Dissection of the Ureter The ureter is dissected free from the medial peritoneal ﬂap at the level of the uterosacral ligament. As the ureter passes near the uterine artery, there is a consistent arterial branch from the uterine artery to the ureter. This branch is sacrificed in the standard radical (type III) hysterectomy but preserved in the modified radical (type II) hysterectomy. Dissection of the ureter from the vesicouterine ligament (ureteral tunnel) may now be accomplished. If the patient has a deep pelvis, ligation of the uterosacral and cardinal ligaments may be undertaken first to bring the ureteral tunnel dissection closer to the operator. The roof of the ureteral tunnel is the anterior vesicouterine ligament. It should be ligated and divided to expose the posterior ligament. The posterior ligament is divided in the radical (type III) hysterectomy but conserved in the modified radical (type II) hysterectomy.
Posterior Dissection The peritoneum across the cul-de-sac is incised, exposing the uterosacral ligaments. The rectum is rolled free from the uterosacral ligaments, which are divided midway to the sacrum in a radical (type III) hysterectomy and near the rectum in the modified radical (type II) operation. This allows the operator to isolate and separate the cardinal ligament from the rectum. A surgical clamp is placed on the cardinal ligament at the lateral pelvic sidewall in a radical hysterectomy and at the level of the ureteral bed in the modified radical procedure. A clamp is placed on the specimen side to maintain traction and to ensure that the full cardinal ligament is excised with the specimen. A right-angled clamp is placed caudad to this clamp across the paravaginal tissues. A second paravaginal clamp is usually needed to reach the vagina.
The vagina is entered anteriorly, and a suitable margin of proximal vagina is removed with the specimen. More vaginal epithelium can be excised if necessary, depending on the previous colposcopic findings. The vaginal edge may be sutured in a hemostatic fashion and left open with a drain from the pelvic space or closed with a suction drain placed percutaneously. The ureteral fistula and pelvic lymphocyst rates from these two techniques are similar.
Complications of Radical Hysterectomy
Acute Complications The acute complications of radical hysterectomy include (74):
Blood loss (average, 0.8 L)
Ureterovaginal fistula (1% to 2%)
Pulmonary embolus (1% to 2%)
Febrile morbidity (25% to 50%)
Febrile morbidity is most often caused by pulmonary infection (10%) and is seen frequently with pelvic cellulitis (7%) and urinary tract infection (6%). Wound infection, pelvic abscess, and phlebitis all occur in fewer than 5% of patients (75).