2 English reference tube anastomosis
Operation name: Fallopian tube anastomosis
4 alias tube anastomosis
5 Classification of Obstetrics and Gynecology/Family Planning Operation/Tubal Recanalization
6 ICD code 66.7 10 1
To summarize the application of tubal anastomosis in fallopian tube recanalization. Tubal recanalization is infertility caused by tubal factors, and pregnancy can be achieved through repair surgery. It is not only to make the lumen unobstructed, but also to consider the functional state of organs, so the choice of preoperative cases, the fine surgical technique and the meticulous postoperative treatment are all factors that determine the success or failure of the operation. The recanalization includes tubal ligation and tubal obstructive infertility. The effect of recanalization after tubal ligation is different according to the original ligation method. The original ligation method used isthmus pump pericardium embedding method or double-fold ligation and cutting method, and the cutting and ligation site was in the middle section of fallopian tube 1/3 section, which was convenient for anastomosis. Due to the progress of microsurgery technology, the success rate of surgery has improved. A large number of clinical data reported that the success rate of microsurgical tubal anastomosis after sterilization was over 90%. To perform fallopian tube recanalization under microscope, the operator and assistant should first carry out basic skills training, be familiar with the structure, performance and usage of the surgical microscope, train the unity of eye and hand movements, and cooperate with each other tacitly is also the key to the success of the operation. The operation of anastomosis is simple, and the success rate and pregnancy rate after operation are much higher than those of ostomy and transplantation. Of course, in some cases, the removal of too many cores or the great difference in diameter between the two ends will affect the effect of the operation.
Infertility caused by tubal obstruction accounts for about 30% ~ 40% of infertility cases. According to different pathological types, the success rate of operation varies greatly, and different surgical methods should be selected according to different parts of tubal obstruction. If the obstruction is in the far isthmus or ampulla, the obstruction can be removed for anastomosis, the obstruction can be used for salpingostomy in the umbrella or ampulla, and the tubal transplantation can be used for the obstruction in the corner of uterus (interstitial part) or near isthmus, and the tubal transplantation can also be done by itself according to the degree of bilateral fallopian tube lesions.
Tubal obstruction caused by infection is not only lumen obstruction, but also inflammatory adhesion around the fallopian tube, which destroys the normal anatomy and physiological function of the fallopian tube, and the success rate of recanalization is very low, and ectopic pregnancy may occur. Because of the interference of operation, re-adhesion and infection will affect the effect of recanalization. In recent years, the development of IVFET has solved some surgical problems of tubal infertility. The value of fallopian tube recanalization is getting smaller and smaller.
8 Anatomy of fallopian tube The anatomy of fallopian tube is shown in the following figure (figure11~11.3.5.15).
9 indications for tubal anastomosis are as follows:
1. Tubal anastomosis is suitable for those who need to give birth again after tubal sterilization for some reasons and meet the following conditions.
(1). Women of childbearing age.
(2) good health.
(3) After sterilization, menstruation is regular and ovarian function is normal.
(4) There are no obvious pathological changes in genitals, including inflammation and tumor.
2. Infertility caused by tubal obstruction has no contraindications.
Contraindications 10 1. If the patient is over 40 years old, the reproductive ability will decrease, and there is little chance of pregnancy after recanalization, which is generally not suitable for anastomosis.
2. Gynecological tumors, genital inflammation, endometriosis and pelvic tuberculous inflammation with severe adhesion caused by reproductive tract diseases.
3. Ovarian dysfunction, no normal ovulation function.
4. Anastomosis is not suitable for those who have undergone salpingectomy or subtotal salpingectomy, unipolar electrocoagulation sterilization and drug blocking sterilization in previous operations, as well as those whose fallopian tubes are too short due to extensive damage of fallopian tubes and failure of salpingoplasty in previous operations.
5. History of tuberculous salpingitis or diffuse tuberculous peritonitis.
6. Bilateral tubal obstruction, bilateral salpingectomy history or tubal pregnancy history.
7. Male infertility.
8. Suffering from serious diseases or acute stages of various diseases that cannot bear pregnancy.
9. Abdominal skin infection should be suspended.
10. having a slight cesarean section history or two cesarean sections is a relative contraindication.
1 1 preoperative preparation 1. Inquire about the medical history and physical examination in detail, understand the general medical history, previous sterilization methods, postoperative infection, general and gynecological examinations and necessary laboratory examinations.
2. Explain the success rate of operation and possible complications to patients and their families. Both husband and wife are informed and sign the consent form.
3. Hysterosalpingography should be performed before hysterosalpingography to determine the position of tubal obstruction and whether there is any lesion in the uterine cavity. The operation time should be 3 months after angiography. Obviously, after sterilization, there is no need for radiological examination.
4. Endoscopic examination suspected pelvic adhesion, endometriosis, tuberculosis or tumor. , and should do laparoscopy or posterior vault examination. If uterine cavity lesions are suspected, hysteroscopy should be done first.
5. Husband * * * has a routine physical examination.
6. The operation is carried out 3 ~ 7 days after menstruation, when the tubal mucosa is thin and the broken ends are easy to meet, so the early stage of hyperplasia is the best operation opportunity. It is also argued that oral estrogen can prolong the proliferation period and increase the chance of liquid passing through.
6. Apply antibiotics for 3 days before operation and rinse for 3 days.
7. If necessary, conduct an allergy test.
8. Abdominal skin preparation.
9. Prepare surgical instruments for microsurgery.
(1) binocular magnifying glass with magnification of 3 ~ 5 times or binocular surgical microscope with magnification of 6 ~ 30 times.
(2) Microsurgical instruments. During the operation, 70 or 80 non-invasive sutures, surgical instruments for microsurgery, plastic tubes with a diameter of 1 ~ 1.2 mm or catheters for epidural anesthesia were used as scaffolds.
Epidural anesthesia is used for 12 anesthesia and * * *. Take the supine position, head down.
13 operation steps 13. 1. Prepare for routine abdominal disinfection and towel laying, and cut longitudinally in the middle of the lower abdomen, with a length of about 8 ~ 10 cm. If a transverse incision is made, the rectus abdominis should be cut off, the operation field should be fully exposed and covered with a leather towel.
13.2 2. Check that pelvic organs enter the abdominal cavity, wrap the intestinal tube with a large gauze pad and push it to the upper abdomen, and then block the hysterorectal fossa with a large gauze pad to expose the uterus and fallopian tubes to the surgical field. Check the adhesion between fallopian tube and surrounding tissues. If there is adhesion, carefully separate it sharply with anatomical scissors to correct abnormal bending of fallopian tube. For fine adhesion, it can also be separated under a microscope. If there is bleeding, use electrocoagulation to stop the bleeding.
13.3 3. Check the blocked part of fallopian tube. Insert a venipuncture needle, a thin plastic tube or a silicone tube into the umbrella of the fallopian tube and inject diluted methylene blue physiological saline to determine the blocking position (Figure 1 1.3.5. 16), or clamp the cervix with Shirodhar forceps to lock it, and puncture it from the bottom of the uterus with a long needle No.265438. Dilating the uterine cavity is used to determine that the lower end of the thinnest part of the fallopian tube is the blocking part (Figure 1 1.3.5. 17). After the injection, remove the needle tube and don't pull it out, so as to avoid pinhole bleeding caused by repeated acupuncture. Local electrocoagulation can be used to stop bleeding after needle extraction. If Shirodhar forceps are not available, the operator or assistant can hold the isthmus of the uterus with his fingers and inject fluid from the bottom of the uterus.
13.4 4. When removing the tubal scar, lift both ends of the tubal scar with two miniature vascular forceps, inject normal saline or 0.5% procaine under the serosa to separate the serosa layer from the tube core, and cut the serosa layer parallel or vertically with a sharp 1 knife. 1 1, and freely resect the tubal scar until the normal tissues at both ends (Figure 1 1. The scar was excised, the normal lumen mucosa was exposed, and a No.6 flat-headed needle was inserted at the two broken ends to inject normal saline, and the patency was tested (Figure 1 1.3.5. 19).
13.5 5. The materials used as the scaffold should be slender, smooth and not easy to break, such as ponytail, nylon, pediatric epidural anesthesia catheter, chrome ⅱ catgut, etc. Insert the bracket from two broken ends of the nozzle. If the stent is not retained, do not insert it too deep near the uterine end. Crossing the stump is only used to guide anastomosis during operation. If the stent needs to be preserved after operation, the proximal end should be inserted into the uterine cavity. When inserting, the fallopian tube should be flush with the uterine horn, insert slowly, and the distal end will be led out from the umbrella (Figure11.3.5.110).
13.6 6. Suture the fallopian tube with 70 ~ 90 non-invasive nylon thread under binocular operating microscope (it can be placed for 10 ~ 16 times), and suture 1 needle at 12, 6, 3 and 9 respectively, depending on the lumen thickness. The suture * * * penetrates the mucosa, and it is not knotted first (Figure11.3.5.11). After all muscle layers are stitched, they are knotted together to keep the anastomotic surface smooth. In order to enlarge the lumen and facilitate anastomosis, you can also sew a needle traction thread at points 6 and 2 of the oviduct muscle layer with 1 silk thread to make the lumen as wide as possible and facilitate anastomosis. After suturing the myometrium, pull out the traction thread, and then intermittently suture the serosa layer with 60 ~ 50 nylon thread (Figure 1 1.3.5). Different anastomosis methods are adopted according to the lesion site of fallopian tube. Isthmus anastomosis); Is commonly used; Isthmus ampulla anastomosis); Isthmus of fallopian tube; Ampullary ampulla anastomosis; Anastomosis between isthmus and interstitial part of fallopian tube.
Isthmus-to-isthmus end-to-end anastomosis; It is suitable for recanalization after tubal isthmus ligation. Both ends of this site have the same diameter, and end-to-end anastomosis is often used (Figure11.3.5.113). Usually 3 ~ 4 stitches. The fallopian tube left by this method is long enough, the umbrella-shaped end is complete and the pregnancy rate is high.
Anastomosis between isthmus and ampulla: Because the diameter of the distal end is slightly larger than that of the proximal end, the distal end is made into a flat section and the proximal end is made into an inclined section, so that the diameters of the distal end and the proximal end are equal (Figure11.3.5.114). Or when sewing, the needle distance on the isthmus side is small, the needle distance on the ampulla side is slightly large and the needle distance on the same side is equal. The margin should not be too wide (figure11.3.5.114). If the diameter difference between the two ends is large, end-to-end anastomosis can be performed after partial closure, and 2-3 stitches can be intermittently sutured to the back of the enlarged end of the lumen to make the diameters of the two ends consistent (Figure11.3.5.115), or funnel anastomosis can be performed, that is, the ampulla becomes a blind end after the scar tissue is free.
Ampulla-to-ampulla anastomosis: the diameters of both ends are almost equal, and end-to-end anastomosis is adopted. Because of the large lumen, a support line can be sewn on the back of the fallopian tube at both ends to lift it up and turn the mucosal edge inward. Generally, you can sew 6 stitches, and in many cases you can sew 8 ~ 1 10 stitches (Figure 1.3.5+0658).
Anastomosis between isthmus and interstitial part, also known as hysterosalpingotomy, is only suitable for patients with proximal obstruction of tubal isthmus and normal interstitial part and other parts. Because the isthmus and interstitial anastomosis keep the fallopian tube for a long time, and the normal anatomical relationship between fallopian tube and ovary is well maintained, the pregnancy rate is much higher than that of uterine transplantation. The wound surface of serosa anastomosis is close to the uterine horn, and the adhesion probability is small. Because the lumens are roughly equal, the mucosa of the anastomosis is relatively flat and it is not easy to form new scars. After scar resection, sew a support line, put the stent as a guide from both broken ends, and perform end-to-end anastomosis (Figure11.3.5.119). Remove the support line after suturing the muscular layer, then suture the serosa layer, pull out the stent, and introduce liquid until there is no leakage.
13.7 7. Suture the fallopian tube mesothelium with the end of 50 nylon thread, and the incision of the salpingum mesothelium should be perpendicular to the long axis of the fallopian tube (Figure11.3.5.120), so as to prevent the fallopian tube from being pressed by the scar after suturing and affecting the patency and normal peristalsis of the fallopian tube.
13.8 8. Keep the proximal end of the stent coiled in the uterine cavity, and the distal end led out from the abdominal wall, and sew it on the abdominal wall with silk thread to prevent slippage (Figure 1 1.3.5. 1).
13.9 9. Prevention of adhesion In order to prevent the formation of new adhesion, 32% dextran 70 300~500ml, gentamicin 80000 ~ 160000 U, dexamethasone 10mg, heparin 25mg and phenamine 25mg were injected into abdominal cavity before abdominal closure. So that the liquid medicine is distributed in the pelvic cavity.
13. 10 10. Suture all layers of abdominal wall. 14 precautions when operating 1. The operation should be gentle. Use 1 1 knife tip or dissecting scissors to separate adhesion. When cutting the serosa and mesangium of fallopian tube, do not damage the blood vessels in the mesangium, so as not to affect the blood supply at the anastomosis.
2. Properly handle the fallopian tube mesothelium and keep the effective length of fallopian tube. The removal of scar depends on the length of scar and the degree of mold defect. Don't remove too much until you see the normal mucosa. When making mesothelial incision, if there are many tube core defects, the mesothelium has enough width and the incision can be parallel to the long axis of fallopian tube. If there are few defects in the tube core and the tube core is twisted, the mesothelium will shrink relatively after release, so the mesothelium incision should be perpendicular to the long axis of fallopian tube. No matter what kind of incision, the mesentery should be sutured perpendicular to the long axis of fallopian tube; Before scar excision and before and after anastomosis, the length of fallopian tube was measured with sterile ruler and recorded. The total length of fallopian tube is not less than 5cm, the ampulla is not less than 3cm, and the umbrella end remains intact.
3. Protect tissues and wounds from mechanical abrasion, do not wipe blood with gauze, and constantly wash the operation field with normal saline containing 0.25% heparin, which can keep the operation field clean and keep the tissue wounds moist. Tubal bleeding, can not be clamped, gently press the wound or mesangial blood vessels with your fingers to stop bleeding.
4. The suture * * * penetrates the mucosa, not too dense, and the ligation is moderately elastic. The anastomosis is smooth, the mucosa can not evert, and there is no crack in the suture mesentery. The needle spacing should be uniform, and the muscle seam and serosa seam should be staggered.
5. Correct the position of the uterus to keep the uterus in the front position. If the uterus is backward, it is necessary to shorten the ligamentum teres to prevent the uterus and its accessories from falling into the hysterorectal fossa to form new adhesions. There are also bilateral attachments fixed to the anterior abdominal wall.
15, after tubal anastomosis, do the following treatment:
1. Fill in the tubal anastomosis operation record (table 1).
2. Use broad-spectrum antibiotics at least 1 week. Appropriate use of antihistamines to reduce anastomotic edema.
3. Semi-supine position, so that the drugs put into abdominal cavity during operation are concentrated in pelvic cavity. Early activities to prevent adhesion.
4. If there is no stent in the operation after operation, the oviduct fluid should be drained as soon as possible, usually on the 5th and 7th day after operation 1 time, and then every time after menstruation for 3 consecutive menstrual cycles. Commonly used drugs for drainage fluid are normal saline or 0.5% procaine 15~20ml, dexamethasone 5- 15~20ml and gentamicin 8.
5. 7 ~ 10 days after the stent is taken out, hook the stent out of the uterine cavity with a loop hook, then cut the suture of the abdominal wall fixing stent, cut off a section of the stent exposed to the abdominal wall, and then take it out of the uterine cavity.
6. Guide sexual life. Sexual life is forbidden within 65,438+0 weeks after each rehydration. Contraception is generally not needed. For those who have been transplanted to the corner of fallopian tube or have different diameters or have undergone salpingostomy, it is not advisable to get pregnant too early, and guide contraception for 3 months.
7. If lipiodol angiography is needed, it should be performed 6 months after operation.
8. Routine postoperative follow-up.
9. Those who are not pregnant within half a year after operation can be rehydrated or hysterosalpingography with iodized oil.
16 complications