Table of Contents
Procedure Summary
- The video proposes an alternative approach to uterine artery ligation during laparoscopic hysterectomy, with colpotomy performed before ligation of uterine arteries.
- Traditional approach involves five steps: creating the bladder flap, dissecting the pubocervical fascia, skeletonizing uterine arteries, ligating uterine arteries, and performing colpotomy.
- Alternative approach involves performing colpotomy after skeletonizing uterine arteries, followed by ligation of uterine arteries and completing colpotomy.
- A study found that performing anterior colpotomy prior to uterine artery ligation improved resident understanding and visualization of surgical anatomy, reduced surgical operating time, blood loss, and bladder injury.
- The alternative approach is demonstrated in straightforward and complex cases, with clear delineation of anatomy, improved surgical education, and versatility in both simple and complex cases.
Presented By
Affiliations
University of Calgary
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What is Routine Anterior Colpotomy?
- Routine anterior colpotomy is a surgical procedure performed during a hysterectomy, involving the incision and opening of the anterior vaginal wall.
- It is traditionally performed after securing the uterine arteries through ligation, which helps reduce blood loss and maintain a clear surgical field.
- The procedure aids in the separation of the uterus and cervix from the upper part of the vagina during a hysterectomy.
- Anterior colpotomy helps improve visualization and access to the surgical area while reducing the risk of injury to surrounding structures.
- An alternative approach suggests performing anterior colpotomy before ligation of uterine arteries, which can improve surgical anatomy understanding, reduce operating time, blood loss, and bladder injury.
- The technique is adaptable for both simple and complex cases and can enhance surgical education and confidence in anatomy for learners.
Video Transcript
In this video, we propose an alternative approach to the timing of the uterine artery ligation during laparoscopic hysterectomy. We’ll review the traditional approach and demonstrate how this alternative technique can be used in both straightforward and complex cases.
The Traditional Approach to Securing the Uterine Artery
The traditional approach involves five major steps to securing the uterine artery. Creation of the bladder flap, dissection of the pubocervical fascia, skeletonisation of the uterine arteries, ligation of the uterine arteries bilaterally and finally, colpotomy. In the alternative approach the first three steps done traditionally are completed but after skeletonisation of the uterine arteries, the colpotomy is initiated. Followed by ligation of the uterine arteries bilaterally and then completion of the colpotomy.
There is no literature available on this approach with the exception of an abstract published in JMIG in 2016. A five-year study done in an academic centre found that when performing the anterior colpotomy prior to uterine artery ligation, it improved resident understanding and visualisation of surgical anatomy. Decreased surgical operating time, decreased blood loss and decreased bladder injury.
We will now demonstrate the traditional approach to securing the uterine arteries. Initial anatomy inspection shows a normal appearing pelvis with an absence of pathology. After treatment at the adnexa, the bladder flap is then created by making a lateral to medial incision along the peritoneum. The bladder flap is further dissected off of the cervix revealing the pubocervical fascia beneath. It is here that we first identify the right uterine artery.
The uterine arteries are then further skeletonised bilaterally. The uterine artery is then ligated at three locations at the level of the cold cup. This is then repeated on the contralateral side in the same fashion.
The anterior colpotomy is then created at the level of the cold cup. It is carried out circumferentially transecting through both ligated uterine arteries. The colpotomy is continued posteriorly and the specimen is then removed.
Alternative Approach to Securing the Uterine Artery
We will now demonstrate the alternative approach to securing the uterine artery. This is the case of a 39-year-old G3P3 with a history of dysmenorrhea and abnormal uterine breeding refractory to medical management.
The anatomy demonstrates a prior tubal ligation with Filshie clip application, a bulky globular 12-week sized uterus with a large posterior fibroid. Like in the traditional approach, the alternative approach begins with creation of the bladder flap by incising the peritoneum from lateral to medial, exposing the pubocervical fascia below. The pubocervical fascia is then further dissected to create a clean plane for the colpotomy. The uterine artery is identified and further skeletonised.
With clear visualisation of the uterine artery, the colpotomy is initiated on the anterior surface of the pubocervical fascia. The exposure of the uterine artery at this time allows for easy identification of the level at which the uterine artery will be secured. The uterine artery can also be seen as a separate structure to the vagina so the vaginal branch can be safely and easily secured.
With continued visualisation, the colpotomy is extended just to the level of the uterine artery. The uterine artery is then ligated in three locations in the level of the cold cup. The colpotomy is continued to the level of the contralateral uterine artery.
Contralateral uterine artery is then ligated at the precise level of the colpotomy. It is secured with complete control and visualisation prior to transection and completion of the colpotomy.
Complex Colpotomy Creation with the Alternative Approach
We will now demonstrate colpotomy creation with increasing complexity using the alternative approach. This is a case of a patient with stage four endometriosis undergoing definitive surgical management. Pelvic side wall resection of endometriosis had been completed followed by bilateral ureterolysis to the level of the uterine arteries. Followed by lateral to medial dissection of the rectum off the posterior vagina. The anatomy is demonstrated here.
The posterior colpotomy was created initially to assist with dissection of the rectum off the posterior vagina by creating a plane laterally thus allowing skeletonisation of the uterine artery from a posterior to anterior direction. With complete ureterolysis having been performed distally to the level of the uterine artery.
In conclusion, creation of the colpotomy prior to securing the uterine arteries has several advantages. It improves surgical technique through clear delineation of anatomy, improving patient outcomes based on limited data and or experience. This technique improves surgical education and confidence with anatomy for learners. It is easy to teach and versatile for use in both simple and complex cases.