when the bowel and bladder are involved and there is impairment of the normal function
of the urinary and gastrointestinal tracts.
b. Preparation of the Patient. An internal and external vaginal prep precedes
the skin prep. A Foley catheter is inserted to provide constant bladder drainage during
the operation. The supine and high Trendelenburg positions are used.
c. Operative Procedure.
(1) As the skin is incised, the head and upper section of the operating table
are lowered slowly, approximately 10 at a time. When the peritoneal cavity is opened,
as described previously for laparotomy, the patient is in the desired position for pelvic
(2) In cases of obese patients or for exploration of the upper abdominal
cavity, a left rectus or midline incision is made. For simple hysterectomy, a Pfannestiel
incision may be used. The abdominal layers and the peritoneum are opened as for
(3) The round ligament is grasped with Allis-Adair forceps, clamped with
curved Rochester-Pean hemostats, and ligated with medium silk or chromic gut sutures
swaged to 1/2- circle, taper-point needles secured on long needle holders. Pedicles are
cut with Metzenbaum scissors; sutures are tagged with a hemostat to be used as
traction later. The procedure is done on both sides.
(4) The uterus is pulled upward, exposing the anterior surface of the uterus,
and the peritoneum at the cervicovesical fold is incised.
(5) By use of the surgeon's fingers, the layer of the broad ligament close to
the uterus is separated on each side; bleeding vessels are clamped and ligated. The
fallopian tube and the utero-ovarian ligaments are doubly clamped together with
Ochsner or Carmalt clamps or Heaney hemostats, cut with a knife, and tied doubly with
(6) The uterus is pulled forward to expose the posterior sheath of the broad
ligament that is incised with knife and Metzenbaum scissors. Ureters are identified.
The uterine vessels and uterosacral ligaments are doubly clamped with Ochsner,
Heaney, or Carmalt hemostats, divided with a knife at the level of the internal os, and
doubly ligated with suture ligatures.
(7) The severed uterine vessels are bluntly dissected away from the cervix
on each side with the aid of sponges on holders, scissors, and tissue forceps.
(8) The bladder is separated from the cervix and upper vagina with a knife
or scissors and blunt dissection assisted by sponges on holders.