Simulation

Total Abdominal Hysterectomy

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Hysterectomy Classification

Diagram of female reproductive system with labels indicating types of hysterectomies.

Source: Williams Gynecology 2nd edition

Preoperative Issues

Indications and alternatives
- Informed consent
Surgical planning
- Incision choice
- Elective oophorectomy
- Opportunistic salpingectomy
- Total versus subtotal

Prophylactic Antibiotics

Cephalosporins are the antibiotics of choice
- Adjust dose for Body Mass Index (BMI) >35
Should be administered just before induction
Redosing should occur if surgery > 3 hrs or blood loss >1500ml
Agents of choice in women with hypersensitivity to penicillin or cephalosporins include:
- Clindamycin plus gentamycin or quinolone
- Metronidazole plus gentamycin or quinolone

Prophylaxis for Venous Thromboembolism

Risk Classification for Venous Thromboembolism in Patients Undergoing Surgery Without Prophylaxis

Level of Risk	Definition	Successful Prevention Strategies
Low	Surgery lasting less than 30 minutes in patients younger than 40 years with no additional risk factors	No specific prophylaxis; early and "aggressive" mobilization
Moderate	Surgery lasting less than 30 minutes in patients with additional risk factors; surgery lasting less than 30 minutes in patients aged 40-60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors	Low-dose unfractionated herapin (5,000 units every 12 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
High	Surgery lasting less than 30 minutes in patients older than 60 years or with additional risk factors; major surgery in patients older than 40 years or with additional risk factors	Low-dose unfractionated heparin (5,000 units every 8 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device
Highest	Major surgery in patients older than 60 years plus prior venous thromboembolism, cancer, or molecular hypercoagulable state	Low-dose unfractionated heparin (5,000 units every 8 hours), low molecular weight heparin (5,000 units dalteparin or 40 mg enoxaparin daily), or intermittent pneumatic compression device/graduated compression stockings + low-dose unfractionated heparin or low molecular weight heparin Consider continuing prophylaxis for 2-4 weeks after discharge

Modified from Geerts WH, Pineo GF, Heit JA, Bergquist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference in Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338S-400S.

Supracervical Hysterectomy

Lack of data demonstrating clear benefits of a supracervical hysterectomy. No difference in the following:
- Sexual function
- Urinary symptoms
- Future pelvic organ prolapse
Potential advantages of a supracervical hysterectomy over total hysterectomy is a decrease in operative time and blood loss (though transfusion rates are similar)
Potential complications of a supracervical hysterectomy include:
- Cyclical vaginal bleeding
- Need for continued cervical cancer screening
Contraindications:
- Suspected cancer
- Current or recent cervical dysplasia
- Endometrial hyperplasia

Elective Oophorectomy

Factors favoring oophorectomy
- Genetic risk for ovarian cancer
- Bilateral ovarian neoplasms
- Severe endometriosis
- Pelvic Inflammatory Disease (PID) or tubo-ovarian abscesses
- Postmenopausal status
Factors favoring ovarian conservation
- Premenopausal status
- Desire for fertility
- Impact on sexual function/libido/quality of life
- Osteopenia/osteoporosis or risk factors

Opportunistic Salpingectomy

Opportunistic salpingectomy may be offered for the primary prevention of ovarian cancer in a woman already undergoing pelvic surgery for another indication
Performance of opportunistic salpingectomy does not increase the risk of surgical complications
Ovarian function does not appear to be affected by the performance of opportunistic oophorectomy

Indications for Hysterectomy

Abnormal bleeding
Leiomyoma/Adenomyosis/Endometriosis (with endometriosis consider bilateral salpingooophorectomy (BSO)
Pelvic organ prolapse (add cuff support procedure)
PID unresponsive to medical or interventional treatment
Malignant disease

Relative Indications for Abdominal Hysterectomy

Large leiomyoma, abnormal position of leiomyoma
Uterus >12 week size
PID, extensive adhesions/endometriosis
Cancer, extensive metastases

Informed Consent

Alternative treatment options
Elective and opportunistic oophorectomy
General risks of surgery
- Bleeding requiring transfusion < 2%
- Infection: Urinary tract infection is most common complication
Specific risks of hysterectomy
- Sterility
- Potential damage to lower urinary tract or rectum requiring further surgery
- Potential need for open abdominal surgery if vaginal hysterectomy is not feasible
Specific risks associated with abdominal hysterectomy
- Increased operative time
- Increased complications: fever, blood transfusion
- Longer hospital stay
- Wound complications (seroma)

Preoperative Planning

Patient Positioning
- Supine versus lithotomy
Instruments and Retractors
Incision choice
- Transverse
- Midline vertical
- Obese patients
Prophylactic measures
- Thromboprophylaxis
- Preoperative antibiotics

Preparation

CBC (if suspected anemia)
Type and screen
Cross-match 2 units of PRBCs for Hgb< 10 g/dl
Current cervical screening
Endometrial biopsy for abnormal uterine bleeding
Transvaginal ultrasound advisable
Bowel prep not necessary
Enema optional

Fundamental Anatomy

Blood supply
- Major blood supply from uterine arteries via cardinal ligaments
- Ascending uterine artery branch communicates with ovarian arteries
- Ovarian arteries
Bladder
Connected to the cervix only by 1-2 cm, then an avascular plane is entered
Ureters
Retroperitoneal structures that should be identified during a hysterectomy

Complications

Bleeding
- Most common site is between utero-ovarian and uterine artery pedicles
- Second most common is posterior vaginal cuff
Bladder injury
- Cystotomy: usually occurs well above trigone, not near ureteral orifices
- Avoid blunt dissection, especially with a history of previous cesarean delivery
Nerve injury: Risk factors for retractor injuries
- Prolonged operating time (> 4 hours)
- Improper retractor placement
- Large transverse incision
- Narrow Pelvis
- BMI < 20

Complications

Nerve injuries from gynecologic pelvic surgery
- Femoral Nerve: Typically compression against lateral sidewall from retractors
- Obturator: Typically injuries occur with concomitant trans-obturator tape (TOT) or lymph node dissection
- Pudendal: Injury during sacrospinous ligament fixation or pelvic reconstructive procedures during which sutures are placed in the arcus tendinous fascia
- Peroneal: Injury can be secondary to leg positioning during surgery
- Iliohypogastric /ilioinguinal: Usually suture entrapment at lateral angles of incision
Ureteral injury
- Risk increased based on patient risk factors that distort anatomy:
  - Endometriosis
  - Obesity
  - Leiomyomas and large pelvic masses (particularly cervical)
  - Bleeding from uterine artery pedicle or lateral vaginal cuff
  - History of pelvic radiation
  - Prior pelvic surgery

Steps in Performance of Abdominal Hysterectomy

The round ligament is transected and the broad ligament is incised and opened.
Choice of instruments:
- Large Kelly® clamp or Heaney clamp used to grasp uterine cornua
- Kelly® clamps may be used to clamp round ligaments and divided

Illustration of round ligament being sutured. — Suture ligation of the round ligament. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.

- The uterus is kept on traction cephalad
- The bladder can be dissected off with blunt dissection or sharply with Metzenbaum® scissors
- The bladder is mobilized inferiorly by sharp dissection away from the cervix. To avoid unnecessary bleeding, this step may be done in stages as necessary
Identification of the ureter location on the medial leaf of the broad ligament. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.
- Open posterior leaf of broad ligament parallel to the infundibulopelvic (IP) ligament
- Identify external iliac vessels
- Identify the ureter on the medial leaf of the broad ligament
- Review the course of the ureter
Creation of a window in the posterior peritoneum with clamping of the infundibulopelvic ligament. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.
- Isolate the IP ligament and create a space in the posterior pelvic peritoneum between the IP vessels and ureter
- A curved clamp is placed lateral to the ovary
- Each IP ligament is cut and ligated with a free tie followed by a suture ligature medial to the free tie
Potentially with Opportunistic Salpingectomy
- A window is created in the posterior leaf of the broad ligament under the utero-ovarian ligament and fallopian tube
- When performing opportunistic salpingectomy, care should be taken to entirely resect both tubes with the uterus
- The utero-ovarian ligament is clamped, cut, and ligated with a free tie followed by a suture ligature placed medially
- Sharp dissection is used to skeletonize the uterine vessels
- With the uterus on traction, a curved clamp is placed perpendicular to the uterine artery at the junction of the cervix and lower uterine segment
- Place additional clamp for back bleeding
- Uterine vessels are cut and ligated with a suture ligature placed at the tip of the clamp
- Vessels may be single or doubly clamped per surgeon preference
- Suture is not placed in middle of pedicle
- Proper clamp placement is critical to avoiding ureteral injury
Clamp placement perpendicular to the uterine vasculature. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.
- Straight clamps are placed medial to the uterine vessel pedicle and parallel to the cervix along cardinal for a distance of 2-3 cm
- The pedicle is cut and suture ligated
- The number of bites will depend on length of the cervix
Clamp placement across broad ligament and cardinal ligaments. With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.
- Clamp bilaterally
- Cut and ligate the pedicle at the tip of the clamp with suture
- After bladder and rectum are clear, the vagina is cross clamped with long, curved clamps just below the cervix (dotted line)
- The vagina is divided above the clamps with a knife or angled scissors
- Vaginal angles are closed incorporating uterosacrals
- Numerous techniques
- Figure-of-eight or running locked sutures
With permission from Mann/Stovall Gynecologic Surgery. Churchill Livingston 1996.