Final stage of uterine removal
Application of clamps, ligation, and transection of the uterosacral ligaments is the first step of the final stage. Then, the rectouterine peritoneal fold (pouch of Douglas) is opened between these ligaments and gently pushed down below the level of the uterine cervix.
Following the mobilization of the cervix, the surgeon opens the vagina (preferably along the anterior wall, below the cervix itself). Amputation of the cervix from the vaginal fornices is performed with scissors. At this moment, the vaginal walls are immediately grasped with clamps to perform additional hemostasis if necessary. Only after this is the uterus finally extracted from the abdominal cavity.
Cuff formation and wound closure
Cuff formation begins by suturing the anterior and posterior vaginal walls together using interrupted sutures. This is followed by a crucial step: peritonization. It is performed using a continuous suture utilizing the peritoneal leaves of the broad uterine ligaments as well as the vesicouterine fold. Final hemostasis control is mandatory at this stage.
In traditional (open) access, the surgery concludes with layered primary closure of the anterior abdominal wall:
- Peritoneum and muscles: sutured with a continuous suture (catgut or Vicryl is used).
- Aponeurosis: interrupted silk or Vicryl ligatures are applied.
- Skin: closed depending on the type of incision (tantalum staples, interrupted silk sutures, or a subcuticular cosmetic suture).
Features of the laparoscopic approach
Laparoscopic surgery is performed exclusively under endotracheal anesthesia (ETA). The patient is placed on the operating table using reinforced leg holders. The legs are abducted at an angle of approximately 90 degrees, and the perineum must protrude beyond the edge of the table (it is optimal to use a table with a special recess for vaginal manipulations). A sterile drape is placed under the perineum, allowing the assistant to safely manipulate the uterine sound without violating asepsis rules.
The antiseptic preparation boundaries are extensive: from the costal margin to the middle of the thighs, with particularly thorough preparation of the perineum and vagina. The surgical field is draped with sterile sheets on the left and right (fixed with towel clips at the xiphoid process), and covered with a drape at the pubic level, forming a working area in the shape of a triangle.
Surgical team, instruments, and the first stage of laparoscopy
The surgeon stands to the left of the patient: they perform the main manipulations with their left hand and control the camera with their right. The first assistant stands on the right, and the second stands between the patient's spread legs. The primary task of the assistants is to create optimal tissue tension (traction and counter-traction).
The surgery requires an electrosurgical unit with a capacity of at least 300 W and a standard endoscopic tower. The minimum set includes one 10 mm trocar (for the telescope) and two 5 mm ports. Necessary instruments include 5 mm grasping forceps with locking ratchets, a dissector, scissors, bipolar forceps, an suction-irrigation cannula, as well as 10 mm forceps, a morcellator, and an aponeurosis-closing needle.
A Cohen uterine sound (secured with single-tooth vulsellum forceps) or a Clermont uterine manipulator (especially convenient for total hysterectomy as it provides a favorable position for transecting the fornices) is inserted into the uterus. The first trocar and Veress needle are traditionally inserted at the umbilical ring. However, if scars from previous laparotomies (lower midline or Pfannenstiel incision) are present, an alternative point is chosen—2 cm above and to the left of the umbilicus.
Briefly: answers to topical questions
Which blood vessels are transected and ligated during supracervical hysterectomy?
During supracervical hysterectomy, the uterine blood vessels are transected and ligated.
- Uterine arteries (a. uterina) — their ascending branches are clamped in the lower uterine segment at the level of the internal os.
- Uterine veins (v. uterina) — accompany the uterine arteries and are ligated together with them.
Heavy surgical clamps are applied to the vessels perpendicular to the lateral margin of the uterus, after which they are transected and securely ligated or coagulated to ensure hemostasis prior to organ amputation.
Which uterine ligaments are transected during supracervical hysterectomy?
During supracervical hysterectomy, the following ligaments are transected to mobilize the organ:
- Round ligaments of the uterus (lig. teres uteri) — clamped, transected, and ligated between applied clamps.
- Ovarian proper ligaments (lig. ovarii proprium) — transected in a similar manner on both sides.
Along with the aforementioned ligamentous apparatus, the Fallopian tubes (tuba uterina) are also clamped, transected, and ligated.
At what anatomical level is the uterine body amputated during supracervical hysterectomy?
Amputation of the uterine body during supracervical hysterectomy is performed strictly at the level of the internal os (ostium uteri internum).
Anatomically, this level corresponds to the lower uterine segment and is located above the origin of the uterosacral ligaments. The incision is made using a scalpel or electrosurgical generator in a transverse direction. The incision is made in a wedge-like fashion to excise a shallow wedge from the remaining cervical stump (cervix uteri), which subsequently facilitates the apposition of the stump edges during its closure.
To memorize the layers of abdominal wall closure, use the rule "PMAA": Peritoneum and Muscles (continuous absorbable suture), Aponeurosis (interrupted strong ligatures), Skin (cosmetic or staples).
Class and exam questions
Why must the patient's thighs be strictly at the level of the torso during laparoscopy?
If the thighs are elevated, they will block the range of motion of the external parts of the surgical instruments inserted through the lateral trocars.
Which structures are used for the peritonization of the stump?
Peritonization is performed using a continuous suture, capturing the peritoneal leaves of the broad uterine ligaments and the vesicouterine fold.
How to avoid ureteral injury during uterine amputation?
Strict visual control of their location is necessary. The urinary bladder and ureters must be preliminarily mobilized and displaced below the level of cervical transection.
What else to study on this topic
- Technique for the safe mobilization of the urinary bladder and ureters prior to the uterine amputation stage.
- Comparative characteristics and selection of uterine manipulators (Cohen sound and Clermont manipulator).
- Rules for establishing pneumoperitoneum using a Veress needle and complication prevention.
- Features of hemostasis with bipolar forceps in laparoscopic interventions.
- Algorithm for selecting alternative access points in severe adhesive disease following previous laparotomies.
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