Lateral Approach to Uterine Artery & Scarred Bladder in Difficult TLH

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Ligating the uterine arteries is a key step in successfully performing a total laparoscopic hysterectomy. However, in the presence of pelvic pathology, the anatomy can be significantly distorted making visibility and accessibility difficult.

Securing the uterine arteries at the origins of the internal artery is a useful technique for any gynecologists performing hysterectomies. In this total laparoscopic hysterectomy, we encountered an obliterated anterior cul-de-sac from the previous Caesarean section scar and an inaccessible posterior cul-de-sac from a large posterior fibroid.

Since it was not possible to ligate the uterine arteries at the level of the internal cervical os, we decided to use the lateral approach to ligate the uterine arteries by dissecting the pararectal fossa.

This video aims to highlight the importance of identifying landmarks, hemostatic dissection, and adaptive intraoperative planning.

Presented By

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Dr. Li-Hsuan Hsiao
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Dr. Fariba Mohtashami

Affiliations

University of British Columbia

Read More: Lateral Approach to Uterine Artery and Scarred Bladder in Difficult TLH

Ligating the uterine arteries is a key step to a successful hysterectomy. In the presence of distorted pelvic anatomy, the conventional approach to the uterine artery may not be feasible. Securing the uterine arteries at the origins of the internal iliac is a useful approach for any gynecologist. This video aims to highlight retroperitoneal anatomy, laparoscopic dissection and adaptive intraoperative planning.

The patient is a 47-year-old woman with symptomatic uterine fibroids who elected to have a hysterectomy. She had three prior cesarean sections, and on a bimanual exam, the uterus was 18 weeks’ size. Her BMI is 25.

A total of five 5 millimetre ports were placed to achieve a top-down view of the pelvis and access the pathology through different port configurations. Inspection of the pelvis revealed an enlarged uterus with a 10×10 centimetre posterior fibroid. Anteriorly an 8×8 centimetre has densely adhered to the bladder and the anterior abdominal wall. An anterior cul-de-sac was completely obliterated.

Ten international units of diluted vasopressin was used to minimize blood loss. After the utero-ovarian and round ligaments were coagulated and dissected, the uterus gained more mobility.

The posterior fibroid and the obliterated anterior cul-de-sac made it difficult and unsafe to secure the uterine artery at the level of the internal os. Therefore, we decided to ligate the uterine arteries at the origin from the internal iliac.
The pararectal space is bounded by the ureter medially and the internal iliac artery laterally. The paravesical space is bounded by the ureter medially and the obliterated umbilical artery laterally. The uterine artery separates these two spaces.

We identified the ureter in the posterior leaf of the broad ligament on the right side, then entered the pararectal fossa lateral to the course of the ureter. Hemostatic dissection is very important in the retroperitoneal space as visualization is essential for identifying correct surgical planes. Observe adequate traction-counter traction, push, spread and gentle wiping of the tissue.

We found the internal iliac artery and tugged it to see that it was connected to the medial umbilical ligament. Using this as a reference point, we continue our dissection into the pararectal space. Dissection is performed millimetre by millimetre parallel to the planes [?] in the avascular areolar tissue. Respect for tissue and judicious use of energy helped maintain hemostasis.

We identified the first branch of the internal iliac artery coursing towards the uterus and eventually passing over the ureter. This was the uterine artery.

Observe the relationship between the internal iliac artery and the uterine artery. Use the V shape formed by these two structures as a visual cue. Notice, again, that the uterine artery travels over the ureter. The uterine artery is the border between the pararectal space in the back and the paravesical space in the front. The uterine artery was further skeletonized and secured with a 5 millimetre endoclip. A similar dissection was then performed on the left side.

The uterine artery was dissected from its origins over the ureter and then secured by endoclips.
After the uterine artery was ligated bilaterally, the uterus was devascularised. We started the bladder dissection from the right side, where the anatomy was less distorted. We inflated the bladder to help identify the borders. The bladder adheres to the C-section scar on the uterine isthmus anteriorly. Therefore, we began our dissection from the lateral aspect.

Using a combination of blunt and electrosurgical dissection, we identified the pubocervical fascia under the bladder. We then skeletonized and sealed the uterine vessels on the right side. Having multiple port configurations allows us to coagulate and transect the uterine vessels perpendicular to the direction of the blood flow. This allows for optimal hemostasis. We carried out a similar dissection on the left side.

We identified the pubocervical fascia under the bladder adhesions and created a tunnel to reach the right side.
We passed a laparoscopic grasper through the tunnel between the bladder and cervix to maintain perspective and to retract the bladder as we secured the left uterine vessels at the level of the internal os.

Once the uterus was completely devascularised, we tackled the dense adhesions between the uterus and the anterior abdominal wall and, finally, the uterus and the bladder.

Using the reflection of the uterine manipulator as a reference point, we began developing the bladder flap.

The cardinal ligaments and the uterine vessels were coagulated and transected bilaterally.
Colpotomy was then performed, and the uterus was morcellated vaginally. The vaginal cuff was closed laparoscopically using a number zero V-Loc suture. The time between skin incision to detachment of uterus was two hours and 24 minutes. Total procedure time, including morcellation and cystoscopy, was three hours and 14 minutes.

Uterine weight is 460 grams. Estimated blood loss was less than 15 mils. Knowledge of retroperitoneal anatomy, proper dissection techniques in avascular surgical planes and adaptive intraoperative planning were key factors in enabling us to navigate through distorted pelvic anatomy.

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