After cesarean delivery, the placenta is typically removed. In cases of placenta accrete syndrome for which hysterectomy is already planned, the placenta is usually left undisturbed in situ. In either situation, if the hysterotomy incision is bleeding appreciably, it can be sutured or Pennington or sponge forceps can be applied for hemostasis. If bleeding is minimal, neither maneuver is necessary.
he round ligament is divided close to the uterus between clamps, and each pedicle is ligated (Fig. 30-13). Either 0 or no. 1 suture can be used in either chromic gut or delayedabsorbable material. he anterior leaf of the broad ligament is incised downward to meet the former bladder flap incision. he posterior leaf of the broad ligament adjacent to the uterus is bluntly or sharply perforated just beneath the fallopian tube, uteroovarian ligament, and ovarian vessels (Fig. 30-14). hese structures together are then divided between sturdy clamps placed close to the uterus 30-15). he lateral pedicle is doubly ligated. The medial clamp remains and is removed later with the entire uterine specimen. he posterior leaf of the broad ligament is incised toward the uterosacral ligaments (Fig. 30-16). Next, the bladder and attached peritoneal flap are further deflected and dissected as needed. If the bladder flap is unusually adhered, as it may be after previous hysterotomy incisions, careful sharp dissection may be necessary (Fig. 30-17).
Posterior leaf of broad ligament Uterosacral :n�s �
FIGURE 30-16 The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligament.
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FIGURE 30-17 The bladder is dissected sharply from the lower uterine segment.
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FIGURE 30-18 The uterine vessels are clamped, and a third medial clamp helps prevent "back bleeding." Once divided, the lateral vascular pedicle is doubly ligated to ensure hemostasis.
Special care is required from this point on to avoid injury to the ureters, which pass beneath the uterine arteries. To help accomplish this, an assistant places constant traction to pull the uterus in the direction away from the side on which the uterine vessels are being ligated. he ascending uterine artery and veins on either side are identiied. These vessels are then clamped adjacent to the uterus. For security, some may prefer two lateral clamps as shown in Figure 30-18. he most medial clamp helps prevents back bleeding from the uterus and remains for later removal with the specimen. The uterine vessels are divided, and the lateral tissue pedicle is doubly suture ligated. After securing the uterine vessels on one side, the round ligament, adnexal pedicle, and uterine vessels are then addressed on the contralateral side.
With cesarean hysterectomy, it may be more advantageous in cases of profuse hemorrhage to rapidly double clamp and divide all of the vascular pedicles between clamps to gain hemostasis. The surgical team can then return to ligate all of the pedicles.
Even if total hysterectomy is planned, we find it technically easier in many cases to finish the operation after amputating the uterine fundus and placing Ochsner or Kocher clamps on the cervical stump for traction and hemostasis. Self-retaining retractors also may be placed at this time. To remove the cervix, the bladder is mobilized further if needed. This carries the ureters caudad as the bladder is retracted beneath the symphysis and will prevent laceration or suturing of the bladder during cervical excision and vaginal cuf closure.
FIGURE 30-19 The cardinal ligaments are clamped, incised, and ligated.