Steps 1 and 2 are repeated on the opposite sites ( Fig. The bladder flap is cut by grasping the peritoneum of the vesicouterine fold just below its reflection onto the uterus ( Figs. The round ligaments are clamped, divided, and suture-ligated with 0 Vicryl ( Fig. Thus, surgery is performed in a logical stepwise fashion.ġ. A malleable retractor has been placed between the uterus and the sigmoid colon.įIGURE 11–2 Schematic topographic view of the pertinent anatomy encountered during hysterectomy. A 0 Vicryl stitch placed into the uterine fundus pulls the uterus posteriorly, exposing the vesicouterine peritoneum. A Richardson retractor is positioned between the bladder and the uterus. The myomatous uterus in situ, the Balfour self-retaining retractor is in place. The pelvic contents in the operative field are identified, and any pathology or anatomic distortion is noted ( Fig. The abdomen has been previously explored. Total Abdominal Hysterectomy With Bilateral Salpingo-oophorectomyĪfter the abdomen has been opened and the intestine carefully packed, a self-retaining retractor is placed ( Fig. The latter also takes origin from the anterior division of the hypogastric artery. The artery divides into a larger, ascending branch and a smaller, descending branch that supplies the cervix and anastomoses with the vaginal artery. The uterine artery crosses from the anterior division of the hypogastric artery obliquely above the ureter to join the uterus at the junction of the corpus and cervix. The venous drainage enters the hypogastric veins, the vena cava (right ovarian), and the left renal vein (left ovarian). The blood supply to the uterus emanates from the hypogastric arteries and via the ovarian arteries from the aorta. Strategic surrounding structures include the bladder anteriorly, the rectum posteriorly, and the ureters and great vessels laterally. These supporting structures include (1) vascular pedicles together with their peritoneal and connective tissue investments (e.g., infundibulopelvic ligament, uterine artery and veins) (2) muscular supports (e.g., the round ligaments) (3) connective tissue–vascular/neural condensations (e.g., cardinal, uterosacral ligaments) and (4) fat and peritoneum (e.g., broad ligament, uterovesical, uterorectal folds). The basis for this operation is an open abdomen (laparotomy), which provides adequate exposure for isolation of the uterus and adnexa from surrounding structures to allow cutting and securing of support structures that attach the uterus to the pelvic floor and sidewalls. Abdominal hysterectomy is one of the most frequently performed surgical procedures in the United States.
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