PAPER PRESENTATION: TOTAL ABDOMINAL HYSTERECTOMY (TAH)

PART I: PATIENT INFORMATION (Header)

PART II: CHIEF COMPLAINTS

1. Heavy menstrual bleeding for 1 year
2. Progressively increasing lower abdominal heaviness for 8 months
3. Dysmenorrhea for 6 months

PART III: HISTORY OF PRESENT ILLNESS

PART IV: PAST HISTORY

• Menstrual History: Menarche at 13 years; cycles irregular, heavy; last menstrual period: DD/MM/YYYY
• Obstetric History: P3L3 - All three deliveries were full-term normal vaginal deliveries; no abortions
• Contraceptive History: Not using any contraception currently
• Medical History: No diabetes mellitus, hypertension, or thyroid disorders
• Surgical History: No prior abdominal surgeries
• Drug/Allergy History: No known drug allergies
• Family History: Not significant

PART V: GENERAL AND SYSTEMIC EXAMINATION

• Conscious, cooperative, well-built female
• Pallor: Present (mild to moderate)
• Icterus / Cyanosis / Clubbing / Lymphadenopathy / Edema: Absent
• Vitals: BP - 120/80 mmHg, Pulse - 88/min, Temperature - Afebrile, RR - 16/min
• Weight: 62 kg, Height: 155 cm, BMI: 25.8 kg/m²

• Cardiovascular System: S1 S2 heard, no murmurs
• Respiratory System: Bilateral equal air entry, vesicular breath sounds
• Central Nervous System: Intact, no focal deficits
• Per Abdomen: Soft, non-tender; lower abdomen - see below

PART VI: LOCAL EXAMINATION

• A firm, non-tender mass in the lower abdomen, 16-week uterine size, arising from the pelvis, smooth surface, restricted mobility

• Cervix - nulliparous os, healthy; no erosion, polyp, or discharge

• Uterus: Enlarged to 16 weeks size, firm, irregular, restricted mobility
• Bilateral fornices: Free, non-tender
• Parametria: Free

PART VII: INVESTIGATIONS

• Hemoglobin: 8.2 g/dL
• PCV: 26%
• WBC: 7,800/mm³
• Platelet count: 2.4 lakhs/mm³
• Blood group: B+ve

• Serum creatinine: 0.9 mg/dL, Blood urea: 22 mg/dL
• Blood glucose (fasting): 88 mg/dL
• LFT: Within normal limits
• Serum electrolytes: Normal

• Ultrasound (transabdominal and transvaginal): Uterus enlarged (16-week size) with multiple intramural and subserosal fibroids; largest fibroid 8 x 7 cm; both ovaries normal; no free fluid
• Chest X-ray: NAD
• ECG: Normal sinus rhythm

PART VIII: DIAGNOSIS

PART IX: PRE-OPERATIVE MANAGEMENT

1. Hematinics and IV iron infusion for correction of anemia; pre-operative Hb raised to 10.2 g/dL
2. Pre-operative GnRH agonist (Inj. Leuprolide 3.75 mg IM) given 4 weeks prior to shrink fibroids
3. Bowel preparation: Low residue diet 48 hours prior; laxative the night before
4. Catheterization: Foley's catheter inserted pre-operatively
5. Antibiotic prophylaxis: Inj. Cefazolin 2g IV 30 min before skin incision
6. DVT prophylaxis: TED stockings applied; low-molecular-weight heparin considered
7. Consent: Informed written consent obtained; procedure, alternatives, risks, and benefits explained

PART X: OPERATIVE NOTE (PAPER PRESENTATION CORE)

Patient Details

• Date of Surgery: DD/MM/YYYY
• Surgeon: Dr. __________ (Consultant Gynecologist)
• Assistants: Dr. __________, Dr. __________
• Anesthesiologist: Dr. __________
• Type of Anesthesia: General anesthesia with endotracheal intubation / Spinal anesthesia
• Position: Supine
• Duration: 90 minutes
• Estimated Blood Loss (EBL): 300 mL

Pre-Operative Findings

• 16-week size uterus, multiple fibroids
• Fallopian tubes and ovaries bilateral - normal in appearance

Operative Procedure (Step-by-Step)

1. Patient preparation: The patient was positioned supine under general anesthesia. Foley's catheter was inserted and urinary output monitored throughout. Abdomen and perineum were painted with povidone-iodine and draped in a standard sterile fashion.
2. Abdominal incision: A Pfannenstiel (low transverse) incision was made approximately 3 cm above the pubic symphysis. The subcutaneous tissue was divided. The rectus sheath was incised and the recti muscles separated in the midline. The peritoneum was identified, lifted with artery forceps, and opened vertically to enter the peritoneal cavity.
3. Exploration: A thorough exploration of the peritoneal cavity was performed. The uterus was enlarged with multiple fibroids. Bowel, liver, spleen, appendix, and omentum were unremarkable. A self-retaining O'Connor-O'Sullivan retractor was placed. The bowel was packed superiorly with warm moist laparotomy packs. The table was tilted in the Trendelenburg position.
4. Uterine elevation: The uterus was grasped with two Toothed (Lane's) tissue forceps at the fundus and elevated out of the pelvis to provide traction and counter-traction.
5. Round ligaments: The round ligaments were clamped bilaterally with Kocher's forceps, cut, and ligated with No. 1 vicryl suture.
6. Broad ligament dissection: The anterior and posterior leaves of the broad ligament were opened using Mayo scissors, creating a window lateral to the infundibulopelvic ligament.
7. Utero-ovarian ligaments (ovaries conserved): Since the ovaries were conserved, the utero-ovarian ligament and fallopian tube were doubly clamped with curved Kocher's forceps close to the uterus, divided, and ligated (suture-ligated with No. 1 vicryl).
8. Bladder flap: The uterovesical peritoneum was incised transversely, and the bladder was dissected sharply and bluntly downward away from the lower uterine segment and cervix using pledget dissection to avoid bladder injury.
9. Uterine vessels: The uterine vessels (uterine artery and veins) were clamped bilaterally at the level of the internal os using straight Heaney's clamps, cut, and suture-ligated with No. 1 vicryl suture. The pedicles were transfixed to prevent slipping.
10. Cardinal ligaments: The cardinal ligaments were serially clamped using curved Heaney's clamps, cut, and ligated bilaterally down to the level of the vaginal vault.
11. Uterosacral ligaments: The uterosacral ligaments were clamped, cut, and ligated bilaterally, providing additional support to the vaginal vault.
12. Vaginal cuff: The vagina was entered anteriorly using curved scissors (Jorgensen scissors). Curved clamps were placed across the vaginal angles on both sides. The uterus and cervix were excised completely and delivered. The specimen was placed in a kidney basin and sent for histopathological examination.
13. Vaginal cuff closure: The vaginal cuff was closed with interrupted figure-of-8 sutures using No. 1 vicryl, incorporating the uterosacral ligaments at the angles for vault support (McCall-type culdoplasty). Hemostasis was confirmed throughout.
14. Peritonization: The pelvic peritoneum was closed with continuous 2-0 vicryl suture to peritonealize all pedicles.
15. Peritoneal irrigation: The peritoneal cavity was irrigated with approximately 500-700 mL warm normal saline and aspirated. The laparotomy packs were removed and counted (all 5 accounted for).
16. Abdominal closure:
    • Peritoneum: Continuous 1-0 vicryl
    • Rectus sheath (fascia): Continuous No. 1 PDS/vicryl
    • Subcutaneous tissue: 2-0 vicryl (if fat > 2 cm)
    • Skin: Stainless steel staples or 3-0 monocryl subcuticular
17. Dressing: Wound dressed with Telfa pad, gauze, and adhesive tape.
18. Sponge, needle, and instrument count: Correct at opening and closure. No discrepancy.

Post-Operative Findings

• Uterus with cervix: 16-week size, multiple intramural and subserosal fibroids
• Specimen weight: approximately 480 g
• Bilateral fallopian tubes and ovaries: Normal; conserved in-situ
• No intraoperative complications

PART XI: POST-OPERATIVE MANAGEMENT

• Monitor vitals every 30 min for 2 hours, then every 4 hours
• IV fluids: Ringer's lactate at 125 mL/hr; transition to oral when bowel sounds return
• Foley's catheter: In situ; monitor urine output (target > 0.5 mL/kg/hr)
• Analgesics: IV paracetamol 1g every 8 hours + Inj. Ketorolac 30 mg every 8 hours PRN
• Antiemetics: Inj. Ondansetron 4 mg IV PRN
• DVT prophylaxis: Low molecular weight heparin (Enoxaparin 40 mg SC OD from 12 hours post-op) + early ambulation
• Antibiotic cover: Continue IV Cefazolin for 24 hours

• Encourage early ambulation
• Soft diet when peristalsis returns
• Remove Foley's catheter at 24 hours post-op
• Wound inspection
• Transition to oral analgesics (Tab. Ibuprofen 400 mg + Tab. Paracetamol 500 mg)

• Regular diet
• Wound care; staple/suture removal on Day 7-10
• Check Hb; transfuse if < 7 g/dL with symptoms
• Discharge planning and counseling

PART XII: COMPLICATIONS (DISCUSSED WITH PATIENT)

• Bladder injury (most common; risk 1-2%)
• Ureteral injury
• Bowel injury
• Hemorrhage requiring transfusion

• Vault hematoma or abscess
• Deep vein thrombosis / Pulmonary embolism
• Wound infection or dehiscence
• Urinary tract infection
• Vault prolapse (late)
• Bladder/urethral dysfunction

PART XIII: HISTOPATHOLOGY REPORT (SPECIMEN)

• Specimen: Uterus with cervix
• Gross: Enlarged uterus (480 g), multiple well-circumscribed whorled intramural nodules
• Microscopy: Interlacing bundles of smooth muscle cells; no atypia, necrosis, or mitoses
• Diagnosis: Multiple leiomyomata (uterine fibroids)

PART XIV: DISCUSSION

• Symptomatic fibroid uterus unresponsive to medical management
• Completed family
• Uterus > 12-week size with pressure symptoms
• Anemia due to menorrhagia

• Completed family - definitive treatment preferred
• Large uterus (>16 weeks) - myomectomy carries high recurrence and re-operation risk
• Laparoscopic approach not ideal due to uterus size
• Vaginal route not feasible for large fibroid uterus

PART XV: PROGNOSIS

• Excellent for benign disease
• Symptoms (menorrhagia, pelvic pressure) resolve completely
• If ovaries conserved (as in this case): no surgical menopause; hormonal function intact
• Long-term follow-up: Pap smear no longer required (cervix removed); counseled on sexual health and pelvic floor exercises

Summary Table for Quick Reference

What's inside (14 slides):