The cardinal ligament, the uterosacral ligaments, and the many large vessels these ligaments contain are clamped systematically with sturdy Heaney-type curved or straight clamps (Fig. 30-19). he clamps are placed as close to the cervix as possible, taking care not to include excessive tissue in each clamp. The tissue between the pair of clamps is incised, and the lateral pedicle is suture ligated. hese steps are repeated caudally and bilaterally until the level of the lateral vaginal fornix is reached on each side. In this way, the descending branches of the uterine vessels are clamped, cut, and ligated as the cervix is separated from the cardinal ligaments.
If the cervix is efaced and dilated considerably, its softness may obscure palpable identiication of the cervicovaginal junction. he junction location can be ascertained through a vertical uterine incision made anteriorly in the midline, either through the open hysterotomy incision or through an incision created at the level of the ligated uterine vessels. A finger is directed inferiorly through the incision to identiy the free margin of the dilated, efaced cervix. The contaminated glove is replaced. Another useful method to identiy the cervical margins in cases of planned hysterectomy is to transvaginally place four metal skin clips or brightly colored sutures at 12, 3, 6, and 9 o'clock positions on the cervical edges.
Immediately below the level of the cervix, a curved clamp is placed across the lateral vaginal fornix on each side, and the vagina is incised above the clamp (Fig. 30-20).The cervix is inspected to ensure that it has been completely removed. A transfixing suture is used for vaginal cuf closure as each clamp is removed. Interrupted stitches may be added to approximate the middle portion
FIGURE 30-20 A curved clamp is placed across the lateral vaginal fornix below the level of the cervix, and the tissue incised medially to the point of the clamp.
of the cuf Each lateral vaginal fornix is secured to the uterosac raliligaments to mitigate later vaginal prolapse. For cuf closure, some surgeons instead prefer to close the vagina by apposing the anterior and posterior vaginal walls with interrupted figure-of ll sites are examined carefully for bleeding. One technique is to perform a systematic bilateral survey from the fallopian tube and ovarian ligament pedicles to the vaginal vault and bladder lap. Bleeding sites are ligated with care to avoid the ureters. The abdominal wall normally is closed in layers, as previously described for cesarean delivery (p. 578).
To perform a subtotal nysterectomy, the uterine body is amputated immediately above the level of uterine artery ligation. The cervical stump may be closed with continuous or interrupted chromic catgut suture. Subtotal hysterectomy is often all that is necessary to stop hemorrhage. It may be preferred for women who would benefit from a shorter surgery or for those with extensive adhesions that threaten significant urinary tract injury.
Because of the large adnexal vessels and their close proximity to the uterus, it may be necessalY to remove one or both adnexa to obtain hemostasis. Briery and colleagues (2007) reported unilateral or bilateral oophorectomy in a fourth of cases. Preoperative counseling for anticipated hysterectomy should include this possibility.
hese injuries are rare during cesarean delivery. The bladder laceration rate approximates 2 per 1000 cesarean deliveries,
FIGURE 30-21 A running-lock suture approximates the vaginal wall edges.