If the ovaries are to be removed, the peritoneal opening is enlarged and extended cephalad to the ovarian vessels (infundibulopelvic ligament) and caudad to the uterine artery. This opening allows proper exposure of the uterine artery, the ovarian vessels, and the ureter.
In this manner, the ureter is released from its proximity to the uterine vessels and uterine vessels.
A curved Heaney or Ballantine clamp is placed lateral to the ovary (Fig. 24.6); care is taken to ensure that the entire ovary is included in the surgical specimen. The uterine vessels on each side
Figure 24.3 The incision in the anterior broad ligament is extended along the vesicouterine fold. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.4 Identification of the ureter in the retroperitoneal space on the medial leaf of the broad ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.5 Ligation of the utero-ovarian ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.6 Ligation of the infundibulopelvic ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.)
Figure 24.7 Transection of the infundibulopelvic ligament. (From Mann WA, Stovall TG. Gynecologic surgery. New York: Churchill Livingstone, 1996, with permission.) are doubly ligated and cut (Fig. 24.7). Alternatively, free ties can be passed around the uterine vessels, two cephalad and one caudad, before they are cut.
Bladder Mobilization Using Metzenbaum scissors or Bovie, the bladder is dissected from the lower uterine segment and cervix. An avascular plane, which exists between the lower uterine segment and the bladder, allows for this mobilization. Tonsil clamps may be placed on the bladder edge to provide countertraction and easier dissection (Fig. 24.8).
Uterine Vessel Ligation The uterus is retracted cephalad and deviated to one side of the pelvis, stretching the lower ligaments. The uterine vasculature is dissected or “skeletonized” from any remaining areolar tissue, and a curved Zeppelin or Heaney clamp is placed perpendicular to the uterine artery at the junction of the cervix and body of the uterus. Care is taken to place the tip of the clamp adjacent to the uterus at this anatomic narrowing. The vessels are cut, and the pedicle is ligated. The same procedure is repeated on the opposite side (Fig. 24.9).
Incision of Posterior Peritoneum If the rectum is to be mobilized from the posterior cervix, the posterior peritoneum between the uterosacral ligaments just beneath the cervix and rectum may be incised (Fig. 24.10). A relatively avascular tissue plane exists in this area, allowing mobilization of the rectum inferiorly out of the operative field.
Cardinal Ligament Ligation The cardinal ligament is divided by placing a straight Zeppelin or Heaney clamp medial to the uterine vessel pedicle for a distance of 2 to 3 cm parallel to the uterus. The ligament is cut, and the pedicle is suture ligated. This step is repeated on each side until the junction of the cervix and vagina is reached (Fig. 24.11).