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.