The Red Alert Zone in Pelvis for Radical Hysterectomy: The Precise Anatomy and Safe Surgical Technique

Abstract

Objective:

Radical hysterectomy/modified radical hysterectomy (RH/MRH) is one of the commonly performed pelvic surgeries. However, in most cases, bleeding is an obvious phenomenon in the zone below the uterine vessels. The current authors termed that zone in the pelvis the red alert zone. An anatomical exploration of this zone was conducted and the surgical approach was modified to learn if this would reduce the bleeding that occurs during RH/MRH.

Materials and Methods:

Two hundred and fifty-five RH/MRH operations were performed for carcinomas of the cervix, endometrium, and ovaries. The reasons for bleeding in the red alert zone were explored, and it was determined that most of the catastrophic bleeding events—such as those caused by ureteric, pelvic-nerve, and even bladder injuries—occurred inadvertently because of iatrogenic interventions by the surgeons. After the exploration, the authors modified their surgical approach for the last 105 cases. The new approach involved the following: After ligating the uterine artery and superficial uterine vein, the red alert zone of the pelvis was reached. The connective tissue of the vesicocervical ligament was divided before entering the ureteric tunnel. The ureter was freed from its attachment to the posterior leaf of the ligament. Vessels of the anterior leaf of the vesicocervical ligament were isolated, ligated, and divided. Middle and inferior vesical veins were identified, ligated, and divided in the posterior leaf of the vesicocervical ligament that was draining to the deep uterine vein. Deep cervical veins were approached similarly, safeguarding the pelvic splanchnic nerves below them.

Results:

The mean observed blood loss with the modified technique in the last 105 cases was 100 ± 50 mL, compared to 450 ± 100 mL in the cases operated on with the previous conventional technique.

Conclusions:

Anatomical knowledge is essential for reducing blood loss, as well as pelvic nerve, and ureter, and bladder injuries, during RH/MRH. (J GYNECOL SURG 36:194)