Topographic Perspective and Surgical Approach
Laparoscopic surgeries on the uterine appendages (adnexa uteri) require perfect visualization of the surgical field. Examination of the pelvic organs is traditionally performed from the perspective of the rectouterine pouch. This topographic perspective provides the surgeon with a full posterior view. It is precisely this position that allows a detailed assessment of the anatomical relationships of the structures before initiating active surgical steps. The laparoscopic approach enables precise control over each stage of the intervention, starting from the initial tissue grasping and ending with final hemostasis on the formed stump.
Tubectomy: Isolation and Removal of the Uterine Tube
Tubectomy (Tubectomia) is the isolated surgical removal of the uterine tube (tuba uterina). The essence of this stage of the operation consists of the sequential and careful isolation of the organ. Intraoperative endophotographs (posterior view, left side) clearly visualize the process of grasping the tissues of the mesosalpinx (mesosalpinx). Following secure grasping, bipolar coagulation and subsequent transection of the mesosalpinx tissues are performed. These manipulations allow the complete mobilization of the uterine tube for its safe extraction from the abdominal cavity, minimizing the risk of bleeding.
Adnexectomy: Transection of the Appendages from the Uterus
During adnexectomy (Adnexectomia), the entire adnexal complex is removed — both the uterine tube and the ovary. The most important surgical step at the initial stage (documented using the left side as an example, posterior view) is the detachment of the adnexa directly from the uterus. For this, a surgical instrument is placed on the proper ovarian ligament (ligamentum ovarii proprium). This ligament anatomically connects the uterine pole of the ovary to the uterine horn. After it is transected, the surgeon also transects the isthmus of the uterine tube (isthmus tubae uterinae), thereby completely freeing the medial edge of the adnexa from the uterine structures.
Mobilization from the Pelvic Wall and Hemostasis
The next critical step is the mobilization of the appendages from the pelvic wall. At this stage, the suspensory ligament of the ovary, also known as the ligamentum suspensorium ovarii or ligamentum infundibulopelvicum, is transected. The clinical significance of this manipulation is immense: it is precisely within this ligament that the ovarian artery and vein (a. et v. ovarica) run. The transection of these major vessels requires maximally reliable hemostasis. The final view of the surgical field demonstrates the formed stump after the complete transection of the uterine appendages. Traces of bipolar coagulation in the form of a characteristic black eschar are visualized in the area of the stump, visually confirming the provision of adequate and definitive hemostasis.
To remember the structures transected during adnexectomy, use the rule: from the uterus, we transect the Proper ligament and Isthmus (PI), and from the pelvic wall, the Suspensory ligament with Vessels (SV).
Class and exam questions
What anatomical structures are transected during the separation of the appendages from the uterus during adnexectomy?
When transecting the appendages from the uterus, the surgeon sequentially transects the proper ovarian ligament (ligamentum ovarii proprium), which connects the uterine pole of the ovary to the uterine horn. Immediately after this, the isthmus of the uterine tube (isthmus tubae uterinae) is transected.
What is the main clinical significance of the suspensory ligament of the ovary during appendage removal?
The clinical significance of the suspensory ligament of the ovary (ligamentum suspensorium ovarii / ligamentum infundibulopelvicum) is that major vessels—the ovarian artery and vein (a. et v. ovarica)—run within it. Their transection requires extremely reliable hemostasis to prevent massive bleeding.
How is the achievement of definitive hemostasis on the stump confirmed visually after appendage removal?
On the final view of the surgical field in the area of the formed stump, traces of bipolar coagulation are visualized. They appear as a characteristic black eschar that ensures reliable cessation of bleeding from the transected vessels.
What topographic perspective is used during laparoscopic examination of the pelvic organs in gynecology?
Examination of the pelvic organs during these laparoscopic interventions is performed from the rectouterine pouch perspective. This provides the surgeon with an optimal posterior view for detailed visualization of all necessary anatomical structures.
What else to study on this topic
- Technique of bipolar coagulation of mesosalpinx tissues (mesosalpinx).
- Anatomy and boundaries of the rectouterine pouch.
- Topography of the ovarian artery and vein (a. et v. ovarica).
- Formation of the surgical stump after complete transection of the uterine appendages.
- Features of instrument application to the proper ovarian ligament.
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