Total Abdominal Hysterectomy
Total abdominal hysterectomy, abbreviated as TAH encompasses the drawing out the cervix from the body of a woman. It can be carried out on various conditions involving the reproductive system including for both benign and malignant illnesses. For this case study, the patient had uterine fibroids. After performing the surgical scrub procedure, I assisted the surgeon to prepare for the operation. The patient was put under anesthesia and placed her in a supine manner. We chose a midline incision as it offers the highest level of flexibility. The surgeon utilized a sharp incision all through the practice. The peritoneum located opposite to the womb and the gonadal vessels were split. This opened the extensive connective membrane and allowed the ureter, as well as exterior and inner iliac vessels to be visible. It was crucial to incise and uncover a few centimeters of the complete sides of the anterior vagina beneath the cervix level. This was meant to ensure that total bladder mobilization had been achieved. After having the uterus on tension, the connective membranes were identified. A round region under the cervix at the tip of the vagina was also recognized. The uterus was then drawn towards the left in an anterior style.
Total Abdominal Hysterectomy
Hysterectomy is a common surgical procedure among women in the U.S. Based on statistics, almost a third of women in the U.S undergo a hysterectomy by the time they are 60 years (Wright, et al. 2013). Total abdominal hysterectomy (TAH) is the most preferred and allows the removal of the uterus when intact. Unlike a partial hysterectomy, TAH also involves the removal of the cervix. It can be performed on both benign and malignant conditions if it is indicated by the doctor that the removal of internal genitalia is necessary. While carrying out a TAH, the surgeon often considers various factors to determine whether they will make a vertical or a horizontal bikini-line incision on the lower abdomen. The mass of the womb, the occurrence of marks from earlier abdominal and vaginal operations, the projected pathology, and the surgeon’s competence are various features that guide the style of incision. Sometimes a surgeon may perform TAH alongside bilateral or unilateral salpingo-oophorectomy, a procedure that involves taking out one or both ovaries as well as the fallopian tubes. Patients with benign diseases might choose to undergo or forgo this procedure but in malignant cases it is often mandatory. For the sake of this case study, the patient going through a TAH procedure had uterine fibroids which is a benign condition. Malignancy was ruled out.
Surgical scrub procedure
As a surgical scrub tech, I was also acting as an assistant to the surgeon. Before entering the operation suite, the surgeon and I performed our surgical hand scrubs. This was to eliminate microorganisms which might be present in the hands that can cause infection during an operation. Besides, surgical hand scrub acts as a barrier to rapid and rebound growth of viruses, bacteria, or other pathogens that can cause infection (Tanner, et al. 2016). The technique consisted of:
- Removal of jewelry including watches and rings.
- Removing dirt in the subungual areas with a nail file. The parts include the front and back sides of both hands, between fingers, as well as each side of the fingers.
- Cleaning hands and arms using antimicrobial soap under running warm water for 5 minutes.
- Rinsing the hands and arms while facing one direction and proceed to the operating room with hands above the elbows.
- Drying the hands using a sterile towel and disease-free technique after getting into the operating chamber.
- Finally, donning gowns and gloves that have been sterislized.
Putting the patient in position and preparing for TAH
The anesthesiologist infused the patient with anesthesia and set her in a supine position. Lower leg ties were then used to prevent any movements when the Trendelenburg position is being accomplished all through the medical procedure. A povidone-iodine fluid was used to disinfect the abdominal covering and the vagina to avert bacterial contamination later when the vaginal sleeve would be uncovered. A transurethral cylinder to canal urine amid the medical procedure was situated. A three-way catheter was favored because of its benefit in making work easier while inlaying the bladder when the surgery is taking place (Aarts, et al. 2015). Finally, the surgeon incorporated a careful time out before making the incision. This was intended to guarantee that he had the correct patient, deciding the technique and the type of incisionwhich had been picked, notwithstanding knowing the presence of any hypersensitivities.
The surgeon picked a midline incision as it offers the most adaptability. A Balfour still retractor which has thin uteri that permits quality exposure but can prompt slight misery on the abdominal wall after the task was utilized. Additionally, it keeps retractor-connected contamination from happening. A wet stomach cushioning was used to help in pressing the bowel towards the upper abdomen over the span of the procedure. This advanced the visibility of the operative field. The surgeon used a sharp incision amid the methodology. An unblemished and sharp analyzation shields the adjacent organs from being harmed and makes it simple to perceive any harm for a snappy fix (Aarts, et al. 2015).
Fitting hold and counter traction were utilized on tissues for right assurance of the correct tissue planes notwithstanding empowering the ID of vital anatomic organs. Fundamental parts ought to be perceived and, if necessary, activated before any immobilizers are set or pedicles incised (Aarts, et al. 2015). We found the bladder and rectum and unbound them anteriorly and posteriorly to maintain a strategic distance from unintentionally including them when shutting the vagina, just as to diminish the danger of fistula improvement. These organs were then strongly moved by at least 1 cm from the spot planned for the vaginal opening. Finally, we bolstered the sides of the vagina divider by moving the uterosacral cardinal ligaments to the finishes of the vaginal vault.
Identifying the ureter
In the wake of getting the desired introduction and acceptable Trendelenburg position, I helped the surgeon to put Kocher clasps through the corneal fragment of the uterus. This gave left-side bond making it peaceful for us to spot roundabout tendon arranged on the inverse area and caught it utilizing a Kocher immobilizer then incised it. The peritoneum on the opposite side of the belly and the gonadal vessels were part. This leaves the main tendon uncovered which thusly, empowers the surgeon to effortlessly find the ureter and all the iliac vessels (Gebhart, 2014). After locating the ureter, a window known as the pubocervical belt was created in the muscle found specifically overhead to the ureter. Utilizing an average to a flat technique, the surgeon set his center finger in that peritoneal opening, to affirm that the ureter was underneath and would not be influenced. A Kocher immobilizer was later situated over the conduit and utero-ovarian pedicle, which was incised and suture-ligated leaving the cylinder and the ovary unblemished. This procedure was performed on the patient’s left belly.
I helped the surgeon to convey an upward draw on the belly while he presented the peritoneum over the bladder utilizing Russian forceps at that point incised it on a level plane. Afterward, a sharp entry point of the insecure areolar tissue was made and respectably stretched out to the second rate uterine area. Any blood shows closeness to the bladder or it could be indicate that the surgeon has incised profound and across (Gebhart, 2014). It was essential to incise and reveal a couple of centimeters of the entire sides of the vagina underneath the cervix level to make sure that total bladder assembly had been accomplished and ensure it would not be erroneously included later when shutting the vaginal sleeve.
Ligation of uterine-based arteries
Cephalad attachment was utilized on the belly and a Harrington retractor used to make a separation between the bladder and the cervix. After analyzing the ureter pathway, a Kocher clasp was situated on the appropriate segment of the second rate cervix yet in the wake of surveying the ureter. This raised the uterine layers and vessels. The uterine vessel– cardinal tissue close to the cervix, was isolated, prompting a pubocervical fascia opening. A while later, the fascia progressed and took care of as an unmistakable layer when shutting the vaginal vault (Gebhart, 2014).
The vaginal cuff preparation and exposure
Subsequent to making the fascia, the other piece of the tissue under the front cervix is known as the upper vaginal divider. The uterus was pulled up and front oriented pubic syphilis to encourage permeability of the uterosacral tendons which were later chiseled. From that point forward, the surgeon incised the issue between the ligaments on a level plane. With minor finger division, as appropriate, this should separate the rectosigmoid colon and the vaginal divider in the back end (Gebhart, 2014). After having the belly on weight, the connective layers were recognized. A circular locale under the cervix at the tip of the vagina was additionally perceived. The uterus was then drawn towards the left in a front way. It was then disconnected through vagina circumcision in nearness to the cervix to impede vaginal shortening.
Closing the cuff
A 0-polyglactin endless suture was used in sewing the vaginal opening. The surgeon began via fixing with a privilege vaginal methodology, to guarantee that all the minor vessels and the auxiliary tissues had been situated in the right point. This shuts the “window” framed when the cardinal tendon was gently undermined previously (Gebhart, 2014). He kept on sewing on the left side and ensured that all the epithelial finishes were encased inside the vagina. The suture was then bolted and returned over the vaginal vault and tied. We shut the sleeve and checked hemostasis.
A lap saline wipe was used to wash down the careful zone, and a light searing spread along the sleeve. The Kocher immobilizer holding the cardinal film and uterine vessels were raised. From that point onward, I inspected the ureter. This stage gives an extra examination on the site where ureter is situated before binds the cardinal tendon to the vault’s end (Gebhart, 2014). Utilizing a needle, the pedicle was placed over the finish of the vagina, making a stump which was sans then tied. A similar procedure was done on two sides. Homeostasis was checked all through the employable site, and the patient expelled from the Trendelenburg position. Wipe, and needle tallies were later finished and the guts shut using a layered system.
Aarts, J. W., Nieboer, T. E., Johnson, N., Tavender, E., Garry, R., Mol, B. W. J., & Kluivers, K. B. (2015). Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, (8).
Gebhart, J. B. (2014). Total abdominal hysterectomy the Mayo Clinic way. Surgical Techniques.
Tanner, J., Dumville, J. C., Norman, G., & Fortnam, M. (2016). Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews, (1).
Wright, J. D., Herzog, T. J., Tsui, J., Ananth, C. V., Lewin, S. N., Lu, Y. S., … & Hershman, D. L. (2013). Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstetrics and gynecology, 122(2 0 1), 233.