Plate 178
###### Figure 12

The surgeon then holds the uterus forward and makes certain that the rectum is not adherent to the upper portion of the vagina. Should the rectum be adherent to the vagina, it is sharply dissected free to avoid possible injury. This is a critical step if a total hysterectomy is to be performed. After the relative position of the ureters has been identified, a moist gauze sponge is loosely introduced into the pouch of Douglas to prevent any intestine from coming into the field of operation. The uterus is rotated slightly to the right in preparation for the application of a pair of straight Ochsner clamps (Figure 7). The straight Ochsner clamps are applied from the side at a 45-degree angle to the cervix to include a small bite of cervical tissue. The second clamp is similarly placed 1 to 2 cm above the first to ensure a good pedicle of tissue for double ligation. The Ochsner clamps should never be directed downward parallel to the cervix because of possible injury to the ureter. It is important to note in Figure 7A, how these clamps are applied at an angle to the cervix with a sliding motion, which pulls the uterine vessels into the clamp. Now the uterine vessels are divided with curved scissors (Figure 7). If the uterus is quite large, a half-length clamp may be affixed to the vessels higher up along its wall to prevent troublesome backbleeding as the uterine vessels are divided. The paracervical tissue is divided with scissors to a point just below the level of the lower Ochsner clamp to develop a free pedicle that can be tied easily (Figure 8). Failure to carry the incision beyond the tip of the distal clamp hinders accurate ligation of the uterine vessel pedicle, and troublesome bleeding results. A transfixing suture, a, of 0 absorbable suture is tied as the lower Ochsner clamp is slowly withdrawn, and a second similar suture, b, is taken toward the severed end of the pedicle (Figure 8). The development of an easily tied pedicle that includes the uterine artery is one of the most important steps in abdominal hysterectomy.

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