 2008, a total of 1532 cases of each type of negative surgery were completed in the hospital, and there were more than 200 cases in the collaborating hospitals. A small number of complications have occurred. The more serious ones are the following 8 cases.
1. Hemorrhage 1 case
The patient went into hemorrhagic shock 2h after returning to the ward due to a total hysterectomy with no drainage tube, and a second operation was performed to stop the bleeding. The surgeon already felt some insecurity during the operation, but still took a chance and did not put the drainage tube, which led to serious consequences.
2, bladder injury 4 cases
Case 1: The bladder wall was directly cut when the scissors separated the bladder-cervical space because the cervical-vaginal mucosa was cut too high, and the bladder was repaired by open surgery.
Case 2: The vaginal mucosa was cut too low and the bladder-cervical space was separated blindly with blunt fingers because the vaginal mucosa was too low and the scissors did not dare to separate it, resulting in direct entry of the fingers into the bladder, and the bladder was repaired by open surgery.
Case 3: For the same reason as case 2, direct transvaginal bladder repair was performed and continued to complete the cathartic surgery.
Case 4: The uterine fibroids were removed in the negative procedure, but the fibroids were large and a “T” shaped incision was made in the middle of the vaginal wall, but the incision was still small. The uterus was pried into the abdominal cavity with a vaginal hook, resulting in bladder laceration, which was repaired by open abdomen.
3. 1 case of abdominal abscess
After myomectomy of the uterus in the negative type, severe pelvic infection occurred (no drainage tube was placed) and a pelvic abscess was formed, and then the vaginal stump was opened again, a drainage tube was placed, and the pelvic cavity was flushed and drained.
4. 2 cases of hematoma
After total hysterectomy in the femoral style, there was no drainage fluid from the pelvic drainage tube, and hematoma on the stump appeared after dialing the tube. Negative pressure suction with abortion
Under ultrasound monitoring, a No. 7 metal tip used for abortion was inserted into the hematoma through the vaginal stump, and the accumulated blood and blood clots were aspirated and repeatedly flushed with saline and metronidazole solution. The hematoma was analyzed as probably coming from the bladder stripping surface or from the bleeding between the posterior vaginal wall and the rectum.
IX. The author’s experience
1, position: head low hip high position (15°), which is very important. Not only is it good for the surgical field of view and surgical operation, but it also prevents the major omentum of the bowel from emerging downward from the incision, and also facilitates the illumination of the surgical field.
It is important to determine the location of the bladder sulcus. Before “playing the water pad”, the cervix is pulled downward, at which time the mucosa is pulled tight and the location of the bladder sulcus is not identified.
3, the water pad must be played adequately. If the water pad is well played, it will be easy to separate the gap and there will be less bleeding.
4. It is also important to cut the vaginal wall to the right depth. This again depends on the water pad.
A good water pad will naturally cut the vaginal wall. On the contrary, it may be too deep or too shallow, which will affect the next step of the separation gap.
5. Be bold and use scissors to separate the gap. Blind blunt separation with fingers will increase the chance of bladder injury.
6, Leave as much stump as possible when dealing with ligaments and vessels to avoid slipping of the ligature line.
7, T-shaped incision of the anterior vaginal wall can effectively expand the surgical field.
8.Drainage tube not only can detect bleeding in time, but also can reduce postoperative infection. The vaginal uterine surgery is relatively sterile surgery.
But even if infection occurs, pelvic drainage itself is a best treatment.
9, Lateral or median perineal incision is an effective way to enlarge the surgical field.
10. In case of bladder injury, do not panic and clip the edge of the rupture in time, most of them can be repaired transvaginally. If it can be detected in time
If detected in time, it is effectively repaired transvaginally and the procedure continues to be completed, this does not mean a complete failure of the procedure. Injuries to the bladder triangle should be repaired decisively and openly.
11. Giant hysterectomy: laparoscopic assisted cathartic hysterectomy can be done. First, laparoscopy is used to explore the abdominal cavity and sever the
Then, most of the fibroids and uterine tissues are removed by laparoscopic crushing, and then the broad ligament is completely severed vaginally and the remaining tissues are removed vaginally. In one case, the author performed this procedure in less than 2 hours and there was not much bleeding. In the case of large inferior uterine fibroids or broad ligament fibroids that interfere with the opening of the bladder-cervical space or the cervical-rectal space, it is feasible to remove the fibroids laparoscopically and then open the anterior-posterior space vaginally. The exfoliated myoma can be removed vaginally or crushed and removed by uterine cutter.
X. Common complications of negative hysterectomy
The main complications of the negative uterine surgery are seen in bleeding, bladder injury, rectal injury, ureteral injury, and infection. Intraoperative complications: peripheral organ injury and bleeding during surgery; postoperative complications: hemorrhage within 1 day after surgery; postoperative stump bleeding to form hematoma and pelvic infection.
The incidence of complications varies from literature to literature: bladder injury rate is 0.5%-1.5%; rectal injury rate is 0.03%-0.4%; ureteral injury rate is 0.02%-0.4%; postoperative bleeding is 0.01%-0.2%; postoperative infection is 0.04%-0.6%.
The above incidence rates were lower than those of laparoscopic surgery.
There were 1532 cases of all types of negative uterine surgery in our hospital. Bladder injury 0.26% (4/1532); postoperative stump hematoma 0.13% (2/1532); postoperative hemorrhage 0.06% (1/1532); severe postoperative infection 0.06% (1/1532); ureteral injury 0 (0/3452); rectal injury 0 (0/3452)
(I) Bladder injury
Common causes: the cervicovaginal mucosal incision is too high and too deep; the cervicovaginal mucosal incision is cut too shallowly; when suturing the vaginal mucosal incision margin, the position of the needle is too high and the suture enters the bladder; the cervicovaginal incision is too small or the bladder-cervical ligaments on both sides of the incision are not cut, the bladder-uterine gap is not sufficiently separated, and the bladder is injured when opening the peritoneal reflex, or the bladder is injured when clamping the sacral main ligament.
Prevention of bladder injury: grasp the height and depth of the cervicovaginal mucosal incision; fully expose the bladder-cervical space; carefully identify and cut the peritoneal reflexes, and cut them only when they are identified as peritoneal; when suturing the vaginal stump, the needle entry position should not be too high to avoid the suture entering the bladder and forming a vesicovaginal fistula.
Management of bladder injury: Intraoperative bladder injury is found, and most bladder repair procedures can be completed transvaginally. Firstly, the relationship between the fissure and the bladder triangle is checked and the tissue around the fissure is fully freed; the bladder fissure is closed intermittently with 3-0 absorbable sutures in the whole layer, paying attention not to leave holes in the two corners, and then the bladder muscle layer is closed intermittently with 3-0 absorbable sutures. The urinary catheter was injected with melphalan solution and observed for leakage. The urinary catheter was placed for 7 days after surgery, and broad-spectrum antibacterial agents were applied to prevent infection; postoperative bladder injury was found, and timely open surgery was advocated to repair it.
(B) Rectal injury
Causes of rectal injury: the posterior vaginal mucosal incision is too high and injures the rectum; the posterior incision is too shallow or too deep, the level is not correct, and the rectum is not fully free and pushed down; pelvic inflammation or endometriosis makes the rectum adhere to the posterior wall of the uterus, and the rectum is accidentally injured when the posterior wall is cut or the uterine rectal gap is separated, which is common; inexperience, blind clamping, injures the rectum.
Prevention of rectal injury: if there is severe endometriosis causing close adhesions to the posterior wall of the uterus, the operation should not be performed reluctantly, and laparoscopic assistance is available; if the peritoneum of the rectal fossa cannot be found during the operation, the rectum should be separated as closely as possible to the posterior wall of the cervix to avoid injury to the rectum; if the rectum is widely adhered to the posterior wall of the uterus and cannot be easily separated, the uterine vessels can be dealt with first, the uterine fundus can be turned out from the anterior vault, and the uterine attachments can be cut and sutured After that, the adhesions between the rectum and the posterior wall of the uterus are separated under direct vision. In the case of a total hysterectomy, the cervix can be broken and then the uterine body can be turned out, so that it is relatively easy to turn out the uterine body.
Treatment of rectal injury: Most of the repair can be completed transvaginally; rectal injury can be repaired after removal of the uterus if the fissure is not large. First, the tissue around the fissure is fully freed, and the rectal mucosa layer is intermittently sutured with 3-0 absorbable thread, and then the rectal muscle layer and fascia layer are intermittently sutured; postoperative antibiotics are applied to prevent infection, fasting for 3 days, and then a liquid diet until exhaustion and defecation.
(iii) Ureteral injury
Causes of injury: Inadequate separation on both sides of the bladder-cervical space; variation in the anatomical site of the ureter, such as in the case of III degree uterine prolapse, adnexal inflammation or broad ligament myoma; blind clamping or suturing of too much tissue when the uterine artery slips; severe pelvic endometriosis with tight adhesions around the posterior wall of the uterus and the sacral ligament.
Prevention of ureteral injury: detailed preoperative history and careful gynecological examination; adequate freeing of the uterine bladder space and pushing the ureter upward; intraoperative avoidance of slippage of the uterine artery ligature; surgical operation as close as possible to the edge of the uterus; if there are tight adhesions around the posterior wall of the uterus and the parametrium that are difficult to separate, do not clamp rigidly and change to open surgery if necessary.
Treatment of ureteral injury: after ureteral injury is found, promptly change to open surgery, and according to the site of injury, urologists will assist in ureteral end-to-end anastomosis or transplantation, and place ureteral catheters, and postoperative catheters will be placed to prevent infection treatment.
(iv) Bleeding
Hemorrhage in negative uterine surgery mainly includes heavy bleeding (bleeding ≥ 400 ml) within 24 h after surgery, and postoperative stump hematoma. The incidence of hemorrhage was higher in negative myomectomy and negative subtotal hysterectomy than in negative total hysterectomy.
Causes of bleeding: total hysterectomy, mainly slippage of the uterine vessels or ligature of the adnexal stump; subtotal hysterectomy, mainly leakage of the ligament stump, slippage and bleeding of the cervical fascial trauma; negative myomectomy, mainly due to blood leakage from the uterine wall incision, but also bleeding of the broken vessels at the edge of the myoma cavity, bleeding of the cervical fascial trauma and bleeding of the vessels at the broken end of the cervical ligament of the bladder.
Prevention and control of bleeding: check the stump of each ligament and the vaginal wall for active bleeding and stop bleeding completely; detect postoperative stump bleeding in time and deal with the product in time; do not cut too deep on both sides of the vaginal mucosa; inject posterior pituitary hormone or uterine contractin into the uterine wall to strengthen uterine contraction before incising the myoma wall; do not leave a dead cavity when suturing the myoma stump, and suture the small artery with active bleeding separately before suturing; suture the myoma and sub-total hysterectomy routinely. In the case of myoma debridement and subtotal hysterectomy, the cervical fascia is routinely sutured; at the end of surgery, a drainage tube is routinely placed in the pelvic cavity for observation of postoperative bleeding; postoperative hemorrhage can be stopped by vaginal examination again. The sutures of the vaginal stump should be removed to clear the accumulated blood or hematoma, find the bleeding point, and suture to stop the bleeding. If there is difficulty, the abdomen should be opened promptly to stop bleeding.
(v) Infection
Causes of infection: inadequate vaginal preparation before surgery, insufficient vaginal disinfection during surgery; more difficult surgery, longer surgery time; more bleeding during surgery or more postoperative blood leakage, decreased resistance or pelvic blood accumulation causes infection; suturing the cavity of the tumor leaving a dead cavity to form a hematoma causes infection; during myomectomy, the uterine body is turned to the vagina and contaminated and sent back to the abdominal cavity causes infection. If myomectomy is performed before menstruation, the pelvic cavity is congested, there is a lot of bleeding during surgery, a lot of postoperative blood leakage, or there is a recent menstrual flow after surgery, infection is likely to occur.
Prevention and control of infection: exclude inflammation of the vagina before surgery; ensure that the vagina is scrubbed with iodophor for 3 days, twice a day; suture the myoma cavity without leaving a dead cavity; disinfect the uterus with iodophor when sending the uterus back to the abdominal cavity by myoma removal; detect and remove pelvic hematoma and abscess in time under ultrasound monitoring; use antibacterial agents in the perioperative period; place pelvic drainage tube.
(F) Recurrence of myoma
Every patient with resected fibroids is at risk of recurrence. The greater the number of myomas removed, the higher the risk of recurrence. The risk of myoma recurrence is much lower than that of laparoscopic myomectomy, because the myomectomy can be performed by touching the uterus directly, and some small fibroids that have not been detected by ultrasound can be found.
X. Outlook
With the advantages of minimally invasive surgery, simple equipment requirements and easy to master surgical methods, the negative surgery will be favored by more and more obstetricians and gynecologists. In a country with many poor areas like ours, there is bound to be a bigger market. Extensive negative hysterectomy with laparoscopic pelvic lymph node dissection is nowadays a minimally invasive procedure for cervical and endometrial cancer.