Abdominal Hysterectomy — Step-by-Step Procedure

Preoperative Preparation

Patient Positioning

• Dorsal supine position
• After anesthesia induction: place legs in stirrups → perform pelvic examination to confirm preoperative findings
• Insert Foley catheter to decompress the bladder; cleanse vagina with chlorhexidine or iodine solution
• Return legs to flat position

Surgical Technique

Step 1 — Incision

1. Simplicity and exposure required
2. Need for potential enlargement
3. Wound strength and cosmesis
4. Location of prior scars

Step 2 — Abdominal Exploration

• Peritoneal cytology specimens collected before exploration if indicated
• Systematic exploration: liver, gallbladder, stomach, kidneys, para-aortic nodes, small and large bowel, and pelvis

Step 3 — Retractor Placement

• Self-retaining retractors placed (Balfour, O'Connor-O'Sullivan, or Bookwalter for obese patients)
• Small bowel packed out of the pelvis with moist laparotomy pads

Step 4 — Elevation of the Uterus

• Broad ligament clamps (e.g., Heaney or Ballantine) placed at each cornu, crossing the round ligament — this elevates and manipulates the uterus throughout the procedure

Pertinent surgical anatomy — Berek & Novak's Gynecology

Step 5 — Round Ligament Ligation and Transection

• Uterus deviated to the left to stretch the right round ligament
• The distal round ligament is ligated with a suture ligature (or divided with electrosurgery) and cut
• This separates the anterior and posterior leaves of the broad ligament
• The anterior leaf of the broad ligament is incised with Metzenbaum scissors or electrosurgery along the vesicouterine fold, separating the bladder peritoneum from the lower uterine segment
• Repeated on the left side

Elevation of uterus with clamps; round ligament transected and anterior broad ligament opened — Berek & Novak's

Step 6 — Ureter Identification

• The retroperitoneum is entered by extending the incision cephalad on the posterior leaf of the broad ligament, staying lateral to the infundibulopelvic ligament and iliac vessels
• The external iliac artery is identified along the medial psoas muscle by blunt dissection
• Following it cephalad to the common iliac bifurcation, the ureter is identified crossing the common iliac artery
• The ureter is left attached to the medial broad ligament leaf to protect its blood supply — this is critical throughout the remainder of the procedure

Step 7 — Utero-Ovarian / Infundibulopelvic (IP) Ligament Ligation

If ovaries are preserved:

• Uterus retracted toward pubic symphysis and deviated to one side
• The utero-ovarian ligaments are clamped bilaterally with curved Heaney or Ballantine clamps, cut, and ligated (free tie + suture ligature) at each uterine cornua
• Opportunistic salpingectomy may be performed at this point if desired

If ovaries are removed (BSO):

• The peritoneal opening is enlarged toward the infundibulopelvic ligament (ovarian vessels) cephalad and to the uterine artery caudad
• This releases the ureter from proximity to the ovarian vessels
• A curved Heaney/Ballantine clamp is placed lateral to the ovary across the IP ligament; the vessels are doubly clamped, incised, and doubly ligated
• Remaining posterior broad ligament leaves are incised inferiorly to skeletonize the uterine vessels

Division of ovarian/uterine vessels — Sabiston Textbook of Surgery

Step 8 — Development of the Bladder Flap

• The vesicouterine peritoneum (anterior leaf) is further incised and dissected
• The bladder is dissected off the cervix sharply with Metzenbaum scissors or electrocautery
• The bladder is pushed and retracted inferiorly, well below the level of the cervix, before any colpotomy is made
• This is the most important step to avoid bladder injury

Step 9 — Uterine Vessel Ligation

• A curved Heaney or Zeppelin clamp is placed across the uterine vessels (uterine artery and vein) at the level of the internal cervical os, perpendicular to the uterus
• The pedicle is cut and suture ligated (transfixion stitch)
• Performed bilaterally — the ureter must be clearly visualized and free of the clamp (it passes within ~1 cm of the uterine artery)

Step 10 — Cardinal Ligament Ligation

• A straight Zeppelin or Heaney clamp is placed medial to the uterine vessel pedicle, 2–3 cm parallel to the uterus across the cardinal ligament
• The ligament is cut and the pedicle suture ligated
• This step is repeated in serial bites on each side, progressing inferiorly until the cervicovaginal junction is reached

Step 11 — Uterosacral Ligament Division

• If the rectum needs mobilization from the posterior cervix, the posterior peritoneum between the uterosacral ligaments just beneath the cervix is incised
• The relatively avascular plane here allows the rectum to be mobilized inferiorly out of the field
• The uterosacral ligaments are included in the final clamps placed for uterine removal

Step 12 — Colpotomy and Removal of the Uterus

• The uterus is placed on cephalad traction and the tip of the cervix palpated
• Curved Heaney clamps are placed bilaterally incorporating the uterosacral ligament and upper vagina just below the cervix (taking care not to foreshorten the vagina)
• The uterus and cervix are removed with a scalpel or curved scissors, cutting just above the clamps
• The specimen is passed off the field

Step 13 — Vaginal Cuff Closure

• A figure-of-eight suture (0 braided absorbable) is placed at each vaginal angle for traction and hemostasis
• Heaney transfixion stitches are placed incorporating the uterosacral and cardinal ligaments at the vaginal angles — this provides apical support
• The vaginal cuff is closed with running-locked or figure-of-eight sutures
• Alternatively: interrupted or running sutures with the lateral apex sutures incorporating the ipsilateral uterosacral ligament

Vaginal cuff closure incorporating uterosacral and cardinal ligaments — Berek & Novak's

Step 14 — Irrigation and Final Hemostasis

• The pelvis is thoroughly irrigated with normal saline
• Meticulous hemostasis of all vascular pedicles is ensured
• Ureters are inspected to confirm they are intact and non-dilated (peristalsis should be visible)

Step 15 — Peritoneal and Fascial Closure

• The pelvic peritoneum is not reapproximated (evidence shows no benefit)
• The parietal peritoneum is also left open
• Fascia is closed with interrupted or continuous 0 or 1 monofilament absorbable suture; bites taken ~1 cm from edge, ~1 cm apart

Step 16 — Skin Closure

• Subcutaneous tissue irrigated with hemostasis achieved
• Subcutaneous fat closed if ≥2 cm depth (reduces wound disruption)
• Skin closed with staples or subcuticular sutures
• Dressing applied for ~24 hours

Postoperative Management

Key Intraoperative Dangers and Prevention