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 A transfixing suture, a, of 0 absorbable suture is tied as the lower Ochsner clamp is slowly withdrawn, and a second similar suture, b, is taken toward the severed end of the pedicle (Figure 8).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.
After a similar procedure has been concluded on the opposite side, Teale forceps are applied to the paracervical tissue between the cervix and the uterine vessels (Figure 9). The peritoneum on the posterior cervical wall is incised and pushed gently downward. Frequently, the incision is carried entirely around the anterior wall of the cervix, and the tissues are pushed downward by blunt dissection until the cervix can be palpated easily through the thinned-out vaginal vault. With the uterus held forward, an incision is made into the vagina posteriorly, and the vaginal vault is divided by long, curved scissors as close to the cervix as possible, or desirable, according to the disease present (Figure 10). As the cervix is freed from the vaginal vault, the anterior and posterior vaginal walls are approximated with Teale forceps to include the full thickness of the vaginal wall as well as its posterior peritoneal surface (Figure 11). The lateral angles of the vaginal vault are first closed with figure-of-eight sutures of 00 absorbable suture on cutting needles (Figure 12), following which one or more sutures are placed at the middle portion to ensure complete closure and hemostasis. The most likely place for troublesome bleeding is at the outer angles of the vagina near the ligated uterine vessels. Accurate and firm closure of the angles is imperative (Figure 12). Upward traction on the vaginal vault is released to determine whether any bleeding occurs.