A safe and efficient approach for ureteral transfer in laparoscopic total hysterectomy - a hybrid technique

Abstract

Introduction

　To prevent cutting the ureter during laparoscopic total hysterectomy (TLH), it is important to identify the point where the ureter intersects with the uterine artery (the entrance to the ureteral tunnel) and determine the height of the cut of the basal ligament. To do this, it is necessary to first identify the ureter. There are three approaches to ureteral passivation: anterior, lateral, and posterior. In order to compensate for the disadvantages of each approach and to optimize safety, we have developed a method that combines the anterior and posterior approaches of laparoscopic total hysterectomy (hereinafter referred to as the anterior-posterior approach)

Method

　In the anterior approach, a cavity is created between the lateral umbilical ligament and the ureter (neobladder lateral cavity). From there, the rectal cavity of Okabayashi could be created and the ureter could be passivated, but in some cases, detachment is difficult. Therefore, once the neobladder lateral cavity has been liberated by the anterior approach, we switch to the posterior approach.

　This approach facilitates ureteral fluoroscopy from the posterior lobe of the broad mesentery as the lateral lumen of the neobladder has been created. This aids the identification of the ureter and the creation of the lateral rectal lumen in a safe and efficient manner.

Results

　The anterior-posterior approach is a safe and efficient method of visualizing and identifying ureteral passages in patients with TLH.

Conclusion

　In TLH, the lateral approach allows the identification of the ureter cephalad to the ovary and as well as that of the site of intersection of the uterine artery and the ureter while isolating the ureter caudally, thus facilitating a better and clearer visualization of the peritoneum. However, the lateral approach is thought to increase the risk of ovarian torsion after TLH. Moreover, it is often difficult to identify the ureter by the posterior approach in cases with high amount of fatty tissue or adhesions in the retroperitoneum. The anterior-posterior approach can compensate for the limitations of the lateral and posterior approaches and potentially help reduce the risk of ureteral injury in cases of TLH.