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INDICATIONS

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A total abdominal hysterectomy is most commonly performed for benign conditions of the uterus including leiomyoma, adenomyosis, endometriosis, pelvic inflammatory disease, and dysfunctional uterine bleeding. Other indications include malignancies of the cervix, uterus, and ovaries.

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POSITION

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OPERATIVE PREPARATION

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Routine vaginal and abdominal preparation is given. The patient is catheterized, and an indwelling Foley catheter, No. 16–18 French, is inserted with inflation of the balloon and then anchored to the inner thigh. If access to the vagina and or anus is required, then the patient should be places in the low lithotomy position.

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INCISION AND EXPOSURE

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DETAILS OF PROCEDURE

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Whenever conditions will permit, the uterus is retracted upward toward the umbilicus, exposing the anterior uterine surface and allowing incision of the peritoneum at the cervicovesical fold (figure 1). The surgeon should anticipate the course of the ureters. The round ligaments are ligated or incised with an electrosurgical unit (ESU) which enhances the surgeon’s ability to dissect the retroperitoneal tissue planes. The loose layer of peritoneum is picked up with atraumatic forceps and incised transversely with scissors, or the ESU, close to its attachment to the uterus (figure 2). If there are indications to remove the tubes and ovaries, the ovarian vessels are clamped proximal to the ovaries with a Heaney or curved Zeppelin clamp and doubly ligated with 2-0 delayed absorbable suture. Prior to applying the clamp the surgeon should insure that the ureter is out of the field of dissection. The ureters are identified along the medial leaf of the broad ligament to insure that they are out of the field of dissection. The adnexa is mobilized away from the pelvic sidewall structures (figure 3). If the adnexa are to be spared, the uterine-ovarian ligament is clamped and ligated (figure 3). The operator uses sharp dissection to open the cervicovesical space and to dissect the areolar tissue between the bladder and the lower uterine segment. Blunt dissection should be used.

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After the ovarian vessels have been ligated, the surgeon can palpate the region of the cervix with two fingers to determine its length and the position of the bladder. The bladder is sharply dissected off of the lower uterine segment and cervix (figure 4). It is advantageous to divide the tissue over the cervix with sharp dissection until a definite avascular cleavage plane is established. Blunt dissection should be used sparingly and only in the midline directly over the cervix, or troublesome bleeding will be induced from tearing vessels in the broad ligament. Sharp dissection will permit the bladder to be directed forward and downward until the operator’s thumb and index finger can compress the vaginal wall below the cervix (figure 5...

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