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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Procedures and Techniques
Exploratory laparotomy or diagnostic laparoscopy
Once general anesthesia is adequate and the patient is draped in the dorsal lithotomy position, the abdomen is entered. The
uterus is examined to confirm normal development, ruling out müllerian agenesis, and a bladder flap is developed to allow
adequate assessment of the lower uterine and cervical anatomy, distinguishing complete cervical agenesis from cervical
dysgenesis and endocervical obstruction. If the cervical stroma is <2 cm in diameter, the surgeons should proceed with
hysterectomy; if >2 cm diameter of cervical stroma is present, creation of a neocervical canal may be considered.
2
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Examination of the vagina and perineum
With the patient in the dorsal lithotomy position under general anesthesia, the vagina should be examined with the guidance
of an intraperitoneal probe delineating the anterior (between the bladder and the uterus) and posterior spaces (between the
rectum and the uterus) from above. Some surgeons advocate that if vaginal agenesis is encountered, the McIndoe
technique may be performed; however, when cervical and vaginal agenesis is diagnosed, vaginal dilator therapy in
conjunction with a hysterectomy may achieve a similar outcome with less perioperative morbidity.
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Examination of the uterine cavity and cervical–uterine canal
A vertical hysterotomy may be made in the uterine fundus through which a probe can be placed through cervical stroma or
an obstructed endocervical canal. If sufficient cervical stroma is identified, the probe can be replaced with a catheter to be
left in place for 6 months while the endocervical canal epithelializes. Interrupted sutures to the uterus and vagina should be
used to hold the catheter in place. Skin grafts and synthetic grafts have also been used to facilitate recanalization of the
endocervical canal.
2–4
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Examination of the abdomen for endometriosis
Due to obstructed anterograde menstruation, many patients will retrograde menstruate into the abdomen via the fallopian
tubes that has been linked to endometriosis. While examining the abdomen and pelvis, any endometriosis implants should be
excised or vaporized to treat dysmenorrhea.
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PEARLS AND PITFALLS
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POSTOPERATIVE CARE
Due to a relatively high rate of postoperative infectious morbidity, if a catheter is left in place, oral antibiotic prophylaxis is
advised. If a uterine–vaginal reanastamosis procedure has been performed, broad spectrum antibiotics are typically given
for at least 2 weeks.
2,5
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OUTCOMES
Measuring success by the ability to obtain cyclic menstruation, in patients not requiring concomitant vaginoplasty, successful
outcomes can be reached in 70%; however, for patients with vaginal agenesis, the success rate falls to approximately
40%.
2,3
Other case series report 50% to 100% reoperation and hysterectomy rate among patients initially achieving a successful
cervicovaginal reconstruction.
2,3
Very few case reports of successful pregnancies have been reported following cervicovaginal reconstruction. The number
of unsuccessful attempts to achieve a pregnancy is unknown and is likely under reported.
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COMPLICATIONS
Reocclusion and hematometra, reoperation and need for subsequent hysterectomy has often been reported among patients,
even those with initially successful cervicovaginal reconstructive surgery.
2
Pelvic inflammatory disease, sepsis, and consequent death have been reported in patients, particularly those with congenital
cervical and vaginal atresia.
5
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KEY REFERENCES
1. Anntila L, Penttilä TA, Suikkari AM. Successful pregnancy after in-vitro fertilization and transmyometrial embryo transfer
in a patient with congenital atresia of cervix. Hum Reprod. 1999;14(6):1647–1649.
2. Rock JA, Roberts CP, Jones HW Jr. Congenital anomalies of the uterine cervix: lessons from 30 cases managed clinically
by a common protocol. Fertil Steril. 2010;94(5):1858–1863.
3. Fujimoto VY, Miller JH, Klein NA, et al. Congenital cervical atresia: report of seven cases and review of the literature.
Am J Obstet Gynecol. 1997;177(6):1419–1425.
4. Deffarges JV, Haddad B, Musset R, et al. Utero-vaginal anastomosis in women with uterine cervix atresia: long-term
follow-up and reproductive performance. A study of 18 cases. Hum Reprod. 2001;16(8):1722–1725.
5. Casey AC, Laufer MR. Cervical agenesis: septic death after surgery. Obstet Gynecol. 1997;90(4 Pt 2):706–707.
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Chapter 2.2
Laparoscopic Abdominal Cerclage for Cervical Insufficiency
Travis W. M cCoy
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