Hysterectomy

Paul R. Kramer, MD

ysterectomy is the second most common operation performed on women in the United States. It is anticipated that the general surgeon will at some time encounter a gynecologic condition necessitating an abdominal hysterectomy. Possible indications for hysterectomy include malignancy, benign growths, functional problems, structural abnormalities, or involvement of the uterus with adjacent structures being excised (Figs 1-7). If the abdomen is not already open when hysterectomy is contemplated, the most important consideration for the pelvic surgeon is the choice of incision. Adequate exposure for the intended procedure is certainly the most important factor. Transverse incisions are used more by the pelvic surgeon because the entire incision is located over the area of interest. Transverse incisions are less painful postoperatively and heal with a lower risk of dehiscence or hernia formation. Exposure to the lateral aspects of the pelvis is limited by the typical Pfannenstiel incision where the rectus muscles are simply retracted laterally from the midline. Although exposure through a transverse incision can be increased by transecting the rectus muscles through the muscle belly (Maylard incision) or through the muscle tendon (Cherney incision), space to work around a large mass or uterus is still limited and access to the upper abdomen is essentially impossible. A vertical incision may be more uncomfortable and is associated with greater healing difculties, but will obviously provide the greatest exposure and free access throughout the abdominal cavity. Once hysterectomy is decided on and the abdominal cavity is entered, the bowel should be packed out of the pelvis and held with a self-retaining retractor. The uterus is grasped at both cornua with Pan or Kocher clamps for manipulation and traction of the uterus out of the pelvis and into the incision. The uterus is pulled to one side placing the opposite round ligament under tension. Once on tension, the round ligament can be suture ligated with a No. 0 absorbable suture and cut with scissors or, alternatively, can be transected with electrocautery. Once the round ligament is transected, air will dissect beyond the peritoneum of the broad ligament into the underlying areolar tissue. The peritoneal incision can then safely be extended from the transected round

From the Department of Obstetrics and Gynecology, Penn State College of Medicine/Milton S. Hershey Medical Center, Hershey, PA. Address reprint requests to Paul R. Kramer, MD, Department of Obstetrics and Gynecology, Penn State College of Medicine/Milton S. Hershey Med Center, Hershey, PA 17033. E-mail: pkramer@psu.edu.

ligament cephalad along the infundibulopelvic ligament containing the ovarian vessels. Blunt dissection of the areolar tissue in the retroperitoneal space will permit identication of the ureter along the medial leaf of the broad ligament as it courses into the pelvis over the bifurcation of the common iliac artery. A similar procedure is performed on the opposite side. At this point in the operation, the decision to remove or preserve the ovaries must be made. Ovaries may be removed because of suspicious morphology, known benign or malignant conditions, the presence of breast cancer, an increased risk of ovarian cancer, including BRCA mutations, or simply because the patient is postmenopausal. If the ovaries are to be removed, after identication of the ureter, an incision is created in the medial leaf of the broad ligament between the infundibulopelvic ligament and the ureter below. The infundibulopelvic ligament is doubly clamped with Kelly or Heaney clamps, transected, and doubly ligated with a No. 0 absorbable tie and suture. This is repeated on the opposite side. In the event the ovaries are to be preserved, a similar defect is created in the medial leaf of the broad ligament above the ureter. The utero-ovarian ligament is doubly clamped with Kelly or Heaney clamps between the ovary and the uterine cornu, transected with scissors, and doubly tied with a No. 0 absorbable suture. This is likewise performed bilaterally. For visualization and safety, the preserved ovaries can be packed out of the pelvis until completion of the hysterectomy. Once the ovaries have been managed, upward traction is placed on the uterus to place the anterior vesicouterine peritoneum on stretch. This peritoneum is incised from one transected round ligament to the other with areolar tissue again encountered. This areolar tissue is dissected down to the anterior surface of the cervix. The peritoneal edge over the bladder can be grasped with forceps or an Allis clamp and the bladder is sharply dissected away from the anterior surface of the cervix with Metzenbaum scissors or electrocautery. Blunt dissection can also be used to develop this vesicocervical and vesicovaginal space, although it may result in more bleeding and a higher incidence of bladder injury. The bladder must be mobilized from the cervix and vagina below the point where the cervix and vagina meet. The length of the cervix and extent of required bladder mobilization can be easily determined by palpation. The surgeons hand is placed in the pelvis with the ngers behind the uterus and cervix and with the thumb anterior to the cervix. The cervix is easily palpated as it protrudes into the vagina. 77

1524-153X/07/$-see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2007.06.002

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Figure 1 Division of the ovarian artery and vein (infundibulopelvic ligament) when performing a salpingo-oophorectomy.

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Figure 2 Division of the utero-ovarian ligament when preserving the ovary.

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Figure 3 Advancement of the bladder.

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Figure 4 Division of the uterine artery and vein at the junction of the fundus and cervix.

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Figure 5 Division of the cardinal ligament.

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Figure 6 Removal of the uterus and cervix.

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Figure 7 Vaginal closure.

After the bladder is safely reected away from the uterus and cervix, the uterine vessels are identied at the uterine isthmus or cervicouterine junction. The vessels are clamped bilaterally, placing curved Heaney or Zeppelin clamps at a 90-degree angle to the vessels (parallel to the oor) and sliding the tip of the clamps off the side of the cervix. Clamping bilaterally generally obviates the need to deal with back bleeding, other than the blood in the uterus itself. The vessels are then cut with Metzenbaum scissors and ligated with a Heaney transxion stitch of a No. 0 absorbable suture. The bladder is again examined to assure it is mobilized sufciently from the underlying vagina just beyond the junction of the cervix and vagina. The cardinal ligament can then be clamped, cut, and sutured. This may require a succession or repetitive steps, depending on the length of the cervix. Using a straight clamp, the cardinal ligament is clamped by

sliding the tips off the cervix and by staying inside of (medial to) the ligated uterine vessel pedicle. If successive bites are required to reach the cervicovaginal junction, all clamps are placed in a like manner, sliding off the cervix and staying inside the previous pedicle. Once clamped, the cardinal ligament pedicle is transected with Mayo scissors or a scalpel and is ligated with a Heaney transxion stitch of a No. 0 absorbable suture. When the cervicovaginal junction is reached, curved Heaney or Zeppelin clamps are placed just below the palpable cervix. These clamps incorporate the vaginal angles and the uterosacral ligaments posteriorly. The tips of the clamps can meet in the midline, although this is not necessary. The bladder should be reected away from the underlying vagina enough to prevent grasping bladder edge in the clamps. Alternatively, the anterior vagina can be opened with a scalpel

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or electrocautery. There should be about a 5 mm margin between this incision and the edge of the reected bladder to permit safe closure of the vagina at the completion of the hysterectomy. Curved Heaney or Zeppelin clamps are then placed bilaterally across the vaginal angles and uterosacral ligaments, just below the cervix, with the anterior tips of the clamps inside the opened vagina. Regardless of the approach to the upper vagina, the uterus and cervix are amputated from the vagina along these clamps using heavy scissors. The vaginal angles are ligated with a Heaney transxion stitch of a No. 0 absorbable suture. The anterior and posterior vaginal edges are grasped with Kocher or Allis clamps with care taken to incorporate the vaginal mucosa. The vagina is closed anterior to posterior with interrupted gure-of-eight No. 0 absorbable sutures. The pelvis is irrigated and hemostasis is assured. Pelvic reperitonealization is unnecessary. The bowel packs are re-

85 moved allowing the bowel, and preserved ovaries, to return to the pelvis.

Suggested Reading
U.S. Department of Health and Human Services, Ofce of Womens Health. Hysterectomy. Available at: http://www.4woman.gov/faq/hysterectomy. htm. Accessed December 22, 2006 Jones HW 3rd: Hysterectomy, in Rock JA, Jones HW 3rd (eds): TeLindes Operative Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins, 2003, pp 810-816 Morrow CP, Curtin JP: Gynecologic Cancer Surgery. New York: Churchill Livingstone, 1996, pp 491-495 Grantcharov TP, Rosenberg J: Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 167:260-267, 2001 Eisen A, Rebbeck TR, Wood WC, et al: Prophylactic surgery in women with hereditary predisposition to breast and ovarian cancer. J Clin Oncol 18:3454-3455, 2000