ONCE in a TAHBSO

SURGICAL STEPS IN ABDOMINAL HYSTERECTOMY(according to Williams)
1.Typically, general anesthesia is used,although regional anesthesia can be used.Patient is positioned supine,foley catheter is placed, and the vagina and abdomen are prepped.Then draping is done
2.Transverse (pfannensteil) or vertical incision for abdominal entry depending on indication
3.Placement of self-retaining retractor (in our institution,it is Balfour)then visual inspection visually and manually of the pelvis and abdomen.Bowel is packed from the operating field.Uterus is grasped with tenaculum
4.Curved Heaney clamps are placed in the round ligaments and is cut in between clamps.Transfixing suture using silk 2-0 is used distal to the clamps
5.The broad ligament then separates to create anterior and posterior leaves, and in between them,gauzy areolar connective tissue is seen.The leading medial and lateral edges of the anterior leaf are grasped with samooth atraumatic forceps.Tension on these edges is directed upward and outward.The tented anterior leaf then is incised sharply, with the line of curving inferiorly and medially to the level of vesicouterine fold.similarly, the posterior of the broad ligament is opened.the incision extends inferomedially toward the uterosacral ligaments.At this point,it is advantageous toidentify the ureters.
6.If the adnexa are to be preserved,the surgeon's index finger can be curved under the fallopian tube and uteroovarian ligament.Two Heaney clamps are placed lateral to the finger,with each clamp arc directed toward the uterus.Incision is done between the clamps.Free tie of 0-gauge delayed absorbable suture is placed around the more lateral of the two clamps.AS the knot of the suture is tied securely, the lateralk of the two clamps is removed.A transfixing suture then is placed around the remaining Heaney clamp.This suture is placed above and distal to the first free tie.As the knot is cinced in place,the heaney is left in place.The adnexa is now freed from the uterus
7.If the adnexae are to be removed, the tube and ovary are grasped w/ a Babcock clamp and elevated away from the infundibulopelvic ligament(IP).The peritoneum lateral to this ligament is incised and this incision is extended cephalad and laterally. ( The peritoneum medial to the IP was incised earlier as part of the posterior leaf of the broad ligament).Two curved Heaney clamps can be placed around the IP ,application is done proximal to the planned site of incision.Another ndistal clamp can also be placed.All arcs of the clamps are directed toward the site of incision.Then transection of the IP is done.A free tie 0-gauge delayed absorbable suture like silk is placed around the more proximal of the two Heaney clamps.A transfixing suture then is placed around the remaining heaney clamp.This suture is placed above and distal to the 1st free tie.As the knot is cinched in place, the remaining heaney clamp is removed
8.The peritoneum that connects to the superior edge of the bladder to the uterine isthmus was cut when the anterior leaf of the the broad ligament was opened.A hand can be wrapped around the uterus and a thumb used to exert pressure under the bladder and against the uterine surface inferiorly under the vagina .Counter tensions on the uterus is created by pulling upward on the Kelly clamp previously placed on the cornua.Similarly,A sponge stick can be used to create this pressure.In this way, the bladder can be separated from the underlying lower uterine segment and cervix.
Alternatively, some patients may have scar tissue connecting the posterior surface of the bladder to the anterior uterine surface.Sharp dissection with metzembaum scissor may detach the bladder from the isthmus.
9.UTERINE ARTERIES.> Excess connective tissue around these vessels is grasped w/ fine,smooth forceps.It is retracted laterally and away from the vessels.Curved metzenbaum scissor incise this tissue from superior to inferior.This is called skeletonization.Two curved Heaney clamps are placed on the uterine vessels inferior to the planned site of vessel transection.The clamp tips are placed horizontally across the vertical axis of the uterine vessels.A 3rd curved clamp is placed above the planned incision.Its tip crosses the vessels at 45-degree angle.A simple stich of 0-gauge delayed absorbable suture is placed below the lowest clamp's tip and the suture ends are wrapped to the heel of the clamp.As the knot is cinched, the middle of the three clamps is opened and then immediately closed.A simple stitch is placed above the first suture and below the middle clamp, which is removed as the knot is cinched .The upper clamp is left to prevent vessel bleeding from rich collateral circulation
10.FUNDAL AMPUTATION.fundus may be severed sharply from the isthmus and cervix.After removal of the corpus, Kocher clamps can be placed on the anterior and posterior walls of the uterine isthmus to elevate the cervix
11.CARDINAL LIGAMENT INCISION.These ligaments lie lateral to the uterus and are inferior to the uterine vessels.A straight Heaney clamp is used to clamp the cardinal ligament parallel to the side of the uterus.As the clamp is closed,it is angled 45degrees from the vertical axis of the uterus.A second clamp may be placed medial to the 1st.A scalpel is used to transect the portion of the cardinal ligament held between the clamps.A transfixing suture of 0-gauge non-absorbable suture is placed below the clamp.The medial heaney clamp if used is left in place to avoid bleeding.Because of the veeertical length and vascularity of the cardinal ligament,it may be necessary to repeat the step 11 .The cardinal ligament is ligated from its superior to inferior extent, using series of clamping and suturing down the lateral aspect of the uterus and upper vaginal vault
12.UTEROSACRAL LIGAMENT TRANSECTION.Upward tranction is exerted by kelly clamps on the uterine cornua .Each ligament is grasped w/ straight Heaney clamp close to its uterine attachment, as close to the uterus as possible to avoid the ureter.The ligament is severed medial to the clamp, a transfixing suture is placed and clamp is removed
13.VAGINAL ENTRY.The surgeon may palpate through the anterior and posterior vaginal walls to identify the most inferior level of the cervix.Curved Heaney clamps are used to grasp and bring together the anterior and posterior vaginal walls just below the cervix
14.REMOVAL OF THE UTERUS.the vaginal tissue above these clamps is incised and the vaginal tissue between these clamps is cut either w/ knife or mayo scissor.This frees the uteruis from the pelvis.Transfixing sutures are placed below the heaney clamps before they are removed
15.VAGINAL CUFF CLOSURE.A long length of 0-gauge delayed absorbable suture is used to join together the uterosacral ligaments pedicle and the vaginal apex pedicle on the right.A knot will cinch these together.Same is done on the left.The short end of the suture used to bind these pedicles are grasped w/ hemostats w/c are directed upward and laterally to create tension along the vaginal cuff.The anterior cut edge of the vagina then is reapproximated to the posterior cut vaginal edge w/ several figure-of eight sutures using 0-gauge delayed absorbable suture.The lateral elevating sutures are cut.
16.WOUND CLOSURE.Abdomen is closed in layers as usual