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Shaymardanov Erkin Karjovovich, Senior Researcher, Department of Surgery for GP, Tashkent Medical Academy Navruzov Behzod Sarimbekovich, The doctor of Medical Sciences E-mail: [email protected] 1-republican clinical hospital, department of сoloproctology, Tashkent
MODIFIED METHOD SURGICAL CORRECTION OF THE RECTOCELE IN WOMEN WITH DYSFUNCTION OF THE PELVIC FLOOR
Abstract: introduction of modified levatoroplasty allowed us to achieve appreciable positive results at surgical treatment of the rectocele in women with dysfunction of the pelvic floor. Also new method in the remote period authentically improves results of surgical treatment.
Keywords: pelvic prolapse, rectocele.
Introduction
The pelvic prolapse is an actual problem of health care and its frequency varies from 8 to 41% among parous women [1; 2] and there was the tendency to increase [3]. High indicators of a pelvic prolapse women contributes to manifestation various pathologies, as rectocele [5; 8]. Operations for a pelvic prolapse make 10-20% of all big gynecologic interventions [3; 6]. Thus a quarter of patients are exposed to repeated interventions in connection with recurrence. Rectocele is a form of a pelvic prolapse with involvement of back wall of a vagina and a forward wall of a rectum [4; 9].
In the past surgical treatment rectocele was directed mainly by elimination of omission of back wall of vagina. Because of insufficient understanding of communication of anatomic support and work of pelvic bodies functional results were not considered in details [5; 9]. Thanks to growth of the elderly population and increase of its activity the measure of productivity of operations extended from exclusively anatomic restoration before improvement of sexual functions and the related quality of life [7].
Traditional way of elimination of rectocele is restoration of a rectovaginal partition by levatoroplasty of various accesses. Operation gives good anatomic effect [2; 6]. However, connected with rectocele the complicated defecation can remain or even to worsen irrespective of existence or absence of recurrence [8].
One of the possible reasons of adverse functional results can be the accompanying syndrome of puborectal muscles at which the superfluous contractility of these muscles interferes with smoothing of an anorectal corner at a defecation, there by complicating it [4]. In that case the lobby of levatoroplasty aggravates functional obstruction of rectum and can lead to the adverse remote results concerning the quality of defecation.
The aim of our research was to study the results of surgical correction of the rectocele in women with dysfunction of the pelvic floor.
Materials and methods: In the 1-republican clinical hospital in the department of Coloproctology were treated 64 women with rectocele. The age of patients fluctuated from 24 to 62 years (average 44.6 ± 5.8 years).
Depending on the way of perineal levatoroplasty the patients were divided into 2 groups: control group with 31 patients passed front levatoroplasty by perineal access by means of two sets of seams, and the main group of 33 women passed levatoroplasty by the modified way offered by us (an improvement suggestion No. 639).
Updating of the way consists in the following (fig. 1): the cross-section of 4 cm dissects skin in the middle to border between mucous vaginas and crotch skin (stage I). The hydraulic dissection of a rectovaginal partition is made by a well-known technique. The sharp way makes mobilization of a forward wall of rectum, back wall of vagina and forward portions of levator on the right and at the left. Beginning from proximal edge of levator 3 seams (maxon, vikril, polysorb 2/0.0) not in the perpendicular direction, and in parallel, i.e. on a course of muscles lifting back pass and 2 seams on an anal sphincter accordingly (by stage II, III) are imposed. An additional number of goffering seams on a forward wall of rectum is not imposed. The perineal wound is restored in the longitudinal direction by central seams, then the increase in distance between vagina and an anus (stage IV) is reached. After that, at rectocele surplus of mucous rectum on a forward semi-circle will be mobilized and reduced to the anal canal (stage V). Excision is made by the mucous surgery of Milligan-Morgan, and edges of the mucous hem to skin of the crotch «n» - figurative seams (stage VI).
Section 2. Medical science
Figure 1. Stages of surgery by the modified way of levatoroplasty
The standard classification of rectocele was used. At rec-tocele of degree I (there were no such patients) the prolapse of back wall of a vagina does not reach the threshold, at degree II (control group of 19 patients, main group of 21 patients) a prolapse to vagina threshold is available, at degree III (control group of12 patients, main-12) it falls outside the limits of vagina threshold. Compared groups were represented by age (to t = = 0.304; p > 0,05) and disease stages (^2 = 1.75; p > 0.05).
Results of the carried-out inspection were estimated in a complex by the following criteria: good, satisfactory, unsatisfactory: the good - absence of complaints, clinical, radiological and ultrasonic symptoms of rectocele; the satisfactory - a free evacuation ofrectum at corrective diet without application ofa manual grant, existence of a outpouching of a gut in vagina at the rate to
2 cm according to tool inspections; the unsatisfactory - preservation of the complicated evacuation, use of a manual grant at a defecation, absence of reduction of the sizes of rectocele.
Statistical data processing was carried out on the computer by means of the Excel 7.0 programs. For each series of results calculated arithmetic-mean (M), a standard deviation (ff) and an error of an average (m). Besides, for indicators with the wrong distribution calculated a median. In tables and schedules results are presented in the form of M ± m. For comparison of average sizes used t-criterion Student. For level of reliability of statistics p < 0.05 is accepted.
Results and discussions: After surgical intervention at 55(85.9%) patients were not observed earlier revealed outpouching of a wall of rectum in a vagina, at 9(14.1%) the
patients who earlier had the rectocele in the size more than 4 cm, remained outpouching to 2.0 cm, thus at all these anastomosis patients settled down highly (higher than 4-5 cm of the gear line), but violations of an out pouching of a rectum against observance of corrective high-slag diet in the postoperative period was not observed at anybody. Back rectocele and a superfluous crinkle of a mucous membrane of rectum are noted in one case in comparison with indicators before operation.
Results of comparison on duration of operation showed that in control group duration of operation averaged 80.3 ± 5.7 minutes, and this indicator in the main group made 58.3 ± 6.2 minutes (t = 2.61; p > 0.05). Reduction of duration of operation speaks that at performance modified levetoroplasty is applied single-row seams and without additional goffering seams on a forward wall of a rectum.
Also in the postoperative period duration of days in hospital decreased (7.5 ± 0.5 days in control group and 5.4 ± 0.4 days - the main group; t = 3.28; p < 0.05) at the expense of reduction ofpostoperative complications (16.1% in control group and 6.1% - control; x2 = 1.66; p > 0.05).
Violations of the act ofa defecation in all groups of patients were estimated by a locking scale and a control defecography. The moderate locking semiology before operation is revealed at patients of all groups. In control group there was no essential change of an indicator (before operation - 11.2 ± 2.6, after -13.0 ± 3.1; t = 0.44; p = 0.66). Essential changes took place in the main group of patients - well-founded from the anatomic point of view levatoroplasty led to sharp decrease in an obstructive defecation that was shown by increase of points on scale oflocks (before operation - 10.5 ± 2.8, after - 16.0 ± 3.2;
t = 1.29; p = 0.2). We did not see authentic improvement of quality of a defecation in control group.
As a whole quite good results are received: in control group at 67.7% of patients good results are received, satisfactory - at 22.6% and recurrence is revealed - at 9.7%, and in the main group good results are noted at 90.9% of patients, satisfactory - at 9.1% and recurrence of a disease is noted at one patient (x2 = 6.13; p < 0.05).
Undoubtedly, in most cases rectocele is operated as anatomic defect, at not expressed functional frustration. Therefore, there is a need in effective anatomic and safe for anorectal function a method of intervention as which we consider modified levatoroplasty.
Thus, introduction of modified levatoroplasty allowed us to achieve appreciable positive results at surgical treatment of the rectocele in women with dysfunction of the pelvic floor. Also new method in the remote period authentically improves results of surgical treatment.
Conclusions
1. The technique offered by us in comparison with traditional methods authentically reduces days in hospital (7.5 ± 0.5 days in control group and 5.4 ± 0.4 days - the main group; t = 3.28; p < 0.05) and postoperative complications (16.1% in control group and 6.1% - control; x2 = 1.66; p > 0.05).
2. The new method in the remote period authentically increases good results (in control group - 67.7% and basically -90.9%) and sharply reduces disease recurrence.
3. This way is universal and can be offered for operative treatment of the disease, in particular rectocele and a postnatal rupture of a rectovaginal partition with insufficiency of an anal sphincter.
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