Total Abdominal Hysterectomy (TAH)

Step 7:

Bladder is bluntly dissected from lower uterus and cervix along an avascular plane Consideration: blunt dissection may require "sponge on a stick"

Step 16:

The abdomen is closed in usual manner.

Step 15:

The abdomen is thoroughly irrigated and drained and checked for hemostasis. The ureters are reassessed for positioning and integrity and to ensure they are not dilated. (If left behind, the ovaries may be sutured to the lateral pelvic walls) Consideration: Usual closure routine, counts as needed.

Step 12:

The cardinal ligament is clamped, divided, and ligated on both sides Consideration: CCCT routine

Step 11:

The rectum can now be mobilized from the posterior cervix and reflected inferiorly out of the way

Step 14:

The resulting vaginal "cuff" can now be closed with interrupted or running #1 or 0 absorbable suture or stapled. The peritoneum is closed over it, in a similar manner Consideration: Various types of drains may be placed. Anticipate used of warm irrigation. Prepare suture.

Step 13:

Uterus placed in cephalic traction again and curved clamps are placed bilaterally, incorporating the uterosacral ligament. The uterus is freed and removed Consideration: These instruments are considered dirty since they may protect into the vagina. Mayo or Jorgensen scissors are commonly used. Bring specimen container after passing scissors. They should be isolated or removed from the field following use

Step 10:

Keeping the uterus retracted cephalic, the surgeon will use the #3 knife handle and/or the Metz to dissect the paracervical fascia to mobilize and preserve the uterus Consideration: long instruments usually required

Step 4:

Ligament clamps are placed across the round and ovarian ligaments Consideration: some of these clamps, after division of the ligament, will be left in place to aid with elevation and deviation of the uterus during its excision

Step 3:

A teneculum may be placed into the fundus of the uterus to facilitate control of the organ Consideration: Most commonly a multi tooth teneculum is used to manipulate the uterus

Step 8:

Peritoneal opening enlarged to expose ovarian suspensory ligament and uterine artery. A curved Ballentine or Heaney clamp is placed medial to the ovary and the suspensory ligament is ligated and divided Consideration: CCCT, tie is usually stick tie, Heaney NH often used, surgeon may use electrosurgery or harmonic scalpel to divide ligaments

Order ligaments are cut from abdomen down

RFOCU: Round Fallopian Ovarian Cardinal Uterosacral

Step 5:

Round ligaments now divided electrosurgically or are sutured ligated and cut, developing anterior and posterior "leaves" of the broad ligament Consideration: Sutures are immediately placed in area of dissection; dissection ay be sharp, blunt, or combined

Step 2:

Self-retaining retractor is placed, bowel is packed cephalic with moist lap sponges Consideration: Balfour, O'Sullivan O'Connor, or Bookwalter are commonly used, have full selection of blades for Bookwalter, warm, moist laps needed, count laps as they are placed

Step 9:

The uterus is now retracted cephalic and deviated to one side, stretching the lower ligaments and facilitating exposure of the uterine vessels, which are then cross-clamped at the junction of the uterus and cervix, cut, and ligated Consideration: Depending on patients anatomy, more caudal portions of the procedure may require extra long instruments

Step 6:

These are incised with Metz, separating peritoneum of bladder from lower uterus, and opening the retroperitoneum to expose underlying iliac vessels and the ureters- these structures are properly identified and protected at all times for the remainder of the procedure Consideration: Hysterectomy is methodical, same steps must be repeated bilaterally- CST should have adequate supply of clamps and sutures

Step 1:

Transverse Pfannestiel or vertical incision, abdomen explored for unsuspected path, uterus and adnexa assessed Consideration: Adjust according to incision