Total laparoscopic hysterectomy with posterior cul-de-sac obliteration: step-by-step procedures based on precise anatomical landmarks

Background Dense adhesion due to severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterates the cul-de-sac and distorts normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries, as well as voiding dysfunction. It is important to develop the retroperitoneal avascular space based on precise anatomical landmarks to minimize the risk of ureteral, rectal, and hypogastric nerve injuries. We herein report the anatomical highlights and standardized and reproducible surgical steps of total laparoscopic hysterectomy for posterior cul-de-sac obliteration. Operative technique We approach the patient with posterior cul-de-sac obliteration using the following five steps. Step 1: Preparation (Mobilization of the sigmoid colon and bladder separation from the uterus). Step 2: Development of the lateral pararectal space and identification of the ureter. Step 3: Isolation of the ureter. Step 4: Development of the medial pararectal space and separation of the hypogastric nerve plane. Step 5: Reopening of the pouch of Douglas.

Surgeons should recognize the importance of developing the retroperitoneal avascular space based on precise anatomical landmarks, and each surgical step must be reproducible. Similar content being viewed by others

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TI; manuscript writing/editing, assistant surgeon. MS; manuscript writing/editing. YS; manuscript writing/editing. Corresponding author Ethics declarations Conflict of interest The authors report no conflict of interest. Ethics approval Not applicable. This study was deemed not to fall under the “Ethical Guidelines for Life Sciences and Medical Research Involving Human Subjects” in Japan, and thus did not require institutional ethical review. Consent to participate Informed consent was obtained from the patient. The authors affirm that the patient provided informed consent for publication of the images in Figs. 1, 2, 3, 4 and Video. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Supplementary file1 Step-by-step procedures of total laparoscopic hysterectomy with posterior cul-de-sac obliteration (MP4 127301 KB) Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Tanaka, Y., Kuratsune, K., Otsuka, A. et al. Total laparoscopic hysterectomy with posterior cul-de-sac obliteration: step-by-step procedures based on precise anatomical landmarks. Arch Gynecol Obstet 310, 1795–1799 (2024). https://doi.org/10.1007/s00404-024-07614-y Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00404-024-07614-y