Introduction

Obliteration of the anterior cul-de-sac (OAC) refers to dense adhesive disease of the vesicouterine avascular space.1,2 OACs present significant operative challenges to gynecologists during robotic-assisted total laparoscopic hysterectomy (RATLH) due to the loss of surgical planes between the bladder serosa and lower uterine segment. Distorted anatomy increases the risk of intraoperative complications such as bladder injury and quantitative blood loss.3,4 With the prevalence of OACs becoming more frequent, this “Top 10 Facts” edition provides gynecologists and women’s health providers with an overview of OAC. The “Top 10 Facts” are categorized into common causes, diagnosis, surgical considerations, and key RATLH steps and principles for OACs.

Top 10 Facts

Common Causes of OAC

  1. OAC is most commonly due to a history of prior cesarean section (CS).3,4 Risk of anterior pelvic adhesions correlates with the number of prior cesarean deliveries (32% after one CS, 42% after two CS, and 59% after three CS.3 Advanced maternal age (≥35 years), obesity (BMI ≥30), and intrauterine infection further increase the incidence of pelvic adhesions following cesarean delivery.3

  2. Additional causes of OAC include history of myomectomy (abdominal > laparoscopic), history of adnexal surgery, endometriosis, prior pelvic infection (i.e., pelvic inflammatory disease), and presence of intraperitoneal blood.2,4–6 The inflammatory sequela of endometriosis and pelvic infections can also lead to severe scarring between the uterus and rectum, causing obliteration of the posterior cul-de-sac (OPC).7 Simultaneous occurrence of an OAC and OPC can limit the feasibility of performing a laparoscopic hysterectomy.

Diagnosis of OAC

  1. Patients with an OAC may or may not complain of chronic pelvic pain or discomfort. Symptoms can include dysmenorrhea, dyspareunia, dyschezia, and urinary frequency. Speculum exam may reveal an anteriorly and superiorly displaced cervix that is difficult to visualize. Bimanual exam may appreciate decreased uterine and adnexal mobility.

  2. Transvaginal ultrasound (TVUS) may show a “negative uterine sliding sign” or “uterine peaking” due to adhesions distorting the anterior uterine surface on sagittal view.8,9 Furthermore, there may be a notable difference between perceived uterine size on bimanual exam and the measured uterine length on TVUS. The estimated uterine bimanual size may appear greater than the measured uterine length on TVUS due to peritoneal adhesions pulling the uterus up above the pubic symphysis.

  3. OACs are ultimately diagnosed intraoperatively upon laparoscopic entry. As such, having a high suspicion for OAC based off pertinent history, physical exam, and imaging findings is key to proper preoperative patient counseling and surgical planning. It is critical for surgeons to have a reproducible approach to managing OACs as pelvic adhesions are routinely encountered, even in 10% of patients who have never had a CS.3

Hysterectomy Considerations with OAC

  1. OACs can impact the ability to place a uterine manipulator due to cervical distortion. As such, surgeons need to be comfortable performing a colpotomy without a cervical cup in the case that a uterine manipulator is unable to be placed. In addition, OACs are associated with increased risk of intraoperative complications such as visceral injury, quantitative blood loss, and increased operating time.3,4

  2. RATLH is the preferred approach over conventional laparoscopy for OACs.4 In fact, RATLH is steadily becoming the most common route of hysterectomy for benign indications across the United States. However, the utility of RATLH is limited by surgeon experience and advanced pathology.4 Laparotomy may be required for severe pelvic disease involving an OAC and OPC

Hysterectomy Approach to OAC

  1. Proper patient positioning and trocar placement are critical for safe and effective use of robotic technology. See Advincula and Reynolds for details on RATLH technical setup .4 RATLHs are commonly performed using a 3-arm approach (camera arm and 2 robotic arms) and 1 conventional assistant port. However, a 4-arm approach (camera arm and 3 robotic arms) can be used for cases with advanced pathology and adhesions. Trocar placement can be modified based on the Da Vinci operating system being used (i.e., Si, Xi), patient body habitus, and intrabdominal pathology.

  2. Systematic surgical steps to approaching RATLH with an OAC are listed in Table 1.4,10–13

  3. Surgical principles that can help guide RATLH with an OAC are listed in Table 2.4,10–13

Table 1.Surgical steps to completing a RATLH with an OAC.4,10–13
Step Description
1 Restore normal anatomy of the adnexa and posterior cul-de-sac prior to initiating the hysterectomy. Lyse avascular filmy adhesions connecting adnexal structures to viscera and pelvic sidewalls.
2 Identify the ureter traversing the pelvic brim and sidewall. Identify the round ligaments to help visualize uterine orientation and estimate bladder location.
3 Release the adnexal pedicle (infundibulopelvic ligament for salpingo-oophorectomy or utero-ovarian ligament for salpingectomy) and the round ligament.
4 Develop the anterior and posterior broad ligaments. Emphasis is placed on posterolateral dissection of the broad ligament to lateralize the ureter and avoid engaging bladder adhesions prior to cauterize the uterine pedicles.
5 Identify the endopelvic fascia along the colpotomy cup located anterior and medial to the uterine artery. Use blunt dissection (“push and spread” technique) and short bursts of electrosurgery to skeletonize the uterine artery from bladder adhesions. Coagulate the uterine pedicle with bipolar energy at this location.
6 Repeat steps 2-5 on the contralateral side.
7* Use blunt dissection to create a tunnel along the anterior endopelvic fascia between the cervix and bladder adhesions. Make a posterior colpotomy using monopolar energy and extend anteriorly in both directions. The cervix is now freed from the surrounding vaginal mucosa and the uterus is completely avascularized.
8* Dissect away abdominal peritoneal attachments followed by dissection of bladder adhesions from the lower uterine segment to complete the hysterectomy.

* Portions of Steps 7 and 8 are interchangeable. Moving back and forth between these two steps may be necessary to safely complete the hysterectomy.

Table 2.Surgical principles that help guide RATLH with an OAC4,10–13
Surgical Principles
Restore normal anatomy when possible.
Dissect tissue moving from known to unknown surgical planes.
Identify and develop safe surgical planes (i.e., vesico-vaginal, para-vesicle, and para-rectal spaces) that are free of pelvic adhesions.
Identify the location of the ureter when operating near the pelvic brim and sidewall.
Use “push and spread” and “tunnel and bridge” techniques to dissect obliterated and fibrotic tissue planes.
Maximize tissue tension (i.e., traction, countertraction) and tenting while limiting electrosurgical diathermy to protect underlying structures (i.e., ureters, bladder).
Skeletonize and ligate uterine vascular pedicles (i.e., uterine arteries, utero-ovarian arteries) prior to adhesiolysis of the OAC.
Cauterize tissue back bleeding to maximize visualization of the surgical field.
Consider ligating the uterine artery at its origin in the retroperitoneum if adhesive disease obliterates the lower uterine segment at the level of the colpotomy cup.
Backfilling the bladder with normal saline can help delineate bladder serosal edges from lower uterine segment adhesions and tissue.
A 30-degree laparoscopic scope can be used to improve visualization of surgical planes (especially during colpotomy and lysis of bladder and peritoneal adhesions).
A small amount of uterine tissue may remain attached to the bladder serosa following adhesiolysis of the OAC. This helps ensure that the bladder remains intact.

Conclusions

RATLH is a safe and effective approach to hysterectomy with OAC.4 Surgeon experience and advanced pelvic pathology are the limiting factors for completing RATLH cases with OAC.4 The above “Top 10 Facts” highlight the common causes, diagnostic process, surgical considerations, and key systematic steps and principles for RATLH with an OAC. Approaching OACs with the above reproducible steps can help gynecologists successfully perform a RATLH with an OAC.

Acknowledgements

None.

Disclaimer

Authors have nothing to disclose.