Abdominal Hysterectomy

Definition
  • Surgical removal of the entire uterus through an abdominal incision.
  • A hysterectomy is indicated for a variety of conditions, including endometriosis, adnexal disease, postmenopausal bleeding, dysfunctional uterine bleeding, and benign fibromas or malignant tumors.
  • For women in their childbearing years, this surgery, as with a vaginal hysterectomy, can be a devastating blow psychologically, since they may feel they have lost their primary sexual characteristic and therefore can no longer function as women.

Positioning
  • Supine, with arms extended on armboards.

Incision Sites
  • Lower transverse (Pfannenstiel), vertical, midline, or paramedian.

Packs/ Drapes
  • Laparatomy pack and/ or transverse Lap sheet.
  • Four folded towels

Instrumentation
  • Major Laparotomy tray or abdominal hysterectomy tray
  • Self-retraining retractor
  • Internal stapling instruments

Supplies/ Equipment
  • Basin set
  • Blades
  • Needle counter
  • Suction
  • Foley catheter with drainage bag
  • Solutions
  • Suture
  • Internal stapling

Procedure Overview
  1. After incising the skin, the incision is deepened through the subcutaneous tissue with the deep knife or cautery pencil.
  2. The fascia is nicked with the deep knife and incised using a curved Mayo dissecting scissors.
  3. Grasping one edge of the fascial margin with two or more Kocher clamps, blunt dissection separates the fascia from the underlying muscle.
  4. The muscle is divided manually. The peritoneum is then knicked with the deep knife, and the incision is lengthened with Metzenbaum scissors.
  5. A self-retraining retractor is placed in the wound, with moist lap sponges to protect the wound edges; the surgeon will “pack the bowel” away from the uterus with additional moist warm Lap sponges, and the operating table is placed in slight Trendelenberg position.
  6. The uterus is isolated by severing it from the uterine ligaments ans adnexa.
  7. The round ligaments of the uterus are ligated, divided, sutured, and tagged with a hemostat.
  8. To divide the ligaments, a curved Mayo scissors or scalpel is used. An internal stapling device can be used to free the uterus from the adnexa.
  9. The surgeon mobilizes the uterus to the level of the bladder.
  10. Using a Metzenbaum scissors and long tissue forceps, the surgeon separates the two structures by dissecting the peritoneal covering away from the bladder. This is called the bladder flap, and will be reattached (reperitonealized) later.
  11. Once the bladder has been separated from the uterus, mobilization is continued.
  12. At the level of the cervix, long Allis or Kocher clamps are placed around the edge of the cervix, and it is divided from the vagina using a long scissors or a long knife.
  13. If the ovaries are to be preserved, the ovarian ligaments is ligated and divided adjacent to the uterus.
  14. The uterosacral ligaments are ligated and divided, along with the cardinal ligaments.
  15. To close the wound, the surgeon begins by suturing the vaginal vault using an absorbable suture.
  16. The wound is irrigated with warm saline, and hemostasis is achieved.
  17. To close the peritoneum, the surgeon grasps the edges with several Kelly hemostats and the peritoneum is closed with a running suture.

Perioperative Nursing Considerations
  1. Foley catheterization is usually performed after the internal vaginal prep is completed but before the abdominal prep is begun.
  2. A sterilization permit may be required in addition to the operative permit.
  3. Instruments that have come in contact with the cervix and or vagina must be treated as contaminated and discarded into a basin that can be passed off the yield.
  4. Once the abdomen is opened, 4 x 4 Raytec sponges should be replaced by Lap sponges.
  5. If a free sponge has been placed in the vagina prior to closing, it is included in the sponge count and must be removed from the vagina before the count is correct and the patient leaves the room.
  6. Internal staples are usually contraindicated in severe cases of pelvic inflammatory disease or endometriosis.

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