You may occasionally have to do an emergency hysterectomy if a patient has: (1) A ruptured uterus, and repair is impossible (not uncommon). (2) Uncontrollable postpartum haemorrhage (PPH, uncommon). Hysterectomy for a ruptured uterus differs from the operation described below, and is described in Section 18.17. The only occasion on which you may have to use the method which follows urgently, is for an otherwise uncontrollable PPH; all other indications are nonurgent.

The indications for nonurgent ''cold' hysterectomy include: (1) Severe anaemia, as the result of excessive bleeding, due to fibroids. (2) Carcinoma of the body of the uterus. (3) Severe DUB (dysfunctional uterine bleeding) which you cannot control by other means (rare, 20.2). (4) Removal of the Fallopian tubes with the uterus for chronic pelvic pain due to PID which fails to respond to medical treatment. If possible try to refer all these cases, especially the last. ''Cold hysterectomies' can have disastrous complications, even in the hands of experts, and their patients even die occasionally. So don't do them, unless you are experienced, and cannot refer a patient. Fibroids may cause disability, but they seldom threaten life. If you are going to operate on them, start with nicely mobile uteri, without huge intraligamentary or cervical fibroids.

You can do a total hysterectomy by removing a patient's entire uterus; the advantage of doing this is that you remove her cervix, which is a common site for carcinoma. Or, you can do a subtotal operation, and leave a stump of her cervix behind. Experts almost always remove the whole uterus, so that subtotal hysterectomy is almost obsolete. Subtotal hysterectomy is contraindicated, if there is any suspicion of carcinoma in either the cervix, or the body of her uterus. But it is an easier operation, because you can more easily avoid the ureters. If you are inexperienced, start by doing a subtotal operation, particularly if you are operating for fibroids. But even this can be difficult, if there are adhesions from chronic PID. Don't attempt a radical hysterectomy which also removes her pelvic lymph nodes. It is the only adequate surgical treatment for carcinoma of the cervix, but this really is a task for an expert.

If you start by making a bladder flap, you will see the relations of the patient's ureter, her uterine artery, and her cervix more easily. The great danger is that you may cut, tie or clamp her ureters. They are at risk at several stages: (1) When you tie her ovarian vessels. So, lift these clear of her ureters before you tie them. (2) In the base of her exposed broad ligament. So before you do anything in this region which might injure her ureters, feel for them carefully. You can roll a ureter between your finger and thumb, and when you pinch one, it slips through your fingers.

Gentle continued traction is the secret of all pelvic surgery: (1) It demonstrates the tissue planes. (2) You are less likely to pick up structures that you do not want to cut. (3) Vessels stand out more clearly. (4) You are less likely to injure her bladder, or her ureter. (5) You can find the relation of her bladder to her cervix and vagina more easily.

Bleeding can be severe, especially from the uterine vessels. Divide these late in the operation, after most of the other structures have been removed from around them. Even when you have divided them, you are still in a bloody triangle at the sides of her vaginal vault.

If you are not careful, you can also cause a vesicovaginal fistula. This will be much less likely if: (1) You develop a bladder flap. (2) You carefully separate her bladder from her cervix. (3) You separate it from her uterine vessels.

All these dangers will be much more likely if you clamp blindly with a large clamp. So: (1) Don't clamp blindly. Only clamp what you can see. (2) Don't include more tissue in a clamp than it can safely hold.

Finally, wound infection is likely to be disturbingly common.

ANATOMY. The most critical items of a patient's pelvic anatomy are her ureters, as shown in Fig. 20-16. ''Ligaments' mean quite different things to gynaecologists and to orthopaedic surgeons. To a gynaecologist a ''ligament' is a fold of peritoneum, or a local thickening of the pelvic connective tissue. Gynaecologists recognize: (1) A patient's broad ligaments which are folds of tissue running from her Fallopian tubes towards the floor of her pelvis. The ureter and the uterine artery lie in the base of the broad ligament; vessels run round its edge, and its middle is avascular (see Fig. 18-20). (2) Her infundibulopelvic ligaments are folds of tissue which run from the lateral ends of her tubes to her pelvic wall. Their importance is that the ovarian vessels run in them. (3) Her round ligaments are folds of tissue which run from her uterus close to its junction with her tubes, anterolaterally towards the brim of her pelvis. They are really anterior folds or leaves in her broad ligaments. (4) Her ovarian ligaments support her ovaries, and hang off the back of her broad ligaments. (5) Her cardinal (transverse cervical) ligaments are thickenings of her pelvic connective tissue which run laterally from her cervix to the sides of her pelvis. (6) Her uterosacral ligaments run from her lower segment to her sacrum on each side of her rectum. They are, in effect, the posterior edges of her cardinal ligaments. Fig. 20-17 THE LIGAMENTS OF THE PELVIS. A, you are standing on the patient's right and looking down into her pelvis. B, a sagittal section of part of her pelvis along line ''X[nd]Y' in Diagram A. C, a section through a her pelvis, parallel with her pelvic brim. D, the main supporting ligaments of her pelvis viewed from above.

1, her broad ligaments. 2, her infundibulopelvic ligaments. 3, her round ligaments. 4, her ovarian ligaments. 5, her cardinal (transverse cervical) ligaments. 6, her uterosacral ligaments.

7, her bladder. 8, her rectum. 9, the fundus of her uterus. 10, her cervix. 11, her ovaries. 12, her Fallopian tubes. 13, her ureters. 14, her uterine arteries. 15, the veins of her pelvis. 16, fat filling the odd spaces in her pelvic connective tissue. 17, the arrow shows how an opening can be made from her posterior fornix into her pouch of Douglas. A, after James Young. C, after Last. D, after Jeffcoate. Fig. 20-18 HYSTERECTOMY[md]ONE. Make the incision (1), open the patient's broad ligament (4), reflect her bladder (6 and 7). Either remove her ovary (9) or retain it (10 and 11). After Parsons L, and Ulfelder H, ''An Atlas of Pelvic Operations', pp. 21ff. WB Saunders, with kind permission.


CONTRAINDICATIONS TO TOTAL HYSTERECTOMY. (1) An inexperienced operator. (2) Active PID. (3) A uterus, which on clinical examination is ''fixed' in the pelvis. Dense adhesions, such as those due to PID, may pull the ureters out of place and make the operation difficult. (4) Obesity does the same.

ANAESTHESIA. You must be able to keep the gut out of the operative field, so you will need good muscular relaxation, and a moderate head-down tilt. (1) General anaesthesia with a long acting relaxant (A 14.3). (2) Lumbar epidural anaesthesia (A 7.2). (3) Subarachnoid anaesthesia (A 7.6). (4) Ether alone (A 11.3).

Set up a drip, and have blood cross-matched.

EQUIPMENT. A general set, a catheter, a uterine probe and sounds, a suitable self-retaining retractor, preferably Kirschner's, Gosset's, or Balfour's; also a Deaver's retractor and a tenaculum. At least 4 and preferably 6 long curved uterine clamps, either Hunter's or Maingot's. 1% iodine or Bonney's blue or gentian violet, a large damp pack with a tape. ''0' or ''1' multifilament or ''1' or ''2' chromic catgut for all pedicles. ''1' catgut for the vagina. 2/0 catgut for the peritoneum.

PREPARATION. Make sure that she has signed the consent form and understands that she will have no more children and no periods.

Four hours before the operation give her a gram of metronidazole rectally (tablets or a suppository, 2.9). Find yourself a competent assistant. If he is inexperienced, go through this account with him first.

Catheterize her bladder. Compress it suprapubically to make sure it is empty, and leave the catheter in for continuous drainage.

First put her into the lithotomy position, to paint and drape her perineum. Paint her vagina with 1% iodine, Bonney's blue, or gentian violet. This will make a big difference when you come to open it. Then lay her supine on the table and remove the lithotomy poles. Tip her slightly head-downwards to let her gut fall away from her pelvic cavity. Provided the angle is not too steep, it will not make anaesthesia difficult. Ideally, adjust the break in the table so that her knees are slightly flexed. Abduct her arm on an arm board.

You can choose whether you stand on her left or her right. The illustrations here assume you are standing on her left, which most right-handed surgeons find easier.

Fig. 20-19 HYSTERECTOMY[md]TWO. Isolate and tie the patient's round ligaments (13 and 14), find her uterine arteries (15 and 16), tie her uterosacral ligaments (18), reflect the peritoneum off the back of her cervix (21), and clamp her uterine arteries (22). After Parsons L, and Ulfelder H, ''An Atlas of Pelvic Operations', pages 21ff. WB Saunders Co, with kind permission.

INCISION. If you are inexperienced, make a median or a left paramedian incision (9.2), from her symphysis to her umbilicus (1, in Fig. 20-18). If you are skilled, and her uterus is not more than 15 cm high (equivalent to a 14[nd]16 week pregnancy), a transverse (Pfannensteil) incision gives the best cosmetic result. Open her peritoneum in the middle of the incision, and make the first cut upwards, so as to more easily avoid her bladder.

CAUTION ! Make sure your incision is long enough, and that you have divided her rectus sheath and muscles as far as her symphysis pubis (an extra 1 cm at the bottom is worth 5 cm at the top). If necessary extend the incision generously above her umbilicus.

Exploration is the first step. Inspect her pelvic cavity. If you find an inflammatory lesion, don't proceed to explore her upper abdomen, because you may spread the infection.

Otherwise, put your left hand into the wound to feel the organs in her abdominal cavity quickly and thoroughly. Follow a set pattern, for example[md]right kidney, liver, gall-bladder, stomach, duodenum and pancreas, left kidney, spleen, and finally her colon from her caecum to her sigmoid. Look particularly for metastases in her liver.

Clear the operative field. This is often the most difficult part of the operation. Don't start removing any organs until you have cleared the site of operation: (a) Clean away any adherent bowel or omentum from her pelvis. (b) Use blunt dissection to free any loose adhesions between her uterus and its surrounding structures[md]her sigmoid colon, her ovaries, or the walls of her pelvic cavity. Her tubes and ovaries may be stuck down behind her broad ligaments; get your fingers under them and free them from below upwards. Denser adhesions will have to be divided with scissors, or if you think they are likely to contain blood vessels, clamped, divided, and tied. Try stretching them before you divide them. Divide any adhesions between the fundus of her bladder and the fundus of her uterus. (c) Carefully pack her gut out of the way with a large damp pack, marked by a tape, to which a haemostat is attached.

Protect the wound edges with moist gauze, and insert a self retaining retractor (2). You can put the crossbar towards her head or towards her feet, and use the third blade to retract her bladder. Make sure it does not compress her caecum, her sigmoid, her small gut, or her iliac vessels. When necessary, use Deaver's retractor.

Put clamps on either side of her fundus, over her tubes and round ligaments (3). Use them to exert traction, and control back bleeding. Alternatively, if these structures are friable, use a myomectomy screw or traction sutures on the fundus.

Ask your assistant to pull on the clamps, so as to demonstrate the thin part of her broad ligament more clearly. Push your finger through this thin part near her uterus, from behind forwards, to make a hole (4). Do the same on the other side.

Reflect her bladder. Incise the peritoneum on the front of her cervix, near to its vesico[nd]cervical reflexion (5). Dissect her bladder off the front of her cervix, and upper vagina (6 and 7), until you can feel the tip of her cervix (8). Feel her cervix from in front and behind. Separate her bladder from the underlying tissues also.

Find her ureters. They enter her pelvis at the bifurcation of her iliac vessels. Trace them distally to beyond the tip of her cervix; recognize them by their feel: they are rather hard, they do not pulsate, and you can roll them between your finger and thumb[md]see Fig. 20-16.

CAUTION ! Ureters are apt to be easy to find when they are in no danger, and almost impossible to find when you need to find them. If you cannot find them these steps will protect them: (a) Free her adnexa from adhesions before you remove them. (b) Lift her infundibulopelvic ligament and find her ovarian vessels before you clamp them. (c) Carefully dissect her bladder away from her cervix, and the adjoining part of her broad ligament. (d) Cut and mobilize downwards the posterior peritoneal leaf of her broad ligament, and the posterior surface of her cervix.

Deal with her ovaries. You must now decide if you want to retain them or not. If they have multiple cysts, they are better removed, but try to retain at least one if she is premenopausal, or less than 5 years postmenopausal.

If you are going to remove an ovary, clamp its vessels, lateral to it, taking care not to clamp her ureter at the same time (9). Divide her ovarian pedicle medial to the clamp, and tie it with a double transfixion suture using No. 1 or No. 2 catgut.

If you are going to retain an ovary, apply a clamp across the Fallopian tube and its pedicle, 1 cm lateral to the first clamp that you applied to these structures near her uterus (10). Divide her tube and broad ligament between these clamps (11 and 12). Remove the lateral clamp and tie its pedicle as above.

Do the same thing on the other side, removing or retaining her ovary, as you decide.

Tie her round ligaments. Define, tie, and divide the lateral end of her round ligament. Do this by pushing your finger under it and tying it (13 and 14).

Find her uterine artery. Cut the posterior leaf of her broad ligament with the loose areolar tissue inside it, almost as far as the artery (15 and 16). If your assistant stretches her broad ligament well by pulling on the clamps, you may see the artery through the tissues you are going to cut. Repeat this on the other side.

Ask your assistant to lift up her uterus again (17). This will demonstrate her uterosacral ligaments. Clamp, divide, and tie them (18 and 19). Dissect the peritoneum off the back of her cervix (20 and 21), if it is not too adherent, otherwise leave it. Her uterus will now be much more mobile.

Divide her uterine arteries. Feel for her uterine arteries again. There is no need to dissect them out. Next feel for her ureters on each side of her distal cervix. Again, identify them by their feel[md]firm cords which you can roll between your finger and thumb.

Clamp the pedicle containing her uterine artery almost horizontally, well away from her ureter, with the tip of the clamp biting the side of her cervix, and leaving 0.5 to 1 cm of tissue on the uterine side (22). Better, use two clamps and divide between them. Use scissors, not a knife, in this region (23).

Complete the task of pushing her bladder down her cervix, if you have not already done so (24). Blunt dissection is usually enough.

You can now decide if you want to do a subtotal or total hysterectomy. If you are inexperienced, do a subtotal one. But, before proceeding, here is an alternative to some of the above steps, as used by one contributor:

An alternative to the above method, and some say a safer one: (a) Divide her round ligaments between clamps, 2[nd]3 cm from her uterus; this opens the anterior peritoneal leaf of her broad ligament. (b) Enlarge the opening. (c) Find the avascular area of her broad ligament and push your finger through it. (d) Clamp and divide her infundibulopelvic ligament (or her tube and ovarian ligament). (e) Do the same on the other side. (f) Divide the peritoneum between her bladder and her cervix. (g) Feel for her cervix. (h) Lift the peritoneum over her bladder while an assistant pulls on her uterus. This will stretch the connective tissue between her bladder and cervix. Cut this with scissors and push her bladder downwards bluntly. Then proceed to deal with her uterine arteries and uterosacral ligaments as above.

Fig. 20-20 HYSTERECTOMY[md]THREE, SUBTOTAL HYSTERECTOMY. The part of the uterus to be retained (24). Making a cone[nd]shaped cut to remove the uterus (25 to 28). Suturing the round ligaments to the cervix (32). Closing the peritoneum over the stump (33). After Parsons L, and Ulfelder H, ''An Atlas of Pelvic Operations', pp. 45 and 47. WB Saunders Co, with kind permission.

SUBTOTAL HYSTERECTOMY When you are sure you have reflected her bladder adequately (24), pull on the clamps attached to her uterus and incise the anterior wall of her cervix, above the reflexion of her bladder and the stump of her uterine vessels (25). Then draw her uterus sharply forwards towards her symphysis, and incise the posterior wall of her cervix (26). Place a clamp on its anterior incised edge (27). Make a cone[nd]shaped cut, so that you remove the endocervical lining.

Place clamps on the posterior and anterior cut edges of her cervix (28), so that you can maintain traction[md]making sure that you avoid clamping her bladder!

Bring the two cut edges of her cervix together to control bleeding. Use a cutting Mayo half-circle needle, and place the first stitch in the edge of her cervix, close to the point where you tied her uterine arteries. Control bleeding by placing the sutures through the posterior peritoneal reflection, deep into the muscle of both lips, at the apex of the cone (29, 30 and 31).

Suture her round ligaments to her cervix (32), and close her peritoneum, taking care to avoid her bladder (33).

TOTAL HYSTERECTOMY Cut through her cardinal ligaments flush with her cervix, until you feel the end on each side (34). Meanwhile, ask your assistant to pull on her cervix to give you good exposure. You should be able to feel her cervix through the wall of her vagina from in front and behind with your finger and thumb (35).

Opening her vagina. Before you do this insert clamps on her vaginal angles immediately below her cervix[md]these are not shown in (35) and (36) or (37) but they are shown in (38)]. Ask your assistant to pull up her uterus. Use a broad-bladed or right-angle retractor to pull back her bladder. Plunge the scalpel into her vagina through its anterior wall, just distal to where you feel her cervix is. Hold it at an angle of 45[de] from the line of her cervix (36). Cut laterally to the left and right, keeping near to her cervix. If you can easily see to complete the cut, cut across her posterior vaginal wall with a scalpel. If not, use curved scissors (37). Complete the incision across her anterior and posterior vaginal walls to remove her uterus (38).

CAUTION ! To avoid damage to her ureters, make sure you find them. Clamp her uterine pedicles away from them, and cut her vaginal wall very close to her cervix.

Use transfixion sutures to tie her uterine pedicles, making sure that you do not include her ureters (not illustrated). Use ''1' or ''2' catgut, or ''0' or ''1' multifilament, keeping the ends long as markers.

Closing her vagina. Hold the cut ends of her anterior and posterior vaginal walls with clamps or vulsellum forceps. Close her vagina with ''1' continuous chromic catgut (39 and 40). This should stop any bleeding. If it does not, control it with mattress figure of eight sutures[md]taking care to avoid her ureters!

If you can easily do it, suture her round ligaments to the ends of her vaginal vault (41). This will help to prevent prolapse, but is not essential.

Starting at one end, use ''0' chromic catgut to close her peritoneum with one long continuous stitch (42 to 45). Leave her ovaries free in her peritoneal cavity. If you sew them into the extraperitoneal space, or fix them to the side wall of her pelvis, she may have dyspareunia.

CAUTION ! When you close up her peritoneum make sure that you do not pick up her ureters by mistake. They may be very close.

Remove the swab holding her gut, and close her abdomen in the usual way. There is no need for a drain.

CLOSING HER ABDOMEN [s7]AFTER A HYSTERECTOMY Remove and count all packs and sponges. Grasp her sigmoid colon and carefully place it so that it fills the lower part of her pelvis. Place her omentum so that her small intestine is completely covered.

Close her abdomen as usual. Postoperatively, check her vaginal pads to make sure she is not bleeding.

Alternatively, suspend the vault of her vagina by sewing her cardinal ligaments separately from her cervix. Clamp them as far distally as you can from her uterine artery pedicles, before you cut them away from her cervix. Check the position of her ureters before you do this. When you have removed her uterus, use a mattress suture to join her cardinal ligaments to the ends of her vagina, before you close it.

THE SPECIMEN. Open her uterus to see if there is a carcinoma of its body. Do this after the operation, to avoid contaminating the wound with tumour cells if any are present.

DIFFICULTIES [s7]WITH HYSTERECTOMY If ADHESIONS from old PID or endometriosis prevent you starting, begin by dividing her round ligaments. Then put your hand behind her uterus and push a finger through her broad ligament under her tube and out through her divided round ligament. You now have her tube and ovarian vessels and can clamp and divide them safely.

If her UTERUS is so LARGE that it obstructs your access to her pelvis, do a subtotal operation first, and, if necessary, cut across her cervix quite high up. When you have removed the body of her uterus you will have plenty of room to complete the operation.

If you CANNOT FIND HER URETER, but must proceed with the operation, keep close to her uterus. You will nearly always be safe there. Do only a subtotal operation.

If a FIBROID EXTENDS INTO HER BROAD LIGAMENT, this may: (1) Be growing out from her uterus and displace her uterine vessels and ureter downwards and laterally, and her ovarian vessels upwards. (2) Be separate from her uterus and arise de novo from the connective tissue in her broad ligament. Both are difficult; if possible refer her.

If you must attempt to deal with (1), divide both her ovarian vessels and dissect out the upper part of the fibroid. Then proceed with the operation as usual on the normal side of her uterus only. Clamp and tie her uterine artery and uterosacral ligament. Cut across her vagina. As you reach the affected side of her vagina you will see her uterine artery on that side. Clamp and divide it (it may be large) and shell out the remainder of the fibroid.

If you must attempt to deal with (2), open her broad ligament by dividing her round ligament, as you would for a broad ligament cyst. Her ureter will be attached to the posterior edge of her broad ligament above; lower down it will be displaced downwards and medially by the fibroid.

If there is a FIBROID IN HER CERVIX, removing it can be very difficult. Either do only a subtotal operation. Or, do a subtotal one and then cut down on to the fibroid as for a myomectomy and shell out the fibroid before you remove her cervix.

If you DIVIDE HER URETER and recognize that you have done so, you can: (1) Repair her ureter over a T-tube. (2) Refer her for reimplantation. This is better if the cut end will reach her bladder.

If you OPEN HER BLADDDER, repair it in at least two layers. Leave a catheter in for 10 days. The tear is likely to heal uneventfully.

If you HAVE INJURED HER COLON, repair the tear and do a proximal defunctioning colostomy.

Iif she BLEEDS or there is a PERSISTENT OOZE at the end of the operation, try a warm pack and tie any arterial bleeders. If this fails, don't close her vaginal vault. Instead, insert a purse string suture all round her vaginal vault and pull it tight. This will leave a central hole in her vagina through which any haematoma can escape.

If she suffers from insidious RETENTION OF URINE postoperatively (uncommon), it is likely to be due to detrusor failure, and to be difficult to treat. Try 4 weeks of catheter drainage and urethral dilatation. If this fails, teach her intermittent self-catheterization (64.16), which is effective and safe. Use a clean but not sterile simple plastic catheter, which she can use for at least a week. In a woman a retentive bladder is much better than a leaky one.

Fig. 20-21 HYSTERECTOMY[md]FOUR, TOTAL HYSTERECTOMY. Reflect the patient's bladder (34), feel for her cervix (35), incise the fornices of her vagina (36 and 37), and cut her uterus free (38). Close her vagina (39 and 40). Suture her round ligaments to her cervix (41). Close her peritoneum laterally (42). Close it over her vagina (43 to 45). After Parsons L, and Ulfelder H, ''An Atlas of Pelvic Operations', pp. 33 and 34. WB Saunders, with kind permission.