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 UA ligation at its vascular origin is a valuable skill set in such situations but requires comprehensive anatomic knowledge of the retroperitoneum and UA variations to ensure complete control of the uterine blood supply.
Traditionally, the UA arises from the anterior division of the internal iliac artery (IIA) as a common trunk with the umbilical artery. However, evidence from UA embolization as well as anatomic dissections demonstrates that the origin of the UA may vary in up to 1 of 5 cases. Alternative branching patterns have been described with the UA arising directly from the IIA, superior gluteal, internal pudendal, or obturator artery ( Figure 1 ). One particular variation, which may complicate the vascular network encountered at the UA origin, is a C-shaped configuration in which 1 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 UA ligation in the setting of distorted pelvic anatomy.
Our solution
We present a Video demonstrating ligation of the UA as it arises from the IIA in a C-shaped configuration with 2 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 space (PRS) or the paravesical space (PVS) by utilizing the medial umbilical ligament (MUL). The PRS is bounded laterally by the IIA, medially by the ureter, and anteriorly by the cardinal ligament. The 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 PVS 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.
PRS 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 2 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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