Transection of the uterine body (Amputatio corporis uteri)
The first key stage of the surgical intervention is the transection of the uterine body. This manipulation requires the operating surgeon to strictly observe topographical landmarks. The key level at which tissue transection is performed is the internal os of the uterus (ostium uteri internum).
To ensure adequate surgical access and good visual control (surgical field perspective — anterior view), active traction is applied. The uterine body is grasped and pulled upward. This classic maneuver provides the necessary tissue tension and ensures the clearest possible visualization of the lower uterine segment, which is critical for the safe execution of the incision.
Immediately before transection, a crucial step in preventing intraoperative hemorrhage is performed. Reliable hemostatic clamps are applied to the main uterine vessels (vasa uterina) as well as the uterine ligamentous apparatus on both sides. Only after this does the surgeon use a scalpel to completely transect the uterine body from its cervix.
Formation and suturing of the cervical stump
After the uterine body (corpus uteri) is completely transected with a scalpel and removed, a stump remains in the pelvic cavity. This anatomical structure is represented by the remaining vaginal and supracervical parts of the cervix (cervix uteri).
At this stage, excellent visualization is required: the surgical field must be widely retracted using surgical specula, as the formed stump is located quite deep in the pelvis. To ensure reliable surgical hemostasis, sturdy interrupted sutures are placed on the tissues of the cervical stump.
This surgical maneuver pursues two main clinical goals:
- Definitive arrest of hemorrhage from damaged vessels of the cervix itself.
- Technical preparation of tissues for the next stage of the surgery — closure of the wound surface with the visceral peritoneum.
Peritonealization: technique
The final stage of supracervical hysterectomy is peritonealization. The essence of the procedure is the meticulous covering of all resulting wound surfaces and the formed cervical stump with folds of visceral peritoneum.
Technically, peritonealization is performed by placing a continuous surgical suture running strictly in a transverse direction. This suture connects the anterior and posterior peritoneal folds with absolute tightness:
- Anteriorly, the vesicouterine peritoneal fold is included in the suture.
- Posteriorly, the peritoneum of the posterior vaginal fornix and the posterior leaves of the broad ligaments of the uterus are sutured.
Along the lateral edges of the surgical wound, the stumps of the transected ligamentous apparatus are carefully incorporated into this same continuous suture. Depending on the extent of the surgery on the appendages, these may include the stumps of the fallopian tubes, as well as the round and proper ovarian ligaments. As a result, the cervical stump becomes completely submerged beneath the peritoneal folds (extraperitonealized).
Clinical significance of peritonealization
The stage of stump coverage accomplishes several strategic tasks aimed at a favorable postoperative course:
- Ensuring reliable hemostasis: Additional compression of the underlying tissues by the continuous suture prevents the risk of bleeding.
- Isolation of infected pathways: The cervical canal is considered a potentially infected environment. Extraperitonealization reliably isolates its lumen from the sterile peritoneal cavity.
- Prevention of adhesion disease: The formation of an absolutely smooth peritoneal surface over the sutured stump prevents the development of pathological adhesions in the pelvis.
Briefly: answers to topical questions
What is the principal anatomical difference between supracervical hysterectomy and total hysterectomy?
The principal anatomical difference lies in the preservation of the cervix during a supracervical hysterectomy.
| Characteristic | Supracervical hysterectomy | Hysterectomy |
|---|---|---|
| Extent of resection | Transection of the uterine body (corpus uteri) at the level of the internal os (ostium uteri internum) | Total removal of the uterus along with the cervix |
| Remaining structures | A stump is preserved, represented by the vaginal and supracervical parts of the cervix (cervix uteri) | The cervix is completely removed |
The cervix is extremely crucial for the formation of the pelvic floor and adequate blood supply to the urogenital system.
What are the main gynecological indications for supracervical hysterectomy?
The main indications for hysterectomy in uterine diseases are:
- large uterine myoma (13–14 weeks of pregnancy);
- rapid tumor growth (more than 4 weeks per year);
- nutritional disturbance or necrosis of a myomatous node;
- cervical localization of myoma;
- menometrorrhagia leading to patient anemia;
- myoma growth in postmenopause;
- dysfunction of adjacent organs.
The scope of surgery may include total hysterectomy or supracervical hysterectomy without adnexa. In case of myomatous node necrosis in pre- and postmenopausal patients, supracervical hysterectomy or total hysterectomy is indicated.
In postmenopausal patients with ovarian tumors, supracervical hysterectomy with adnexa is performed.
To remember the structures sutured during peritonization from front to back: Bladder-uterine fold — Stump (and ligaments on the sides) — Posterior fornix/broad ligaments (B-S-P).
Class and exam questions
At what level is the uterine body transected during this procedure?
Transection (amputatio corporis uteri) is performed strictly at the level of the internal os (ostium uteri internum) using a scalpel.
Which vessels are ligated prior to uterine transection?
Before transection, hemostatic clamps must be applied to the main uterine vessels (vasa uterina) and the ligamentous apparatus on both sides.
What is the main purpose of peritonealization of the stump?
Peritonealization ensures reliable hemostasis, isolates the potentially infected cervical canal from the peritoneal cavity, and prevents the development of adhesion disease by creating a smooth surface.
Which structures are incorporated into the lateral margins of the suture during peritonealization?
The lateral edges of the continuous transverse suture incorporate the stumps of the fallopian tubes, as well as the round and proper ovarian ligaments (depending on the scope of intervention on the adnexa).
What else to study on this topic
- Topographical anatomy of the main uterine vessels (vasa uterina) and their ligation technique.
- Anatomy of the uterine ligamentous apparatus: round, broad, and proper ovarian ligaments.
- Structure of the cervix: vaginal and supracervical parts, internal os (ostium uteri internum).
- Technique of continuous surgical and interrupted sutures in operative gynecology.
- Pathophysiology of pelvic adhesion disease and the barrier function of the visceral peritoneum.
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