Keywords
abdominal hysterectomy - intrafascial method - Aldridge's procedure - gynecologic
surgery - benign tumor
The Preoperative Evaluation
A cytological examination of the uterine cervix must be performed to detect any cervical
neoplastic diseases. The collection of detailed clinical information on endometriosis
and the medical history concerning colorectal surgery is also important.
In-Depth Explanation
Opening the Pelvic Cavity
The length of the low abdominal wound depends on the size of the uterus; the skin
incision should be started two fingerbreadths above the pubis. Of note, the extension
of the skin incision toward the pubis will not improve the visibility of the operating
field.
Processing of Ligaments of the Uterine Corpus and Exfoliation of the Urinary Bladder
While holding the uterus with the fallopian tube, ovarian ligament and round ligament
using long forceps, cut and ligate the round ligament and cut the anterior broad ligament
of the uterus to exfoliate the urinary bladder from the uterine cervix. Cut and ligate
the mesosalpinx to release the fallopian tube, and cut and ligate the ovarian ligament
as close as possible to the uterus when performing an ovarian-preserving procedure.
Cut the infundibulopelvic ligament and place double ligatures when performing salpingo-oophorectomy.
After treatment of the bilateral salpinx or ovaries, cut the posterior broad ligament
of the uterus as far as the point of uterine attachment of the uterosacral ligament
to safely separate the ureter from the uterine cervix. After confirming the center
of the uterine cervix by palpitation, the bladder is released from its attachment
to the uterine cervix by sharp dissection of the conjunctive tissue using scissors
under traction of the vesicouterine peritoneum ([Fig. 1]).
Fig. 1 Exfoliate the urinary bladder from the uterine cervix using scissors. Exfoliation
should not be performed any more than is necessary by considering the parametrial
clamping position. (Reproduced with permission from Watanabe Y, Nagaoka A, Hoshiai
H. Aldridge method modified by Noda. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda
S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.2 Total Abdominal
Hysterectomy (Japanese). Tokyo: Medical View; 2010: 74-83. Copyright © Medical View).[1]
Processing of the Parametrial Tissues
To confirm the uterine artery, cut the connective tissue around the uterine cervix
with upward traction of the uterus and lateral traction of the peritoneum using forceps
for safe preparation ([Fig. 2]). Although the original Aldridge's procedure involves clamping the parametrial tissue
directly beneath the internal cervical os, the Noda's method involves placing parametrial
clamps at the intermediate position between the internal and external cervical os.
Furthermore, it is easy to perform the intrafascial approach, including the longitudinal
muscle layer of the uterine cervix when the parametrial tissue is appropriately clamped
([Fig. 3]). However, the position of parametrial clamping should be shifted to the upper position
when firm adhesion around the uterine cervix is observed.
Fig. 2 Arrange the parametrial tissues. Cut the connective tissue around the uterine cervix
and parametrium to ensure safe clamping of the parametrium.
(Reproduced with permission from Watanabe Y, Nagaoka A, Hoshiai H. Aldridge method
modified by Noda. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering
the Essential Surgical Procedures OGS NOW, No.2 Total Abdominal Hysterectomy (Japanese).
Tokyo: Medical View; 2010: 74-83. Copyright © Medical View).[1]
Fig. 3 Clamp the parametrial tissues. The parametrial tissues are clamped at the intermediate
position between the internal and external cervical os, including part of the longitudinal
muscle layer of the uterine cervix. (Reproduced with permission from Watanabe Y, Nagaoka
A, Hoshiai H. Aldridge method modified by Noda. In: Hiramatsu Y, Konishi I, Sakuragi
N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.2 Total
Abdominal Hysterectomy (Japanese). Tokyo: Medical View; 2010: 74-83. Copyright © Medical
View).[1]
Intrafascial Approach
Cut the bilateral parametrial tissues with scissors including a part of the longitudinal
muscle layer of the uterine cervix. ([Fig. 4]) and suture-ligated with delayed absorbable material ([Fig. 5]
). Ligation should be made just under the forceps, toward not the Douglas's pouch but
the uterine cervix. After processing the bilateral parametrial tissues ([Fig. 6]), confirm that the urinary bladder has been exfoliated below the ligation position
of the parametrial tissue. Connect the bilateral cutting tips of the cervical longitudinal
muscle layer using a cold or electronic scalpel under sufficient traction of the uterus
([Fig. 7]). Then gradually elevate the uterus by cutting the longitudinal muscle layer, notably
elevating it when cutting the uterosacral ligament ([Fig. 8]). The vaginal canal will spontaneously open when the intrafascial approach is properly
performed ([Fig. 9]).
Fig. 4 Cut the parametrial tissues. The parametrial tissues are cut, including part of the
longitudinal muscle layer of the uterine cervix. (Reproduced with permission from
Watanabe Y, Nagaoka A, Hoshiai H. Aldridge method modified by Noda. In: Hiramatsu
Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures
OGS NOW, No.2 Total Abdominal Hysterectomy (Japanese). Tokyo: Medical View; 2010:
74-83. Copyright © Medical View).[1]
Fig. 5 Ligate the parametrial tissue with sutures. Ligation of the parametrial tissues should
be made not to the Douglas's pouch but to the uterine cervix. (Reproduced with permission
from Watanabe Y, Nagaoka A, Hoshiai H. Aldridge method modified by Noda. In: Hiramatsu
Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures
OGS NOW, No.2 Total Abdominal Hysterectomy (Japanese). Tokyo: Medical View; 2010:
74-83. Copyright © Medical View).[1]
Fig. 6 Confirm the parametrial status. When starting the intrafascial approach, confirm
that part of the longitudinal muscle layer of the uterine cervix has been cut. (Reproduced
with permission from Watanabe Y, Nagaoka A, Hoshiai H. Aldridge method modified by
Noda. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential
Surgical Procedures OGS NOW, No.2 Total Abdominal Hysterectomy (Japanese). Tokyo:
Medical View; 2010: 74-83. Copyright © Medical View).[1]
Fig. 7 Start the intrafascial approach. Connect the bilateral cutting tips of the cervical
longitudinal muscle layer. (Reproduced with permission from Watanabe Y, Nagaoka A,
Hoshiai H. Aldridge method modified by Noda. In: Hiramatsu Y, Konishi I, Sakuragi
N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.2 Total
Abdominal Hysterectomy (Japanese). Tokyo: Medical View; 2010: 74-83. Copyright © Medical
View).[1]
Fig. 8 Cut the utero-sacral ligaments. The uterosacral ligaments were cut under sufficient
traction of the uterus, allowing the uterus to be markedly elevated. (Reproduced with
permission from Watanabe Y, Nagaoka A, Hoshiai H. Aldridge method modified by Noda.
In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical
Procedures OGS NOW, No.2 Total Abdominal Hysterectomy (Japanese). Tokyo: Medical View;
2010: 74-83. Copyright © Medical View).[1]
Fig. 9 Open the vaginal canal. Because the vaginal canal will spontaneously open with proper
performance of the intrafascial approach, the vaginal cuff should not be resected
any more than is necessary. (Reproduced with permission from Watanabe Y, Nagaoka A,
Hoshiai H. Aldridge method modified by Noda. In: Hiramatsu Y, Konishi I, Sakuragi
N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.2 Total
Abdominal Hysterectomy (Japanese). Tokyo: Medical View; 2010: 74-83. Copyright © Medical
View).[1]
Closure of the Vaginal Cuff and Abdomen
It is important to confirm that no uterine cervix remains and hold the vaginal canal,
including the vaginal mucous membrane, using long forceps ([Fig. 10]). After sterilization and confirmation of bleeding at the vaginal stump, close the
vaginal cuff by ligation with sutures and delayed absorbable material ([Fig. 11]). Place antiadhesive material on both the visceral and parietal cut ends of the
peritoneum and close the abdomen.
Fig. 10 Confirm hysterectomy has been performed by checking for remnants of the uterine cervix.
(Reproduced with permission from Watanabe Y, Nagaoka A, Hoshiai H. Aldridge method
modified by Noda. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering
the Essential Surgical Procedures OGS NOW, No.2 Total Abdominal Hysterectomy (Japanese).
Tokyo: Medical View; 2010: 74-83. Copyright © Medical View).[1]
Fig. 11 Close the vaginal canal. Lack of bleeding from the bilateral parametrium and the
uterosacral ligaments should be confirmed. (Reproduced with permission from Watanabe
Y, Nagaoka A, Hoshiai H. Aldridge method modified by Noda. In: Hiramatsu Y, Konishi
I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW,
No.2 Total Abdominal Hysterectomy (Japanese). Tokyo: Medical View; 2010: 74-83. Copyright
© Medical View).[1]
Tips and Warnings
Important points for successful performance of the intrafascial approach include imaging
as not “cut down” the uterine cervix but “pull out” the uterine cervix under enough
traction of the uterus. The uterus should be clearly elevated when cutting the proper
longitudinal muscle layer of the uterine cervix. Because the vaginal canal will open
spontaneously with the proper performance of the intrafascial approach, do not cut
into the vaginal canal forcibly.
