INTRODUCTION:
Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of
entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the
case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of
the ovaries eliminates the main source of the hormone estrogen, so menopause occurs
immediately.
INDICATION FOR OPERATION:
The patient recently presented with postmenopausal bleeding and was found to have a Grade II
endometrial carcinoma on biopsy. She was counseled to undergo staging laparotomy.
PREPARATION FOR OPERATION
Examination under anesthesia revealed a small uterus with no nodularity. During the
laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread
of disease. Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small
and large bowel, and peritoneal surfaces, were palpably normal. There was no evidence of
residual neoplasm after removal of the uterus. The uterus itself showed no serosal
abnormalities and the tubes and ovaries were unremarkable in appearance.
PROCEDURE FOR OPERATION
The patient was brought to the Operating Room with an IV in place. Anesthesia was induced,
after which she was examined, prepped and draped.
A vertical midline incision was made and fascia was divided. The peritoneum was entered
without difficulty and washings were obtained. The abdomen was explored with findings as
noted. A Bookwalter retractor was placed and bowel was packed. Clamps were placed on the
broad ligament for traction. The retroperitoneal spaces were opened by incising lateral and
parallel to the infundibulopelvic ligament. The round ligaments were isolated, divided, and
ligated. The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.
Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters. The
infundibulopelvic ligaments were isolated, divided, and doubly ligated. The uterine artery
pedicles were skeletonized, clamped, divided, and suture ligated. Additional pedicles were
developed on each side of the cervix, after which tissue was divided and suture ligated. When
the base of the cervix was reached, the vagina was cross-clamped and divided, allowing
removal of the uterus with attached tubes and ovaries. Angle stitches of o-Vicryl were placed,
incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-
of-eight stitches. The pelvis was irrigated and excellent hemostasis was noted.
Retractors were repositioned to allow exposure for lymphadenectomy. Metzenbaum scissors
were used to incise lymphatic tissues. Borders of the pelvic node dissection included the
common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep
circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the
hypogastric artery medially. The posterior border of dissection was the obturator nerve, which
was carefully identified and preserved bilaterally. Ligaclips were applied where necessary. After
the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.
Retractors were again repositioned to allow exposure of para-aortic nodes. Lymph node tissue
was mobilized, Ligaclips were applied, and the tissue was excised. The pelvis was again
irrigated and excellent hemostasis was noted. The bowel was run and no evidence of disease
was seen.
All packs and retractors were removed and the abdominal wall was closed using a running
Smead-Jones closure with #1 permanent monofilament suture. Subcutaneous tissues were
irrigated and a Jackson-Pratt drain was placed. Scarpa's fascia was closed with a running stitch
and skin was closed with a running subcuticular stitch. The final sponge, needle and instrument
counts were correct at the completion of the procedure.
The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit
in stable condition.
POSTOPERATIVE MANAGEMENT
Endometrial cancer General, endotracheal tube.
Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph
nodes, para-aortic nodes.The patient recently presented with postmenopausal bleeding and
was found to have a Grade II endometrial carcinoma on biopsy. She was counseled to undergo
staging laparotomy
INSTRUMENT USE USE FOR THE PROCEDURE
The instruments required for vaginal hysterectomy are the following: Long, heavy Mayo
scissors. Short and long weighted vaginal speculums with an extra-long blade. Heaney right-
angle retractors
NCP FOR THE CASE:
ASSESSMENT:
INFERENCE:
NURSING DIAGNOSIS: Disturb Sleeping Pattern
OUTCOME IDENTIFICATION:
PLANNING:
NURSING INTERVENTION/ RATIONALE:
EVALUATION:
