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An Approach to the Lower Third of the Ureter
Vol. Printed in
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
AN APPROACH TO THE LOWER THIRD OF THE URETER T. E. HODGINS
R. A. HANCOCK
AND
From the Department of Surgery, University of Pittsburgh and Presbyterian University Hospital, Pittsburgh, Pennsylvania
We wish to describe an approach to the lower third of the ureter which, although referred to in the literature,1- 4 has not received the popularity it deserves. The common method of exposing the lower third of the ureter is Gibson's approach in which a curved incision is made in the lower quadrant of the abdomen, the aponeuroses of the external oblique and internal oblique muscles are incised in the same direction as the skin incision, the lateral border of the rectus abdominis muscle is identified and the peritoneal cavity and its contents are retracted medially and superiorly to expose the ureter. 5 The muscle fibers of the external oblique, internal oblique and transversus abdominis muscles run anteromedially, become aponeurotic and insert into the linea alba. Traditionally, the aponeurosis of the internal oblique muscle splits at the semi-lunar line into 2 laminae, one passing anterior to the rectus abdominis muscle to join with the aponeurosis of the external oblique muscle to form the anterior of the rectus sheath while the other passes posteriorly to the rectus abdominis muscle to join the aponeurosis of the transversus abdominis muscle to form the posterior layer of the rectus sheath. Usually at a point just below the umbilicus the aponeurotic fibers which form the posterior layer of the rectus sheath pass anterior to the rectus abdominis muscle and with the aponeurosis of the external oblique muscle form the anterior layer of the rectus sheath. The rectus abdominis muscle is Accepted for publication September 1, 1970. Campbell, M. F.: Urology, 2nd ed. Philadelphia: W. B. Saunders Co., p. 19, 1963. 2 Pool, T. L. and Ferris, D. 0.: Treatment of ureteral calculi. S. Clin. North America, 25: 982, 1945. 3 Thorek, M.: Modern Surgical Technic, 2nd ed. Philadelphia: J. L. Lippincott Co., p. 2964, 1949. 4 Wins bury-White, H. P. and Fergusson, J. D.: Textbook of Genito-Urinary Surgery, 2nd ed. Baltimore: The Williams & Wilkins Co., p. 794, 1961. 5 Gibson, C. L.: The technic of operations on the lower portion of the ureter. Amer. J. Med. Sci., 139: 65, 1910. 1
separated in this area from the peritoneal by the transversalis fascia and the extraperitoneal fat (part A of figure). The surgeon stands at the side of the patient opposite the ureter which is to be exposed so that he may retract the peritoneal and its contents medially. The skin incision extends from the superior surface of the symphysis to the lateral edge of the rectus sheath at the level of the umbilicus and is deepened to the anterior rectus sheath (part B of figure). The anterior rectus sheath is incised in the same direction as the skin incision and the rectu.s abdominis muscle is exposed. It is important for maximum exposure that the lower end of the incision in the rectus sheath goes right down to the pubic bone. The lateral flap of the rectus sheath is separated and elevated from the lateral border of the rectus abdominis muscle and, beyond that, the extraperitoneal fat. \Ve have found it easier to use finger dissection and separation of the lateral flap at the lower end of the incision and gradually ,rnrk superiorly. The transversalis fascia is incised the length of the incision. The surgeon, beginning at the lower end of the incision, retracts the rectus abdominis muscle and the peritoneal medially from the lateral pelvic wall to expose the retroperitoneal contents of the pelvis (part C of figure). The inferior epigastric blood vessels and, in women, the round ligament are clamped, cut and tied. Although the ureter is often seen on the retracted posterior parietal peritoneum, it is easier to find as it passes anterior to the external iliac artery just distal to the bifurcation of the common iliac artery. It then may be followed to the bladder. Posterolateral to the ureter is the internal iliac artery, the origins of the branches of the internal iliac artery passing to the viscera and the obturator nerve and vessels. The external iliac artery descends along the lateral wall of tbe At the lower end of the incision the uterine blood vessels or the vas deferens passes anterior to the ureter and the vesical veins and nerves surround the ureter. In women the terminal ureter passes 647
648
HODGINS AND HANCOCK
skin
exfe:r. obl. muse. inter. o bL muse. frcmsv. abd.muse.
recius sheath
B
transversal is fascia Peritoneal Cavity
A, in lower abdomen, aponeuroses of 3 anterior abdominal muscles, as rectus sheath, pass anterior to rectus abdominis muscle. Rectus abdominis muscle is separated by transversalis fascia and extraperitoneal fat from peritoneal cavity. B, incision extends from upper surface of symphysis pubis, superiorly and slightly laterally to cross lateral margin of rectus sheath at level of umbilicus. C, lateral edge of incision in rectus sheath is reflected laterally. Surgeon's hand retracts rectus abdominis muscle and peritoneal cavity and its contents medially to expose retroperitoneal contents of pelvis.
through the cardinal ligament and the base of the broad ligament. Closure of the incision is simple. A stab wound for drainage is made lateral to the incision. The peritoneal cavity and its contents and rectus abdominis muscle fall into place. A running suture of 0-zero chromic catgut approximates the edges of the rectus sheath. A few subcutaneous sutures are inserted and the skin is closed. There are several advantages to this approach. The only incision is in the anterior rectus sheath and this may be extended superiorly. Retrac-
tion of the rectus abdominis muscle and the peritoneal cavity medially gives good exposure to the pelvic ureter. The iliac vessels are controlled easily. The bladder may be exposed and opened with little difficulty. When the wound is closed the intact rectus abdominis muscle supports the suture line in the anterior rectus sheath. We have been impressed by the simplicity, good exposure and lack of complications with this approach.
501 Jenkins Building, Pittsburgh, Pennsylvania 15228 (T.E.H.)
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
AN APPROACH TO THE LOWER THIRD OF THE URETER T. E. HODGINS
R. A. HANCOCK
AND
From the Department of Surgery, University of Pittsburgh and Presbyterian University Hospital, Pittsburgh, Pennsylvania
We wish to describe an approach to the lower third of the ureter which, although referred to in the literature,1- 4 has not received the popularity it deserves. The common method of exposing the lower third of the ureter is Gibson's approach in which a curved incision is made in the lower quadrant of the abdomen, the aponeuroses of the external oblique and internal oblique muscles are incised in the same direction as the skin incision, the lateral border of the rectus abdominis muscle is identified and the peritoneal cavity and its contents are retracted medially and superiorly to expose the ureter. 5 The muscle fibers of the external oblique, internal oblique and transversus abdominis muscles run anteromedially, become aponeurotic and insert into the linea alba. Traditionally, the aponeurosis of the internal oblique muscle splits at the semi-lunar line into 2 laminae, one passing anterior to the rectus abdominis muscle to join with the aponeurosis of the external oblique muscle to form the anterior of the rectus sheath while the other passes posteriorly to the rectus abdominis muscle to join the aponeurosis of the transversus abdominis muscle to form the posterior layer of the rectus sheath. Usually at a point just below the umbilicus the aponeurotic fibers which form the posterior layer of the rectus sheath pass anterior to the rectus abdominis muscle and with the aponeurosis of the external oblique muscle form the anterior layer of the rectus sheath. The rectus abdominis muscle is Accepted for publication September 1, 1970. Campbell, M. F.: Urology, 2nd ed. Philadelphia: W. B. Saunders Co., p. 19, 1963. 2 Pool, T. L. and Ferris, D. 0.: Treatment of ureteral calculi. S. Clin. North America, 25: 982, 1945. 3 Thorek, M.: Modern Surgical Technic, 2nd ed. Philadelphia: J. L. Lippincott Co., p. 2964, 1949. 4 Wins bury-White, H. P. and Fergusson, J. D.: Textbook of Genito-Urinary Surgery, 2nd ed. Baltimore: The Williams & Wilkins Co., p. 794, 1961. 5 Gibson, C. L.: The technic of operations on the lower portion of the ureter. Amer. J. Med. Sci., 139: 65, 1910. 1
separated in this area from the peritoneal by the transversalis fascia and the extraperitoneal fat (part A of figure). The surgeon stands at the side of the patient opposite the ureter which is to be exposed so that he may retract the peritoneal and its contents medially. The skin incision extends from the superior surface of the symphysis to the lateral edge of the rectus sheath at the level of the umbilicus and is deepened to the anterior rectus sheath (part B of figure). The anterior rectus sheath is incised in the same direction as the skin incision and the rectu.s abdominis muscle is exposed. It is important for maximum exposure that the lower end of the incision in the rectus sheath goes right down to the pubic bone. The lateral flap of the rectus sheath is separated and elevated from the lateral border of the rectus abdominis muscle and, beyond that, the extraperitoneal fat. \Ve have found it easier to use finger dissection and separation of the lateral flap at the lower end of the incision and gradually ,rnrk superiorly. The transversalis fascia is incised the length of the incision. The surgeon, beginning at the lower end of the incision, retracts the rectus abdominis muscle and the peritoneal medially from the lateral pelvic wall to expose the retroperitoneal contents of the pelvis (part C of figure). The inferior epigastric blood vessels and, in women, the round ligament are clamped, cut and tied. Although the ureter is often seen on the retracted posterior parietal peritoneum, it is easier to find as it passes anterior to the external iliac artery just distal to the bifurcation of the common iliac artery. It then may be followed to the bladder. Posterolateral to the ureter is the internal iliac artery, the origins of the branches of the internal iliac artery passing to the viscera and the obturator nerve and vessels. The external iliac artery descends along the lateral wall of tbe At the lower end of the incision the uterine blood vessels or the vas deferens passes anterior to the ureter and the vesical veins and nerves surround the ureter. In women the terminal ureter passes 647
648
HODGINS AND HANCOCK
skin
exfe:r. obl. muse. inter. o bL muse. frcmsv. abd.muse.
recius sheath
B
transversal is fascia Peritoneal Cavity
A, in lower abdomen, aponeuroses of 3 anterior abdominal muscles, as rectus sheath, pass anterior to rectus abdominis muscle. Rectus abdominis muscle is separated by transversalis fascia and extraperitoneal fat from peritoneal cavity. B, incision extends from upper surface of symphysis pubis, superiorly and slightly laterally to cross lateral margin of rectus sheath at level of umbilicus. C, lateral edge of incision in rectus sheath is reflected laterally. Surgeon's hand retracts rectus abdominis muscle and peritoneal cavity and its contents medially to expose retroperitoneal contents of pelvis.
through the cardinal ligament and the base of the broad ligament. Closure of the incision is simple. A stab wound for drainage is made lateral to the incision. The peritoneal cavity and its contents and rectus abdominis muscle fall into place. A running suture of 0-zero chromic catgut approximates the edges of the rectus sheath. A few subcutaneous sutures are inserted and the skin is closed. There are several advantages to this approach. The only incision is in the anterior rectus sheath and this may be extended superiorly. Retrac-
tion of the rectus abdominis muscle and the peritoneal cavity medially gives good exposure to the pelvic ureter. The iliac vessels are controlled easily. The bladder may be exposed and opened with little difficulty. When the wound is closed the intact rectus abdominis muscle supports the suture line in the anterior rectus sheath. We have been impressed by the simplicity, good exposure and lack of complications with this approach.
501 Jenkins Building, Pittsburgh, Pennsylvania 15228 (T.E.H.)