21 Mullerian anomalies and operative considerations

Abstract

Our objectives are to review the embryology of the female reproductive tract, understand the development of Mullerian anomalies, and discuss important operative considerations in these patients through reviewing a series of cases. Mullerian anomalies or congenital uterine anomalies are common and can provide operative challenges for surgeons whether diagnosed preoperatively or newly encountered in the operating room. To better understand the formation of these congenital uterine anomalies, we first review the embryology and differentiation of the female reproductive tract. We then discuss the most common Mullerian anomalies and considerations for preoperative evaluation. We demonstrate and review operative considerations and techniques to consider through a series of cases with a septate, didelphys, and finally, unicornuate uterus with a rudimentary horn. In difficult surgical cases, we show the importance of utilizing a retroperitoneal approach and consideration of alternative uterine manipulators. In women with congenital uterine anomalies, surgeons should consider obtaining ultrasound and MRI preoperatively for characterization of the specific anomaly for surgical planning and to evaluate associated renal anomalies. Surgeons should consider a retroperitoneal approach to identify the ureter and ligate the uterine artery at its origin and use of alternative uterine manipulators to safely and effectively perform these procedures.