Drainage of pelvic phlegmon
Pelvic cellular space phlegmons are drained via two main routes: through the anterior abdominal wall or through the posterior vaginal fornix in women. Retropubic phlegmons are opened via a suprapubic Key incision along the linea alba or via a transrectal approach through the rectus abdominis muscle. Perivesical phlegmons are drained through pararectal incisions along the edge of the rectus muscles with drainage tubes placed on the sides of the urinary bladder.
For deep pelvic abscesses, the Buyalski–MacWhorter method is used: the patient lies in the Trendelenburg position, and a transverse incision is made on the inner surface of the thigh 3–4 cm below the femoroperineal fold. The fibers of the external and obturator muscles are bluntly separated, the obturator membrane is incised, the ischioanal fossa is reached through the obturator foramen, and the perivesical space is reached through the levator ani muscle.
In parametritis, the approach is chosen depending on the direction of the process spread: for an infiltrate of the anterior abdominal wall, an incision is made above the inguinal ligament with penetration into the properitoneal space; for a process toward the fornix, a vaginal approach is used. Lateral parametritis is dangerous due to the risk of damage to the uterine artery and ureter.
Abscesses of the rectouterine pouch (pouch of Douglas) are opened through the rectum or the posterior vaginal fornix: after dilating the sphincter or exposing the fornix with specula, a puncture with a thick needle is performed in the most prominent area, and the cavity is opened along the needle and drained.
Surgeries on the urinary bladder
Suprapubic puncture is indicated for acute urinary retention when catheterization is impossible (e.g., in prostate cancer). The needle is inserted along the linea alba 2–3 cm above the pubic symphysis, passing through the transversalis fascia, prevesical space, and the anterior wall of the bladder.
Cystotomy (high section) is performed for stones, polyps, and foreign bodies. The bladder is preliminarily filled via a catheter to displace the peritoneum upward. Following a lower-median laparotomy, the rectus muscles are separated, the retropubic space is exposed, two stay sutures are applied to the anterior wall of the bladder, it is opened, the pathological contents are removed, and it is closed with a submucosal suture with peritonization.
Cystostomy is the creation of an anastomosis for ruptures of the urethra or the anterior wall of the bladder. It can be temporary (with suturing of the bladder wall to the parietal peritoneum — cystopexy) and permanent labiiform (the bladder mucosa is sutured to the skin).
Surgeries on female reproductive organs
For tubal ectopic pregnancy, tubectomy is most commonly performed. The approach is via Pfannenstiel incision, two clamps are applied to the fallopian tube — on the uterine side grasping the mesosalpinx and on the opposite side, the tube is transected, and the stump is peritonized with the round ligament of the uterus.
Wedge resection of the ovary is indicated for sclerocystic changes: a wedge-shaped section of tissue is excised from the surface facing the peritoneal cavity, with mandatory wound closure using interrupted sutures.
Supravaginal amputation of the uterus is performed for uterine fibroids. The uterus is fixed with bullet forceps, the round ligaments, fallopian tubes, ovarian proper ligaments, and vessels are ligated and transected, the uterine body is amputated in a cone shape, and the cervical stump is sutured with a figure-of-eight stitch without capturing the cervical canal mucosa. When amputating with appendages, the technique is supplemented by transecting the appendages.
Hysterectomy (extirpation of the uterus) is indicated for oncological conditions. The key difference from amputation is the removal of the uterus along with the vaginal part of the cervix as a single block. Transection of the vaginal part of the cervix is performed from the vaginal side.
Cesarean section
The operation of extracting the fetus and placenta from the pregnant uterus bypassing the cervical canal. It can be elective (narrow pelvis, placenta previa) and emergency (premature placental abruption). A mandatory condition is a live fetus.
A Pfannenstiel approach is performed, the aponeurosis is transversely incised, the rectus muscles are separated, and the peritoneum is bluntly opened. The uterus is rotated to the left to protect the left border and the neurovascular bundle. The vesicouterine fold is incised 2–3 cm above its transverse transition to expose the lower segment. A transverse incision according to Gusakov 1 cm long is performed and expanded with index fingers. After extracting the fetus and removing the placenta, the uterine wall is sutured with a continuous or interrupted suture with peritonization by the vesicouterine fold.
Paraproctitis and its surgical treatment
Paraproctitis is inflammation of the perirectal cellular tissue. Classification by localization: subcutaneous, submucosal, ischioanal, pelvirectal, retrorectal. Treatment consists of opening and draining the abscess and eliminating the fistulous tract connecting the cavity with the rectum.
- A radial incision is used for subcutaneous and submucosal forms with a superficial location of the abscess.
- A semilunar incision is used for pelvirectal, ischioanal, and retrorectal forms for deep access while minimizing the risk of rectal injury.
- In subcutaneous paraproctitis, the incision is made over the fluctuation, stepping back 3 cm from the anal opening so as not to damage the external sphincter.
- In the pelvirectal form, the levator ani muscle is incised; in women, drainage through the posterior vaginal fornix is permissible.
Chronic paraproctitis is characterized by a formed fistulous tract. Fistulas can be complete, incomplete external and internal, simple rectilinear, and complex with cavities.
Surgeries for male genital pathology
Cryptorchidism is the absence of a testicle in the scrotum due to impaired descent. A high position of the testicle is dangerous due to atrophy and malignant transformation caused by inappropriate temperature. Orchiopexy is performed in a single stage according to Ombredanne or in two stages according to Herzen. In Herzen's method, the testicle is fixed to the broad fascia of the thigh, forming a femoroscrotal anastomosis, which is transected after 3–4 months.
Hydrocele (water testicle) is an accumulation of serous fluid between the layers of the tunica vaginalis. Winkelmann's operation is performed: the anterior wall of the inguinal canal is incised, the hydatid tumor is delivered, the tunica vaginalis is opened, the proximal part of the vaginal process of the peritoneum is ligated, the tunic is everted with the serous surface outward and sutured behind the testicle.
Phimosis is the narrowing of the foreskin opening, which can be congenital or acquired. Paraphimosis is the entrapment of the glans penis by the foreskin with impaired blood flow, requiring emergency intervention. The main surgical method is circumcision (circular excision of the foreskin) with two circular incisions and suturing of the edges with catgut.
Key points
- Pelvic phlegmons are drained through the anterior abdominal wall, the posterior vaginal fornix, or via Buyalski–MacWhorter through the obturator foramen.
- Cystotomy is preferably performed via an extraperitoneal approach after filling the bladder to displace the peritoneum.
- In tubal ectopic pregnancy, the standard is tubectomy with peritonization of the stump using the round ligament of the uterus.
- Uterine amputation preserves the vaginal part of the cervix, whereas hysterectomy removes it as a single block.
- Lower segment Cesarean section is performed via a transverse incision according to Gusakov after incising the vesicouterine fold.
- The choice of incision in paraproctitis (radial or semilunar) is determined by the depth of the abscess location.
- Orchiopexy for cryptorchidism is mandatory due to the risk of atrophy and malignancy; Ombredanne and Herzen techniques are used.
- Paraphimosis is an urgent condition requiring emergency circumcision to prevent necrosis.