What are the steps for a Total Abdominal Hysterectomy (TAH) plus Bilateral Salpingo-Oophorectomy (BSO)?

Steps of Total Abdominal Hysterectomy (TAH) plus Bilateral Salpingo-Oophorectomy (BSO)

Total abdominal hysterectomy with bilateral salpingo-oophorectomy should be performed through a paramedian incision with comprehensive staging for optimal patient outcomes and survival. 1

Preoperative Preparation

• Appropriate bowel preparation should be completed, especially if bowel resection might be necessary 1
• Patient should be positioned for a vertical midline abdominal approach for optimal exposure 1

Surgical Steps

Step 1: Abdominal Entry and Initial Assessment

• Make a paramedian incision to access the abdominal cavity 1
• Collect ascitic fluid or perform peritoneal lavage for cytologic examination 1
• Thoroughly explore the entire abdominal cavity to assess disease extent 1

Step 2: Oophorectomy Procedure

• Identify and isolate the infundibulopelvic ligament containing the ovarian vessels 2
• Carefully identify the ureter to avoid injury before ligating the infundibulopelvic ligament 2
• Completely excise the lumbar-ovarian vessels bilaterally 1
• Ligate and transect the infundibulopelvic ligament 2

Step 3: Hysterectomy Procedure

• Perform total hysterectomy with vaginal closure 1
• Ensure complete removal of the uterus and cervix 1
• Achieve hemostasis and re-evaluate ureter integrity 2

Step 4: Additional Staging Procedures

• Complete infracolic omentectomy 1
• Perform appendectomy 1
• Assess pelvic and para-aortic nodes; remove suspicious or enlarged nodes 1
• Take routine peritoneal biopsies from multiple sites 1

Step 5: Debulking (if malignancy present)

• Remove all visible disease when possible for optimal cytoreduction 1
• Consider additional procedures as needed for optimal debulking:
  • Bowel resection and/or appendectomy 1
  • Stripping of the diaphragm or other peritoneal surfaces 1
  • Splenectomy, partial hepatectomy, cholecystectomy 1
  • Partial cystectomy and/or ureteroneocystostomy 1
  • Partial gastrectomy or distal pancreatectomy 1

Special Considerations

• For early-stage ovarian cancer in women desiring fertility preservation, unilateral salpingo-oophorectomy with preservation of the contralateral ovary and uterus may be considered 1
• In advanced disease, the volume of residual tumor after surgery significantly impacts prognosis; patients with complete or optimal excision have better survival 1
• Minimally invasive approaches (laparoscopic or robotic) may be considered for select patients but should be converted to open procedure if optimal debulking cannot be achieved 1, 3

Potential Complications

• Blood loss requiring transfusion 3
• Injury to adjacent structures (ureter, bladder, bowel) 3
• Vaginal cuff dehiscence 3
• Urinary tract infection 3
• Delayed recovery requiring prolonged catheterization 3

Documentation Requirements

• The operative report must include a precise and detailed description of operative findings and surgery performed 1
• Documentation should specify the side, presence/absence of exophytic growths, ruptured capsule, histological type, and degree of differentiation 1
• The quality of excision margins should be documented, especially in cases of extensive surgery 1

Following these systematic steps ensures appropriate surgical management for patients requiring TAH+BSO, with the ultimate goal of improving morbidity, mortality, and quality of life outcomes.