Stepwise Procedure for Total Abdominal Hysterectomy (TAH)
The standard TAH procedure involves sequential transection of supporting ligaments moving progressively away from the ureter, followed by circumferential parametrial dissection in three distinct stages around the cervix to minimize ureteral and vascular injury. 1
Preoperative Setup
- Position the patient for optimal exposure with preparation for a vertical midline or paramedian abdominal incision 2, 3
- Perform bowel preparation if there is potential for bowel involvement or resection 2, 3
Abdominal Entry and Exploration
- Make a paramedian or midline vertical incision to access the abdominal cavity 2, 3
- Thoroughly explore the entire abdominal cavity including inspection and palpation of liver, diaphragm, omentum, peritoneal surfaces, and pelvic organs 2, 3
- Obtain peritoneal washings for cytology if malignancy is suspected 2, 4
Sequential Ligament Transection (Moving Away from Ureter)
The critical principle is to cut sequentially from ligaments furthest from the ureter, progressively moving the ureter away from the cervix with each transection stage to prevent ureteral injury 1:
- Ligate and divide the round ligaments bilaterally first 2, 4
- Complete excision of the lumbar-ovarian vessels (infundibulopelvic ligaments) bilaterally if performing bilateral salpingo-oophorectomy 2, 4, 3
- Develop the bladder flap by dissecting the bladder off the lower uterine segment and cervix 5
- Identify and protect the ureters throughout the dissection, ensuring proper visualization 5
Three-Stage Circumferential Parametrial Dissection
This is the most critical phase to avoid complications. Cut the parametrial tissue along the circumference of the cervix in three sequential steps 1:
First Step:
- Clamp, ligate, and divide the uterine arteries bilaterally at the level of the internal cervical os 2, 1
- Transect the upper portion of the cardinal ligament 1
Second Step:
- Clamp, ligate, and divide the uterosacral ligaments 1
- Transect the posterior half of the cardinal ligament 1
Third Step:
- Clamp, ligate, and divide the vesicouterine ligament 1
- Transect the anterior half of the cardinal ligament 1
Uterine Removal and Closure
- Incise the vagina circumferentially at the level of the cervix to complete removal of the uterus and cervix 2
- Close the vaginal cuff with interrupted or running absorbable sutures 2, 3
- Ensure hemostasis throughout the operative field 5
- Close the abdomen in layers 6
Critical Technical Points to Avoid Complications
The two most important principles are: (1) sequential ligament transection moving away from the ureter, and (2) circumferential parametrial dissection in three stages 1. This approach ensures "the uterus has been naturally removed" and minimizes risk of ureteral injury (the most common serious complication), intestinal damage, and bladder injury 1, 5.
Proper dissection of the ureter, bladder, and rectum requires meticulous technique and is essential for every pelvic surgeon 5. The ureter should be visualized and palpated throughout the procedure, particularly before clamping any parametrial tissue 5.