ABSTRACT
Figure 13.5. Abdominal radical hysterectomy: anatomic relationship. When a radical hysterectomy is performed abdominally, the uterus is pulled upwards, bringing with it the parametrium and the uterine vessels, while the bladder base is mobilized downwards. Therefore, the uterine vessels lie above the concavity of the ureters as the ureters course into the parametrial tunnel to enter the bladder base. Thus, after mobilization, the ureters are brought lateral and below the parametrium before it is divided. (From Plante and Roy9 with permission.)
1 – Bladder 2 – Uterus 3 – Parametrium 4 – Ureter 5 – Uterine artery
Figure 13.6. Vaginal radical hysterectomy: anatomic relationships. Conversely, when the radical hysterectomy is done vaginally, the relationship between the structures is completely opposite to that when performed abdominally. The uterus is pulled downwards and the bladder base, along with the ureters, is mobilized upwards. As such, the uterine vessels end up below the concavity, or the ‘knee’, of the ureter. After mobilization, the ureters course above the parametrium when it is clamped. The radical vaginal surgical approach requires the surgeon to clearly understand the relationship between the ureter, the uterine artery, and the cardinal ligament (parametrium), as well as the relationship between the bladder base and the lower uterine segment. (From Plante and Roy9 with permission.)
Figure 13.7. Positioning of the patient. In order to facilitate the vaginal approach, the patient’s legs are slightly extended, but the thighs are hyperflexed onto the abdomen. To avoid having to redrape after the laparoscopic lymphadenectomy and parametrectomy, hydraulic leg holders are very useful. (a) The legs are down for laparoscopy and (b) are moved up in order to attain a vertical line between the feet and the buttocks for the vaginal surgery.
