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Lymphatic anatomy: lymphatics of the cervix
Published in Charles F. Levenback, Ate G.J. van der Zee, Robert L. Coleman, Clinical Lymphatic Mapping in Gynecologic Cancers, 2022
Anca Chelariu-Raicu, Katherine C. Kurnit
Anatomically, the cervix is defined as the region of the uterus from the isthmus to its vaginal termination. Depending on a woman’s age and on uterine and cervical factors, the size of the cervix varies with respect to the size of the corpus.1 In general, the cervix ranges from 2 to 4 cm in length in the nulligravid woman. It is connected to the vagina through an oblique fibrous attachment where approximately one-third of the anterior wall and approximately one-half of the posterior wall are exposed to the vagina (infravaginal cervix)2 (Figure 4.1). The vaginal portion, or exocervix, is convex. Centrally located within the exocervix is the external cervical os. The size of this opening to the uterus varies depending on a woman’s age and history of parturition. Proximal to the external os is the elliptical endocervical canal, which terminates at the internal cervical os. Here the cervix joins the uterine isthmus. Anteriorly and posteriorly, the supravaginal cervix is covered by the parietal peritoneum.
Radical vaginal trachelectomy
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
The cardinal ligament is composed of condensed fibrous tissue and some smooth muscle fibers. It extends from the lateral aspect of the uterine isthmus toward the pelvic wall. This fibrous sheath contains the ureter, the uterine vessels and associated nerves, the lymphatic channels and lymph nodes draining the cervix, and some fatty tissue. It is commonly referred to as the parametrium. The cardinal ligament is in continuity anteriorly to the uterovaginal endopelvic fascia, and posteriorly, fibers are integrated with the uterosacral ligament. Since VRT is performed in patients with small lesions, only the medial part (i.e., approximately 2 cm) of the cardinal ligaments is usually taken at the time of a VRT (Figure 11.3).
Vaginal Vault Prolapse: Treatment of Posterior IVS
Published in Victor Gomel, Bruno van Herendael, Female Genital Prolapse and Urinary Incontinence, 2007
A classical posterior colpotomy is performed taking care not to incise the perineum. The latter maneuver avoids excessive pain sensation with the patient. The deepest point of the incision reaches the uterine cervix. The recto-vaginal septum and the enterocele are dissected out. The two pararectal fossae are opened by the fingers and sharp dissection with scissors if needed. The landmarks on both sides are the ischial spines, the sacro-spinal ligaments and the muscle bundles of the levator ani muscles ileo- and pubococcygeus muscles). On the anterior side the uterine isthmus is exposed at the insertion of the sacro-uterine ligaments. This is a classical dissection and is carried out without valves. The complications are the same as in classical surgery: rectal injuries—especially in case of re-intervention—bleeding and secondary haematomas. The dissection therefore has to be very cautious and meticulous as it is the cornerstone of the future results of the repair of the rectocele by the prosthesis.
Isthmocele: When Surgery Is Both the Problem and the Solution
Published in Journal of Investigative Surgery, 2022
Antonio Simone Laganà, Simone Garzon, Ibrahim Alkatout, İsmet Hortu, Georgios Gitas, Salvatore Giovanni Vitale, Giampietro Gubbini
Isthmocele is defined as a pouch-like defect of the anterior uterine wall, at the level of the uterine isthmus, connected to the uterine cavity. One of the most important characteristics of the isthmocele is that it is usually an “iatrogenic” disease, being a possible consequence of cesarean section: the uterine isthmus heals without a proper restitutio ad integrum of the myometrial layers after hysterotomy of the anterior wall, and a fibrotic reaction leads to a locus of minor resistantiae. Consistently, the prevalence of isthmocele, defined for this reason also cesarean scar defect, increases with the number of previous cesarean sections. According to recent data [1], an isthmocele is present in approximately 60% of patients after a primary cesarean section and in 100% after 3 cesarean sections. Considering these elements, the worldwide reduction of cesarean deliveries recommended by the World Health Organization [2] may play a role to decrease the incidence of post-cesarean isthmocele.
Fertility-Sparing Surgery Using Knitted TiNi Mesh Implants and Sentinel Lymph Nodes: A 10-Year Experience
Published in Journal of Investigative Surgery, 2021
Alena Chernyshova, Larisa Kolomiets, Timofey Chekalkin, Vladimir Chernov, Ivan Sinilkin, Victor Gunther, Ekaterina Marchenko, Gulsharat Baigonakova, Ji Hoon Kang
Alongside an improvement in the technical aspects and surgical management of the primary tumor and adjacent tissues, the prevention of postoperative complications, reduction in surgical invasiveness and desired reproductive outcomes should come to the fore. It is to be noted that when suggesting sparing-surgery methods, a clear balance must be maintained between ensuring surgical radicality and achieving a functional/reproductive score, which can be the rationale to overall treatment success. A timely and unresolved issue at present is the need to strengthen the anastomosis area and maintain a retentive potential of the lower uterine segment for a subsequent pregnancy in the extremely short or resected cervix. The concerns typically encountered when considering uterine isthmus (isthmicocervical) insufficiency are related to the descent and prolapse of the amniotic sac, predisposing it to infection. In addition, the amniotic sac may protrude through the anastomotic area, leading to further widening with an increased risk of miscarriage.
Does Suture Material Affect Uterine Scar Healing After Cesarean Section? Results from a Randomized Controlled Trial
Published in Journal of Investigative Surgery, 2019
Alper Başbuğ, Ozan Doğan, Aşkı Ellibeş Kaya, Çiğdem Pulatoğlu, Mete Çağlar
Cesarean section (CS) is the most common type of obstetric surgery,1 with substantial increases in the number of CS deliveries in middle- and high-income countries in recent years.2 The rates of cesarean section vary by region, accounting for 3.3% of deliveries in Africa, 33.7% in Latin America, 27.3% in Asia, and 40.5% in China, with a global average of 15.9%.3 In Turkey, the rate of CS is considerably higher, at 53% of deliveries.4 When medically justified, CS can effectively prevent maternal and perinatal mortality and morbidity5,6; however, there are many short and long-term complications of CS, including effects on other surgical procedures, as well as on subsequent CS operations.7,8 One of the most common complications is the CS scar defect, which is noted more frequently with increasing CS operations. CS scar defects can develop after transverse incision of the lower uterine segment, which may result in prolonged postmenstrual bleeding, spotting, pelvic pain, and infertility. This pouch-like structure, first described by Morris in 1995, also called isthmocele, niche, or cesarean scar dehiscence, is located at the site of the old cesarean scar on the anterior uterine isthmus.9,10