Assessment of the parametrium and ureteric tunnelling
Extensive invasion into the right broad ligament and pelvic sidewall
Antenatal scanning may have raised the suspicion of invasion of the placenta or neo-vasculature laterally into the broad ligaments and/or parametria.
* It is vital that the clinician undertaking the reporting of the antenatal imaging understands the importance of reporting on this aspect.
If confirmed intra-operatively, further ureterolysis may be necessary to safely isolate the distal ureter from this highly vascular tissue and safely undertake parametrectomy as indicated for haemostasis.
This step is akin to that performed in a radical type 2/3 hysterectomy. The assistant firstly applies gentle traction via the ureteric sling, aiding identification of its course. The surgeon then uses Russian forceps to gently grasp the ureter, before tunnelling along the superior ureteric border with a Lahey’s.
In SAC, we use either the Ligasure Impact device (Medtronic, UK) or Bipolar scissors (Ethicon, UK) to carefully and systematically dissect the surrounding tissues, whilst also securing the distal uterine pedicles.