Opening the pelvic sidewall

Opening the pelvic sidewall

Counter-traction is applied via the round ligament pedicle to lift the pelvic peritoneum off the underlying sidewall structures. Using Russian’s forceps to grasp and the monopolar diathermy pencil for cutting and coagulation, the peritoneum is safely opened lateral and parallel to the infundibulo-pelvic (IP) ligament, advancing towards the pelvic brim.

Identifying the ureter

At the brim, anterior to the sacroiliac joint, the common iliac artery bifurcates into the external and internal iliac (hypogastric) arteries. Here, the ureter can be identified crossing the bifurcation, aided by medialising the IP ligament and using a Russian’s forcep to sweep the overlying areolar tissue laterally. By the third trimester of pregnancy, the structures of the renal tract are often dilated – a combination of hormonal effect and mechanical obstruction by the gravid uterus – with effects more pronounced on the right side. This degree of physiological hydroureter may aid with visualisation at caesarean.

Slinging the ureter

Once identified, the ureter is grasped gently with the Russian’s. A Lahey’s forcep is used for ureterolysis from medial (peritoneal) side, with vigilance to avoid tearing the small vessels running along the inferior border.

The tip of the Lahey’s are passed below the ureter, medial to lateral, and, with the help of the surgical assistant, a mounted vessel loop (yellow) is passed into the open jaws and the ureter is slung from underneath.

This will facilitate quick location of the ureter throughout the remainder of the surgery.

Video of slinging the ureter