Surgical approaches to the pelvic organs
Two main approaches are used for female genital surgeries: transperitoneal (laparotomy) and vaginal.
Vaginal approaches (Colpotomia) involve working through the vaginal walls. These include anterior colpotomy (access via the anterior wall) and posterior colpotomy (via the posterior wall). Incisions of the anterior wall can be linguiform, longitudinal midline, or combined (with an additional lower transverse incision).
Transperitoneal approaches include lower midline laparotomy and the Pfannenstiel suprapubic transverse incision. Features of the Pfannenstiel approach:
- Skin: incised in a slightly curved fashion within the suprapubic skin fold.
- Aponeurosis: the anterior wall of the rectus abdominis sheath is opened transversely. The upper flap is sharply separated from the muscles.
- Muscles: the rectus abdominis muscles are not cut, but bluntly separated along the linea alba and retracted laterally.
- Advantages: excellent cosmetic outcome and absence of postoperative hernias.
Technique of supracervical hysterectomy
The operation is performed via lower midline laparotomy and consists of strictly regulated steps.
- Organ exteriorization: the uterine fundus is grasped with Museux forceps and carefully exteriorized into the surgical wound.
- Ligament mobilization: to ensure hemostasis, clamps are applied to the round ligament of the uterus (lig. teres uteri), the ovarian proper ligament (lig. ovarii proprium), and the fallopian tube. A second clamp is applied parallel to the uterine angle. The structures are divided between the clamps and ligated. Similar steps are performed on the opposite side.
- Bladder dissection: surgeons incise both layers of the broad ligament up to the uterine border and open the vesicouterine fold of the peritoneum (plica vesicouterina). The urinary bladder is pushed down from the uterine cervix, partly bluntly and partly sharply, strictly avoiding injury to it.
- Vessel management: the uterine vessels are clamped, divided, and ligated. At this stage, it is critically important not to include the ureter in the ligature.
- Amputation: the uterine body is severed above the level of origin of the uterosacral ligaments. The incision is wedge-shaped — a small wedge is excised from the remaining cervix to make the edges easier to approximate.
Stump management and peritonization
Stump peritonization is a crucial step aimed at achieving definitive hemostasis and securely closing the wound surface.
- The edges of the cervical stump are treated with iodine and approximated with catgut sutures.
- The same sutures are used to transfix the edges of the anterior and posterior layers of the broad ligament of the uterus.
- When tying the knots, all vascular bundles and ligament stumps are buried beneath the peritoneum.
- The edges of the bladder fold are sutured to the peritoneum of the posterior surface of the remaining uterine stump (forming the so-called "cap").
- The anterior abdominal wall wound is closed in layers tightly.
Fallopian tube resection and defect closure
If tube resection is required during the procedure, surgeons mobilize its uterine (isthmic) end and mesosalpinx (mesosalpinx). Clamps are sequentially applied to the mesosalpinx for hemostasis, and the tube is then resected.
To peritonize the resected tube stump, a loop of the round ligament of the uterus (lig. teres uteri) is used and sutured to the uterine angle:
- Main option: the round ligament is sutured with a continuous catgut suture to the remnants of the tube mesosalpinx (broad ligament layers), completing the suture line in a half-purse-string fashion.
- In case of tissue deficiency: if the size of the remaining mesosalpinx is insufficient, the round ligament is sutured directly to the ovary, also completing the step with a half-purse-string suture.
Briefly: answers to topical questions
From which arteries does the uterus receive its blood supply, and which of them must be ligated during its amputation?
The uterus receives its blood supply from three sources:
- Uterine arteries (aa. uterinae) are branches of the internal iliac arteries.
- Ovarian arteries (aa. ovaricae) arise directly from the abdominal aorta.
- Arteries of the round ligaments of the uterus (aa. lig. teretis uteri) are branches of the inferior epigastric arteries.
During abdominal subtotal hysterectomy without adnexa, it is explicitly indicated: clamps are applied to the uterine vessels, which are then transected and ligated. The round ligament of the uterus, the proper ovarian ligament, and the fallopian tube are also transected between clamps and ligated.
Which ligaments are part of the fixation apparatus of the uterus?
In the provided sources, the complete composition of the uterine fixation apparatus is not detailed. It is indicated that the fixation of the uterine position is ensured by the interaction of the suspension, fixation, and support systems. The round and broad ligaments of the uterus are classified as part of the suspension system. The cardinal ligaments are mentioned during vaginal hysterectomy as structures that are sequentially clamped, transected, and ligated when separating the uterus from its fixation and blood supply systems.
Which lymph nodes provide regional lymphatic drainage from the body and cervix of the uterus?
In the provided sources, separate regional lymphatic drainage from the body and cervix of the uterus is not detailed. The following are indicated:
- Parauterine lymph nodes (nodi lymphoidei parauterini): 2–3 nodes located along the margins of the uterine body within the duplication of its broad ligament.
- Internal iliac lymph nodes (nodi lymphoidei iliaci interni) are located along the internal iliac artery and receive lymph from the pelvic organs.
For quick memorization of the structures crossed during adnexal mobilization, use the mnemonic RUT: Round ligament of the uterus, Uterine (proper) ligament of the ovary, Tube.
Class and exam questions
Which instrument is used to fix and deliver the uterus?
Museux forceps are used for a secure grasp of the uterine fundus and its delivery into the surgical wound.
Why is a wedge-shaped incision made during the transection of the uterine body?
Excision of tissue in the shape of a shallow wedge allows the edges of the cervical stump to be easily approximated without tension when placing sutures.
How to protect the urinary bladder during a hysterectomy?
It is necessary to open the vesicouterine peritoneal fold and carefully separate the urinary bladder from the anterior surface of the cervix by displacing it downward.
What should be done in case of tissue deficiency during peritonealization of the tubal stump?
If the remaining portion of the mesosalpinx is insufficient in size, an alternative approach is used: a loop of the round ligament of the uterus is sutured directly to the ovary, and the procedure is completed with a half-purse-string suture.
What else to study on this topic
- Layer-by-layer topography of the anterior abdominal wall during the Pfannenstiel incision.
- Incision options for vaginal approaches (tongue-shaped, longitudinal, combined).
- Topography of the uterine arteries and their relationship with the ureters.
- Technique for placing a half-purse-string suture during peritonealization of the adnexa.
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