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15
II. ХИРУРГИЯ
МРНТИ 76.29.39
DISCUSSION ISSUES OF SURGICAL TREATMENT USING NEW TECHNOLOGIES FOR RECONSTRUCTION OF PELVIC FLOOR IN THE PROLAPSE OF RECTUM, UTERUS AND VAGINA
(literature review)
ABOUT THE АUTHORS
Mamedov M. M.- Professor, chief researcher of the Department of surgical Coloproctology. Scientific center of surgery M. A. Topchibasheva, sevilmm@rambler.ru tel +994506616759
Musaev Kh.N. - Doctor of Medical Sciences, Professor of the Department of Surgical Diseases of the Azerbaijan Medical University.
Shirinova F.M. - dissertation candidate of the Department of Surgical Diseases of Azerbaijan Medical University
Keywords
prolapse of the rectum, genital prolapse, vagina
Musaev Kh.N., Mamedov M.M., Shirinova F.M.
Scientific Center of Surgery named after M.A. Topchibashev, Department of Surgical Diseases, AMU, Baku, Azerbaijan
Abstract
Currently, the prolapse of the vaginal walls is considered as a result of ruptures of the pubic-cervical and rectovaginal fascias, as well as their separation from the walls of the pelvis. Given the high recurrence rate of the disease, most surgeons prefer the combined methods of surgical treatment of prolapse. These interventions include strengthening the pelvic floor, plasticizing the walls of the vagina and fixing the uterus, cervical stump or vaginal vault in different ways. However, the existing combined methods also do not always contribute to the complete recovery of patients, since they do not always eliminate and do not prevent functional disorders of neighboring organs.
The review presents data on surgical treatment of the pelvic floor for prolapse of the rectum, uterus and vagina. The general assessment of the above literature data suggests the existence of a number of difficulties and unsolved problems in the surgical rehabilitation of women with diseases of the perineum of non-tumor etiology.
Tík шектщ, жатырдьщ жэне кынаптыц пролапсындагы жамбас ty6íh калпына келлрудщ жаца технологияларын колдана отырып хирургиялык емдеу мэселелерш талкылау (эдебиеттерге шолу)
АВТОРЛАР ТУРАЛЫ
Мамедов М.М. - М.А. Топчибашев ат. Гылыми хирургия ортальшшьщ хирургиялык колопроктология бел1мшес1н1ц бас Fылыми кызметкер!, профессор.
sevilmm@rambler.ru; tel +994506616759
Мусаев Х.Н. - медицина Fылымдарыньщ докторы, Эз!рбайжан медициналык университетам хирургиялык аурулар кафедрасыныц профессоры.
Ширинова Ф.М. - Эз!рбайжан медициналык университету хирургиялык аурулар кафедрасыныц диссертанты
Туйш свздер
тк шектщ темен тусу '\, reнитaльдын пpoлaпcы, кынaп
Мусаев Х.Н., Мамедов М.М., Ширинова Ф.М.
М.А. Топчибашев атындагы гылыми хирургия орталыгы, хирургиялык, аурулар кафедрасы, АМУ, Баку, Эзiрбайжан
Андатпа
Крзipri ya^ina вarинaльды кaбыpFaлapдьщ пpoлaпcы жыныcтык-жaтыp мoйны жэне peктoвa-rинaльды фaccияньщ жapылyы, coндaй-aк oлapдьщ жaмбac кaбыpFaлapынaн бел'шу.i нэтижесШде кapacтыpылaды, aypyдьщ peцидивтepiнiщ жoFapы пaйызын ес^е oтыpып, хиpyprтapдьщ кепшлИ пpo-лaпcты хиpyprиялык емдеудщ apaлac эдicтepiн кaлaйды. Бул apaлacyлapFa жaмбac тубШ ньтйту, жэне жaтыpды, жaтыp мoйныныц немесе кынaп кумбезШ 6ip жoлмeн бек'иу фе^. Aлaйдa кoлдaныcтaFы apanac эдicтep де эpдaйым пaциeнттepдщ тлык cayыFyынa ы^л ете бepмeйдi, ейткен'1 oлap эpдaйым кepшi aFзanapдыц фyнкциoнanдык бузыnynapын жoймaйды жэне anдын anмaйды. Шony кезШде тк шеклщ жaтыpдыц жэне кынaптыц пpoлaпcымeн жaмбac тубШ хиpyprиялык емдеу тypanы мэлiмeттep кел^тен. ЖoFapыдa кепт^ 'т^н эдебиет дepeктepiн жanпы 6aFanay im емес этиoлorияньщ пepинэя aypyы бap эйeлдepдi хиpyprиялык oqanry кез 'тде бipкaтap киындыктap мен шешшметн мэceлeлepдiц болуын болжайды.
Дискуционные вопросы хирургического лечения с использованием новых технологий по реконструкции тазового дна при опущении прямой кишки, матки и влагалища (обзор литературы)
Мусаев Х.Н., Мамедов М.М., Ширинова Ф.М.
Научный центр хирургии им. М.А. Топчибашева, кафедра хирургических болезней АМУ, Баку, Азербайджан
Аннотация
В настоящее время опущение стенок влагалища рассматривают как результат разрывов лобково-шеечной и прямокишечно-влагалищной фасций, а также их отрыва от стенок таза, учитывая высокий процент рецидивов заболевания большинство хирургов отдают предпочтение комбинированным методам хирургического лечения пролапса. Эти вмешательства предусматривают укрепление тазового дна, пластику стенок влагалища и проведение фиксации матки, культи шейки матки или купола влагалища тем или иным способом. Однако существующие комбинированные методы тоже не всегда способствуют полному выздоровлению больных, так как не всегда ликвидируют и не предупреждают функциональные нарушения соседних органов. В обзоре приведены данные хирургического лечения тазового дна при опущении прямой кишки, матки и влагалище. Общая оценка приведенных литературных сведений позволяет говорить о существовании целого ряда трудностей и не решенных задач в хирургической реабилитации женщин с заболеваниями промежности неопухолевой этиологии.
Relevance. Modern operative surgery has a variety of pelvic floor reconstruction surgeries for the prolapse of the rectum, uterus and vagina (2.5.11.) Until recently, it was believed that the prolapse of the vaginal walls is a consequence of protrusion or stretching of the pelvic fascia (3.7). Currently, the prolapse of the vaginal walls is considered as a result of ruptures of the pubic-cervical and rec-tovaginal fascias, as well as their separation from the walls of the pelvis. Given the high recurrence rate of the disease, most surgeons prefer the combined methods of surgical treatment of prolapse. These interventions include strengthening the pelvic floor, plasticizing the walls of the vagina and fixing the uterus, cervical stump or vaginal vault in different ways (1.4.21.). However, the existing combined methods also do not always contribute to the complete recovery of patients, since they do not always eliminate and do not prevent functional disorders of neighboring organs. The number of patients with severe degrees of prolapse and prolapse of the pelvic organs at a young age is 26% today (6.8.9.22). Taking this into account, at the present stage of development of medicine, there is a need for operations with the preservation of organs, which will help to restore relationships with neighboring organs and create conditions for their normal functioning, as well as rehabilitation of specific functions of the woman's body (10, 11, 23.31).
Despite the large number of surgical methods of treatment, there is no univocal opinion on the
ОБ АВТОРАХ
Мамедов М.М. - профессор, главный научный сотрудник отделения хирургической колопроктологии. Научного центра хирургии им. М.А. Топчибашева, sevilmm@rambler.ru tel +994506616759
МусаевХ.Н. - д.м.н., профессор кафедры хирургических болезней Азербайджанского медицинского университета.
Ширинова Ф.М. - диссертант кафедры хирургических болезней Азербайджанского медицинского университета
Ключевые слова
опущение прямой кишки, генитальный пролапс, влагалище
tactics of treating patients with rectal prolapse (2, 12, 13, 33). Some types of interventions lead to the occurrence of a large number of relapses of the disease, when using other methods, previous constipation reappears or intensifies. In many patients with rectal prolapse, anal spasm insufficiency was simultaneously revealed, which accompanied rectal prolapse in 30-90% of them and persisted in many patients after surgical correction of rectal prolapse (14, 24, 34). This disease significantly reduces the quality of life of patients, limits their social activity, leads to disability, and sometimes to changes in mental health (15, 26, 35).
For the first time in 1959, C. Wells (13) proposed posterior-loop rectopexy for the surgical treatment of rectal prolapse. A feature of the technique of this surgical intervention is that the rectum is mobilized to the level of levators with the intersection of the lateral rectal ligaments. Then a rectangular polypropylene mesh is attached to the sacrum, and its "wings" are fixed to the lateral surfaces of the intestine. As a result of this, the nerve fibers passing in these ligaments are damaged, the violation of innervation leads to increased constipation in the postoperative period. (16.25). Thus, a rigid fixation of the mobile intestinal wall to the fixed surface of the sacrum is created, which can also be the cause of increased constipation in the long term. After performing posterior loop rectopexy, the recurrence rate of the disease reaches 11.1%, and the motor-evacuation function of the colon worsens in 38-48% of operated patients (16, 27, 28).
A.D. Hoore (40) proposed a new method of rectal fixation - rectosacropexy, reporting its good functional results. The proposed method differs from the posterior-loop rectopexy in that the rectum is mobilized only along the antero-right semicircle, preserving the lateral ligaments of the rectum, which prevents damaging of the rectal wall innervation and development of constipation in the postoperative period. Fixation of the intestine to the sacrum occurs behind its anterior wall according to the type of free plasty, thus the intestine retains mobility and motility, which also serves as the prevention of disorders of the motor-evacuation function of the colon after surgery (17, 36).
According to two systematic reviews that included analysis of 2000 patients, constipation symptoms decrease in the postoperative period in almost half of the operated patients, and the recurrence rate does not exceed 4.8% (18, 29). According to (34), after rectosacropexy, no intensification of constipation symptoms was found, that is, the implementation of this intervention does not cause deterioration of the motor-evacuation function of the colon in the postoperative period. After the posterior-loop rectopexy, in turn, a statistically significant increase in constipation symptoms was found. Thus, Wells operation (13) impairs the motor function of the colon compared to that after recto-sacropexy.
(27) proposed a new method of making a ''ligament'' from an aponeurotic flap of the oblique abdominal muscles for fixing the lowered pelvic organs. The incision is made in the direction of the fibers of the aponeurosis of the oblique muscles of the abdomen, the edges made of the graft flap are sutured to each other around a polyethylene tube 4-5 mm in diameter. Due to this, a strong, 2-layer aponeurotic flap is obtained, much stronger and half the width of a pelvic flap.
Among the surgical methods of treating the prolapse of the pelvic organs, the operation of fixing them to the aponeurosis of the anterior abdominal wall has relatively better results (27.29). According to (29), the principle of surgery using TVM technology (transvaginal mesh conduction) is to form a new artificial pelvic fascia (neofascia) instead of the destroyed old one, which makes it possible to create a reliable frame for the bladder, vagina and rectum. This type of operation is used when it is necessary to create neofascia instead of destroyed ones (pubic-cervical and rectal-vaginal). At the same time, the existing fascial defect is eliminated and reliable fixation of the fascia to the pelvic walls is restored, which prevents pathological protrusion of the vaginal walls with an increase in intra-abdominal pressure. The absence of tension in the vaginal wall when using a polypropylene
mesh (Ethicon) minimizes the risk of developing its degenerative disorders (29, 38). Accordingly, the number of postoperative pyoinflammatory processes, erosions, vaginal stenoses, as well as the risk of postoperative mesh rejection are reduced. The indication for the installation of a mesh implant for complete reconstruction of the pelvic floor is the prolapse of the anterior and posterior walls of the vagina, complete prolapse of the uterus and vaginal walls (29, 33, 38). Contraindications to the installation of mesh implants are purulent-inflammatory diseases of the pelvic organs, severe physical conditions and anemia.
Rectal prolapse causes severe suffering for patients and is an important problem in coloproctol-ogy. The protrusion of the rectum through the anus significantly reduces the quality of life of patients, and the accompanying difficulties in emptying the intestine and weakness of the anus pulp lead to pronounced social maladjustment (20, 21, 36). Violation of the innervation of the rectum can serve as one of the prerequisites for increased constipation in the postoperative period.
In Azerbaijan, given the large number of children in families, the recent increase in the number of births at home, when there can be no talk of restoring the integrity of the pelvic floor, a sharp decrease in quality of life of population, hard work of women, unfavorable environmental factors and others, the problem of lowering and prolapse of internal genital organs remains one of the acute ones (27). One of the well-known Russian gynecologists, Professor R. Guseynov (27), wrote about the urgency of this problem for medicine in 1939 in his Ph.D. thesis "Treatment and long-term results in prolapse and prolapse of the uterus and vagina". In the etiology of genital prolapse, the primary role belongs to the pelvic floor muscles insufficiency (PFMI), which can be a congenital or acquired condition as a result of burdened childbirth, factors that contribute to an increase in intra-abdominal pressure (20, 29, 30). Lowering and prolapse of internal genital organs (IGO) is a polyetiological complex disease since not only physical, but also genetic, constitutional, endocrine, and psychological factors play an important role in its development (2, 21, 37). When describing the pathophysiology of pelvic floor muscles insufficiency (PFMI), the main reason is the insufficiency of a key element of the pelvic floor support apparatus - the levator ani muscle (m. Levator ani). As a result of age-related changes, atrophy of the nerve endings develops, followed by denervation and muscle atrophy.
With lowering and prolapse of IGO, the sexual function of women also suffers significantly. The operations performed today for genital prolapse do not always lead to the restoration of the full sexual
activity of patients. (31) studying the effect of anterior colporrhaphy with levatoroplasty on the sex life of patients, found that after this operation, 14% of women did not experience any improvement, and in 20%, sexual function worsened. The concept of surgical treatment of genital prolapse includes the correction of anatomical and topographic defect, restoration of fertility, which is especially important for young women.
To date, a huge number of operations have been proposed, which are carried out by vaginal, abdominal and combined approaches. However, the problem of surgical treatment of prolapse cannot be considered solved. Since despite the variety and multiplicity of the proposed operations, relapses are quite often observed after surgical correction (1, 21, 33)
Genital prolapse is a complex, polyetiologic disease, in which development a physical, genetic and psychological factors play an important role. Of the reasons that affect the condition of the pelvic floor and the ligamentous apparatus of the uterus, the following can be especially highlighted: age, heredity, childbirth, birth trauma, hard physical work and increased intra-abdominal pressure, scars after inflammatory diseases and surgical interventions, psychosomatic effects on smooth muscles and vascular structures in the pelvic region, changes in the production of sex steroids that affect the response of smooth muscles, leading to sclerosis and atrophy of muscle fibers, the development of coarse-fibrous connective tissue and the inability of striated muscles to ensure the integrity of the pelvic floor (27, 29). Due to the close anatomical connections that exist between the internal genital organs, the bladder and the rectum, lowering and prolapse of the internal genitals is almost always accompanied by a violation of the location and functions of these adjacent organs. Dysfunctions of the urinary system are found in 43% of patients, that is, in almost half of patients with genital prolapse, and rectal dysfunction - in 55% of patients with prolapse (3, 28).
Thus, due to the topographic and anatomical proximity, common innervation and blood circulation, as well as supporting structures, lowering and prolapse of the internal genitals almost always occur with dysfunction of the pelvic organs. Therefore, treatment methods should pursue the goal of not only anatomical correction of the identified changes in individual organs, but also the elimination of functional disorders of the pelvic organs as a whole. To date, about 500 different types of operations and their modifications have been proposed for the treatment of genital prolapse. However, the problem of surgical treatment of lowering and prolapse of the internal genital organs is still cannot be
considered solved. Since, despite the large number of described operations after surgical correction, relapses of the disease are quite often observed, the frequency of which, according to different authors, ranges from 1.6% to 40%.
Various authors, who retrospectively studied the long-term results of surgical treatment of lowering and prolapse of the internal genital organs, found that after anterior and posterior colporrha-phy, relapses are observed in 33.3%, and after anterior colporrhaphy using the Marlex loop - in 26% of cases; after vaginal hysterectomy with fixation of the sacrospinal ligament - only 8%; colposacropexy with posterior colporrhaphy gives 1.1%, colposacropexy without colporrhaphy - 7.9%; Manchester surgery - 16%, Dartig-Webster surgery - 12.2%, McCall culdoplasty - 5% of cases of recurrence of lowering and prolapse of the uterus and vaginal walls (3, 13, 27, 29). The final decision can be influenced by numerous factors: the nature of prolapse, features of etiology and pathogenesis, the degree of involvement of adjacent organs, their condition, age and profession of the patient, general health, the presence and type of concomitant pathology, combination with other gynecological diseases, menstrual condition, generative and reproductive functions, combination with other surgical diseases, the need for several simultaneous surgical interventions, the degree of operational risk, the preparedness of the surgeon and others. Relapses after operations fixing the uterus to the anterior abdominal wall range from 6.7 to 33.3% (3, 7, 27, 29).
(7), giving a high assessment of the Manchester operation, considers it possible to use it in women under 40 and in old age, and not only with incomplete prolapse of the uterus, but also with complete prolapse. The author considers this operation highly effective, since it is designed to strengthen the ligamentous apparatus and the muscles of the pelvic floor. In addition, when it is performed, the altered cervix is amputated. When talking about the effectiveness of the Manchester operation, one should not overlook the recurrence of prolapse after this operation (3, 27, 29).
Zakharov E.I. (11) performed ventrofixation of the uterus to the anterior abdominal wall using a nylon mesh covering the uterus in the form of a stocking. Tkachenko D.F. (24) used the method of fixation of the uterus and vagina to the anterior-superior spines of the iliac bones by means of an alloplastic graft made of lavsan. Synthetic meshes were also used to fix the vaginal stump to the prom-ontorium in the treatment of uterine prolapse. Using alloplastic materials (nylon, aivalon, lavsan, teflon) to replace a tissue defect and strengthen the anterior abdominal wall in the treatment of hernias, a number of authors have obtained stable positive
results (24). In the last decade, the operation of sacral colpopexy with synthetic grafts, carried out with an abdominal approach with a high efficiency (80% -99%), has become widespread (13). But when performing these operations, serious complications are noted, such as injury to large vessels with significant bleeding, osteoarticular inflammatory processes, damage to the sciatic nerve, rectum, bladder, cases of intestinal obstruction are described. There are also cases of graft rejection or removal due to infection; in a large percentage of cases, urinary incontinence is not eliminated, recurrences of cystocele and rectocele are frequent (25). Despite all this, the technique of sacral colpopexy is likely to be used in the future, mainly in cases of prolapse of the vaginal stump or cervix after hysterectomy or recurrence of vaginal prolapse after vaginal extirpation of the uterus.
The Neugebauer-Lefort operation is the most widespread and used to this day, which consists in stitching the wound edges of the anterior and posterior walls of the vagina together after excision of their mucous membranes (27.29). The disadvantages of these operations, as many gynecologists emphasize, are the following points: the lack of the possibility of sexual activity, subsequent examination of the cervix or any other manipulations, as well as a significant number of relapses in the presence of secondary healing. It can also not be used if functional urinary incontinence is present at the same time. This operation can be performed only in old age, with complete prolapse of the uterus (25, 27, 29, 31).
With the improvement of laparoscopic technique, sacral fixation of the vaginal vault began to be performed with a good result in 90% of cases. After such an operation, a functioning vagina with minimal dyspareunia is preserved, the Douglas space is obliterated, which allows avoiding entero-cele in the future. The disadvantages of these operations are technical difficulties, the possibility of injury to large vessels, sciatic nerve, rectum; cases of transplant rejection and its infection have also been described. According to (27) according to the World Health Organization, approximately 10.0% of women have prolapse of the uterus. Among the surgical methods of treatment of prolapse of the uterus, the shortening of the round ligaments and their fixation to the posterior surface of the uterus are relatively better results. Meanwhile, after these operations, the recurrence of the disease ranges from 5 to 12% (27).
In view of the above, a new "two-storey" ventro-suspension of the uterus has been proposed. The round ligaments of the uterus are mobilized with holders 2 cm away from the inguinal canals and cut off (13, 27, 29, 40). The proximal part of the round
ligaments of the uterus is excreted through the aponeurotic - muscular-peritoneal layer 4-5 cm above the symphysis. The distal part is fixed to the cervix. Thus, the "first floor" of the operation is performed. The proximal parts of the round ligaments of the uterus are fixed to each other and to the aponeu-rosis, which is the "second floor" of this operation.
During 2001-2004 3 similar operations were performed without any significant postoperative complications. The new method of ventrosuspen-sion of the prolapsed uterus to the anterior abdominal wall is not technically difficult and can be recommended for use in practical surgery (3, 13, 27, 31). In posthysterectomy vaginal prolapse, especially recurrent, it is advisable to perform plastic surgery using synthetic grafts, as these patients have weakness of connective tissues and the liga-mentous apparatus is hardly to differentiate. If lapa-rotomy is indicated for any other reason, the best intervention is to fix the vagina to the sacrum. In other cases, vaginal access is indicated. We recommend giving preference to sacrospinal fixation on both sides using a synthetic mesh. In this case, the operation can be performed for any length of the vagina and maintains its physiological position. When fixing the prolapsed organs of the small pelvis to the sacrum using a synthetic mesh in order to increase reliability, as well as to prevent and stop bleeding that has arisen, it is recommended to use a metal plate with spikes (39).
The disadvantage of operations associated with shortening the round ligaments and fixing the uterus to the anterior abdominal wall or pelvic walls is that they do not eliminate the causes of prolapse of the genitals and are unreliable, fundamentally incorrect and logically unjustified. Operations fixing the uterus are not widely used today, since they are non-physiological due to the unnatural position of the vaginal axis, and the uterus, fixed to the anterior abdominal wall, turns into an immobile organ. The disadvantages of operations aimed at strengthening the supporting apparatus - the pelvic floor, as many researchers emphasize, are: the lack of the possibility of sexual activity, subsequent examination of the cervix or any other manipulations, as well as a significant number of relapses in the presence of secondary healing, the presence of urinary incontinence (3, 7, 13, 29, 39).
Thus, in the domestic and foreign literature, the issues of surgical treatment of these diseases using traditional methods of surgery and a detailed description of the technique of various interventions of vaginal or abdominal approaches are widely covered (7). It is assumed that ethnicity is a significant risk factor for prolapse of pelvic organs (PPO); however, the origin of the pelvic organs in different ethnic groups, especially in Asian populations,
is not well understood. The aim of this study was to compare the stages of prolapse, descent of the pelvic organ, and hiatal dimensions between East Asian and Caucasian women with PPO symptoms.
According to (36), the pelvic prolapse is the prolapse of the pelvic organs in isolation or in combination with the prolapse of the perineum. It is one of the leading health problems affecting women of all ages. The prolapse of the perineum is the cause of difficult defecation and incontinence of intestinal contents (27, 29, 39). The development of pelvic prolapse depends on many factors, the main of which are childbirth, age, and an increase in body mass index (3). These factors lead to an increase in intra-abdominal pressure, and later to dysfunction of the complex of muscles that levitate the anus and pelvic ligaments and, as a result, to prolapse of the perineum (30). Obstructive defecation and intestinal incontinence are the main manifestations of the syndrome of prolapse of the perineum (21). Despite the fact that the syndrome of prolapse of the perineum was described several decades ago, it is still not always diagnosed and difficult to treat (29, 40).
Sacrocolporectopexy has been widely used in recent years for the surgical treatment of prolapse of the pelvic organs in recent years (3, 31). However, there are no data on its effectiveness in correcting perineal prolapse in the literature. In research (39) substantiated the advantages of surgical treatment of PPO in women using abdominal sacrocolporec-topexy in terms of improving anatomical and functional results, compared with perineoplasty with the patient's own tissues. However, studies have shown that this technique does not allow correcting the prolapse of the rectal mucosa, which is present in 52% of patients with prolapse of the perineum. In this category of patients, additional excision of the excess rectal mucosa is necessary. In the course of work, the possibility of simultaneous execution of abdominal sacrocolporectopexy and transanal excision of the rectal mucosa using stapling technologies (STARR) was shown.
(18) in her dissertation work analyzed the effectiveness of various methods of surgical treatment of perineal prolapse syndrome in a comparative aspect in the postoperative period and in the long-term period of 3 years. The work proved that with the existing prolapse of the rectal mucosa, its additional excision by transanal access is necessary. Normal defecation is a complex process involving voluntary and involuntary processes in four different phases: the basal phase, the pre-defecatory phase that induces the urge to defecate, the expulsive phase, and stopping defecation (18). In PPO syndrome, there is a "vicious circle" of straining and defecation, which leads to even greater tension and
progression of anatomical abnormalities. Chronic repetitive straining leads to a gradual descent of the perineum and displacement of the anterior rectal wall into the anal canal and caudally outward, which leads to a feeling of inadequate emptying, this, in turn, leads to increased straining, and later to prolapse of the rectal mucosa, which entails the release of mucus, blood, maceration of the perianal region (13, 18, 29).
The pelvic floor (PF) is formed by muscles, fascia and ligaments, interconnected with each other and the bones of the pelvis, forming a single anatomical space. It includes the levator muscles, the coccygeal muscles covered with fascia, the perineal membrane, the superficial and deep perineal muscles, and the perineal body. In the literature (1, 18, 39), three types of fascia are described: visceral, parietal and endopelvic, which forms tendon arches on the lateral walls of the pelvis. The muscles that lift the anus include the iliococcygeal, pubo-rectal, pubo-coccygeal muscles, further subdivided into pubo-perineal, pubovaginal, pubic-anal type I striated muscles. The perineal membrane is a triangular-shaped fibromuscular structure that attaches anteriorly to the pubic bones. The deep and superficial transverse muscles of the perineum perform a supporting function, m. bulbospongiosus and m. is-chiocavernosus - sexual function. Arcus tendinous levator ani and arcus tendinous pelvic fascia attach the muscles to the pelvic walls.
Considering the etiology and pathogenesis of pelvic prolapse, it is necessary to dwell on the integral, muscular-elastic, theory of the function and dysfunction of the pelvic floor, developed by the Australian researcher Peter P. Petros. According to this theory, PPO and its symptoms, stress urinary incontinence, constipation, some forms of bowel incontinence and pelvic pain are due to weakness of the ligaments that support the vagina as a result of damage to the connective tissue. The main etio-logical factor is childbirth, leading to a weakening of connective tissue, which is aggravated with age.
The vagina in the pelvic cavity is located like a suspension bridge that hangs on ligaments, and is supported by muscles from below. Since the vaginal ligaments are simultaneously supporting structures for the bladder and rectum, their damage affects the location of the latter. 18-25% of women with prolapse of the perineum have obstructive defecation (OD) and 32% of women with OD have PPO. In this case, the patients complain of the need for constant strong straining during bowel movements, a feeling of obstruction in the rectum during bowel movements, a feeling of incomplete emptying of the rectum during bowel movements. Complaints of mucous discharge, bleeding, perineal irritation, chronic anal pain and itching of the perineum are
also not uncommon due to prolapse of the anterior rectal wall. Up to 30% of women with PPO suffer from intestinal incontinence (II). II factors are similar to those leading to PPO. These are childbirth, aging of the body, an increase in body mass index, hysterectomy, frequent straining, dysfunction of connective tissue.
In 21% of women with PPO, prolapse of the genitals is noted, they also have a correlation between the degree of prolapse and II. With rectal prolapse, II is observed in 50% of patients. 38% of women with II have PPO. To exclude pathology from the rectum and colon, endoscopic research methods are also carried out: sigmoidoscopy, colonoscopy. Straining sigmoidoscopy according to the method proposed by A. Parks allows diagnosing prolapse of the rectal mucosa. Despite its importance, physical examination does not provide all the necessary information about PF defects (3).
To diagnose various dysfunctions in PPO, additional research methods are used: - ultrasound examination; - X-ray examination (cystourethrog-raphy at rest and during emptying, defecography, as well as a combination of these methods - cysto-urethrodefecography); - magnetic resonance imaging (MRI) of the pelvic bottom; - functional tests: anorectal manometry, studies of the terminal motor activity of the pudendal nerve, electromanometry. The most common way to visualize PF is ultrasound. There are various techniques: transverse or introi-tal, transvaginal, transrectal (3, 12, 9). With the
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help of perineal and transvaginal ultrasound, it is possible to diagnose various defects of the leva-tor ani muscles, including their ruptures, impaired contractility, an increase in the angle between them as a result of divergence, hypermobility of the urethra, its shape, and prolapse of the bladder neck. An intravaginal scan measures the anorectal angle and the angle between the levator muscles (9, 12) Transrectal ultrasound is the gold standard for anal sphincter imaging.
Studies have shown the benefits of abdominal sacrocolporectopexy in the surgical treatment of perineal prolapse in women. The high efficiency of this technique for correcting the level of the perineum and rectocele is shown. Based on the studies carried out during the work, it was shown that as a result of abdominal sacrocolporectopexy, there is no correction of the prolapse of the rectal mucosa (3, 9, 27, 29, 31, 39). The general assessment of the given literature data suggests the existence of a number of difficulties and unsolved problems in the surgical rehabilitation of women with diseases of the perineum of non-neoplastic etiology (9, 15, 16, 40).
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