A small infraumbilical incision is ideal for several reasons. As noted, the fundus in most cases lies near the umbilicus. Second, the umbilicus usually remains the thinnest portion of the anterior abdominal wall and requires less subcutaneous dissection to reach the linea alba fascia. hird, an infraumbilical incision ofers fascia with suicient integrity to provide a closure that has minimal risk for later incisional hernia. Last, incisions that follow the natural curve of the lower umbilical skin fold yield suitable cosmesis. A 2-to 4-cm transverse or vertical skin incision is usually suicient for normal-weight women. For obese women, a 4-to 6-cm incision may be needed for adequate abdominal access.
Beneath this incision, the subcutaneous tissue is bluntly separated to reach the linea alba fascia. For this, an Allis clamp can be opened and closed as downward pressure is exerted. Similarly, the blades of two army-navy retractors both pulling in downward yet opposite directions can part the subcutaneous layer. Clearing this fatty tissue away from the fascia isolates the fascia for incision and for later closure without intervening fat, which may impede wound healing.
he fascial incision may be transverse or vertical and follows the same orientation of the skin incision. For this, once the linea alba is reached, it is grasped with two Allis clamps-one placed on either side of the planned fascial incision. The purchase of tissue with each clamp should be substantial and creates a small roll of fascia to be incised. Often, the peritoneum is incorporated simultaneously and entered. If not, the peritoneum is grasped with two hemostats and sharply cut. Others may prefer to bluntly enter with a single index finger. Notably, if the initial fascial incision is too small, it can be extended with curved Mayo scissors.
Adequate exposure is critical, and army-navy or appendiceal retractors are suitable. For obese women, a slightly larger incision and narrow deeper retractors may be required. If bowel or omentum is obstructing, Trendelenburg position can help displace these cephalad. Digitally packing with a single, moist, fanned-out piece of surgical gauze can also be used, but a hemostat should always be attached to the distal end to avert
FIGURE 39-1 Parkland method. A.An avascular site in the meso salpinx adjacent to the fallopian tube is perforated with a small hemostat. The jaws are opened to separate the fallopian tube from the adjacent mesosalpinx for approximately 2.5 cm. B. The freed fallopian tube is ligated proximally and distally with O-chromic suture. The intervening segment of approximately 2 cm is excised, and the excision site is inspected for hemostasis. This method was designed to avoid the initial intimate proximity of the cut ends of the fallopian tube inherent with the Pomeroy procedure. (Reproduced with permission from Hoffman BL, Corton MM: Surgeries for benign gynecologic conditions. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 201o6.) its retention. At times, tilting the entire table to the opposite side of the tube being exposed assists tube isolation.
he fallopian tube is identiied and grasped at its midportion with a Babcock clamp, and the distal fimbria conirmed. his prevents confusing the round ligament with the midportion of the tube. A common reason for sterilization failure is ligation of the wrong structure, typically the round ligament. Therefore, identiication and isolation of the distal tube prior to ligation is necessary. Whenever the tube is inadvertently dropped, it is mandatory to repeat this identification process. Surgical steps for ligation are outlined in Figures 39-1 and 39-2.