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Accepted Manuscript

Anatomic vascular considerations in uterine artery ligation at its origin during

laparoscopic hysterectomies

Ann Peters, MD MS, Mallory A. Stuparich, MD, Suketu M. Mansuria, MD, Ted T.M.

Lee, MD

PII: S0002-9378(16)30313-1

DOI: 10.1016/j.ajog.2016.06.004

Reference: YMOB 11141

To appear in: American Journal of Obstetrics and Gynecology

Received Date: 25 February 2016

Revised Date: 23 May 2016

Accepted Date: 1 June 2016

Please cite this article as: Peters A, Stuparich MA, Mansuria SM, Lee TTM, Anatomic vascular

considerations in uterine artery ligation at its origin during laparoscopic hysterectomies,American

Journal of Obstetrics and Gynecology(2016), doi: 10.1016/j.ajog.2016.06.004.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to

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http://dx.doi.org/10.1016/j.ajog.2016.06.004

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Anatomic vascular considerations in uterine artery ligation at its origin

during laparoscopic hysterectomies

Ann PETERS MD MS1, Mallory A. STUPARICH MD1*, Suketu M. MANSURIA

MD1, Ted T.M. LEE MD1

1Department of Obstetrics and Gynecology and Reproductive Sciences, Magee-

Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA

*Corresponding author: Mallory A. Stuparich, MD Magee-Womens Hospital,

University of Pittsburgh Medical Center, Division of Gynecologic Specialties,

Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology

and Reproductive Sciences

300 Halket Street, Pittsburgh, PA 15213.

Email: stuparichma@upmc.edu

Work phone: 412-641-1440, Fax: 412-641-3447

Conflict of Interest: T.T.L is a consultant for Ethicon Endosurgery. S.M.M. has

been providing educational services for Covidien since 2015. All other authors

have no conflict of interest.

Funding or Disclaimer:None

Paper Presentation Information:The findings will be presented at the 42nd

Annual Society for Gynecologic Surgeons Scientific Meeting in Palm Springs, CA

on April 11th, 2016. Abstract number 2393057.

Word Count: Abstract: 134 words; Main Text: 647 words

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Short Title: Uterine artery ligation during laparoscopic hysterectomies

Condensation: Knowledge of anatomic uterine artery variations is necessary for

successful vascular ligation at its origin during difficult laparoscopic

hysterectomies.

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Key words: Laparoscopic hysterectomy, medial umbilical ligament, uterine

artery ligation, uterine artery variations

Abstract

Pelvic pathology such as fibroids, endometriosis, adhesions from previous pelvic

surgeries, or ovarian remnants can distort anatomy and pose technical

challenges during laparoscopic hysterectomies. Retroperitoneal dissection to

ligate the uterine artery at its vascular origin can circumvent these obstacles,

resulting in a safer procedure. However, detailed anatomic knowledge of the

course of the uterine artery and understanding of vascular variations are

essential for optimal dissection. Our video demonstrates a C-shaped uterine

artery variation encountered during retroperitoneal dissection. We describe the

key steps in identification and isolation of this variant, approaching the uterine

artery origin either from the pararectal space or by utilizing the medial umbilical

ligament coursing through the paravesical space. We also review other known

uterine artery configurations. These techniques allow for safe completion of

complex laparoscopic hysterectomies performed for various gynecologic

diseases.

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Problem: uterine artery variations during laparoscopic ligation at its

vascular origin

During a hysterectomy, the uterine artery (UA) is traditionally ligated at the

level of the internal cervical os. However, in cases with anatomic distortion from

pelvic pathology, this approach may not be technically feasible. Laparoscopic

uterine artery ligation (UAL) at its vascular origin is a valuable skill set in such

situations but requires comprehensive anatomic knowledge of the

retroperitoneum and uterine artery variations to ensure complete control of the

uterine blood supply.

Traditionally, the UA arises from the anterior division of the internal iliac

artery as a common trunk with the umbilical artery.1,2However, evidence from UA

embolization as well as anatomic dissections demonstrates that the origin of the

UA may vary in up to one out of five cases.1Alternative branching patterns have

been described with the UA arising directly from the internal iliac (IIA), superior

gluteal, internal pudendal, or obturator artery1,3-6 (Figure 1). One particular

variation, which may complicate the vascular network encountered at the UA

origin, is a C-shaped configuration in which one UA arises from the anterior

division in the traditional fashion while a second UA branch originates directly

from the IIA. Anticipation of these UA configurations allows the laparoscopic

surgeon to successfully approach UAL in the setting of distorted pelvic anatomy.

Our solution

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We present a video demonstrating ligation of the UA as it arises from the

IIA in a C-shaped configuration with two UA branches that proceed through the

retroperitoneum toward the uterine body (Figure 2). The surgeon may identify

the UA at its origin and any variants from either the pararectal or the paravesical

space by utilizing the medial umbilical ligament (MUL). The pararectal space

(PRS) is bounded laterally by the IIA, medially by the ureter, and anteriorly by the

cardinal ligament. The paravesical space (PVS) is bounded posteriorly by the

cardinal ligament, medially by the bladder and ureter, and laterally by the

external iliac vein. The MUL then further subdivides the paravesical space into

medial and lateral compartments. The decision to approach the UA via the PRS

or MUL largely depends on the existing pelvic pathology. The PRS approach is

most useful when anatomic distortion does not involve the proximal ureter, which

serves as an important landmark for dissection.

Pararectal Space Approach

Dissection begins with transection of the round ligament to access the

retroperitoneum. The pelvic sidewall peritoneum is then incised parallel to the

infundibulopelvic ligament. Within the PRS, blunt dissection in the areolar tissue

at the level of the external iliac vessels serves to locate the ureter and the IIA

(Figure 3). Dissection then proceeds caudally between these two landmarks,

ultimately leading to the UA as it originates from the IIA. In our experience, gentle

blunt dissection around the UA commonly reveals a second UA branch off the IIA

in a C-shaped configuration (Figure 4). Ligation of the UA and all potential

accessory vessels is crucial to optimize hemostasis.

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Medial Umbilical Ligament Approach

When the PRS is not accessible due to complex pelvic pathology

distorting the visualization or dissection of the ureter, then retroperitoneal

dissection can proceed along the MUL through the PVS. Again, the round

ligament is transected, and the anterior leaf of the broad ligament is opened. The

peritoneal fat between the bladder and EIV is separated bluntly to identify the

MUL within the PVS. Gentle traction on the MUL should cause tenting of the

anterior abdominal wall to confirm correct identification (Figure 5). Dissection

then proceeds cephalad along the MUL, first encountering the superior vesical

artery followed by the UA at its vascular origin. Lateral traction on the MUL aids

in skeletonizing the UA and its vascular variants while increasing distance to the

medially coursing ureter (Figure 6).

Conclusion

These dissection techniques reliably isolate the UA at its vascular origin

while identifying accessory branches and key anatomic landmarks (Figure 7).

These strategies help the laparoscopic surgeon successfully complete complex

hysterectomies while minimizing blood loss, improving visualization, and

preventing need for conversion to laparotomy.

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References

1. Chantalat E, Merigot O, Chaynes P, Lauwers F, Delchier MC, Rimailho J.

Radiological anatomic study of the origin of the uterine artery. Surg Radiol

Anat 2014;36:1093-1099.

2. Lipshutz B. A composite study of the hypogastric artery and its branches. Ann

Surg 1918;67(5):584-608.

3. Gomez-Jorge J, Keyoung A, Levy EB, Spies JB. Uterine artery anatomy

relevant to uterine leiomyomata embolization. Cardiovasc Intervent Radiol

2003;26:522-527.

4. Roberts WH, Krishinger GL. Comparitive study of human internal iliac artery

based on Adachi classification. Anat Rec 1967;158(2):191-196.

5. Obimbo MM, Ogengo JA, Saidi H. Variant anatomy of the uterine artery in a

Kenyan population. Int J Gynaecol Obest: Off Organ Int Fed ynaecol Obstet

2010;111(1):49-52.

6. Holub Z, Jabor A, Lukac J, Kliment L, Urbanek A. Variability of the origin of

the uterine artery: laparoscopic surgical observations. J Obstet Gynaecol Res

2005;31(2):158-163.

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Figures

Figure 1: Illustration of the origin of the uterine artery

The illustration shows the most common origin of the uterine artery (UA) and the

C-shaped variant configuration. The UA may also arise from the superior gluteal

(SGA), pudendal (PA), and obturator artery (OA) or directly from the internal iliac

artery (IIA). EIV External iliac vein, EIA External iliac artery, CIA Common iliac

artery, Ao Aorta, SVA Superior vesical artery, MUL Medial umbilical ligament,

MRAMiddle rectal artery, IGAInferior gluteal artery

Figure 2: Left C-shaped uterine artery configuration

The C-shaped uterine artery (UA) configuration (dashed white line) is

skeletonized from its origin coursing towards the left uterine body. MULMedial

umbilical ligament

Figure 3: Pararectal approach: Caudal dissection along the left ureter

The left pararectal space is entered laterally to the ureter by locating the internal

iliac artery medial to the external iliac vein (EIV) and dissecting along the ureter

in a caudal direction. EIAExternal iliac artery

Figure 4: Pararectal approach: Skeletonization and ligation of the left

uterine artery

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The C-shaped uterine artery (UA) configuration has been skeletonized in the left

pararectal space between the internal iliac artery (IIA) and ureter. EIV External

iliac vein; MULMedial umbilical ligament

Figure 5: Medial umbilical ligament approach: Identification of the left

medial umbilical ligament

Anterior-posterior blunt separation of adipose tissue in the left paravesical space

identifies the medial umbilical ligament between the bladder and the external iliac

vein (EIV).

Figure 6: Medial umbilical ligament approach: Dissection along the left

medial umbilical ligament

Cephalad dissection along the left medial umbilical ligament (MUL) lateral to the

direction of the ureter (dotted line) will identify the uterine artery at its origin. EIV

External iliac vein

Figure 7: Retroperitoneal dissection of a right C-shaped uterine artery

configuration

Demonstration of the right uterine artery (UA) C-shaped configuration (green

dashed line) within the completely dissected pararectal (PRS) and paravesical

spaces (PVS) with key anatomic structures highlighted. SVA Superior vesical

artery, MULMedial umbilical artery, IIAInternal iliac artery, EIVExternal iliac vein

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