Case Paper Study: Total Abdominal Hysterectomy (TAH) for Fibroid Uterus

For Obs & Gynec Residents

CASE SUMMARY

INDICATION FOR SURGERY

• Menorrhagia / Abnormal uterine bleeding (AUB-L) unresponsive to medical management
• Uterus > 12-14 weeks size
• Pressure symptoms (urinary frequency, constipation)
• Rapid growth / suspicion of malignancy
• Infertility / recurrent pregnancy loss (not applicable - completed family)

PRE-OPERATIVE PREPARATION

OPERATIVE NOTES (Detailed Steps)

A. Setup & Incision

1. Patient placed in supine position under satisfactory spinal/general anaesthesia.
2. Abdomen and perineum painted with 10% povidone-iodine solution and draped.
3. Foley catheter inserted; urine output monitored throughout.
4. Incision type selected (choose one):
   • Pfannenstiel (low transverse) - preferred for benign fibroid, cosmesis, lower morbidity
   • Lower midline vertical - preferred if uterus is very large (>20 weeks size), poor visualization anticipated, or previous multiple surgeries
5. Skin incised, subcutaneous fat divided. Rectus sheath incised transversely; rectus muscles separated/reflected.
6. Peritoneum identified, lifted between two tissue forceps, and opened with scissors after confirming no bowel adherence.
7. Abdominal cavity entered; systematic exploration performed:
   • Uterus: size (state equivalent weeks), surface, mobility, adhesions
   • Ovaries and tubes: appearance, presence of cysts
   • Appendix, bowel, liver, omentum: brief note
8. Bladder identified inferiorly and a bladder blade/Doyen retractor placed.

B. Exposure & Round Ligament Division (Step 1)

1. Uterus grasped with two large straight artery forceps (Pean/Littlewoods) applied at the cornua bilaterally to control bleeding and provide traction.
2. Round ligament identified on each side. Clamped with two straight Kocher clamps, divided between them, and ligated with No. 1 Vicryl (transfixion suture). This opens the broad ligament and provides access to retroperitoneal structures.

C. Broad Ligament & Infundibulopelvic/Utero-ovarian Vessel Division (Step 2)

1. Anterior and posterior leaves of the broad ligament are incised with Metzenbaum scissors toward the uterovesical fold.
2. Utero-ovarian ligament + proximal fallopian tube clamped with two curved Heaney clamps at the cornua, divided, and suture ligated with No. 1 Vicryl.
3. The fallopian tubes are included in this pedicle (opportunistic salpingectomy may be performed here - current evidence supports this to reduce future ovarian cancer risk).

1. Posterior broad ligament leaves incised; ureter identified and pushed laterally (critical step to avoid ureteric injury).
2. Infundibulopelvic (IP) ligament containing ovarian vessels doubly clamped with curved Heaney/Zeppelin clamps, divided between them, and doubly ligated.
3. Specimen sides ligated to prevent back-bleeding.

D. Bladder Dissection (Step 3)

1. Uterovesical peritoneum (vesico-uterine pouch) identified and incised transversely at the level of the lower uterine segment.
2. Bladder reflected downward off the anterior aspect of the cervix using sharp dissection with Metzenbaum scissors or gentle electrocautery - not blunt, to avoid injury.
3. Bladder pushed well below the level of the external os. Doyen retractor repositioned.

E. Posterior Broad Ligament & Uterine Vessel Skeletonisation (Step 4)

1. Posterior leaves of the broad ligament incised inferiorly to the level of the uterine isthmus, skeletonising the uterine vessels as they travel along the lateral wall of the uterus/cervix.
2. Ureters confirmed safe - palpated or visually traced in the parametrium before clamping uterine vessels.

F. Uterine Vessel Ligation (Step 5 - Most Critical Step)

1. Curved Heaney or Zeppelin clamp placed perpendicular to the uterus, flush against the cervix, at the level of the internal os bilaterally.
2. Pedicle cut and suture ligated with No. 1 Vicryl transfixion suture.
3. Repeat on opposite side.

G. Cardinal and Uterosacral Ligament Division (Step 6)

1. Straight Heaney/Zeppelin clamps placed serially on the cardinal ligaments bilaterally in incremental steps, working down toward the vaginal fornix.
2. Each pedicle divided and suture ligated.
3. Uterosacral ligaments similarly clamped, divided, and ligated.
4. These steps continue until tissue is clear at the level of the external cervical os.

H. Colpotomy and Removal of Specimen (Step 7)

1. Two curved clamps placed across the upper vagina just below the cervix, one from each side meeting in the midline.
2. Curved Mayo scissors cut just above the clamps (between clamps and cervix), separating the uterus and cervix from the vagina.
3. Uterus + cervix delivered out of the abdomen. Specimen handed to the scrub nurse/technician.
4. Specimen examined: size, surface irregularity, cut section (fibroids noted - number, size, location).

I. Vaginal Cuff Closure (Step 8)

1. Vaginal edges grasped with Allis clamps to provide visibility.
2. Vaginal angles (lateral corners) closed first with Heaney transfixion sutures (No. 1 Vicryl) incorporating the ipsilateral uterosacral ligament into each angle stitch - this provides apical support and prevents future vault prolapse.
3. Vault closed with continuous locking suture or interrupted figure-of-eight sutures (No. 1 Vicryl).
4. Vault haemostasis confirmed.

J. Haemostasis, Irrigation & Closure (Step 9)

1. All pedicles inspected for bleeding; any bleeding points controlled with sutures or bipolar cautery.
2. Bilateral ureteric peristalsis confirmed visually (important to confirm ureteric integrity).
3. Bladder integrity checked - no visible injury.
4. Peritoneal lavage with warm normal saline.
5. Parietal peritoneum closed (or left open - either is acceptable, per surgeon preference).
6. Rectus sheath closed with loop PDS No.1 or No. 2 continuous suture.
7. Subcutaneous fat approximated if thick. Skin closed with subcuticular Vicryl / interrupted Ethilon.
8. Sterile dressing applied. Catheter secured.

INTRAOPERATIVE FINDINGS

POST-OPERATIVE ORDERS (Brief)

COMPLICATIONS TO DISCUSS (for Viva / Case Presentation)

• Haemorrhage (most common - from uterine vessels, ovarian pedicles)
• Bladder injury (most common organ injured - usually during bladder flap dissection)
• Ureteric injury (often unrecognised intraoperatively - kinking, ligation, transection)
• Bowel injury
• Vault haematoma

• Vault haematoma / infection
• Urinary tract infection
• Fistula (vesico-vaginal, uretero-vaginal)
• Vault dehiscence
• Ileus / bowel obstruction
• DVT / pulmonary embolism
• Psychological - surgical menopause if BSO done

TEACHING POINTS FOR RESIDENT

1. Ureteric safety is the single most important principle throughout the case - identify and protect at IP ligament, broad ligament, and uterine vessel steps.
2. The round ligament is ligated first - it opens the broad ligament and gives you the surgical planes.
3. Bladder must be reflected well below the external os before attempting colpotomy.
4. Uterine vessels are ligated flush against the cervix at the internal os level - this naturally displaces the ureter laterally.
5. Uterosacral ligament incorporated into vault angles prevents long-term vault prolapse.
6. Confirm bilateral ureteric peristalsis before closing.
7. Routine opportunistic salpingectomy at the time of hysterectomy is now recommended by RCOG/ACOG as it reduces lifetime ovarian cancer risk.

REFERENCES

• Sabiston Textbook of Surgery, 21st Edition - Chapter 120: Gynecologic Surgery, pp. 2799-2801 (Steps A-I with operative diagrams, Figure 120.12)
• Berek & Novak's Gynecology, 16th Edition
• RCOG Green-top Guideline No. 10: Surgical Treatments for Heavy Menstrual Bleeding

PubMed Evidence Summary: TAH vs Alternatives - Complication Rates & Management

1. Surgical Approach Comparison - The Cochrane Benchmark

2. Large Fibroid Uterus Specifically - Which Route is Safest?

3. Postoperative Ileus After Hysterectomy - Risk Factors & Management

• Laparoscopic approach: OR 0.43 (reduces ileus by 57% vs open)
• Vaginal approach: OR 0.35 (reduces ileus by 65% vs open)

4. TAH Alternatives for Fibroid - UAE vs Myomectomy (Uterus-Sparing Options)

5. Pre-operative Medical Optimization Before Surgery

Summary Table for Resident Reference

Clinical Bottom Line for Residents

1. If TAH is being performed, focus on blood loss minimisation - transfusion risk is the key differentiator vs minimally invasive routes (6-fold higher, PMID 38743951).
2. Ureteric injury is paradoxically higher with laparoscopic approaches (not TAH) - confirm ureteric peristalsis at end of any approach.
3. Post-op ileus risk is highest after TAH - use multimodal analgesia, minimize opioids, encourage early ambulation, prefer spinal over GA.
4. Pre-op GnRHa for 2-3 months is evidence-based in anaemic patients to reduce intraoperative blood loss and correct Hb before TAH (Cochrane 2025).
5. UAE is not a permanent solution - one in four women undergoing UAE will eventually need hysterectomy at 4 years (PMID 39164326). Counsel patients accordingly.

Key Citations

• Pickett et al. (2023). Cochrane review - surgical approaches to hysterectomy. [PMID: 37642285]
• Mamik et al. (2024). Hysterectomy for benign large uteri. Obstet Gynecol. [PMID: 38743951]
• Hou et al. (2024). Risk factors for post-op ileus in hysterectomy. PLoS One. [PMID: 39088416]
• Peng et al. (2024). UAE vs myomectomy for fibroids. Sci Rep. [PMID: 39164326]
• Puscasiu et al. (2025). Preoperative medical therapy before fibroid surgery. Cochrane Database. [PMID: 40183418]