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Total Abdominal Hysterectomy
 With and Without Bilateral 
 Salpingo-oophorectomy

Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one or both sides. In benign disease, the possibility of bilateral and unilateral oophorectomy should be thoroughly discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and ovaries, since they are frequent sites of micrometastases. In general, the modified Richardson technique of intrafascial hysterectomy is used. The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube and ovaries. Physiologic Changes. The predominant physiologic change from removal of the uterus is the elimination of the uterine disease and the menstrual flow. If the ovaries are removed with the specimen, the predominant physiologic change noted is loss of the ovarian steroid sex hormone production. Points of Caution. The predominant point of caution in performing abdominal hysterectomy is to ensure that there is no damage to the bladder, ureters, or rectosigmoid colon. Mobilization of the bladder with a combination of sharp and blunt dissection frees the bladder from the lower uterine segment and upper vagina. This reduces the incidence of damage to the bladder. By exercising extreme care in management of the uterine artery pedicle, the surgeon may minimize the risk of injury to the ureter. The same is true of the management of the cardinal and uetrosacral ligament pedicles. If the vaginal cuff is left open with the edges sutured, the incidence of postoperative pelvic abscess is dramatically reduced.

. the Pfannenstiel incision is an adequate alternative to the midline incision. midline incisions are preferred for malignant disease. and the bowel is packed off with warm. After the abdomen is entered. since they allow accurate staging and exposure to the upper abdomen and aortic lymph nodes. This is frequently impossible when the patient is examined in the gynecologic clinic. In general. kidneys. This is extremely important because it allows the surgeon to become acquainted with the anatomy of the internal genitalia. The patient is then put in approximately a 15° Trendelenburg position. and aortic lymph nodes. The uterus is deviated to the patient's right. moist gauze packs. gallbladder. the midline incision should be extended around and above the umbilicus for appropriate exposure. For benign disease. Self-retaining retractors are placed in the abdominal incision. If investigation of the upper abdomen and aortic lymph nodes is needed. A Foley catheter is left in the bladder and connected to straight drainage. A 0 synthetic absorbable suture is placed in the fundus of the uterus and used for uterine traction. The left round ligament is placed on stretch and incised between clamps. it should be thoroughly explored. including the liver. and an adequate pelvic examination is performed with the patient under general anesthesia. stomach.Technique/Procedure The patient is placed in the dorsal lithotomy position.

or pelvic irradiation. previous cesarean sections. At this point the leaves of the broad ligament are opened both anteriorly and posteriorly. While retracting the uterus cephalad. This is performed by delicate dissection with the Metzenbaum scissors. the surgeon opens the anterior lead of the broad ligament to the vesicouterine fold.The distal stump of the round ligament is ligated with 0 synthetic absorbable suture. If there has been extensive lower segment disease. The bladder can be dissected off the lower uterine segment of the uterus and cervix by either blunt or sharp dissection. The vesicoperitoneal fold is elevated. and a sharp dissection technique should be performed. Steps 2-4 are carried out on the opposite side. The proximal stump is held with a straight Ochsner clamp. and the fine filmy attachments of the bladder to the pubovesical cervical fascia are visible. . blunt dissection of the bladder off the cervix is dangerous.

transverse. the uterus is retracted toward the pubic symphysis and deviated to one side with the infundibulopelvic ligament. The filmy tissue surrounding the uterine vessels is skeletonized by elevating the round ligament and dissecting the tissue away from the uterine vessels. The distal stump of this structure is best doubly tied. This is best performed by placing the tips of the curved Ochsner clamps onto the uterus and allowing them to slide off the body of the uterus. and tied with 0 synthetic absorbable suture.If the ovaries are to be preserved. The same procedure is carried out on the opposite side. curved incision is made in the pubovesical cervical fascia overlying the lower uterine segment. The middle Ochsner clamp is left in place and is similarly suture-ligated by a second ligature placed at the tip of the Ochsner clamp and tied behind the base of the clamp. tube. The separation of the pubovesical cervical fascia from the underlying cervical stroma is facilitated by placing traction on the uterus in the cephalad position. A finger should be inserted through the peritoneum of the posterior leaf of the broad ligament under the suspensory ligament of the ovary and Fallopian tube. This is suture-ligated with two 0 synthetic absorbable sutures. Three curved Ochsner clamps are placed at the junction of the lower uterine segment on the uterine vessels. first with a single tie of 0 synthetic absorbable suture and then with a ligature of 0 synthetic absorbable suture. The uterus is then retracted cephalad and deviated to one side of the pelvis with the lower broad ligament on stretch. incised. thus ensuring complete clamping of the uterine vessels. The tube and suspensory ligament are doubly clamped. and ovary on tension. placing the first suture at the tip of the lower Ochsner clamp and tying the suture behind the base of the clamp. since it contains blood vessels and a pedicle hematoma can be created. The same procedure is carried out on the opposite side. . No attempt is made to place a suture in the middle of the pedicle. A delicate. An incision is made between the upper Ochsner clamp and the two lower Ochsner clamps.

The suture is tied at the base of the clamp.The uterus is held in traction in the cephalad position. The cardinal ligament is incised between the two clamps. The same procedure is carried out on the opposite cardinal ligament. This step mobilizes the ureter laterally and caudally Two straight Ochsner clamps are applied to the cardinal ligament for a distance of approximately 2 cm. The posterior leaf of the broad ligament is incised down to the uterosacral ligaments and across the posterior lower uterine segment between the rectum and cervix . and the handle of the knife is used to dissect the pubovesical cervical fascia inferiorly. and the distal stump is ligated with 0 synthetic absorbable suture. no attempt is made to place this suture within the body of the pedicle because vessels can be torn and hematomas created.

and the lower uterine segment and upper vagina are palpated between the thumb and first finger of the surgeon's hand to ensure that the ligaments have been completely incised. The edges of the vagina are picked up with straight Ochsner clamps in a north. The uterus is placed on traction cephalad.The uterosacral ligaments on both sides are clamped between straight Ochsner clamps. and west direction. The vaginal cuff is never closed in our clinic. This alone has accounted for a radical decrease in postoperative febrile morbidity and abscess formation. incised. which are sutured into the angle of the vagina. c. The edges of the vaginal mucosa are sutured with a running locking 0 synthetic absorbable suture starting at the midpoint of the vagina underneath the bladder and carried around to the stumps of the cardinal and uterosacral ligaments. The running locking suture is carried around the posterior wall of the vagina ensuring that the rectovaginal space is obliterated. and ligated with 0 synthetic absorbable suture. The uterus is removed. At this point. and the reefing process has been completed to the midpoint of the anterior vaginal wall. east. a. b. south. . The cardinal and uterosacral ligaments of the opposite side have been included in the running locking 0 synthetic absorbable suture. The vagina is entered by a stab wound with a scalpel and is cut across with either a scalpel or scissors.

Drains are rarely needed. If the tube and ovary are to be removed. suspensory ligament of the ovary. At this point. The stumps of the tubo-ovarian round. This can be a site of hemorrhage. If they are indicated. Meticulous care is taken to ensure that hemostasis is present throughout the dissected area. and the cardinal and uterosacral ligaments are buried retroperitoneally.meticulous care should be taken to ensure that the lateral angle of the vagina is adequately secured and that hemostasis is complete between the lateral angle of the vagina and the stumps of the cardinal and uterosacral ligaments. The pelvis is reperitonealized with running 2-0 synthetic absorbable suture from the anterior to the posterior leaf of the broad ligament. they are placed through the open vaginal cuff and carried along the lateral pelvic wall retroperitoneally. they are removed at Step 6 in the . the pelvis is thoroughly washed with sterile saline solution.

etc. Postoperatively.operation. Instead of placing a finger underneath the tube and suspensory ligament of the ovary. and no Foley catheter drainage of the bladder is indicated. .). The remainder of the operation is carried out as described in Steps 7-13. The patient is allowed to resume sexual intercourse 4 weeks after examination in the clinic and is allowed to resume work 5 weeks postoperatively. The tube and ovary have been mobilized medially with the uterine specimens. In various forms of pelvic disease (endometriosis. the same procedure is carried out on the opposite infundibulopelvic ligament. Rarely. a small bit of granulation tissue is noted in the upper vagina and is adequately treated by application of silver nitrate 4 weeks postoperatively in the clinic or office. the ureter can be deviated close to the infundibulopelvic ligament. The infundibulopelvic ligament is doubly clamped and incised. no vaginal packing is left in the vagina. The peritoneum of the pelvis has been reestablished with the tube and ovary removed. and the distal stump of the ligament is doubly ligated with a tie of 0 synthetic absorbable suture plus a ligature of 0 synthetic absorbable suture. Care is taken to ensure that the ureter is not included. a finger is placed under the infundilbulopelvic ligament on that side. The stump of the infundibulopelvic ligament is buried retroperitoneally. For a bilateral salpingo-oophorectomy. The open vaginal cuff closes without difficulty. pelvic inflammatory disease.

 Return the patient’s leg to their original position.  Apply electrosurgical dispersive pad.Indications     Endometrios Benign Uterine tumors (Leiomyomas) Endometrial or Uterine Cancer Ovarian Cancer Preoperatively • Before the patient is brought back to the room. and replace the safety belt. Skin Preparation  A vaginal and an abdominal preparation are required.  Insert a Foley catheter and connect to continuous drainage.  Put the patient’s legs in a frog-like position and prepare as for Dilatation and Curettage. arms may be extended on arm boards. she may perform the abdominal and vaginal prep with an iodine or chlorhexidine solution. and down to the tables at the sides Draping o Folded towel and a transverse or laparatomy sheet MANAGEMENT Pre-Operation • Secure consent • Interprets and upholds administrative body. • She then gowns and gloves the surgeons and helps with draping. Preparation and Positioning of the Patient  The patient is supine. policies and procedures as determined by • Identify knowledge and skills of peri-operative nursing. • After the patient is brought back to the room and anesthetized.  For abdominal preparation using iodine solution. the scrub nurse makes sure that the proper instruments and supplies are available for the procedure. . • She opens the appropriate sterile packs and trays before scrubbing in to organize and count them. begin at the incision extending from nipple to mid-thighs.

prepares and send specimen obtained during operation for examination. equipment’s and supplies. maintenance and care of equipment and instrument. Responsible for the upkeep. if can move extremities every 15 minutes (or as often as possible or as indicated by the patient’s condition) on the Nurse’s Post Anesthesia Record. Diligently carries out doctor’s orders as soon as possible. providing maximum safety and comfort. Assess patient’s stability and should know to report to the attending physician/s. Administer post-operative care. temperature. shock. thyroid storm and cardiac arrest. Caries out doctor’s post-operative order diligently. Responsible for endorsing such items to patient’s relatives or floor nurse. Notifies the anesthesiologist immediately for any unusual symptoms manifested by the patient. respiratory rate. Submits sundry report and account for the supplies and equipment used. thus.    . Informs appropriate personnel when supplies are needed or equipment and instruments are out of order. Observes keenly the patient’s who might undergo post-operative complications like bleeding. checks and record patient assessment and refer when necessary. Observes and records neuro vital signs for neurological cases on the neurological vital signs form provided by the unit. respiratory distress. color and condition of skin.Intra-Operation           Ensure quality of care through proper use of instruments. Post-Operation     Responsible for all the safekeeping of patients personal belongings endorse by OR nurse. Observes. Check and record vital signs – blood pressure. pulse rate. Observes proper positioning of the patient and maintaining the dignity of the individual As well. O2 saturation. Identifies.

INSTRUMENTS Grasping/Clamps/Forceps/Retractor Heaney forcep Mixter Kelly Debakey Balfour Richardson Deaver Malleable .

2 needle holders Thumb Forceps. This kind of forceps provide a strong hold on tough tissues. and delicate or heavy Toothed Forceps. 2 suture scissors. 2 tissue forcep. Its jaw can be straight or curve. Used to grasp tissue and is available also in long sizes. straight or bayonet (angled). appendix.mayo. 5 towel clips Kocher (Ochsner). Used to hold drapes. Backhaus towel clip. most especially the skin. Unlike the thumb forceps with serrations.5 allis. most especially towels in place The sharps (16): long thumb. army navy. ovary. metz. They are tapered and have serrations or grooves at the tip. . 2 thumb forcep.5 kochers straight. also available in long sizes Allis Forcep. Bobcock forcep. Utilized to grasp delicate tissue such as intestine. They can be short or long. fallopian tube. 5 bobcock. Army Navy Retractor (also called right angle retractor/US Army retractor). Use to retract superficial or shallow incision. they have row of multiple teeth at the top or single tooth on one side that fits between the two teeth on the other side. 2 blade holders #4. we also utilize this to hold a peanut. Used to grasp heave tissue and can be also used as a clamp. They looked like tweezers.

orsupply. muscle.r:53 .ph/imgres?q=grasping+instruments+for+tah+ bso&um=1&hl=fil&sa=X&tbo=d&biw=1280&bih=648&tbm=isch&tbni d=0_zEXcYbwWYR3M:&imgrefurl=http://girlinscrubs.com. uterus.we often use this during OB-Gyne Procedure Metzenbaum Scisoors (Metz).html  http://www.com/doc/36487576/TAH-BSO  http://www.com/5Uterus/10TotalAbdominalHyst erectomy/chap5sec10.bp.scribd.Blade 4 (for Blades Size 20 and above).google. Use to cut heavy tissues such as fascia.i:239&tx=118&ty=41 .atlasofpelvicsurgery.com/ _4cCd4HHPR90/TNaZKU_TN9I/AAAAAAAAAJ8/TzPvIyxgZs/s1600/Photo0046.jpg&w=1600&h=1200&ei=zJDxUMeTOoLukQWi wIDgDA&zoom=1&iact=rc&dur=556&sig=105734889608851269354 &page=3&tbnh=134&tbnw=174&start=50&ndsp=30&ved=1t:429.s:0.com/product/Hysterectomy-Surgical-InstrumentSet/16625  http://www. breast) .html&docid=KNxij5VtAVvfZM&imgurl=http://4.com/2 010/11/major-basic-set-operatingroom. Use to cut the skin Suture Scissor. Use to cut suture and supplies Mayo Scissors (curve). Utilized to cut delicate tissues Sources:  http://www.blogspot.blogspot.