Stepwise laparoscopic uterine artery ligation using pararectal and paravesical retroperitoneal approaches

UNLABELLED: Mastering the paravesical and pararectal spaces facilitates the vascular control within the pelvis. A single method or a combination of surgical techniques, pararectal or paravesical approach, can be employed depending on the characteristics of the patient Objective: This surgical video aims to provide an anatomy-based educational demonstration of different laparoscopic uterine artery ligation techniques. SETTING: A tertiary academic hospital dedicated to women's health, training, and research. PARTICIPANTS: Three patients with endometrial cancer and no significant anatomical distortion who underwent laparoscopic hysterectomy with retroperitoneal pelvic and/or para-aortic lymph node dissection were included. In each patient, the demonstrated approach was an integral part of the planned surgical procedure. All surgical recordings were retrospectively reviewed. INTERVENTIONS: Uterine artery ligation can provide prophylactic vascular control in patients with uterine pathology, such as myomas, large uterine masses, or tumors, and may reduce blood loss during pelvic hemorrhage. Laparoscopic uterine artery ligation can be performed through the medial pararectal, lateral pararectal, or paravesical approach. After entering the retroperitoneum, accurate identification of the key anatomical landmarks is essential. Particular attention should be paid to identifying and protecting the ureter to prevent mechanical or thermal injury. The lateral pararectal approach is recommended when direct proximal control of the uterine artery at its origin is required, particularly in patients with a large or hypervascular uterus, cervical or broad-ligament myomas, or when substantial blood loss is anticipated. The medial pararectal approach may be useful when ureterolysis is required and the course of the ureter must be clearly defined, such as in cases involving ureteral displacement by a cervical or parametrial mass. The paravesical approach may be preferred when the obliterated umbilical artery is clearly identifiable, when the paravesical space has already been developed during oncologic surgery, or when posterior adhesions or endometriosis make pararectal access difficult. Ligation of the umbilico-uterine trunk should be reserved as an alternative approach when selective isolation of the uterine artery is unsafe or rapid vascular control is required, because this maneuver also sacrifices the superior vesical artery. CONCLUSION: Mastery of the paravesical and pararectal spaces facilitates safe vascular control within the pelvis. The approach should be selected according to the accessibility of the relevant retroperitoneal spaces, the course of the ureter, the location of the pelvic pathology, and the need for rapid or proximal vascular control.