Figure 24.24 Delivery of the uterine fundus posteriorly. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.25 Ligation of the utero-ovarian and round ligaments. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Peritoneal Closure Because the pelvic peritoneum does not provide support and re-forms within 24 hours after surgery, the peritoneum need not be reapproximated routinely. If it is important, the anterior peritoneal edge is identified and grasped with forceps. A continuous absorbable 0 suture is begun at the 12-o’clock position. The suture is continued in a purse-string fashion and incorporates the distal portion of the left upper pedicle and the left uterosacral ligament (Fig. 24.27). At the beginning of the procedure tension is applied to the suture that incorporates the posterior peritoneum and vaginal mucosa. This allows for high posterior reperitonealization, which shortens the cul-de-sac and helps prevent future enterocele formation. The right uterosacral ligament and the distal portion of the right upper pedicle are incorporated, and this continuous suture ends at the point on the anterior peritoneum where it began.
Figure 24.26 Removal of the ovaries and fallopian tubes by clamping across the ovarian vessels (infundibulopelvic ligament). (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.27 Closure of the peritoneum. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Vaginal Mucosa Closure The vaginal mucosa can be reapproximated in a vertical or horizontal manner, using either interrupted or continuous sutures (Fig. 24.28). The vaginal mucosa is, in this case, reapproximated horizontally with interrupted absorbable sutures. The
Figure 24.28 Closure of the vaginal mucosa. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.) sutures are placed through the entire thickness of the vaginal epithelium, with care taken to avoid entering the bladder anteriorly. These sutures will obliterate the underlying dead space and produce an anatomic approximation of the vaginal epithelium, thereby decreasing the postoperative formation of granulation tissue.
Bladder Drainage After completion of the procedure, the bladder is drained. Unless an anterior or posterior colporrhaphy or other reconstructive procedure is performed, neither bladder catheter nor vaginal packing is mandatory.
Injection of Vaginal Mucosa The use of paracervical and submucosal injection of 20 to 30 mL of 0.5% lidocaine with 1:200,000 epinephrine before incision of the vaginal mucosa may decrease postoperative pain and facilitate identification of surgical planes. There is no need to inject the cervix. Areas to be injected include the bladder pillars, lower portion of the cardinal ligament, uterosacral ligaments, and paracervical tissue. The incidence of cuff cellulitis and cuff abscess formation is increased when epinephrine is injected into the cervicovaginal mucosa.