Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

Подождите немного. Документ загружается.

1074 Section XIV • Gynecology

◆ The Maylard and Cherney transverse incisions are used when a larger opening in required

than that allowed by the Pfannenstiel. In comparison with the Pfannenstiel incision the

rectus muscles must not be separated from the anterior fascia or rectus sheath in either

incision.

◆ For the Maylard incision, after the transverse skin incision, the inferior epigastric vessels

are ligated bilaterally, lateral to the rectus muscles (Figure 97-6). After the blood supply

has been secured, the rectus muscles are transected. To avoid retraction of the muscles

cephalad, the anterior sheath must remain attached. The posterior fascia and peritoneum

are then incised the length of the incision. For the closure, because the muscles were not

separated from the anterior rectus sheath, they are reapproximated by the fascial closure.

Dividing pyramidalis and

rectus muscles

Inferior epigastric

vessels

FIGURE 97 –6

CHAPTER 97 • Abdominal Hysterectomy 1075

◆ For the Cherney incision, after the transverse skin incision, the rectus muscle is tran-

sected at its tendon, near its insertion to the pubic bone (Figure 97-7). As with the

Maylard, to avoid retraction of the muscles cephalad, the anterior sheath must remain

attached. The posterior fascia and peritoneum are then incised the length of the incision.

For the closure, the tendons are reapproximated with 0 interrupted absorbable

sutures. A limitation to the Cherney incision is that many women do not have a well-

demarcated rectus abdominis tendon. In these cases, the Maylard incision is a better

option.

Rectus abdominis

tendon

Pyramidalis and

rectus tendon

FIGURE 97 –7

1076 Section XIV • Gynecology

2. DISSECTION

◆ The operative ﬁ eld is prepared by placing the patient in Trendelenburg position, inserting a

self-retaining retractor to expose the pelvis, and packing the intestines away from the opera-

tive ﬁ eld with moist laparotomy pads.

◆ The uterus is grasped with atraumatic curved clamps placed on the uterine horns bilaterally

for traction. Each of the next steps is performed on each side of the uterus before advancing

to the next step. Delayed absorbable suture of the appropriate caliber for the size of the

pedicles (2-0 or 0) is used throughout.

◆ The broad ligament is opened, starting with the round ligament ligation bilaterally

(Figure 97-8).

◆ If the adnexal structures are not to be removed, they are separated from the uterus by liga-

tion of the utero-ovarian ligament (Figure 97-9).

CHAPTER 97 • Abdominal Hysterectomy 1077

Ureter

Round ligament

FIGURE 97 –8

Utero-ovarian ligament

FIGURE 97 –9

1078 Section XIV • Gynecology

◆ The incised peritoneal incision is extended anteriorly across the midline to the loosely

attached peritoneum of the bladder reﬂ ection (Figure 97-10). The bladder ﬂ ap or cervico-

vesical space is developed by placing traction on the incised bladder peritoneum and

sharply dissecting the vesicocervical fascia at the midline for 3 to 4 cm until the level of the

vagina is reached (Figure 97-11). At the completion of this step, the bladder and ureter

have been displaced caudad, as upward traction is placed on the uterus, resulting in

increasing the distance between the uterine arteries and the ureters in preparation for liga-

tion of the uterine arteries.

Ureter

Round ligament

Uterine artery

FIGURE 97 –11

FIGURE 97 –10

CHAPTER 97 • Abdominal Hysterectomy 1079

◆ In preparation for ligation of the uterine artery, the surgeon cleans the retroperitoneal areo-

lar tissue at the level of the internal cervical os to skeletonize the uterine vessels. The uter-

ine vessels are clamped at the level of the internal cervical os, at a right angle to the cervix

(Figure 97-12). For bleeding from the pedicle to be avoided, the tips of the heavy curved

hysterectomy clamps should approximate and slide off the cervix. The pedicle is incised

around the tip of the clamp to separate the ligated pedicle from the specimen and expose

the cardinal ligaments.

Uterine vessels

Cervix

Uterine bladder

FIGURE 97 –12

1080 Section XIV • Gynecology

◆ After the uterine arteries have been ligated bilaterally, attention is brought to the cardinal

ligament. Serial bites of this dense ligament are incised at its insertion on the cervix down

to the vagina (Figure 97-13). To avoid retraction of this thick pedicle, use a straight hyster-

ectomy clamp and incise a wedge-shaped pedicle, stopping 1 to 2 mm short of the tip of

the clamp.

◆ The uterosacral ligament is ligated at its insertion on the posterior cervix (Figure 97-14).

These pedicles may be tagged for incorporation into the vaginal closure for added vaginal

support.

CHAPTER 97 • Abdominal Hysterectomy 1081

Uterosacral ligament

FIGURE 97 –14

Cardinal ligament

FIGURE 97 –13

1082 Section XIV • Gynecology

◆ Identify the upper vagina by palpating the hollow organ at the end of the cervix

(Figure 97-15). Incise across the upper vagina circumferentially, clamping to decrease

spillage of uterine contents into the operative ﬁ eld (Figures 97-16 and 97-17).

3. CLOSING

◆ The vagina is closed with interrupted ﬁ gure-of-eight sutures. To avoid injury to the bladder,

suture from anterior to posterior (Figure 97-18). The pelvis is copiously irrigated.

◆ The abdominal wall is closed in layers. The anterior rectus fascia is closed in a continuous

mass closure.

FIGURE 97 –16

Uterine bladder

FIGURE 97 –15

CHAPTER 97 • Abdominal Hysterectomy 1083

Closure of

vaginal cuff

FIGURE 97 –18

Vaginal cuff

FIGURE 97 –17