Role of Laparoscopic Uterine Artery Clipping in Refractory Abnormal Uterine Bleeding Related to Benign Causes

laparoscopic uterine artery ligation in cases of irregular uterine bleeding due to benign causes .The patient is placed in low lithotomy position using Allen stirrups. After establishment of pneumoperitoneum and introduction of the first optic trocar through the umbilicus , the patient is put in Trendelenburg position of approximately 25 degrees. Maximal intrabdominal pressure is set to 12–13 mmHg. Two ancillary 5-mm trocars are inserted in each iliac fossa under direct vision lateral to the inferior epigastric vessels and one ancillary 10–12 mm trocar is inserted in the suprapubic area. Scissors, bipolar overhold. A uterine manipulator will be introduced, and laparoscopy will be performed using a 10-mm 0-degree laparoscope inserted using the open technique through an umbilical incision to primary port. Using monopolar diathermy (90 W cutting current and 60 W coagulation) with micro scissors and graspers, the peritoneum of the anterior leaf of the right broad ligament, between the round ligament and the infundibulopelvic ligament, will be incised. Ask the assistant to pull the infudibulopelvic ligament medially in more cephalic position to open the space. Extend the incision cephalic till the level of sacral promontory (the bifurcation of two common iliac arteries). Then gentle sweeping between external iliac artery towards the infundibulopelvic ligament to expose the ureter. the ureter which is the first key once seen, by gentle sweeping technique open the lateral pararectal space (dissection parallel to the ureter by one grasper and medialization of ureter by the other). Once the lateral pararectal space is opened, you will be able to see the internal iliac artery, just follow the direction and dissect over the obliterated umbilical artery which is the second key. Then grasp the obliterated umbilical artery and pull it up while asking the assistant to keep the space opened. This pulling technique will allow to see the vascular tree of the pelvis with clear vision of the uterine artery which is the first branch of anterior division of internal iliac artery which cross the lateral pararectal space from lateral to medial crossing above the ureter (water under bridge) and take care there may be a branch from the internal iliac cross the space also but passing to the ureter not above which is the ureteric branch. As the uterine artery still covered by fascia and for more safe clipping, dissect the medial Para vesical space above the uterine artery .so, you can clearly see the uterine artery which is the border between lateral pararectal and medial Para vesical space. You can now grasp uterine artery itself, dissect the artery from fascia below to avoid injury of the deep uterine vein, uterine artery will be isolated and permanently occluded with Liga clips Yasargil vascular clips and then coagulated. The procedure will be then repeated on the left side. The investigator is the surgeon . It will be done once in the setting The procedure will be done in the minimally invasive unit in department of Obstetrics and Gynecology. The approximate duration of the procedure is 45 - 55 minutes . counseling of patient about the details of procedure and postoperative follow up