Video Clips on DVD
Total Abdominal Hysterectomy, Basic Techniques
Total Abdominal Hysterectomy, Endometriosis
Total Abdominal Hysterectomy, Fibroid Uterus
Over 500,000 hysterectomies were performed in the United States in 2003 for benign disease, of which two thirds were performed via the abdominal route ( ). Despite advancements in laparoscopy and data supporting vaginal hysterectomy outcomes, the abdominal route is still more popular than the vaginal and laparoscopic routes combined. Furthermore, despite advances in medical management and less invasive techniques for the treatment of benign gynecologic conditions such as menorrhagia, the rate of hysterectomy does not seem to be decreasing.
Once the decision to perform a hysterectomy has been made, the type and route of hysterectomy must be decided. Chapter 4 contains a detailed discussion on choosing the route of hysterectomy. Factors that lead to the choice of the abdominal route include vaginal shape and access to the uterus, uterine size and shape, extent of extrauterine disease, need for concurrent procedures, surgeon experience and preference, and patient preference. Generally speaking, abdominal hysterectomy for benign disease is indicated for the following: large fibroid uterus (especially when the uterus is broad), suspected presence of disease outside the uterus (adnexal disease, severe adhesive disease, endometriosis, bowel disease), and insufficient access to the vagina. Though many skilled laparoscopists would argue that laparoscopy should be used for the preceding indications, the abdominal approach is completely acceptable and may be safer in the general gynecologist’s hands ( ; ).
The preoperative and perioperative considerations for abdominal hysterectomy are described in Chapter 4 . This chapter will review the basic techniques of abdominal hysterectomy as well as techniques for difficult abdominal hysterectomies.
Case 1: Uterovaginal Prolapse
CM is a 34-year-old gravida 2, para 2 woman who presents with the complaint of symptomatic uterovaginal prolapse. She reports the feeling of a bulge in her vagina since her last delivery. She denies urinary or bowel complaints and is sexually active and denies any dysfunction. She has two healthy children and states that she definitely does not desire any additional children. Her medical and surgical histories are unremarkable and she has never had an abnormal Papanicolaou (Pap) smear or abnormal bleeding. Physical examination reveals a small, anteflexed uterus with stage III uterovaginal prolapse with predominant anterior vaginal wall prolapse. Her laboratory studies are unremarkable and a recent Pap smear and human papillomavirus (HPV) DNA assay are negative. Urodynamics reveal normal voiding function and no evidence of detrusor overactivity or stress urinary incontinence. The treatment options including conservative and surgical management are discussed at length with the patient, including uterine-sparing procedures, and she desires hysterectomy. Given the patient’s young age and significant pelvic organ prolapse, a total abdominal hysterectomy, sacral colpopexy, and Burch colposuspension are planned.
Discussion of Case
As quality of life issues become more important and the stigma of pelvic floor disorders decreases, women are seeking treatment for pelvic organ prolapse with increasing frequency. Treatment options include observation, pelvic muscle exercises, pessary placement, and surgical management. Although surgical treatment options include uterine-sparing procedures, the outcomes data for these operations are newer and less studied compared to the procedures that include hysterectomy. Uterovaginal prolapse often facilitates vaginal hysterectomy, which can be combined with vaginal apex suspension. Vaginal procedures to treat prolapse are associated with good anatomic outcomes. However, according to the Cochrane review, the abdominal sacral colpopexy is better than vaginal sacrospinous colpopexy, in terms of a lower rate of recurrent apical prolapse and less dyspareunia, but is associated with higher cost and a slower return to activities of daily living ( ). Given this patient’s young age and stage III uterovaginal prolapse, it is reasonable to offer the most aggressive therapy that has the strongest data supporting long-term anatomic success.
The patient elected abdominal sacral colpopexy with total abdominal hysterectomy. Alternatively, a supracervical hysterectomy could be considered, especially if cervical elongation was not present. Patients without cervical dysplasia, uterine hyperplasia, premalignancy, known or suspected malignancy, or cervical fibroids may have the choice between total and subtotal hysterectomy. Subtotal hysterectomy is defined as the removal of the uterine corpus at or below the level of the internal os with attempted ablation of the endocervical canal after removal of the corpus. Historically, the supracervical or subtotal hysterectomy was abandoned in favor of total hysterectomy because of problems related to the retained cervix. However, subtotal hysterectomy has gained a renewed interest as one technique to reduce the effects of hysterectomy on urinary and sexual function. Unfortunately, to date, the possible benefits of supracervical hysterectomy with regard to perioperative morbidity and postoperative sexual and urinary function are not supported by research. In three randomized controlled trials using laparotomy for access, there were no differences in complications including infection; blood loss requiring transfusion; or urinary tract, bowel, or vascular injury ( ; ; ). Reported rates of postoperative cyclical vaginal bleeding in women randomized to subtotal hysterectomy were 5% to 20%. Approximately 1.5% of participants had a second operation within 3 months to remove the cervix. Additionally, choosing to preserve the cervix to conserve sexual and urinary function has not been supported by prospective randomized trials ( ). There were no differences in postoperative stress or urge urinary incontinence, urinary frequency, or incomplete bladder emptying in most studies. One European study did find a higher incidence of urinary incontinence after subtotal hysterectomy ( ). In regard to sexual function, there was no difference in any outcome in any of the prospective studies. Despite the lack of data supporting superior outcomes for subtotal hysterectomy, the decision between total and subtotal hysterectomy is often highly personal. Many patients have strong preexisting ideas about retaining the cervix and this should be discussed with the patient preoperatively in detail. Also, future studies using laparoscopic or robotic techniques may show different results.
Candidates interested in subtotal hysterectomy must have normal results from a recent cytologic cervical examination and a normal gross appearance of the cervix documented before surgery. Clinicians should also consider testing for high-risk human papillomavirus strains. In general, unless the patient is at high risk for ovarian cancer or the ovaries appear abnormal intraoperatively, we do not advocate prophylactic oophorectomy in a premenopausal woman undergoing hysterectomy by any route. Please see Chapter 9 for further discussion of prophylactic oophorectomy.
See DVD Video 6-1 for video demonstration of simple abdominal hysterectomy.
There are many variations in the technique of abdominal hysterectomy. Given that there are no randomized controlled trials comparing various surgical techniques, slight variation in technique likely results in minimal or no change in outcome.
After general anesthesia is induced and the patient is intubated, the abdominal hysterectomy begins with proper positioning of the patient. Abdominal hysterectomy can be performed in the dorsal supine or dorsal lithotomy position ( Fig. 6-1 ). If vaginal access is necessary for other procedures or if a difficult abdominal hysterectomy is anticipated, the dorsal lithotomy position may be advantageous because an additional surgical assistant can stand between the legs in close proximity to the surgical field. When placing the patient in the dorsal lithotomy position, she should be positioned in the low lithotomy position using adjustable cushioned stirrups, such as Allen or Yellofin stirrups. Care must be taken to not overflex or extend the joints. Additionally, the weight of the patient’s leg should rest on the heel as opposed to the calf or lateral leg. The arms can be tucked and cushioned to help prevent nerve injury or secured to arm boards. If tucked, arm sleds may be necessary in patients who are obese. If the arms are secured to arm boards, they should not extend beyond 90 degrees and all operative personnel must take care not to rest or place any weight against the arms. The pubic hair is clipped to the level of the pubic symphysis. An examination under anesthesia is performed. Careful attention should be paid to uterine size, contour, and width; uterine mobility; cervical size and location; ovarian size; and evidence of masses or signs of endometriosis. This information will help guide the decision of what type of skin incision to make. A single dose intravenous antibiotic and antiembolic prophylaxis are routinely given. The patient’s abdomen, vagina, and upper thighs are prepared with povidone-iodine or hibiclens and the patient is draped. A Foley catheter attached to a continuous drainage system is inserted into the bladder.
Based on the planned procedures, patient body habitus, presence of prior surgical scar, and uterine or other disease, a laparotomy incision is made. The anatomic considerations for the different incision types are covered in Chapter 2 . In the case of abdominal hysterectomy, this includes several incision types: Pfannenstiel incision, vertical midline incision, Maylard incision, and Cherney incision. The Pfannenstiel incision is the least invasive, preserving the rectus muscles and is ideal in normal-weight patients who have normal-sized uteri and don’t require additional procedures.
The Pfannenstiel incision is performed by making a horizontal incision 2 cm above the pubic symphysis with a scalpel. The width of the incision depends on the planned procedure. Once the skin is open, the subcutaneous tissue is divided sharply or with electrocautery. Upon identification of the fascia, it is incised and the fascial incision is extended laterally to the border of the skin incision. Kocher clamps are applied to the superior edge of the fascial incision and the rectus muscles are dissected bluntly or with electrocautery from the fascia. Perforating vessels are cauterized as this dissection takes place. Similarly, the rectus muscles are dissected from the inferior aspect of the fascial incision. The rectus muscles are then separated in the midline. Starting near the superior aspect of the fascia, the preperitoneal fat is separated until the peritoneum is identified. Once identified, it is grasped with two clamps and elevated. After palpating for underlying structures such as bowel, the peritoneum is opened bluntly or sharply with Metzenbaum scissors. After the defect is created and proper cavity entry is assured, one finger is used to explore the underside of the peritoneum for adhesions. The peritoneum is then opened vertically to the superior extent of the fascial incision and inferiorly toward the bladder. As one gets close to the bladder, the peritoneum should be taken down in layers to avoid cystotomy. If necessary, the peritoneal incision can be extended laterally to create more space and avoid the bladder. Ultimately, the incision should be taken down to the pubic symphysis which requires division of the pyramidalis muscles.
For cases of an enlarged uterus (typically ≥ 16 weeks), pelvic mass, or cancer, or when procedures above the umbilicus are anticipated, a vertical incision may be appropriate. In these cases, a vertical skin incision is made with a scalpel from the pubic symphysis to the umbilicus. If necessary, the incision can be carried through the umbilicus or to the left of the umbilicus to the xiphoid process. The subcutaneous tissue is divided sharply or with electrocautery. The fascia is identified and opened sharply, then extended vertically for the length of the incision. Kocher clamps are applied to one side of the fascia and elevated. The rectus muscles are dissected from the fascia with the goal of identifying where the rectus muscles meet in the midline. Once this area is identified, the rectus muscles are separated, the preperitoneal fat is cleared, and the peritoneum is grasped with two sets of pick-ups and opened sharply or bluntly. The peritoneum is incised superiorly and inferiorly with good visualization of the bladder.
For cases when lateral access is required, a Maylard incision may be useful. A horizontal skin incision is made 2 cm above the pubic symphysis with the scalpel. The subcutaneous tissue is divided and the fascia is identified and opened sharply. The fascial incision is opened in a horizontal fashion to the border of the skin incision. The rectus muscles are identified and the lateral aspect of the rectus muscle is moved medial, exposing the inferior epigastric vessels. A right-angle clamp is passed under the vessels and used to bring two ties of No. 0 polyglactin 910 under the vessels. The vessels are then suture-ligated and divided. Once this has been performed bilaterally, the rectus muscles are divided with electrocautery. The peritoneum is identified and opened as described above.
The Cherney incision is useful when a transverse skin incision is desired and more operative space is required. The initial steps are similar to those of the Pfannenstiel skin incision. However, once the anterior rectus sheath is opened, the rectus muscles are identified, and the tendons of the rectus abdominis and pyramidalis muscles are transected 1 to 2 cm above their insertion into the pubic symphysis. The muscles can then be moved cephalad to provide better access to the pelvis. This incision should be kept in mind when one is struggling during a difficult hysterectomy, as a Pfannenstiel incision can be converted to a Cherney when visualization is suboptimal.
Once the laparotomy is accomplished, an examination of the upper abdomen via palpation is performed. A variety of self-retaining retractors are available to assist with visualization, including the Bookwalter, Balfour, Turner-Warwick, and O’Connor-O’Sullivan. The bowel is gently packed cephalad with moistened laparotomy sponges and the retractor is applied. Great care must be taken to choose retractor blades of the appropriate length to avoid iatrogenic nerve injury. This is of most concern when using lateral blades because retractors that are too long will place pressure on the psoas muscle and femoral nerve. Thin patients are especially at risk for this nerve injury.
The pelvic anatomy is examined ( Fig. 6-2 ). Restoration of normal anatomy is achieved with adhesiolysis, if necessary. The uterus is grasped at each cornu with a long clamp such as a Kelly or Kocher clamp and elevated toward the incision ( Fig. 6-3 ). This clamp should incorporate the cornu, round ligament, and fallopian tube. Traction and countertraction is a key principle for the successful completion of any hysterectomy. The uterus is deviated to the patient’s left side, placing tension on the right round ligament. The round ligament is grasped with forceps and a suture is placed directly below the round ligament through the mesosalpinx approximately 3 to 4 cm from the cornu ( Fig. 6-4 ). The same suture is then placed through the round ligament at this same location and tied. Electrocautery is used to desiccate and transect the round ligament medial to the suture. The suture is tagged and placed laterally over the retractor, thereby holding the peritoneum open laterally.
The anterior leaf of the broad ligament is opened inferiorly to the level of the uterine vessel and then medially along the vesicouterine peritoneal fold separating the bladder peritoneum from the lower uterine segment in preparation for bladder flap development. The surgical assistant can place an opened tonsil clamp below the peritoneum and guide the surgeon’s dissection. This dissection is carried to the midportion of the vesicouterine peritoneum. An identical procedure is performed on the contralateral side. When anatomy is not distorted, the area to incise is easily identified by grasping the peritoneum with atraumatic forceps and identifying where it becomes pliable and loose. The posterior leaf of the broad ligament can be dissected sharply or with electrocautery lateral to the infundibulopelvic ligament to open up this space further. With the anterior and posterior leaves of the broad ligament open, the ureter is identified in the retroperitoneum ( Fig. 6-5 ). This vital step should be performed during every hysterectomy to help prevent ureteral injury. With the leaves of the broad ligament separated, the areolar tissue is gently separated with a blunt instrument such as rounded forceps or the suction tip. Placing these instruments at an angle toward the medial leaf of the broad ligament and moving them in a craniocaudad fashion, the ureter is identified. If the ureter cannot be identified, the gentle blunt dissection can be carried toward the bifurcation of the common iliac artery where the ureter crosses this structure at the pelvic brim. The use of ureteral catheters is advocated by some surgeons; however, in our experience, prophylactic ureteral catheterization is not helpful and can be associated with ureteral injury ( ). Others advocate ureteral identification through palpation; however, the internal iliac artery, ovarian vessels, and vessels of the broad ligament are easily confused with the ureter.
Once the ureter is identified, either the infundibulopelvic ligament or the utero-ovarian ligament is clamped and transected, depending on whether a salpingo-ophorectomy is planned or not. In cases in which an oophorectomy is planned, a defect is created in the posterior broad ligament inferior to the ovary with the ureter in sight. This defect is extended toward the infundibulopelvic ligament. Typically, three clamps are passed from lateral to medial through this defect lateral to the ovary, making certain that the entire ovary is included in the surgical specimen ( Fig. 6-6A ). The ligament is then transected and suture ligated. We use a free tie of No. 0 polyglactin 910 behind the most proximal clamp, followed by suture ligation with the same suture type using the fore-aft technique behind the most distal clamp. Tying the pedicle before suturing it prevents formation of an expanding hematoma through inadvertent puncture of the ovarian vessels. The clamp on the specimen side is then removed after suture ligation. The free ends of the suture can be used to tie the adnexa to the clamp on the cornu to improve visualization.