Total Abdominal Hysterectomy (Uterus Removal)

Open Technique for Total Abdominal Hysterectomy

Surgical Details of Procedure of Total Abdominal Hysterectomy

1. A lower midline incision is made vertically (up and down) in the skin with a No. 10 scalpel.

2. Dissection is done through the subcutaneous tissue with Bovie cautery.

3. The midline between the rectus muscles is appreciated and the fascia is incised.

4. Some clinicians performing a total abdominal hysterectomy may elect to use a transverse skin incision called a Pfannenstiel incision placed just above the symphysis pubis (pubic bone).

Total abdominal hysterectomy

Pfannensteil incision in suprapubic area

5. In the transverse incision approach in total abdominal hysterectomy the subcutaneous tissue is dissected with Bovie cautery

6. Skin flaps are raised superiorly toward the skin to allow exposure of the midline of the rectus muscles.

7. Occasionally in large patients receiving total abdominal hysterectomy,  the rectus muscles are cut to afford better exposure

8. After the midline fascia is dissected or the rectus musles are cut the peritoneum is appreciated and grasped with forceps on either side of the midline (never with hemostats to avoid trapping bowel inadvertently).

9. If possible the uterus is grasped and pulled out of the incision and superiorly toward the umbilicus (belly button) to expose the anterior uterine surface.

10. The peritoneum at the cervicovesical fold is incised transversely (side to side) close to where it attaches to the uterus.

11. Blunt finger dissection is used in total abdominal hysterectomy to appreciate the avascular (without blood vessels) plane in the posterior leaf of the broad ligament.

12. This is performed until the round ligament and fallopian tubes are appreciated.

13. The round ligament on each side is then controlled by placing an Ochsner clamp on it and dividing it after a mattress 0 absorbable suture has been placed on the right and left round ligaments to ligate the ovarian vessels.

14. The clamps are then removed on either side of the fundus of the uterus.

15. The gynecologist palpates the cervix with two fingers to gain an appreciation of the position of the bladder.

16. The bladder is then bluntly dissected off the uterus with a gauze-covered finger caudally (towards the feet).

17. Care must be taken when doing a total abdominal hysterectomy to keep the blunt dissection in the midline to avoid inadevertently tearing the vessels in the broad ligament.

18. The dissection is carried downward until the vaginal wall can be compressed between the gynecologist’s fingers.

19. The uterus is the pulled forward and the posterior surface is visualized to insure that it is not adherent to the rectum.

20. The uterus is grasped with a tenaculum and rotated slightly to one side to expose the uterine vessels.

21. Two Ochsner clamps are then placed at 45 degrees to the uterus and slid down onto the uterine vessels.

22. The uterine vessels are incised with a Metzenbaum scissors and the vascular pedicle doubly ligated with sikl suture.

23. The similar procedure to ligate the urterine vessels is performed on the opposite side.

24. Teale forceps are applied to the cervical tissue at the level of the vagina.

25. The posterior cervical peritoneum is incised and gently bluntly downward.

26. The incision is carried cirumferentially around the cervix.

27. The uterus is held forward the posterior vaginal wall is incised using curved scissors.

28. The anterior and posterior walls of the cut vagina are grasped by Teale forceps.

29. The lateral edges of the cut vagina are sutured together with figure of eight absorbable 0 sutures.

30. The rest of the vaginal opening is then closed with additional figure of eight absorbably 0 sutures.

31. The reapproximated vagina is the released from the Teale forceps to visualize any bleeding points.

32. The peritoneum is then closed with a running absorbable suture (general surgeons almost never close the peritoneum after abdominal surgery)

33. Fascia is reapproximated using either a running or interrupted large suture.

34. Subcutaneous tissue may be closed using absorbably 2-0 or 3-0 suture.

35. The skin is closed using staples or sutures to complete the total abdominal hysterectomy.

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