Operation Wertheim: the course of the operation, the consequences, complications, reviews

One of the features of performing operations in oncology is radicality, 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 excised lymph nodes and lymphatic vessels flowing into them.

Radical treatment of cervical and uterine cancer

The Wertheim operation fully meets 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 supporting the uterus ligaments and surrounding fatty tissue with lymph nodes.

Indications for surgery include cancer of the cervix and the body of the uterus. But in some cases, surgery is not recommended:

• In the presence of distant metastases;
• In the case of huge tumor size, with the germination of vessels and a number of located organs, and sometimes the walls of the pelvis;
• With severe accompanying pathologies;
• In old age.

Wertheim's surgery for cervical cancer

If we talk about the treatment of this pathology, it should be noted that this operation can be used alone or as part of a combination therapy.

In the case of diagnosing squamous, highly differentiated cancer (stage T1bN0M0), this operation can radically solve the problem without involving methods such as chemo- and radiotherapy. However, most often the Wertheim surgery is a component of combined treatment.

In case of cancer of the uterus body (even in stage IB), other therapies are always prescribed, in addition to surgical intervention.

Operation Wertheim: progress of the operation

Surgical intervention for the radical removal of the uterus with appendages involves several stages. These include:

1. Access.
2. Intersection of the uterine ligaments.
3. Mobilization of the fallopian tubes and ovaries.
4. Mobilization of the bladder.
5. Bandaging and crossing of the main feeding vessels.
6. Removal of tissues from the anterior surface of the cervix.
7. Intersection of ligaments fixing the uterus from behind (sacro-uterine).
8. Intersection of cervical ligament.
9. Resection of the cervix.
10. Hemostasis of the stump of the vagina.
11. Peritonization.

Surgical access

Wertheim's operation is an extensive intervention requiring a good visualization of the operating field and the possibility of manipulation, not accompanied by difficulties or limitations. Therefore, the cut must be adequate. Mini-access and endoscopic surgery in this case are not suitable. In the treatment of cancer, the cosmetic result is of the last importance.

Usually, a medial longitudinal laparotomy is performed (dissection of the anterior abdominal wall along the white abdominal line with a bypass of the navel) or access via Czerny (transverse laparotomy with dissection of the rectus abdominis muscles).

Mobilization of the uterus

For this purpose, the round ligament of the uterus, own and hanging ligament of the ovary, as well as the uterine end of the tube intersect. All specified formations should be crossed, if possible, in places deprived of blood vessels. This will reduce blood loss. The uterus itself is taken at the clamps and taken away.

After crossing the suspension of the ovary ligament, it becomes possible to remove the appendages of the uterus. The main thing, when mobilizing them, is not to damage the ureter. For this, palpation of the broad ligament of the uterus is required during the operation. On the back of the leaf, it is usually easy to find the ureteral fold. This manipulation allows you to mobilize the uterus and appendages without damaging the ureters.

After opening the vesicle-uterine fold, the bladder is separated from the anterior wall of the cervix with a tuffle. Do this without deviating from the central line to reduce the risk of injury to the vascular plexuses.

If the bladder is fused with the uterus with spikes, separating it can be difficult. Begin the manipulation in this case from the round ligaments and go to the cervix at the sites with the greatest mobility, separating the bladder with scissors.

Further, Wertheim's operation involves bandaging the vessels. The main vascular bundle of the uterus is the uterine artery and the accompanying veins that run along the edge of the uterus. Their ligation is carried out at the level of the internal pharynx.

For additional mobilization of the uterus, the dissection of the pre-bladder fascia and the displacement of the blunt tissue from the anterior surface of the cervix down. Further, ligaments that previously were inaccessible to manipulation are intersected: sacro-uterine and ligament cervical. After that, the hysterectomy reaches the final stage.

Actually hysterectomy, hemostasis and peritonization

The vaginal vault is opened, the cervix is taken to the clamps and gradually cut off from the vagina. After this, hemostasis and peritonization are performed. The cult of the vagina can not be sutured tightly, it can serve as a natural drainage in the case of any pathological processes in the cavity of the small pelvis and the accumulation of pus or blood there.

The vaginal tube is treated in a special way. The walls of the vagina are stitched with vesicovato-uterine and rectal-uterine folds, as well as with sacro-uterine ligaments, thus achieving hemostasis and peritonization.

Postoperative period

How does the patient feel after Wertheim surgery? Such a radical surgical intervention can not pass completely without a trace. Without a doubt, it affects health, both physical and mental.

What does the Wertheim operation entail? The consequences of this method of treatment are divided into early and late.

Complications arising in the early postoperative period

Postoperative period may complicate:

1. Infection of seams (not only skin, but also internal).
2. Peritonitis and sepsis.
3. Bleeding from the seam area, including the internal one.
4. Hematomas of the seam area.
5. Dysuria.
6. PE (pulmonary embolism).

Even the strictest observance of sterility does not always prevent purulent complications. It is due to the fact that the operation is performed in patients whose body is already weakened by the fight against a malignant tumor, the immunity is reduced. Therefore, the 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 a re-surgical intervention is needed - wound revision and flushing of bleeding vessels.

Dysuria - 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 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 also certain complications after the Wertheim surgery, developing in the distant period:

1. Emotional problems: fear of possible changes in appearance and loss of sexual desire (after all, the ovaries are removed, which means that the level of sex hormones is changed), the experience of the inability to conceive, an ugly scar on the anterior abdominal wall.
2. Adhesive process of abdominal cavity.
3. Climax.
4. Omission of the vagina.
5. Formation of retroperitoneal lymphokist.

The experience of a woman about the consequences of a hysterectomy is understandable. Therefore, in the postoperative period, support and understanding of relatives are very important.

With some complications (postoperative scar, the inability to have children), one has only to accept. With other fears, you can and should fight, because they are often unreasonable. The removal of the ovaries does not entail any major changes in the appearance or sexual sphere. However, there may be discomfort during intercourse if, after hysterectomy, a too short stump of the vagina is left.

Spikes after Wertheim surgery are formed in the same way as after any cavitary surgical intervention. This is due to the trauma of the peritoneum during the operation, which leads to the formation of connective tissue strands between its sheets and internal organs.

Adhesive process in the abdominal cavity can cause pain in the abdomen, micturition and defecation, 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 the holding of physiotherapy are important already in the first day after the operation.

Climax after hysterectomy occurs due to removal of the ovaries. Postoperative menopause is more difficult to tolerate naturally, because in this case hormonal changes occur dramatically. To reduce discomfort, hormone replacement therapy is used.

And 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 missing uterus. To prevent this complication, the patient is recommended to perform special gymnastics, wearing a bandage, limiting physical exertion at least 2 months after the operation.

Often in the retroperitoneal space , a lymphokist is formed after Wertheim's operation. Her treatment is surgical. However, it is much more effective to prevent the appearance of this complication at the stage of the operation than to treat it. To this end, various methods of drainage of the retroperitoneal space are used.

What they say about Wertheim's operation

For the radical disposal of cervical or uterine cancer, Wertheim surgery is used. Reviews about it are different.

Doctors and patients note the positive aspects after the operation:

1. Increased life expectancy.
2. Guaranteed absence of uterine diseases, including cancer.
3. Contraception, which does not allow even a small probability of unwanted pregnancy.
4. The operation does not reduce efficiency, there is an opportunity to return to a full life.

Cons of operation:

1. Impossibility to have children.
2. An ugly scar on the anterior abdominal wall.
3. The possibility of complications, both early and remote (discussed above).

Let's sum up the results

Wertheim's hysterectomy is an effective radical treatment for 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, hysterectomy is fraught with the development of complications. However, with proper organization of the postoperative period and observance of the necessary preventive measures, they can be avoided.