Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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Figure 97-3 demonstrates the parts of the uterus.

The uterine corpus has two horns laterally.

The internal cervical os is where the uterine arteries enter the uterine body.

The external cervical os is at the junction with the vagina.

Figure 97-4 demonstrates the cervicovesical potential space that separates the bladder from the cervix.

STEP 2: PREOPERATIVE CONSIDERATIONS

Several laboratory tests should be documented as part of the preoperative evaluation for a hysterectomy.

Pap smear to exclude invasive cervical carcinoma

Negative pregnancy test in women of reproductive age

Endometrial biopsy revealing no malignancy in a woman with abnormal uterine bleeding

Indications for concomitant bilateral salpingo-oophorectomy (BSO) should be discussed with the patient. In general, BSO is recommended in any woman older than the age of 40 to 45 years or in a younger woman with familial or hereditary breast or ovarian cancer risk or severe endometriosis.

Prophylactic antibiotics are indicated because the peritoneal cavity is contaminated by the vaginal incision to remove the cervix.

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STEP 3: OPERATIVE STEPS

1.INCISIONS

A vertical skin incision allows for excellent exposure, as well as the ability to extend the incision to the upper abdomen, at the expense of cosmetic result and an increased rate of wound complications.

A transverse skin incision allows for adequate exposure in the pelvis. Three transverse incisions are available to the pelvic surgeon, depending on the body habitus of the patient and the uterine pathology. Figure 97-5, A, depicts the skin incision for all transverse incisions, 1 to 2 cm above the symphysis pubis extending approximately 6 cm to both sides of the rectus abdominis muscles. This incision is carried down to the anterior rectus sheath or fascia (Figure 97-5, B). The fascia is then incised, also transversely, for the length of the incision. After the fascial incision, the procedures diverge.

The Pfannenstiel skin incision is the most popular transverse skin incision and is appropriate for removal of a normal-sized uterus. The rectus muscles are dissected from the anterior rectus sheath in both the cephalad and caudad directions (Figure 97-5, C). The posterior rectus sheath is then opened vertically at the midline (Figure 97-5, D), the rectus muscles are retracted laterally, and the exposed peritoneum is opened the length of the incision to expose the pelvis.

Pubic tubercle

Pyramidalis muscle

Pfannenstiel incision

Inferior epigastric artery

Rectus abdominis muscle

A

FIGURE 97–5

C H A P T E R 97 • Abdominal Hysterectomy 1073

Rectus sheath

B

Rectus sheath

C

Transversalis

fascia

Inferior epigastric vessels

D

FIGURE 97–5, cont’d

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The Maylard and Cherney transverse incisions are used when a larger opening in required than that allowed by the Pfannenstiel. In comparison with the Pfannenstiel incision the rectus muscles must not be separated from the anterior fascia or rectus sheath in either incision.

For the Maylard incision, after the transverse skin incision, the inferior epigastric vessels are ligated bilaterally, lateral to the rectus muscles (Figure 97-6). After the blood supply has been secured, the rectus muscles are transected. To avoid retraction of the muscles cephalad, the anterior sheath must remain attached. The posterior fascia and peritoneum are then incised the length of the incision. For the closure, because the muscles were not separated from the anterior rectus sheath, they are reapproximated by the fascial closure.

Inferior epigastric vessels

Dividing pyramidalis and rectus muscles

FIGURE 97–6

C H A P T E R 97 • Abdominal Hysterectomy 1075

For the Cherney incision, after the transverse skin incision, the rectus muscle is transected at its tendon, near its insertion to the pubic bone (Figure 97-7). As with the Maylard, to avoid retraction of the muscles cephalad, the anterior sheath must remain attached. The posterior fascia and peritoneum are then incised the length of the incision. For the closure, the tendons are reapproximated with 0 interrupted absorbable

sutures. A limitation to the Cherney incision is that many women do not have a welldemarcated rectus abdominis tendon. In these cases, the Maylard incision is a better option.

Rectus abdominis tendon

A

Pyramidalis and

rectus tendon

B

FIGURE 97–7

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2. DISSECTION

The operative field is prepared by placing the patient in Trendelenburg position, inserting a self-retaining retractor to expose the pelvis, and packing the intestines away from the operative field with moist laparotomy pads.

The uterus is grasped with atraumatic curved clamps placed on the uterine horns bilaterally for traction. Each of the next steps is performed on each side of the uterus before advancing to the next step. Delayed absorbable suture of the appropriate caliber for the size of the pedicles (2-0 or 0) is used throughout.

The broad ligament is opened, starting with the round ligament ligation bilaterally

(Figure 97-8).

If the adnexal structures are not to be removed, they are separated from the uterus by ligation of the utero-ovarian ligament (Figure 97-9).