Pelvic floor dysfunctional diseases refer to the dysfunction of the pelvic floor tissues and organs, which in women mainly include uterine prolapse, anterior and posterior vaginal wall bulge, bladder neck and urethra subluxation resulting in stress urinary incontinence, rectal prolapse, etc. There are two main types of causes, one refers to its own tissue structure defects, the other is injury (birth injury and trauma), the treatment mainly adopts the strategy of structural reconstruction or correction, the current laparoscopy in this field has achieved good clinical results. The application of laparoscopy in this field has achieved good clinical results, and several new surgical methods are described below.
1, laparoscopic surgery for uterine prolapse There are many surgical procedures for uterine prolapse, but those that can be done laparoscopically with good results include fixation of the uterus and vaginal sacral head, folding and shortening of the uterosacral ligament, fixation of the uterus and vaginal vault sacral ligament, etc.
1 . 1.1 Indications and contraindications Uterine prolapse, combined with the anterior and posterior vaginal wall bulge after conservative treatment is ineffective, and seriously affect the patient’s quality of life, need to be treated surgically. Those with severe lung disease and chronic cough; chronic constipation and heavy physical labor should not be treated surgically. Those with contraindications to laparoscopy should not undergo laparoscopic surgery.
1 . 2 Fixation of the uterine cervix and vaginal mesh sacral capsule
(1) Separation of retroperitoneal space: firstly, the vesico-vaginal space or the vesico-uterine space is separated, these two spaces are bounded by the bladder pillars, the bilateral bladder pillars meet at the base of the bladder, and the ureter is located at the same level, and the bladder pillars are incised and separated at the medial midline. To separate the rectovaginal space, the lateral peritoneum is opened and the ureter is found and then pushed away from the sacral ligament. The junction of the bilateral sacral ligaments located in the recto-uterine recess is identified, the peritoneum is lifted, and the peritoneum of the rectal recess is cut open to separate the rectovaginal space. The extent of separation requires reaching down to about 2 cm above the perineal union. The broad ligament is perforated, the uterus is lifted and pushed to the other side, and the posterior lobe of the broad ligament is opened, so that the anterior and posterior lobes of the broad ligament are connected and used to place the repair mesh.
(2) Exposure of the sacral promontory: The best way to expose the sacral promontory is to carefully push away the sigmoid colon in a head-low-hip-high position, and to improve the visual field, the sigmoid colon can be fixed to the anterior abdominal wall. The right ureter and common iliac vein are identified, and the retroperitoneum is incised vertically from the sacral promontory to free and expose the ureter. The posterior peritoneum is continued to the upper part of lumbar 5 or sacral 1, and the anterior vertebral ligament is separated and the artery and median sacral vein within it are pushed out.
(3) Placement of repair mesh: Mersilene type repair mesh is chosen because it is firm and has better longitudinal extension than lateral, and will not remain fixed, facilitating laparoscopic operation. If the uterus has been removed, the repair mesh is first placed posteriorly and the gap between the mesh and the vagina is closed by suturing the mesh to the vagina with nylon thread; then the anterior vaginal wall is covered and sutured to the anterior vaginal wall. If the uterus is not removed, the repair mesh is placed posteriorly to the vagina and fixed to the vaginal part of the uterus and the main ligament with 0-gauge non-absorbable nylon sutures.
(4) Rectohysteroplasty: The aim is to raise and reposition the rectum and pull the vagina posteriorly. It includes closure of the posterior vault and the recto-uterine recess, which can be closed with 2 sutures. The uterosacral ligament is sutured posteriorly. The ureter is identified first and the main ligament is sutured. Finally, the repair mesh is sutured to the vagina and the opposite side is treated in the same way.
(5) Fixation of the repair mesh: The repair mesh is unfolded in the vesicovaginal space. If the uterus is not removed, the two wings of the repair mesh are passed through the hole made by the posterior lobe of the broad ligament. A wide knot is tied posterior to the isthmus, where there is no peritoneum at the time of separation of the rectovaginal space, and the mesh is secured to the anterior vaginal wall using 2/0 nylon thread and tied. (6) Sacral capsule fixation: The anterior and posterior repair mesh is fixed to the anterior vertebral ligament and sacral capsule periosteum at the sacral capsule, entering only the fibrous layer of the tendon membrane to avoid spondylolisthesis and spinal perforation. The sutures are checked for secure closure. Pelvic peritonealization: the incision between the anterior bladder-uterine separation surface and the posterior rectovaginal separation surface, and the median line from the sacral promontory to the recto-uterine trap. 2 to 3 stitches of 2/0 nylon thread and curved needle are used to close the incision, and steel staples can also be used.
(7) Peritonealization of the retroperitoneum: after the sacral promontory is sutured, the polypropylene mesh is placed in the retroperitoneal right pararectal space to close the retroperitoneum.
1 . 3 Folding and shortening of the uterosacral ligament
(1) Separate the lateral peritoneum: first identify the course and position of the ureter, open the lateral peritoneum, free and push away the ureter so as not to damage the ureter when suturing the sacral ligament.
(2) Uterosacral ligament folding and shortening: U-shaped folding sutures are performed along both sides of the uterosacral ligament, rectovaginal septum and vaginal wall respectively, and the uterosacral ligament is shortened, then continuously sutured to the top of the vagina and the intersection of the bilateral sacral ligaments, and fixed with vaginal fascia, so that the two sides and the posterior part of the pericervical fascial ring can be reinforced.
(3) Uterosacral ligament fixation: The folded uterosacral ligament is fixed at the level of the cervix with non-absorbable 0 nylon sutures on both sides, and then tied with a knot after the sutures are completed.
(4) Closure of the rectal fossa: The uterosacral ligaments on both sides were interrupted with No. 0 nylon sutures to close the rectal fossa of the uterus.
If the ureter is twisted after suturing the uterosacral ligament, the pelvic lateral peritoneum on the inner side of the sacral ligament is opened, and the ureter is freed and pushed away to make it travel naturally.
1 . 4 Uterine cervix and vaginal dome sacrospinous ligament fixation
(1) Separation of the gap: Similar to vaginal sacral fixation, the cervical and paravaginal gaps are first separated to expose the fascial tissue above the sciatic spine. Then the rectovaginal space is separated, the lateral peritoneum is opened first, the ureter is found and its course is identified, and it is pushed into the uterosacral ligament to avoid injury. Identify
The junction of the bilateral sacral ligaments in the recto-uterine recess, lift the peritoneum, cut the peritoneum of the recto-uterine recess, and separate the recto-vaginal space.
(2) Separate the perirectal space: extend the peritoneal incision of the rectal recess on the medial side of the uterosacral ligament to reach the anterior part of the second and third sacrum, and separate and push open the rectum to expose the bilateral sacrospinous ligaments, caudalis muscle and sciatic spine.
(3) The posterior wall of the vaginal part of the cervix or the posterior wall of the vagina is sutured on both sides, respectively, and the sutures are passed through the caudate muscle and the sacrospinous ligament at 2-3 cm from the medial aspect of the sciatic spine, with no more than 2 stitches on each side of the sacrospinous ligament, and the posterior wall of the vagina or the vaginal part of the cervix is fixed to the sacrospinous ligament by knotting.
1 . 5 Precautions and management of common complications
(1) Traumatic hemorrhage and vascular injury: including traumatic hemorrhage during separation of the gaps, injury to the presacral venous plexus during suturing of the sacral ligament and injury to the uterine artery during perforation of the broad ligament, traumatic hemorrhage and injury to the uterine artery can be stopped by bipolar electrocoagulation and, if necessary, suturing. Injuries to the anterior sacral vein need to depend on the size of the laceration, if it is a small laceration, only compression or bipolar electrocoagulation can be used to stop bleeding, if it is a relatively small wound can try to suture under the laparoscope, if suturing is difficult or the laceration is large, open surgery can be used to perform vascular suturing or anastomosis.
(2) Ureteral injury: If there is ureteral injury, ureteral and ureteral or ureteral and bladder anastomosis can be performed, and ureteral stent can be placed after surgery to prevent ureteral stricture. The stent is usually removed about 3 months after surgery.
(3) Intestinal obstruction: Intestinal obstruction occurs when the small intestine enters the sink due to incomplete closure of the rectal sink, resulting in an internal hernia of the small intestine. Mild internal hernia can be relieved automatically by conservative treatment, but in severe cases, intestinal necrosis can occur and requires surgery. Therefore, it is necessary to close the rectovaginal recess thoroughly and leave no gap to avoid intestinal hernia.
1 . 6 Evaluation of surgical procedures Genital tract prolapse is a common gynecological disease, and more than 30 surgical procedures are currently used to treat this disease, which illustrates the intractability of this disease. Laparoscopy only provides a new means of transabdominal surgery that allows better visualization of the anterior and posterior gaps, and this new procedure combines traditional vaginal or cervical fixation with a new surgical approach, achieving minimally invasive, precise separation of tissues and fast recovery, which has good clinical application prospects. However, the difficulty of laparoscopic surgery limits its clinical application, so it is necessary to strengthen the training of laparoscopic surgical suturing techniques so that more gynecologic laparoscopists can master the technique and serve in the clinic.
2.Laparoscopic surgical treatment of stress urinary incontinence
There are various surgical methods for stress urinary incontinence, but the purpose of surgery is mainly to correct the lack of urethral support to relieve the symptoms of urinary incontinence. And laparoscopic surgery to the bladder neck and urethral suspension is most commonly used, and the results are good.
2 . 1 Indications and contraindications. Tension incontinence of degree II or greater can be treated surgically if conservative treatment is ineffective or recurrent. Those with contraindications to laparoscopic surgery are not suitable for laparoscopic surgery.
2 . 2 Burch bladder neck suspension
(1) Separation of the retropubic Retzius space: there are two routes, namely the transabdominal route and the extraperitoneal route. Transabdominal route: the peritoneal incision is made from one side of the umbilical artery to the other side of the umbilical artery, fully freeing the anterior bladder space, and filling the bladder is desirable in patients with difficulty in revealing the bladder. The posterior pubic fascia is then continued downward to open the Retzius space, exposing the pubic bone and bilateral Cooper’s ligament to the bladder neck. The bladder is pushed posteriorly and medially with a separator forceps.
At the same time, the vaginal wall tissue is grasped with a grasping forceps on the opposite side to completely separate the bladder from the vagina and expose the anterior vaginal wall. Extraperitoneal approach: A 2 cm long horizontal incision is made at the midpoint between the umbilicus and the pubis to bluntly separate the Retzius space under the rectus abdominis muscle on both sides to the Cooper’s ligament, either with a 1000-1500 ml volume balloon built into the space or with a blunt finger. A 5 mm trocar is then placed on each side, and a set of trocar needles is placed over the pubic bone to act as a retractor. The rectus abdominis muscle is sutured around the 10 mm trocar needle and then inflated with low pressure (8-12 mmHg) in the Retzius space.
(2) Suture: First, the Cooper ligament is sutured as far as possible through the entire Cooper ligament to enhance its resistance to tension, and the needle is removed in the direction of its longitudinal axis, without forcing the needle in order not to break it. The middle finger or index finger of the left hand is inserted into the vagina to expose the urethral-vestibular junction and the point where the anterior vaginal wall is to be sutured, and the finger is used to guide the needle in and avoid the bladder to penetrate the anterior vaginal wall, but avoid penetrating the whole layer. After the needle is removed, the suture is tightened and knotted, and the knot is tied as tightly as possible so that the urethral-vesical connection does not form an acute angle. The first suture must be close to the urethrocystic junction, and then the second and third sutures in the suspension in sequence, with an interval of about 1 cm between each suture. If there is bleeding on the trauma surface, bipolar electrocoagulation can be used to stop the bleeding, and if necessary, suture to stop the bleeding, rinse the trauma surface, and thoroughly check that there is no active bleeding, that is, interrupted sutures with absorbable sutures to close the peritoneum.
2 . 3 mid-urethral sling suspension
(1) Preparation of sling: There are two kinds of materials, i.e. autologous tissue and synthetic material, synthetic material is mostly used because of the high chance of infection, erosion and rejection by the body, therefore, the material of own tissue (autograft) or the material after denaturation of allograft (allograft) is used. Excision of autologous or allogeneic fascial band: The strong tendon of the rectus abdominis or quadriceps surface of the thigh, about 10 cm long and 1 cm wide, is excised, and the tendon tissue is then bandaged with a gauze compression bandage to stop bleeding, and the patient does not experience significant discomfort after surgery because of the small incision. If the patient’s body is weak or older, the effect of using allograft tissue as a sling is the same as that of autologous tissue. Synthetic material preparation: generally use polypropylene net or nylon net, cut into strips can be.
(2) Placement of the sling: The sling is placed into the retropubic space through the perforation sheath hole of the laparoscope, before the retropubic space is free and thoroughly hemostatic through the laparoscope, and the bladder and ureter, as well as the junction of the ureter and bladder, are distinguished. At this time, the vaginal mucosa and part of the submucosa were incised longitudinally with a scalpel at the bladder neck of the anterior vaginal wall, and a pointed vascular forceps was inserted from this incision along the submucosa of the vagina and penetrated laterally into the bladder neck to reach the retropubic space, and the vascular forceps grasped one end of the sling, clamped and pulled into the vagina; at this time, the vascular forceps of the sling were penetrated from the other side under the vaginal mucosa into the tissue gap of the vaginal wall, and on the other side of the bladder neck The vascular clamp of the sling is then inserted into the posterior pubic space from the other side under the vaginal mucosa and on the other side of the bladder neck.
(3) Suturing of the sling: The ends of the sling are sutured to the Cooper’s ligaments bilaterally with No. 0 needle nylon thread, and the tension of the sling should not be too great after suturing, that is, the urethra should not form an acute angle. The posterior peritoneum and vaginal mucosa are closed and the peritoneum is intermittently sutured with absorbable sutures. The vaginal incision is then closed with absorbable sutures.
2 . 4 Precautions and management of common complications
(1) Bleeding and vascular injury: when opening the retroperitoneum, attention should be paid to prevent bleeding from injury to the inferior abdominal artery, if any, bipolar electrocoagulation can be used to stop the bleeding; if bleeding occurs when suturing Cooper’s ligament or vaginal wall, immediate bipolar electrocoagulation is needed to stop the bleeding to prevent bladder or urethra injury due to unclear anatomical relationship; sometimes heavy bleeding often requires intermediate open surgery, so the posterior pubic space should not be too close to the pubic bone when separating it, to avoid injury to the occluded vein.
(2) Bladder perforation or suture needle penetration: This occurs firstly when the retroperitoneum is incised and the bladder is easily incised because of the poor recognition of the bladder margin; secondly, when the Retzius space is separated and the suture needle passes through the vaginal wall, it can be filled with methylene blue solution in the bladder first, and if there is any injury, it can be repaired laparoscopically immediately. A urinary catheter is left in place for more than 7 days after surgery.
(3) Urethral injury also occurs, such as penetrating injury, the removal of stitches can be, such as transection injury, it is necessary to open the urethral anastomosis, the post-operative urethral tube should be properly extended until the urethral anastomosis is completely healed, otherwise easy to occur urethral stricture.
(4) Urethral obstruction: Due to the excessive angle of suspension of the bladder neck, there can be difficulty in urination, or urethral obstruction, some of which is related to the body position. If urethral obstruction occurs, conservative treatment is needed, including urethral dilatation, changing the urinary position and medication to relax the bladder neck, etc. If this does not work, the sutures should be removed and the bladder neck should be resuspended until the obstruction is corrected.