2024 Part VIII: Nongastrointestinal Transabdominal Surgery
A B
Fig. 3. The vesicouterine peritoneum is incised (A), and the bladder is pushed away from the cervix (B).
(Fig. 3A,B). This allows the bladder to then
be bluntly pushed in the midline inferiorly
off the cervix. If there are any adherent ar-
eas, they must be sharply dissected in order
to prevent bladder injury. This is commonly a
problem in women who have previously had
low segment transverse cesarean sec-tions. If
bladder damage is suspected at any time
during the operation, the bladder should be
filled with a sterile colored solu-tion, which
will quickly identify a cysto-tomy. One easily
obtained solution that will not permanently
stain the tissues is sterile nursery formula.
Dyes like methylene blue can also be used,
but if there is a cystotomy, the spilled dye
will attach to the pelvic tis-sues and they will
remain stained during the remainder of the
operation.
The surgeon can then bluntly dissect the
retroperitoneal space posterior to the round
ligament. This will allow visualization of the
iliac vessels on the lateral pelvic wall and the
ureter on the medial peritoneal fold. A
decision about retaining or remov-ing the
ovaries should be discussed with the patient
prior to surgery. In general, if the ovaries are
normal and the woman is 50 years of age or
older, it is recommended that they be
removed. Removal of ovaries in younger
women will reduce their estrogen and
androgen hormone levels and is not routinely
done unless there is obvious gross ovarian
pathology, a strong family history of ovarian
cancer, or a disease process where ovarian
hormones either aggravate the disease or may
in fact harbor the dis-ease, such as with
endometriosis or chronic pelvic infection.
If the ovaries are to be removed, then the
infundibulopelvic ligaments need to be
identified bilaterally, doubly clamped with
instruments like the Heaney clamps, cut, and
ligated (Fig. 4). Because there are many large
vessels in these ligaments, they are
first ligated with a free tie, and then a
suture ligature is placed distal to that first
tie for permanent closure. This prevents
the for-mation of a hematoma if the needle
should penetrate a vessel. If the ovaries are
to be preserved, the uteroovarian ligaments
are clamped, cut, and ligated in a similar
man-ner (Fig. 5). These ligaments should
be clamped as close to the uterus as
possible to reduce ovarian blood flow
disruption and ovarian hypofunction.
The broad ligament support of the uterus
is then excised from the top of the uterus in a
series of clamps onto the cardinal and then
vaginal mesentroid ligaments below the
cervix (Fig. 6). The number of clampings
needed will depend on the uterine size and
cervical length. Because the ureter passes
approximately 1.5 cm lateral to the uterus
Fig. 4. The infundibulopelvic ligaments are identi-
fied, clamped, cut, and sutured if the ovaries are to
be removed. Care is taken to avoid the ureter.
Fig. 5. The utero-ovarian ligaments are
clamped, cut, and sutured when the ovaries
are to be pre-served.
and under the uterine artery, it is important to
keep the clamp applied close to the uterus.
When clamping tissue in curved areas of the
uterus the Heaney clamp is use-ful, whereas
when clamping in straight ar-eas as along the
cervix a straight Ballantine clamp is helpful.
Clamping occurs in se-quence down the
broad ligament to the up-per vaginal cuff
area. After each clamp the tissue is cut and
then ligated with a trans-fixation ligature.
Each suture is cut after it is tied. In general,
absorbable (Vicryl, chro-mic) 0 or 1 suture is
used.
The hysterectomy can be done with
complete removal of the cervix, which is the
usual procedure (Fig. 7), or the cervix can be
left in place in a subtotal hysterec-tomy (Fig.
8A,B). If the latter procedure is selected,
cervical disease should have been excluded
with a normal preoperative pelvic
examination and Pap test. Retaining the
cervix may be elected in some patients based
on the theory that the cervix is im-portant for
orgasm or pelvic wall support. If there is
difficulty in dissecting off the blad-der or if
the patient develops significant in-
traoperative problems like cardiac arrhyth-
mias, the surgeon may decide to shorten the
operative time and leave the cervix. In some
cases of advanced ovarian cancer the cervix
is retained to prevent cancer growth into the
vagina. When the cervix is left, the
endocervical canal should be excised or
cauterized to prevent later bleeding from
retained endometrium.