Navigating the Obliterated Anterior Cul-De-Sac with a Novel Zavanelli of the Cervix

Abstract

<h3>Study Objective</h3> The objectives of this video include to review risk factors for the obliterated anterior cul-de-sac (OAC), discuss patient evaluation for an OAC including ultrasound imaging, and display surgical techniques for approaching an OAC. Surgical techniques include restoring normal anatomy, controlling the uterine vascular supply, beginning dissection posterolaterally, backfilling the bladder, starting the colpotomy posteriorly, and optimizing the surgeon's perspective with a novel Zavanelli maneuver of the cervix. <h3>Design</h3> N/A. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> The obliterated anterior cul-de-sac (OAC) is an obstacle that is becoming much more common in gynecologic surgery with the increasing rate of cesarean section (CS). When patients have risk factors like a history of CS, surgical planning requires a high level of suspicion for preparedness. This video reviews the thorough pre-operative patient evaluation, including ultrasound findings that could indicate an OAC. The video exhibits surgical techniques for navigating an obliterated anterior cul-de-sac, including the restoration of normal anatomy, uterine vascular control, posterolateral dissection, backfilling the bladder, posterior colpotomy and a novel Zavanelli maneuver of the cervix, in which the uterine manipulator is removed, and cervix lifted cranially to provide the surgeon with a new perspective for safe dissection.