Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy

8/10/2019 Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy

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-Chapter 57

Total Abdominal Hysterectomy and Bilateral Salpingo-OophorectomyEllen C. WellsEllen C. Wells, MDAssistant Professor, Division of Gynecology, University of North Carolina, Chapel Hill, North Carolina (Vol 1, Chaps 11, 57)

INTRODUCTIONHysterectomy is the second most common major

surgical procedure performed in the UnitedStates.1Over one third of women in this countryhave undergone a hysterectomy by the age of

60.2The technique and route of delivery of the

uterus depend on a combination of factors, includingthe anticipated pathology, the patient's body

habitus, the degree of pelvic relaxation, the needfor concurrent abdominal and vaginal procedures,

and the expertise of the surgeon. The abdominal

hysterectomy is a basic component in thearmamentarium of any pelvic surgeon. A standard

approach with emphasis on principles of surgicaltechnique is presented.Back to Top

TECHNIQUEPreparing the Surgical Field

The operation is performed with the patient in thesupine position. Some surgeons prefer a modifiedlithotomy position using Allen universal stirrups to

allow potential access to the vagina and closer

proximity of a second assistant. A pelvic examunder anesthesia is routinely performed. This exam

further delineates the existing pathology and mayhelp with the selection of the type of incision. It also

provides the examiner with immediate feedback oninterpreting abnormal findings. The vagina and

urethra should be prepped and a Foley catheter

placed for straight drainage. A low transverseabdominal incision can be used if cancer is notsuspected. This incision can be converted to a

Maylard or Cherney incision if increased exposure is

necessary. In cases of known or suspectedmalignancy, a vertical incision is preferred to allow

increased exposure to the upper abdomen and

improved visualization for appropriate biopsies and

node dissection.When the surgeon enters the peritoneal cavity, theupper abdomen is explored by visualization and

palpation to identify any adhesions or masses. Asystematic check includes the liver edge,

gallbladder, stomach, omentum, small bowel, colon,kidneys, and paraaortic lymph node chain. Any

adhesions are released to provide adequate

exposure to the pelvic anatomy. The Trendelenburgposition assists in maintaining the bowel out of the

operative field.

The Balfour retractor is placed. Care should betaken that the ends of the blades do not rest heavilyon the psoas muscle because the femoral and

genitofemoral nerves can be compressed. The bowe

is lifted out of the cul-de-sac with the operator'sright hand. The left hand is then used to positionthe edge of an opened laparotomy pad under the

suspended bowel. This laparotomy pad is thendraped across the bowel, covering it from right toleft gutters like an apron, with the remaining edge

tucked under the anterior abdominal wall. A rolledlaparotomy pad is then placed immediately laterallyin each gutter and pushed directly cephalad to

ensure that no bowel escapes down these lateralmargins. An upper blade is attached to the Balfourto maintain this position. This blade should be flatand perpendicular to the abdominal wall and not

allowed to rest on the aorta and vena cava. A wide,

curved Deaver retractor is used to hold back thebladder. This can be held by an assistant and

moved from right to left to assist with visualization

on each side as the hysterectomy progresses.The Round and Broad Ligaments

A Kelly clamp is placed immediately lateral to theuterus at each cornua and incorporates the isthmic

portion of the fallopian tube and the utero-ovarian

ligament within its grasp. Bilateral clamps in thisposition will allow for elevation, traction, and

rotation of the uterus, which will aid in visualizationand dissection. The round ligament is grasped with

a Kocher clamp midway between the uterus and theinternal inguinal ring. A transfixion suture of 2-0

delayed absorbable suture is placed through thedistal portion of the round ligament and tagged (Fig

1). A second suture and/or large hemoclip may beplaced across the proximal portion of the round

ligament to prevent back-bleeding. The round

ligament is transsected and the anterior leaf of the

broad ligament is incised toward the level of theinternal cervical os with Metzenbaum scissors. This

will begin the development of the bladder flap (Fig.2). The posterior leaf of the broad ligament mayalso be incised parallel to the infundibulopelvic

ligament toward the side wall. This exposure is

particularly helpful if the ovaries are to be removed.With traction of the uterus away from the side wall

and lifting the tagged, round ligament upward and

lateral, the operator can separate the areolar tissuewithin the broad ligament by spreading the indexand middle fingers in a scissorlike manner.
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Fig. 1. The round ligament is identified, clamped,

and transfixion sutured. This procedure initiatesthe hysterectomy and allows entrance into the

broad ligament and retroperitoneum.(ThompsonJD, Rock JA: Telinde's Operative Gynecology, 7th

ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 2. The anterior leaf of the broad ligament isincised toward the level of the internal os withMetzenbaum scissors. Bilateral incisions meet in

the midline.(Thompson JD, Rock JA: Telinde'sOperative Gynecology, 7th ed, Ch 29.Philadelphia, JB Lippincott, 1992)

The ureteris visualized on the medial leaf of the broad ligament in this space. If adhesive disease

impedes visualization here, the uretercan be identified at the pelvic brim where it crosses the iliacvessels at their bifurcation. The uretercan then be followed downward through its course to ensure that

further dissection does not compromise its integrity (Fig. 3). The ureterappears as a white, nonpulsatile

tubular structure with fine blood vessels noted longitudinally on the adventitia. It is best identified byvisualization of its characteristic peristaltic activity. It can also be palpated by the operator's thumb beingplaced deep on the intraperitoneal side of the posterior medial leaf of the broad ligament and the index

finger deep on the retroperitoneal side of this medial leaf. As the operator holds the index finger and

thumb together with the peritoneum trapped between and moves upward, the ureterwill be palpable and
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Fig. 4. The posterior broad ligament is tented

upward in the avascular space lateral to theuterus, posteromedial to the adnexa and anterior

to the ureter. This space is entered to create awindow in the broad ligament.(Thompson JD,

Rock JA: Telinde's Operative Gynecology, 7th ed,Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 5. If the ovary and fallopian tube are to beconserved, two Kelly clamps are placed across thefallopian tube and utero-ovarian ligament in close

proximity to the uterus. The Kelly clamp at the uterinecornua is advanced so that its tip extends into thewindow.(Thompson JD, Rock JA: Telinde's Operative

Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott,

1992)
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Fig. 6. A free tie is placed with removal of the lateral

clamp.A transfixion suture is then placed beneath thesecond clamp.(Thompson JD, Rock JA: Telinde's

Operative Gynecology, 7th ed, Ch 29. Philadelphia, JBLippincott, 1992)

When the ovary and fallopian tube are to be removed, the window produced in the broad ligament servesto isolate the infundibulopelvic ligament, which is clamped with two Kelly clamps above the level of theureter. The most distal clamp is placed first. A third clamp immediately adjacent to the ovary and

fallopian tube prevents back-bleeding (Fig. 7). The ligament is cut above the two distal clamps. The distalend is free tied and then transfixion sutured with 2-0 delayed absorbable suture. The proximal end is alsotied and may be suspended from the Kelly clamp on the uterus to prevent the ovary and tube from

obstructing the operative field.

Fig. 7. If the ovary and fallopian tube are to be

removed, three Kelly clamps are placed across theinfundibulopelvic ligament through the window in the

broad ligament.(Thompson JD, Rock JA: Telinde'sOperative Gynecology, 7th ed, Ch 29. Philadelphia,JB Lippincott, 1992)

Developing the Bladder Flap


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The bladder flap is further developed by lifting the anterior peritoneum and retracting the uterus cephalad

to expose the bladder reflection and enter the vesicocervical space (Fig. 8). This space can be developedbluntly if there is no scarring from previous surgery or adhesive disease. Otherwise, sharp dissection in

the midline is recommended. Excessive dissection in the anterolateral direction may disrupt the bladderpillars (vesicouterine ligaments) and cause unnecessary bleeding. Care should also be taken not to cut

into the cervix when dissecting free the bladder, because this also creates extra bleeding. If the bladder isdensely adherent to the cervix in the midline, the lateral areolar spaces can be developed approaching the

midline to help define the appropriate plane between the bladder and cervix in prelude to sharp dissectionIn the most difficult cases, a small cystotomy in the dome of the bladder can be made to allow the

surgeon to insert a finger into the bladder and apply pressure to the bladder mucosa in the area being

dissected. The dissection can then be accomplished with full awareness of the proximity of the bladder.

Fig. 8. The bladder flap is developed by lifting the

anterior peritoneum and retracting the uteruscephalad to expose the bladder reflection and enter

the vesicocervical space.(Thompson JD, Rock JA:

Telinde's Operative Gynecology, 7th ed, Ch 29.Philadelphia, JB Lippincott, 1992)

After the surgeon mobilizes the bladder inferiorly, the pelvic ureteris palpable through its course beneaththe uterine artery lateral to the internal cervical os. Mobilization of the bladder is continued at intervals

during the remainder of the hysterectomy to ensure that it is completely free from the base of each

pedicle.Uterine Vessels and Cardinal LigamentsThe uterine vessels are skeletonized by removing any overlying avascular areolar tissue and further

incising the posterior peritoneum toward the internal cervical os (Fig. 9). Incision of the peritoneum overthe posterior cervix between the uterosacral ligaments may be delayed until later to avoid extra bleeding.

This peritoneum may require no further mobilization if the reflection of the rectum is below the lowermargin of the cervix. The uterine vessels are triple clamped with curved Heaney clamps at the level of the

internal cervical os (Fig. 10). The lowest clamp is placed first. The vessels are cut with Mayo scissors,leaving two clamps on the distal pedicle. This pedicle is ligated with a single suture, then a transfixion

suture of 0 delayed absorbable suture. The cardinal ligament is then approached with a straight Heaneyclamp placed medially to the previously ligated uterine vessels. The anterior portion of the clamp is placed

on the cervix in the vesicocervical space and the posterior portion on the cervix medial to the uterosacral

ligament (Fig. 11). As the clamp is closed, it is allowed to slide off the lateral surface of the cervix.Because the ureteris located approximately 2 cm lateral to the cervix within the cardinal ligament, this

technique allows the minimal amount of lateral tissue to be incorporated into this pedicle and decreasespotential pulling or kinking of the ureteras the pedicle is tied. The cardinal ligament pedicle is cut with

the knife and transfixion sutured with 0 delayed absorbable suture. Depending on the length of the cervix,several progressive bites with the straight Heaney clamp down each side of the cervix may be required

before reaching the level of the external cervical os. The uterosacral ligaments may be included with the
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cardinal ligament pedicles or taken separately with a curved Heaney approaching the cervix from the

posterolateral direction (Fig. 12).

Fig. 9. The posterior peritoneum is incised

toward the posterior cervix at the level of theinternal cervical os. The uterosacral ligaments

join the cervix just beneath this level. Incision ofthe peritoneum immediately posterior to the

cervix may be delayed until later to avoid extra

bleeding. This peritoneum between theuterosacral ligaments may require no further

mobilization if the reflection of the rectum isbelow the lower margin of the cervix.(Thompson

JD, Rock JA: Telinde's Operative Gynecology,7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 10. The uterine vessels have been

skeletonized. Three curved Heaney clampsare placed at right angles to the vessels. Thelowest clamp is placed first and is at the level

of the internal cervical os.(Thompson JD,

Rock JA: Telinde's Operative Gynecology, 7th

ed, Ch 29. Philadelphia, JB Lippincott, 1992)


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Fig. 11. A straight Heaney clamp is placed across the cardinal ligament

medial to the previously ligated uterine vessels. As the clamp is closed,it is allowed to slide off the lateral surface of the cervix. Maintaining

close proximity to the cervix maximizes the distance between thepedicle and the ureter.(Thompson JD, Rock JA: Telinde's Operative

Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 12. The uterosacral ligament may be approached with acurved Heaney clamp from the posterolateral direction. Theligament is then cut and ligated with 0 delayed absorbable

suture.(Thompson JD, Rock JA: Telinde's OperativeGynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott,1992)

Cervix Removal and Cuff Closure

A closed technique for removing the cervix from the upper vagina is beneficial in decreasing spillage ofvaginal contents into the abdomen. This technique decreases the risk of infection and the formation of

symptomatic granulation tissue at the vaginal apex. The lower edge of the cervix is palpated by placing

the operator's hand into the cul-de-sac with the palm facing the uterus, the index and middle fingers onthe posterior cervix and vagina, and the thumb on the anterior cervix and vagina. Palpation andvisualization in this area will ensure that the bladder and, if necessary, the rectum have been adequately

mobilized. A curved Heaney is placed across the lateral vaginal apex with its tip extending across the

upper vagina immediately beneath the cervix (Fig. 13). A similar placement on the other side allows the


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two Heaney clamps to meet in the midline. If the vagina is wide enough that the two clamps do not meet,

then these pedicles can be cut and the procedure repeated across the remainder of the upper vagina.Statinsky scissors provide a right-angle cut that is ideal for transsecting these pedicles. Removal of the

uterus is thus achieved. The pedicle within the curved Heaney clamp is then transfixion sutured with 0delayed absorbable suture. The vaginal angle sutures are tagged. The anterior and posterior vaginal

mucosa is trapped within the clamp by this technique and does not need to be identified separately. If,however, a clamp slips loose, the anterior and posterior vaginal mucosa must be identified and

incorporated into the closure to prevent these edges from continuing to bleed into the vagina.

Fig. 13. The bladder and, if necessary, the rectumhave been adequately mobilized. A curved Heaney

clamp is placed across the lateral vaginal fornix withits tip extending across the upper vagina

immediately beneath the cervix.(Thompson JD, RockJA: Telinde's Operative Gynecology, 7th ed, Ch 29.

Philadelphia, JB Lippincott, 1992)

Reperitonealization is not necessary unless hemostasis of the peritoneal edge is a concern. Newmesothelium arises from the subperitoneal connective tissue cells, not the adjacent peritoneal edge,3and

occurs simultaneously in all exposed areas independent of the size of the defect.4A smooth, glisteningsurface is visualized within 5 days.3Attempts to cover areas of peritoneal injury may lead to increasedadhesion formation at the sites of reperitonealization by preventing autolysis of early fibrinous

attachments5and introducing reactive responses to suture material.6

In cases where drainage of the pelvic cavity through the vagina is desired, such as surgical interventionfor active pelvic inflammatory disease unresponsive to antibiotic therapy, an open vaginal cuff with a drainis appropriate. This technique involves identifying the anterior vagina in the midline. The full thickness of

the vaginal wall is grasped and held with a long Allis clamp. The vagina above this clamp is enteredsharply. One blade of the Mayo or Statinsky scissors is placed within the vagina immediately beneath the

cervix. The vagina is circumferentially cut to completely remove the cervix and uterus. As the vagina isbeing cut, long Allis clamps are placed at both vaginal angles and on the anterior and posterior vaginal

walls (Fig. 14). Angle sutures of 0 delayed absorbable suture are placed, incorporating the full thickness ofthe anterior vaginal wall, the adjacent cardinal ligament and uterosacral ligament, and the posterior

vaginal wall. A suture of 0 delayed absorbable suture is placed from inside to out through the fullthickness of the vagina beneath its cut edge, locked over the edge, and continued circumferentially around

the top of the vagina for hemostasis (Fig. 15). A T-tube or Malincrot drain is placed through this open cuff

with its end extending into the vagina. The anterior and posterior peritoneum are reapproximated with acontinuous suture over the drain to maintain it in a retroperitoneal position.
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Fig. 14. The vagina is incised circumferentially just

beneath the cervix. Long Allis clamps are placed on thevaginal angles and on the anterior and posterior vaginal

walls.(Thompson JD, Rock JA: Telinde's OperativeGynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott,

1992)

Fig. 15. The angle sutureincorporates the full thicknessof the anterior vaginal wall, the

adjacent cardinal anduterosacral ligament, and theposterior vaginal wall. A suture

is then placed through the full

thickness of the vagina

beneath its cut edge, lockedover the edge, and continued

circumferentially around thetop of the vagina forhemostasis.(Thompson JD,

Rock JA: Telinde's Operative

Gynecology, 7th ed, Ch 29.Philadelphia, JB Lippincott,

1992)

Inspection and Assessment of the Cul-De-SacMeticulous attention should be directed to

hemostasis. The abdomen is copiously irrigated and

each pedicle inspected. The bladder is gently liftedand its base visualized. Cautery or excessivesuturing at the bladder base should be avoided

because subsequent necrosis could predispose to

fistula formation. Any bleeding areas at the uterine

vessels or cardinal ligament should be grasped withan Allis clamp and resutured within the suture line.

Additional suturing outside this line requires re-

evaluation of the proximity of the ureter.Intravenous indigo carmine coupled with a smallcystotomy incision to visualize dye extrusion from

both ureteral orifices will rule out a complete

obstruction in difficult cases. The cystotomy incision
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also allows retrograde placement of a ureteral

catheter to identify the presence and location ofsuspected occlusion. The catheter placement may

be particularly helpful in diagnosing partial occlusionor kinking of the ureter, which would benefit from

surgical release and may not be detected with theindigo carmine test.

Attention should be directed in each case to theprevention of pelvic relaxation. When the cul-de-sac

is noted to be deep, uterosacral ligament plication

can be performed as well as a Moschowitzprocedure with two concentric purse-string sutures

of medium silk below the level of the ureters. TheHalban technique of approximating the anterior to

the posterior peritoneum in the cul-de-sac or a

zigzag from right to left pulling the anterior to theposterior peritoneum is an alternative in cases

where a Moschowitz would cause undesired pulling

or kinking of the ureters. Obliteration of the cul-de-

sac is particularly useful when a retropubic urethralsuspension such as the Marshall-Marchetti-Krantz

(MMK) or Burch procedures is performed. These

procedures, by their marked displacement of theanterior vaginal wall, predispose to futureenterocele formation.

Back to Top

DISCUSSIONPreoperative EvaluationThe indications for hysterectomy in each patient

should be appropriate and well documented. Medical

management should have been determined to be

unsuccessful or unacceptable prior torecommending surgical intervention. Women withheavy or irregular bleeding who are over age 35 or

have risk factors such as obesity, nulliparity, orchronic anovulation require endometrial sampling

prior to their procedure. A recent Pap smear should

be available, with any abnormality appropriatelyevaluated. A preoperative intravenous pyelogram in

selected cases may reveal ureteral obstruction,hydronephrosis, or a nonfunctioning kidney. Rarely,

a duplicated collecting system is identified. This is

not, however, a substitute for intraoperative

identification of the ureter.Each patient should also be evaluatedpreoperatively for any other gynecologic conditions

that could be addressed at the time of her surgicalprocedure, particularly pelvic relaxation and stress

incontinence. A hemoglobin and hematocrit should

be obtained early in her surgical evaluation.Preoperative management of anemia may improveher surgical outcome and decrease her potential for

requiring a transfusion. Most women will also

appreciate being given the option of donatingautologous units of blood if the delay will not

jeopardize their health. Some women will grieve the

loss that they associate with the removal of thewomb and should be given the opportunity to

acknowledge and work through this prior to surgeryProphylactic Oophorectomy

Preoperative discussion should also include anassessment of whether the ovaries will be removed.

If the ovaries are found to contain no pathology,then the decision to retain or remove them must be

based on an informed discussion of the risks and

benefits of removal and the management ofhormone replacement. Most physicians recommend

their removal when a woman is in thepostmenopausal age. Premenopausal women will

weigh their risks and benefits somewhat differently

depending on how close in years they feel they areto menopause, their perception of previous

symptoms that could be attributed to their ovaries,

their family history of cancer, and their own

placement of value on the natural hormones fromthe ovary versus hormone replacement therapy.

Although elective oophorectomy at the time of

hysterectomy for women ages 35 to 45 reduces therisk of future ovarian cancer, this benefit may beoutweighed by the risk of osteoporosis and

cardiovascular disease if she is noncompliant with

the recommended estrogen replacement.7However,many women will remain compliant on estrogen and

will feel comfortable simply initiating hormone

replacement a few years earlier than they wouldhave if waiting for a natural menopause. Thesewomen will look to their physicians for reaffirmation

of the benefits of estrogen replacement and seektheir encouragement to continue with estrogenreplacement therapy in the subsequent years.

Laparoscopic Hysterectomy

The role of laparoscopy in performing ahysterectomy has dramatically expanded in recentyears but has come under increasing scrutiny

regarding its benefits in certain clinical settings andits overall cost-effectiveness. A laparoscopic-assisted vaginal hysterectomy (LAVH) is not a

substitute for a vaginal hysterectomy. As a surgeon

develops expertise and experience with vaginalsurgery, the number of patients for whom he or she

offers a vaginal approach increases. Other patients

will have pathology or coexisting abnormalities thatrequire an abdominal incision. The laparoscopetherefore assists the vaginal hysterectomy and

avoids an abdominal incision when suspected or

uncertain adnexal pathology or adhesive diseasemight otherwise preclude a strictly vaginal

approach. The visualization provided allows for

dissection and removal of the adnexa and therelease of any adhesive disease. If no pathologyexists that requires operative laparoscopy, then a

simple vaginal hysterectomy is performed.
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The Difficult Hysterectomy

When extensive pathology exists, the surgeon mustalter the approach with full awareness of normal

anatomy and the deviation from normal that hasbeen produced by this pathologic process.

Fundamental principles in removing an organinclude isolation and ligation of its blood supply and

dissection and removal from the surrounding tissuewithout injury to adjacent vital organs, nerves, or

vessels. The ability to identify the ureteroutside

the area of pathologic changes and to follow itscourse through the field of dissection is essential. A

retroperitoneal approach is extremely helpful in theisolation and removal of adherent adnexa. The

uretershould be left attached to the peritoneum as

much as possible but can be isolated from it if theadjacent pathology is densely adherent. If extensive

bowel adhesions are suspected, the bowel should beappropriately prepared. An enterotomy can then be

primarily closed with drainage established and atemporary colostomy avoided. Thorough knowledge

and recognition of the anatomy will allow thesurgeon to alter the standard hysterectomy as

required by existing pathology with the minimum

potential for injury or morbidity in these difficultcases.

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REFERENCES1. Graves EJ: National hospital discharge survey: Annual summary, 1990. National Center for HealthStatistics. Vital Health Statistics Series 13, Number 112, 1992

2. Pokras R, Hufnagel VG: Hysterectomies in the United States, 1965-1984. National Center for HealthStatistics. Vital Health Statistics Series 13, Number 92, 1987. DHHS Publication No. (PHS) 8717533. Raftery AT: Regeneration of parietal and visceral peritoneum: An electron microscopical study. J Anat115: 375, 1973

4. diZerega GS: The peritoneum and its response to surgical injury. In diZerega GS, Malinak LR, Diamond

MP, Linsky CB (eds): Treatment of Post-Surgical Adhesions, pp 112. New York, Wiley-Liss, 19905. Buckman RF, Buckman PD, Hufnagel HV, Gervin AS: A physiologic basis for the adhesion-free healing ofdeperitonealized surfaces. J Surg Res 21: 67, 1976

6. Hurd WW, Himebaugh KS, Cofer KF, Gauvin J, Elkins T: Etiology of closure-related adhesion formationafter wedge resection of the rabbit ovary. J Reprod Med 38: 465, 19937. Speroff T, Dawson N, Speroff L, Haber R: A risk-benefit analysis of elective bilateral oophorectomy:

Effects of changes in compliance with estrogen therapy on outcome. Am J Obstet Gynecol 164: 165, 1991

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Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy