Dissecting to locate tumors

Tissue culture microscopy is used in diagnosing tumors. Tissue culture microscopy determines if the tissue sample is benign or malignant. Knowing the latest tissue culture microscopy techniques will greatly aid the physician to correctly diagnose the patient. In order to biopsy a tissue sample, the physician must first locate it. One way of locating these tumors is through dissection of the organs.

A critical step for locating tumors is the dissection of the bladder from the ante¬rior part of the cervix and vagina. Occasionally, tumor extension into the base of the blad¬der (which cannot be detected with cystoscopy) precludes adequate mobilization of the bladder flap, leading to the abandonment of the operation. Therefore, this portion of the operation should be undertaken early in the procedure.

Dissection of the Uterine Artery

The superior vesicle artery is dissected away from the cardinal ligament at a point near the uterine artery. The uterine artery, which usually arises from the superior vesicle artery, is thus isolated and divided and the vesicle arteries are preserved. The uterine vessels are then brought over the ureter by application of gentle traction. Occasionally, the uterine vein will pass under the ureter.

Dissection of the Ureter

Tbe ureter is dissected free from its medial peritoneal flap at the level of the uterosacral ligament. As the ureter passes near the uterine artery, there is a consistent branch from the uterine artery to the ureter. This branch is sacrificed in the stan¬dard radical (type III) hysterectomy but preserved in the modified radical (type II) hys¬terectomy.

Dissection of the ureter from the vesicouterine lIgament (ureteral tunnel) now may be ac-complished. If the patient has a deep pelvis, ligation of the uterosacral and cardinal ligaments may be undertaken first in order to bring the ureteral tunnel dissection closer to the operator.

The roof of the ureteral tunnel is the anterior vesicouterine ligament. It should be ligate, divided to expose the posterior ligament. This ligament is also divided in the radical (type III) hysterectomy but conserved in the modified radical (type II) hysterectomy.

Posterior Dissection

The peritoneum across the cul-de-sac is incised, exposing uterosacral ligaments. The rectum is rolled free from the uterosacral1igaments, and ligaments are divided midway to the sacrum in a radical (type III) hysterectomy and the rectum in the modified radical (type II) operation. This allows the operator to lift the cardinal ligament and separate it from the rectum. A surgical clamp is placed on the ligament at the lateral pelvic sidewall in a radical hysterectomy and at the level of the ureteral bed in the modified radical procedure. A clamp is placed on the specimen side to maintain traction and is left on to ensure that the full cardinal ligament is excised with the specimen. A right-angled clamp then is placed to this clamp across the paravaginal tissues. A second paravaginal clamp is usually needed to reach the vagina.

Vagina

The vagina is entered anteriorly, and the upper one-third of the vagina moved with the specimen that is then sent to the pathology department for biopsy using the latest tissue culture microscopy techniques. More vaginal epithelium can be excised if necessary, depending on the previous colposcopic findings. The vaginal edge may be sutured in a hemostatic fashion and left open with a drain from the pelvic space or closed with a suctiOI1 placed percutaneously. The ureteral fistula and pelvic lymphocyst rates from these two techniques are similar.