1. A Pfannenstiel incision is used for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. This transverse incision is made above the pubic bone and exposes the rectus sheath.
2. The round ligaments are clamped first as they are the most anterior ligament attaching to the uterus. Then the infundibulopelvic ligaments, which contain the ovarian vessels, have two clamps and sutures placed to ensure hemostasis.
3. The bladder is deflected off the cervix with a retractor before clamping the uterine vessels to minimize risk of injury. Two clamps are also placed on the uterine pedicle
1. A Pfannenstiel incision is used for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. This transverse incision is made above the pubic bone and exposes the rectus sheath.
2. The round ligaments are clamped first as they are the most anterior ligament attaching to the uterus. Then the infundibulopelvic ligaments, which contain the ovarian vessels, have two clamps and sutures placed to ensure hemostasis.
3. The bladder is deflected off the cervix with a retractor before clamping the uterine vessels to minimize risk of injury. Two clamps are also placed on the uterine pedicle
1. A Pfannenstiel incision is used for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. This transverse incision is made above the pubic bone and exposes the rectus sheath.
2. The round ligaments are clamped first as they are the most anterior ligament attaching to the uterus. Then the infundibulopelvic ligaments, which contain the ovarian vessels, have two clamps and sutures placed to ensure hemostasis.
3. The bladder is deflected off the cervix with a retractor before clamping the uterine vessels to minimize risk of injury. Two clamps are also placed on the uterine pedicle
1. A Pfannenstiel incision is used for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. This transverse incision is made above the pubic bone and exposes the rectus sheath.
2. The round ligaments are clamped first as they are the most anterior ligament attaching to the uterus. Then the infundibulopelvic ligaments, which contain the ovarian vessels, have two clamps and sutures placed to ensure hemostasis.
3. The bladder is deflected off the cervix with a retractor before clamping the uterine vessels to minimize risk of injury. Two clamps are also placed on the uterine pedicle
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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.
