Mobilization of the Uterus and Adnexa

This phase of intra-abdominal surgery is difficult to illustrate pictorially, but represents an essential preliminary maneuver for any surgical procedure in the female pelvis.

In order to secure an adequate operating field, the intestine must be gently packed out of the pelvis with moist gauze. Frequently, however, the uterus and adnexa are fixed in the pelvis by previous surgery or by inflammatory disease. In such instances the bowel may be densely ad¬≠herent to the uterus, adnexa or broad ligaments. It is imperative that the bowel be freed from these structures and packed out of the field before the uterus is removed. The proper line of cleavage is best established by gentle, gloved finger manipulation. Where the bowel loops can be grasped, separation is often possible by gentle rolling of the tissue between the thumb and forefinger; only occasionally will help from a sharp instrument such as a knife or scissors be needed. The useful slogan, “stay on the uterine side,” should be followed closely, for it is better to leave benign disease on the attached viscera than to remove a section of small bowel or sigmoid with the specimen.

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The adnexa must be freed from the posterior leaves of the broad ligaments and sigmoid before any attempt is made to remove either the adnexa or the uterus, or both. Application of a tenaculum to the fundus or a clamp on the tubal angle and ovarian ligament for traction may be a helpful maneuver.

It is important to recognize that the fixation of tissues resulting from either endometriosis or malignant lesions differs materially from that encountered in pelvic inflammation from other causes. This observation has practical value. A line of cleavage can always be established between pelvic inflammatory disease involving tube and ovary and the attached viscera. For the most part, mobilization in pelvic inflammation should be begun from below upward. A suction apparatus should be available for ready use in the event an abscess is entered. Whenever firm bands of tissue are encountered, they should be brought under complete vision before clamps are applied. The presence of adhesive bands that will not separate suggests that either vessels are present or a false cleavage plane has been established.

The invasive tendency of endometriosis differs from that of pelvic inflammation. Ovarian endometriosis invades the posterior leaf of the broad ligament and cannot be separated without rupture of the adherent chocolate cysts. Great care must be taken that endometriosis has not invaded the small bowel or sigmoid adherent to the pelvic masses. The approach to this type of pathology is usually made from above downward rather than from below upward as in pelvic inflammation. It is extremely important to stay on the uterine side in the dissection.

When the surgeon encounters a large malignant ovarian cyst or pathologic state involving the side wall of the pelvis, it is important to ascertain the position of the ureter by exposing it at the pelvic brim through the posterior peritoneal covering.

The mobilization of the uterus and adnexa simply constitutes a preparation of an adequate operative field and represents a basic preliminary step for whatever type of pelvic surgery the surgeon elects to perform.

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