Posterior Approach for Uterine Artery Ligation

Increasing rate of cesarean sections, endometriosis and other operative interventions has led to significant challenges in performing total laparoscopic hysterectomy (TLH) due to obscured anatomy; extensive and dense uterine adhesions to the bladder and anterior abdominal wall. This chapter describes the “Posterior Approach” as an anatomically guided strategy to address such challenges while doing total laparoscopic hysterectomy. This approach involves dissection of the posterior fold of the broad ligament followed by ligation of the uterine artery prior to developing a bladder flap, then tackling adhesions of the anterior cul-de-sac last. This enables better identification of anatomy and securing blood supply before dissecting adhesions. Thus, decreasing the risk of urinary tract injuries and blood loss. Additionally, the use of uterine manipulator or alternative retractors for delineation of structures is emphasized. Overall, the posterior approach, combined with appropriate surgical principles, offers a promising solution for navigating the complexities associated with total laparoscopic hysterectomy in patients with extensive uterine adhesions.