Ramiro Cabrera Carranco1, Andres Vigeras2, Reitan Ribeiro3, Monica Tessmann Zomer4, William Kondo4. 1. Department of Gynaecological Surgery (Drs. Carranco, Zomer, and Kondo), Vita Batel Hospital, Curitiba, Brazil. Electronic address: ramirorcc@gmail.com. 2. Department of Minimally Invasive Surgery Unit (Dr. Vigeras), Centro Hospitalar Universitário do Porto, Porto, Portugal. 3. Department of Minimally Invasive Surgery Unit (Dr. Reitnan), Erasto Gardner Hospital, Curitiba, Brazil. 4. Department of Gynaecological Surgery (Drs. Carranco, Zomer, and Kondo), Vita Batel Hospital, Curitiba, Brazil.
Abstract
OBJECTIVE: Laparoscopic uterine artery ligation may be performed during myomectomy or other uterine invasive procedures to reduce the amount of blood loss during surgery. In this video, the authors describe 3 different laparoscopic techniques to approach the uterine artery. DESIGN: Step-by-step video demonstration of 3 different surgical techniques. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure. ANTERIOR APPROACH: The impression of the uterine vessels can usually be seen anteriorly and laterally to the uterine cervix. After identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be performed with extreme caution because the uterine veins are very close to the artery. Venous bleeding at this point of the dissection can be very difficult to control without ligating the vessels. After circumferential dissection of the artery, temporary occlusion is conducted using 2-0 polyester suture. POSTERIOR APPROACH, LATERAL TO THE INFUNDIBULOPELVIC LIGAMENT: For ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel and medial to the external iliac vessels toward the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection (traction and countertraction), identifying the lateral (external iliac vessels) and medial (pelvic infundibulum and the ureter attached to the peritoneum of the ovarian fossa) landmarks. The external iliac artery is dissected cranially to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac usually is the uterine artery. After circumferential dissection of the uterine artery, it may be ligated according to the same technique described above. MEDIAL APPROACH: For the medial approach, the peritoneum should be opened medial to the infundibulopelvic ligament. The assistant grasps the infundibulopelvic ligament, creating a peritoneal tent. Immediately after broad ligament opening, anatomic landmarks are identified. First, the ureter is identified and medialized. For the identification of vascular anatomy, movement of the obliterated umbilical artery is made active, which reduces the risk of error to ligate the uterine artery. After circumferential dissection of the artery, it may be ligated according to the same technique described above. CONCLUSION: Laparoscopic uterine artery ligation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to the position of the myomas within the uterus as well as the uterine volume, the surgeon may choose among 1 of the above-mentioned techniques to perform. This technique could also be applied to other types of invasive uterine procedures to reduce blood loss. Standardization of these techniques could help to reduce the laparoscopic learning curve.
OBJECTIVE: Laparoscopic uterine artery ligation may be performed during myomectomy or other uterine invasive procedures to reduce the amount of blood loss during surgery. In this video, the authors describe 3 different laparoscopic techniques to approach the uterine artery. DESIGN: Step-by-step video demonstration of 3 different surgical techniques. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: The main steps of uterine artery ligation are described in detail as well as different laparoscopic variants to this procedure. ANTERIOR APPROACH: The impression of the uterine vessels can usually be seen anteriorly and laterally to the uterine cervix. After identification of the path of the uterine arteries, the peritoneum of the anterior cul-de-sac is opened over the vessels and the uterine artery is carefully dissected next to the lateral border of the uterine cervix. This dissection must be performed with extreme caution because the uterine veins are very close to the artery. Venous bleeding at this point of the dissection can be very difficult to control without ligating the vessels. After circumferential dissection of the artery, temporary occlusion is conducted using 2-0 polyester suture. POSTERIOR APPROACH, LATERAL TO THE INFUNDIBULOPELVIC LIGAMENT: For ligation of the uterine artery posteriorly to the uterus and laterally to the pelvic infundibulum, opening of the peritoneum of the broad ligament should start immediately below the round ligament, parallel and medial to the external iliac vessels toward the base of the pelvic infundibulum. The avascular space is dissected by blunt dissection (traction and countertraction), identifying the lateral (external iliac vessels) and medial (pelvic infundibulum and the ureter attached to the peritoneum of the ovarian fossa) landmarks. The external iliac artery is dissected cranially to find the bifurcation of the common iliac artery and the internal iliac artery. The first medial branch of the anterior division of the internal iliac usually is the uterine artery. After circumferential dissection of the uterine artery, it may be ligated according to the same technique described above. MEDIAL APPROACH: For the medial approach, the peritoneum should be opened medial to the infundibulopelvic ligament. The assistant grasps the infundibulopelvic ligament, creating a peritoneal tent. Immediately after broad ligament opening, anatomic landmarks are identified. First, the ureter is identified and medialized. For the identification of vascular anatomy, movement of the obliterated umbilical artery is made active, which reduces the risk of error to ligate the uterine artery. After circumferential dissection of the artery, it may be ligated according to the same technique described above. CONCLUSION: Laparoscopic uterine artery ligation may be performed during laparoscopic myomectomy to reduce intraoperative blood loss. According to the position of the myomas within the uterus as well as the uterine volume, the surgeon may choose among 1 of the above-mentioned techniques to perform. This technique could also be applied to other types of invasive uterine procedures to reduce blood loss. Standardization of these techniques could help to reduce the laparoscopic learning curve.