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S0002-9378(16)30313-1
DOI:
10.1016/j.ajog.2016.06.004
Reference:
YMOB 11141
To appear in:
23 May 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.
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Email: stuparichma@upmc.edu
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ligation
at
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during
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laparoscopic
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hysterectomies.
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successful
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Key words:
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Abstract
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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
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diseases.
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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
but
requires
comprehensive
anatomic
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situations
of
the
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Traditionally, the UA arises from the anterior division of the internal iliac
artery as a common trunk with the umbilical artery.1,2 However, evidence from UA
embolization as well as anatomic dissections demonstrates that the origin of the
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UA may vary in up to one out of five cases.1 Alternative 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
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Our solution
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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
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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
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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).
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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
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MUL within the PVS. Gentle traction on the MUL should cause tenting of the
anterior abdominal wall to confirm correct identification (Figure 5). Dissection
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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).
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Conclusion
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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
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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.
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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
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Kenyan population. Int J Gynaecol Obest: Off Organ Int Fed ynaecol Obstet
2010;111(1):49-52.
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2005;31(2):158-163.
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Figures
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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
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artery (IIA). EIV External iliac vein, EIA External iliac artery, CIA Common iliac
artery, Ao Aorta, SVA Superior vesical artery, MUL Medial umbilical ligament,
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umbilical ligament
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skeletonized from its origin coursing towards the left uterine body. MUL Medial
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iliac artery medial to the external iliac vein (EIV) and dissecting along the ureter
in a caudal direction. EIA External iliac 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
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vein (EIV).
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identifies the medial umbilical ligament between the bladder and the external iliac
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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
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configuration
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