Complete removal of the uterus and appendages
The scope includes the intersection of the infundibulopelvic ligaments (with control of the ureters), removal of the appendages en bloc with the uterus, a thorough examination of the abdominal cavity and, for oncological indications, washings, biopsy of the omentum and lymph nodes. In postmenopausal women, the ovaries no longer function, and their removal eliminates the risk of ovarian cancer without consequences for well-being; In younger patients, when the ovaries are removed, hormone replacement therapy is prescribed in the absence of contraindications. All tissues are sent for histology; further tactics are determined by its results.
Indications
- multiple and large uterine fibroids (more than 12–14 weeks) with bleeding, anemia, pressure on neighboring organs;
- adenomyosis, atypical endometrial hyperplasia, recurrent bleeding in perimenopause;
- uterine prolapse (vaginal access), combined with prolapse of the vaginal walls;
- ovarian tumors in combination with uterine pathology, hereditary risk - with removal of the appendages;
- contraindications or impossibility of laparoscopy: very large sizes, adhesions, severe concomitant diseases.
Scope of operation
Amputation (supravaginal) - removal of the uterine body while preserving the cervix with a healthy cervix: in short, with less risk to the ureters; extirpation - removal of the uterus along with the cervix in case of cervical pathology, adenomyosis, hyperplasia; “with appendages” means the simultaneous removal of tubes and ovaries (in postmenopause, with tumors, hereditary risk), “without appendages” - preservation of the ovaries and hormonal function in women before menopause (tubes are usually removed to prevent cancer). Vaginal access (through the vagina) is used for prolapse of the uterus and its small size - without incisions on the abdomen and with the fastest recovery, often together with plastic surgery of the vaginal walls; laparotomy - for a large uterus, adhesions, or the need for revision.
When to choose laparotomy
Open access through a transverse Pfannenstiel incision (along the bikini line) remains the method of choice for very large sizes of the uterus and formations, multiple fibroids with deep nodes, severe adhesions after many operations, suspected malignancy with the need for revision, severe heart and lung diseases in which pneumoperitoneum is undesirable, as well as when laparoscopy is unavailable. Laparotomy gives the surgeon direct control of the tissue and a reliable multi-layer suture on the uterus; the scar after cosmetic suturing is barely noticeable. Recovery is longer than after laparoscopy: hospital stay 3–6 days, exercise limitation 1.5–2 months.
