Abdominal Hysterectomy as a Surgical Approach in Large Fibroids

1. Opening Abdomen and Uterine Exposure

• The patient should be positioned supine, urethral catheter is inserted to keep the bladder empty. The vaginal cavity is prepared with povidone-iodine.
• The primary operator stands on the left side of the patient, with the assistant on the right. The assistant helps with traction and visibility.
• A midline longitudinal incision from the pubis to the umbilicus is standard, but a transverse incision is used if the uterus is small.
• The intestines are moved upward with gauze, and a self-retaining retractor is used to maintain the operative field.
• Before surgery, the operator examines the uterus, adnexae, and surrounding organs for abnormalities or adhesions. Adhesions are released unless cancer is present.
• The assistant maintains traction on the uterus using Kocher clamps or by hand.^10,11,12

2. Division of Utero-ovarian Pedicles 

• Lift the right-sided round ligament with forceps, identifies the transparent area beneath it, and places two absorbable sutures. The ligament is then tied and cut with Cooper scissors, allowing air to enter the retroperitoneal cavity and reveal the loose connective tissues.
• Incise the anterior leaf of the broad ligament, ensuring to identify the target endpoint to avoid bleeding. The incision line is concave-shaped to minimize blood loss from the uterine vessels. The broad ligament is lifted, and subperitoneal connective tissues are detached with Cooper scissors before incising the thin, transparent peritoneum. If the connective tissues are incompletely detached, the veins and capillaries remain in the peritoneal side, and so the incision results in bleeding.
• Incise the middle leaf of the broad ligament upward, with similar dissection and incision toward the infundibulopelvic ligament.
• The ovarian ligament and fallopian tube are clamped with two forceps, cut, and ligated with figure-of-eight sutures. Double ligation is necessary to prevent the suture from slipping off the ligament stump.
• All of the above procedures are done for the left-side also.^10,11,12

3. Mobilization of the Bladder

• Start at the midline of the cervix to prevent bleeding from lateral vesicouterine ligaments.
• Palpate the cervix from both anterior and posterior sides to confirm its position and assess the height of the lower end of the cervix or vaginal fornix.
• Lift the cut end of the anterior leaf of the broad ligament.
• Make the first incision in the center of the cervix, pushing Cooper scissors vertically and cutting the connective tissues to expose the cervix.
• Dissect the connective tissues and bladder downward from the cervix until the lower end of the cervix.
• Treat the lateral vesicouterine ligaments by carefully removing loose connective tissues to avoid bleeding.
• Mobilize the bladder to approximately 1 cm below the vaginal fornix.
• Place an L-shaped retractor at the detached portion to push the bladder downward.^10,11,12

4. Division of Uterine Vessels 

• Carefully dissect and remove loose connective tissue from the uterine artery and vein. Remove connective tissues from the vesicouterine ligament to prevent ureteral injury.
• Skeletonize the ascending branch of the uterine artery and veins. Assistant keeps the uterus in traction upward and pushes the bladder downward with an L-shaped retractor. Operator palpates the ureter along the posterior leaf of the broad ligament to identify its level.
• Clamp and cut the cardinal ligament, including the uterine artery and veins, in two steps. First clamp placed at a 45-degree angle for the upper half of the cervix, ensuring complete clamping of vessels. Confirm distance between clamp tip and ureter (2–3 cm apart). Place another upper clamp to prevent backflow bleeding.
• Cut, needle, and ligate the upper half of the ligament with 1-0 absorbable suture, ensuring double ligation of the uterine artery.
• Place the second clamp along the cervix for hemostasis from small veins. Cut and suture the lower half of the cardinal ligament, recognizing the plane between the cervix and ligament. Avoid deep cutting into the paracolpium to prevent significant bleeding.
• All of the above procedures are done for the left-side also.^10,11,12

5. Ligation of the Uterosacral Ligament 

• Align the cardinal ligament stump, vesicouterine ligament, and sacrouterine ligaments at the same level using the push-down procedure.
• Place one arm of Heaney’s forceps inside the sacrouterine ligament and the other arm against the posterior half of the cardinal ligament.
• Clamp the convex surface of the forceps diagonally behind the uterus.
• Cut and ligate the sacrouterine ligament.
• Grip and retract the ligature.^10,11,12

6. Excision of Uterus, Cervix, and Closure of the Vaginal Cuff

• Palpate the cervix to identify the boundary. Clamp the vaginal wall with right-angle or Heaney’s forceps.
• Incise rectal adhesions with an electric knife if present. Repeat clamping on the opposite side.
  • Place a large gauze in the Douglas pouch.
  • Palpate the transitional area between the cervix and vagina.
  • Insert a sharp scalpel vertically into the uppermost portion of the anterior vaginal wall.
  • Prepare the portio and vagina with povidone-iodine and insert gauze into the vaginal cavity.
  • Sequentially place long straight Kocher clamps on the cut end of the vaginal wall.
  • Simultaneously cut and clamp the sacrouterine ligament with the vaginal wall.
  • Use a curved Kelly clamp along the vaginal fornix as a landmark to facilitate cutting the vagina with a scalpel or scissors.
  • Grasp and retract the cervix, incise the vaginal wall, and remove the uterus.
  • Close the vaginal vault with Z-figure sutures.^10,11,12

7. Closure

• Wash the retroperitoneal space with warm saline and confirm there are no bleedings or foreign bodies.
• Complete the gauze count.
• Suture the pelvic peritoneum with 2-0 continuous sutures and close completely.
• Place the cut ends of ligaments retroperitoneally, taking care not to injure the ureter.
• Remove the retractor and intraperitoneal sponge-gauze.
• Restore the intestines to their normal position.
• Close the abdomen with sutures for the peritoneum, fascia, and skin.^10,11,12