Saint Louis University

Baguio City
School Of Nursing
S.Y 2017-2018

Outline procedure for

Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy

Submitted by:
Dumagas, Jeanette Dimalanta. BSN-III C3
Submitted to:
Mrs. Maryknole Dumo Boadilla,RN

A Compilation of Academic Work

and
Other Forms of Educational Evidence

November 27, 2017

 Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy

TECHNIQUE

Preparing the Surgical Field

The operation is performed with the patient in the supine position. Some surgeons prefer a modified lithotomy position using Allen
universal stirrups to allow potential access to the vagina and closer proximity of a second assistant. A pelvic exam under anesthesia is
routinely performed. This exam further delineates the existing pathology and may help with the selection of the type of incision. It
also provides the examiner with immediate feedback on interpreting abnormal findings. The vagina and urethra should be prepped and
a Foley catheter placed for straight drainage. A low transverse abdominal incision can be used if cancer is not suspected. This incision
can be converted to a Maylard or Cherney incision if increased exposure is necessary. In cases of known or suspected malignancy, a
vertical incision is preferred to allow increased exposure to the upper abdomen and improved visualization for appropriate biopsies
and node dissection.

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)

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.

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)

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)

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)

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)

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)
 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)

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)

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)

REFERENCE:
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) 87–1753