Abdominal

Hysterectomy
Hariyono Winarto, M.D., Ph.D
Abdominal Hysterectomy
STEPS IN THE PROCEDURE Abdominal Hysterectomy
• Secure and transect round ligament. This allows access to the retroperitoneum for identification of the pelvic ureter and forisolation of the
ovarian pedicles.
• Incise anterior leaf of the broad ligament to begin vesicouterine dissection.
• Open the posterior leaf of the broad ligament and identify the ureter.
• Isolate and clamp the infundibulopelvic ligament (if bilateral salpingo-oophorectomy is planned) or utero-ovarian ligament (if ovaries will be
retained).
• Transect infundibulopelvic ligament (if bilateral salpingo-oophorectomy is planned) or uteroovarian ligament (if ovaries will be retained).
• Create vesicouterine space and mobilize the bladder off the cervix and proximal vagina.
• Isolate the uterine artery and vein. This will minimize tissue in uterine vascular pedicle and will also lateralize the ureters. However, when
skeletonizing these vessels, efforts to completely unsheathe the vessels may result in accidental vascular injury or transection.
• Clamp, incise, and ligate the uterine artery and vein to achieve hemostasis.
• If supracervical hysterectomy is planned, amputate the uterine corpus. This is also an intermediate step in total hysterectomy for benign
disease if the uterus is bulky (e.g., if visualization of the cervix would be facilitated by removing the fundus).
• Secure and divide the cardinal ligaments. Excise the cervix from vaginal attachments. Close the vaginal cuff.
• Universal cystoscopy improves the early detection of urinary tract injury. Surgeons should have a low threshold for evaluation of the urinary
tract when there is concern for injury.
• FIGURE 20.1 The technique
of abdominal hysterectomy
begins with dividing the round
ligament. The ligament is
ligated with transfixion sutures
and cut. The broad ligament is
opened. (When the round
ligament is contained in a
clamp at the cornu, a second
ligature on the medial pedicle,
as shown here, is optional.)
ADDITIONAL TIPS
Opening and Dissecting the Retroperitoneum
• Dissecting the anterior leaf of the broad ligament: Injection of 20 cc of normal saline
beneath the peritoneal reflection may facilitate dissection of the vesicouterine space
(but is rarely necessary).
• Palpating the ureter: The ureter is most easily palpated by facing the patient's feet. The
surgeon on the patient's left places the thumb of the right hand in the left
retroperitoneal space and the index finger on the smooth medial peritoneal surface of
the broad ligament. The tips of the thumb and index finger pinch the peritoneum deep in
the pelvis at the level of the psoas, and the ureter slides through the opposed thumb and
finger as the surgeon's hand is elevated toward the ceiling.
FIGURE 20.2 A: Undermining and tenting the peritoneum with open vascular forceps lateral to and parallel to the infundibulopelvic
ligament provides a helpful guide, especially for learners. B: The peritoneum is then incised with cautery (shown here) or scissors
parallel to the IP ligament. (Photograph courtesy of Laurie S. Swaim.)
• FIGURE 20.3 Identifying the
ureter along the medial leaf of the
broad ligament. Once the
retroperitoneal space is opened,
lean the flat surface of the blunt end
of a pair of tissue forceps along the
medial leaf of the broad ligament.
Draw the forceps end against the
broad ligament medially and upward
(anterior) to reveal the ureter as it
courses toward the pelvis.
(Photograph courtesy of Laurie S.
Swaim.)
FIGURE 20.4 A: Scissors are used to
create a window in the medial leaf of the
broad ligament. The window is then
extended toward the uterus so that the
clamp containing the utero-ovarian
ligament and round ligament stump can
be repositioned with the tip in this
window. B: The infundibulopelvic
ligament is secured with a Heaney clamp
(concave side of the clamp toward the
pelvis). A Kocher clamp containing the
fallopian tube, utero-ovarian ligament,
and the round ligament stump prevents
back bleeding from the divided cornual
structures and also provides traction on
the uterus.
FIGURE 20.5 A: When securing the IP or utero-ovarian ligament, the surgeon first places the index finger through the window in the
broad ligament, serving as a guide for clamp placement and isolating the IP or utero-ovarian pedicle as seen here. B: Next, a curved
clamp is guided into the window in the broad ligament. This is most easily done by orienting the clamp so the heel faces the lateral
pelvis, opening the clamp wide enough to encompass the IP or utero- ovarian ligament and fallopian tube complex, and resting the
tip of the posterior blade on the tip of the index finger. While maintaining this relationship, the index finger is drawn back through the
peritoneal opening until the tips clear the tissue and the entire pedicle is contained and secure the clamp. (Photograph courtesy of
Laurie S. Swaim.)
• FIGURE 20.6 The utero-
ovarian pedicle is transected
with Mayo scissors and secured
with a freehand 0-Vicryl tie. The
free tie is followed by a 0-Vicryl
transfixion stitch, which will be
placed distal to the free tie.
• FIGURE 20.7 The bladder is
mobilized inferiorly by sharp
dissection away from the cervix.
To avoid unnecessary bleeding,
this step may be done in stages
as necessary.
• FIGURE 20.8 While the assistant retracts
the bladder, the surgeon's left hand (in this
case) provides traction on the cervix to gain
the appropriate angle to identify the
vesicouterine space. To dissect the bladder
off the cervix and anterior vagina, the cut
edge of the bladder peritoneum is grasped
with vascular forceps or a Sarot clamp in the
midline. Resting the tips of the scissors on the
anterior cervix, the surgeon snips a few
millimeters of tissue overlying the cervical
fascia. Without removing the scissors, the
surgeon immediately advances or “pushes”
the tips of the closed scissors 3 to 4 mm, then
spreading the blades 3 to 4 mm in the same
plane. Note that the tips of the scissors rest
on the anterior cervix as dissection proceeds.
(Photograph courtesy of Laurie S. Swaim.)
• FIGURE 20.9 A: The uterine
vessels are skeletonized. B: A
curved Heaney clamp is used to
clamp the uterine vessels
immediately adjacent to the
uterus at the level of the
internal os. Note the course of
the ureter passing under the
uterine vessels. As shown in the
inset, the uterine vessels are
ligated by a suture ligature. This
pedicle is often doubly ligated
(even when singly clamped).
ADDITIONAL TIPS
Bladder Dissection
• Incision of the vesicouterine peritoneum: If scarring makes identification of the superior margin of
the bladder impossible, a uterine sound inserted through the urethra to the top of the bladder can
delineate the superior margin of the bladder and identify a suitable area for dissection above the
sound tip.

• Dissecting the bladder off the cervix bluntly: In order to proceed bluntly, elevate the peritoneal edge
of the bladder with forceps and insert the second and third fingertips behind the bladder and gently
spread over the cervix until the dissection is complete. Alternatively, grip the cervix with one hand,
and gently peel the bladder from the cervix with the thumb, using a downward sweeping motion
against the cervix.
• FIGURE 20.10 When ligating
the uterine vessels, the suture
is placed at the inferior tip of
the curved clamp. (Inset shows
detail.) The ligature is tied
under the clamp as an assistant
opens and withdraws the
clamp. (Photograph courtesy of
Laurie S. Swaim.)
ADDITIONAL TIPS
Clamp Placement
• Uterine artery pedicle: To situate the clamp and secure the uterine vessels, the primary surgeon elevates the
uterus with the nondominant hand toward the ceiling and slightly forward. In order to ensure appropriate
placement, open a Heaney clamp fully with the dominant hand and lay the open face of the posterior blade against
the posterior uterus at the appropriate level. Maintain the relationship of the posterior blade and the tissue, and
rock the uterus posteriorly. Forward pressure and slight rotation of the dominant hand helps to preserve the
location of the posterior blade against the uterus. While the assistant retracts the bladder inferiorly, swing the
anterior blade so its tips surround a few millimeters of the lateral cervix at the internal os, and completely close the
clamp. While closing the clamp, the Heaney slides off the lateral cervix so that the tips of the clamp are
immediately adjacent to the uterus.

• Clamping across the vaginal apex: If the tips of two curved clamps are not touching, leave a space of 1 cm or more
between the clamps. The space between clamps should be wide enough to allow the surgeon to confidently
identify and include the edges of the anterior and posterior vaginal mucosa in the cuff.
FIGURE 20.11 After the
uterine artery and vein have
been ligated, the remaining
lower portion of the cardinal
ligament is clamped with a
series of straight clamps. The
tips are placed on the edge of
the cervix and the back of the
jaw immediately adjacent to
the previous pedicle.
• FIGURE 20.12 When
transecting the cardinal ligament,
to free residual fibers of cardinal
ligament without traveling past
the clamp tip, rest the belly of a
knife blade at and perpendicular
to the very tip of the Ballantyne.
While holding the blade steady,
gently rotate the clamp clockwise
and counterclockwise to free the
residual fibers without traveling
past the knife tip. (Photograph
courtesy of Laurie S. Swaim.)
ADDITIONAL TIPS
Cardinal Ligament Pedicles
• To transect the clamped cardinal ligament pedicles, outline a wedge-shaped pedicle by
drawing a knife blade medially from the tip to heel of the clamp on each side of the
ligament. Using the outline as a guide, alternate incisions from anterior and posterior
directions until the pedicle is free.

• As the cardinal ligament pedicles are sutured with a transfixion stitch, the surgeon should
cinch the suture directly along the back of the clamp so the knot lies squarely over the
cut tissue without including lateral pedicles.
• FIGURE 20.13 After checking to be
sure the bladder and rectum are
clear, the vagina is crossclamped with
curved Heaney or Zeppelin clamps
just below the cervix (dotted line).
The vagina is divided just above the
clamps (with a knife or angled
scissors). The lateral pedicles are
closed with a Heaney suture ligature,
incorporating the uterosacral
ligament in the closure. In addition,
the central portion of the cuff is
closed with one or more figure-of-8
sutures.
ADDITIONAL TIPS
Supracervical Hysterectomy
• For supracervical hysterectomy or to amputate the fundus, place a wide malleable in the
cul-desac to protect the sigmoid and retract the fundus firmly toward the ceiling.

• Amputating the cervix: Using cautery, heavy scissors, or a long-handled knife, begin the
incision a few centimeters above the uterine vascular pedicles or remaining Heaney
clamps. Cut straight across the cervix, being careful not to angle downward toward the
vascular pedicles.
FIGURE 20.14 Subtotal or
supracervical hysterectomy.
After the uterine vessels have
been ligated, the fundus is
amputated using the
electrocautery in a shallow
cone-shaped technique. As
shown here, straight clamps
at the insertion of each
cardinal ligament can be used
to stabilize the cervical stump
and for traction.
• FIGURE 20.15
• The cervical stump is closed
with delayed absorbable suture.
Reference
• Handa V, Van Le L. Te Linde's operative gynecology. 12th ed.
Philadelphia: Wolters Kluwer; 2020.