Laparoscopy of the uterus and appendages

Laparoscopic surgery has become especially popular in the last few decades. Previously, any surgical intervention required large incisions in the skin and tissues, sometimes up to tens of centimeters in length. Laparoscopy made it possible to carry out surgical interventions through literally 3-4 small punctures, using a laparoscope – a tube with a video camera and a lighting device, as well as special trocars with instruments for various surgical procedures. So, for example, the procedure of laparoscopy of the uterus and appendages can be prescribed for therapeutic or diagnostic purposes, and is performed with minimal surgical intervention.

The uterus and appendages in a woman’s body: anatomy and functions

The uterus refers to the internal genital organs of a woman. It is a hollow organ formed by muscle tissue, and has a pear-shaped shape, compressed in the anteroposterior direction. During the life of a woman, the size and weight of the organ changes: in nulliparous women, the uterus weighs up to 50 grams, in those who have given birth – about 80-90 grams. The length of the virgin uterus is approximately 7-8 centimeters, the thickness of its walls is 1-2 centimeters.

The anatomical location of the organ is between the rectum and the bladder in the pelvic area.

The structure of the uterus is represented by a bottom, walls and a tapering neck, while it is interesting that the bottom is located in the upper part of the organ, and the neck at the bottom adjoins the upper section of the vagina.

The main functions of the body is participation in the process of the menstrual cycle and the conception of the fetus. It is in the uterine cavity that the fertilized embryo is fixed, where it develops and grows for 9 months, and the uterus itself is significantly stretched.

The appendages of the ovary in a woman are rudimentary elements. The appendages of the appendages are called the periovaries. It is the epididymis that is anatomically represented by the supraovaries. It is located between the sheets of the mesentery of the fallopian tube lateral to the back of the ovary.

The appendages of the ovary consist of longitudinal ducts and convoluted tubules that flow into them. These tubules are transverse ducts with a small lumen, the blind ends of which are turned towards the hilum of the ovary.

The uterine appendages include the ovaries and fallopian tubes. Fallopian tubes (fallopian tubes) are paired oblong organs. They are located on both sides of the uterus, and connect its cavity with the abdominal cavity.

The ovaries are oval or almond-shaped – paired organs with a pinkish-gray color, about 4 centimeters long, 2 centimeters wide, and about 1 centimeter thick. The anterior part of the ovaries is attached to the broad uterine ligament, while the posterior part of them is located freely.

The surface of the ovaries is represented by the germinal epithelium, under which is located:

• inner medulla;
• outer cortical.

The cortical component of the ovary contains follicles – female eggs that are involved in the process of conception.

The essence of the procedure of laparoscopy of the uterus and appendages

Operations performed by laparoscopy have proven to be minimally invasive and relatively safe for the patient. The rules of preparation and the mechanism of the surgical manipulations themselves in the abdominal cavity are similar to those for laparotomy – abdominal penetration.

Laparoscopy of the uterus and appendages, unlike laparotomy, does not require incisions of large length and area – all actions with internal organs occur through 3-4 punctures. The length of the punctures usually does not exceed 1 centimeter. In one of the punctures, the doctor inserts a long hollow tube with a camera – a laparoscope. The device displays an image of the state of the internal organs on the screen, and it is on it that the doctor will be guided in the operation. Other punctures are made in order to introduce trocars into the abdominal cavity – hollow tubes with special devices and fasteners. Through trocars, the surgeon gets the opportunity to perform surgical manipulations – incisions, stitching, coagulation of blood vessels, and others.

Laparoscopy is considered an operation, after which the risks of large blood loss and developed adhesions are minimized.

Indications and contraindications for laparoscopy of organs

Most often, laparoscopy is prescribed specifically for the removal of the uterus and appendages. If the attending physician raises the question of the need to harvest organs from a woman of reproductive age, it means that diseases of these organs make the process of conception and gestation impossible, moreover, they endanger the life of the patient. When a woman goes through menopause, the doctor may recommend removing the organ at the slightest sign or suspicion of the development of tumor processes.

The most common indications for the procedure are:

• multiple uterine fibroids, along with its diseases such as hypertrophy, precancerous degeneration, scars;
• endometrial hyperplasia in women over forty (atypical or recurrent);
• uterine cancer, multiple or atypical polyps in the uterus, adenomyosis;
• diagnosis and treatment of peritoneal or tubal infertility;
• inability of the myometrium to contract or exfoliation of the accrete placenta urgently after childbirth;
• progressive ovarian tumors;
• sclerocystosis or apoplexy of the ovaries in combination with tumors in the uterus;
• purulent inflammation of the ovary, which moved to the fallopian tubes and closely located organs;
• ectopic pregnancy;
• the need to monitor the effectiveness of the treatment, or confirm the diagnosis (we are talking about diagnostic laparoscopy).

It should be understood that if the operation is performed on a patient at an age when menopause has not yet set in, with the appendages or uterus removed, she will not be able to conceive and bear a child, and her further life will be spent with hormone replacement therapy, therefore, to remove these internal organs, there must be objective, confirmed and verified evidence.

For women over the age of 50, the attending physician prescribes surgery if:

• profuse bleeding from the uterus was diagnosed;
• there are tumor formations that are actively progressing;
• a woman is at risk for the development of oncological diseases of the reproductive system.

When is laparoscopic intervention not possible? Among the contraindications to it:

• prolapse of the uterus: in this case, laparoscopic access to the abdominal cavity is impractical, and surgery is performed through the vagina;
• the size of the uterus is similar to the size of the 16th week of pregnancy, and does not return to normal even after appropriate drug therapy;
• ovarian cystomas exceed 8 centimeters in diameter: neoplasms of this size simply will not pass through a laparoscopic puncture without violating their integrity, which is strictly prohibited;
• if more than 1 liter of free fluid has accumulated in the abdominal cavity, a laparotomy operation is prescribed;
• obesity;
• diaphragmatic hernia;
• a large number of adhesions around the intestines;
• pathology of blood flow in the region of the brain stem.

Preparing for the procedure

Surgical intervention of this nature requires pre-planned preparation.

If the patient develops anemia against the background of heavy menstruation or other factors, it is necessary to treat it: for example, take a course of iron-containing drugs, in severe cases of significantly reduced hemoglobin, perform a blood transfusion.

The increased size of the uterus is an indication for preliminary treatment with special hormonal agents of gonadotropin-releasing factor. The course in this case lasts from 3 to 6 months.

A colposcopic examination of the uterus is mandatory to identify the possible presence of erosion or other pathologies. If they are detected, the patient undergoes appropriate treatment, and the operation can be performed no earlier than a month after its successful completion.

14 days before the specific date of the operation, the woman takes the following tests:

• total urine and blood;
• coagulogram;
• blood chemistry;
• analysis for the Rh factor and blood type;
• PCR smears from the cervical canal to determine the causative agents of sexually transmitted diseases, as well as the presence of cancer cells;
• PCR for HIV and hepatitis;
• blood test for antibodies to syphilis.

In addition, a woman needs to undergo a fluorography and an ECG procedure.

It is forbidden to take hormonal contraceptives during preparation for removal – the barrier method of protection is optimal.

The operation is preceded by hospitalization of the patient at least a day in advance, since laparoscopy itself is performed only in a hospital setting.

The date of the intervention is chosen in the period between the end of menstrual flow and the onset of ovulation.

A day before the procedure, a woman switches to a light diet – it is necessary to exclude fried and fatty foods from the diet, and give preference to vegetable soups and mashed potatoes, cereals, sour-milk products. In the evening before going to bed and in the morning before the operation itself, it is necessary to clean the intestines with an enema. Hair from the pubis and lower abdomen must be removed.

Since the operation is performed exclusively under general anesthesia, it is forbidden to eat after 18 hours. Liquids should not be consumed 6-8 hours before the intervention.

On the eve of laparoscopy in the evening, and later, in the morning, the patient is given an injection of a drug that reduces anxiety.

How the operation is performed: types of laparoscopy of the uterus and appendages

Before starting the intervention, the patient puts special compression stockings on her legs. After she has settled down on the couch in the operating room, two catheters are inserted into her vein and bladder. Through the venous anesthetic is supplied to the body, as a result of which the woman goes into a state of drug-induced sleep.

As soon as anesthesia begins to take effect, the doctor makes the required number of incisions through which instruments are inserted into the abdominal cavity. A prerequisite for the operation is ultrasound control, that is, the state of the cavity from the inside, the doctor sees both on the monitor of the ultrasound machine and through the laparoscope camera.

There are three types of transactions. Their differentiation depends on the volume of the removed organs:

• supravaginal amputation involves the removal of only the body of the uterus, while the cervix and appendages remain;
• total hysterectomy: in this case, the uterus is removed completely, while the appendages are not affected;
• radical hysterectomy, in which the uterus and appendages are completely removed, sometimes the upper sections of the vagina, as well as the pelvic and inguinal lymph nodes.

Rehabilitation: what happens after laparoscopy

Of course, the recovery period after laparoscopy is significantly shorter than after laparotomy, but it still takes about 1 month.

On the first day immediately after the operation, a woman is forbidden to get up and move. All physiological needs are met using a special vessel.

On the second day, it is allowed to get out of bed, but only wearing compression stockings or tights, and a supporting bandage on the stomach. Such “ammunition” will need to be put on every time before you start walking. Doctors insist that after the second day a woman needs to walk a lot in order to prevent the formation of adhesions, as well as the onset of congestive processes in the lungs.

The stay in the hospital lasts from 3 to 5 days. At this time, nurses treat the woman’s wounds, and also inject painkillers as needed.

After discharge, once home, it is forbidden to take a bath or shower – it is absolutely impossible to wet the stitches until they are removed. Partial washing is allowed.

A component of rehabilitation after laparoscopy is dietary restrictions. Excluded from the diet:

• sweets;
• coffee;
• chocolate;
• White bread;
• fatty and spicy foods.

The main task of the diet after the procedure is to prevent constipation. It is necessary to switch to a fractional diet – eat 5-7 times a day in small portions. In the woman’s menu after the operation, dairy and vegetable soups, cereals, sour-milk products are allowed.

Physical activity, especially with an emphasis on the abdomen, is strictly prohibited, so it will be necessary to wait a little while lifting weights or doing abdominal exercises. It is also necessary to refrain from sexual intercourse. The doctor may recommend special therapeutic exercises. It also determines the duration of the imposed restrictions on food, intimate life and physical activity.

The sutures are removed approximately 2 weeks after the intervention.

Possible complications and consequences of the operation

Laparoscopic removal of the uterus and appendages, naturally, causes a woman to no longer become pregnant and bear a fetus. She also stops menstruating.

When the ovaries are removed, in the first three weeks a woman feels symptoms similar to the manifestations of menopause – sweating, tearfulness and irritability, insomnia and bouts of heat.

After the operation, continuous hormonal therapy becomes a daily necessity for the patient. If you do not take the appropriate drugs, after some time problems will develop in the work of the heart and blood vessels, there will be discomfort in the vagina (dryness, itching), and chronic cystitis. In addition, a complication after removal of the ovaries is osteoporosis and thyroid disorders.

After the operation, if the surgeon worked carelessly and performed laparoscopy unskilledly, bleeding, suppuration, adhesions, urinary incontinence and constipation, and blood poisoning may occur.

Laparoscopy of the uterus and its appendages is an extreme measure to get rid of some diseases of these organs. If the issue of preserving the reproductive organs, or saving the life of the patient, is at stake, of course, the attending physician will recommend their removal.

As a diagnostic procedure, laparoscopy is rarely performed, and only in cases where all non-invasive examination methods do not provide complete and objective information necessary for making a diagnosis and developing a treatment regimen. At the same time, as a method of performing surgical intervention, laparoscopy has a number of obvious advantages over laparotomy, for example, a shorter postoperative recovery period, a lower likelihood of developing severe complications, and the absence of large scars and scars from dissection of the abdominal wall.