Plate 177

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 ...