Surgical Details of the Procedure

1. The patient is placed supine on the operating table with legs placed in stirrups

2. A Jacobs tenaculum is inserted into the vagina and is used to grasp the cervix so the uterus can be antiflexed (tipped up).

3. A periumbilical port is placed. Although most general surgeons have abandoned the use of the Veress needle to enter the abdomen, some gynecologists still use this technique.

4. The Veress needle is inserted into the peritoneal cavity by grasping the area around the umbilicus and retracting it upward with a “blind stick” into the peritoneal cavity.

5. When placing the needle into the cavity the experienced clinician will ascertain two discrete “pops” as the needle goes through the tissue layers.

6. Most clinicians then open the needle to allow fluid flow through the lumen and then place several cc’s of sterile saline into the needle to insure that it drains rapidly and suggests that the tip of the needle is free in the peritoneal space.

7. Insufflation of the abdomen is then performed by attaching the carbon dioxide line to the side port of the needle.

8. The intraperitoneal pressure is allowed to rise to 15 mm Hg.

9. The Veress needle is then removed and a 10 mm umbilical port with trochar is inserted blindly into the peritoneal space.

10. The inner trochar is removed and the cap is placed onto the port.

11. The laparoscopic camera is placed through the port and visual inspection of the abdominal cavity is performed.

12. A lower midline port is placed via the trochar maneuver under direct visualization of the laparoscopic camera.

13. The uterus is antiflexed by manipulating the previously placed Rubin’s cannula and Jacobs tenaculum.

14. The tongs of the Silastic band instrument is loaded with a Fallope-ring and inserted into the abdomen.

15. The fallopian tube is drawn into the Silastic band applicator with care taken to not draw too much much fallopian tube tissue into the housing of the the banding scope to prevent laceration of the fallopian tube.

16. The “knuckle” of fallopian tube tissue is drawn into the Silastic band applicator.

17. The Fallope-ring is pushed off the applicator onto the grasped tissue.

18. The contralateral (opposite side) fallopian tube is located and the above steps are repeated.

19. The pelvic area is thoroughly inspected to insure there is no hemorrhage.

20. The instruments are withdrawn through the trocar sites.

21. Gentle pressure is placed on the outside of abdominal wall to express any remaining pneumoperitoneum (carbon dioxide left in the abdomen).


Copyright 2007 InsideSurgery.com

Open technique

When this procedure is performed using an open technique it is most commonly performed in association with total abdominal hysterectomy. The steps described below are for isolated salpingo-oopherectomy and are slightly different than if the tube and ovaries are taken out en bloc with the uterus.

Indications

Malignancy – virtually all ovarian cancer requires removal of the Fallopian tube and ovary

Ectopic Pregnancy – this condition is when the fertilized egg is implanted in the Fallopian tube instead of the uterus. Ectopic pregnancy can cause rupture of the tube as the fetus develops and can be a surgical emergency.

Cyst

Surgical Details of Procedure

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 may elect to use a transverse skin incision called a Pfannenstiel incision placed just above the symphysis pubis (pubic bone).

5. In the transverse incision approach 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, 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. The uterus is pulled foward by an absorbably stay suture placed in the fundus or by grasping the uterus with a tenaculum.

10. Clamps are applied to the infundibulopelvic ligament that contains the ovarian vessels.

11. A clamp is applied to the Fallopian tube.

12. The Fallopian tube and ovary are pulled superiorly and an incision is made in the exposed broad ligament with a scalpel.

13. The ovarian vessels are visualized and ligated with 0 silk sutures.

14. The cut edges of the broad ligament are plicated with mattress sutures.

15. The section of the Fallopian tube inside the uterine wall is removed by making an ellipical incision around the base of the insertion site on the outside of the uterus.

16. Dissection is done through the muscle plane of the uterus until the Fallopian tube is freed.

17. The now full thickness opening in the uterus is closed using a mattress suture of an absorbably 0 suture.

18. The cut surface of the infundibulopelvic ligament is now covered by taking a bite of peritoneum on either side with a suture and plicating it over the ligament remnant.

19. The suspension of the uterus is done by shortening the round ligament by taking peritoneum on either side and plicating it along the length of the round ligament with 3 or 4 mattress sutures to insure midline suspension of the uterus.

Copyright 2007 Insidesurgery.com

Open Technique

Surgical Details of Procedure

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 may elect to use a transverse skin incision called a Pfannenstiel incision placed just above the symphysis pubis (pubic bone).

5. In the transverse incision approach 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, 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 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 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.

Please check back. More soon.


Copyright 2007 Insidesurgery.com

Surgical Details of Procedure

1. A transverse (side to side) skin incision is made at the level of the pubic bone with a No. 10 scalpel. A midline incision can also be used.

2. Bovie cautery is used to dissect through the subcutaneous tissue to the bilateral rectus muscles.

3. The rectus muscles and the accompanying fascia are then incised with lateral retraction of each muscle belly.

4. The abdominal cavity is then entered and the vesicouterine fold is identified (fold of tissue between the bladder and uterus).

5. A No. 10 scalpel is used to make a superficial incision in the vesicouterine fold.

6. The bladder is retracted caudally (toward the feet) with a Deaver retractor.

7. A transverse (side to side) incision is made in the anterior uterine wall with return of amniotic fluid.

8. The incision is extended sufficiently to permit two fingers to be inserted into the uterus.

9. The uterus is then stretched transversely.

10. The fetus is grasped (preferably by the legs) and delivered out of the uterus.

11. The umbilical cord is then clamped with two Kelly clamp and incised (cut) with a scissors.

12. The newborn’s mouth is them immediately suctioned and the infant is handed to the pediatrician or nurse.

13. The placenta is then manually extracted from the uterus (the surgeon places their hand into the uterus and pulls/pushes out the placenta). Some practitioners deliver the uterus out of the incision first before extracting the placenta.

14. A large hand-held retractor (e.g., Deaver retractor) is then inserted into the opening of the uterus and the inside of the uterus is inspected for any retained placenta or bleeding or injury sites.

15. The blood in and around the uterus is removed by suction.

16.The uterus is then closed in two layers with the first layer using a continous suture with an absorbable 0 suture (e.g., Vicryl suture).

17. The second layer of uterus is closed using an interrupted 0 suture.

18. The serosa (the outermost layer) of the uterus and the vesicouterine fold are closed in one layer using a continous 3-0 absorbable suture (e.g., Vicryl suture).

19. The parietal peritoneum (anterior leaf of peritoneum) is closed using a running 3-0 absorbably suture (e.g., Vicryl suture).

20. The rectum muscle sheaths are reapproximated in the midline and the muscle fascia is closed using either a continous or interrupted suture (both permanent and absorbable sutures are used).

21. The superficial layers are closed in 1 or 2 layers – if there is a well-developed layer of Scarpa’s fascia this is closed using a 3-0 Vicry suture in an interrupted fashion.

22. The skin is closed with staples or sutures.

23. During closure it is customary to irrigate the wounds before each layer is reapproximated with saline solution.


Copyright 2007 Insidesurgery.com