Surgical Notes: TAH-BSO

Definition

Indications

• Endometrial carcinoma
• Ovarian carcinoma
• Endometriosis with adnexal involvement
• Uterine fibroids (when vaginal/laparoscopic routes not suitable)
• Cervical carcinoma (as part of radical surgery)
• High-risk BRCA1/2 mutation carriers (risk-reduction surgery)
• Pelvic inflammatory disease with tubo-ovarian abscess unresponsive to treatment

Pre-operative Preparation

• Informed consent (including menopause, infertility, HRT discussion)
• Blood group & crossmatch
• Bowel preparation if colonic involvement anticipated
• DVT prophylaxis: TED stockings, LMWH
• Broad-spectrum antibiotic prophylaxis at induction
• Foley catheter insertion
• Patient positioned supine; Trendelenburg tilt may be used

Incision

1. Pfannenstiel (low transverse) - preferred for benign disease; cosmetically superior
2. Vertical midline - preferred for malignancy, large uterus, need for greater exposure

Step-by-Step Operative Technique

Step 1 - Entry and Exploration

• Enter peritoneum; pack bowel superiorly
• Abdominal exploration to assess uterus, adnexa, and peritoneum
• Place self-retaining retractor (e.g., Balfour)

Step 2 - Uterine Elevation and Exposure

• Grasp the uterine fundus bilaterally with straight Kocher clamps or Lahey thyroid forceps
• Elevate the uterus out of the pelvis

Step 3 - Round Ligament Division

• Identify the round ligament on each side
• Clamp, cut, and ligate (suture ligation) the round ligament bilaterally
• This opens the anterior and posterior leaves of the broad ligament

Step 4 - Broad Ligament Dissection

• Incise the anterior leaf of the broad ligament toward the bladder fold
• Incise the posterior leaf of the broad ligament inferiorly
• This exposes the retroperitoneal space and allows ureteral identification

Step 5 - Bladder Dissection (Vesicouterine Pouch)

• Identify and incise the vesicouterine (uterovesical) peritoneal fold
• Dissect the bladder off the lower uterine segment and cervix using sharp dissection (Metzenbaum scissors) or electrocautery
• Retract the bladder inferiorly - this protects the bladder and ureters during subsequent steps

Step 6 - BSO: Division of Infundibulopelvic (IP) Ligament

• Critical step for BSO: Identify the ureter on the medial leaf of the broad ligament as it courses to the bladder
• Doubly clamp the infundibulopelvic (IP) ligament (contains the ovarian vessels) with curved Heaney or Zeppelin clamps
• Divide between the clamps with curved Mayo scissors
• Doubly ligate both pedicles (proximal and distal) to prevent back-bleeding

Step 7 - Skeletonization of Uterine Vessels

• Incise the remaining leaves of the posterior broad ligament inferiorly
• Skeletonize the uterine vessels as they travel along the lateral edge of the uterus
• The posterior broad ligament is cleared down to the uterosacral ligaments

Step 8 - Uterine Vessel Ligation

• Place a curved Heaney or Zeppelin clamp across the uterine vessels at the level of the internal cervical os, perpendicular to the uterus
• Cut and suture ligate the pedicle (transfixion stitch)
• Repeat on the opposite side

Step 9 - Cardinal and Uterosacral Ligament Division

• Further dissect the bladder completely below the level of the cervix
• Apply straight Heaney or Zeppelin clamps across the cardinal ligaments and uterosacral ligaments in serial steps bilaterally
• Cut and suture ligate each pedicle
• Continue until the level of the external cervical os is reached on both sides

Step 10 - Colpotomy (Vaginal Cuff Excision)

• Place curved clamps across the vagina medial to the prior pedicles, just below the cervix from both sides meeting in the midline
• Cut just above the clamps with curved scissors to separate the uterus and cervix from the vagina

• Make a direct sharp incision into the vagina just below the cervix
• Extend the incision around the cervix with curved scissors until the cervix is completely freed
• Grasp vaginal edges with Allis clamps for visualization

Step 11 - Specimen Removal

• The uterus, cervix, both fallopian tubes, and both ovaries are removed as one specimen
• Send for histopathology

Step 12 - Vaginal Cuff Closure

• Heaney transfixion stitches placed beneath the two vaginal clamps to ligate vaginal corners
• Vagina closed in the midline with:
  • Interrupted figure-of-eight sutures, OR
  • Running suture, OR
  • Interrupted sutures
• Lateral apex sutures incorporate the ipsilateral uterosacral ligament for apical support (prevents vault prolapse)

Step 13 - Hemostasis and Closure

• Inspect all pedicles for hemostasis
• Check bladder integrity (may fill bladder with methylene blue if injury suspected)
• Irrigate the pelvis
• Visualize ureters for peristalsis
• Close the abdomen in layers (peritoneum optional, fascia with looped PDS or Vicryl, subcutaneous tissue, skin)

Specimen

Important Anatomical Danger Points

• Ureters - most common structure at risk; injury most likely at IP ligament ligation and uterine vessel clamp
• Bladder - during vesicouterine dissection
• Uterine vessels / iliac vessels - hemorrhage
• Rectum - during uterosacral ligament division in cases with endometriosis/adhesions

Post-operative Care

• Foley catheter for 24 hours
• Early mobilization and DVT prophylaxis
• NSAIDS + opioid analgesia as required
• Monitor urine output, hemoglobin
• HRT counselling (surgical menopause if pre-menopausal)
• Discharge typically Day 3-5

Complications

• Hemorrhage
• Ureteric injury
• Bladder injury
• Bowel injury

• Wound infection/dehiscence
• DVT/PE
• Urinary tract infection
• Ileus

• Vault prolapse
• Urinary dysfunction (urge/stress incontinence)
• Sexual dysfunction
• Premature menopause (if pre-menopausal) - risk of cardiovascular disease, osteoporosis
• Lymphoedema (if lymphadenectomy performed with malignancy cases)