Total Abdominal Hysterectomy



  • Do a thorough orientation of the room, equipment and simulators; this should take no more than 5-10 minutes
  • Alternatively, if you want to have the learners build the simulator; this will take 20-30 minutes
  • Set the stage for the simulation by doing the following:
    • Discuss the learning objectives for the day
    • Have the learners practice patient counseling by counseling you about the procedures
    • Explain that everything should either be verbalized or done as if this was an actual operating room setting

Simulator Assembly


Create a hysterectomy model for simulation of performing a total abdominal hysterectomy (TAH) to achieve the following educational objectives and surgical skills:

  • Identification of anatomical structures
  • Knowledge of steps in TAH including dissection of bladder from lower uterine segment, cervix and upper vagina
  • Flow of operation and assessment of forward planning, time and motion
  • Knowledge and use of instruments
  • Use of assistants
  • Knot tying/ligation

Materials and Preparation

Assembly Steps

Room Preparation


  1. Enter abdomen, abdominal exploration.
  2. Place self-retaining retractor.
  3. Pack bowel.
  4. Grasp round ligaments and uteroovarian ligaments with large clamp (i.e., Kelly).
  5. A 0 delayed absorbable suture is placed under the round ligament half way between the uterus and pelvic sidewall. A second suture is placed 1 cm medial to the first suture. These sutures are tied. The round ligament is held taut and divided between the two sutures.
  6. The retroperitoneal space is opened, and the external iliac artery is identified. The ureter should be identified crossing the pelvic brim at the Bifurcation of the common iliac artery.
  7. If the ovaries are to be taken: A window is made in the peritoneum between the ureter and the ovarian vessels. The IP is doubly clamped (tonsil, unless significant edema/inflammation may use heavy clamp such as Heaney) and ligated with a free tie, then a transfixion suture
  8. If the ovaries are to be left in place: A window is made in the peritoneum between the uterus and ovary below the fallopian tube. The pedicle is then clamped (Heaney/Kocher), ligated, free tied and suture ligated.
  9. The bladder is dissected off the anterior cervix: the peritoneum is divided inferior to its attachment to the lower uterine segment. Metzenbaum scissors are used to develop a plane between the bladder and the anterior cervix.
  10. The uterine artery and vein are skeletonized, and clamped with a heavy curved clamp (Heaney/Zeppelin/Masterson), the vessels are cut and doubly ligated.
  11. Confirm separation of rectum from cervix (blunt dissection is generally enough).
  12. Lift the uterus on tension, Clamp remaining portion of broad ligament with straight Heaney/zeppelin clamps, then cut with knife in sequential fashion and suture ligate.
  13. Clamp across the vagina below the cervix using two large Zeppelin clamps that meet each other in the middle. (The clamps should include the base of the cardinal ligaments laterally, the uterosacral ligament posteriorly, the vaginal wall anteriorly and posteriorly.) A knife or Jorgenson scissors are used to cut the vagina from the cervix.
  14. Anchor this portion of the vagina with a figure of eight in the midline. Then Heaney ligate under each clamp. Make sure to include the uterosacral ligament posteriorly and cardinal ligament laterally.
  15. Close the reminder of the vagina with figure of eight sutures.
  16. Irrigate the pelvis.
  17. Inspect the pedicles for hemostasis. Use electrocautery or suture ligatures for small bleeders.
  18. Remove all packing.
  19. Replace omentum anteriorly and consider closure of the peritoneum.
  20. Close fascia- running or mass closure if needed.
  21. Close skin with absorbable suture or staples.
  22. Leave Indwelling catheter until patient mobile.
  23. Oral intake may start as tolerated.

Competency Assessment

The resident is able to demonstrate appropriate pre-operative assessment and planning including the selection of antibiotics and DVT prophylaxis. The resident performs a time out, positions the patient properly and requests the appropriate instruments and suture. The resident demonstrates appropriate tissue handling and flow of the procedure including choosing the most appropriate incision and retractors. In addition, the resident should be able to identify the ureters, perform a bladder dissection, maintain hemostasis and anticipate potential complications. The resident should be able provide postoperative care including thromboembolic prophylaxis and management of medical co-morbidities.

Contributing Authors

Johns Hopkins University School of Medicine Department of Gynecology and Obstetrics

  • Kristiina Altman, MD
  • Dayna Burrell, MD
  • Grace Chen, MD
  • Betty Chou, MD
  • Tola Fashokun, MD