Securing the round ligament
The round ligaments extend from the anterior uterine fundus to the pelvic retroperitoneum, running lateral to the inferior epigastric vessels and passing into the inguinal canal. Securing the round ligament facilitates opening of the pelvic side wall, fundamental to safe PAS hysterectomy.
Each round ligament is identified and a Robert’s artery forcep applied across the full thickness. A second forcep is placed parallel and lateral to the first. The Robert’s are held by the surgical assistant, whilst the surgeon secures the round ligament using either Bipolar scissors or the Ligasure Impact device (Medtronic, UK).
The free ends of the divided round ligament are then tied using a mounted 2-0 Vicryl suture (Ethicon, UK) for additional haemostatic security given the potential for increased vascularity and round ligaments varices (RLV) in pregnancy. The suture of the lateral pedicle is left long and clipped, available for counter-traction in the next stage of surgery.