Preparatory stage and work with the appendages
Any major intervention, such as a hysterectomy (total or subtotal), begins with the mobilization of the organ. At the initial stage, surgeons work with the appendage apparatus. In order to gain adequate access to deeper pelvic structures, it is necessary to isolate the uterus from its main supporting elements. On both sides, the round ligaments of the uterus (lig. teres uteri), proper ovarian ligaments (lig. ovarii proprium), and fallopian tubes (tuba uterina) are sequentially clamped, securely ligated, and transected. Performing this step allows the organ to be brought into the surgical wound and prepares the tissues for further manipulations on the visceral peritoneum.
Opening of the vesicouterine fold
The next critically important step is working with the vesicouterine fold of the peritoneum (plica vesicouterina). This is the site where the visceral peritoneum transitions from the anterior surface of the uterus (uterus) directly to the posterior wall of the urinary bladder (vesica urinaria). For the dissection to be safe, the surgeon grasps the uterine body (corpus uteri) and performs active traction upward (in the cranial direction) and posteriorly. This action creates optimal tissue tension. The dissection itself is performed with surgical scissors, while the tissues are gently supported with anatomical forceps or special clamps.
Access formation and bladder protection
The main purpose of dissecting the plica vesicouterina is to gain direct access to the vesicocervical fascial space. This is necessary for subsequent blunt or sharp separation of the urinary bladder and its downward (caudal) displacement. Bladder mobilization is of paramount clinical importance: it moves this hollow organ out of the active surgical intervention zone. This maneuver prevents iatrogenic injury, in particular perforation of the bladder wall, during subsequent stages of the operation—isolation of the uterine cervix (cervix uteri), management of the vaginal fornices, and ligation of the main vascular bundles.
Clamping of the uterine vessels
After the bladder has been dissected away, the surgeons proceed to the most critical stage: managing the uterine vessels (a. et v. uterina). The vascular bundle ascends along the lateral margin (border) of the uterus. For its adequate visualization, strong traction of the uterine body upward and contralaterally (away from the side being operated on) is performed. This puts tension on the broad ligament of the uterus. Rigid surgical clamps are applied strictly perpendicular to the lateral margin of the uterus. The level of application corresponds to the region of the lower uterine segment, approximately at the level of the internal os of the cervix. The clamps are fixed in such a way as to subsequently safely transect the tissues between them (or between the clamp and the uterine wall) and place a secure ligature on the vascular stump.
Topographic risks and ureters
The clinical significance of proper vessel clamping technique cannot be overemphasized due to the complex topographic anatomy of the parametrium. The main danger at this stage is the high risk of iatrogenic injury to the ureters (ureter). The ureters run within the parametrial adipose tissue in close proximity to the uterine artery, crossing it (they are located inferiorly and posteriorly to the vessel). To minimize the risk of catching the ureter in the instrument jaws, the surgeon is obligated to apply the clamp pressing it as tightly as possible against the lateral margin of the uterus.
Briefly: answers to topical questions
Which ligaments form the fixing apparatus of the uterus?
The fixative apparatus of the uterus is represented by the cardinal ligaments. During surgical interventions, working with this apparatus involves the following structures:
- Cardinal ligaments (ligamenta cardinalia) are transected during the mobilization of the uterus during vaginal hysterectomy. Their shortening and suturing together (transposition) is the goal of the Manchester procedure to strengthen the fixative apparatus in cases of uterine prolapse and incomplete descensus.
Sources also mention the uterosacral ligament (lig. sacrouterinum), the reinforcement of which with aponeurotic grafts is used in the surgical treatment of uterine malpositions.
Which arteries supply blood to the ovary?
Blood supply to the ovary is provided by the ovarian artery and a branch of the uterine artery.
- Ovarian artery — originates directly from the aorta or the renal artery (more frequently on the left), descends into the pelvis within the suspensory ligament of the ovary (lig. infundibulo-pelvicum), and gives off branches directly to the ovary.
- Branch of the uterine artery — forms a pronounced anastomosis with the ovarian artery, providing combined blood supply to the organ.
What branches does the uterine artery give off?
The uterine artery gives off branches supplying blood to the uterus, ovary, and the intervillous space of the placenta. The following branches are distinguished:
- Branch to the ovary — forms an anastomosis with the ovarian artery.
- Ascending branches — are clamped during the transection of the uterine body during subtotal hysterectomy.
- Arcuate and radial arteries — evaluated during Doppler ultrasound of uteroplacental blood flow.
- Spiral arteries — terminal branches (150–200 in number) that provide blood supply to the intervillous space. During pregnancy, they undergo physiological changes, including an increase in diameter and loss of sensitivity to vasoconstrictors.
From which nerve plexuses is the uterus innervated?
Innervation of the uterus is derived from the uterovaginal (pelvic) plexus. The following structures participate in the formation of nerve pathways:
- Celiac plexus — sympathetic fibers originate from it.
- Superior hypogastric plexus (plexus hypogastricus superior) — forms at the level of the 5th lumbar vertebra.
- Inferior hypogastric plexuses — fibers emerge from the superior hypogastric plexus, forming the right and left inferior hypogastric plexuses.
- Uterovaginal plexus (plexus uterovaginalis, s. pelvicus) — located in the parametrial tissue; sympathetic and parasympathetic fibers emerging from it innervate the uterus, vagina, inner parts of the fallopian tubes, and urinary bladder.
The golden rule for vessel clamping: "Closer to the border — further from the ureter." Pressing the surgical clamp tightly against the lateral margin of the uterus reliably protects the ureter (ureter), which runs inferiorly and posteriorly to the uterine artery.
Class and exam questions
Why is the uterine body retracted upward and posteriorly when opening the peritoneal fold?
This action creates the necessary tension of the visceral peritoneum in the area of the plica vesicouterina, which allows the surgeon to safely and accurately dissect tissues with scissors.
Which structures of the uterine appendages are transected before working with the vesicouterine fold?
At the initial stage of the operation, the round ligaments of the uterus, proper ovarian ligaments (lig. ovarii proprium), and fallopian tubes (tuba uterina) are clamped, ligated, and transected.
What is the main danger when applying clamps to the uterine vessels?
There is a high risk of iatrogenic injury to the ureters, as they are located within the parametrial adipose tissue in close proximity to the uterine artery.
Why is the urinary bladder displaced caudally?
Bladder mobilization removes it from the surgical field, preventing accidental perforation during the isolation of the cervix (cervix uteri) and vascular ligation.
What else to study on this topic
- Technique for reliable ligation of the uterine vessel stump after their transection.
- Topographic anatomy of the vesicocervical fascial space.
- Features of isolating the vaginal fornices during hysterectomy.
- Syntopy of the ureters and the uterine artery in the parametrial tissue.
- Key differences between the stages of total and subtotal hysterectomy.
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