A guide to laparoscopically restoring anatomy in the ventrofixed uterus

Articles in the Tips and Techniques section are personal views from experts in their field on how to carry out procedures in obstetrics and gynaecology. Adhesions are the formation of connective tissue between anatomical structures and are the result of abnormal tissue healing. They can range from thin flimsy tissue to thick fibrotic bands containing blood vessels and nerves.1 Post-surgery, this finding is common with some studies reporting the complication occurring in 60–90% of patients following gynaecological surgery.2, 3 Adhesions can be associated with complications such as pain, bowel obstruction and fertility issues.2 When dense adhesions occur between the uterus and anterior abdominal wall, the uterus becomes adherent in a ventrofixed position. Significantly, a ventrofixed uterus is associated with caesarean birth and the rates have progressively increased; NHS England Maternity services reported 43% of babies in the United Kingdom in January 2024 were delivered by caesarean section.4 This trend is echoed internationally with WHO reporting global caesarean rates of 21% in 2021 compared to 7% in 1990 and the rate is predicted to continue rising.5 Adhesiolysis may be necessary to manage the associated symptoms of these adhesions. Furthermore, this finding may be discovered at surgery for other indications, such as laparoscopic hysterectomy where the bladder must be mobilised to enable colpotomy or in urogynaecology surgery where access to the prevesical space is necessary for incontinence procedures. Identifying safe planes of dissection between tissue layers can be difficult and therefore presents a significant surgical challenge of how to restore the normal anatomy of the uterus without causing injury to surrounding structures such as the bladder. With increasing caesarean section rates, the prevalence of this problem is likely to increase. This article aims to provide a structured anatomical approach to restoring anatomy when surgeons are faced with this problem. The uterus most commonly sits in an anteverted and anteflexed position. A retroverted uterus is a normal variant found in approximately 15–20% of patients.6 Anterior to the uterus is the bladder and the uterovesical pouch. The uterus should be mobile with no anterior attachments. In a ventrofixed uterus, dense adhesions form at the site of previous surgery between the anterior abdominal wall and the anterior surface of the uterus. This results in obliteration of the uterovesical space and the bladder cannot be seen. The degree of adhesions can vary between cases; in others, the fallopian tubes and ovary may also be adherent (Figure 1). A ventrofixed uterus may be suspected at clinical examination when the cervix is high or not palpable.7 Ultrasound imaging and MRI can confirm the diagnosis and aid surgical planning by delineating the proximity of the bladder and how high the fundus is. Despite the increasing incidence of this finding, there is limited discussion in the literature about how to surgically manage a ventrofixed uterus laparoscopically. The female pelvis is divided into potential spaces by folds of peritoneum. These spaces are useful anatomical landmarks in surgery. Furthermore, they are devoid of vessels and nerves and contain loose areolar tissue, which therefore provides safe areas of dissection, allowing access to pelvic organs and vessels in both benign gynaecology and oncology surgery.8 Understanding these spaces is the first step to all pelvic surgery and in approaching the ventrofixed uterus. The retroperitoneal spaces of the female pelvis include the following: The most significant spaces to consider in approaching the ventrofixed uterus are the vesicouterine pouch and the paravesical spaces (Figure 2). The fold of peritoneum over the bladder and uterus forms the vesicouterine pouch. This area is commonly divided at caesarean section to allow mobilisation of the bladder inferiorly and away from the lower segment of the uterus. Adhesion formation post-operatively obliterates this space in the ventrofixed uterus. This finding can also be seen in endometriosis. The adhesions can make it difficult to distinguish the bladder edge; therefore, a bladder injury can occur. Approaching the uterus laterally and opening the paravesical spaces can help to avoid this complication. The paravesical space is bordered medially by the bladder, laterally by the pelvic side wall and is separated from the pararectal space inferiorly by the uterine artery. It can be further divided into the medial and lateral paravesical spaces by the obliterated umbilical artery. The theatre is set up as for standard laparoscopy. The patient is positioned in the lithotomy position, cleaned and draped and a catheter is inserted. A vaginal examination should be performed to assess the position of the uterine fundus to aid planning of port placement. As the uterus is being pulled cranially, a supra umbilical port may provide a better view than an umbilical port. This decision should be made by considering the preoperative imaging and where the fundus of the uterus is felt in relation to the umbilicus at vaginal examination. Insertion of a uterine manipulator and attempts to retrovert may also cause dimpling of the anterior abdominal wall and this can be used as a marker and the primary port is inserted 3–4 cm above this point. A pneumoperitoneum is established, and the primary port is inserted. Two accessory ports are inserted in the right and left iliac fossa. A 360-degree check is done. In some cases, the view of the uterus may be obscured by omental or bowel adhesions. These adhesions may need to be divided before proceeding to the next step to enable a clear view (Figure 3). The round ligament is identified on one side (Figure 4). This is then used as a landmark, and the adhesions medial to this are divided below the rectus sheath using an energy device of the surgeon's choice. As the space is opened, the carbon dioxide gas enters the space helping to show the plane of dissection. Traction and counter traction along with the use of the energy device in more dense areas are used to open the space whilst the integrity of the round ligament is maintained. The aim of this step is to restore the anatomy of the round ligament and enable access to the paravesical space, which is entered in the next step. In this step, the medial paravesical space is opened. The paravesical space is covered by the peritoneum of the anterior leaf of the broad ligament; therefore, by dividing this, the space is accessed (Figure 5). The space is further developed utilising blunt dissection by using two blunt instruments to provide traction and counter traction in opposite directions against the tissue (caudal and cranial as well as medial and lateral motion). As this space opens, the obliterated umbilical artery will be visible, which forms the border between the medial and lateral paravesical spaces. Dissection into the lateral paravesical space is not required and risks injury to the obturator neurovascular bundle. The bladder forms the medial border of this space, and caution needs to be taken with identifying the bladder edge. If it is difficult to define this border, then the bladder can be filled with methylene blue dye to help delineate the edges. The area needs to be divided until the bladder or isthmic cervical junction is seen. The uterine artery and its ascending branch will become visible. Dissection is limited to avoid injury to the bladder, ureter and uterine vessels, and as the space is filled with loose areolar tissue, blunt dissection should be sufficient and the use of energy should be minimal to avoid thermal injury to the bladder. Dissection does not need to be too deep, and identification of the bladder pillars is sufficient. The same process is repeated on the contralateral side enabling the round ligament anatomy to be restored and the opening of the paravesical space on the opposite side. The end result is that the bladder edge on both sides is now defined leaving the central band of adhesions more clearly defined. The dense band of adhesions at the centre is usually very fibrotic and can be vascular. They are divided gradually layer by layer using an energy device to enable haemostasis (Figure 6). The plane between the adhesions and myometrium can be difficult to define, and surgeons should aim to stay close to the uterus but avoid going too deep into the myometrium, which will cause more bleeding. Dissection is carried out ventral to the bladder to enter the uterovesical space. Once the uterus becomes more mobile, retroflexion will be possible, and this enables the tissue to be put on tension and opens up the plane to guide adhesiolysis. The adhesions are divided in small sections, and as the uterovesical space approaches again, awareness of the proximity of the bladder is of paramount importance. The bladder can be identified by the presence of fatty tissue, as the dictum states ‘fat belongs to the bladder’. The fatty tissue can be pushed away caudally with blunt dissection. Again, the use of bladder filling with methylene blue or saline can be useful. If not done in the previous steps, then at this stage, the bladder is filled with saline or methylene blue to identify any potential injury, which can then be immediately repaired. The uterus should now be free of the anterior abdominal wall and lay in its more natural position. If uterus preserving surgery is being performed, then any myometrial defect should be sutured in a similar fashion to closure at laparoscopic myomectomy to approximate the tissues' edges and control bleeding. Most commonly, a barbed continuous suture is used to reduce operative time. If a hysterectomy is to be performed, this step is not required. Finally, a haemostatic antiadhesion agent can also be applied at the site of adhesiolysis prior to closure (Figure 7). Adhesions are a well-known post-operative complication posing a significant disease burden. Mechanisms to reduce adhesion formation have been researched, but preventing them remains a challenge. Minimising tissue damage by meticulous surgical technique controlling bleeding and preventing infection are required to avoid adhesions.9 Where possible, a minimal access approach should be used; however, when caesarean birth is necessary, this is not an option. The evidence on preventing adhesions specifically at caesarean birth is limited. One may hypothesise that closure of the uterovesical peritoneum to restore anatomy may help prevent adhesions between the uterus and a bladder; however, evidence of this is limited. NICE currently advises against closure of the visceral and parietal peritoneum,10 but this has not been updated since 2004. Similarly, a Cochrane review on short- and long-term outcomes of peritoneal closure versus non-closure included only four studies that assessed post-operative adhesion formation (n = 282). This concluded the evidence was limited and inconsistent recommending that the additional surgical time required for closure was not justified based on current evidence.11 There are a number of different antiadhesion barriers available on the market, and their use was explored by Arif-Adib et al. (2019) in the The Obstetrician and Gynaecologist publication ‘Preventing adhesions in laparoscopic surgery: the role of anti-adhesion agents’.9 Furthermore, the 2020 Cochrane review ‘Fluid and pharmacological agents for adhesion prevention after gynaecological surgery’ included 32 randomised controlled trials (n = 3492) and considered the use of hydroflotation agents, gel agents and steroids.12 It concluded that gel and hydroflotation agents appear to be effective adhesion prevention agents. However, as this did not translate to improved fertility outcomes or pelvic pain, the authors recommended further research is required. With increasing caesarean section rates, a ventrofixed uterus is likely to be an increasing problem gynaecologist will face. Understanding the surgical problem and anatomical spaces is necessary to tackling this challenge. We describe a systematic approach (Figure 8) to enable safe dissection and restoration of anatomy to help guide gynaecologist. This can provide a solution for patient's symptoms associated with the adhesions or enable surgeons to continue with further procedures such as a hysterectomy. Further consideration needs to be taken on techniques for prevention of adhesion formation at primary surgery and how to prevent recurrence after adhesiolysis. GKK instigated and wrote this article. KR edited and supervised. All authors approved the final version including the Video S1. Neither author has a disclosure of interest to declare. Video S1. Stepwise approach to restoring anatomy in the ventrofixed uterus. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.