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In Reply:
We appreciate Dr. Sheth's interest in our article and differ with his assertion that the new space1 was previously reported by him, vaginally,2,3 and by Sizzi et al,4,5 laparoscopically.
In his vaginal approach, Dr. Sheth enters an avascular plane lateral to the cervix, which he calls the “uterocervical broad ligament space.”2,3 He describes this small space as located immediately adjacent to the uterus, measuring approximately 2×1.5 cm in size. This is not the new space, which covers a significantly larger territory and is located laterally, traversing all the way to the pelvic sidewall, with visualization of this space aided by the laparoscopic view of the entire pelvis. Our dissection is much more lateral to the uterocervical border as compared with his vaginal approach. We start by ligating the round ligament close to the pelvic sidewall past the obliterated umbilical ligament and continue this plane medially into the vesicovaginal and vesicocervical space below the level of the bladder adhesions (see the Video, available online at https://www.youtube.com/watch?v=TQ34vX0ob2A). Pneumo-dissection facilitates access to the paravesical, vesicovaginal, and paravaginal spaces, developing the new space, far lateral to the uterocervical broad ligament space that Dr. Sheth has described previously. In contrast, Dr. Sheth's pictorial description shows transection of the round ligament close to the uterine body,6 completely different from our approach, thus not cited in our article.
As we stated in our article, this new space is bordered medially by the vesicocervical ligament, distally by the bladder, anteriorly by the remaining anterior leaf of the broad ligament, posteriorly by the parametrium where the ureter traverses toward the bladder, and laterally by the obliterated umbilical artery.1
Neither Sizzi et al4 nor Paparella et al5, which Dr. Sheth cites, address the technique of bladder dissection through the uterocervical broad ligament space. These articles mainly address the advantages of laparoscopy in patients in whom vaginal hysterectomy cannot be performed unless the laparoscope is used to remove the ovaries or perform lysis of adhesion. It is in fact Sinha et al7 who have accessed the uterocervical broad ligament space laparoscopically, and this is cited appropriately in our article.
The new space and dissection technique described in our report are different from previously reported spaces and methods. This approach affords surgeons more options when identifying an avascular, untouched space to approach the bladder flap in women with severe adhesions.
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