VIDEO

SKILL

TOTAL
HYSTERECTOM
Y
without bilateral
salpingooophorectomy
Indications :

 Leiomyoma
 Abnormal Uterine Bleeding
 Intractable dysmenorrhea
 Pelvic pain (whose pain is of gynecologic origin and does not respond to nonsurgical treatments)
 CIN
 Obstetric emergency
 PID
 Endometriosis
 Pelvic mass
 Pelvic organ prolapse
Surgical Technique

Incision
The choice of incision should be determined by the following considerations:
1. Simplicity of the incision
2. Need for exposure
3. Potential need for enlarging the incision
4. Strength of the healed wound
5. Cosmetics of the healed incision
6. Location of previous surgical scars

The skin is opened with a scalpel, and the incision is carried down through the subcutaneous tissue and fascia. With traction
applied to the lateral edges of the incision, the fascia is divided. The peritoneum is opened similarly. This technique
minimizes the possibility of inadvertent enterotomy while entering the abdominal cavity.
Surgical Technique

• Abdominal Exploration

Cytologic sampling of the peritoneal cavity, if needed, should be performed before abdominal exploration.
The upper abdomen and the pelvis are explored systematically. The liver, gallbladder, stomach, kidneys, para-
aortic lymph nodes, and large and small bowel should be examined and palpated.
Surgical Technique

• Retractor Choice and Placement

A variety of retractors were designed for
pelvic surgery. The Balfour and the
O’Connor–O’Sullivan retractors are used
most often. The Bookwalter retractor has
a variety of adjustable blades that can be
helpful, particularly in obese patients.
Surgical Technique

Elevation of the Uterus

The uterus is elevated by placing broad ligament clamps at each cornu so that it crosses the round ligament
 Surgical Technique
• Round Ligament Ligation or Transection

The uterus is deviated to the patient’s left side, stretching the right round
ligament. With the proximal portion held by the broad ligament clamp,
the distal portion of the round ligament is ligated with a suture
ligature or simply transected with an electrosurgical device

The distal portion can be grasped with forceps, and the round ligament is
cut to separate the anterior and posterior leaves of the broad ligament.
The anterior leaf of the broad ligament is incised with Metzenbaum
scissors or electrosurgery along the vesicouterine fold, separating the
peritoneal reflection of the bladder from the lower uterine segment
 Surgical Technique

• Ureter Identification

The retroperitoneum is entered by extending the incision cephalad on the

posterior leaf of the broad ligament. Care must be taken to remain lateral to
the infundibulopelvic ligament and iliac vessels. The external iliac artery
courses along the medial aspect of the psoas muscle and is identified by
bluntly dissecting the loose alveolar tissue overlying it.

By following the artery cephalad to the bifurcation of the common iliac

artery, the ureter is identified crossing the common iliac artery. The
ureter should be left attached to the medial leaf of the broad ligament to
protect its blood supply
Surgical Technique

• Utero-Ovarian Vessel and Ovarian Vessel (Infundibulopelvic Ligament) Ligation

If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side,
placing tension on the contralateral ovarian vessels (also called infundibulopelvic ligament), the tube, and the
ovary. If the fallopian tube is taken, the mesosalpinx is incised with progressive clamping, cutting, and
ligating.
Surgical Technique

• Bladder Mobilization
Using Metzenbaum scissors or an electrosurgical device, the bladder is dissected from the lower uterine
segment and cervix. An avascular plane, which exists between the lower uterine segment and the bladder,
allows for this mobilization.
 Surgical Technique

• Uterine Vessel Ligation

The uterus is retracted cephalad and deviated to one side of

the pelvis, stretching the lower ligaments. The uterine
vasculature is dissected or “skeletonized” from any remaining
areolar tissue, and a curved Zeppelin or Heaney clamp is
placed perpendicular to the uterine artery at the junction of
the cervix and body of the uterus. The vessels are cut, and the
pedicle is ligated.
Surgical Technique

• Incision of Posterior Peritoneum

If the rectum is to be mobilized from the posterior cervix, the posterior

peritoneum between the uterosacral ligaments just beneath the cervix and
rectum may be incised. A relatively avascular tissue plane exists in this area,
allowing mobilization of the rectum inferiorly out of the operative field.

• Cardinal Ligament Ligation

The cardinal ligament is divided by placing a straight Zeppelin or

Heaney clamp medial to the uterine vessel pedicle for a distance of 2- to
3-cm parallel to the uterus. The ligament is cut, and the pedicle is suture
ligated. This step is repeated on each side until the junction of the cervix
and vagina is reached
Surgical Technique

• Removal of the Uterus

The uterus is placed on traction cephalad,

and the tip of the cervix is palpated. Curved
Heaney clamps are placed bilaterally,
incorporating the uterosacral ligament and
upper vagina just below the cervix. Care
should be taken to avoid foreshortening the
vagina. The uterus is removed with scalpel
or curved scissors
Surgical Technique

• Vaginal Cuff Closure

A figure-of-eight suture of 0 braided absorbable material is placed at the angle of the vagina for traction and
hemostasis. The pedicles are sutured with a Heaney stitch, incorporating the uterosacral and cardinal ligament at the
angle of the Vagina. A running-locked or figure-of-eight sutures can be used for hemostasis along the cuff edge
Surgical Technique

• Irrigation and Hemostasis

The pelvis is thoroughly irrigated with saline
• Peritoneal Closure and Fascia Closure
The parietal peritoneum is not reapproximated as a separate layer. Fascia can be closed with an interrupted or
continuous 0 or 1 monofilament absorbable suture. A prospective randomized trial did not show any
advantage of interrupted versus continuous fascial closure
• Skin Closure
The subcutaneous tissue should be irrigated, with careful hemostasis. Skin staples or subcuticular sutures are
used to reapproximate the skin edges.
Intraoperative Complications

• Ureteral Injuries
• Bladder Injury
• Bowel Injury
• Hemorrhage
VIDEO
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