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Avoidance of ureteral injury by routine palpation during total hysterectomy
AVOIDANCE OF URETERAL INJURY BY ROUTINE PALPATION DURING TOTAL HYSTERECTOMY JOHN C.
BURCH, M.D. AND HORACE T.
LAVELY, M.D.
Nashville, Tennessee
T
HE danger of uretera injury is ever present in major peIvic surgery and with a greater trend to tota hysterectomy there wilI be a proportionate increase in the number of damaged ureters. Many surgeons have advocated preoperative catheterization of the ureters as an aid to its paIpation and to facihtate its exposure. In the course of our work we have graduaIIy evoIved a simpIe method of palpating the ureter which is so uniformIy satisfactory that it largely eIiminates the danger of uretera injury. In the performance of tota hysterectomy the ureter is paIpated just before the uterine artery is Iigated. The uterus is drawn to the opposite side by rather firm traction with the object of tensing the uterosacral Iigament. The index Iinger is pIaced on the tense uterosacra1 Iigament and is then sIid out IateraIIy aIong the Iigament to the side waI1 of the peIvis. The ligament stands out rather sharpIy and has a fairIy dehnite caudad and cephaIad surface. The thumb is then pIaced opposite the index Iinger in the raw, deperitonealized, anterior surface of the Iigament. The two
June,
1950
Iingers are opposed and drawn toward cervix using the caudad surface of
the the
uterosacra1 Iigament as a guide. As the Iingers pass over the ureter it is clearly feIt and jumps
just
as does the
vas deferens
when paIpated in the scrotum. The ureter may be found anywhere from I to 4 cm. IateraI to the cervix. In dividing the uterine artery it is advisable to carry the incision through the cervica1 fascia for about I cm. or more anterior and posterior to the artery. This aIIows the Iigated artery to drop away from the cervix and faciIitates the placing of a11 subsequent cIamps media1 to the Iigated uterine artery. As is we11 known, this is vaIuabIe in preventing uretera damage. Palpation of the ureter can aIso be very heIpfu1 during the reperitoneaIization of the peIvis. The ureter often Iies very cIose to the cut edge of the posterior peritonea1 leaf. Unless care is taken to determine its position, it may be caught with a cIosing stitch. This method is now routineIy used by the authors and we believe it has been vaIuabIe in preventing uretera injury.
819
BURCH, M.D. AND HORACE T.
LAVELY, M.D.
Nashville, Tennessee
T
HE danger of uretera injury is ever present in major peIvic surgery and with a greater trend to tota hysterectomy there wilI be a proportionate increase in the number of damaged ureters. Many surgeons have advocated preoperative catheterization of the ureters as an aid to its paIpation and to facihtate its exposure. In the course of our work we have graduaIIy evoIved a simpIe method of palpating the ureter which is so uniformIy satisfactory that it largely eIiminates the danger of uretera injury. In the performance of tota hysterectomy the ureter is paIpated just before the uterine artery is Iigated. The uterus is drawn to the opposite side by rather firm traction with the object of tensing the uterosacral Iigament. The index Iinger is pIaced on the tense uterosacra1 Iigament and is then sIid out IateraIIy aIong the Iigament to the side waI1 of the peIvis. The ligament stands out rather sharpIy and has a fairIy dehnite caudad and cephaIad surface. The thumb is then pIaced opposite the index Iinger in the raw, deperitonealized, anterior surface of the Iigament. The two
June,
1950
Iingers are opposed and drawn toward cervix using the caudad surface of
the the
uterosacra1 Iigament as a guide. As the Iingers pass over the ureter it is clearly feIt and jumps
just
as does the
vas deferens
when paIpated in the scrotum. The ureter may be found anywhere from I to 4 cm. IateraI to the cervix. In dividing the uterine artery it is advisable to carry the incision through the cervica1 fascia for about I cm. or more anterior and posterior to the artery. This aIIows the Iigated artery to drop away from the cervix and faciIitates the placing of a11 subsequent cIamps media1 to the Iigated uterine artery. As is we11 known, this is vaIuabIe in preventing uretera damage. Palpation of the ureter can aIso be very heIpfu1 during the reperitoneaIization of the peIvis. The ureter often Iies very cIose to the cut edge of the posterior peritonea1 leaf. Unless care is taken to determine its position, it may be caught with a cIosing stitch. This method is now routineIy used by the authors and we believe it has been vaIuabIe in preventing uretera injury.
819