One of the features of performing operations in oncopathology is radicalism, i.e. removal of not only the tumor itself, but also a significant amount of healthy tissue located next to the pathological focus. In addition, along with the tumor, the lymph nodes and the lymph vessels flowing into them are excised.
Radical treatment for cervical and uterine cancer
The Wertheim operation is fully consistent 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 cervical and uterine cancer. But in some cases, surgery is not recommended:
- in the presence of distant metastases;
- in the case of a huge tumor, with the germination of blood vessels and adjacent organs, and sometimes the walls of the pelvis;
- with severe concomitant pathologies;
- in old age.
Wertheim operation for cervical cancer
If we talk about the treatment of this pathology, it should be noted that this operation can be used both independently and as part of combination therapy.
In the case of diagnosis of squamous highly differentiated cancer (stage T1bN0M0), this operation can radically solve the problem without involving methods such as chemo- and radiation therapy. However, most often, Wertheim surgery is a component of combination treatment.
With cancer of the uterus (even in stage IB), other methods of therapy are always prescribed, in addition to surgical intervention.
Operation Wertheim: Operation
Surgical intervention for radical removal of the uterus with appendages involves several stages. These include:
- Access.
- The intersection of the uterine ligaments.
- Mobilization of the fallopian tubes and ovaries.
- Mobilization of the bladder.
- Ligation and intersection of the main supply vessels.
- Removal of tissue from the anterior surface of the cervix.
- The intersection of the ligaments that fix the uterus behind (sacro-uterine).
- Intersection of cervical ligaments.
- Cervical resection.
- Hemostasis of the vaginal stump.
- Peritonization
Surgical access
The Wertheim operation is an extensive intervention requiring a good visualization of the surgical field and the possibility of manipulations that are not accompanied by difficulties or limitations. Therefore, the incision must be adequate. Mini-accesses and endoscopic surgery are not suitable in this case. In the treatment of cancer, the cosmetic result is in last place in importance.
Typically, a median longitudinal laparotomy (dissection of the anterior abdominal wall along the white line of the abdomen with a bypass of the navel) or access along Czerny (transverse laparotomy with dissection of the rectus abdominis) is usually performed.
Uterine Mobilization
To this end, the circular ligament of the uterus, the own and suspensory ligaments of the ovary, as well as the uterine end of the tube, intersect. All these formations should be crossed, if possible, in places devoid of vessels. This will reduce blood loss. The uterus itself is taken to the clamps and laid aside.
After crossing the suspensory ligament of the ovary, removal of the uterus becomes possible. The main thing when mobilizing them is not to damage the ureter. For this, during the operation, palpation of the wide 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 appendages without damaging the ureters.
After opening the vesicle-uterine folds, the bladder is separated with a tuffer from the front wall of the cervix. This should be done without deviating from the center line to reduce the risk of injury to the vascular plexuses.
If the bladder is fused to the uterus by adhesions, it can be difficult to separate. In this case, they begin to manipulate from round ligaments and go to the neck in areas with the greatest mobility, separating the bubble with scissors.
Further, Wertheim operation involves vascular ligation. The main vascular bundle of the uterus is the uterine artery and its accompanying veins running along the uterine rib. Their ligation is carried out at the level of the internal pharynx.
For additional mobilization of the uterus, dissection of the prevesical fascia and displacement of the tissues from the front surface of the cervix downward by a blunt pathway are performed. Next, ligaments that were previously inaccessible for manipulation intersect: sacro-uterine and cervical ligaments. After this, the hysterectomy goes to the final stage.
Actually hysterectomy, hemostasis and peritonization
The vaginal arch is opened, the cervix is taken to the clamps and is gradually cut off from the vagina. After that, hemostasis and peritonization are performed. The vaginal stump cannot be sutured tightly, it can serve as a natural drainage in the event 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 with the vesico-uterine and rectal-uterine folds, as well as with the sacro-uterine ligaments, thereby achieving hemostasis and peritonization.
Postoperative period
How does the patient feel after Wertheim surgery ? Such a radical surgical intervention can not go completely without a trace. Without a doubt, it affects both physical and mental health.
What does Wertheim operation entail? The consequences of this treatment method are usually divided into early and late.
Complications in the early postoperative period
The postoperative period may complicate:
- Infection of sutures (not only cutaneous, but also internal).
- Peritonitis and sepsis.
- Bleeding from the suture area, including internal.
- Hematomas of the suture area.
- Dysuria.
- Pulmonary embolism (pulmonary embolism).
Even the strictest adherence to sterility does not always avoid purulent complications. This is due to the fact that the operation is performed for patients whose body is already weakened by the fight against a malignant tumor, immunity is reduced. Therefore, inflammation of the sutures in them is a possible situation. In order to prevent this condition in the postoperative period, a course of antibiotics is mandatory.
Bleeding and the appearance of hematomas indicate insufficient hemostasis. The appointment of hemostatic drugs is not always enough, sometimes repeated surgical intervention is required - revision of the wound and flashing of bleeding vessels.
Dysuria is a frequent and painful urination. The appearance of this symptom is possible with damage to the urethral mucosa by a catheter and the occurrence of traumatic urethritis.
Pulmonary embolism can occur as a complication of vein thrombosis of the lower extremities. That is why in the postoperative period, anticoagulants ("Heparin") are prescribed and it is recommended to wear compression stockings or elastic bandages.
Consequences of the late period
There are certain complications after Wertheim surgery, developing in the long term:
- Emotional problems: fear of possible changes in appearance and loss of sex drive (after all, the ovaries are removed, which means that the level of sex hormones is changed), worries about the inability to get pregnant, an ugly scar on the anterior abdominal wall.
- Adhesive process of the abdominal cavity.
- Climax
- Vaginal prolapse.
- The formation of retroperitoneal lymphocytes.
The woman's experiences about the consequences of a hysterectomy are understandable. Therefore, in the postoperative period, support and understanding of loved ones is very important.
With some complications (postoperative scar, inability to have children) you only have to put up with it. Other fears can and should be fought, as they are often unreasonable. Removal of the ovaries does not entail any cardinal changes in appearance or sexual sphere. However, discomfort during intercourse may occur if the vaginal stump is too short after hysteretomy.
Adhesions after Wertheim surgery are formed in the same way as after any abdominal surgery. This is due to trauma to the peritoneum during the operation, which leads to the formation of connective tissue cords between its sheets and internal organs.
Adhesive process in the abdominal cavity can cause abdominal pain, urination and bowel movements, and in some cases even lead to intestinal obstruction. To prevent the formation of adhesions in the postoperative period, early activation of the patient and physiotherapy in the first day after the operation are important.
Menopause after hysterectomy occurs due to removal of the ovaries. Postoperative menopause is harder to carry naturally, because in this case, hormonal changes occur sharply. To reduce discomfort, hormone replacement therapy is used.
And the omission of the vagina after Wertheim surgery 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 absent uterus. To prevent such a complication, the patient is recommended to perform special gymnastics, wearing a bandage, limiting physical activity for at least 2 months after the operation.
Often in the retroperitoneal space a lymphocyst is formed after Wertheim operation. Her surgical treatment. However, it is much more effective to prevent the occurrence of this complication at the stage of surgery than to treat it. To this end, various methods of drainage of the retroperitoneal space are used.
What they say about Wertheim operation
For a radical cure for cancer of the cervix or body of the uterus, Wertheim operation is used. Reviews about her are different.
Doctors and patients note positive moments after surgery:
- Increased life expectancy.
- Guaranteed absence of uterine diseases, including cancer.
- Contraception that prevents even a small chance of an unwanted pregnancy.
- The operation does not reduce performance, there is an opportunity to return to a full life.
Cons of the operation:
- Inability to have children.
- An ugly scar on the anterior abdominal wall.
- The possibility of complications, both early and distant (discussed above).
To summarize
Wertheim hysterectomy is an effective radical treatment of malignant tumors of the cervix and uterine body. 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, a hysterectomy is fraught with the development of complications. However, with the competent organization of the postoperative period and the observance of the necessary preventive measures, they can be avoided.