What are the operative steps for a total abdominal hysterectomy in an adult female aged 35–65 years?

Operative Steps for Total Abdominal Hysterectomy

The standard operative technique for total abdominal hysterectomy involves sequential transection of supporting ligaments moving progressively away from the ureter, followed by circumferential parametrial dissection in three distinct stages around the cervix. 1

Preoperative Planning

• Perform a midline or paramedian laparotomy incision as the standard approach for surgeons without specific training in alternative techniques 2
• Assess uterine size, adnexal pathology, and anticipated surgical difficulties at the preoperative conference to plan procedural modifications 3

Initial Abdominal Exploration

• Obtain peritoneal washings for cytology upon entering the abdomen (standard for staging procedures) 4, 5
• Systematically inspect and palpate the liver, diaphragm, omentum, peritoneal surfaces, and all abdominal organs 4
• Evaluate the pelvis for extent of disease, adhesions, and anatomical distortion 3

Sequential Ligament Transection (Moving Ureter Away from Operative Field)

The critical principle is cutting ligaments sequentially from structures furthest from the ureter, which progressively displaces the ureter away from the cervix with each transection stage. 1

Step 1: Round Ligament Division

• Clamp, divide, and ligate the round ligaments bilaterally 1
• This initial step begins the lateral displacement of the ureters 1

Step 2: Utero-Ovarian Ligament Management

• If removing the ovaries (bilateral salpingo-oophorectomy): Clamp, divide, and ligate the infundibulopelvic ligaments after identifying and protecting the ureters 2
• If preserving the ovaries: Clamp, divide, and ligate the utero-ovarian ligaments and fallopian tubes close to the uterus 2
• Mark preserved ovaries with radio-opaque labels if postoperative radiotherapy is planned 2

Step 3: Anterior Leaf of Broad Ligament

• Incise the anterior leaf of the broad ligament and develop the bladder flap 1
• Sharply dissect the bladder off the lower uterine segment and upper cervix 1

Step 4: Posterior Leaf of Broad Ligament

• Incise the posterior leaf of the broad ligament 1
• Enter the posterior cul-de-sac 1

Circumferential Parametrial Dissection (Three-Stage Technique)

This three-step circumferential approach around the cervix is the key to avoiding ureteral and bladder injury. 1

First Stage: Uterine Artery and Upper Cardinal Ligament

• Clamp, divide, and ligate the uterine artery at its origin from the internal iliac artery 1
• Simultaneously transect the upper portion of the cardinal ligament 1
• This step provides the greatest displacement of the ureter laterally 1

Second Stage: Uterosacral Ligament and Posterior Cardinal Ligament

• Clamp, divide, and ligate the uterosacral ligament 1
• Simultaneously transect the posterior half of the cardinal ligament 1
• This further mobilizes the ureter away from the operative field 1

Third Stage: Vesicouterine Ligament and Anterior Cardinal Ligament

• Clamp, divide, and ligate the vesicouterine ligament 1
• Simultaneously transect the anterior half of the cardinal ligament 1
• This completes the circumferential parametrial dissection 1

Cervical Amputation and Vaginal Cuff Closure

• Amputate the cervix at the level of the internal os for total hysterectomy 1
• Ensure complete cervical removal (the uterus should be "naturally removed" following the correct release layer) 1
• Close the vaginal cuff with interrupted or running absorbable sutures 1
• Peritonealize the vaginal cuff (optional) 1

Additional Procedures When Indicated

Lymphadenectomy (For Malignancy)

• Perform pelvic lymphadenectomy including external iliac nodes for endometrial or cervical cancer staging 2
• Selective para-aortic lymphadenectomy only for enlarged nodes (routine para-aortic dissection not recommended due to morbidity without proven benefit) 2

Omentectomy

• Complete infracolic omentectomy is standard for ovarian/tubal malignancies 5
• Perform omentectomy if ovaries are involved in endometrial cancer 2

Appendectomy

• Mandatory for all mucinous ovarian tumors (8% have appendiceal involvement; primary appendiceal cancer mimics ovarian cancer) 5
• Standard component of ovarian cancer cytoreduction 6, 5

Critical Pitfalls to Avoid

• Ureteral injury: The sequential ligament transection technique moving away from the ureter is specifically designed to prevent this complication 1
• Bladder injury: Adequate bladder flap development and careful dissection of the vesicouterine space prevents this 1
• Incomplete cervical removal: Ensure the entire cervix is removed to avoid future cervical stump complications 1
• Inadequate hemostasis: Secure ligation of all pedicles, particularly the uterine artery, is essential 1

Postoperative Prophylaxis

• Administer prophylactic antimicrobials consistently (key to surgical success) 7
• Implement thromboembolic prophylaxis measures (essential for all abdominal hysterectomies) 7
• Prevent urinary retention with appropriate catheter management 7