Total Abdominal Hysterectomy Case File

Total Abdominal Hysterectomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 16

Your patient for surgery is a 40-year-old obese black woman, G2P2002, with increasingly heavy, painful menses and pelvic pressure. She has a long history of symptomatic uterine fibroids which have been treated in the past with gonadotropin-releasing hormone agonists (GnRH-a) and myomectomy. She has also had two cesarean sections and a bilateral tubal ligation. On physical examination, her BMI is 35 kg/m2. Her uterus was enlarged to 20 weeks’ size, irregular, and there was a firm mass protruding into the left adnexa. Pelvic sonography confirmed your suspicion of multiple uterine leiomyomata, one of which is protruding into the left adnexal area.

You have decided to proceed with a total abdominal hysterectomy. A vertical midline incision is used to open the abdomen, and you immediately encounter extensive omental adhesions, involving the abdominal wall, uterus, and bowel. These structures are freed, the uterus is exposed, and a self-retaining retractor is used to provide adequate exposure. The round ligaments are located and transected to expose the retroperitoneal space. The right ureter is easily identified, and you are able to secure the right uterine vasculature without difficulty. The left ureter is more difficult to find and you are never sure it is positively identified because of limited exposure due to the protruding fibroid and increased bleeding on that side.

➤ What pre- or intraoperative strategies might have made the operation easier and safer?

➤ What can be done to confirm the presence or absence of ureteral injury?

➤ What complications could you anticipate in the postoperative period for this patient?

ANSWERS TO CASE 16:

Total Abdominal Hysterectomy

Summary: A 40-year-old black woman with multiple abdominal surgeries in the past, a large fibroid uterus, and obesity is taken to the operating room for symptomatic uterine fibroids, which have failed medical management and myomectomy. A leiomyoma is protruding into the left adnexal region, and the left ureter is difficult to identify.

➤ Preoperative strategies: Pretreatment with GnRH-agonists or antagonists, aromatase inhibitors, or progesterone receptor modulators may be useful.

➤ Intraoperative strategies: Intraoperative myomectomy, midline vertical abdominal incision, and a large self-retaining retractor.

➤ Strategies to safeguard ureter: Preoperative placement of a ureteral stent, cystoscopy prior to the completion of the case.

➤ Postoperative complications: Wound infection, ileus, deep vein thrombosis, atelectasis, blood transfusion, neuropathies.

ANALYSIS

Objectives

1. Describe the common indications for hysterectomy.
2. Describe other surgical approaches to hysterectomy.
3. List the two most common complications of abdominal hysterectomy, and how to avoid them.

Considerations

Our case presents the gynecologic surgeon with several challenges. The size of the patient and the size of the uterus make the procedure more difficult. GnRH-agonists or antagonists, aromatase inhibitors, or progesterone receptor modulators have all been shown to shrink the size of most leiomyomas to some degree. Any decrease in uterine size should make the procedure less difficult and reduce blood loss. The next question would be how to access the abdominal cavity. Depending on the skill and experience of the surgeon, the laparoscopic approach may be feasible, and robotic surgery may be an option if those resources were available. An abdominal hysterectomy, however, would be the classic approach to this patient. A vertical midline incision allows for adequate exposure of the entire abdominal cavity and can easily be extended if necessary. This type of incision also makes lysis of adhesions somewhat easier.

In these cases with a large mass in an obese patient, exposure is critical. Several types of retractors are available to use, depending on the surgeon’s preference. The Bookwalter retractor (Codman Raynham, MA) is a large retractor that allows for the placement of multiple blades in almost any position

around the incision. This can be immensely helpful. Mobility of the uterus is the next issue that must be resolved. How easy will it be to visualize the structures necessary to successfully and safely complete the operation? At this point, the surgeon must decide whether to reduce the size of the uterus. There are multiple approaches to intraoperative myomectomy, again depending on the surgeon’s skill and experience. Once the uterus is mobile enough to expose the pelvic sidewall, the broad ligament can be opened. This allows for entry into the retroperitoneal space, which then allows for identification of the ureter and the uterine blood supply. It also helps in freeing the bladder from the lower uterine segment, especially when the patient has had previous cesarean sections. Using sharp dissection with gentle “push-and-spread” blunt dissection reduces bladder injuries when the bladder is adherent to the lower uterine segment.

Identification of the ureter is essential and should not be too difficult if one has adequate exposure. Preoperative stenting of the ureter has been proposed as a way to help identify the ureter. Lighted stents are also available. There is debate about how useful the stents really are, and their use should be individualized. Opening the retroperitoneal space over the bifurcation of the iliac vessels higher in the pelvis is another way to identify the ureter, especially when dissection lower in the pelvis is difficult or obscured. Assuming that the ureter can be identified, the ovary can be removed if necessary and the uterine arteries skeletonized and ligated. Once the blood supply to the uterus is secured, amputation of the uterine fundus should be considered. This gives the surgeon much better access to the cervix if it is to be removed, or the procedure can be completed if the surgeon has decided to do a subtotal hysterectomy. In those instances of a deep pelvis and a long cervix, a subtotal procedure, if appropriate, can be a wise decision.

Intraoperative cystoscopy should be considered, especially if there is difficulty taking down the bladder flap and identifying the ureter, or there is concern that the ureter may have been injured. If a cystoscope is not available or if you do not routinely do cystoscopy, the dome of the bladder can be opened, the bladder inspected, and the ureters visualized. By giving the patient indigo carmine dye intravenously, you should clearly demonstrate bilateral ureteral patency within about 10 minutes. Two important considerations are to ensure that the patient’s volume status is adequate; a patient who has had significant hemorrhage may have decreased urine production and delayed dye in the bladder. Additionally, the surgeon should be prepared to visualize the ureteral openings prior to infusion of the indigo carmine. Once the dye is in the bladder, further evaluation becomes complicated. In other words, the best time to assess ureteral patency is with the first spurts of dye. If ureteral patency is not demonstrated, reexploration of the retroperitoneal space and correction of the problem can be accomplished without having to return the patient to the operating room. The bladder can then be closed in two layers and a Foley catheter left in place for 7 to 10 days. There are several concerns postoperatively for this patient. Obesity puts our patient at increased risk of wound infection, deep vein thrombosis, and postoperative atelectasis. Her intra-abdominal adhesions increase her risk of a small bowel injury, and increased manipulation of the bowel with lysis of the adhesions increases her risk of a postoperative ileus. Her large, myomatous uterus and possible intraoperative myomectomy increase the risk of significant intraoperative blood loss, and may necessitate a blood transfusion. The use of surgical retractors may result in peripheral nerve injuries and subsequent neuropathies.

APPROACH TO

Total Abdominal Hysterectomy

DEFINITIONS

SUBTOTAL HYSTERECTOMY: Removal of the corpus of the uterus from the cervix at or below the level of the internal cervical os.

GNRH-AGONIST: Synthetic compounds which bind to the gonadotropinreleasing hormone receptor in the pituitary gland and cause receptor downregulation. This suppresses the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), thus creating reversible hypogonadism.

AROMATASE INHIBITOR: Compounds that inhibit the action of the aromatase enzyme which converts androgens into estrogens.

BOOKWALTER RETRACTOR: A large versatile self-retaining retractor for abdominal incisions that allows for the use of multiple blade applications.

CLINICAL APPROACH

Hysterectomy is the most common, nonobstetrical surgical procedure performed in the United States, but recently the rate has been declining. The rate has decreased from 5.38/1000 women-years in 2003 to 5.1/1000 women-years in 2004. In 2004, 67.9% of hysterectomies were done by the abdominal approach.1 This rate varies in different regions of the country but has been fairly consistent for several years. This is in spite of many authors promoting vaginal surgery for the large uterus and advancements in laparoscopic instrumentation and robotics.

The traditional indications for hysterectomy include abnormal uterine bleeding unresponsive to medical management, large pelvic masses, dysmenorrhea unresponsive to conservative therapy, cancerous or precancerous conditions of the pelvic organs, and uterine prolapse. Certain causes of pelvic pain such as chronic pelvic inflammatory disease, pelvic endometriosis, or ectopic pregnancy may be appropriately treated with hysterectomy as well. Of course, other conditions may be present that warrant hysterectomy, thus making clinical judgment and experience important in the management of the individual patient. Uterine fibroids and their associated problems continue to be the most frequent indications for hysterectomy. Recently, there have been several new medical and surgical advances which are effective in treating many of these common gynecologic problems while preserving the uterus. GnRH-a (eg, Leuprolide) have been shown to shrink uterine fibroids and relieve the associated symptoms on a temporary basis.2 Aromatase inhibitors (eg, letrozole) and progesterone receptor modulators (mifepristone) have also been found to have similar effects. Procedures such as uterine artery embolization, ultrasound myolysis, and hysteroscopic or laparoscopic myomectomy may be effective treatment modalities in selected cases. Patients, however, often request hysterectomy and see it as the permanent solution to their ongoing gynecologic problems. The combination of multiple symptoms, lack of symptom resolution with previous treatment, and a previous history of GnRH-a usage increase the likelihood of the patient eventually having a hysterectomy.3

Once the decision for an abdominal hysterectomy has been made, there are many options regarding surgical approach. The surgeon has a choice of the type and location of the abdominal incision. Whatever incision is chosen should allow for adequate exposure of the pelvis. The presence of lateral masses, broad ligament fibroids, or a deep pelvis is especially important to ascertain. In other words, during the preoperative physical examination, the surgeon should carefully assess the patient’s pelvis for number, extent, and mobility of the uterus in the pelvis. All too often, the less experienced surgeon merely “traps” the uterus between the two hands to confirm an enlarged uterus. A systematic approach will be rewarded: during vaginal examination, palpation of the anterior lower uterine aspect and cervix for masses and tenderness, then laterally, and then finally posteriorly. A rectovaginal examination should then be performed correlating the findings from the vaginal examination. Mobility of the uterus and masses should be tested. The surgeon should make a mental note of feasibility of elevating the uterus, working around cervical fibroids, and ligating uterine vessels. Palpation of the bony pelvis to determine adequate room is likewise important. If there is no room between the uterus and the pelvic sidewall, assessment for hydronephrosis and possible ureteral compression should be suspected.

Another important consideration of the type of abdominal incision is the need for exposure of the upper abdomen. Any adhesions from the patient’s previous surgeries can be addressed. The retroperitoneal space is easily accessible for visualization of the ureter, exposure of the uterine vessels, and development of the bladder flap; unless the patient has had prior extensive retroperitoneal surgery and/or malignancy, this space should be easily accessible. Adnexal or other unexpected abdominal pathology can be thoroughly evaluated and treated. Other gynecologic problems such as pelvic prolapse or stress urinary incontinence may be corrected at the same time. Prophylactic appendectomy or salpingo-oophorectomy is often combined with abdominal hysterectomies. Abdominal hysterectomy is associated with higher complication rates and longer recovery times for the patient.

Vaginal hysterectomy is an underutilized procedure. Many pelvic surgeons use the vaginal approach when the uterus is not too large, sufficiently mobile, and the pathology is benign and confined to the uterus. Difficulty comes with limited descent of the uterus, a small pelvis with limited visibility, or the suspicion of adnexal disease. Laparoscopically assisted vaginal hysterectomy has helped overcome many of these limitations. Vaginal hysterectomy has fewer complications, less blood loss, shorter hospital stays, and is well tolerated by the patient.4

The laparoscopic hysterectomy continues to gain favor among pelvic surgeons, and has recently increased in frequency. Improvement in instrumentation and the optics of the laparoscopic cameras, new energy sources, as well as robotic devices have dramatically enhanced the surgeon’s armamentarium. This approach allows the pelvic surgeon to visualize the abdominal cavity, treat adnexal disease or other pelvic pathology, and accomplish difficult dissections while maintaining the advantages of minimally invasive surgery. As the skills of the laparoscopic surgeon advance, more hysterectomies that traditionally would have been done abdominally are now being done laparoscopically. In fact, the proportion of abdominal hysterectomies has decreased as a result of these minimally invasive procedures. While laparoscopic surgery is associated with shorter hospital stays and faster patient recovery, it is still more expensive (in most cases) and requires special training and equipment.

In recent years, the supracervical or subtotal hysterectomy is being performed more commonly. Advocates for preservation of the cervix assert that it improves sexual satisfaction and pelvic support. Studies have not shown substantial benefits.5,6 Many debate the necessity of removing the cervix, especially as our knowledge and treatment of cervical disease changes. It is a valuable technique in difficult cases when there is limited visibility or accessibility to the cervix in a deep pelvis.

Technique

Once the surgeon has opened the abdomen and exposed the pelvic organs, the uterus should be elevated out of the pelvis. This is usually done by grasping the cornual area on each side with a Kocher or Kelly clamp. Care should be taken to use another technique when uterine leiomyomata may make the cornual regions less flexible and more prone to bleeding. The round ligaments are identified and suture ligated with a transfixing stitch. The round ligament is then transected which opens the broad ligament, opening the way into the

Figure 16–1. Round ligaments are ligated, divided, and anterior leaf of the broad ligament opened. (Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York: McGraw-Hill, 2008:906.)

retroperitoneal space, and enabling the bladder to be dissected away from the uterus (Figures 16–1 to 16–3). Using Metzenbaum scissors, the anterior leaf of the broad ligament is opened in the direction of the lower uterine segment. Using sharp dissection, the bladder flap is taken off the lower uterine segment and pushed off the cervix. Care should be taken in patients with prior cesareans to avoid injury to the bladder. The posterior leaf of the broad ligament is opened parallel and lateral to the infundibulopelvic ligament. This incision may be extended cephalad as necessary. The retroperitoneal space can be exposed by using blunt and sharp dissection techniques. The ureter should be identified on the medial leaf of the broad ligament. Once the ureter is positively identified, the infundibulopelvic ligament can be isolated and ligated safely. With the retroperitoneal space open, the uterine arteries can be identified and extraneous connective tissue skeletonized of the vessels. Using a Heaney clamp, the uterine arteries are clamped at the junction of the body of the uterus and the cervix. This step is one of the most dangerous regarding possible ureteral injury, and thus, it is critical for the surgeon to have dissected the

Figure 16–2. Uterine artery is ligated. (Reproduced, with permission, from Schorge

JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York: McGraw-Hill,

2008:908.)

bladder anteriorly and the connective tissue laterally away from the uterus. Assuming that the cervix will be removed, the dissection is carried down the sides of the cervix being sure that the clamp “slides off” the cervix. Keeping the clamp as close to the uterus as possible also reduces the risk of ureteral injury. When the dissection reaches the tip of the cervix, a curved, heavy clamp is used to clamp the uterosacral ligament, any remaining paracervical tissue, and a small part of the upper vagina. Often, cutting this pedicle will open the top of the vagina. With the top of the vagina open, the cervix can be removed from the vagina by using curved Mayo or Jorgenson scissors. Care must be taken not to excise an excessive amount of vaginal tissue with the cervix. The vaginal cuff can then be closed or left open. If the cuff is being closed, this can be accomplished by using interrupted figure-of-eight sutures or a running suture. If the cuff will be left open, the edges of the cuff should be oversewn with a running, interlocking suture. All pedicles should be inspected and hemostasis ensured before closing the abdomen. The choice of suture to be used is probably best

Figure 16–3. After curved clamps are placed on the vagina, the cervix is excised.

(Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams

Gynecology. New York: McGraw-Hill, 2008:909.)

left to the preference of the surgeon. A 0- or 2-0–delayed absorbable suture is most commonly used. Most surgeons prefer to ligate vascular pedicles twice, once with a tie followed by a transfixing suture ligature. The abdominal wall closure can be done with a 0-delayed absorbable suture in an interrupted or running fashion. A locking-type stitch should not be used on the fascia as it may contribute to strangulating the tissue and diminishing the strength of the wound. The skin edges may be approximated with suture or clips.

Measures to Simplify the Surgery

All surgeries are easier when you operate with good assistants and a welltrained operating room team. If special instruments, retractors, suture, or energy sources may be needed, they should be requested prior to starting the operation. All instruments should be in good working order, and the operating room staff should know how to operate all special equipment and/or devices. Adequate exposure is mandatory, and the abdominal incision should provide adequate exposure for you to operate on the expected pathology. While cosmetic concerns are important, they should never compromise your ability to perform the right operation safely.

Once inside the abdomen, the bowel should be packed out of the pelvis. Large moist lap sponges are excellent for this purpose. Proper selection of retractors is also important in maintaining exposure. Several self-retaining retractors are available and each has strengths and limitations. The Bookwalter retractor, however, is an excellent retractor for large incisions in large patients. The blades of all retractors should be checked after placement to be sure that they are not pressing against the abdominal wall; for instance, lateral retractors may impinge on the femoral nerves of the patient leading to a nerve palsy. Also, moist sponges should be used to protect the edges of the incision before placing the retractor blades. All dissection should be done either sharply or using the “push-and-spread” technique. Blunt dissection using the surgeon’s finger is a frequently used technique, but must be done carefully and gently to minimize inadvertent injury. All pedicles should be clamped so that the tips of the clamp are clearly visualized, and the surgeon should always be sure that extraneous tissue has not been included in the pedicle. Pedicles should be securely tied with square knots and the surgeon should always “push” the knot down with their index finger. The uterus should always be pulled up and deviated to the opposite side from the operating surgeon when dissecting or placing clamps. When clamping the uterine arteries, the clamp should be placed at a 90-degree angle to the uterus. The pedicle should be cut to the tip of the clamp, but not past.

When suturing these pedicles, the needle must be inserted at the tip of the clamp so that all of the tissue is included in the tie so as not to allow vascular deligation. Again, good hemostasis must be ensured before closing the abdomen. Filling the pelvis with normal saline, then slowly aspirating it out will often allow the surgeon to see small but actively bleeding vessels they might have otherwise missed.

Complications

Total abdominal hysterectomies are associated with more complications than the other routes of removing the uterus. This may be because the more difficult cases are often done abdominally (ie, malignancies). Urinary tract injuries and wound infections are the two most common complications of abdominal hysterectomy. Urinary tract injuries occur in up to 4.8% of cases.7 Eighty percent of these injuries involve the bladder, especially if the patient has had previous surgery (ie, cesarean sections), radiation, or malignancy.7 Ureteral injuries occur most commonly as the ureter crosses inferior to the uterine artery. Ureteral injuries are often unrecognized at the time of surgery and are frequently asymptomatic. Risk factors for ureteral injuries include an enlarged uterus, significant adnexal pathology, prior pelvic surgery, and pelvic prolapse. Routine cystoscopy prior to the completion of the procedure has dramatically increased the detection rate of both bladder and ureteral injuries.8 Wound infections after abdominal hysterectomy occur in 3% to 8% of cases.7 Risk factors include obesity, diabetes, and length of procedure. Prophylactic antibiotics have been shown to reduce this risk and are recommended for routine use.9 The use of subcutaneous drains or closure of the subcutaneous space has not been shown to be particularly effective at reducing the rate of subsequent infection.7,10 Bleeding problems, either intraoperatively or postoperatively, can be significant and may require transfusion. Less common problems arise with postoperative ileus, neuropathies related to the use of surgical retractors, deep vein thromboses (DVT), pulmonary embolus, and incisional hernias. Abdominal hysterectomy is not associated with an increased risk of new-onset urinary incontinence and does not adversely affect sexual satisfaction.11,12 As mentioned, all patients should receive prophylactic antibiotics prior to the procedure. The patient, in this case, should be evaluated for her risk of DVT. Pelvic surgery is, by itself, a risk factor for DVT, and prophylaxis with graduated compression stockings, sequential compression devices, or medical therapy using either unfractionated heparin or low-molecular- weight heparin is indicated.13 Other risk factors include obesity, age more than 40 years, smoking, diabetes, cancer, and known thrombophilias. Adequate postoperative pain management is imperative. Patient-controlled analgesia (PCA) pumps allow for more patient control, quicker relief, and less dependence on the nursing staff.

Comprehension Questions

16.1 A total abdominal hysterectomy is performed on a 44-year-old woman with a large uterine fibroid. Postoperatively, the patient complained of the inability to walk. On examination, she had weakness of the right leg and absent right patellar reflexes. Which of the following is the most likely etiology?

A. Ligation of the external iliac artery

B. Nerve compression at the right popliteal region

C. Right lateral retractor impinging on the femoral nerve

D. Injury to the right obturator nerve near the obturator foramen

16.2 A 39-year-old woman is taken to the operating room for an abdominal hysterectomy. The left retroperitoneal space is opened from the round ligament cephalad. Where should the surgeon look for the left ureter?

A. Adjacent to the left lateral pelvic side wall.

B. At the floor of the retroperitoneal space described.

C. Attached to the medial leaflet of the broad ligament.

D. The ureter is not found in this area, and the surgeon should advance the incision higher in the pelvis.

16.3 In performing a hysterectomy, the surgeon dissects the areolar tissue away from the uterine vessels (skeletonization) prior to performing ligation of the vasculature. Which of the following describes the main purpose of the skeletonization process?

A. Allows for less chance of bowel injury

B. Allows for less chance of urinary tract injury

C. Allows for less chance of vascular injury

D. Allows for less chance of nerve injury

ANSWERS

16.1 C. In laparotomy surgeries, especially with an abdominal hysterectomy, the lateral retractor blades may impinge on the femoral nerve and cause femoral nerve palsy. The symptoms include decreased

strength of the quadriceps, absent patella reflex, and inability to walk. Prevention includes ensuring sufficient padding between the lateral retractor and the lateral side wall, especially with deep retractor blades.

16.2 C. The ureter is routinely found adherent to the medial leaflet of the broad ligament upon opening the retroperitoneal space cephalad to the round ligament. If the patient, however, has had prior surgery

and the retroperitoneal space has been dissected previously, the ureter may be in other locations.

16.3 B. Although the skeletonization process serves multiple purposes, including ensuring a better ligation of the vessels, the main purpose is to release the ureter and bladder from the uterus, thus minimizing the clamps and ligation from injuring those urinary structures.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ The preoperative use of GnRH-a to reduce the size of the uterus may make the surgical procedure easier to perform and reduce blood loss (Level B).

➤ The Bookwalter retractor is an excellent retractor to use for surgery on obese patients and large masses (Level C).

➤ If the ureter cannot be identified deeper in the pelvis, look for it as it crosses over the common iliac artery (Level C).

➤ Postoperative cystoscopy has increased the detection rates of unrecognized bladder and ureteral injuries (Level B).

➤ If you are not comfortable with cystoscopy,opening the dome of the bladder allows for visualization of the ureteral orifices with minimal risk to bladder function (Level C).

➤ Subtotal hysterectomy should be considered if removing the cervix is difficult (Level C).

REFERENCES

1. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Obstet Gynecol Surv. 2008 May;63(5):304-305. 

2. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Alternatives to Hysterectomy in the Management of Leiomyomas. Washington, DC. No. 96, August 2008. 

3. Learman LA, Kuppermann M, Gates E, Gregorich SE, Lewis J, Washington AE. Predictors of hysterectomy in women with common pelvic problems: a uterine survival analysis. J Am Coll Surg. 2007 Apr;204(4). 

4. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev. 2006;(3):CD003677. 

5. Learman LA, Summitt RL Jr, Varner RE, et al. Total or Supracervical Hysterectomy (TOSH) Research Group. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol. 2003 Sep;102(3):453-462. 

6. Sokol AI, Green IC. Laparoscopic hysterectomy. Clin Obstet Gynecol. 2009 Sep;52(3):304-312. 

7. Stany MP, Farley JH. Complications of gynecologic surgery. Surg Clin North Am. 2008 Apr;88(2). 

8. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol. 2009 Jan;113(1):6-10. 

9. Tanos V, Rojansky N. Prophylactic antibiotics in abdominal hysterectomy. J Am Coll Surg. 1994;179:593-600. 

10. Cardosi RJ, Drake J, Holmes S, et al. Subcutaneous management of vertical incisions 3 or more centimeters of subcutaneous fat. Am J Obstet Gynecol. 2006;195(2):607-614. 

11. Gustafsson C, Ekström A, Brismar S, Altman D. Urinary incontinence after hysterectomy— three-year observational study. Urology. 2006 Oct 1;68(4):769. 

12. Mokate T, Wright C, Mander T. Hysterectomy and sexual function. J Br Menopause Soc. 2006 Dec;12(4):153-157. 

13. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Prevention of Deep Vein Thrombosis and Pulmonary Embolism. No. 84, August 2007.

HomeGynecologic Surgery Case FileTotal Abdominal Hysterectomy Case File