••• CHAPTER 32^ Hysterectomy^309
❍ If the adnexa are to be left in, where are the next clamps placed?
On the tube and utero-ovarian ligament, as close to the uterus as possible. A window can be made in the
peritoneum inferior to the fallopian tube; a clamp is then placed across the tube and the utero-ovarian ligament,
just next to the uterus. This preserves the blood vessels located in the broad ligament as much as possible.
❍ What must be identified and located prior to clamping the infundibulopelvic ligament?
The ureter. The most common site of ureteral injury is at the pelvic brim near the infundibulopelvic ligament and
the most common procedure during which it is injured is abdominal hysterectomy.
❍ When is the ureter most likely to be injured?
During attempts to obtain hemostasis.
❍ Why are the anterior and posterior broad ligament peritoneum incised prior to clamping the uterine vessels?
This procedure, often referred to as “skeletonizing” the uterine vessels, aids in avoiding injury to the ureters and
bladder, and provides a smaller pedicle that is less likely to slip out of a clamp.
❍ The blood supply to this organ crosses over the ureter 2 cm lateral to the cervix.
Uterus.
❍ What is the purpose of incising the anterior leaf of the broad ligament?
To facilitate dissection of the bladder from the lower uterine segment. In order to perform a TAH, the bladder
must be completely mobilized.
❍ Where are the ureters located when the uterine vessels are being clamped?
The ureter passes underneath the uterine artery (“water under the bridge”) very close to the level of the internal
cervical os. If the bladder has been mobilized, and the uterine vessels skeletonized, the ureter will be about 1 1/2 to
2 cm inferior and lateral to the uterine vessel clamps.
❍ Why are the uterine arteries usually doubly clamped abdominally, while they are only singly clamped
during a vaginal hysterectomy?
Double clamps are useful abdominally because there is a danger of tissue slipping out of a single clamp and
the uterine artery retracting. Attempts at reclamping a retracted vessel may result in injury to the ureter. When
operating vaginally, there is not enough room between the ureter and the uterine artery to safely apply two clamps.
Curved Heaney clamps are designed to be used as single vascular clamps.
❍ What structures must be avoided when clamping the uterosacral ligaments?
The pelvic portion of the ureter and the anterior rectal wall.
❍ What mistake in performing a TAH is most likely to result in a vesicovaginal fistula?
Inadequate lateral and inferior mobilization of the bladder can result in unrecognized bladder injury and formation
of a vesicovaginal fistula.