Supravaginal amputation of the uterus: initial stage
A surgical procedure classified as supravaginal amputation of the uterus without adnexa (Subtotalis hysterectomia sine adnexis) begins with establishing a wide surgical approach. For this purpose, a laparotomy (Laparotomia) is performed, allowing surgeons to gain full visual and manual control over the pelvic organs.
At the initial stage of the operation (stage "a"), the topographic perspective is assessed from a posterior view. The main task of the surgeon at this step is to securely grasp and prepare for subsequent transection the anatomical structures that support the uterus and supply it with blood from the adnexa.
Specialized instruments—Kocher forceps—are used for this task. These are heavy hemostatic forceps equipped with sharp teeth at the working end, ensuring the firmest possible tissue grip. The following key structures are subject to clamping (grasping):
- Proper ligament of the ovary (ligamentum ovarii proprium).
- Isthmus of the Fallopian tube (isthmus tubae uterinae).
Important clinical rule: since the surgery is performed strictly without adnexa, the Fallopian tubes and ovaries must be preserved in their entirety. To avoid accidental damage, tissue transection is performed medial to their anatomical location, i.e., shifting closer to the uterine body itself.
Technique of transecting the uterine body from the cervix
The next crucial stage of the surgical intervention is the amputation of the uterine body itself (amputatio uteri supravaginalis). By the time this stage begins, the body of the uterus (corpus uteri) has already been completely mobilized by the surgeon and gently retracted to one side to ensure tissue tension.
The ligamentous apparatus, including the round ligaments of the uterus, as well as the proper ovarian ligaments (or infundibulopelvic ligaments) and Fallopian tubes, has been pre-clamped, transected, and securely ligated. In the surgical field on either side of the uterus, formed stumps with surgical ligatures applied are clearly visible.
The surgical action itself consists of transecting (amputating) the uterine body from the cervix (cervix uteri). The incision is made with a surgical belly scalpel. The incision line runs strictly in a transverse direction at the level of the lower uterine segment, which topographically corresponds to the area of the internal os.
To prevent massive hemorrhage, meticulous hemostasis is ensured prior to organ transection. For this purpose, two straight Kocher-type hemostatic forceps are applied bilaterally (on both sides). They are positioned strictly perpendicular to the lateral border of the uterus. These forceps reliably occlude the ascending branches of the uterine arteries (a. uterina) and accompanying veins. The incision with the belly scalpel is made directly above the applied forceps, guaranteeing a dry surgical field.
Classical (corporal) Caesarean section (median hysterotomy)
As part of studying surgical interventions on the uterus, the classical Caesarean section (sectio caesarea corporalis), otherwise referred to in surgical practice as median hysterotomy, is also examined in detail.
During this procedure, a significantly enlarged (presumably pregnant) uterus (uterus) is visualized. To ensure convenient and safe access, the organ is exteriorized by the surgeons directly into the anterior abdominal wall wound.
The main surgical action in a classical Caesarean section is performing a longitudinal (vertical) incision. This incision runs precisely along the midline of the anterior uterine wall, providing wide access to the uterine cavity.
During work at this stage, the following basic instruments are used:
- Surgical scalpel, with which the surgeon directly makes the incision through the muscular wall of the uterus.
- Hemostatic forceps. They are visualized in the lower part of the surgical field and are used to securely grasp the edges of the surgical wound or to hold isolation material protecting surrounding healthy tissues from contamination.
Briefly: answers to topical questions
How does a classical Caesarean section differ from a lower segment Caesarean section?
A classical Caesarean section is a longitudinal midline incision in the body of the uterus. A lower uterine segment Caesarean section is performed via a transverse incision without bladder detachment. The most rational and widely accepted method globally is the lower uterine segment procedure with a transverse incision.
What are the absolute indications for a classical Caesarean section?
Strict indications for a classical Caesarean section include: placenta accreta or lower segment uterine aneurysm; severe adhesions and lack of access to the lower uterine segment; pronounced varicosities in the lower segment area; dehiscence of a longitudinal uterine scar from a previous classical Caesarean section; need for subsequent hysterectomy; preterm fetus and unformed lower segment; conjoined twins; neglected transverse fetal lie; presence of a living fetus in a dying woman; lack of proficiency by the doctor in performing a lower segment Caesarean section.
Which layers of the uterine wall are grasped when closing the incision after a classical Caesarean section?
The provided teaching materials lack exact information on the specific uterine wall layers grasped when closing the incision specifically after a classical Caesarean section. They only mention the placement of a continuous two-layer suture on the uterus in a classical Caesarean section, as well as placing one interrupted stay suture through all layers, 1 cm away from the wound angles when preparing for uterine closure.
Which adjacent anatomical structures are at the greatest risk of injury when applying clamps to the ascending branches of the uterine arteries?
When applying clamps to the ascending branches of the uterine arteries, the ureter poses the greatest danger near the uterine artery. Approximately 2 cm from the cervix, the uterine artery crosses the ureter and lies superior to it; the ureter also crosses the uterine artery, passing inferior to it, at a distance of 1.5–2.0 cm from the internal os of the cervix.
To memorize the structures clamped during amputation with preservation of the adnexa, use the mnemonic "SPTU" (Sacro-Proper Ligament — Tube Isthmus / Ligamentum ovarii proprium and isthmus tubae uterinae where Kocher forceps are applied). This will help quickly recall the ligamentum ovarii proprium and isthmus tubae uterinae onto which Kocher forceps are placed.
Class and exam questions
Where exactly is the incision line made during subtotal hysterectomy?
The incision is made with a surgical belly scalpel in a transverse direction at the level of the lower uterine segment, which anatomically corresponds to the region of the internal os of the cervix.
How is reliable hemostasis achieved before amputating the uterine body?
Two straight Kocher hemostatic forceps are applied bilaterally and strictly perpendicular to the lateral border of the uterus. They occlude the ascending branches of the uterine arteries (a. uterina) and veins.
What is the topographic feature of the procedure "without appendages"?
The ovaries and Fallopian tubes must be preserved. For this, tissue transection is performed medial to their anatomical location, i.e., closer to the body of the uterus.
What type of incision is typical for classical (corporal) Cesarean section?
During median hysterotomy (classical Caesarean section), a longitudinal or vertical incision is made strictly along the midline of the anterior wall of the enlarged uterus.
What else to study on this topic
- Topographic anatomy of the lower uterine segment and the internal os of the cervix.
- Technique of forming and ligating the stumps of the uterine ligamentous apparatus.
- Characteristics of uterine blood supply: topography of the ascending branches of a. uterina and venous drainage.
- Comparative characteristics of straight and belly surgical scalpels in operative gynecology.
- Rules for managing surgical wound edges and using surgical draping material during median hysterotomy.
Master the entire topic in the "Obstetrics and Gynecology" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Operations on the Cervix" and 973 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 21 video lessons on the subject
Other topics in the "Gynecology" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.