removal of not only the tumor itself, but also a significant amount of he althy tissue located next to the pathological focus. In addition, along with the tumor, the lymph nodes and the lymphatic vessels flowing into them are excised.
Radical treatment of cervical and uterine cancer
Wertheim's operation fully complies with the above requirements. Its essence is to remove the uterus with appendages (fallopian tubes and ovaries), the upper third of the vagina, as well as the ligaments supporting the uterus and the surrounding fatty tissue with lymph nodes.
Indications for surgery are cancer of the cervix and body of the uterus. But in some cases, surgery is not recommended:
- in the presence of distant metastases;
- in the case of a huge tumor, with germination of blood vessels and adjacent organs, and sometimes the walls of the pelvis;
- with severe comorbidities;
- in old age.
Wertheim's operation for cervical cancer
Speaking oftreatment of this pathology, it should be noted that the named operation can be used both independently and as part of combination therapy.
In the case of diagnosing highly differentiated squamous cell carcinoma (stage T1bN0M0), this operation can radically solve the problem without involving such methods as chemotherapy and radiation therapy. However, most often the Wertheim operation is a component of combined treatment.
For cancer of the body of the uterus (even in stage IB), other methods of therapy are always prescribed, in addition to surgery.
Operation Wertheim: progress of the operation
Surgical intervention for radical removal of the uterus with appendages includes several stages. These include:
- Access.
- Crossing the uterine ligaments.
- Mobilization of the fallopian tubes and ovaries.
- Mobilization of the bladder.
- Ligation and transection of the main supply vessels.
- Removal of tissues from the anterior surface of the cervix.
- Crossing the ligaments that fix the uterus from behind (sacrouterine).
- Cervical ligament transection.
- Resection of the cervix.
- Hemostasis of the vaginal stump.
- Peritonization.
Surgical access
Wertheim's operation is an extensive intervention that requires good visualization of the surgical field and the possibility of manipulations that are not accompanied by difficulties or limitations. Therefore, the cut must be adequate. Mini-accesses and endoscopicsurgery in this case is not suitable. In matters of cancer treatment, the cosmetic result is in last place in importance.
Usually a median longitudinal laparotomy (incision of the anterior abdominal wall along the linea alba, bypassing the navel) or Czerny approach (transverse laparotomy with incision of the rectus abdominis muscles) is usually performed.
Uterine mobilization
For this purpose, the round ligament of the uterus, the proper and suspensory ligaments of the ovary, as well as the uterine end of the tube are intersected. All of these formations should be crossed, if possible, in places devoid of blood vessels. This will reduce blood loss. The uterus itself is taken on clamps and set aside.
After the transection of the suspensory ligament of the ovary, it becomes possible to remove the uterine appendages. The main thing during their mobilization is not to damage the ureter. For this, during the operation, palpation of the broad ligament of the uterus is mandatory. On its back sheet, the ureteral fold is usually easily located. This manipulation allows the mobilization of the uterus and adnexa without damaging the ureters.
After opening the vesicouterine fold, the bladder is separated from the anterior wall of the cervix with a tupfer. This should be done without deviating from the center line to reduce the risk of injury to the choroid plexuses.
If the bladder is adherent to the uterus by adhesions, it may be difficult to separate it. In this case, manipulation begins from the round ligaments and goes to the neck along the areas with the greatest mobility, separating the bladderscissors.
Further, Wertheim's operation involves ligation of vessels. The main vascular bundle of the uterus is the uterine artery and its accompanying veins, which run along the uterine rib. Their dressing is carried out at the level of the internal pharynx.
For additional mobilization of the uterus, the prevesical fascia is dissected and the tissues are bluntly displaced from the anterior surface of the cervix down. Next, ligaments that were previously inaccessible for manipulation are crossed: sacro-uterine and cervical ligaments. After that, the hysterectomy enters the final stage.
Hysterectomy proper, hemostasis and peritonization
The vaginal fornix is opened, the cervix is taken on clamps and gradually cut off from the vagina. After that, hemostasis and peritonization are performed. The stump of the vagina cannot be tightly sutured, it can serve as a natural drainage in case of any pathological processes in the pelvic cavity and accumulation of pus or blood there.
The vaginal tube is treated in a special way. The walls of the vagina are sutured to the vesicouterine and recto-uterine folds, as well as to the sacro-uterine ligaments, thereby achieving hemostasis and peritonization.
Post-operative period
How does the patient feel after the Wertheim operation? Such a radical surgical intervention cannot pass completely without a trace. Without a doubt, it affects both physical and mental he alth.
What does Wertheim's operation entail? The consequences of this method of treatment are accepteddivided into early and late.
Complications occurring in the early postoperative period
Postoperative period may be complicated:
- Infection of sutures (not only skin, but also internal).
- Peritonitis and sepsis.
- Bleeding from the suture area, including internal bleeding.
- Hematomas in the suture area.
- Dysuria.
- PE (pulmonary embolism).
Even the strictest observance of sterility does not always allow to avoid purulent complications. This is due to the fact that the operation is performed in patients whose body is already weakened by the fight against a malignant tumor, immunity is reduced. Therefore, inflammation of the seams in them is a possible situation. In order to prevent this condition in the postoperative period, a course of antibiotics is required.
Bleeding and the appearance of hematomas indicate insufficient hemostasis. The appointment of hemostatic drugs is not always enough, sometimes a second surgical intervention is required - revision of the wound and stitching of bleeding vessels.
Dysuria is frequent and painful urination. The appearance of this symptom is possible if the urethral mucosa is damaged by a catheter and traumatic urethritis occurs.
PE can occur as a complication of thrombosis of the veins of the lower extremities. That is why anticoagulants ("Heparin") are prescribed in the postoperative period and the wearing of compression stockings or elastic bandages is recommended.
Consequenceslate period
There are certain complications after Wertheim's operation that develop in the long term:
- Emotional problems: fear of possible changes in appearance and loss of sexual desire (after all, the ovaries have been removed, which means that the level of sex hormones has changed), worries about the impossibility of getting pregnant, an ugly scar on the anterior abdominal wall.
- Adhesion process of the abdominal cavity.
- Climax.
- Vaginal prolapse.
- Formation of retroperitoneal lymphocysts.
Women's worries about the consequences of a hysterectomy are understandable. Therefore, in the postoperative period, the support and understanding of loved ones is very important.
With some complications (postoperative scar, inability to have children) you just have to put up with it. Other fears can and should be fought, as they are often unfounded. Removal of the ovaries does not entail any cardinal changes in appearance or sexual sphere. However, there may be discomfort during intercourse if a too short vaginal stump is left after a hysterectomy.
Adhesions after Wertheim's operation are formed in the same way as after any abdominal surgery. This is due to traumatization of the peritoneum during the operation, which leads to the formation of connective tissue strands between its sheets and internal organs.
Adhesion in the abdominal cavity can cause abdominal pain, urination and defecation disorders, and in some cases even lead to intestinalobstruction. To prevent the formation of adhesions in the postoperative period, early activation of the patient and physiotherapy on the first day after surgery are important.
Climax after hysterectomy occurs due to the removal of the ovaries. Postoperative menopause is more difficult to endure naturally, because in this case, hormonal changes occur abruptly. Hormone replacement therapy is used to reduce discomfort.
And the prolapse of the vagina after Wertheim's operation becomes possible due to damage to the ligamentous apparatus (a necessary condition for performing a hysterectomy) and displacement of the pelvic organs to the place of the missing uterus. To prevent such a complication, the patient is recommended to perform special exercises, wear a bandage, limit physical activity for at least 2 months after the operation.
Often a lymphocyst is formed in the retroperitoneal space after Wertheim's operation. Its treatment is surgical. However, it is much more effective to prevent the occurrence of this complication even at the stage of the operation than to treat it. For this purpose, various methods of drainage of the retroperitoneal space are used.
What they say about the Wertheim operation
Wertheim's operation is used to radically get rid of cancer of the cervix or body of the uterus. Reviews about her vary.
Doctors and patients note positive moments after surgery:
- Increased life expectancy.
- Guaranteedabsence of uterine diseases, including cancer.
- Contraception that prevents even a small chance of unwanted pregnancy.
- The operation does not reduce performance, it is possible to return to a full life.
Cons of operation:
- Unable to have children.
- Ugly scar on the anterior abdominal wall.
- Possibility of complications, both early and late (discussed above).
Summarize
Wertheim's hysterectomy is an effective radical treatment of malignant tumors of the cervix and body of the uterus. This operation is not only able to save the patient from cancer, but also in some way improves the quality of life.
Of course, like any surgical intervention, hysterectomy is fraught with complications. However, with proper organization of the postoperative period and compliance with the necessary preventive measures, they can be avoided.
