TAH Types, Hysterectomy Types, Suture Materials & Surgical Steps

1. CLASSIFICATION OF HYSTERECTOMY

A. By Extent (What Is Removed)

B. By Route (How It Is Done)

Per Berek & Novak's Gynecology: "LH offers no advantage for women in whom VH is possible... The ideal place for LH is as a replacement for laparotomy." Laparotomy-based hysterectomy should be reserved for cases where minimally invasive approaches are not appropriate (cardiopulmonary disease, known/suspected uterine malignancy requiring morcellation avoidance, severely distorted anatomy).

C. Querleu-Morrow (QM) Classification of Radical Hysterectomy (Replacing the Piver-Rutledge Classification)

2. INDICATIONS FOR HYSTERECTOMY

• Fibroids (leiomyoma) - most common indication (~40%)
• Abnormal uterine bleeding (adenomyosis, DUB)
• Endometriosis/pelvic pain unresponsive to conservative therapy
• Uterovaginal prolapse
• Gynecological malignancy (endometrial, cervical, ovarian)
• Complications of pregnancy (uterine rupture, uncontrolled PPH)
• Recurrent high-grade CIN after other treatments

3. TOTAL ABDOMINAL HYSTERECTOMY (TAH) - SURGICAL STEPS

Pre-operative

• Patient supine, Trendelenburg position
• Urinary catheter inserted
• Abdomen prepped and draped
• Antibiotic prophylaxis

Incision

• Pfannenstiel (transverse) - preferred for benign disease, better cosmesis
• Midline (vertical) - preferred for malignancy, large uterus, need for exploration

Step-by-Step Operative Procedure

• Laparotomy, systematic exploration of abdomen/pelvis
• Pack bowel away with moist lap pads
• Place self-retaining retractor (Balfour/O'Connor-O'Sullivan)
• Grasp the uterine fundus with tissue forceps (Allis or Kocher clamps) to provide traction

• Clamp, cut, and ligate the round ligament bilaterally
• Suture with 0 or 2-0 Vicryl (polyglactin)
• This opens the broad ligament

• Incise the anterior and posterior leaves of the broad ligament
• Develops the vesicouterine space and retroperitoneal space

• If ovaries removed: clamp, cut, ligate the IP ligament (contains ovarian vessels)
• If ovaries preserved: clamp, cut, ligate the utero-ovarian ligament and fallopian tube
• Suture/tie with 0 Vicryl or 0 chromic catgut (transfixation sutures used)

• Incise the vesicouterine peritoneum (bladder fold)
• Dissect bladder down off the cervix and upper vagina using sharp/blunt dissection
• Critical step to avoid bladder injury and fistula formation

• Uterine vessels identified at the level of the internal os
• Clamp at right angles to uterus, cut, and double ligate with 0 Vicryl
• This is the most important hemostatic step

• Cardinal ligaments clamped, cut, suture-ligated bilaterally
• Uterosacral ligaments clamped, cut, suture-ligated
• Sutures: 0 Vicryl or delayed absorbable (0 PDS)

• Anterior colpotomy - circumferential incision around the cervix at vaginal fornix
• Uterus removed
• Angled clamps (Zeppelin/Heaney/Kocher) used on vaginal angles

• Vaginal vault closed with 0 or 1 Vicryl (polyglactin)
• Options: continuous locking suture, interrupted figure-of-8, or purse-string
• Vaginal angles secured to the cardinal/uterosacral ligament stumps for vault support
• Per Schwartz's Principles of Surgery: "Vaginal closure of the cuff appears to decrease the rate of vaginal cuff dehiscence in MIS hysterectomy"

• Re-peritonealisation of pelvic floor (controversial; many surgeons omit this)
• If done: 2-0 or 3-0 Vicryl continuous suture

• Fascia: 1 Vicryl or PDS (loop PDS No.1) - continuous mass closure or Smead-Jones
• Subcutaneous fat: 2-0 Vicryl (if thick layer)
• Skin: Staples or 3-0 Vicryl subcuticular or Prolene

4. SUTURE MATERIALS USED IN TAH

• Chromic catgut (natural absorbable): historically used for pedicles; absorbed in 10-14 days; less commonly used now
• Vicryl/Polyglactin 910 (synthetic braided absorbable): most widely used; absorbed in 56-70 days; preferred for pedicles and vault
• PDS/Polydioxanone (synthetic monofilament absorbable): used for fascia and occasionally vault; absorbed in 180-210 days; good tensile strength
• Prolene/Polypropylene (non-absorbable monofilament): used for skin or when permanent suture needed

5. VAGINAL HYSTERECTOMY - KEY DIFFERENCES

1. Anterior and posterior colpotomy
2. Uterosacral and cardinal ligaments divided first
3. Uterine arteries ligated
4. Utero-ovarian/IP ligaments last
5. Vaginal cuff closed

6. POST-OPERATIVE COMPLICATIONS

• Hemorrhage - especially from uterine artery pedicles
• Urinary tract injury - ureter at risk during uterine artery ligation; bladder during vault dissection
• Vesicovaginal fistula - most common after TAH for benign disease in developed countries (Berek & Novak's)
• Vaginal cuff dehiscence - higher with laparoscopic/robotic approach due to cautery use
• Bowel injury
• Vault prolapse - prevented by securing vault to uterosacral stumps