The uterus undergoes atrophy after menopause. In a very old woman, it may be of the size of one distal phalanx of the middle finger of a good sized hand, or one and a half times the size of that phalanx of an average sized hand. If one has to perform hysterectomy in such a case, as one has to if she has a genital prolapse, clamping the uterosacral-cardinal ligament complex, uterine vessels, and corneal structures separately would be a rather difficult task. It is also unnecessary. If the ureter and the bladder are retracted away quite well, a single clamp can be applied to the three structures on one side. They are then cut together, and a single transfixion ligature is applied around them. I prefer to put a safety ligature around them, as I do for all pedicles at all times. This maneuver saves time spent by the patient under anesthesia, the amount of suture material left inside the patient’s body, and reduces morbidity related to these two things. It also reduces the time the assistants have to spend standing in an uncomfortable position.
I had seen this being done when I was a house officer. I did it successfully in appropriate cases many times thereafter. When I assisted a new Assistant Professor performing vaginal hysterectomy in a case of procidentia, I guided him to do it this way.
“Um… I have never done it this way before” he said. He probably meant that perhaps it was not OK.
“Well, you have to learn something new once in a while. If you keep doing the same thing every time, your life will stagnate” I said.
He did it successfully.
“Don’t do it if I am not around” I said. I was afrain he might not select a case properly, or might not retract the bladder anterolaterally sufficiently to retract the ureter too, so that ureteric injury would not occur. After all, the ureter falls away only after the uterosacral ligament is clamped, cut, and ligated. That does not happen if all structures on one side are clamped together.
“No, Sir.”
I realized that there was no mention of this technique in any of the books in the market or libraries, any of the journals, and even on the net. I had forgotten to write about it in my own books too. So here it is now. One of my Assistant Professors is fond of Googling for education. He and others like him will now find a reference to this technique next time they Google.
