Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
2-36
2-36. TOTAL ABDOMINAL HYSTERECTOMY
a. General. This operation involves the opening of the abdomen and the peritoneal cavity, with removal of the entire uterus, including the corpus and the cervix. It is done in the presence of fibroids (myomas) of the uterus resulting in uncontrollable bleeding, degeneration, or in some cases, endometriosis or adenomyosis that is far advanced. Total hysterectomy is also indicated in older women with endometriosis when the bowel and bladder are involved and there is impairment of the normal function of the urinary and gastrointestinal tracts.
b. Preparation of the Patient. An internal and external vaginal prep precedes the skin prep. A Foley catheter is inserted to provide constant bladder drainage during the operation. The supine and high Trendelenburg positions are used.
c. Operative Procedure.
(1) As the skin is incised, the head and upper section of the operating table are lowered slowly, approximately 10º at a time. When the peritoneal cavity is opened, as described previously for laparotomy, the patient is in the desired position for pelvic surgery.
(2) In cases of obese patients or for exploration of the upper abdominal cavity, a left rectus or midline incision is made. For simple hysterectomy, a Pfannestiel incision may be used. The abdominal layers and the peritoneum are opened as for laparotomy.
(3) The round ligament is grasped with Allis-Adair forceps, clamped with curved Rochester-Pean hemostats, and ligated with medium silk or chromic gut sutures swaged to 1/2- circle, taper-point needles secured on long needle holders. Pedicles are cut with Metzenbaum scissors; sutures are tagged with a hemostat to be used as traction later. The procedure is done on both sides.
(4) The uterus is pulled upward, exposing the anterior surface of the uterus, and the peritoneum at the cervicovesical fold is incised.
(5) By use of the surgeon's fingers, the layer of the broad ligament close to the uterus is separated on each side; bleeding vessels are clamped and ligated. The fallopian tube and the utero-ovarian ligaments are doubly clamped together with Ochsner or Carmalt clamps or Heaney hemostats, cut with a knife, and tied doubly with suture ligatures.
(6) The uterus is pulled forward to expose the posterior sheath of the broad ligament that is incised with knife and Metzenbaum scissors. Ureters are identified. The uterine vessels and uterosacral ligaments are doubly clamped with Ochsner, Heaney, or Carmalt hemostats, divided with a knife at the level of the internal os, and doubly ligated with suture ligatures.
(7) The severed uterine vessels are bluntly dissected away from the cervix on each side with the aid of sponges on holders, scissors, and tissue forceps.
(8) The bladder is separated from the cervix and upper vagina with a knife or scissors and blunt dissection assisted by sponges on holders.
(9) The bladder is retracted with a laparotomy pack and a retractor with an angular blade. The vaginal vault is incised with a knife close to the cervix.
(10) The anterior lip of the cervix is grasped with an Allis or tenaculum forceps. With Metzenbaum scissors, the cervix is dissected and amputated from the vagina. As the vagina is opened, the anterior and posterior walls are approximated with Allis or Teale forceps. The uterus is removed. Potentially contaminated instruments used on the cervix and vagina are placed in a discard basin and removed from the field (including sponge forceps and suction). Bleeding is controlled with hemostats and sutures.
(11) The vaginal vault is reconstructed with chromic interrupted sutures. Angle sutures anchor all three connective tissue ligaments to the vaginal vault.
(12) Vaginal mucosa is approximated with a continuous chromic gut suture swaged to a 3/8-circle needle on a long needle holder. The muscular coat of the vagina is closed with figure-of-eight sutures to make the vault of the vagina firm and provide resistance against prolapse.
(13) The peritoneum is closed over the bladder, vaginal vault, and rectum. The laparotomy packs are removed, and the omentum is drawn over the bowel.
(14) The abdominal wound is closed in the regular way.
