What Are the Pros and Cons of a Hysterectomy for Cancer?

Extensive hysterectomy, also known as radical hysterectomy, is a surgical treatment for cervical cancer.

General hysterectomy

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Extensive hysterectomy, also known as radical hysterectomy, is a surgical treatment for cervical cancer.

Chinese name

General hysterectomy

Alias

Radical hysterectomy

Classification

Obstetrics and Gynecology / Gynecological Surgery / Abdominal Surgery

ICD encoding

68.4 07

General hysterectomy

Radical hysterectomy; wetem operation; Wertheim Operation

Obstetrics and Gynecology / Gynecological Surgery / Abdominal Surgery / Malignant Tumor Surgery / Cervical Cancer Surgery

Extensive hysterectomy is used for the surgical treatment of cervical cancer. The basic procedure for the surgical treatment of cervical cancer is to remove all regional lymph nodes and perform extensive total hysterectomy. Pelvic lymph nodes must be completely and carefully removed, including the total iliac crest, external iliac crest, internal iliac crest, obturator, main ligament group, and if necessary, the paraabdominal aorta, anterior lumbosacral, and deep groin groups. Extensive hysterectomy must open the side fossa of the bladder, separate and cut the ligaments and connective tissues connecting the uterus before, after, and on both sides, remove the fatty tissue around the main ligament, and cut off near the pelvic wall. After all the connective tissues near the vagina are removed , Resection of the vagina, the margin is generally 3 to 4 cm away from the lesion. Surgery-related anatomy, pathology, and imaging findings.

Extensive hysterectomy is suitable for:

1. Applicable to cervical cancer b a (including combined pregnancy or postpartum).

2. Patients with vascular infiltration and fusion infiltration in stage a.

1. Those who are over 65 years old and have other adverse factors.

2. Weak constitution or those with heart, lung, liver, kidney and other organ diseases.

3. Pelvic inflammation or endometriosis, and extensive adhesions.

4. Patients with stage IIa or above with obvious infiltration of the cervix, or metastasis to the bladder and rectum.

5. Overweight people.

Extensive hysterectomy is a large and complex operation. Preoperative preparation, postoperative treatment, and surgical operation are equally important to the effect of surgery. The following preparations must be made before surgery.

Mental preparation

The operator must give full consideration to the surgical procedures, the problems that may occur during the operation, and the solutions. Serious preoperative discussions are also required to complete a major surgery declaration form. The patient and his family were introduced to the patient's condition and surgery separately. On the one hand, the patient's enthusiasm was mobilized to actively cooperate with the treatment; on the other hand, the family members were informed about the possible consequences to gain understanding and cooperation.

2. Inquire about medical history and examination in detail

Understand the current and past medical history, whether there is disease in important organs, whether there is bleeding tendency and history of inflammation.

Routine examination of patients' heart, lung, liver, kidney and other organ functions, chest X-rays, ECG, B ultrasound, cystoscopy and intravenous pyelography if necessary. If there is a suspected transfer, further CT examination can be performed.

3. Management of comorbidities before and after surgery

Anemia should be corrected, bleeding tendencies should be effectively treated, and infected lesions should be controlled; malnutrition and metabolic disorders should be actively corrected; blood pressure in patients with hypertension should be properly controlled, but should not be lowered too much; excessive obesity And the elderly frail, the surgery should be particularly meticulous, hemostasis should be sure, and infection should be prevented.

4. Preparation before surgery

Diet: Start a low-dreg diet 3 days before surgery, from semi-liquid to liquid, fasting at night 1 day before surgery; enema: clean enema before surgery; vaginal preparation: rinse the vagina with potassium permanganate solution 3 days before surgery, Or use Xinjieer to wipe the vagina once a day; Sleep: Stabilize the night before the operation; Skin preparation: 1d before the operation, the patient takes a shower. From the abdomen to the xiphoid process, down to the pubic symphysis, scrub and shave with soapy water within the range of 1/3 of the vulva and upper thigh. Pay special attention to cleaning the dirt in the umbilical fora; blood preparation; apply atropine or scopolamine before surgery. Lumina.

General continuous epidural block anesthesia or general anesthesia. General hysterectomy has a long operation time and more operations in the deep part of the pelvic floor. In order to ensure muscle relaxation, the surgical field can be fully exposed, and to ensure patient safety, continuous epidural anesthesia or general anesthesia is the most ideal. .

After the patient entered the operating room, the bladder lithotomy position was taken to disinfect the vulva, vagina, and cervix. Gentiana purple on the vagina. Place and retain the catheter. Taking an upright supine position during surgery is conducive to exposing the pelvic surgical field. Routine disinfection of the abdominal skin.

An important part of general hysterectomy is the removal of lymph nodes. Recently, large-scale carpet resections have been advocated, including lymph nodes, lymph vessels, and surrounding fatty tissue. For the sake of clarity, it is still explained by disassembly surgery.

Incision

Generally, a longitudinal abdominal incision is used, extending 3 to 5 cm to the left side of the umbilicus, and the pubic symphysis is delivered. Cut the layers of the abdominal wall one by one, and the fascia below must be cut to the pubic bone in order to expand the surgical field and facilitate the operation. Some people also advocate taking a transverse abdominal incision, but the rectus abdominis muscle must be severed, the tissue damage is large, and the exposed surgical field is inferior to the longitudinal incision. After the abdominal cavity is opened, first explore the uterine activity, whether there are adhesions and lesions on the two sides of the appendix, whether there is infiltration, hypertrophy or adhesion in the uterine tissue, bladder, rectum, etc .; check the pelvic lymph nodes and abdominal aortic lymph nodes for swelling and induration ; Explore liver, gallbladder, spleen, kidney, diaphragm, and greater omentum. If there is extensive adhesion or cancer metastasis, it is estimated that surgical resection is difficult. The operation should be stopped, the abdominal cavity should be closed, and radiation therapy should be replaced. Otherwise, the operation continues.

2. Clamp the horns of the uterus

Clamp the round ligaments, ovarian uterine ligaments, and fallopian tubes on both sides with two long-curved vascular forceps to pull the uterus. Lift the uterus gently, and push the intestine up gently with a large cotton pad to completely leave the surgical field, and place an automatic hook to fully expose the surgical field. In the past, the conventionally used two-claw forceps or single-claw forceps are used to pull the uterus, which is not suitable for patients with malignant tumors. The main consideration is that if there is cancer infiltration in the uterus, clamping the uterus will inevitably promote the spread of cancer cells and must be prevented in advance.

3. Cut the pelvic funnel ligament

Starting from the right side, in order to avoid damage to the ureter, the position where the ureter crosses the common iliac artery must be checked, and the peritoneum is opened after being lifted on its side, first cut 3 to 4 cm, and then cut down along the ureter. Here the peritoneum is thin and the ureter is superficial, often seen through the peritoneum. If you are not sure, you can gently stimulate the device and see the ureter peristalsis.

4. Clamp, cut, and suture ovarian vessels

Because the posterior peritoneum is opened, it is easy to identify the bundled ovarian arteries and veins, make blunt or sharp separation, fully expose its direction of travel, clamp, cut, suture near the pelvic wall, and do double suture. Some people do not advocate opening the posterior peritoneum and free ovarian blood vessels, but adopting direct clamping, cutting and suture will increase the chance of ureteral injury.

5. Clamp, cut, and stitch the right circular ligament

Clamp and cut at the junction of the middle and outer 1/3 of the right circular ligament, sew on the 7th silk thread, and leave a long thread at the far end for traction. The left round ligament was treated in the same way.

6. Cut the anterior leaf of the broad ligament

Cut the anterior leaflet of the broad ligament along the lateral side of the pelvic leak ligament to the left end of the round ligament.

7. Cut back the bladder and peritoneum

Starting from the right round ligament stump, make an arc cut forward and down to the left round ligament stump.

8. Push down the bladder

Push the bladder directly to the outer mouth of the cervix. According to the anatomical structure, there are 3 folds between the cervix of the bladder, which can be bluntly separated with fingers, and if necessary, push down with the scissors while separating. Start from the middle, then separate to the left, and finally push to the right. If the anatomical level is clear, it is easy to push the bladder without bleeding. If the adhesion is tight, a sharp incision can be made, and the bleeding site is ligated to stop bleeding. Due to the rich blood vessels on both sides of the cervix and vagina, it is advisable to push the bladder along the blood vessels to the sides to push the bladder laterally, so as not to damage the venous plexus on both sides and cause bleeding. After the bladder is pushed open, it can be pressed here with saline gauze.

9. Exposing common iliac arteries and ureters

The cut posterior peritoneum was sutured on both sides with silk sutures or pulled with small vessel forceps to fully expose the common iliac artery and its bifurcation. The external iliac artery and internal iliac artery can be seen in the visual field, and the ureter crosses from the front of the common iliac artery to the inside.

10. Exposing the external iliac artery and genital femoral nerve

Isolate the honeycomb tissue before the external iliac artery, and expose the external iliac artery, psoas muscle, and the genital femoral nerve between them. With a little attention, the genital femoral nerve can be protected from damage.

11. Exposing the external iliac vein and deep circumflex vein

The fibrous fat mass in front of the iliac vessels was separated, and the external iliac vein was visible behind the external iliac artery. Separate down to the external iliac artery, and see the circumflex deep vein.

12. Clear the total lymph nodes

Using a hook to pull open at the upper right of the incision, the common iliac lymph nodes can be exposed in front of and inside the common iliac arteries. When the lymph nodes are dissected according to the anatomical characteristics, they are removed from the outside to the inside and from the distance to the near. The sharp separation of lymph nodes and fat separation has many advantages, it can accurately remove the relevant tissue and overcome the shortcomings of cancer cell spread caused by the blunt separation of the surrounding tissue. When lymphatic tissue is resected, the lymphatic vessels are incision, and the lymphatic incision is made in less places, and the upper and lower ends are ligated. According to pathological studies, cancer metastasis is generally confined to the lower segment of the common iliac artery, so it is cleared from the lower segment. Take care to protect the ureter.

13. Ligament the small branch of common vein

The common iliac vein is located behind the common iliac artery. There is a small vein branch at the branch of the common iliac artery. It must be clamped, cut, and sutured to avoid injury and bleeding, which affects the entire operation.

14. Exposing the external iliac lymph nodes

The outer iliac artery sheath was cut longitudinally along the external iliac artery, and the lymph nodes and adipose tissue around the blood vessel were removed from top to bottom. Be careful not to damage the genital femoral nerve on the medial side of the psoas muscle and close to the blood vessels.

15. Clear deep groin lymph nodes

There is a large deep inguinal lymph node below the medial inguinal ligament of the lowermost segment of the external iliac blood vessel, and the lower part is the deep circumflex venous vein. Pay attention to protect and prevent damage when removing the lymph nodes. Because the lymphatic vessels are thicker here, when the lymph nodes are cleared, the distal end is ligated with a filament to reduce the formation of postoperative lymphatic cysts.

16. Clearing the iliac lymph nodes

Lymph nodes in this group are small and run deep along the internal iliac vein. Free the fat and lymph nodes inside the external iliac vein with hemostatic forceps or curved scissors, and then pull the fat and lymph tissue to the outside to expose the internal iliac artery. Separate and remove the fat and lymph tissue above and outside the artery. Be careful not to damage nearby veins. Remove the lymph nodes and adipose tissue as much as possible. At this point, the fat lymphoid tissues between the inner and outer vessels of the iliac crest have all been cleared.

17. Ligament the small branch of the external iliac vein

After the fat and lymphoid tissues between the internal and external vessels of the iliac crest are cleared, there is a small branch in the lower segment of the external iliac vein. At this time, ligation should be performed to prevent bleeding and affect the surgical field.

18. Exposing the obturator fossa

Pull the bladder inward, and gently pull the external iliac vein outward with a small hook, and continue to separate it with scissors or fingers on the outside of the internal iliac artery until it reaches the obturator fossa. The obturator fossa is located between the external iliac vein and the pelvic wall.

19. Separation of obturator lymph nodes

Use fingers or curved blood vessel forceps to separate the fat in the obturator fossa, reveal the obturator lymph nodes, behind the obturator nerve, parallel to the left pelvic wall. The vascular forceps used for separation should not be rough and should not be inserted too deep to prevent damage to obturator arteries and veins, obturator nerves and pelvic floor venous plexus.

20. Clear the obturator lymph nodes

Because obturator lymph nodes are sometimes close to obturator vessels and obturator nerves, special care must be taken when removing lymph nodes to prevent damage to blood vessels and nerves. If there is damage to the small blood vessels in the obturator fossa, there will be a lot of bleeding, and ligation or compression of hemostasis is necessary when necessary. Because the lymphatic vessels are thicker here, they should be ligated when removing the lymph nodes.

21. Isolate Uterine Artery

Both the uterine artery and the superior bladder artery are separated from the posterior internal iliac artery. Before ligating the uterine artery, the two must be distinguished to prevent accidental ligating of the superior bladder artery. The uterine arteries branch down and inwardly, and enter the uterus at the inner mouth of the cervix; while the superior bladder arteries are on the outside and go all the way to the bladder. Uterine arteries are slender and curly, with a diameter of no more than 2mm; the superior bladder arteries are relatively straight and non-curly. Separate the uterine artery from the internal iliac artery, and be careful not to damage the uterine vein.

22. Clamping Uterine Artery

After the uterine artery is identified clearly, 1 cm away from the internal iliac artery, clamp 2 blood vessels on the uterine artery. Under normal circumstances, the uterine vein is not parallel to it, but the ureter should be recognized, and clamped outside the ureter, a few centimeters apart. If you do not swim away from the uterine artery, do not clamp it near the internal iliac artery, and clamp it in front of the ureter, it is likely to damage the ureter.

23. Cut off and ligate the uterine artery

After the uterine artery is cut, the distal end is double-ligated, and a line is left near the end of the uterus to serve as a sign of traction.

24. Isolation of uterine veins

It is not difficult to identify the uterine veins. There is a certain distance between the uterine veins and the uterine arteries. The deeper part of the uterine arteries enters the internal iliac veins. Most of them walk behind the ureter and approach the uterus at an acute angle. Therefore, when separating the uterine vein, care must be taken not to damage the ureter and adjacent blood vessels.

25. Clamping, cutting, and ligation of uterine veins

The purpose of ligating the uterine veins is to create conditions for proper control of bleeding when the ureteral tunnel is separated in the future. Generally, the uterine artery is not ligated together. On the one hand, the uterine arteries and veins are far away, which is easy to damage the ureter. On the other hand, if the uterine artery is ligated together, the vein will easily rupture during the subsequent operation, causing bleeding and increasing surgical difficulties.

26. Free superior bladder artery

The superior bladder artery is divided by the internal iliac artery, and is finally distributed on the surface of the bladder, located outside the ureter, and freed from injury during the next operation. However, some people have argued that separation is not necessary. At this point, the right side is all over, and the left side is treated in the same way.

27. Free ureter

In order to meet the requirements of extensive hysterectomy, free ureter is an important step. The blood flow of the ureter comes from the attached blood vessels. In order to prevent the occurrence of ureteral fistula, the blood supply of the ureter should be preserved as much as possible. Therefore, it is advisable to start the ureter freely from the uterine artery across 2 to 3 cm above the ureter. Nutritional branch of the ureter. To free the ureter from the posterior peritoneum, first lift the posterior peritoneum, and then use scissors to cut loose connective tissue 1 cm away from the ureter, with the concave side of the scissors upward, and gently free the ureter to the uterine artery.

28. Continue pushing down the bladder

The bladder has reached the outer mouth of the cervix. In order to extensively remove the vagina and adjacent tissues, continue to separate the bladder with scissors or fingers to clearly show where the ureters on both sides enter the tunnel.

29. Isolate and cut the anterior lobe of bladder and cervical ligament

In order to adequately remove the cervical and paravaginal tissues and lymph nodes, the bladder and cervical ligaments must be opened to free the ureter. Here, the ureter travels inward and forward. When clamping the bladder and anterior leaflet of the cervical ligament, use curved vascular forceps to extend into the tunnel, with the concave side facing forward, and then gently separate in this direction, pressing the ureter to the rear. Only when it is confirmed that the ureter is not clamped, it can be cut and sutured. It is necessary to be bold and decisive in handling ureteral tunnels, and to be cautious; to prevent coarse clamps that damage the ureter, but also not to be timid, to separate the anterior leaflet too shallowly, to treat the remaining parts insufficiently, to cause insufficient ureteral freeness, and to treat the posterior leaflet. There are bound to be difficulties. If the anterior layer is completely cut off, the entire ureter can be seen with less bleeding. On the contrary, the anatomy is unclear and there is a lot of bleeding. It has also been suggested that the use of indicators here for blunt separation can avoid bleeding and damage to the ureter. However, this method is very slow, and if it is stuck, it is more difficult. Because the vaginal venous plexus is distributed above and below the tunnel and the ureter is in between, care must be taken during separation to avoid bleeding.

30. Isolate and cut off the bladder and posterior lobe of cervical ligament

Carefully separate the posterior ligament leaf to prevent bleeding and damage to the ureter.

31. Incision of the posterior leaf of the broad ligament and uterine and rectal peritoneum

Pull the uterus in the direction of the pubic symphysis, use scissors to cut the uterus and rectum peritoneum in a transverse direction, and extend to the posterior leaf of the broad ligament along both sides to the free ureter. If this incision position is too high, it is difficult to separate the peritoneal reflex and it is easy to damage the ureter.

32. Push the rectum away

Lift the cut posterior peritoneum and use curved scissors or fingers to separate the rectum from the posterior wall of the vagina along the lower posterior direction of the cervix.

33. Continue to push down the rectum

Along the medial side of the uterine and sacral ligaments on both sides, push the two sides of the rectum away, and the middle part continues to separate the rectum from the vaginal wall, reaching 2/3 below the vagina.

34. Exposing lateral rectal fossa

On the outside of the ligament of the uterus and sacrum, loosen the cellular tissue with scissors or fingers to expose the rectal fossa. At the same time, most of the uterine sacrum ligaments are free.

35. Cut and suture the superficial layer of the right patella ligament

Use the hook to gently pull the right iliac vessel and ureter to the outside, push the rectum to the opposite side, fully expose the iliac ligament, clamp the superficial layer of the iliac ligament with curved vessel forceps, cut off, and sew on the 7th silk thread.

36. Cut and suture the deep layer of the right patella ligament

Because the patient takes a supine position, the lower rectum is lifted higher. When clamping and cutting the ligament of the uterus and sacrum to the deep, it is necessary to pay attention to the curvature of the sacrum and the direction of the rectum walking along this curve. Failure to pay attention to this anatomical feature may damage the rectal wall. The deeper you go, the more you need to pay attention. It is better to use the curved blood vessel forceps and scissors.

37. Cut and suture the main cervical ligament on the right

Push the superior bladder artery apart to avoid injury, and use the index finger to separate the bladder fossa along the side wall of the bladder. Then use the hook to gently pull the ureter outward to expose the main ligament. Use long curved blood vessel forceps near the pelvic wall to make one or two clamps, cut, and sew with a 10-gauge silk thread. When the main ligament is separated, pelvic floor vein bleeding is often prone to occur, and it is difficult to handle. The operation should be gentle during surgery to prevent bleeding.

The steps from processing the left pelvic funnel ligament to processing the left main ligament are the same as the right.

38. Isolate left paravaginal tissue

The uterus is completely separated from the posterior wall of the pelvis, the lymph nodes beside the cervix and the vagina are all free, the tissues around the iliac vessels have been separated, the rectum and the vagina are separated, and the uterus is only connected with the vagina and the anterior wall. At this time, pull the bladder and ureter with a pull hook, and use curved scissors to separate the bladder and the side more than 3 cm to the side of the bladder. There is more bleeding here, preventing damage to the bladder and ureter when ligation and hemostasis. The depth of the separation of the paravaginal tissue should be consistent with the level of the separation of the rectum, that is, the plane at which the vagina is to be removed. The opposite side is treated in the same way.

39. Clamping, cutting and suture the paravaginal tissue

Use long-curved vascular forceps to clamp the tissue near the vagina. The tip of the forceps should reach slightly below the expected vaginal plane, and the stump of the ligament of the uterus should be reached behind. Before clamping, cutting, and suture, you must check whether there is any damage to the bladder and ureter. Only when the check is correct, you can cut it. Use a 10-gauge silk thread for penetrating suture. If the tissue around the vagina cannot be completely removed at one time, it can be performed in several steps.

40. Clamping and circumcision of vaginal wall

Pull the uterus up to reveal the vaginal area. Use two right-angle vascular forceps to clamp the vaginal wall 3 to 4 cm below the cervix, one left and one to prevent cancer cells from falling out of the pelvic cavity. Cut the vaginal wall under the right-angle vascular forceps and remove the entire specimen.

41. Suture the vaginal wall

After circumcision of the vagina, use mouse tooth forceps to lift the front, back, left, and right of the incision at 4 o'clock. After routine disinfection of the broken end, stuff the dry gauze into the vagina, and push all the pollutants that may reach the pelvis to the vagina. Remove the gauze at the time. However, some people do not advocate clogging the gauze and believe that the possibility of contamination is unlikely. The treatment of vaginal stump is different from each other. Commonly used are continuous locking sutures to close the vagina, close the vagina, put 2 extraperitoneal drainage tubes in the pelvis, and extend from both sides of the lower abdomen, so that the pelvic extraperitoneum Bleeding and lymph fluid drained out. Another method is to suture the vaginal wall continuously, open the vagina, and place two extra-peritoneal drainage tubes from the pelvis to the vaginal drainage. Both have advantages and disadvantages. The former has scars on the abdominal wall and drainage is not as smooth as vaginal drainage, but the latter has more opportunities for vaginal ascending infections than abdominal wall drainage. Another method is to suturing the vaginal wall intermittently. After placing a cigarette drainage tube in the pelvic peritoneum, the method is simple and less exudative. However, when the vaginal wall is bleeding, the hemostatic effect of intermittent suture is not as good as the first two. After placing the drainage tube, observe the amount of exudate to determine the time to take it out, usually 3 to 5 days. There was not much bleeding and little exudation during the operation, and some people suggested that the vaginal wall be continuously locked or mattress sutured, all closed and not drained. In short, suture the vaginal wall and related drainage problems, there are many kinds, which can be selected based on their own experience. After the vaginal wall suture is completed, some people also advocate suture the anterior rectum wall and the posterior vaginal wall to prevent premature healing of the open vaginal wall; purse suture the bladder to prevent urinary retention; fold the peritoneum of the bladder back to the anterior vaginal wall to prevent the bladder Leaning back; urine retention to strengthen the bladder. However, some people do not advocate such surgery. In this regard, more experience needs to be accumulated.

42. Suture the pelvic peritoneum

Check the surgical field for sutures before suture. If there is bleeding, you must stop bleeding; pay attention to the ureter, bladder, rectum for damage; whether the ureter is ectopic or warped, it should be kept in place. The pelvic peritoneum was sutured continuously or intermittently with No. 0 intestine or No. 4 silk, and the round ligaments were fixed on it. It is not easy to tighten the pelvic peritoneum when sutured. Be careful not to damage the ureter.

Finally, clean the abdominal cavity, count the gauze and instruments, and suture the abdominal wall incision in layers. Remove the vaginal gauze at the same time. The removed specimens were measured and cut open according to regulations, made a detailed record, and sent for pathological examination.

1. Avoid damage to the ureter

You should be familiar with the anatomical relationship of the ureter. During the operation, care should be taken to protect the ureter from accidental injury. Particular attention should be paid to freeing and ligation of ovarian arteries and veins, treatment of sacral ligaments, separation of ureteral tunnels, and suture of pelvic peritoneum. Do not clamp the ureter with surgical instruments or excessively stretch it for a long time. The free ureter should not be too long to avoid damaging the ureteral sheath and ureteral nutrition vessels to protect its blood supply. If there is bleeding around the ureter, avoid ligating with thick wires or excessive knots.

2. Clearance of lymph nodes

When removing the lymph nodes from the outside to the inside, from the distance to the near, according to the anatomical characteristics, try to make a large excision, because the lymph nodes and lymph vessels are embedded in the surrounding honeycomb tissue and adipose tissue. Because the lymph nodes run along the blood vessels, and the lymph vessels are often accompanied by small blood vessels, care must be taken not to hurt the accompanying blood vessels. According to the direction of the lymphatic vessels when removing lymphoid tissues, the lymphatic vessels should be carefully ligated to prevent the formation of lymphatic cysts, especially in the outer iliac group, deep inguinal lymphatic group, and obturator group.

3. Prevent bleeding

The wall of the venous tube is thin and easy to be damaged, especially at the intersection of the internal and external iliac veins. When the lymph nodes are cleared, it can be damaged with a little care, and difficult to control large bleeding occurs. In the deep pelvic ligation and hemostasis, it is important to tie the knot accurately. If the ligature is loosened, the stump of the blood vessel is retracted, and then clamping is likely to cause injury or major bleeding. Pay attention to the anatomy and operation points of each step in the operation, it is important to prevent bleeding. For example, when clearing the obturator lymph nodes, do not forcibly pull them from the pelvic wall, and do not involve the deep layers of obturator nerves. When uterine arteries and veins are free, pay special attention to their anatomical position and direction, and ligate them separately. Be sure to stop bleeding. When suturing and ligating the tissue near the vagina, do not pull the uterus excessively to prevent bleeding between the posterior wall of the vagina and the pelvic floor. The anterior iliac venous plexus is generally not easy to be damaged. There was more than a major bleeding. At this time, do not clamp, so as not to cause more tears, but can only compress the hemostasis, and then suture the hemostasis when the bleeding point is found.

After extensive hysterectomy, do the following:

1. Pay close attention to blood pressure and pulse, especially in 12 hours after surgery. At the same time, pay attention to the drainage and bleeding of the drainage tube. If there are complications such as shock, it can be detected early and treated in time.

2. Record the amount of input and output and pay attention to the electrolyte and acid-base balance in the body.

3. Diet should be determined according to the recovery of digestive function, generally 1 to 2 days into the juice, change to semi-liquid after exhausting, and then gradually resume the ordinary diet. In principle, a high-protein, high-calorie, high-vitamin diet should be based.

4. Antibiotics are routinely applied to prevent infection after antibiotics.

5. Open the drainage within 5 days after indwelling the catheter, pay attention to urine volume and urine color. If there is no hematuria, open it regularly and remove it around 7 days. After the catheter is removed, encourage yourself to urinate and measure the remaining urine. If the remaining urine exceeds 100ml, treat as urine retention.

6. The vaginal or abdominal wall drainage tube is removed 3 to 5 days after surgery, and local care should be taken.

Bladder and ureteral injury

The main causes of bladder vaginal fistula and ureteral vaginal fistula are two types of direct injury and ischemic injury. Direct injuries are accidental injuries caused by unfamiliar anatomical locations or anatomical variations. Ischemic injury is caused by ischemic necrosis due to blocked local blood circulation. If a urinary fistula has appeared and the fistula hole is not large, the time for placing the urinary catheter can be extended for 4 to 6 weeks, and the hips can be raised to fully rest the bladder and ureteral end in order to obtain self-healing. If conservative treatment is ineffective, early surgical treatment should be performed.

2. bleeding

During extensive hysterectomy, pelvic floor vein bleeding is often prone to occur when the main ligament and ureteral tunnel are separated. At this time, temporary block of the internal iliac artery or common iliac artery can be used to control local bleeding and find the bleeding point and then sew Tie to stop bleeding; or use compression to stop bleeding (at least 7min), and add vasoconstriction drugs, and sew until the bleeding point is found, do not clamp blindly. If large vessels are damaged, non-invasive sutures or anastomosis are required. Anticoagulation and anti-infection must be treated during and after surgery.

Recent postoperative bleeding is mostly due to inaccurate hemostasis or loosening of the ligature. If the vagina can be clamped, sutured to stop bleeding, such as in the pelvic cavity, and there is more bleeding, the abdomen should be opened immediately to stop bleeding. If it occurs within a few days after the operation, it is mostly caused by secondary infection, and a large number of antibiotics can be used to control the infection. Such as vaginal bleeding, local antibiotics, vasoconstrictors, coagulants can be used to stop bleeding; if bleeding in the pelvic cavity, you should open the abdomen in time for vascular occlusion or stuffing, drainage, plus large doses of antibiotics.

No matter what method is used to stop bleeding, blood volume must be replenished in a timely manner, complications caused by blood loss must be corrected, and infection must be prevented. If there is a tendency for bleeding, the cause should be investigated and corrective measures taken.

3. infection

The cause is a potential infection or co-infection before surgery, or accidental contamination during surgery, or a secondary infection after surgery. Preventive or therapeutic anti-infection measures should be adopted according to the situation. Preventive measures should use broad-spectrum antibiotics. For therapeutic anti-infection, timely choose antibiotics that are sensitive to pathogens. If there is a pelvic abscess or lymphatic cyst, drainage should be timely.

4. Dysfunction Paralysis of the bladder: due to pelvic visceral nerves and blood vessels being damaged during operation, the detrusor function of the bladder is weakened and urinary retention is formed. The measures to prevent bladder paralysis include preserving the pelvic plexus and its collaterals, retaining the superior and inferior bladder arteries and ganglia, and avoiding urinary retention and infection after surgery. Rectal anesthesia is rare. Try to keep the blood vessels, nerves and other tissues inside the uterine and sacral ligaments during the operation as much as possible to prevent the occurrence of rectal paralysis. shorten the vagina, remove most of the vagina, will affect sexual life. Can be resolved by extending the vagina. The bladder peritoneum is reversely sewn on the anterior wall of the vaginal stump, and the rectal peritoneum is reversely sewn on the posterior wall of the vaginal stump. Finally, the serous muscle layer of the posterior bladder wall and the anterior rectum wall is continuously sewn to an appropriate height to make the vaginal depth To be extended. Artificial menopause, young women undergoing extensive hysterectomy and double appendectomy can form artificial menopause. In particular, estrogen deficiency can also cause osteoporosis. According to statistics, 9 times as many patients with fractures died of osteoporosis as cervical cancer. Therefore, in recent years, it has been emphasized that the scope of surgery depends on the stage of cervical cancer. For young patients before stage b, normal ovaries can be retained. In order to prevent the recurrence of cancer, the ovary can be moved to the peritoneum high in the abdominal cavity, or the ovary can be transplanted to the abdominal wall, under the armpit, etc. Pelvic retroperitoneal lymph cysts, mainly due to the removal of lymph tissue, leaving dead space behind the peritoneum; the returning lymph fluid retains to form cysts, and the cysts gradually increase can produce compression symptoms; secondary infections appear fibrosis, forming hard masses, often Easily misdiagnosed as recurrent cancer. The precautionary measures are to ligate the stump of the lymphatic vessels, especially those with thick lymphatic vessels, which should be ligated. The drainage tube was placed behind the pelvic peritoneum, and it was taken out 3 to 5 days without leaving the dead space, which could prevent the formation of lymphocysts. If symptoms have occurred and compression symptoms have occurred, then topical application of Glauber's salt can be used; in cases of secondary infection, incision and drainage outside the peritoneum; formation of fibrotic cysts and symptoms, extraperitoneal resection is feasible.