Surgical approaches and preparation of the operative field
In gynecological practice, two main types of surgical approaches are used: laparotomic and laparoscopic. Before starting any intervention, thorough preparation of the operative field is performed. This includes treating the entire surface of the anterior abdominal wall with antiseptic solutions. After preparation, the operative field is strictly delimited with sterile drapes so that only the site of the planned incision remains exposed.
To perform open interventions on pelvic organs, laparotomy (opening of the anterior abdominal wall) is required. The most acceptable and frequently used approaches in gynecology are:
- Median laparotomy (midline laparotomy). With this approach, the anterior abdominal wall is opened strictly layer by layer. The incision runs from the upper edge of the pubic symphysis (pubis) and continues upward to the umbilicus.
- Pfannenstiel transverse incision. The skin and subcutaneous adipose tissue are incised transversely. The incision line runs parallel to the pubis, located 3–4 cm above it. The optimal length of such an incision is 10–12 cm. An important feature of this approach is the technique of working with the aponeurosis: it is incised in a horseshoe shape, with the upper edges of the aponeurosis incisions positioned at the level of the umbilicus.
Technique of tissue dissection and abdominal cavity revision
Regardless of the chosen incision, the intermuscular fascia located between the rectus abdominis muscles is opened exclusively by sharp dissection.
Special attention is required at the stage of opening the peritoneum. The surgeon must lift it using soft forceps and dissect it extremely carefully. The incision line must run strictly along the midline between the pubis and the umbilicus. The main goal of this precaution is to prevent accidental damage to the intestinal loops and the urinary bladder, which anatomically lies directly beneath the pubic symphysis. After opening, the edges of the peritoneum are securely fixed with clamps to surgical sponges previously placed along the incision on both sides.
A scalpel or electrosurgical knife is used to dissect the wall. The use of an electrosurgical knife requires mandatory coagulation or ligation of the transected vessels. Silk, catgut, or Vicryl are traditionally used as suture material.
After successfully opening the anterior abdominal wall, the surgeon must perform the following actions:
- Perform a thorough visual and palpational revision of the abdominal cavity organs (palpation is performed with a hand introduced directly into the cavity).
- Insert a surgical retractor into the wound.
- Carefully move the intestinal loops away into the upper abdomen using a sponge. This step is critically important as it provides the necessary exposure and accessibility of the pelvic organs for further manipulations.
Basic principles of organ removal and adnexectomy
When removing internal genital organs or parts thereof, surgeons follow a strict basic algorithm. It consists of three consecutive steps:
- Vascular clamping.
- Tissue dissection (surgical scissors are permitted at this stage).
- Ligation.
Various threads, including silk, catgut, and Vicryl, are used to suture the ligamentous apparatus, blood vessels, cervical stump, and vaginal walls.
Technique of uterine tube removal Regardless of the specific nosological form of the disease, surgical intervention is always performed on the mesosalpinx (mesosalpinx) and the isthmus of the uterine tube. The anatomical rationale for this approach is that branches of the ovarian and uterine vessels (arteries) run precisely in these zones.
Adnexectomy via laparotomy The surgery to remove the uterine appendages includes an important stage of their isolation. To ensure hemostasis, clamps are sequentially applied to the following anatomical structures:
- Suspensory ligament of the ovary (lig. infundibulopelvicum).
- Ovarian proper ligament (lig. ovarii proprium).
- Uterine tube (tuba uterina).
After transecting the uterine appendages and securely ligating the resulting stumps, the operative field is thoroughly inspected to check the condition of the tissues.
Stages of uterine mobilization and ligation of uterine vessels
When performing more extensive interventions, complete mobilization of the uterus is required. To obtain safe access to the main vascular bundle, a number of preparatory steps must be performed.
First, the surgeon opens the peritoneum of the vesicouterine pouch (plica vesicouterina). After this, the urinary bladder is carefully dissected downward, pushing it below the level of the uterine cervix. Next, they proceed to the posterior leaf: behind the uterus, the posterior leaf of the broad ligament of the uterus (lig. latum uteri) is opened. The dissection of this leaf is carried strictly downward, down to the level of the external os of the cervix.
Management of uterine vessels This is one of the most critical stages of the surgery. Hemostatic clamps are applied directly to the uterine vessels (a. et v. uterinae). In doing so, the surgeon must observe an important topographic rule: the clamps must be applied strictly parallel to the lateral border of the uterus and as close to it as possible. This positioning of the instrument is critically necessary to prevent accidental inclusion and injury of the ureter. Only after secure clamping are the uterine vessels transected.
Briefly: answers to topical questions
What instruments are used to dilate the cervical canal during uterine cavity curettage?
Hegar dilators are used to dilate the cervical canal during uterine cavity curettage.
- Hegar dilators — are introduced strictly sequentially and advanced somewhat beyond the internal os for gradual dilation of the cervical musculature.
Each dilator is held with three fingers for the careful passage of the internal os. During fractional diagnostic curettage, dilation is performed up to No. 8–9.
What is the sequence of instrument use during uterine curettage?
The sequence of instrument use during uterine curettage includes sounding, dilation, and direct curettage.
- Uterine sound — used for sounding the uterus.
- Hegar dilators — used for dilating the cervical canal.
- Abortforceps and curette are used for the destruction and removal of the ovum.
- Blunt curette No. 6 — used at the initial stage of curettage of the uterine walls.
- Smaller sharp curettes — used at subsequent stages as the uterus contracts and decreases in size.
How is cervical preparation performed prior to curettage surgery?
Cervical preparation before surgery includes exposure, antisepsis, fixation, and positioning. First, vaginal specula are inserted into the vagina, and the vaginal portion of the cervix is treated with a disinfectant solution. Next, the cervix is fixed: it is grasped by the anterior lip with bullet forceps (tenaculum). After that, the anterior speculum is removed, and the posterior speculum is handed over to the assistant. Then, traction is performed to straighten the cervical canal:
- When the uterus is in anteflexio — the cervix is pulled downward and backward.
- When the uterus is in retroflexio — the cervix is pulled forward.
What complications can occur during uterine cavity curettage?
During uterine cavity curettage, intraoperative and early postoperative complications may occur.
- Uterine perforation — perforation of the uterine wall with a uterine sound, Hegar dilators, curette, or abortion forceps, which carries the risk of intraabdominal hemorrhage and injury to adjacent organs.
- Uterine bleeding — occurs due to incomplete removal of the ovum or insufficient uterine contractility.
- Cervical injury — tears resulting from forced insertion of dilators.
- Retained products of conception — incomplete removal of elements from the uterine cavity.
Why is diagnostic fractional curettage (DFC) performed?
Diagnostic fractional curettage (DFC) of the uterine mucosa is performed for therapeutic and diagnostic purposes.
- Cessation of bleeding — used for uterine bleeding, including in postmenopause.
- Diagnostics of pathologies — indicated for scant prolonged spotting, menstrual irregularities, and ultrasound signs of pathology.
- Morphological examination — obtaining scrapings for mandatory histological examination to exclude morphological pathology (e.g., endometrial cancer).
Which instrument is used for sounding the uterine cavity?
A uterine sound is used for sounding the uterine cavity.
- Uterine sound — inserted into the uterine cavity to clarify its position, determine the direction of the cavity, and measure its length. This helps determine the correct direction for the subsequent insertion of dilators. In laparoscopic surgeries, a Cohen uterine sound may be used, which is inserted into the uterus and fixed with bullet forceps for active mobilization of the organ.
Where are the scrapings sent after curettage of the uterine cavity?
The scrapings obtained after curettage of the uterine cavity are mandatorily sent for histological (morphological) examination. This is necessary to establish the definitive diagnosis, exclude morphological pathology (including malignancies), and perform differential diagnosis.
The tissue removal algorithm is easy to remember with the "CCL" rule: Clamping vessels → Cutting tissue → Ligation.
Class and exam questions
How to avoid bladder injury during peritoneal opening?
The peritoneum must be elevated with soft forceps and incised strictly in the middle between the pubic symphysis and the umbilicus, as the urinary bladder is anatomically located directly beneath the pubis.
What is the specific feature of the aponeurosis incision in a Pfannenstiel approach?
During a transverse Pfannenstiel incision, the aponeurosis is opened in a horseshoe shape, with the upper edges of the incisions reaching the level of the umbilicus.
How to properly apply clamps to uterine vessels?
Hemostatic clamps are applied to the uterine artery and vein (a. et v. uterinae) as close to the uterus as possible and strictly parallel to its lateral border. This critical rule helps prevent accidental inclusion of the ureter.
What structures are clamped during adnexectomy?
When isolating the adnexa, clamps are applied to the suspensory ligament of the ovary (lig. infundibulopelvicum), ovarian proper ligament (lig. ovarii proprium), and uterine tube (tuba uterina).
What else to study on this topic
- Topographic anatomy of the ureter and uterine vessels
- Comparative characteristics of suture materials: silk, catgut, Vicryl
- Safety precautions when using an electrosurgical knife in gynecology
- Features of laparoscopic access in surgeries on the adnexa
- Anatomy of the broad ligament of the uterus and vesicouterine pouch
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