Checklist for Abominal Hysterectomy

Preoperative Checklist
(Please indicate   - Done,   X - Not done,   NA – Not applicable)
 * 1) ___ Screen for bacterial vaginosis and treat patients if positive (prevent vaginal cuff infection)
 * 2) ___ Make sure of uterine width and ovarian size (prevent inability to perform surgery through incision)
 * 3) ___ Check interspinous distance for possible transverse incision length (prevent inability to perform surgery through incision)
 * 4) ___ Check umbilical to symphysis distance for possible infraumbilical incision length (prevent inability to perform surgery through incision)
 * 5) ___ Check uterine size for height above symphysis (prevent inability to perform surgery through incision)
 * 6) ___ Determine chance of malignancy (prevent inability to perform surgery through incision)
 * 7) ___ Assess pain threshold to know if high, normal or low (eg. grade rectal exam on 1-10 pain scale) (prevent post operative pain)
 * 8) ___ Choose incision type – Pfannenstiel, midline, Maylard based on history and physical exam (prevent inability to perform surgery through incision)
 * 9) ___ Inform patient of wound complications and their likelihood of occurrence   (wound infection, hematoma, dehiscence, pain, cosmetic changes) along with complications of the primary procedures being performed   (prevent incorrect expectations)
 * 10) ___Inform patient and sign consent for possible complications: bleeding, bladder injury, ureteral injury, bowel injury, ileus, infection, pelvic abscess, burn injury, nerve injury, postoperative vault prolapse, back pain, dyspareunia, and continued incisional/pelvic pain (prevent unreasonable expectations of surgery)
 * 11) ___Recommend to clip abdominal/mons hair prior to surgery but no shaving (prevent infection)
 * 12) ___Recommend to shower/cleanse incision site  prior to surgical prep with antibacterial soap (prevent infection)
 * 13) ___Order mechanical bowel prep for the day before surgery (prevent bowel injury) (prevent inadequate visualization)
 * 14) ___Order prophylactic antibiotics, at least 30-60 minutes before incision and consider repeating antibiotics (up to three doses) for high risk patients (prevent cuff abscess)
 * 15) ___ Discontinue ASA (5 days preop), Plavix (3 days preop)and other anti-clotting meds prior to surgery


 * 1) ___Be familiar with myomectomy, subtotal hysterectomy, coring, bivalving, and  morcellation techniques to reduce uterine mass (prevent inability to perform surgery through incision)
 * 2) ___Be familiar with intrafascial hysterectomy technique (prevent ureter/bladder injury)

Cautery Management

 * 1) ___ Confirm that patient is grounded (prevent cautery injury)
 * 2) ___ When cauterizing using metal instruments check for any unintended skin/tissue contact (prevent cautery injury)

Abdominal Wall Incision

 * 1) ___ Identify midline and anterior iliac spine and mark on skin the line of the incision if needed (prevent  asymmetry of incision)
 * 2) ___ Start transverse incision at least 3-5 cm above symphysis pubis (prevent nerve transection)
 * 3) ___ Follow lines of Langer, curving transverse skin incision upward laterally (prevent cutaneous nerve transection)
 * 4) ___ If  removing old scar, excise subcutaneous tissue symmetrically (prevent poor cosmetic scar result)
 * 5) ___ Cut fascia only to edge of rectus muscle, avoid  lateral incision extension into internal oblique  (prevent nerve transection)
 * 6) ___ Cauterize or ligate superficial epigastric vessels on transverse incision even if not bleeding at time of transection (prevent post operative bleeding)
 * 7) ___ Cauterize or ligate rectus perforating vessels on Pfannenstiel incision even if not bleeding at time of  transection (prevent post operative bleeding)
 * 8) ___ If midline incision, if  incision is extended above the umbilicus, extend around the left of the umbilicus to avoid the ligamentum terres (prevent post operative bleeding)
 * 9) ___ If midline incision, close peritoneum with fascia through the rectus sheath using continuous delayed absorbable or permanent suture (prevent wound dehiscence)
 * 10) ___ If Maylard incision, ligate inferior epigastic vessels on Maylard incision (prevent post operative bleeding)

Intraperitoneal management
29.___ Pack bowel away from the surgical field as much as possible (prevent bowel injury) 30.___Use moist laparotomy packs (prevent ileus) 31.___Minimize the amount of packing used and handling of the bowel (prevent ileus) 32.___Use Trendelenberg position (prevent bowel injury) 33.___Avoid excessive use of coagulation cautery intraabdominally (prevent pain from abdominal adhesions) 34.___ Avoid sharp dissection near large vessels (ovarian, uterine, illiac) if possible (prevent post operative bleeding) 35.___ Avoid excessive blunt dissection (prevent post operative bleeding) 36.___ Tie square knots and avoid unnecessary tension on the first throw of a suture (prevent post operative bleeding) If performing adhesiolysis: 36.1 ____identify bowel wall closest to the adhesion where lysis will occur (prevent bowel injury) 36.2 ___ if using cautery, use cutting current (coagulation current will draw bowel into field) (prevent bowel injury) 36.3.___ when using cautery cut 2-3 cm away from bowel wall (prevent bowel injury) (Please indicate   - Done,   X - Not done,   NA – Not applicable) 37.___ Identify the ureter on the posterior leaf of the broad ligament and near the infundibulopelvic ligament (prevent ureter injury) 38.___ Maintain medial and anterior traction of the ovary when clamping the infundibulopelvic ligament/ovarian vessels (prevent ureter injury) 39.___ For ligation of ovarian vessels, if single ligature is used it should be a suture ligature and no tag (hemostat) is used to put tension on suture (prevent post operative bleeding ) 40.___ For ligation of ovarian vessels, if tagged suture is used, double ligate, with first tie being an anchor stitch, then the second a free tie behind the suture ligature which can be tagged (prevent post operative bleeding ) 41.___ Incise anterior broad ligament peritoneum from round ligament, to just below the uterovesical peritoneal reflection, to opposite round ligament (prevent bladder injury) 42.___ Incise posterior broad ligament peritoneum to the cervix on each side (prevent ureter injury) 43. ___Dissect bladder from cervix along the midline of the pubovesical fascia plane with blunt (not sharp) dissection to move bladder off of anterior cervix to about 1 cm below the edge of the palpated cervix (prevent bladder  injury, prevent ureter injury) 44.___ Dissect posterior parietal peritoneum off of cervix to the uterosacral ligaments (prevent ureter injury) 45. ___ Maintain upward traction of the uterus throughout the procedure until the uterus is removed (prevent ureter injury) 46. ___ Roll clamps off of the cervix and uterine corpus (prevent ureter injury) 47. ___ Leave urine in bladder (unless exposure is compromised) to identify any bladder damage (prevent bladder fistula) If there is difficulty identifying the correct plane between the bladder and the cervix: 45.1 ___ incise pubovesicocervical fascia and place clamps intrafascially (prevent bladder injury, prevent ureter injury) 48. ___ Keep uterine vessel hemostatic sutures immediately underneath the metal clamps (prevent ureter injury) 49. ___ Use Haney stitches on large pedicles and major vessels (prevent postoperative bleeding 50. ___ Use curved clamps at the vaginal angles (prevent ureter injury) 51. ___ If bladder edge is not distinctly seen:             49.1___ use indigo carmine and cystoscopy to rule out bladder injury (prevent bladder fistula) 52. ___ Avoid irrigation with open cuff (prevent infection) 53 ___ Avoid placing suction tip in the vagina  (prevent infection) 54. ___ Avoid vaginal contents from entering abdominal cavity  when cuff is open (prevent infection) 55. ___ Close anterior to posterior vaginal fasica (prevent enterocoele, vaginal cuff or vaginal wall prolapse) 56. ___ Run and lock anterior and posterior cuff closure with absorbable suture (as opposed to interrupted  sutures) (prevent post operative bleeding, avoid stitch erosion/ granulation tissue)             If any venous oozing at cuff:             54.1 ____consider JP drain into the vagina (prevent infection) 54.2 ____compartmentalize to retroperitoneal space by closing parietal peritoneum (prevent intraabdominal infection) 57. ___ Check cuff mobility and if hypermobile, perform culdoplasty/colposuspension with permanent suture (prevent post-procedure vaginal vault prolapse) 58. ___ Ensure adnexae are away from the cuff at end of procedure (prevent post operative dyspareunia) 59. ___ Both surgeon and assistant need to check for retained sponges and confirm sponge count (prevent retained lap packs) 60. ___ Close abdominal peritoneum with suture (prevent future excessive adhesions) Closing abdomen 61. ___ Observe subfascial space before closing fascia for bleeding (prevent hematoma) 62. ___ Place fascial sutures approximately 1.0 cm from edge of fascia and approximately 1.0 cm apart (prevent wound dehiscence) 63. ___ When closing anterior rectus fascia, avoid subcutaneous tissue (prevent nerve entrapment) 64. ___ Approximate fascia without tension on sutures (prevent wound dehiscence) 65. ___ On transverse incisions, reapproximate Scarpa’s fascia superiorly to Scarpa’s fascia inferiorly and Camper’s to Camper’s if     present (prevent poor cosmetic scar result) 66. ___ Close subcutaneous tissue with running continuous absorbable suture if >=2.0 cm of fat tissue (prevent wound infection) 67. ___ Place subcuticular stitches below the dermis (prevent poor cosmetic scar result) 68. ___ Use a hypo allergenic skin adhesive rather than benzoin (prevent poor cosmetic scar result) 69. ___ Close skin with steristrips or bonding (prevent poor cosmetic scar result) 70. ___ Avoid skin staples or if used, remove by 3rd day (decrease postoperative incisional pain) (prevent poor cosmetic scar result) 71. ___ Use compression dressing for 48 hours before removing (prevent wound hematoma) 72. ___ Avoid patient controlled analgesia with opiate derivatives as much as possible (prevent ileus)
 * 1) ___ Enter abdominal peritoneum as cephalad to the fascial incision as possible (prevent bladder injury)
 * 2) ___ Visualize anterior bladder edge upon peritoneal entry by transillumination (prevent bladder injury)
 * 3) ___ Check to be sure that lateral blades of abdominal retractor are not impinging the femoral, genitofemoral or lateral cutaneous femoral  nerves lateral to the  iliopsoas muscles (prevent nerve injury)
 * 4) ___ If Maylard incision or Pfannenstiel incision and thin patient, place sponges between lateral abdominal retractor blades and tissue (prevent nerve injury)