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Obstetrics & Gynaecology

Total Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy

1. What incision is used?


The Pfannenstiel Incision a transverse incision made just superior to the mons pubis through
the skin and subcutaneous tissue. This exposes the rectus sheath which is incised transversely.
This incision provides a low risk of wound complications (eg. incisional hernia, wound
dehiscence and significant scarring).

2. How many layers does the rectus sheath have?


2 layers - an anterior and a posterior layer, which encase the rectus abdominis. However below
the arcuate line (located approximately midway between the umbilicus and the pubis), and
hence at the level of the Pfannenstiel incision, there is only an anterior layer.

3. Why are Kochers forceps used to grasp the rectus sheath?


They are toothed forceps and are used to grasp dense tissue/ fibrous sheaths.

4. Which muscles of the anterior abdominal wall would be seen?


The recti and pyramidalis muscles.
The rectus sheath contains the rectus abdominis muscle and the pyramidalis muscle- a
triangular muscle that lies anterior to the lower part of the rectus abdominis. These muscles are
separated at the midline and the peritoneum incised to access the central pelvis. (Posterior to
these muscles are the transversalis fascia, pre-peritional fat and the peritoneum).

5. Why are the round ligaments clamped first?


This is because they are the most anterior ligament. They are attached to the uterus
anteroinferiorly to the lateral coruna. The round ligament enters the inguinal ring, traverses the
inguinal canal, and terminates in the mons pubis above the labium majus.

6. Why are 2 curved artery forceps and 2 separate sutures used to clamp and suture the
infundibulopelvic (suspensory) ligament respectively?
This is because it contains the ovarian artery and vein (as well as lymphatics and nerves). 2 are
placed so that one can act as a back-up if the other becomes loose.

7. Where do the ovarian arteries originate?


They originate from the abdominal aorta inferior to the renal arteries.

Where do the ovarian veins drain?


The left ovarian vein drains into the left renal vein and the right ovarian vein drains into the
inferior vena cava.
8. How and why is the bladder deflected off of the cervix before the clamping of the uterine
pedicle?
The bladder is deflected off of the cervix and pulled down with a Deaver Retractor, before
clamping the uterine pedicle, to minimise injury to the bladder and ureter. It is deflected
downwards towards the middle to avoid trauma to the bladder pillars laterally, which could lead
to haemorrhage.

9. Why are 2 clamps are placed onto the uterine pedicle?


So that one can act as a back-up if the other were to loosen.

10. Which forceps are used to clamp the cardinal ligaments and what structure must be avoided
during ligation of these ligaments?
Lateral to the cervix are the cardinal ligaments (aka transverse cervical/ Mackenrodts
ligaments) which also extend from the lateral fornix of the vagina to attach to the pelvic wall.
Long straight Spencer Wells forceps clamp these ligaments which are then ligated, so that the
cervix can be removed from the vagina. The cardinal ligament is ligated starting from the lower
end while ensuring to avoid the ureter.

NB: The lower uterine segment can be distinguished from the upper uterine segment by looking
at the attachment of the vesicouteric fascia. At the lower segment, there is a loose fold of
vesicouteric fascia which is much more adherent in the upper segment.

11. Which forceps are used to clamp the vaginal edges?


Long Kochers forceps are clamped onto the vaginal edges to lift up the vagina for suturing.

12. How is the vaginal vault supported?


It is supported onto the cardinal and uterosacral ligaments to prevent vaginal prolapse.

13. How is the vagina closed and why?


It is closed with the vaginal edges facing superiorly. If the edges were to enter the vagina, vault
granulation tissue would occur which would present as post-coital bleeding. This is treated with
silver nitrate. Separate sutures are placed when closing the vagina (each suture runs from the
anterior surface to the posterior surface, and back to the anterior surface where a knot is tied).
Continuous suturing of the vagina is not done as this would lead to vault tenting which presents
as deep dyspareunia.

14. Tacking of the muscle can be done. However suturing would tear the muscle tissue.

15. Upon closing the rectus sheath, why is it important not to suture too close to the edge of the
rectus sheath?
This is to decrease the risk of a hernia. Intraoperatively, a finger can be placed along the rectus
sheath to ensure that no defects are present.
16. Why is a flavine swab (aka a happy swab) placed into the vagina pre-operatively?
To prevent ascending infection during the operation and to determine if haemorrhage is still
occurring when it is removed after the operation, by looking for the presence of heavy bright
red blood on the swab.

Additional Notes

The utero-oavrian ligament (aka the ovarian ligament) attaches the inferomedial surface of the
ovary to the lateral surface of the uterus. It is continuous with the medial border of the round
ligament, both of which are remnants of the gubernaculum.
The vesico-uterine pouch lies anterior to the uterus, and is formed by the deflection of the
peritoneum from the badder to the body of the uterus.
The recto-uterine pouch (pouch of Douglas, cul-de-sac) lies posterior to the uterus, and is formed
by the deflection of peritoneum from the uterus to the rectum.