Total Abdominal Hysterectomy (TAH)

Definition

A subtotal (supracervical) hysterectomy removes only the corpus, leaving the cervix behind. TAH removes both.

Types of Hysterectomy (by extent)

Indications

• Uterine leiomyomas (fibroids) - most common benign indication
• Abnormal uterine bleeding refractory to conservative management
• Endometriosis / adenomyosis (especially with bilateral oophorectomy if severe)
• Uterine prolapse (often via vaginal route, but TAH if added pathology)
• Endometrial carcinoma (TAH + BSO is standard surgical staging)
• Ovarian carcinoma staging (TAH + BSO + omentectomy + lymph node dissection)
• Uterine leiomyosarcoma (TAH + bilateral oophorectomy)
• Intractable postpartum hemorrhage / placenta accreta (emergency cesarean hysterectomy)
• Cervical carcinoma (early stages)

Preoperative Preparation

• Informed consent including risks of bleeding, infection, urinary tract injury, bowel injury, and loss of fertility
• Urine culture, CBC, coagulation profile, blood typing
• Bowel preparation (individualized)
• Prophylactic antibiotics (cephalosporin) within 60 minutes of incision
• DVT prophylaxis (compression stockings ± LMWH)
• Foley catheter placement

Patient Positioning & Incision

• Pfannenstiel (low transverse) - preferred for benign disease; better cosmesis, lower wound complications
• Vertical midline - chosen for malignancy, large pathology, need for full abdominal exploration, or re-operative cases

Step-by-Step Surgical Technique

1. Abdominal Entry & Exploration

• Enter the abdomen through the chosen incision
• Inspect the upper abdomen for evidence of extrapelvic disease
• Place a suitable self-retaining retractor (e.g., Balfour)
• Grasp the uterus at each cornu with clamps (Kocher or Lahey) and elevate into the incision

2. Round Ligament Transection

• Identify and divide the round ligament bilaterally
• This opens the anterior and posterior leaves of the broad ligament

3. Broad Ligament Incision & Ureter Identification

• Extend the peritoneal incision from the round ligament laterally past the ovarian hilum (if oophorectomy planned) or medially below the utero-ovarian ligament (if ovaries are conserved)
• Bluntly open the retroperitoneal space and identify the ureter on the medial leaf of the broad ligament - this is critical to prevent ureteric injury

4. Adnexal Management

• Incise posterior leaves of broad ligament
• Double-clamp the infundibulopelvic (IP) ligament containing the ovarian vessels with curved Heaney or Zeppelin clamps
• Divide between clamps with curved Mayo scissors; doubly ligate pedicles

• Create an opening below the utero-ovarian ligament and fallopian tube
• Clamp, divide, and doubly ligate the utero-ovarian vessels with Kelly or Heaney clamps

5. Bladder Mobilization

• Sharply dissect the bladder off the anterior surface of the uterus and cervix using Metzenbaum scissors or electrocautery
• Retract the bladder inferiorly below the level of the cervix

6. Uterine Vessel Ligation

• Skeletonize the uterine vessels along the lateral uterus by incising the remaining posterior broad ligament leaves
• Place a curved Heaney or Zeppelin clamp across the uterine vessels at the level of the internal cervical os
• Cut and suture-ligate the pedicle

7. Cardinal & Uterosacral Ligament Division

• Serially clamp, cut, and ligate the cardinal ligaments (Mackenrodt's ligaments) bilaterally in steps
• Divide the uterosacral ligaments
• Continue until both sides are clear at the level of the external cervical os

8. Colpotomy & Specimen Removal

• Place curved clamps across the vagina just below the cervix bilaterally
• Cut with curved scissors just above the clamps to amputate the cervix from the vagina
• The specimen (uterus + cervix ± adnexa) is removed

9. Vaginal Cuff Closure

• Place Heaney transfixion stitches at each lateral vaginal angle - importantly, incorporating the ipsilateral uterosacral ligament for apical support (prevents vault prolapse)
• Close the remainder of the vaginal cuff with running or interrupted absorbable sutures (e.g., Vicryl 0 or 1)
• An alternative: direct sharp colpotomy around the cervix with Allis clamps placed on the vaginal edges for visualization before closure

10. Closure

• Pelvic reperitonization is not necessary
• Hemostasis confirmed
• Abdominal wall closed in layers (fascia, subcutaneous tissue, skin)

Key Anatomical Danger Points

The ureter is at highest risk near the infundibulopelvic ligament and near the uterine artery (where it passes under the uterine artery - "water under the bridge"). Always identify it before clamping.

Complications

Variants & Related Procedures

• TAH + BSO: adds bilateral salpingo-oophorectomy; standard for endometrial cancer, ovarian cancer, or peri/postmenopausal patients with benign disease
• TAH + BSO + Staging laparotomy: for gynecologic malignancies - includes omentectomy, peritoneal washings, and lymph node dissection
• Radical (Wertheim) hysterectomy: for cervical carcinoma - includes parametrectomy and upper vaginectomy
• Laparoscopic hysterectomy (TLH): same steps but using ports, energy devices, and a uterine manipulator with colpotomizer cup; avoids laparotomy
• Robotic hysterectomy: similar to laparoscopic but higher cost; no proven clinical benefit over laparoscopic for benign conditions

Postoperative Care

• Ambulation within 24 hours (DVT prevention)
• Foley catheter removal by postoperative day 1
• Diet advancement as tolerated
• Pain management (multimodal - NSAIDs + opioid-sparing)
• Pelvic rest for 6-8 weeks (no intercourse, tampon use, or heavy lifting)
• Discharge typically on postoperative day 2-4
• If premenopausal with BSO: hormone replacement therapy counseling

• Sabiston Textbook of Surgery, pp. 2799-2800 (Chapter 120 - Steps to completing hysterectomy)
• Schwartz's Principles of Surgery, 11th Edition, p. 1825 (Chapter 41 - Procedures for Abnormal Uterine Bleeding)
• Tintinalli's Emergency Medicine, Chapter 105 - Complications of Major Gynecologic-Abdominal Surgery