1. Introduction

2. Incision and Access to the Abdominal Cavity

3. Exposure of Uterus

a. Division of Round Ligament

b. Separation of Anterior Layer of Peritoneum

c. Transection of Pedicle

d. Extension of Incision

4. Division of Right Utero-Ovarian Pedicle

5. Division of Left Utero-Ovarian Pedicle

6. Division of Right Uterine Vessels

7. Division of Left Uterine Vessels

8. Ligation and Tagging of Uterosacral Ligaments

9. Excision of Uterus

10. Excision of Cervix

11. Closure of Vaginal Cuff

a. Examination of Specimen

12. Closure

Uterine fibroids, also known as leiomyomas, are usually benign masses that are most commonly found in women of reproductive age. Fibroids are usually asymptomatic and tend to be incidental findings on ultrasound. When clinically relevant, however, patients report symptoms such as menorrhagia, pelvic pain, and bulk-related symptoms. Treatment of symptomatic fibroids may be pharmaceutical with gonadotropin-releasing hormone agonists, radiological using MRI-guided focused ultrasound surgery (or magnetic resonance-guided focused ultrasound), or minimally invasive uterine artery embolization, but the treatment is largely surgical. There are many different surgical approaches that can be utilized, including myomectomy or hysterectomy. Treatment of choice depends on multiple factors, including the severity of symptoms, size of fibroids, and patient’s desire to preserve fertility. However, out of all of the different surgical techniques available, hysterectomy is the only definitive treatment for these patients. Here, an abdominal hysterectomy was performed on a 45-year-old patient with symptomatic uterine fibroids. 


<h4>CHAPTER 1</h4>

<p>Okay, we're going to do a - an abdominal hysterectomy through a midline abdominal incision - a low-midline. The patient is a 45-year-old with a symptomatic leiomyomata uteri. And, she was scheduled for surgery, and after a workup she said she wanted to proceed with the operation, and we're going to do that right now. The first thing we do - she's had a spinal anesthetic - and then we're going to always check to make sure that she doesn't have any pain. And does she have any pain up there? So… The skin is here, so Dr. Perez is going to put a little tension on his side, and I'm going to put a little tension on my side. We're ready to go guys.</p>

<h4>CHAPTER 2</h4>

<p>And we're going to make the incision. She's not seeing if she's feeling this, is she? No. No. This - we're making an incision with this dull knife. And we're approaching the adipose tissue, the fat layer, and she's got a little bit excessive adipose tissue. We're cutting through the adipose tissue. It all looks normal. And we're approaching the fascia. Right here is the fascia - so we're going to open down to the fascia. We're separating the adipose tissue from the fascia. Do you have Metz? The fascia is the strong tissue that covers the muscle. And we're going to open the fascia with a knife. Kelly? No Kelly's. This knife is not quite sharp. And Dr. Perez is separating here, and I'm going to open the fascia with the cautery. Okay. So we've got the skin, adipose tissue, and fascia opened. And now what we can do is enter the peritoneal cavity, and - I can see where the midline is right here. And I'm separating it slightly - you got some Metzenbaums? And we're separating it very gently because we don't want to injure any of the internal organs. I see a vessel here, and we're going to cauterize it so it doesn't bleed. And we're getting close to the… Kelly? Abdominal contents here, and I'm going to just stretch it out a little bit more. Sometimes we can enter the peritoneal cavity with our fingers, but it looks like this one we're going to have to open it with scissors. Well Dr. Perez has just opened it with his fingers, and that's one of the ways to do it. Here… And he likes to stretch it out a little bit. We open the peritoneal layer, and the internal fascia. With these dull Metzenbaum scissors. Be very careful that we don't injure the internal organs. You see these scissors don't cut like they're made to cut, but that's okay, we'll make it work. We're going to stretch it out a little bit.</p>

<h4>CHAPTER 3</h4>

<p>And then what we're going to do is push the adipose tissue onto what's called the omentum up toward her head, and then reach my hand inside to feel what we're dealing with. Kelly? Times two. Another Kelly. Tie. This is an adhesion. I'm going to reach down in, and I can feel - I'm feeling her left ovary right now, which is normal size. And I'm feeling her right overy, which has a cyst on it. You can see the ovary with the small cyst there. I'm getting behind the uterus. I can feel the fibroids. And it's - you can feel the fibroids in front, so we know exactly what we're dealing with. Normally, the uterus is the size of a lemon. And hers, as you'll see in a second, is much larger. Okay. Oh, wait. I think there's some… Adhesions? There you go, okay. Here's the fibroid uterus. Like I say, it's normally the size of a lemon, and hers is the size of a - a big mango maybe, huh? I'm looking on the right side, and you see that she's got a little cyst there. And she's got that cystic ovary. And then over here… I don't see any cyst on this side. But I think the best thing to do is put a retractor in. This is a - what's called a self-retaining retractor. And then we're going to put a bladder blade in here - to pull the bladder down. So we have a little better exposure now, so now we can get ready to do the operation. I'm just going to elevate it up a little bit. Yeah, but once we release the…</p>

<h4>CHAPTER 4</h4>

<p>This instrument is not really adequate because the blades are too short, but what we're doing is we're going to try to release the right adnexa. So that will do two things - it'll kind of control part of the blood supply to the organ, and also release - so, we'll get a little more mobility of it. And this is the round ligament - the right round ligament - that he's ligating right now. And then we're going to tag the - the distal part of the round ligament. Okay, he's ligated part of the round ligament, now he's going to put another ligature around it, and we'll separate the round ligament. So he's got the round ligament ligated in two - two areas, now what he's going to do is separate it. Do you have that Metzenbaum that I used?</p>

<p>Now he's separating the - peritoneum from the portion of the uterus. Pickups. Give me a pickups. With teeth. Okay. Get the Heaney - get the cautery and… Heaney.</p>

<p>Another one. Okay, we just transected the - the right utero-ovarian pedicle, which includes the portion of the fallopian tube on the right side, and the the uterine-ovarian vessels And we're going to double-tie it, it's always good to double-tie it to make sure you don't have any bleeding. So this way the ovary will be preserved on that side, now we have to remember, we might end up taking it out at the end, depending on how things go and what it looks like, but right now we know the ovary has a small cyst on it. This suture we use is a relatively strong suture, and it's what we call a delayed-absorbable. It takes about three months before it absorbs and it's completely gone. But it does disintegrate in the abdomen. Do you have a Rochester-Pean clamp? Do I have a what? Do you have any Rochester-Pean, like those big…</p>

<p>We're going to extend this incision a little bit.</p>

<h4>CHAPTER 5</h4>

<p>This is the left round ligament I'm approaching right now, I'm going to go around it with this suture. Then I'm going to come back and go through it with the same suture. Are you going to tag that? Yes. I'm going to snug it down until the tissue blanches - that means you control the flow of blood through it. And then I'm going to put a second suture in just like Dr. Perez did on the right side - on the left side. I got it. And again, I go around and then through it. Vicryl is easier to tie than this. This is Vicryl, isn't it? Yeah. This is Vicryl? That's Vicryl, yeah. 3-0. Okay, this Vicryl is easier to tie than the other. I'm transecting the left round ligament. Get the Metzenbaums ready.</p>

<p>And I'm going to do the same thing. I'm going to separate the anterior peritoneal layer. It's a relatively avascular layer. Maybe we should sponge stick? Would you cut down over here? What I'm trying to do is just make it where I have a little bit better exposure before I start putting instruments on. We call it deskeletonizing.</p>

<p>We can see the vessel there. Okay, get a couple of Haeneys ready. Okay. Okay, I've double-clamped the left - the left utero-ovarian ligament, incorporating with the fallopian tube and the major vessels. And I've just transected, so I'm going to put a free tie on it. Get ready to cut. And I'll take a stick tie. Okay, we put a free ligature around it, and I always double-tie it. So now I'm going to put a suture ligature around it. Because major vessels come through there. Okay, so now we have that taken care of. Now let's see what side we're going to work on first.</p>

<h4>CHAPTER 6</h4>

<p>He's dissecting the tissue so we can get down to the right uterine artery, which we want to secure as quickly as we can. This is a very important bite of the operation. And we're going to double-clamp it. He's got the vessel double clamped, and he's cutting between the clamps. Do you have one of those - packs? Those lap sponges? Yeah. Yeah, when we're done here, we're going to see what it looks like. Oh, this isn't Vicryl, is it? That's Vicryl. Is it? Doesn't look like it. No, that's normal. Doesn't look like it. Look - no, he's using Vicryl. Okay, I see, I see.</p>

<h4>CHAPTER 7</h4>

<p>Let me get a… Stay close to me. It's very important we ligate this good, this is the left uterine artery and vein.</p>

<h4>CHAPTER 8</h4>

<p>Knife. We'll tag this too. Okay, ease it off. Okay, tag that, and cut this. I don't always do this, but I want to tag them because this is… I'm ligating the proximal portion of the uterosacral… This one. Okay, I have the proximal uterosacrals tagged with a suture, so we can always have control of that portion of the uterus. Tag? Okay. Knife. Tag. Knife. Okay. Good? Mm hmm.</p>

<h4>CHAPTER 9</h4>

<p>Knife. I got it, I got it, I got it. Oh, you got the...? Okay, perfect. Yeah. I got a good grip. Here's the uterus without the cervix that we just removed. Watch this knife, John.</p>

<h4>CHAPTER 10</h4>

<p>So we have a good view - there, much better. We'll just push it down, and then… Okay. There are certain instruments that would make this procedure a little bit easier, but they're not available right now, so we're improvising. Then we need a couple full-length sutures. Okay, put it inside...? Yeah, yeah.</p>

<h4>CHAPTER 11</h4>

<p>Tag this one. If they're big, it's usually in these corners. We have the uterus and cervix removed. We did it in two parts because of the clinical situation we have here. And we have had no major bleeding, which was good. We're going to - right now we're closing the vagina. Cut, please. Okay. Cut. Ease it down, ease it down. Cut. Tag that. We want to stay out of bladder, here. That's bad… Tag. How much more? One more and then… If you have one of those partial sutures that's a little bit long, he can use that. Okay. One more and you got it. Best to leave them there. Cut this part before it. Cut the suture? The whole thing. Yeah. We're irrigating right now. Making sure there's no bleeding or leaks, and we'll go ahead and remove the irrigating fluid, which is saline. And it's nice and dry we call it. So we've removed the uterus, preserved the ovaries, and removed the uterus in two pieces because of the situation. You know what? I'm going to - I'll tell you what I'm going to do - I'm going to take these uterosacrals… I like to tag these uterosacrals to make sure that… Let's see, what is this on? That's the other tag.</p>

<h4>CHAPTER 12</h4>

<p>We're removing the sponges that we put in. And then we're going to check for any bleeding before we terminate the procedure here, and it's nice and dry, everything looks good. So we're going to go ahead and remove the retractor, which is partially working. And we're going to prepare to close. I like to put the omentum, which is this flap of adipose tissue down, and cover the - the bowel and the internal organs. And we're going to close the abdomen in layers. I like to go about 1-1.5 cm…</p>

Watch this full-length, narrated surgical video of an abdominal hysterectomy for uterine fibroids performed in Honduras during a surgical mission.

Hospital Leonardo Martinez, Honduras