[intro-text]Единственный эффективный метод лечения варикоцеле – хирургический. Убрать патологию яичковых вен можно 120 разными способами. Но чаще всего рекомендуется операция по методике Мармара — оптимальный вариант на любой стадии.[/intro-text]
[contents]
Особенности и преимущества
Под операцией Мармара подразумевается перевязка пораженной вены через разрез в месте, где семенной канатик прилегает к коже. Процедура осуществляется микро хирургическими инструментами под оптическим увеличением. Благодаря этому удается полностью устранить варикоцеле.
Если сравнивать другие виды хирургического вмешательства и операцию Мармара, у последнего способа лечения варикоцеле есть такие преимущества:
- малоинвазивность. Применение микрохирургических инструментов позволяет избежать травмирования тканей, мелких сосудов;
- надежность: эффективность операции – 95-98%;
- отсутствие большого шрама: пораженную яичковую вену убирают через мини-разрез в области немного ниже пахового кольца. Оставшийся после операции шрам трудно увидеть невооруженным глазом и легко можно скрыть нижним бельем;
- низкий риск появления осложнений;
- небольшой период восстановления (2-3 дня);
- минимальная вероятность повторного возникновения варикоцеле;
- быстрая выписка (за исключением отдельных случаев).
Преимуществ у хирургического вмешательства по Мармару немало. Но и у него есть недостатки – высокая стоимость, сложность в исполнении.
Показания
Операцию Мармара чаще всего делают на последних стадиях развития варикоцеле при таких симптомах:
- интенсивные боли паху;
- сильно измененные результаты спермограммы;
- неэстетичный внешний вид мошонки;
- бесплодие;
- атрофия яичка, уменьшение его размеров;
- высокий риск нарушения фертильности у подростка.
При варикоцеле проводить операцию не обязательно. На ранних стадиях его развития, при отсутствии клинических признаков, пациент вправе отказаться от лечения. В таких случаях за течением патологии просто наблюдают.
Противопоказания
Как и у всех хирургических вмешательств, у операции Мармара есть ограничения к проведению. Процедуру не выполняют при:
- острых заболеваниях вирусной, инфекционной природы;
- плохой свертываемости крови;
- нестабильной стенокардии;
- лечении антикоагулянтами;
- прохождении реабилитации после перенесения инфаркта, инсульта;
- воспалении почек, мочевого пузыря, уретры или предстательной железы;
- обострении хронических заболеваний (язва двенадцатиперстной кишки, желудка);
- циррозе печени в стадии декомпенсации;
- гнойно-воспалительных процессах на коже;
- гипертонии;
- сезонной аллергии.
Многие из противопоказаний – временные. Возможность и необходимость проведения операции Мармара при варикоцеле определяет хирург или врачебная комиссия в индивидуальном порядке.
Подготовительный этап
Чтобы убедиться в отсутствии противопоказаний к операции по удалению варикоцеле, оценить общее состояние здоровья мужчине рекомендуется прохождение комплексного обследования. Состоит оно из таких диагностических процедур:
- анализ мочи;
- рентген грудной клетки;
- анализ крови: общий, расширенный;
- электрокардиограмма;
- коагулограмма (рекомендуется при склонности к тромбообразованию);
- исследование скорости свертываемости крови;
- спермограмма;
- анализ на вирусные гепатиты типа B и C, ВИЧ-инфекцию, сифилис;
- исследование гормонального фона.
Результаты обследования и заключение о возможности проведения хирургического вмешательства выдает терапевт.
[frame-icon type=»4″ color=»yellow»]В день выполнения операции Мармара нельзя принимать пищу. От употребления жидкости также рекомендуется отказаться (по возможности). Обязательно проводятся гигиенические процедуры.[/frame-icon]
Особенности выполнения
Операцию Мармара делает хирург-уролог в амбулаторных условиях. После ее завершения, по истечении нескольких часов, мужчина может ехать домой. Но иногда возможны исключения.
Больного оставляют в стационаре на 1-3 дня, если:
- при вмешательстве возникли технические сложности;
- была применена эпидуральная или общая анестезия;
- операция стала причиной декомпенсации сопутствующей патологии, имеющейся у больного.
[frame-icon type=»1″ color=»blue»]Проводить операцию по удалению варикоцеле в детском и подростковом возрасте рекомендуется в условиях стационара.[/frame-icon]
Техника проведения
Начинается операция Мармара с применения анестезии. После того, как она подействует, врач приступает непосредственно к удалению варикоцеле:
- Обрабатывает область вмешательства антисептиком.
- Делает скальпелем разрез длиной до 2 см.
- Рассекает подкожную жировую клетчатку, мягкие ткани, разводит их мини-ретрактором.
- Пережимает мелкие сосуды, высушивает рану.
- Отодвигает отвечающую за поднятие яичка мышцу, еще раз вводит анестетик.
- Фиксирует семенной канатик специальными держателями. Это помогает предупредить его пережатие или перекручивание, возникновение осложнений в послеоперационный период.
- Выделяет вены диаметром более 2 мм, перевязывает их шелковыми нитями.
- Орошает рану раствором Папаверина для исключения кровотечений.
- Проводит пробу Вальсальвы для выявления варикозно расширенных вен, оставшихся незамеченными.
- Послойно ушивает ткани.
- Накладывает косметический шов, используя обычные или рассасывающиеся нити, и стерильную повязку.
Во время операции Мармара все действия выполняют под контролем датчика Допплера и увеличивающих линз. Это позволяет безошибочно отделить пораженные вены от здоровых и провести их перевязку, свести к минимуму риск повреждения артерий, лимфатических сосудов и нервных окончаний. Средняя продолжительность оперативного вмешательства – 30-40 минут.
Особенности выбора наркоза
Методику обезболивания выбирает врач-уролог вместе с анестезиологом в зависимости от длительности вмешательства и состояния здоровья мужчины в целом, инструментального оснащения операционной.
Общий наркоз рекомендуется при операциях длительностью более часа. Он бывает масочным, внутривенным.
При эндотрахеальном наркозе анестетик (Галотан, закись азота, Фторотан) поступает в трахею. Пациента интубируют и переводят на искусственную вентиляцию легких. Этот вид наркоза не используется при наличии заболеваний органов дыхания (бронхиальная астма, воспаление легких, верхних дыхательных путей). При внутривенном наркозе больной дышит самостоятельно. Для обезболивания используются Кетамин, Гексенал, Диприван.
После действия общего наркоза пациент впадает в глубокий сон: о ходе операции ему ничего не известно. После него возможна сонливость, головная боль, тошнота. Функции нервной системы полностью возобновляются через 24 часа.
Эпидуральную анестезию используют для проведения операций, длительностью менее часа. Обезболивающий препарат (Лидокаин, Тетракаин) вводят в канал между 3 и 4 поясничными позвонками. Он блокирует передачу нервных импульсов, отвечающих за двигательные функции и чувствительность. Благодаря такому действию наркоза пациент ничего не чувствует ниже уровня укола. Эпидуральное обезболивание противопоказано при выраженной деформации позвоночника, высоком внутричерепном давлении, аортальном стенозе.
Местная анестезия – самый безопасный способ обезболивания. Но она больше подходит для операций, которые длятся не больше получаса. Обезболивающее средство (Ультракаин, Новокаин или Лидокаин) вводят в место предполагаемого разреза. Во время хирургического вмешательства пациент все время находится в сознании, может ощущать легкий дискомфорт, не интенсивную боль.
[frame-icon type=»4″ color=»green»]Так как операция Мармара длится недолго и поврежденную яичковую вену перевязывают через мини-разрез, чаще всего она проводится под местной анестезией. Но по желанию пациента, если нет у него соответствующих противопоказаний, может применяться эпидуральный или общий наркоз.[/frame-icon]
Восстановление
Эффективность операции Мармара, длительность реабилитационного периода зависит от действий мужчины после выписки домой. В течение 1-1,5 недели нужно:
- Избегать тяжелых физических нагрузок, поднятия тяжестей, длительного пребывания в положении стоя и половых контактов.
- Использовать бандаж или специальное белье для поддержания яичек.
- Применять обезболивающие средства (при болях высокой интенсивности).
- Ежедневно ухаживать за раной – обрабатывать антисептиком, назначенным врачом.
После удаления варикоцеле принимать душ рекомендуется только через 48 часов, ванну – спустя 2 недели. Возвращаться на работу, не требующую повышенных физических нагрузок, можно после снятия или рассасывания швов.
Полное восстановление наступает через полгода после вмешательства. В этот период нужно:
- Избегать перегревания, переохлаждения организма.
- Максимально уменьшить частоту посещения бань, саун.
- Вести умеренную сексуальную жизнь.
- Заниматься лечебной гимнастикой. Возвращаться к силовым упражнениям, профессиональному занятию спортом лучше по окончанию реабилитационного периода.
- Ограничить поездки на велосипеде.
- Отказаться от пробежек на длительные расстояния.
[frame-icon type=»3″ color=»red»]При лечении запущенной формы варикоцеле с осложнениями, восстановление может длиться до 9 месяцев.[/frame-icon]
Последствия
Операция Мармара – малоинвазивное хирургическое вмешательство. Но сразу после него могут наблюдаться:
- гиперемия кожи;
- небольшие гематомы;
- боли в мошонке, ее отечность;
- уплотнение кожного покрова в месте сшивания раны.
Все эти последствия имеют временный характер и являются естественной реакцией организма на оперативное вмешательство. Если придерживаться рекомендаций по восстановлению, они быстро исчезают.
Высокая температура тела, большие гематомы, потеря чувствительности в области бедра, неприятно пахнущие выделения из раны желтоватого или бурого цвета, выраженные и не проходящие отеки, болевые ощущения в мошонке и внизу живота после операции Мармара – те симптомы, при появлении которых нужно сразу же обратиться к врачу.
Возможные осложнения
Переносится операция Мармара обычно хорошо. Но если она проводится неопытным специалистом, существует риск появления таких осложнений:
- выраженный болевой синдром, длительностью более месяца;
- гидроцеле;
- воспаление, атрофия яичка;
- повторное развитие варикоцеле;
- кровотечения;
- образование тромбов в глубоких венах ног.
[frame-text-border]Редкое осложнение хирургического вмешательства, которое не зависит от квалификации врача — аллергия на материал шва. Она легко устраняется антигистаминными средствами и не беспокоит пациента.[/frame-text-border]
Стоимость
Средняя стоимость операции Мармара в России – 35-40 тыс. руб., в Украине – 10 тыс. грн. Цена зависит от:
- вида наркоза;
- места проведения вмешательства (частная или государственная клиника);
- степени варикоцеле;
- необходимости пребывания в стационаре после удаления варикозно расширенных яичковых вен.
Стоимость хирургического лечения варикоцеле в государственных учреждениях может быть ниже, чем в частных клиниках. Но низкая цена не всегда является показателем того, что операция будет выполнена качественно. При выборе места проведения оперативного вмешательства в первую очередь рекомендуется обращать внимание на уровень квалификации врача.
Эффективность
Операция Мармара – «золотой стандарт» лечения варикоцеле. После нее около 69% мужчин становятся отцами спустя два года.
Риск возникновения рецидивов после операции минимален – всего 1%. Случаи развития водянки или атрофии прооперированного яичка встречаются крайне редко.
Видео по теме:
Отзывы
По мнению врачей, операция Мармара – хорошая альтернатива классической методике оперативного лечения варикоцеле: она не требует длительной реабилитации, может проводиться на любой стадии патологии.
Мужчины, перенесшие операцию по удалению варикоцеле, отзываются о ней по-разному. Некоторые больные сталкивались с проблемой длительного болевого синдрома, появления дискомфорта при ходьбе, другой физической активности. Но в большинстве случаев мнения пациентов об эффективности оперативного вмешательства по методике Мармара положительные:
[frame-text-big]«Диагностировали варикоцеле, но от оперативного лечения отказался. Обратился к хирургу, когда уже терпеть боли в мошонке не стало сил. Варикоцеле удаляли по методике Мармара. Спустя несколько дней после операции рана немного побаливала, но тяжелых осложнений не возникало. Уже год прошел после вмешательства. Рецидивов варикоцеле не было.»
Евгений[/frame-text-big]
[frame-text-big]«Около 2 месяцев назад делали операцию Мармара, но болевой синдром остался. Дискомфорт ощущается в яичке и тянется вверх. Иногда бывают боли очень интенсивные, похожие на защемление нерва»
Дмитрий[/frame-text-big]
[frame-text-big]«В 27 лет выдали направление на операцию Мармара на основании результатов УЗИ, проведенного у нескольких специалистов. Хирургическое вмешательство длилось 45 минут, из которых 15 ждал, пока подействует спинальный наркоз. Домой уехал через 3 дня. Придерживался всех рекомендаций по восстановлению, около месяца принимал таблетки, назначенные врачом. Прошло 2 месяца. Болей нет, но иногда шрам реагирует на погоду. Обратился к урологу. Он сказал, что все хорошо. Посоветовал пройти профилактический осмотр через месяц»
Николай[/frame-text-big]
Ответы на часто задаваемые вопросы
Как делают операцию Мармара при варикоцеле?
Оперативное вмешательство по методике Мармара – перевязка варикозно расширенной яичковой вены через доступ в области немного ниже пахового кольца. Когда анестетик начинает действовать, делают разрез длиной в 1-2 см и выводят через него семенной канатик. Врач отделяет семенной проток и яичковую артерию (во избежание их травмирования), перевязывает яичковую вену. При необходимости перекрываются другие венозные сосуды. Завершается операция сшиванием тканей и накладыванием косметических швов.
Под каким наркозом делают операцию Мармара?
Применяется местное обезболивание, эпидуральная (редко) или общая анестезия. Вид наркоза выбирает хирург и анестезиолог исходя из желания пациента, наличия у него сопутствующих патологий и степени расширения вен яичек.
Можно ли делать подросткам?
Операция Мармара может быть проведена в подростковом возрасте, если есть соответствующие показания. При варикоцеле 1 степени и отсутствии симптомов прибегать к хирургическому вмешательству не рекомендуется до 18 лет: существует риск недоразвития яичек.
Сколько длится реабилитация?
Средняя продолжительность реабилитационного периода после операции по Мармару – от 1 до 1,5 недели (до момента снятия швов). Полное восстановление наступает через 6 месяцев. Но все зависит от индивидуальных особенностей организма.
Берут ли в армию после операции Мармара?
Мужчинам и подросткам, перенесшим хирургическое вмешательство по поводу удаления варикоцеле, дают отсрочку на полгода. По истечении этого времени заболевание считается излеченным: противопоказаний к несению военной службы нет.
Когда можно приступать к зачатию ребенка после операции Мармара?
Планировать зачатие ребенка при условии отсутствия осложнений и благоприятного течения восстановительного периода можно через 3-6 месяцев после операции. Но чтобы сперматозоид, оплодотворивший яйцеклетку, был более качествен с функциональной точки зрения, рекомендуется отложить планирование беременности на год.
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