Accepted Manuscript

Anatomic vascular considerations in uterine artery ligation at its origin during

laparoscopic hysterectomies
Ann Peters, MD MS, Mallory A. Stuparich, MD, Suketu M. Mansuria, MD, Ted T.M.
Lee, MD
PII:

S0002-9378(16)30313-1

DOI:

10.1016/j.ajog.2016.06.004

Reference:

YMOB 11141

To appear in:

American Journal of Obstetrics and Gynecology

Received Date: 25 February 2016

Revised Date:

23 May 2016

Accepted Date: 1 June 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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Anatomic vascular considerations in uterine artery ligation at its origin

during laparoscopic hysterectomies
Ann PETERS MD MS1, Mallory A. STUPARICH MD1*, Suketu M. MANSURIA

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MD1, Ted T.M. LEE MD1

Department of Obstetrics and Gynecology and Reproductive Sciences, Magee-

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Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA

*Corresponding author: Mallory A. Stuparich, MD Magee-Womens Hospital,

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University of Pittsburgh Medical Center, Division of Gynecologic Specialties,

Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology
and Reproductive Sciences

300 Halket Street, Pittsburgh, PA 15213.

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Email: stuparichma@upmc.edu

Work phone: 412-641-1440, Fax: 412-641-3447

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Conflict of Interest: T.T.L is a consultant for Ethicon Endosurgery. S.M.M. has

been providing educational services for Covidien since 2015. All other authors

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have no conflict of interest.

Funding or Disclaimer: None

Paper Presentation Information: The findings will be presented at the 42nd
Annual Society for Gynecologic Surgeons Scientific Meeting in Palm Springs, CA
on April 11th, 2016. Abstract number 2393057.
Word Count: Abstract: 134 words; Main Text: 647 words

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Short Title: Uterine artery ligation during laparoscopic hysterectomies

Condensation: Knowledge of anatomic uterine artery variations is necessary for

vascular

ligation

at

its

during

difficult

laparoscopic

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hysterectomies.

origin

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successful

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Key words:

Laparoscopic hysterectomy, medial umbilical ligament, uterine

artery ligation, uterine artery variations

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Abstract

Pelvic pathology such as fibroids, endometriosis, adhesions from previous pelvic

surgeries, or ovarian remnants can distort anatomy and pose technical

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challenges during laparoscopic hysterectomies. Retroperitoneal dissection to

ligate the uterine artery at its vascular origin can circumvent these obstacles,

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resulting in a safer procedure. However, detailed anatomic knowledge of the

course of the uterine artery and understanding of vascular variations are
essential for optimal dissection. Our video demonstrates a C-shaped uterine
artery variation encountered during retroperitoneal dissection. We describe the

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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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uterine artery configurations. These techniques allow for safe completion of

complex laparoscopic hysterectomies performed for various gynecologic

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diseases.

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Problem: uterine artery variations during laparoscopic ligation at its

vascular origin
During a hysterectomy, the uterine artery (UA) is traditionally ligated at the

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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

knowledge

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situations

of

the

retroperitoneum and uterine artery variations to ensure complete control of the

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uterine blood supply.

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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variation, which may complicate the vascular network encountered at the UA

origin, is a C-shaped configuration in which one UA arises from the anterior

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division in the traditional fashion while a second UA branch originates directly

from the IIA. Anticipation of these UA configurations allows the laparoscopic
surgeon to successfully approach UAL in the setting of distorted pelvic anatomy.

Our solution

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We present a video demonstrating ligation of the UA as it arises from the

IIA in a C-shaped configuration with two UA branches that proceed through the
retroperitoneum toward the uterine body (Figure 2). The surgeon may identify

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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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cardinal ligament. The paravesical space (PVS) is bounded posteriorly by the

cardinal ligament, medially by the bladder and ureter, and laterally 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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serves as an important landmark for dissection.

Pararectal Space Approach

Dissection begins with transection of the round ligament to access the

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retroperitoneum. The pelvic sidewall peritoneum is then incised parallel to the

infundibulopelvic ligament. Within the PRS, blunt dissection in the areolar tissue

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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).

Ligation of the UA and all potential

accessory vessels is crucial to optimize hemostasis.

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Medial Umbilical Ligament Approach

When the PRS is not accessible due to complex pelvic pathology
distorting the visualization or dissection of the ureter, then retroperitoneal
Again, the round

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dissection can proceed along the MUL through the PVS.

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

These dissection techniques reliably isolate the UA at its vascular origin

while identifying accessory branches and key anatomic landmarks (Figure 7).

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These strategies help the laparoscopic surgeon successfully complete complex

hysterectomies while minimizing blood loss, improving visualization, and

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preventing need for conversion to laparotomy.

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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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3. Gomez-Jorge J, Keyoung A, Levy EB, Spies JB. Uterine artery anatomy

relevant to uterine leiomyomata embolization. Cardiovasc Intervent Radiol

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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.

6. Holub Z, Jabor A, Lukac J, Kliment L, Urbanek A. Variability of the origin of

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the uterine artery: laparoscopic surgical observations. J Obstet Gynaecol Res

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2005;31(2):158-163.

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Figures

Figure 1: Illustration of the origin of the uterine artery

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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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MRA Middle rectal artery, IGA Inferior gluteal artery

Figure 2: Left C-shaped uterine artery configuration

The C-shaped uterine artery (UA) configuration (dashed white line) is

umbilical ligament

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skeletonized from its origin coursing towards the left uterine body. MUL Medial

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Figure 3: Pararectal approach: Caudal dissection along the left ureter

The left pararectal space is entered laterally to the ureter by locating the internal

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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

Figure 4: Pararectal approach: Skeletonization and ligation of the left

uterine 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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iliac vein; MUL Medial umbilical ligament

Figure 5: Medial umbilical ligament approach: Identification of the left

medial umbilical ligament

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Anterior-posterior blunt separation of adipose tissue in the left paravesical space

vein (EIV).

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identifies the medial umbilical ligament between the bladder and the external iliac

Figure 6: Medial umbilical ligament approach: Dissection along the left

medial umbilical ligament

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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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External iliac vein

Figure 7: Retroperitoneal dissection of a right C-shaped uterine artery

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configuration

Demonstration of the right uterine artery (UA) C-shaped configuration (green

dashed line) within the completely dissected pararectal (PRS) and paravesical
spaces (PVS) with key anatomic structures highlighted. SVA Superior vesical
artery, MUL Medial umbilical artery, IIA Internal iliac artery, EIV External iliac vein

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