LAUSR

Video Objective To demonstrate approaches to uterine artery ligation Setting Gynaecology department at a University Hospital. Interventions We demonstrate various methods of uterine artery ligation during complex gynaecological surgery. Conclusion Bleeding is a significant risk during procedures such as hysterectomies and myomectomies. During hysterectomy, the uterine artery is commonly ligated at the level of internal cervical os, though access may be limited in complex pathology such as fibroids, large uteri and adnexal masses. Furthermore, complications such as haemorrhage, ureteric and bladder injury may occur during attempts to secure difficult vascular pedicles. Such challenges can be overcome, by ligating the uterine artery at its vascular origin. During myomectomy, temporary occlusion using clips may help to reduce blood loss in selected cases. [1] We demonstrate simple and reproducible techniques of ligating the uterine artery at its origin. This valuable skill can be learnt by both novice as well as expert surgeons for utilisation during complex hysterectomy and myomectomy. We begin by performing ureterolysis by one of two approaches. [2] The posterior approach begins by opening the peritoneum overlying the ureter following visualisation at the pelvic side wall. Alternatively, a lateral approach is useful when views of the pelvic side wall are limited and includes division of the round ligament and peritoneum towards the base of infundibulopelvic ligament. Once ureterolysis is complete the obliterated umbilical artery is identified and followed into the pelvic side wall. Gentle traction can be used to confirm the ligament. Using open and spread, and traction and counter-traction techniques, the space lateral to the ureter and in front of the obliterated umbilical artery is gently dissected revealing the uterine artery. Using a Thunderbeat, we coagulated the vessels whilst maintaining distance from the ureter to avoid damage. One can use any preferred method for ligation including vessel sealing devices, sutures and temporary or permanent clips.