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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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Blunt dissection at location of suture placement
The location of the internal cervical os is found at the junction of the cervix and uterine body. This junction is usually just
caudal to the uterine artery. Blunt dissection is performed on each side perpendicular to and against the cervix. This can be
performed with a Maryland grasper or the robotic long tip forceps. This blunt dissection moves vessels aside and opens a
pathway for the suture (Te ch Fig. 2.2.3).
If placement is attempted during pregnancy, it may be safer to fully complete the dissected tunnel so that the suture may be
passed through the tunnel without needle placement.
Te ch Fig ure 2.2.3. Bluntly dissecting against t he cervix to create a pathway for suture placement .
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Identifying posterior exit locations
Elevate the uterus anteriorly and locate the planned exit location for the needle. This reference point can be made by using
electrocautery to mark a small point (Tech Fig. 2.2.4). This point will generally be approximately 1 cm cranial to the
insertion of the uterosacral ligament.
Te ch Fig ure 2.2.4. Marking the anticipated exit point for the needle.
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Suture placement
The suture is ideally passed so that it may be tied anteriorly. This leaves the knot anteriorly rather than posteriorly where it
could possibly lead to tubal adhesions. It is generally easier to pass the suture from an anterior to posterior direction, but
with the above dissection, it can be placed in either direction.
Start the first placement in an anterior–posterior direction by placing the needle against the cervix, with the curvature of the
needle angled medially (Te ch Fig. 2.2.5). If the needle is placed through the dense cervical tissue, excessive resistance will
be encountered. While holding the needle in place, partially elevate the uterus so that the posterior reference point can be
visualized and used as a guide for where to exit with the needle (Te ch Fig. 2.2.6). If adequate dissection was done earlier,
there should be very little tissue to pass the needle through. After pulling the needle through, approximately 4 to 5 in of
suture is pulled through the incision.
Te ch Fig ure 2.2.5. Placing needle through broad ligament against body of cervix.
Te ch Fig ure 2.2.6. Needle exiting at int ended locat ion.
The suture is oriented so that it will lie flat against the posterior cervix prior to placement on the opposite side.
The needle is then passed in a posterior–anterior direction on the opposite side (Tech Fig. 2.2.7). The needle is started
though the marked location, then the uterus is lowered and the needle is angled so that it exits through the previously
dissected tunnel (Te ch Fig. 2.2.8). The needle should be redirected if it appears to be coursing through heavier tissue.
If the posterior–anterior needle passage cannot be achieved, options include fully dissecting the tunnel bluntly all the way
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through the broad ligament or as a last resort, passing the other needle from an anterior–posterior direction and tying the
knot posteriorly.
Te ch Fig ure 2.2.7. Passing needle anteriorly.
Te ch Fig ure 2.2.8. Needle exiting through previously dissect ed space.
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Suture tying
The suture should be pulled through so that it lies flat and snug against the posterior portion of the cervix (Tech Fig. 2.2.9).
Care should be taken to tie true square knots which allows the wide tape suture to lie flatly against the cervix (Tech Fig.
2.2.10). The suture should be tied only snugly against the cervix. This allows the cervix to be dilated slightly if needed for
future hysteroscopy or D&C. Approximately 4 to 5 throws should be placed.
Te ch Fig ure 2.2.9. Sut ure pulled t hrough until it lies flat against posterior cervix.
Te ch Fig ure 2.2.10. Tying of square knot s in suture.
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Securing suture/peri toneum closure
A separate small suture such as a 4–0 vicryl or silk is used to tie the ends of the tape together to prevent knot loosening
(Te ch Fig. 2.2.11). This same suture is then used to pull the knot down against the cervix (Tech Fig. 2.2.12).
The peritoneal opening is then closed with a small absorbable suture (Te ch Fig. 2.2.13).
Te ch Fig ure 2.2.11. Suturing the t ag ends together.
Te ch Fig ure 2.2.12. Pulling knot down against cervix.
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Te ch Fig ure 2.2.13. Closure of perit oneal opening.
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PEARLS AND PITFALLS
Suture that should be used is Mersilene 5mm Tape on BP-1 double-armed needle. This should be straightened out using
needle drivers to leave the needle in a ski configuration (Figure 2.2.1).
Blunt dissection should be performed to create a tunnel for suture placement at the level of the internal cervical os. This
corresponds to the junction of the cervix and uterine corpus. This dissection should be caudal to the uterine artery, adjacent
to the cervical body, and medial to the cervical branches of the uterine artery.
The needle should be passed perpendicular to the cervix so that the suture lies at the same cervical location both anteriorly
and posteriorly.
Preconceptual placement is preferred rather than placement after pregnancy is achieved.
The suture should be tied only snugly around the cervix. It is intended to only reinforce the cervix rather than tightly close it
off.
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POSTOPERATIVE CARE
Patients may try to conceive immediately after surgery.
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OUTCOMES
Fetal survivorship following laparoscopic transabdominal cerclage has been reported between 76% and 100%.
5
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