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

C H A P T E R 97 • Abdominal Hysterectomy 1079

In preparation for ligation of the uterine artery, the surgeon cleans the retroperitoneal areolar tissue at the level of the internal cervical os to skeletonize the uterine vessels. The uterine vessels are clamped at the level of the internal cervical os, at a right angle to the cervix (Figure 97-12). For bleeding from the pedicle to be avoided, the tips of the heavy curved hysterectomy clamps should approximate and slide off the cervix. The pedicle is incised around the tip of the clamp to separate the ligated pedicle from the specimen and expose the cardinal ligaments.

Uterine bladder

Cervix

Uterine vessels

FIGURE 97–12

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After the uterine arteries have been ligated bilaterally, attention is brought to the cardinal ligament. Serial bites of this dense ligament are incised at its insertion on the cervix down to the vagina (Figure 97-13). To avoid retraction of this thick pedicle, use a straight hysterectomy clamp and incise a wedge-shaped pedicle, stopping 1 to 2 mm short of the tip of the clamp.

The uterosacral ligament is ligated at its insertion on the posterior cervix (Figure 97-14). These pedicles may be tagged for incorporation into the vaginal closure for added vaginal support.

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STEP 4: POSTOPERATIVE CARE

Bladder drainage is maintained until the first postoperative day.

Diet is advanced as tolerated.

Early ambulation is encouraged.

STEP 5: PEARLS AND PITFALLS

Avoid suturing through the middle of the uterine pedicle, because a vessel may be easily pierced, leading to a retroperitoneal hematoma.

In a patient with previous pelvic surgery or history of endometriosis or pelvic inflammatory disease, a mechanical bowel preparation should be ordered to prepare for extensive bowel lysis of adhesions.

Use the appropriate-length instruments and sutures based on the depth of pelvis and weight of the patient.

SELECTED REFERENCE

1. Rock JA, Jones HW (eds): TeLinde’s Operative Gynecology, 10th ed. Philadelphia, Lippincott Williams & Wilkins, 2008.

C H A P T E R 98

BILATERAL SALPINGO-

OOPHORECTOMY

Concepcion Diaz-Arrastia

STEP 1: SURGICAL ANATOMY

Figure 98-1 demonstrates the key anatomy of the uterus, fallopian tube, and ovary (adnexa) as it pertains to the removal of the adnexa.

The infundibulopelvic ligament carries the blood supply to the adnexa.

Round ligaments are insubstantial anterior lateral attachments of the uterine fundus that help maintain the normal uterine position. They are an important landmark in the opening of the retroperitoneum for identification of the ureters.

Utero-ovarian ligaments connect the uterus to the adnexa.

The ureters cross over the bifurcation of the common iliac arteries and are found inferior to the infundibulopelvic ligament on the medial leaf of the broad ligament. The ureter must be identified before ligation of the infundibulopelvic ligament.

Fallopian tube

Ovary

Infundibulopelvic

ligament

Uterosacral ligament

Ureter

FIGURE 98–1

1085

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STEP 2: PREOPERATIVE CONSIDERATIONS

The indications for salpingo-oophorectomy include excision of an ovarian mass or ovarian cancer prophylaxis.

Frozen section surgical consultation should be available for all cases of ovarian mass. If intraoperative diagnosis of ovarian cancer is made, the surgeon and patient should be prepared to proceed with ovarian cancer surgical staging or cytoreductive surgery as indicated.

STEP 3: OPERATIVE STEPS

1. INCISION

In cases of a suspected ovarian mass, a vertical skin incision is recommended to allow for excellent exposure, as well as the ability to extend the incision to the upper abdomen for exploration, surgical staging, or cytoreductive surgery.

A transverse Pfannenstiel incision or laparoscopic approach is acceptable for prophylactic salpingo-oophorectomy. (See Chapter 97 for discussion of transverse incisions.)

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 upward traction.

An L-shaped incision is made on the peritoneum of the posterior leaf of the broad ligament, parallel and posterior to the round ligament and lateral to the infundibulopelvic ligament (Figure 98-2). This avascular retroperitoneal space is developed by blunt dissection. The external iliac artery is identified on the lateral leaf, and the ureter is identified on the medial leaf, inferior to the infundibulopelvic ligament (Figure 98-3).

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Under visualization of the ureter, the surgeon makes a window in the medial leaf of the broad ligament, between the vascular infundibulopelvic ligament and the ureter, then clamps and incises the infundibulopelvic ligament (Figure 98-4).

Because of the vascularity of the infundibulopelvic ligament and the risk of an ascending retroperitoneal hematoma, the surgeon first ligates the pedicle with a free tie then transfixes the pedicle with suture ligation (Figure 98-5).