Total Abdominal Hysterectomy

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

(See preceding Gynecologic System—Routine for Abdominal Procedures.)

Routine vaginal and abdominal preparation is given. The patient is catheterized, and an indwelling Foley catheter, No. 16 to 18 French, is inserted with inflation of the balloon. The catheter is anchored by adhesive tape to the inner aspect of the thigh. The vagina is cleansed with a soap solution containing hexachlorophene or a povidone-iodine–containing liquid cleanser. A large gaping cervix may be closed with several absorbable sutures. No sponge is placed in the vagina.

(See Gynecologic System—Routine for Abdominal Procedures.)

Whenever conditions will permit, the uterus is pulled upward toward the umbilicus, exposing the anterior uterine surface and allowing incision of the peritoneum at the cervicovesical fold (Figure 1). This loose layer of peritoneum is picked up with toothed forceps and incised transversely with scissors close to its attachment to the uterus (Figure 2). The operator uses sharp and blunt dissection to establish the avascular posterior leaf of the broad ligament opening a space in which the round ligament and fallopian tube are isolated (Figure 2). Should a very large and irregularly shaped uterus be encountered, it may be easier to apply clamps to the adnexa and to start from above downward. It is noteworthy that in many instances the cervicovesical fold of the peritoneum may be incised, and the adnexa may be isolated more easily, even in the presence of an interligamentous fibroid, after the finger has been passed through the avascular space.

When it is desirable to remove a tube, ovary, or both, they are grasped with forceps and reflected medially (Figure 3). When the pelvic structures are considerably relaxed, a pair of Ochsner clamps may be applied to include the infundibulopelvic and round ligaments, saving as much of the round ligaments as possible (Figure 3). A suture of 00 absorbable suture is taken in the round ligament and the edge of the peritoneum adjacent to the ovarian vessels to prevent retraction of the contents. Usually, curved clamps are applied in pairs beneath the tube and ovary, especially if it appears that there is too much tissue for one clamp (Figure 3), and their contents are tied with mattress sutures.

Details of Procedure

For supravaginal hysterectomy, the operation proceeds as in total abdominal hysterectomy except that the uterine arteries may be ligated higher on the cervix. Technically, this is an easier and safer operation to perform, as the uterine artery suture ligatures are placed further away from the ureters. It requires, however, that the patient be compliant with lifelong gynecologic examinations that include cervical Pap tests. The cervix is kept in position by Teale or similar forceps at the lateral margins and is divided at the level of the internal os, or lower (Figure 4). The cervical canal must be coned out completely from above for microscopic examination. The procedure also serves as prophylaxis against the eventual development of carcinoma in the retained cervical stump. The cervical stump then is closed transversely by placing with a cervix-cutting needle several figure-of-eight sutures of 0 absorbable suture, one in each lateral angle and one or more in the central portion. These sutures must be placed sufficiently deep to secure complete hemostasis.

After the ovarian vessels have been tied, the clamps on either side of the fundus are removed so the operator 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 away (Figure 5). It is advantageous to divide the tissue over the cervix with scalpel or scissors 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 6).

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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.

The sigmoid and omentum are returned to the pouch of Douglas. After the peritoneum is closed, the patient is returned to the horizontal position while the fascia and skin are being closed. A patient should never be taken from high Trendelenburg position and placed directly in bed. Only in rare instances is drainage instituted either through the vagina or abdominal wall.

(See Gynecologic System—Routine for Abdominal Procedures.)