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information regarding the loss is documented in an Incident Report that becomes part of the patient’s chart.

Total Abdominal Hysterectomy Definition

Removal of the whole (total) uterus through an abdominal incision.

Discussion

Some indications for total abdominal hysterectomy (TAH) are endometriosis, adnexal disease, postmenopausal bleeding, dysfunctional uterine bleeding, and benign and malignant tumors.TAH was, until recently, considered an absolute necessity to avoid cancer of the cervix. Currently, some gynecologists perform supracervical hysterectomy (instead of TAH) in order to preserve the secretory function of the cervix and to aid in supporting the structures in the pelvis, thereby avoiding prolapse. In conjunction with TAH, gynecologists performing TAH can perform colporrhaphy procedures to correct anterior and posterior prolapse. Hysterectomy may be performed laparoscopically (p. 318) and as a laparoscopic-assisted procedure (p. 318).

Procedure A transverse, Pfannenstiel, midline, or paramedian incision is employed, depending on the diagnosis, anatomical considerations, and preference of the surgeon.The peritoneal cavity is entered, and a selfretaining retractor is placed.The table is placed in Trendelenburg position (the organs fall cephaled, e.g., towards the head) to facilitate viewing the pelvic contents. The intestines are protected with warm moist (saline) lap pads. The fundus of the uterus is grasped with a multi-toothed tenaculum for manipulation (by retracting cephalad); this, too, facilitates pelvic exposure.The round ligaments of the uterus are ligated and divided (by scalpel or Mayo or Jorgensen scissors), and ligatures are tagged with a hemostat, not cut. After identifying the ureters, the broad ligaments are ligated and divided. The bladder is reflected from the anterior aspect of the cervix using blunt and sharp dissection. The infundibulopelvic ligaments are ligated and divided. If the ovaries are to be preserved, the ovarian vessels are ligated and divided adjacent to the uterus (avoiding the ureters). The uterosacral ligaments are ligated and divided. The cardinal ligaments are likewise ligated and divided. Suture ligatures are employed on the patient side of the division.The cervix is grasped anteriorly (with a Kocher or similar clamp), and the vagina is incised circumferentially. The specimen (uterus) is removed. A free raytec sponge (soaked in prep solution) may be placed in the vagina with long smooth forceps prior to closure. Hemostasis is secured. The vaginal cuff is closed with a continuous absorbable suture; a drain may be placed (infrequently).The stumps of the uterosacral and round ligaments are sutured to the angles of the vaginal closure. The peritoneum is approximated, and the wound is closed in layers. Dressings are placed. The free raytec sponge is removed transvaginally; in order for the sponge count to be correct, the free raytec sponge must be retrieved before the patient is taken from the OR to PACU.

Preparation of the Patient Antiembolitic hose are put on the legs, as requested. The patient is supine; arms may be extended on padded armboards.A pillow may be placed under the lumbar spine and/or under the knees to avoid straining back muscles. Padded shoulder braces are secured to the table.The

table may be placed in Trendelenburg position. Pad all bony prominences and areas vulnerable to skin and neurovascular trauma or pressure. Apply electrosurgical dispersive pad.

Skin Preparation A vaginal and an abdominal prep (separate trays) are required. The patient’s legs are placed in a froglike position; prep as for D&C, see p. 278. Insert a Foley catheter and connect to continuous drainage unit. Return the patient’s legs to their original position, place the drainage unit below the level of the table, and replace the safety belt. For the abdominal preparation, begin at the intended site of incision (usually Pfannenstiel), extending from nipples to mid-thighs and down to the table at the sides.

Draping Folded towels and a transverse or laparotomy sheet

Equipment Sequential compression device with disposable leg wraps, if requested Forced-air warming blanket, if ordered Padded shoulder braces Suction ESU

Instrumentation Major procedures tray Abdominal hysterectomy tray Self-retaining retractor (e.g., Balfour or O’Connor-O’Sullivan)

Supplies Antiembolitic hose Blades, (3) #10 Basin set Needle magnet or counter Suction tubing Electrosurgical pencil with blade, cord, holder, and scraper Foley catheter with tubing and drainage unit Sanitary napkin belt or T-binder Perineal pad

Special Notes • N.B. A signed special permit for any sterilization procedure, p. 7, must be on the chart in addition to the signed surgical permit required for the procedure, Total Abdominal Hysterectomy, before the patient may be admitted to the room. The patient needs to indicate in her own words that she understands that she will no longer be able to have children. The patient’s words are documented in the Perioperative Record. • Apply Special Notes from Abdominal Laparotomy, p. 134, as indicated. • N.B. Remember: Check with the patient before surgery and check the chart for patient sensitivities and allergies, particularly to iodine or latex products; many brands of prep solution and packing may contain iodophor; gloves, drains (e.g., Penrose), and elasticized dressings and pressure bandages contain latex. • The patient may have made an autologous blood donation preoperatively. The circulator should verify that the blood is ready

and available, i.e., check with the blood bank. • N.B. Before bringing the patient into the room, the circulator should ascertain that there are two working suctions in the room (in addition to the suction on the anesthesia cart) in case hemorrhage should occur. Keep an accurate record of irrigation used to assist in determining total fluid loss replacement. • Weigh sponges, as necessary, to assist in determining blood and fluid loss replacement, as indicated. • “Spongesticks” (raytec sponge on ringed forceps) may be requested throughout the surgery for blunt dissection. • A “stick tie” refers to a suture ligature with a swaged-on needle; the needle may be loaded onto a curved Heaney needle holder.The needle tip protrudes from the convex aspect of the needle holder. • Instruments that come in contact with the cervix or vagina are isolated in a basin. • The specimen is most conveniently received in a basin due to its large size. • N.B. Three closure counts are taken for TAH: 1) at closure of vaginal cuff, 2) at closure of peritoneum, and 3) at closure of skin. • N.B. A “free sponge” is placed in the vagina prior to closure; the sponge is included in the sponge count, and its placement is noted in the Perioperative Record. The sponge must be removed transvaginally at the termination of the procedure, before the patient leaves the room. • A Foley catheter (connected to a continuous straight drainage unit) is inserted at the conclusion of the surgery to prevent urinary retention resulting from swollen tissues around the operative site. • The drainage tubing of the Foley catheter should be patent (without kinks); the level of the bag should be kept below the level of the patient’s bladder to prevent a reflux of urine that could lead to a urinary tract infection (UTI).

Salpingo-Oophorectomy Definition Removal of the fallopian tube(s) and the corresponding ovary or ovaries.

Discussion Salpingo-oopherectomy is performed for a variety of nonmalignant diseases that include acute and chronic infections, cysts, tumors, and hemorrhage (tubal pregnancy, see p. 326). When a fallopian tube or an ovary is found to contain a malignancy, hysterectomy with excision of the both adnexae is indicated.

Procedure A low midline, paramedian, or Pfannenstiel incision is employed.The peritoneal cavity is entered, and a self-retaining retractor is placed.The table is placed in Trendelenburg position. The intestines are protected with warm, moist (saline) lap pads.The abdomen is explored. If adhesions are present, a hydrodissector (see p. 298) may be employed. When the affected fallopian tube is blocked, a laser fiber may be used to open it and a stent may be placed to maintain patency. For excision, the infundibulopelvic ligament is ligated and divided, as are the broad ligament attachment and the blood vessels of the affected tube and

ovary.The tube and ovary are excised.The site of adnexal excision may be reperitonealized. The wound is closed in layers. A dressing is applied to the wound and a perineal pad is placed. For the laparoscopic approach, see Gynecologic Laparoscopy/ Pelviscopy, p. 295.

Preparation of the Patient Apply antiembolitic hose, as requested.The patient is supine; arms may be extended on padded armboards.A pillow may be placed under the lumbar spine and/or under the knees (to avoid straining back muscles). Padded shoulder braces are secured to the table.The table is placed in Trendelenburg position. Pad all bony prominences and areas vulnerable to skin and neurovascular trauma or pressure.Apply electrosurgical dispersive pad. For Skin Preparation and Draping, see Total Abdominal Hysterectomy, p. 308.

Equipment Sequential compression device with disposable leg wraps, if requested Forced-air warming blanket, if ordered Padded shoulder braces Suction ESU Hydrodissector console, optional Laser (e.g., Nd:YAG, KTP, or Argon) optional

Instrumentation Major procedures tray Self-retaining retractor (e.g., Balfour or O’Connor-O’Sullivan) Somer’s clamp Hydrodissector hand piece and cord

Supplies Antiembolitic, as requested Blades, (2) #10, (1) #15 Basin set Needle magnet or counter Suction tubing Electrosurgical pencil and cord with holder and scraper Sanitary napkin belt or T-binder Perineal pad

Special Notes • N.B. A sterilization procedure permit, in addition to the signed surgical permit for the procedure,bilateral salpingooophorectomy, is required before the patient may be brought into the room.The patient needs to indicate in her own words that she understands that she will no longer be able to have children. Her statement to this effect should be included in the Perioperative Record. • Apply Special Notes from Abdominal Laparotomy, p. 134, as indicated. • “Spongesticks” (raytec sponge on ringed forceps) are often used for blunt dissection and may be requested throughout the surgery. • A Foley catheter connected to a continuous straight drainage unit is inserted at the conclusion of the surgery. • Tubing attached to the Foley catheter should be patent (without kinks); the level of the bag should be kept below the level of patient’s bladder to prevent a reflux of urine that could lead to a UTI.