The so-called vaginal surgery, is the use of the vagina as a natural cavity for surgery 1, vaginal total hysterectomy 2, vaginal fibroids 3, vaginal subtotal hysterectomy 4, vaginal wide hysterectomy 5, vaginal wide cervical resection 6, vaginal residual cervical hysterectomy Hysterectomy is the most common gynecological surgery at present the commonly used methods of hysterectomy include: Abdominal hysterectomy, vaginal hysterectomy, laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy. Laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy. Each procedure has its own limitations, advantages and disadvantages and is suitable for different patients. Advocating individualized treatment When choosing a surgical method for a patient, it is important to choose a more effective and less invasive treatment within the patient’s ability to tolerate it safely and the surgeon’s ability to do so. Instead of blindly pursuing “minimally invasive” without regard to efficacy. This is because sometimes the improper treatment of minimally invasive can also bring huge trauma. Successful surgery lies 25% in surgical technique and 75% in surgical decision-making. Individualized treatment conditions There is an old adage: “When your only tool is a hammer, every problem looks like a nail”. As a doctor you will only have one way to solve a problem and that is not enough. It’s not enough to talk about individualized treatment. Therefore, you should have a variety of treatment methods for the same disease. It is important to choose the best treatment plan for each patient according to her specific situation. The patient’s situation includes the size, location, number of fibroids, clinical symptoms, age, fertility requirements and any comorbidities, and the patient’s wishes, etc. The doctor has to make a comprehensive analysis based on these to make an optimal treatment plan for the patient. Comparison of transabdominal hysterectomy and transvaginal hysterectomy Both procedures have their advantages and disadvantages. The advantage of abdominal hysterectomy is that the surgical field is relatively large and the procedure has been widely used and familiar to obstetricians and gynecologists for many years. However, it is recognized that if the hysterectomy can be done vaginally rather than transabdominally, there are the following advantages: Advantages of vaginal hysterectomy 1. The peritoneum is opened to the smallest possible extent by transvaginal hysterectomy, with minimal interference with the intestines, and the incidence of postoperative intestinal obstruction is much less than that of transabdominal hysterectomy. 2. 2. Transvaginal hysterectomy avoids the complications caused by abdominal incision, such as wound infection and discomfort, and the patient is satisfied with the absence of abdominal scars. Avoiding an abdominal incision also reduces the depth and length of anesthesia. Because the surgery is less invasive, patients can get down to the floor earlier after surgery and take better care of themselves. There is also a reduced need for nursing care, faster recovery of bowel function, and patients can eat earlier with less intravenous rehydration therapy. The postoperative infection rate is only half of that of transabdominal total hysterectomy, and the need for postoperative antibiotics is also reduced, as well as the application of postoperative pain medication, and the patient’s hospitalization time is shortened. 4. Adhesions occur less frequently after transvaginal hysterectomy. 5, Elderly patients and patients with medical comorbidities tolerate transvaginal hysterectomy better. 6, Excessive obesity increases the technical difficulty of transvaginal or transabdominal hysterectomy, but doing transvaginal hysterectomy will be less difficult. 7, Transvaginal hysterectomy can be performed at the same time as the repair of vaginal wall laxity. The superiority of the improved method is manifested in: 1. The indications for surgery are expanded because of the improvement of the surgical method, the indications are expanded, the traditional method is generally considered to be non-prolapsed uterus transvaginal hysterectomy, the uterus size is preferably within the third trimester of pregnancy. In the modified approach, the indications are not limited by the size of the uterus. The largest uterus removed in our department weighed 2600 grams. 2.Surgical method is simple and easy to be mastered by the general public. 3, do not need special instruments, do not need to invest more negative total hysterectomy surgical method 1, ring-shaped incision of the vaginal wall of the cervical attachment of the mucosa 2, push up the bladder to the uterine bladder vesico-peritoneal reflex 3, open the posterior dome, into the abdominal cavity 4, cut the main sacral ligament 5, push up the severed ends of the main ligaments (paramedian tissues) to expose the uterine artery 6, clamping, stitching, cutting off the uterine artery. 7.Push up the broken end of uterine artery over the broad ligament non-vascularized area 8.Sufficiently cut open the anterior and posterior lobes of the broad ligament 9.When the uterus is too large to be turned out directly, the uterus can be chopped up and taken out piece by piece. 10.Turn out the uterus, cut off the uterine horns on both sides, and double suture the severed ends 11.Check the hemostasis, and do another suture of the bilateral uterine arteries. 12.Suture the broken end of the vagina Suture the broken end of the vagina Why is it possible not to ligate the main sacral ligament without bleeding? Three major advantages of suturing the severed end of the vagina 1. peritonization 2. hemostasis 3. prevention of vaginal prolapse. Points to note during surgery 1, Be sure to cut the vesicocervical ligaments on both sides of the bladder when pushing up on the bladder so that the ureter can be pushed away. 2, Pay attention to the position when opening the posterior dome of the uterus. 3, Hemostasis should be complete, and when ligating the uterine arteries again, it is better to ligate rather than suture. 4, The anterior and posterior lobes of the broad ligament should be adequately clipped. 5, The suture of the broken end of the vagina should not be too close. Tips for large hysterectomy 1, preoperative understanding of the location of fibroids and adenomyomas, conducive to operation during surgery. 2.The cervix can be removed first to reduce contamination. 3.Cutting in pieces. 4, One side of the uterine horn dissected. Yin type uterine fibroid excision Currently commonly used uterine fibroid excision 1, abdominal type uterine fibroid excision: applicable to patients with multiple uterine fibroids and relatively large size of fibroids. 2.Laparoscopic myomectomy: It is suitable for patients with fibroids located near the lower uterus, especially cervical fibroids. The fibroid is single or multiple but located in one side wall of the uterus (anterior or posterior wall). Those with large size of submucosal fibroids (patients with relatively long time and high surgical difficulty of hysteroscopic surgery). 3.Hysteroscopic myomectomy: applicable to submucosal fibroids. 4.Laparoscopic myomectomy: suitable for uterine body, uterine bottom fibroid, subplasma fibroid, single fibroid is the best. Comparison of laparoscopic, hysteroscopic, transvaginal and transabdominal myomectomy: Each of the four methods has its own advantages and disadvantages. Abdominal myomectomy: Transabdominal myomectomy can be performed regardless of the location, size and number of fibroids, and with a large field of vision, it has been widely accepted and familiarized by the patients. However, it is not a minimally invasive surgery, and the pain after surgery will be heavier than the other three methods, and the recovery time will be longer. It also leaves large scars on the patient’s abdomen. Laparoscopic Fibroid Removal Laparoscopic surgery is an instrument-dependent surgery, which is best used for fibroids located at the bottom of the uterus, subplasma fibroids or interstitial fibroids protruding into the subplasma, and the size of fibroids should preferably be less than 10 centimeters, and the number of fibroids should not be too many, depending on the surgeon’s surgical ability and skills. Transvaginal myomectomy Transvaginal myomectomy is best performed when the fibroid is located on one side wall of the uterus (anterior or posterior), is solitary, and is most easily removed from the lower uterine segment or the cervix. This procedure is a class II procedure compared to the first two, and has a greater chance of postoperative infection, so the vagina should be well prepared before surgery. The transvaginal approach to removing submucosal fibroids is also preferred for fibroids that are close to the cervix or for fibroids that are pedunculated. Because of the damage to the cervix associated with this procedure, it is best to select patients who no longer need to have children. Or patients whose fibroids have dilated the cervical canal Hysteroscopic myomectomy Hysteroscopic myomectomy is also an instrument-dependent procedure and is only used for the removal of submucosal fibroids. The method of vaginal myomectomy: 1. The location and number of fibroids must be clarified before surgery. 2. Longitudinal incision is made on the anterior vaginal wall for anterior wall fibroids, and transverse incision is made on the posterior wall in the posterior vault of the vagina. 3. Since the uterus is to be preserved, the damage to the wall of the uterus is to be minimized, and the uterine wall is to be opened to expose the nucleus of fibroid and the fibroid is to be gradually divided by stretching and delivered to deliver fibroid and uterus. 4. 4.The uterine wound should be sutured carefully, leaving no dead space and reducing postoperative reaction. 5. Retain the drainage tube after operation. 6. Use uterotonics during and after operation. Submucous fibroid negative excision 1, incision of the mucosal layer of the anterior vaginal wall, longitudinal, transverse can be. Push up the bladder. The peritoneum may not be opened. 2.Make a longitudinal incision on the anterior wall of the cervix, and the upper end should exceed the endocervix. 3, Clamp and twist to remove the fibroid, or block removal of fibroids, 4, uterine incision interrupted suture. 5. Suture the vaginal mucosa. The most common reason for subtotal hysterectomy is the desire to minimize surgical risk. It is indicated for young or elderly patients without cervical lesions. The advantage is that the anatomy supporting the upper end of the vagina is preserved, reducing the chance of urinary tract injury. The disadvantages are that lymphatic return to the cervix is somewhat compromised after removal of the uterus which can exacerbate pre-existing cervical inflammatory conditions and does not prevent the development of cervical cancer. This type of operation is rarely used in our department. The method of subtotal hysterectomy is the same as myomectomy. 2. After delivery of the uterus, subtotal hysterectomy is performed from upward to downward. 3. When closing the peritoneum, care is taken to suture the anterior peritoneum to the posterior wall of the cervix, so that the remnant of the cervix is located outside of the peritoneum. Vaginal apical sacrospinous ligament suspension For severe uterine prolapse, post hysterectomy vaginal apical prolapse. It reduces postoperative recurrence. The sacrospinous ligament is located in the posterior half of the pelvis, with a constant position, strong and sturdy, clearly palpable through the vagina and pararectal area, providing a solid and reliable foundation for the suspension of the vaginal stump. Surgical method 1, after the prolapsed uterus is resected, or the tip of the prolapsed vagina is opened, the peritoneum on the right side of the posterior wall of the vagina is cut upward on the right side of the rectum, and the rectum is pushed away to the left side. 2, The sacrospinous ligament is exposed, and a slight rocking of the right lower extremity may occur when the sacrospinous ligament is pressed with the hand. Hang an absorbable suture on the sacrospinous ligament under the direction of the finger for use in suspending the vaginal stump. After hanging the suture, pull it with tension, and a slight shaking of the right lower limb can be seen. 4.After the end of vaginal repair, sew the thread on the right side of the top of the vagina. Be sure to pull the thread tight when tying the knot.