Outline Procedure For Tahbso

Saint Louis University Baguio City School Of Nursing S.Y 2017-2018

Outline procedure for Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy

Submitted by: Dumagas, Jeanette Dimalanta. BSN-III C3 Submitted to: Mrs. Maryknole Dumo Boadilla,RN

A Compilation of Academic Work and Other Forms of Educational Evidence

November 27, 2017

Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy TECHNIQUE Preparing the Surgical Field The operation is performed with the patient in the supine position. Some surgeons prefer a modified lithotomy position using Allen universal stirrups to allow potential access to the vagina and closer proximity of a second assistant. A pelvic exam under anesthesia is routinely performed. This exam further delineates the existing pathology and may help with the selection of the type of incision. It also provides the examiner with immediate feedback on interpreting abnormal findings. The vagina and urethra should be prepped and a Foley catheter placed for straight drainage. A low transverse abdominal incision can be used if cancer is not suspected. This incision can be converted to a Maylard or Cherney incision if increased exposure is necessary. In cases of known or suspected malignancy, a vertical incision is preferred to allow increased exposure to the upper abdomen and improved visualization for appropriate biopsies and node dissection.

Fig. 1. The round ligament is identified, clamped, and transfixion sutured. This procedure initiates the hysterectomy and allows entrance into the broad ligament and retroperitoneum.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 2. The anterior leaf of the broad ligament is incised toward the level of the internal os with Metzenbaum scissors. Bilateral incisions meet in the midline.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 3. The ureter crosses the iliac vessels at their bifurcation, continues below the infundibulopelvic ligament on the posterior medial leaf of the broad ligament, and crosses under the uterine vessels before turning anterior and medially to enter the bladder.

Fig. 4. The posterior broad ligament is tented upward in the avascular space lateral to the uterus, posteromedial to the adnexa and anterior to the ureter. This space is entered to create a window in the broad ligament.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 5. If the ovary and fallopian tube are to be conserved, two Kelly clamps are placed across the fallopian tube and utero-ovarian ligament in close proximity to the uterus. The Kelly clamp at the uterine cornua is advanced so that its tip extends into the window.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 6. A free tie is placed with removal of the lateral clamp.A transfixion suture is then placed beneath the second clamp.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 7. If the ovary and fallopian tube are to be removed, three Kelly clamps are placed across the infundibulopelvic ligament through the window in the broad ligament.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 8. The bladder flap is developed by lifting the anterior peritoneum and retracting the uterus cephalad to expose the bladder reflection and enter the vesicocervical space.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 9. The posterior peritoneum is incised toward the posterior cervix at the level of the internal cervical os. The uterosacral ligaments join the cervix just beneath this level. Incision of the peritoneum immediately posterior to the cervix may be delayed until later to avoid extra bleeding. This peritoneum between the uterosacral ligaments may require no further mobilization if the reflection of the rectum is below the lower margin of the cervix.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 10. The uterine vessels have been skeletonized. Three curved Heaney clamps are placed at right angles to the vessels. The lowest clamp is placed first and is at the level of the internal cervical os.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 11. A straight Heaney clamp is placed across the cardinal ligament medial to the previously ligated uterine vessels. As the clamp is closed, it is allowed to slide off the lateral surface of the cervix. Maintaining close proximity to the cervix maximizes the distance between the pedicle and the ureter.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 12. The uterosacral ligament may be approached with a curved Heaney clamp from the posterolateral direction. The ligament is then cut and ligated with 0 delayed absorbable suture.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 13. The bladder and, if necessary, the rectum have been adequately mobilized. A curved Heaney clamp is placed across the lateral vaginal fornix with its tip extending across the upper vagina immediately beneath the cervix.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 14. The vagina is incised circumferentially just beneath the cervix. Long Allis clamps are placed on the vaginal angles and on the anterior and posterior vaginal walls.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

Fig. 15. The angle suture incorporates the full thickness of the anterior vaginal wall, the adjacent cardinal and uterosacral ligament, and the posterior vaginal wall. A suture is then placed through the full thickness of the vagina beneath its cut edge, locked over the edge, and continued circumferentially around the top of the vagina for hemostasis.(Thompson JD, Rock JA: Telinde's Operative Gynecology, 7th ed, Ch 29. Philadelphia, JB Lippincott, 1992)

REFERENCE:

Pokras R, Hufnagel VG: Hysterectomies in the United States, 1965-1984. National Center for Health Statistics. Vital Health Statistics Series 13, Number 92, 1987. DHHS Publication No. (PHS) 87–1753