Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

1 0 6 2 S E C T I O N X I I I • A M P U T A T I O N S

Posterior laterally, the tensor fasciae latae muscle is incised below the anterior aspect of the gluteus maximus. This muscle is divided at its insertion to the gluteal tuberosity. The gluteus medius and minimus, piriformis, gemellus, and obturator externus muscles are divided near their insertion to the greater trochanter. The capsule of the hip joint is opened to expose the neck and head of the femur (see Figure 96-5).

The sciatic nerve is transected high, just below the piriformis muscle, and allowed to retract beneath this muscle (Figure 96-6). The insertions of the obturator internus and quadratus femoris to the greater trochanter are divided. The origins of the hamstring muscles are divided off the ischial tuberosity: semimembranosus, semitendinosus, and long head of the biceps. The extremity can be removed once the ligamentum capitis femoris is divided between the head of the femur and the acetabulum (Figure 96-7).

The wound is irrigated and a suction drainage catheter is positioned in the resection bed.

C H A P T E R 96 • Hip Disarticulation 1065

STEP 4: POSTOPERATIVE CARE

After the closed-suction drain and sutures are removed, the patient should be fitted for a prosthetic limb and referred to physical therapy for early ambulation.

STEP 5: PEARLS AND PITFALLS

When possible, all muscles are transected at their origin or insertion to minimize blood loss. Viable muscles are used to cover the exposed acetabulum. Phantom limb pain may be managed in conjunction with experts in pain management and rehabilitation medicine.

SELECTED REFERENCES

1. Boyd HB: Anatomic disarticulation of the hip. Surg Gynecol Obstet 1947;84:346-349. 2. Slocum DB: An Atlas of Amputations. St. Louis, Mosby, 1949.

3. Sugarbaker PH, Nicholson TH: Atlas of Extremity Sarcoma Surgery. Philadelphia, JB Lippincott Company, 1984.

C H A P T E R 97

ABDOMINAL HYSTERECTOMY

Concepcion Diaz-Arrastia

STEP 1: SURGICAL ANATOMY

Figures 97-1 and 97-2 demonstrate the anatomy of the female pelvis as it pertains to gynecologic surgery.

The bladder is attached to the anterior lower uterine segment and cervix at the anterior reflection of the visceral peritoneum.

The uterine arteries insert into the uterus laterally at the level of the internal cervical os.

The ureters cross over the bifurcation common iliac arteries and are found inferior to the infundibulopelvic ligament on the medial leaf of the broad ligament. As the ureter continues on its course to the bladder, it passes under the uterine artery 1 to 2 cm lateral to the insertion of the uterine artery at the level of the internal cervical os (see Figure 97-1).

Figure 97-2 demonstrates the key ligaments of the uterus.

The infundibulopelvic ligament carries the blood supply to the ovaries.

The utero-ovarian ligament attaches the uterus to the adnexal structures, fallopian tubes, and ovaries.

Round ligaments are insubstantial anterior lateral attachments of the uterine fundus that help maintain the normal uterine position.

Cardinal ligaments attach the entire length of the cervix to the pelvic sidewall. These sturdy ligaments supply most of the uterine support.

Uterosacral ligaments attach the cervix to the sacrum.

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