Removal of the Uterus The uterus is placed on traction cephalad, and the tip of the cervix is palpated. Curved Heaney clamps are placed bilaterally, incorporating the uterosacral ligament and upper vagina just below the cervix. Care should be taken to avoid foreshortening the vagina. The uterus is then removed with scalpel or curved scissors (Fig. 24.12).
Vaginal Cuff Closure A figure-of-eight suture of 0 braided absorbable material is placed at the angle of the vagina for both traction and hemostasis. The pedicles are sutured with a Heaney stitch, incorporating the uterosacral and cardinal ligament at the angle of the vagina (Fig. 24.13). A running-locked suture can be used for hemostasis along the cuff edge (Fig. 24.14).
Figure 24.8 Dissection of the vesicouterine plane to mobilize the bladder. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Irrigation and Hemostasis The pelvis is thoroughly irrigated with saline. Meticulous hemostasis in the pelvis, particularly of the vascular pedicles, should be ensured. Ureteral position and integrity are checked to ensure that they are intact and do not appear dilated.
Peritoneal Closure The pelvic peritoneum is not reapproximated. Research using animal models suggests that reapproximation may increase tissue trauma and promote adhesion formation (47).
Fascia Closure The parietal peritoneum is not reapproximated as a separate layer. Fascia can be closed with an interrupted or continuous 0 or 1 monofilament absorbable suture. A prospective randomized trial did not show any advantage of interrupted versus continuous fascial closure (48). Bites should be taken about 1 cm from the cut edge of the fascia and about 1 cm apart to prevent wound dehiscence.
Skin Closure The subcutaneous tissue should be irrigated, with careful hemostasis. Wound disruption seems to be decreased with closure of the subcutaneous fat layer in women with 2 cm or more fat (49). Skin staples or subcuticular sutures are used to reapproximate the skin edges. A dressing is applied and left in place for about 24 hours.
Figure 24.9 Ligation of the uterine blood vessels. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Every surgeon must be prepared to recognize and repair operative injuries, because despite a high level of attention to detail, injuries and complications, recognized and unrecognized, can still occur.
Injury to the pelvic ureter is one of the most formidable complications of hysterectomy (50). It is always essential to be aware of the proximity of the ureter to the other pelvic structures. Most ureteral injuries can be avoided by opening the retroperitoneum and directly identifying the ureter. The use of ureteral catheters as a substitute for direct visualization is often of little help in patients with extensive fibrosis or scarring resulting from endometriosis, pelvic inﬂammatory disease, or ovarian cancer. In these instances, a false sense of security may increase an already high risk for ureteral injury. The use of ureteral catheters are associated with hematuria and acute urinary retention, although their complications are usually transitory in nature.
Direct visualization is accomplished by opening the retroperitoneum lateral to the external iliac artery. Blunt dissection of the loose areolar tissue is performed to visualize the artery directly. The artery may be traced cephalad to the bifurcation of the internal and external iliac arteries. The ureter crosses the common iliac artery at its bifurcation and may be followed throughout its course in the pelvis.