Total Abdominal Hysterectomy (TAH)

• Berek & Novak's Gynecology, p. 1420
• Sabiston Textbook of Surgery, p. 2799

Definition and Terminology

Indications

• Uterine leiomyomas (fibroids) - the most common indication in the United States; abnormal uterine bleeding from fibroids is the leading reason for surgery
• Abnormal uterine bleeding (refractory to medical management)
• Pelvic organ prolapse
• Endometriosis / adenomyosis
• Chronic pelvic pain
• Gynecologic malignancies - endometrial, cervical, ovarian cancer
• Obstetric emergencies - uterine rupture, intractable postpartum hemorrhage

• Large uterus or large pelvic masses are present
• Extensive adhesions or endometriosis are expected
• Simultaneous abdominal exploration is needed
• Adnexal pathology requires assessment

Route Comparison

Preoperative Preparation

• Antibiotics: Cefazolin 1-2 g IV (3 g in obese patients) given 30-60 minutes before skin incision; redose after 3 hours of surgery or with excessive bleeding
• Skin prep: Chlorhexidine-alcohol preparation preferred over povidone-iodine
• Hair removal: Clipping only (no shaving) at time of surgery
• Bowel prep: No longer routinely recommended for most cases
• Positioning: Dorsal supine; Foley catheter placed after anesthesia; pelvic exam under anesthesia to confirm findings
• Infection risk factors to optimize: Glycemic control (diabetes), smoking cessation, nutritional status

Surgical Anatomy

Surgical Steps (Sequential)

1. Incision

• Low transverse (Pfannenstiel): Preferred for benign disease; better cosmesis
• Vertical midline: Used for large uteri, malignancy, need for exploration, or expected adhesions
• Chosen based on indication, body habitus, surgical history, size of pathology, and surgeon preference
• Fascia opened with traction on lateral edges to avoid enterotomy

2. Abdominal Exploration

• Peritoneal cytology if needed (oncologic cases)
• Systematic examination: liver, gallbladder, stomach, kidneys, para-aortic nodes, bowel

3. Retraction

• Balfour or O'Connor-O'Sullivan retractors most commonly used
• Bookwalter retractor useful in obese patients

4. Elevation of the Uterus

• Broad ligament clamps placed at each cornu, crossing the round ligament
• Uterus deviated laterally to place tension on contralateral structures

5. Round Ligament Division

• Uterus deviated to patient's left; right round ligament placed under tension
• Ligated with delayed absorbable suture or transected with electrocautery
• Anterior broad ligament incised medially toward the internal cervical os
• Bladder flap developed to separate bladder from lower uterine segment

6. Ureter Identification

• Retroperitoneum entered by extending incision cephalad on posterior broad ligament
• External iliac artery identified along medial psoas; traced cephalad to iliac bifurcation
• Ureter crosses common iliac artery at its bifurcation
• Ureter left attached to medial broad ligament leaf to protect its blood supply

7. Vascular Ligation

• Posterior broad ligament leaves incised; infundibulopelvic (IP) ligaments doubly clamped with curved Heaney or Zeppelin clamps and divided

• Two Kelly or Heaney clamps placed across the utero-ovarian vessels, which are divided and doubly ligated

8. Bladder Dissection

• Bladder dissected off cervix sharply (Metzenbaum scissors) or with electrocautery
• Bladder retracted inferiorly completely below the level of the cervix

9. Uterine Vessel Ligation

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

10. Cardinal and Uterosacral Ligament Division

• Straight Heaney or Zeppelin clamps placed on cardinal and uterosacral ligaments in serial steps bilaterally
• Pedicles cut and suture ligated until the level of the external cervical os

11. Colpotomy and Specimen Removal

• Curved clamps placed across vagina just below cervix from both sides
• Curved scissors cut above clamps to separate the uterus and cervix from the vagina
• Alternatively: direct sharp circumferential incision around the cervix, extended with curved scissors

12. Vaginal Cuff Closure

• Heaney transfixion stitches placed beneath vaginal corner clamps
• Interrupted figure-of-eight stitches or running suture used to close vagina in midline
• Uterosacral and cardinal ligaments incorporated into vaginal cuff angles for support

13. Hemostasis and Irrigation

• Pelvis irrigated with saline
• Meticulous hemostasis of all vascular pedicles
• Ureters checked for integrity and absence of dilation

14. Closure

• Pelvic peritoneum is not reapproximated as a separate layer
• Fascia closed with interrupted or continuous 0 or 1 monofilament absorbable suture; bites ~1 cm from edge, ~1 cm apart
• Subcutaneous fat closed if ≥2 cm thick (reduces wound disruption)
• Skin closed with staples or subcuticular sutures

Intraoperative Complications

Ureteral Injury

• Three most common sites:
  1. Pelvic brim where ureter crosses over common iliac vessels
  2. Midpelvis where uterine artery crosses over it ("water under the bridge")
  3. Near the cervix at the internal os
• Best prevention: direct visualization via retroperitoneal dissection (NOT reliance on ureteral catheters alone)
• Ureteral catheters may cause hematuria and urinary retention, and may give false sense of security in fibrotic/scarred pelvis
• If obstruction suspected: IV indigo carmine or methylene blue injection + cystoscopy

Hemorrhage

• Identify and ligate all vascular pedicles; back-bleeding from specimen pedicles controlled by double ligation

Bladder Injury

• Most common visceral injury; recognized by direct visualization intraoperatively
• Repaired in two layers; Foley catheter left for prolonged drainage

Bowel Injury

• Risk increased with adhesions, endometriosis, prior surgery

Postoperative Management

Bladder

• Foley catheter removed within 24 hours unless concurrent urogynecologic procedure performed
• Postvoid residuals should be <100 mL before catheter removal

Pain Management

• Multimodal preemptive analgesia: gabapentin, acetaminophen, COX-2 inhibitors started perioperatively
• Reduces postoperative opioid use and improves pain scores
• Preemptive fentanyl lowers postoperative pain scores

Diet

• Resume diet as soon as alert; solids as tolerated
• Early postoperative feeding is safe and speeds return of bowel function

Activity

• Ambulation begins on postoperative day 1 if possible
• No lifting >20 pounds for 6 weeks
• No sexual intercourse for at least 6 weeks (until vaginal cuff fully healed)
• No driving until full mobility returns

Wound Care

• Dressing left on for 24 hours; then daily cleaning with mild soap and water

Postoperative Complications

Key Anatomic Relationships to Remember

• The ureter is ~1-2 cm lateral to the cervix as it passes under the uterine artery - classic site of injury ("ureter is the water under the uterine artery bridge")
• The uterine artery arises from the internal iliac (hypogastric) artery
• The cardinal (Mackenrodt) ligament is the primary support of the cervix and upper vagina - its division is the critical step in gaining access to the vagina
• The uterosacral ligaments provide posterior support and are reattached to the vaginal cuff to prevent vault prolapse