腹腔镜辅助阴式子宫切除术（图文演示）

10. Ovarian vessels

1. Visualization of the right ureter
2. Open retroperitoneal space
3. Electrocautery of the left ovarian vessels
Occlusion of the ovarian vessels:
The ureter with the uterine artery running parallel to it is clearly seen. The ovarian vessels are then grasped, electrocoagulated and cut.
This is then repeated on the other side.

11. Bladder dissection

1. Bladder peritoneum
2. Uterus
3. Vagina
4. Bladder
Dissection of the bladder:
The incision from the round ligament is carried anteriorly towards the bladder. The bladder peritoneum is grasped with an Allis forceps and raised towards the anterior abdominal wall. The bladder peritoneum is incised and dissected caudad. The correct dissection plane is identified by an avascular space. Sharp dissection is used. During the procedure, the uterus is pushed cephalad and in the midline.

12. Uterine vessels
• Identification

1. Right uterine artery
2. Right ureter
3. Vagina
The uterine artery is identified at its origin as the umbilical artery branches from the internal iliac artery and courses anteriorly. The uterine artery then runs parallel to the ureter for a short course before crossing over it.

• Division

The uterine artery is grasped at the cervico-uterine junction with a bipolar device. It is then electrocoagulated and cut.

13. Uterus removal
• Incision

1. Vaginal incision
A sponge on a ring forceps is placed in the vagina in the anterior fornix. The vagina is tented with the sponge on the ring forceps and entered using electrocautery on pure cut (50 W). If a uterine manipulator is in place, the plastic section is used as a guide for the vaginal incision. The incision on the vagina is started anteriorly and continued circumferentially. Once the anterior fornix is entered the peritoneal gas will escape. The vagina can be packed or the balloon of the uterine manipulator inflated to prevent gas leak.

• Uterus removed

1. Morcellated uterus
The uterus is then removed vaginally. If it is too large, a morcellator is used from one of the trocars and it is removed in pieces.

• Vaginal vault closure

The vaginal vault is sutured laparoscopically with 0 polyglactin. The knots are tied extracorporeally.

14. End of procedure
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At the end of the procedure, an ampule of indigo carmine dye is given and a cystoscopy is performed to make sure there is no bladder damage and that the ureters are patent. The fascia of all trocars over 5 mm are closed. A subcuticular suture is used for the skin.

15. Postop period

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The urinary catheter is left in overnight. Intravenous narcotics are used. The patient is allowed a regular diet, as tolerated. The patient is discharged as soon as the following criteria are met (usually within 24 hours):
- afebrile with stable vital signs and hematocrit;
- able to void without difficulty;
- ambulates on his or her own;
- tolerates oral analgesics;
- tolerates at least a clear liquid diet.

16. Reference

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