The skin is opened with a scalpel, and the incision is carried down through the subcutaneous tissue and fascia. With traction applied to the lateral edges of the incision, the fascia is divided.
Figure 24.1 The uterus is elevated by placement of clamps across the broad ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
The peritoneum is opened similarly. This technique minimizes the possibility of inadvertent enterotomy, entering the abdominal cavity.
Abdominal Exploration Cytologic sampling of the peritoneal cavity, if needed, should be performed before abdominal exploration. The upper abdomen and the pelvis are explored systematically. The liver, gallbladder, stomach, kidneys, para-aortic lymph nodes, and large and small bowel should be examined and palpated.
Retractor Choice and Placement A variety of retractors were designed for pelvic surgery. The Balfour and the O’Connor-O’Sullivan retractors are used most often. The Bookwalter retractor has a variety of adjustable blades that can be helpful, particularly in obese patients.
Elevation of the Uterus The uterus is elevated by placing broad ligament clamps at each cornu so that it crosses the round ligament. The clamp tip may be placed close to the internal os. This placement provides uterine traction and prevents back bleeding (Fig. 24.1).
Round Ligament Ligation or Transection The uterus is deviated to the patient’s left side, stretching the right round ligament. With the proximal portion held by the broad ligament clamp, the distal portion of the round ligament is ligated with a suture ligature or simply transected with Bovie cautery (Fig. 24.2). The distal portion can be grasped with forceps, and the round ligament is cut to separate the anterior and posterior leaves of the broad ligament. The anterior leaf of the broad ligament is incised with Metzenbaum scissors or electrocautery along the vesicouterine fold, separating the peritoneal reﬂection of the bladder from the lower uterine segment (Fig. 24.3).
Ureter Identification The retroperitoneum is entered by extending the incision cephalad on the posterior leaf of the broad ligament. Care must be taken to remain lateral to both the infundibulopelvic ligament and iliac vessels. The external iliac artery courses along the
Figure 24.2 The round ligament is transected and the broad ligament is incised and opened. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.) medial aspect of the psoas muscle and is identified by bluntly dissecting the loose alveolar tissue overlying it. By following the artery cephalad to the bifurcation of the common iliac artery, the ureter is identified crossing the common iliac artery. The ureter should be left attached to the medial leaf of the broad ligament to protect its blood supply (Fig. 24.4).
Utero-ovarian Vessel and Ovarian Vessel (Infundibulopelvic Ligament) Ligation If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side, placing tension on the contralateral ovarian vessels (the so-called infundibulopelvic ligament), the tube, and the ovary. With the ureter under direct visualization, a window is created in the peritoneum of the posterior leaf of the broad ligament under the uteroovarian ligament and fallopian tube. The tube and utero-ovarian ligament are clamped on each side with a curved Heaney or Ballantine clamp, cut, and ligated with both a free-tie and a suture ligature. The medial clamp at the uterine cornu should control back bleeding; if it does not, the clamp should be repositioned to do so (Fig. 24.5).