Surgical Steps for Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy
The standard surgical procedure involves peritoneal lavage for cytology, total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO), and systematic inspection of abdominal organs including the diaphragm, liver, omentum, and pelvic and bowel peritoneal surfaces. 1
Procedural Steps
1. Initial Exploration and Assessment
- Perform peritoneal lavage for cytologic examination upon entering the abdominal cavity 1
- Systematically inspect and palpate all abdominal organs including the diaphragm, liver, omentum, and pelvic and bowel peritoneal surfaces 1
- Document any abnormal findings or suspicious lesions 1
2. Restoration of Normal Anatomy
- Lyse adhesions and restore normal anatomic relationships to facilitate safe dissection 2
- This step is particularly critical in patients with prior pelvic surgery or inflammatory disease 2
3. Ureteral Identification
- Identify and trace the course of both ureters bilaterally before proceeding with vascular ligation 2
- This is a critical safety step to prevent ureteral injury during the procedure 2
4. Hysterectomy Component
- Perform total hysterectomy removing the entire uterus including the cervix 1
- The uterus should be removed en bloc with the adnexa 1
5. Bilateral Salpingo-Oophorectomy
- Isolate the infundibulopelvic ligament on each side after confirming ureteral position 2
- Coagulate and transect the infundibulopelvic ligament containing the ovarian vessels 2
- Remove both fallopian tubes and ovaries completely 1
6. Final Hemostasis and Re-evaluation
- Achieve complete hemostasis at all pedicles and surgical sites 2
- Re-evaluate ureter position and integrity to ensure no injury occurred during the procedure 2
- Perform final inspection of the surgical field 2
Pathologic Assessment Requirements
The surgical specimens must undergo comprehensive pathologic evaluation including 1:
- Ratio of depth of myometrial/stromal invasion to myometrial thickness
- Cervical stromal or glandular involvement assessment
- Tumor size and location (fundus versus lower uterine segment/cervix)
- Histologic subtype with grade determination
- Lymphovascular space invasion evaluation
- Assessment of fallopian tubes and ovaries
Important Caveats
Minimally invasive surgery is the recommended approach for stage I G1-G2 endometrial cancer and may be preferred for stage I G3 disease 1. However, the traditional open approach described above remains standard when minimally invasive techniques are not feasible or appropriate 1.
The pathologic information obtained from this comprehensive surgical staging provides the optimal basis for selecting adjuvant therapy 1.