Hello: The Second Hospital of the People's Liberation Army of Gansu Province sincerely answered the question of myomectomy [anesthesia method] 1. Continuous epidural anesthesia. 2. General anesthesia with tracheal intubation. 【 Preoperative preparation 】 Cervical smear and diagnostic curettage were performed before operation to exclude cervical and uterine malignant tumors. [Operation Steps and Technical Points] 1. Lower median incision or upper transverse incision of pubic symphysis. 2. Explore the location, size and quantity of hysteromyoma, and determine the uterine incision. 3. Blocking the blood supply to the uterus Before myomectomy, make a small incision in the avascular area of the left and right broad ligaments in the isthmus of the uterus, put on a rubber tube tourniquet, and ligate the uterine artery and vein to temporarily block the blood supply. If the operation takes a long time, loosen the tourniquet every 10 ~ 15 minutes 1 minute. During the operation, uterine contractile agent can also be injected into the myometrium of uterus to reduce bleeding during the operation. 4. Excise the intramural myoma from the part with less blood vessels on the surface of the myoma. According to the size of the myoma, a longitudinal, spindle or arc incision is made to reach the capsule of the myoma, and then it is passively separated along the surface of the capsule. When there are many blood vessels at the base, the tumor can be removed after clamping and the stump can be sutured. Suture the muscle layer 1 ~ 2 with absorbable thread "8" or continuously. Pay attention to avoid dead ends when sewing. The seromuscular layer was sutured intermittently or continuously with 0 absorbable thread. For multiple leiomyomas, multiple leiomyomas should be removed from one incision as much as possible. For fibroids near the uterine horn, the incision should be as far away from the uterine horn as possible to avoid postoperative scar affecting tubal patency. 5. Subserous myomectomy This kind of myoma is often pedicled and can be clamped against the uterine wall to take the myoma. When the tumor pedicle is wide, a spindle incision can be made at the base to remove the myoma and superficial muscle layer at the pedicle of uterine tumor. 6. Submucous myomectomy If the myoma obviously protrudes into the uterine cavity, it is necessary to enter the uterine cavity to remove the tumor. When suturing myometrium, submucosa should be avoided to avoid implantation of myometrium into endometrium and artificial endometriosis. Pedicled submucosal myoma can be removed via vagina. 7. Cervical myomectomy should understand the relationship between myoma and bladder, rectum and ureter. For the myoma of the anterior cervical wall, firstly, open the bladder and turn the peritoneum, then sharply separate the bladder to the lower and lateral edges of the myoma, then cut the anterior cervical wall to the tumor surface, and then passively separate it to the basal part along the tumor capsule, then clip off the myoma and sew the stump. Suture the cervical myometrium with absorbable line in the shape of "8" or continuous mattress, and turn the bladder peritoneum. If it is a myoma of the posterior wall of the cervix, we should first open the cervical-rectal space to fold the peritoneum, push the rectum open, and then take out the myoma. For huge cervical myoma, the posterior lobe of ligament can be opened to find the ureter, and then the ureter tunnel can be cut to free the ureter if necessary, and then the myoma can be removed. 8. Abdomen, sew the abdominal wall layer by layer. Operation Steps of Hysterectomy This operation is mostly used to remove uterine tumors, partial uterine bleeding and adnexal lesions. The following is the surgical method of abdominal hysterectomy and adnexal lesions. During the operation, we must be careful not to damage the ureter and minimize blood loss. Therefore, the operator must be familiar with the local anatomical relationship of uterus, especially the distribution of blood vessels and the position and direction of ureter. Operative step (1) The incision was taken from the middle of abdomen, from the umbilicus to the upper edge of pubic symphysis. (2) Explore the infundibular ligament and round ligament of pelvic cavity, and find out the lesion scope. Hemostatic forceps with teeth is used to clamp the two corners of uterus for traction, blocking the blood flow of the ascending branch of uterine artery. Sew round ligament with No.7 silk thread 2 ~ 3 cm away from the uterine horn, and double sew pelvic infundibulum ligament (avoiding ureter) at a little distance from the pelvic wall. There are ovarian arteries and venous plexus passing through pelvic infundibular ligament, which can be seen clearly under the light and must be stitched tightly. (3) Cut off the ligament, cut off the uterus, bladder and peritoneum, lift the uterine suture, and cut off the pelvic infundibular ligament and round ligament. The blood flow in the uterus has been blocked at the corner of the uterus, so only a small amount of blood flows back when the ligament is cut off. There is generally no need to clamp bleeding alone. Cut off the anterior lobe of the broad ligament between the pelvic infundibular ligament and the round ligament, free forward, cut off the uterus, bladder and peritoneum, and fold back to the opposite side. (4) Free uterine body. Gently separate the bladder with your fingers along the loose connective tissue plane between the uterus and the bladder to expose part of the cervix, and then gently separate the tissues on both sides to expose the uterine arteries and veins. There is a ureter from the cervix through about 2 cm below the blood vessel. Then, the posterior lobe tissue of the broad ligament on both sides of the uterine body is cut above the uterine artery without bleeding, but it should be cut off slightly from the uterine body to avoid damaging the ascending branches of the uterine artery near both sides of the uterine body. At this time, the uterine body is completely free, and only a small amount of tissue on both sides is connected with the vaginal vault. (5) Free the cervix and properly pull the uterus to the side of the head, push the bladder further below the level of the external cervix with the thumb, and slowly push the ureter to both sides. If you pay attention to the exploration on both sides, you can feel a string sliding about 2cm from the cervix under your fingertips, which is the ureter. As long as the plane is accurate, there is no difficulty in pushing down the bladder and there is not much bleeding. If there is any difficulty, it is mostly related to the depth of the plane, or it may be caused by inflammatory adhesion, so it is necessary to find out before separation. Peeling can be carried out if necessary. After finding out the position of ureter, it is of positive significance to deal with the tissues on both sides of cervix. (6) The uterus is removed, and a gauze pad is filled in the uterine rectal fossa to absorb secretions that may leak from the vagina. Lift the uterus, cut the anterior vaginal vault, clamp and lift the anterior vaginal wall, and insert a small piece of gauze through the incision to prevent the effusion in the vagina from flowing out and polluting the pelvic cavity. Then clamp the front lip of the cervix upwards, cut along the vaginal vault and take out the uterus. When the vaginal vault is circumcised, always pay attention to lifting the cervix, which is conducive to cutting without contact with the surrounding and preventing pollution. After each incision, the vaginal stump is clamped to reduce bleeding, which is used for traction and is convenient for suture after hysterectomy. All instruments that have come into contact with vagina should be put into the contaminated basin immediately after use. (7) Suture the broken vagina and pelvic peritoneum. After removing the uterus, wipe the broken vagina with iodine and alcohol cotton balls, and then suture intermittently or continuously with 1 or No.2 chrome catgut. Pay attention to sew the two corners of the broken head. Finally, carefully check the thickness and peristalsis of both ureters, and whether there is bleeding at each suture point. If there is no abnormality, the pelvic peritoneum should be sutured continuously first, and then the abdominal cavity should be closed routinely. After the operation, take out the gauze from the vagina.
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