This course provides you the practical knowledge for an individual surgical procedure.
- a clear understanding of the steps to be taken to execute the procedure;
- seen an example of how the procedure is executed;
- a clear understanding of all anatomical structures encountered during the procedure;
- seen an example of how the anatomical structures look within the setting of the procedure.
Step by step
Abdominal cavity approach
Either a transverse muscle-splitting (Pfannenstiel) or a lower midline (vertical) incision can be used.
The choice of incision depends on previous abdominal surgery, the risk of incisional hernia, the need to explore the upper abdomen, the size and the mobility of the uterus and the desired cosmetic result. In case of a prior surgical incision, the old incision can be used to avoid making additional scars.
The different type of incisions are elaborated in the module ‘Abdominal wall incisions’.
Round ligament transection
Inspect and palpate the pelvic and abdominal organs for any abnormalities.
Identify the uterine horns, where the uterus and the Fallopian tubes meet.
Place a Kelly clamp across each uterine horn.
Uterine fundus suture
When the room in the small pelvis is limited and there is no uterine malignancy, a traction suture in the uterine fundus can be placed.
Lift the uterus from the pelvis upwards to expose any adhesions and produce tension to facilitates adhesiolysis. This will help to properly visualize the important pelvic structures.
Identify the round ligaments, that originates at the uterine horns.
Transect the round ligaments in the middle or lateral part. The ligaments can be transected with electrocautery or with scissors and then ligated. If a salpingo-oophorectomy is performed, the Fallopian tube is included in the transection of the round ligament.
Round ligament transection
The round ligament should not be divided too close to the uterus. This will limit exposure and make the incision over the broad ligament more difficult.
Incise the peritoneum lateral to the round ligament and extend the incision to superior, parallel to the ligament.
Identify the ureter on the mediocaudal side of the peritoneum and keep it under constant vision.
For better visualization, an elastic band can be placed around the ureter.
Identify the infundibulopelvic ligament by splitting the posterior peritoneum.
Clamp the infundibulopelvic ligament including the ovarian artery and vein.
Transect and ligate the infundibulopelvic ligament including the ovarian artery and vein.
Remove the ovary to perform a salpingo-oophorectomy.
Incise the peritoneum lateral to the round ligament and extend the incision superiorly parallel to the ligament.
Incise the posterior leaf of the broad ligament underneath the utero-ovarian ligament and Fallopian tube.
Clamp the utero-ovarian ligament, that connects the ovary to the lateral surface of the uterus.
Transect and ligate the utero-ovarian ligament.
Incise the peritoneum covering the bladder.
Dissect the bladder from the uterus through the avascular plane between the lower uterine segment and the bladder to open the vesicouterine plane.
Use careful sharp dissection instead of blunt dissection which poses a risk of tearing the bladder wall.
Inspect by palpation the opening between bladder and cervix to check if the bladder is completely freed from the cervix. If not, continue the dissection and palpate again.
Stay central during bladder dissection
Dissecting too lateral to the cervix may cause bleeding by tearing the vessels in the broad ligament. This is avoided by staying as close as possible to the cervix.
Incise the posterior peritoneum of the broad ligament, starting from below the ovaries. When already incised in step 4B, incise the peritoneum further from the posterior side, down to the level of the uterine artery.
Adjacent structures injury
Elevate the uterus adequately and keep tension to the uterus during dissection, what will increase the distance between the uterine body and the ureter, vessels and hypogastric plexus. The dissection is performed close to the cervicouterine junction while avoiding lateral migration.
Ureter identification is important, particularly in patients who have had prior pelvic surgery or extensive pelvic disease. The ureter can be identified as it crosses over the common iliac artery just above the bifurcation. It continues under the infundibulopelvic ligament and passes very close underneath the uterine vessels (“water under the bridge”).
Incise the parametrium to identify the uterine vessels.
Clamp the uterine artery at the junction of the cervix and lower uterine segment, adjacent to the uterus and far from the ureter, while applying sufficient traction to the uterus.
On the first clamped side, place a second clamp before dividing the uterine vessels to prevent backward bleeding through collaterals.
Transect the uterine vessels.
Continue the dissection through the cardinal ligament, what is the inferior part of the parametrium. Beware of lateral migration, that can cause damage to the hypogastric plexus.
Transect and ligate the cardinal ligament close to the cervix.
Supracervical (subtotal) hysterectomy
In a subtotal hysterectomy the cardinal and broad ligaments are clamped until midway between the internal and external cervical os. The cervix is amputated with a scalpel and the cervical apex is closed with a running or interrupted absorbable suture.
Identify the uterosacral ligaments, which travel from the uterus (superior to the vaginal fornices) to the anterior aspect of the sacrum.
Transect the uterosacral ligaments close to the uterus.
Identify the cervicovaginal junction at the level of the external orifice of the uterus.
Place a clamp at the level of the external orifice of the uterus.
Incise the cervicovaginal junction to enter the vaginal apex.
Continue the incision circumferentially with scissors to transect the uterus and cervix from the vagina.
Remove the uterus.
Vaginal cuff closure
Place Kocher clamps on both sides at the vaginal cuff.
The uterosacral ligaments should be included in the sutures to prevent the vaginal cuff from prolabating.
Close the vagina with three or four sutures. Do not close the vagina completely to allow for drainage of hematoma or seroma after the operation.
Inspect the pelvic organs for complete haemostasis and injuries, especially of the bladder and ureter.
Operating field cleaning
In case of problematic hemostasis the operating field can be rinsed with sterilised water. In this way small bleeding can be identified much easier than without water.
The course “Abdominal wall incisions” elaborates in detail how to close the abdominal wall.
- Anterior aspect of sacrum
- Spina iliaca anterior superior
- Round ligament of uterus
- Infundibulopelvic ligament
- Broad ligament of uterus
- Ligament of ovary
- Cardinal ligament
- Uterosacral ligaments
- Inferior hypogastric plexus
- Hypogastric nerve
- Viseral pelvic lymph nodes
- Fundus of uterus
- Lesser pelvis
- Uterine body
- Lower uterine segments
- Supravaginal part of cervix
- External os of the uterus
- Fallopian tubes
- Cervix of uterus
Menorrhagia is the most frequent cause for hysterectomy in premenopausal women, with myomas and adenomyosis constituting the leading pathologies of the uterus.
Another indication for hysterectomy is pelvic pain, mainly caused by endometriosis and/or adenomyosis. This condition can usually be managed with analgesic drugs and anovulatories. Uterine prolapse is also a common indication for hysterectomy, as it cannot be managed in a conservative manner. Malignancy and postpartum hemorrhage are less frequent indications and account for only 10% of the total rate of hysterectomies.
The approaches used in the procedure, are either open abdominal, vaginal, robotic or laparoscopic depending on the preference of the surgeon as well as multifactorial patient indications . As an alternative for the regular abdominal approach, a nerve sparing radical hysterectomy can also be performed .
INSTRUMENTS AND MATERIALS
The hysterectomy set is used in the procedure.
The patient is placed in the supine position.
Besides general complications, specific complications can occur in the abdominal hysterectomy, such as ureteral/bladder injuries, vaginal cuff dehiscence, pelvic abscess formation and Fallopian tube prolapse.
Suspected intraoperative ureteral/bladder injury should be evaluated and, if present, repaired. Postoperatively, ureteral injury may be asymptomatic or may present as flank or groin pain, fever, prolonged ileus, or abdominal mass.
Common sites for abscess formation after hysterectomy include the vaginal cuff and the adnexa. Pelvic abscesses that cannot be drained vaginally can be drained by an interventional radiologist.
Vaginal cuff dehiscence
Vaginal cuff dehiscence is a rare, but potentially morbid, complication of abdominal hysterectomy. This dehiscence denotes the separation of a vaginal incision that was previously closed at time of initial hysterectomy. After dehiscence of the vaginal cuff, abdominal or pelvic contents may be expelled through the vaginal opening. Bowel evisceration can lead to serious sequelae, including peritonitis, bowel injury, necrosis, and sepsis.
Fallopian tube prolapse
Post hysterectomy, prolapse of the fallopian tube is an uncommon complication often confused with granulation tissue at the vaginal apex. Development of a hematoma or abscess at the vaginal apex is a predisposing factor.
Symptoms include vaginal bloody discharge and/or leukorrhea, dyspareunia, and persistent pelvic pain. These symptoms usually arise in two weeks to six months postoperatively, but can appear several years after surgery.