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Stops of. Total abdominal hysterectomy

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steps of total abdominal hysterectomy

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Here are the steps of Total Abdominal Hysterectomy (TAH), based on Sabiston Textbook of Surgery and the Atlas of Pelvic Surgery:

Total Abdominal Hysterectomy — Surgical Steps

Foley catheter placed to decompress the bladder
Patient positioned supine under general anaesthesia
Abdominal incision: low transverse (Pfannenstiel) or vertical midline — choice depends on indication, body habitus, prior surgery, and pathology size

1. Entry & Exposure

2. Division of Round Ligaments (Figure 120.12 A)

Round ligament grasped with clamp laterally, divided with electrocautery or ligated with delayed absorbable suture and divided medially
This opens access to the broad ligament

3. Opening the Broad Ligament (Figure 120.12 B)

Anterior leaf of broad ligament incised medially toward the internal cervical os
Initiates development of the bladder flap
Posterior leaves opened similarly

4. Bladder Dissection (Figure 120.12 C)

Vesicouterine peritoneum elevated
Bladder dissected off the lower uterine segment and cervix — sharply with Metzenbaum scissors or electrocautery
Bladder retracted inferiorly, well below the cervix

5a. Ovarian/Tube Management (if BSO planned) (Figure 120.12 D)

Ureters identified
Infundibulopelvic (IP) ligament doubly clamped with curved Heaney/Zeppelin clamps, incised, and doubly ligated
Pedicle on specimen side also ligated to prevent back-bleeding

5b. Uteroovarian vessels (if ovaries preserved) (Figure 120.12 F)

6. Skeletonization of Uterine Vessels

Posterior broad ligament leaves incised inferiorly to skeletonize uterine vessels along the lateral uterus

7. Ligation of Uterine Vessels (Figure 120.12 G)

Curved Heaney/Zeppelin clamp placed across uterine vessels at the level of the internal cervical os
Pedicle cut and suture-ligated bilaterally

8. Division of Cardinal & Uterosacral Ligaments (Figure 120.12 G)

Bladder fully dissected below cervix
Straight Heaney/Zeppelin clamps placed serially on cardinal and uterosacral ligaments bilaterally
Each pedicle cut and suture-ligated in stepwise fashion until the external cervical os level is reached

9. Colpotomy & Specimen Removal (Figure 120.12 H)

Curved clamps placed across the vagina medial to the prior pedicles, just below the cervix
Curved scissors cut above the clamps → uterus and cervix separated from the vaginal vault
Alternatively: direct sharp incision into the vagina just below the cervix, extended circumferentially

10. Vaginal Cuff Closure (Figure 120.12 I)

Lateral angles: Heaney transfixion stitches ligate vaginal corners — incorporating ipsilateral uterosacral ligament for apical support
Midline: closed with running, interrupted, or figure-of-eight absorbable sutures

11. Reperitonealization & Closure

Pelvis reperitonealized with running 2-0 absorbable suture (anterior to posterior leaf of broad ligament)
Ligament stumps buried retroperitoneally
Abdominal wall closed in layers

Step	Structure
A	Round ligament transected
B	Anterior & posterior broad ligament incised
C	Bladder dissected off cervix
D	Ovarian vessels divided (if BSO)
E	Opportunistic salpingectomy (if done)
F	Uteroovarian vessels divided (if ovaries kept)
G	Uterine vessels + cardinal + uterosacral ligaments divided
H	Vagina incised, specimen excised
I	Vaginal cuff closed

Ureter must be identified before clamping the IP ligament and uterine vessels — the ureter runs ~1–2 cm lateral to the cervix and can be displaced by pelvic pathology (endometriosis, PID).

— Sabiston Textbook of Surgery, p. 2799–2800; Atlas of Pelvic Surgery, 3rd ed.

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