Uterine Artery Ligation Contralateral and downward traction are placed on the cervix. With an effort to incorporate the anterior and posterior leaves of the visceral peritoneum, the
Figure 24.20 Transfixion of the uterosacral ligament to the posterolateral vaginal mucosa. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.21 Ligation of the cardinal ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.22 Ligation of the uterine artery. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996.) uterine vessels are identified, clamped, and cut, and the pedicle is suture ligated (Fig. 24.22). A single suture and single clamp technique is adequate and decreases the potential risk for ureteral injury. When the uterus is large or when a fibroid distorts the anatomic relationships, a second suture may be required to ligate any remaining branches of the uterine artery.
Entry into the Vesicovaginal Space The anterior peritoneal fold can be identified just before or after clamping and suture ligation of the uterine arteries. The anterior peritoneal cavity should not be opened blindly because of the increased risk of bladder injury (Fig. 24.23). The peritoneum is grasped with forceps, tented, and opened using scissors with the tips pointed toward the uterus. A Heaney or Deaver retractor is placed, and the peritoneal contents are identified. This retractor serves to keep the bladder out of the operative field.
Delivery of the Uterus A tenaculum is placed onto the uterine fundus in a successive fashion to deliver the fundus posteriorly (Fig. 24.24). The operator’s index finger is used to identify the utero-ovarian ligament and aid in clamp placement.
Utero-ovarian and Round Ligament Ligation With the posterior and anterior peritoneum opened, the remainder of the broad ligament and utero-ovarian ligaments are clamped, cut, and ligated (Fig. 24.25). The utero-ovarian and round ligament complexes are double ligated with a suture tie followed by a ligature medial to the first suture. A hemostat is placed on the second suture to aid in the identification of any bleeding and to assist with peritoneal closure. A hemostat should not be placed on the first suture or any other vascular pedicle to avoid the risk for loosening the tie.
Removal of the Ovaries During the removal of the adnexa, the round ligaments should be removed separately from the adnexal pedicles. Traction is placed on the utero-ovarian pedicle. The ovary is drawn into the operative field by grasping it with a Babcock clamp. A Heaney clamp is placed across the ovarian vessels (infundibulopelvic ligament), and the ovary and tube are excised (Fig. 24.26). A transfixion tie and suture ligature are placed on the ovarian vessels. The surgeon should not be reluctant to remove the fallopian tube separately from the ovary if taking them together risks loss of the tissue pedicle or injury to the ureter or nearby blood vessels.
Hemostasis A retractor or tagged sponge is placed into the peritoneal cavity, and each of the pedicles is visualized and inspected for hemostasis. If additional sutures are required, they should be placed precisely, with care to avoid the ureter or bladder.
Figure 24.23 Entry into the vesicovaginal space. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)