-Chapter 57

Total Abdominal Hysterectomy and Bilateral SalpingoOophorectomy

Ellen C. Wells

Ellen C. Wells, MD
Assistant Professor, Division of Gynecology, University of North Carolina, Chapel Hill, North Carolina (Vol 1, Chaps 11, 57)

INTRODUCTION

The Balfour retractor is placed. Care should be

taken that the ends of the blades do not rest heavily
on the psoas muscle because the femoral and
genitofemoral nerves can be compressed. The bowel
is lifted out of the cul-de-sac with the operator's
right hand. The left hand is then used to position
the edge of an opened laparotomy pad under the
suspended bowel. This laparotomy pad is then
draped across the bowel, covering it from right to
left gutters like an apron, with the remaining edge
tucked under the anterior abdominal wall. A rolled
laparotomy pad is then placed immediately laterally
in each gutter and pushed directly cephalad to
ensure that no bowel escapes down these lateral
margins. An upper blade is attached to the Balfour
to maintain this position. This blade should be flat
and perpendicular to the abdominal wall and not
allowed to rest on the aorta and vena cava. A wide,
TECHNIQUE
curved Deaver retractor is used to hold back the
Preparing the Surgical Field
bladder. This can be held by an assistant and
The operation is performed with the patient in the
moved from right to left to assist with visualization
supine position. Some surgeons prefer a modified
on each side as the hysterectomy progresses.
lithotomy position using Allen universal stirrups to
The Round and Broad Ligaments
allow potential access to the vagina and closer
A Kelly clamp is placed immediately lateral to the
proximity of a second assistant. A pelvic exam
under anesthesia is routinely performed. This exam uterus at each cornua and incorporates the isthmic
portion of the fallopian tube and the utero-ovarian
further delineates the existing pathology and may
help with the selection of the type of incision. It also ligament within its grasp. Bilateral clamps in this
position will allow for elevation, traction, and
provides the examiner with immediate feedback on
rotation of the uterus, which will aid in visualization
interpreting abnormal findings. The vagina and
and dissection. The round ligament is grasped with
urethra should be prepped and a Foley catheter
a Kocher clamp midway between the uterus and the
placed for straight drainage. A low transverse
internal inguinal ring. A transfixion suture of 2-0
abdominal incision can be used if cancer is not
delayed absorbable suture is placed through the
suspected. This incision can be converted to a
Maylard or Cherney incision if increased exposure is distal portion of the round ligament and tagged (Fig.
1). A second suture and/or large hemoclip may be
necessary. In cases of known or suspected
placed across the proximal portion of the round
malignancy, a vertical incision is preferred to allow
ligament to prevent back-bleeding. The round
increased exposure to the upper abdomen and
ligament is transsected and the anterior leaf of the
improved visualization for appropriate biopsies and
broad ligament is incised toward the level of the
node dissection.
internal cervical os with Metzenbaum scissors. This
When the surgeon enters the peritoneal cavity, the
will begin the development of the bladder flap (Fig.
upper abdomen is explored by visualization and
2). The posterior leaf of the broad ligament may
palpation to identify any adhesions or masses. A
also be incised parallel to the infundibulopelvic
systematic check includes the liver edge,
gallbladder, stomach, omentum, small bowel, colon, ligament toward the side wall. This exposure is
particularly helpful if the ovaries are to be removed.
kidneys, and paraaortic lymph node chain. Any
With traction of the uterus away from the side wall
adhesions are released to provide adequate
exposure to the pelvic anatomy. The Trendelenburg and lifting the tagged, round ligament upward and
lateral, the operator can separate the areolar tissue
position assists in maintaining the bowel out of the
within the broad ligament by spreading the index
operative field.
and middle fingers in a scissorlike manner.
Hysterectomy is the second most common major
surgical procedure performed in the United
States.1 Over one third of women in this country
have undergone a hysterectomy by the age of
60.2 The technique and route of delivery of the
uterus depend on a combination of factors, including
the anticipated pathology, the patient's body
habitus, the degree of pelvic relaxation, the need
for concurrent abdominal and vaginal procedures,
and the expertise of the surgeon. The abdominal
hysterectomy is a basic component in the
armamentarium of any pelvic surgeon. A standard
approach with emphasis on principles of surgical
technique is presented.
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Fig. 1. The round ligament is identified, clamped,
and transfixion sutured. This procedure initiates
the hysterectomy and allows entrance into the
broad ligament and retroperitoneum.(Thompson
JD, Rock JA: Telinde's Operative Gynecology, 7th
ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 2. The anterior leaf of the broad ligament is

incised toward the level of the internal os with
Metzenbaum scissors. Bilateral incisions meet in
the midline.(Thompson JD, Rock JA: Telinde's
Operative Gynecology, 7th ed, Ch 29.
Philadelphia, JB Lippincott, 1992)

The ureter is visualized on the medial leaf of the broad ligament in this space. If adhesive disease
impedes visualization here, the ureter can be identified at the pelvic brim where it crosses the iliac
vessels at their bifurcation. The ureter can then be followed downward through its course to ensure that
further dissection does not compromise its integrity (Fig. 3). The ureter appears as a white, nonpulsatile
tubular structure with fine blood vessels noted longitudinally on the adventitia. It is best identified by
visualization of its characteristic peristaltic activity. It can also be palpated by the operator's thumb being
placed deep on the intraperitoneal side of the posterior medial leaf of the broad ligament and the index
finger deep on the retroperitoneal side of this medial leaf. As the operator holds the index finger and
thumb together with the peritoneum trapped between and moves upward, the ureter will be palpable and

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demonstrates a rubber bandlike twang as released. This palpation can then guide the dissection to
achieve adequate visualization.
Fig. 3. The ureter crosses the iliac vessels at their
bifurcation, continues below the infundibulopelvic
ligament on the posterior medial leaf of the broad
ligament, and crosses under the uterine vessels before
turning anterior and medially to enter the bladder.

The Ovary and Fallopian Tube

The avascular portion of the posterior broad ligament lateral to the uterus, anterior to the ureter, and
posteromedial to the infundibulopelvic ligament is identified and tented upward with the index finger (Fig.
4). It can be bluntly or, if thickened, sharply entered. If the ovary and fallopian tube are not being
removed, this window allows isolation of the proximal fallopian tube and utero-ovarian ligament. These
structures are clamped with two Kelly clamps close to the uterus with care being taken that the lateral
clamp does not impinge on the ovarian capsule. The Kelly clamp on the uterus can be replaced so that its
tip extends into the window. The pedicle is cut, leaving two clamps laterally (Fig. 5). This allows the
pedicle to be free tied as one clamp is released, then transfixion sutured around the second clamp (Fig.
6).

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Fig. 4. The posterior broad ligament is tented
upward in the avascular space lateral to the
uterus, posteromedial to the adnexa and anterior
to the ureter. This space is entered to create a
window in the broad ligament.(Thompson JD,
Rock JA: Telinde's Operative Gynecology, 7th ed,
Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 5. If the ovary and fallopian tube are to be

conserved, two Kelly clamps are placed across the
fallopian tube and utero-ovarian ligament in close
proximity to the uterus. The Kelly clamp at the uterine
cornua is advanced so that its tip extends into the
window.(Thompson JD, Rock JA: Telinde's Operative
Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott,
1992)

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Fig. 6. A free tie is placed with removal of the lateral
clamp.A transfixion suture is then placed beneath the
second clamp.(Thompson JD, Rock JA: Telinde's
Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB
Lippincott, 1992)

When the ovary and fallopian tube are to be removed, the window produced in the broad ligament serves
to isolate the infundibulopelvic ligament, which is clamped with two Kelly clamps above the level of the
ureter. The most distal clamp is placed first. A third clamp immediately adjacent to the ovary and
fallopian tube prevents back-bleeding (Fig. 7). The ligament is cut above the two distal clamps. The distal
end is free tied and then transfixion sutured with 2-0 delayed absorbable suture. The proximal end is also
tied and may be suspended from the Kelly clamp on the uterus to prevent the ovary and tube from
obstructing the operative field.
Fig. 7. If the ovary and fallopian tube are to be
removed, three Kelly clamps are placed across the
infundibulopelvic ligament through the window in the
broad ligament.(Thompson JD, Rock JA: Telinde's
Operative Gynecology, 7th ed, Ch 29. Philadelphia,
JB Lippincott, 1992)

Developing the Bladder Flap

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The bladder flap is further developed by lifting the anterior peritoneum and retracting the uterus cephalad
to expose the bladder reflection and enter the vesicocervical space (Fig. 8). This space can be developed
bluntly if there is no scarring from previous surgery or adhesive disease. Otherwise, sharp dissection in
the midline is recommended. Excessive dissection in the anterolateral direction may disrupt the bladder
pillars (vesicouterine ligaments) and cause unnecessary bleeding. Care should also be taken not to cut
into the cervix when dissecting free the bladder, because this also creates extra bleeding. If the bladder is
densely adherent to the cervix in the midline, the lateral areolar spaces can be developed approaching the
midline to help define the appropriate plane between the bladder and cervix in prelude to sharp dissection.
In the most difficult cases, a small cystotomy in the dome of the bladder can be made to allow the
surgeon to insert a finger into the bladder and apply pressure to the bladder mucosa in the area being
dissected. The dissection can then be accomplished with full awareness of the proximity of the bladder.
Fig. 8. The bladder flap is developed by lifting the
anterior peritoneum and retracting the uterus
cephalad to expose the bladder reflection and enter
the vesicocervical space.(Thompson JD, Rock JA:
Telinde's Operative Gynecology, 7th ed, Ch 29.
Philadelphia, JB Lippincott, 1992)

After the surgeon mobilizes the bladder inferiorly, the pelvic ureter is palpable through its course beneath
the uterine artery lateral to the internal cervical os. Mobilization of the bladder is continued at intervals
during the remainder of the hysterectomy to ensure that it is completely free from the base of each
pedicle.
Uterine Vessels and Cardinal Ligaments
The uterine vessels are skeletonized by removing any overlying avascular areolar tissue and further
incising the posterior peritoneum toward the internal cervical os (Fig. 9). Incision of the peritoneum over
the posterior cervix between the uterosacral ligaments may be delayed until later to avoid extra bleeding.
This peritoneum may require no further mobilization if the reflection of the rectum is below the lower
margin of the cervix. The uterine vessels are triple clamped with curved Heaney clamps at the level of the
internal cervical os (Fig. 10). The lowest clamp is placed first. The vessels are cut with Mayo scissors,
leaving two clamps on the distal pedicle. This pedicle is ligated with a single suture, then a transfixion
suture of 0 delayed absorbable suture. The cardinal ligament is then approached with a straight Heaney
clamp placed medially to the previously ligated uterine vessels. The anterior portion of the clamp is placed
on the cervix in the vesicocervical space and the posterior portion on the cervix medial to the uterosacral
ligament (Fig. 11). As the clamp is closed, it is allowed to slide off the lateral surface of the cervix.
Because the ureter is located approximately 2 cm lateral to the cervix within the cardinal ligament, this
technique allows the minimal amount of lateral tissue to be incorporated into this pedicle and decreases
potential pulling or kinking of the ureter as the pedicle is tied. The cardinal ligament pedicle is cut with
the knife and transfixion sutured with 0 delayed absorbable suture. Depending on the length of the cervix,
several progressive bites with the straight Heaney clamp down each side of the cervix may be required
before reaching the level of the external cervical os. The uterosacral ligaments may be included with the

7
cardinal ligament pedicles or taken separately with a curved Heaney approaching the cervix from the
posterolateral direction (Fig. 12).
Fig. 9. The posterior peritoneum is incised
toward the posterior cervix at the level of the
internal cervical os. The uterosacral ligaments
join the cervix just beneath this level. Incision of
the peritoneum immediately posterior to the
cervix may be delayed until later to avoid extra
bleeding. This peritoneum between the
uterosacral ligaments may require no further
mobilization if the reflection of the rectum is
below the lower margin of the cervix.(Thompson
JD, Rock JA: Telinde's Operative Gynecology,
7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 10. The uterine vessels have been

skeletonized. Three curved Heaney clamps
are placed at right angles to the vessels. The
lowest clamp is placed first and is at the level
of the internal cervical os.(Thompson JD,
Rock JA: Telinde's Operative Gynecology, 7th
ed, Ch 29. Philadelphia, JB Lippincott, 1992)

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Fig. 11. A straight Heaney clamp is placed across the cardinal ligament
medial to the previously ligated uterine vessels. As the clamp is closed,
it is allowed to slide off the lateral surface of the cervix. Maintaining
close proximity to the cervix maximizes the distance between the
pedicle and the ureter.(Thompson JD, Rock JA: Telinde's Operative
Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 12. The uterosacral ligament may be approached with a

curved Heaney clamp from the posterolateral direction. The
ligament is then cut and ligated with 0 delayed absorbable
suture.(Thompson JD, Rock JA: Telinde's Operative
Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott,
1992)

Cervix Removal and Cuff Closure

A closed technique for removing the cervix from the upper vagina is beneficial in decreasing spillage of
vaginal contents into the abdomen. This technique decreases the risk of infection and the formation of
symptomatic granulation tissue at the vaginal apex. The lower edge of the cervix is palpated by placing
the operator's hand into the cul-de-sac with the palm facing the uterus, the index and middle fingers on
the posterior cervix and vagina, and the thumb on the anterior cervix and vagina. Palpation and
visualization in this area will ensure that the bladder and, if necessary, the rectum have been adequately
mobilized. A curved Heaney is placed across the lateral vaginal apex with its tip extending across the
upper vagina immediately beneath the cervix (Fig. 13). A similar placement on the other side allows the

9
two Heaney clamps to meet in the midline. If the vagina is wide enough that the two clamps do not meet,
then these pedicles can be cut and the procedure repeated across the remainder of the upper vagina.
Statinsky scissors provide a right-angle cut that is ideal for transsecting these pedicles. Removal of the
uterus is thus achieved. The pedicle within the curved Heaney clamp is then transfixion sutured with 0
delayed absorbable suture. The vaginal angle sutures are tagged. The anterior and posterior vaginal
mucosa is trapped within the clamp by this technique and does not need to be identified separately. If,
however, a clamp slips loose, the anterior and posterior vaginal mucosa must be identified and
incorporated into the closure to prevent these edges from continuing to bleed into the vagina.
Fig. 13. The bladder and, if necessary, the rectum
have been adequately mobilized. A curved Heaney
clamp is placed across the lateral vaginal fornix with
its tip extending across the upper vagina
immediately beneath the cervix.(Thompson JD, Rock
JA: Telinde's Operative Gynecology, 7th ed, Ch 29.
Philadelphia, JB Lippincott, 1992)

Reperitonealization is not necessary unless hemostasis of the peritoneal edge is a concern. New
mesothelium arises from the subperitoneal connective tissue cells, not the adjacent peritoneal edge, 3 and
occurs simultaneously in all exposed areas independent of the size of the defect.4 A smooth, glistening
surface is visualized within 5 days.3 Attempts to cover areas of peritoneal injury may lead to increased
adhesion formation at the sites of reperitonealization by preventing autolysis of early fibrinous
attachments5 and introducing reactive responses to suture material.6
In cases where drainage of the pelvic cavity through the vagina is desired, such as surgical intervention
for active pelvic inflammatory disease unresponsive to antibiotic therapy, an open vaginal cuff with a drain
is appropriate. This technique involves identifying the anterior vagina in the midline. The full thickness of
the vaginal wall is grasped and held with a long Allis clamp. The vagina above this clamp is entered
sharply. One blade of the Mayo or Statinsky scissors is placed within the vagina immediately beneath the
cervix. The vagina is circumferentially cut to completely remove the cervix and uterus. As the vagina is
being cut, long Allis clamps are placed at both vaginal angles and on the anterior and posterior vaginal
walls (Fig. 14). Angle sutures of 0 delayed absorbable suture are placed, incorporating the full thickness of
the anterior vaginal wall, the adjacent cardinal ligament and uterosacral ligament, and the posterior
vaginal wall. A suture of 0 delayed absorbable suture is placed from inside to out through the full
thickness of the vagina beneath its cut edge, locked over the edge, and continued circumferentially around
the top of the vagina for hemostasis (Fig. 15). A T-tube or Malincrot drain is placed through this open cuff
with its end extending into the vagina. The anterior and posterior peritoneum are reapproximated with a
continuous suture over the drain to maintain it in a retroperitoneal position.

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Fig. 14. The vagina is incised circumferentially just
beneath the cervix. Long Allis clamps are placed on the
vaginal angles and on the anterior and posterior vaginal
walls.(Thompson JD, Rock JA: Telinde's Operative
Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott,
1992)

Fig. 15. The angle suture

incorporates the full thickness
of the anterior vaginal wall, the
adjacent cardinal and
uterosacral ligament, and the
posterior vaginal wall. A suture
is then placed through the full
thickness of the vagina
beneath its cut edge, locked
over the edge, and continued
circumferentially around the
top of the vagina for
hemostasis.(Thompson JD,
Rock JA: Telinde's Operative
Gynecology, 7th ed, Ch 29.
Philadelphia, JB Lippincott,
1992)

Inspection and Assessment of the Cul-De-Sac

Meticulous attention should be directed to
hemostasis. The abdomen is copiously irrigated and
each pedicle inspected. The bladder is gently lifted
and its base visualized. Cautery or excessive
suturing at the bladder base should be avoided
because subsequent necrosis could predispose to
fistula formation. Any bleeding areas at the uterine

vessels or cardinal ligament should be grasped with

an Allis clamp and resutured within the suture line.
Additional suturing outside this line requires reevaluation of the proximity of the ureter.
Intravenous indigo carmine coupled with a small
cystotomy incision to visualize dye extrusion from
both ureteral orifices will rule out a complete
obstruction in difficult cases. The cystotomy incision

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also allows retrograde placement of a ureteral
catheter to identify the presence and location of
suspected occlusion. The catheter placement may
be particularly helpful in diagnosing partial occlusion
or kinking of the ureter, which would benefit from
surgical release and may not be detected with the
indigo carmine test.
Attention should be directed in each case to the
prevention of pelvic relaxation. When the cul-de-sac
is noted to be deep, uterosacral ligament plication
can be performed as well as a Moschowitz
procedure with two concentric purse-string sutures
of medium silk below the level of the ureters. The
Halban technique of approximating the anterior to
the posterior peritoneum in the cul-de-sac or a
zigzag from right to left pulling the anterior to the
posterior peritoneum is an alternative in cases
where a Moschowitz would cause undesired pulling
or kinking of the ureters. Obliteration of the cul-desac is particularly useful when a retropubic urethral
suspension such as the Marshall-Marchetti-Krantz
(MMK) or Burch procedures is performed. These
procedures, by their marked displacement of the
anterior vaginal wall, predispose to future
enterocele formation.
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jeopardize their health. Some women will grieve the

loss that they associate with the removal of the
womb and should be given the opportunity to
acknowledge and work through this prior to surgery.
Prophylactic Oophorectomy
Preoperative discussion should also include an
assessment of whether the ovaries will be removed.
If the ovaries are found to contain no pathology,
then the decision to retain or remove them must be
based on an informed discussion of the risks and
benefits of removal and the management of
hormone replacement. Most physicians recommend
their removal when a woman is in the
postmenopausal age. Premenopausal women will
weigh their risks and benefits somewhat differently
depending on how close in years they feel they are
to menopause, their perception of previous
symptoms that could be attributed to their ovaries,
their family history of cancer, and their own
placement of value on the natural hormones from
the ovary versus hormone replacement therapy.
Although elective oophorectomy at the time of
hysterectomy for women ages 35 to 45 reduces the
risk of future ovarian cancer, this benefit may be
outweighed by the risk of osteoporosis and
cardiovascular disease if she is noncompliant with
the recommended estrogen replacement.7 However,
many women will remain compliant on estrogen and
DISCUSSION
will feel comfortable simply initiating hormone
Preoperative Evaluation
replacement a few years earlier than they would
The indications for hysterectomy in each patient
should be appropriate and well documented. Medical have if waiting for a natural menopause. These
women will look to their physicians for reaffirmation
management should have been determined to be
of the benefits of estrogen replacement and seek
unsuccessful or unacceptable prior to
their encouragement to continue with estrogen
recommending surgical intervention. Women with
replacement therapy in the subsequent years.
heavy or irregular bleeding who are over age 35 or
Laparoscopic Hysterectomy
have risk factors such as obesity, nulliparity, or
The role of laparoscopy in performing a
chronic anovulation require endometrial sampling
prior to their procedure. A recent Pap smear should hysterectomy has dramatically expanded in recent
years but has come under increasing scrutiny
be available, with any abnormality appropriately
evaluated. A preoperative intravenous pyelogram in regarding its benefits in certain clinical settings and
its overall cost-effectiveness. A laparoscopicselected cases may reveal ureteral obstruction,
hydronephrosis, or a nonfunctioning kidney. Rarely, assisted vaginal hysterectomy (LAVH) is not a
substitute for a vaginal hysterectomy. As a surgeon
a duplicated collecting system is identified. This is
develops expertise and experience with vaginal
not, however, a substitute for intraoperative
surgery, the number of patients for whom he or she
identification of the ureter.
offers a vaginal approach increases. Other patients
Each patient should also be evaluated
will have pathology or coexisting abnormalities that
preoperatively for any other gynecologic conditions
require an abdominal incision. The laparoscope
that could be addressed at the time of her surgical
therefore assists the vaginal hysterectomy and
procedure, particularly pelvic relaxation and stress
avoids an abdominal incision when suspected or
incontinence. A hemoglobin and hematocrit should
uncertain adnexal pathology or adhesive disease
be obtained early in her surgical evaluation.
might otherwise preclude a strictly vaginal
Preoperative management of anemia may improve
her surgical outcome and decrease her potential for approach. The visualization provided allows for
dissection and removal of the adnexa and the
requiring a transfusion. Most women will also
release of any adhesive disease. If no pathology
appreciate being given the option of donating
exists that requires operative laparoscopy, then a
autologous units of blood if the delay will not
simple vaginal hysterectomy is performed.

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The Difficult Hysterectomy
When extensive pathology exists, the surgeon must
alter the approach with full awareness of normal
anatomy and the deviation from normal that has
been produced by this pathologic process.
Fundamental principles in removing an organ
include isolation and ligation of its blood supply and
dissection and removal from the surrounding tissue
without injury to adjacent vital organs, nerves, or
vessels. The ability to identify the ureter outside
the area of pathologic changes and to follow its
course through the field of dissection is essential. A
retroperitoneal approach is extremely helpful in the
isolation and removal of adherent adnexa. The

ureter should be left attached to the peritoneum as

much as possible but can be isolated from it if the
adjacent pathology is densely adherent. If extensive
bowel adhesions are suspected, the bowel should be
appropriately prepared. An enterotomy can then be
primarily closed with drainage established and a
temporary colostomy avoided. Thorough knowledge
and recognition of the anatomy will allow the
surgeon to alter the standard hysterectomy as
required by existing pathology with the minimum
potential for injury or morbidity in these difficult
cases.
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REFERENCES
1. Graves EJ: National hospital discharge survey: Annual summary, 1990. National Center for Health
Statistics. Vital Health Statistics Series 13, Number 112, 1992
2. Pokras R, Hufnagel VG: Hysterectomies in the United States, 1965-1984. National Center for Health
Statistics. Vital Health Statistics Series 13, Number 92, 1987. DHHS Publication No. (PHS) 871753
3. Raftery AT: Regeneration of parietal and visceral peritoneum: An electron microscopical study. J Anat
115: 375, 1973
4. diZerega GS: The peritoneum and its response to surgical injury. In diZerega GS, Malinak LR, Diamond
MP, Linsky CB (eds): Treatment of Post-Surgical Adhesions, pp 112. New York, Wiley-Liss, 1990
5. Buckman RF, Buckman PD, Hufnagel HV, Gervin AS: A physiologic basis for the adhesion-free healing of
deperitonealized surfaces. J Surg Res 21: 67, 1976
6. Hurd WW, Himebaugh KS, Cofer KF, Gauvin J, Elkins T: Etiology of closure-related adhesion formation
after wedge resection of the rabbit ovary. J Reprod Med 38: 465, 1993
7. Speroff T, Dawson N, Speroff L, Haber R: A risk-benefit analysis of elective bilateral oophorectomy:
Effects of changes in compliance with estrogen therapy on outcome. Am J Obstet Gynecol 164: 165, 1991
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