A total abdominal hysterectomy is performed most commonly for benign conditions of the uterus, including leiomyoma, adenomyosis, endometriosis, pelvic inflammatory disease, and dysfunctional uterine bleeding. Other indications include neoplastic conditions of the cervix, uterus, and ovaries.
Routine vaginal and abdominal preparation is performed. Prophylactic antibiotics are administered within 30–60 minutes prior to incision. The patient is catheterized, and an indwelling Foley catheter (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 placed in the low lithotomy position. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
Whenever conditions 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, which cross over the common iliac artery at the level of the pelvic brim and then course along the medial leaf of the broad ligament, advancing below the uterine vessels and then coursing medially within the perivesical soft tissues as they insert into the bladder. The round ligaments are ligated or incised with an electrosurgical unit and once divided enhance 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 electrosurgical unit 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 ensure that the ureter is out of the field of dissection. The ureter is most easily identified along the medial leaf of the broad ligament as it crosses over the common iliac artery at the level of the pelvic brim. The adnexa are 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 dissect the areolar tissue between the bladder and the lower uterine segment.
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 the lower uterine segment and cervix (FIGURE 4). It is advantageous to divide ...