Abstract
- The uterus, adnexa, superior bladder, and upper rectum are peritonealized. These structures attach to the pelvis and to one another via a variety of peritoneal reflections and vascular and fibrous ligaments and pedicles.
- Pelvic organs:
- Reproductive organs: uterus, fallopian tubes, ovaries
- Rectum: separated from the uterus by the posterior cul-de-sac, or Pouch of Douglas
- Urinary system:
- Bladder: shares a common peritoneal lining with the lower uterine segment and cervix
- Ureters: Common sites for injury during gynecologic procedures:
- Near the pelvic brim when the ovarian vessels are divided for oophorectomy
- Along the peritoneum during retroperitoneal pelvic dissection
- At the cardinal ligament during transection of the uterine arteries, where the ureter crosses under the uterine vasculature (“water under the bridge”)
- At the lateral angles of the vaginal cuff closure
- Near the pelvic brim when the ovarian vessels are divided for oophorectomy
- Bladder: shares a common peritoneal lining with the lower uterine segment and cervix
- Reproductive organs: uterus, fallopian tubes, ovaries
- Vascular pedicles:
- Ovarian vessels: branch from the aorta (right ovarian vein drains to IVC and left ovarian vein to the left renal vein) and supply the adnexa
- Uterine vessels: branch medially from internal iliac vessels and course toward then along the uterus
- Parametrial/vaginal vessels: branches of the internal iliac arteries that course through the parametria
- Ovarian vessels: branch from the aorta (right ovarian vein drains to IVC and left ovarian vein to the left renal vein) and supply the adnexa
- Ligaments and peritoneal reflections:
- Utero-ovarian ligament: connects ovaries to uterus
- Mesosalpinx: peritoneal reflection that suspends the fallopian tube and contains mesosalpingeal vessels
- Round ligament: extends from the bilateral uterine cornua and courses through the deep inguinal ring
- Broad ligament: peritoneal reflection attaching the uterus to the round ligament, adnexa, and sidewall
- Cardinal ligament: the connection between the lower uterine segment/cervix and pelvic sidewall
- Uterosacral ligament: connects the base of the cervix to the sacrum
- Utero-ovarian ligament: connects ovaries to uterus
- Pelvic organs:
Surgical Anatomy
The uterus, adnexa, superior bladder, and upper rectum are peritonealized. These structures attach to the pelvis and to one another via a variety of peritoneal reflections and vascular and fibrous ligaments and pedicles.
Pelvic organs:
Reproductive organs: uterus, fallopian tubes, ovaries
Rectum: separated from the uterus by the posterior cul-de-sac, or Pouch of Douglas
Urinary system:
Bladder: shares a common peritoneal lining with the lower uterine segment and cervix
Ureters: Common sites for injury during gynecologic procedures:
Near the pelvic brim when the ovarian vessels are divided for oophorectomy
Along the peritoneum during retroperitoneal pelvic dissection
At the cardinal ligament during transection of the uterine arteries, where the ureter crosses under the uterine vasculature (“water under the bridge”)
At the lateral angles of the vaginal cuff closure
Figure 35.2 Anatomy of the female genitourinary tract depicted from a posterior view. Dotted lines indicate where to divide when performing a supracervical hysterectomy and a salpingectomy. An additional dotted oval demonstrates where a uterine artery ligation stitch can be placed to control bleeding. The ureter is shown crossing from posterior to anterior under the uterine vessels which course from lateral to medial.
Vascular pedicles:
Ovarian vessels: branch from the aorta (right ovarian vein drains to IVC and left ovarian vein to the left renal vein) and supply the adnexa
Uterine vessels: branch medially from internal iliac vessels and course toward then along the uterus
Parametrial/vaginal vessels: branches of the internal iliac arteries that course through the parametria
Ligaments and peritoneal reflections:
Utero-ovarian ligament: connects ovaries to uterus
Mesosalpinx: peritoneal reflection that suspends the fallopian tube and contains mesosalpingeal vessels
Round ligament: extends from the bilateral uterine cornua and courses through the deep inguinal ring
Broad ligament: peritoneal reflection attaching the uterus to the round ligament, adnexa, and sidewall
Cardinal ligament: the connection between the lower uterine segment/cervix and pelvic sidewall
Uterosacral ligament: connects the base of the cervix to the sacrum
General Principles
If the uterus has been injured, repair is usually more expeditious and less morbid than hysterectomy. Take into consideration feasibility based on location and extent of damage, as well as the patient’s age and reproductive wishes.
If the defect involves the lateral uterus, the uterine vasculature may be compromised. Attempt to clip or suture ligate bleeding in this area. If the bleeding cannot be controlled, hysterectomy is indicated.
In reproductive-age women, if the ovaries or tubes have been damaged and are bleeding, an attempt should be made to coagulate bleeding from these structures using cautery. If not possible, use suture ligation or surgical clips. However, if the damage to the adnexal structures is extensive, they should be excised. Use of a LigaSure cautery device, if available, may facilitate removal of adnexal structures.
The fallopian tube can be divided from the ovary and the mesosalpinx cauterized with the LigaSure device or the vasculature can be suture-ligated. The fallopian tube can be divided at least 1–2 cm or more distal from the uterine cornua, using the LigaSure or a suture-ligation technique (see Figure 35.2).
Defects in the uterine body, fundus, or lower uterine segment should be repaired with either 0-vicryl or chromic suture in a figure-of-eight or running locked fashion.
Even very large defects may be repaired if the uterine blood supply is not significantly compromised.
Document repair technique, location, size, orientation, and thickness of the defect. If full-thickness, the patient may need cesareans for future pregnancies, and she should be notified postoperatively.
Repair should ideally be a two-layer closure in a reproductive-age woman. A single layer is sufficient if hemostasis is achieved in patient who has completed childbearing or if the time for a second layer would compromise the patient.
If the defect is very small and is not bleeding, it may not require repair.
Ensure the bladder is not involved if the defect is in the cervix or lower uterine segment.
If the above primary repair techniques do not work, uterine artery ligation or embolization may help control bleeding.
Uterine artery ligation: Using a 0-vicryl stitch at the uterine isthmus, place a figure-of-eight suture in a horizontal plane encircling the uterine arteries, which can be identified by palpation. Anchoring each stitch solidly into the underlying myometrium medial to the uterine arteries, come out through the broad ligament superior and lateral to the uterine vessels. Tie the suture tightly lateral to the vessels.
Consider hypogastric or uterine artery embolization (UAE).
Be aware that ligation or embolization may result in postoperative pain and low-grade fever. Fertility outcomes after permanent embolization are not well-studied.
Special Surgical Instruments and Sutures
Bookwalter retractor
LigaSure electrothermal device is desirable
Preoperative Preparation
Hysterectomy may be performed in either the supine or dorsal lithotomy position. Both arms may be abducted. Give preoperative Cefazolin 2 g IV (3 g may be given if the patient weighs >120 kg) with re-dosing every 4 hours or after each 1,500 mL of surgical blood loss. In a penicillin allergic patient, alternatives may include IV Clindamycin 900 mg or Metronidazole 500 mg with Gentamicin 5 mg/kg, Aztreonam 2 g or Ciprofloxacin 400 mg is an alternative.
Procedure
The uterus and pelvic structures should be identified. Pean clamps may be placed on the cornua or triple pedicle (medial fallopian tube, utero-ovarian ligament, and round ligament) to facilitate uterine retraction.
Divide the round ligament bilaterally:
Incise the peritoneum superior and inferior to the round ligament and create a window in the peritoneum parallel to the round ligament. Place a pean clamp on the lateral aspect of the ligament.
Divide the round ligament using Bovie or LigaSure cautery and suture-ligate the divided lateral end.
The medial pedicle often does not always need to be suture-ligated, but may be, if heavily vascular.
Figure 35.3
