How is an abdominal salpingo-oophorectomy performed?

Updated: Feb 06, 2018
  • Author: Stacie M Ward, MD; Chief Editor: Christine Isaacs, MD  more...
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Answer

Answer

The patient is transferred to the operating room table and placed under general anesthesia.

A pelvic examination is performed to determine uterine position, size, shape, and mobility, and to palpate the adnexa. A Foley catheter is normally placed to gravity to drain the urinary bladder throughout the procedure. The patient is positioned in a dorsal supine position and the patient's abdomen is prepped and draped in a sterile fashion.

A transverse or vertical incision may be chosen depending on the indication for surgery, the patient's body habitus, and the preference of the surgeon. The advantages of a transverse incision include improved cosmetic results, a stronger incision with decreased wound dehiscence, and decreased postoperative pain. Disadvantages of a transverse incision include increased blood loss and hematoma formation, increased risk of nerve injury, decreased exposure of the upper abdomen, and longer procedure time.

Advantages of vertical incisions include faster entry into the abdominal cavity, decreased blood loss, decreased risk of nerve injury, and the ability to significantly extend the incision if improved exposure is required, as for surgical staging in cancer cases. Disadvantages of a vertical incision include poor cosmetic results, weaker incision with increased risk of wound dehiscence, and increased postoperative pain.

After the abdomen is entered, the abdomen and pelvis are explored. Care should taken to carefully inspect the uterus, the bilateral ovaries and tubes, the small bowel, colon, omentum, and peritoneal surfaces for any abnormal findings.

A self-retaining retractor is often used to aid with exposure. The bowels are then packed to allow for adequate exposure of the pelvis.

The infundibulopelvic ligament should be identified. The infundibulopelvic ligament contains the ovarian vessels encased in peritoneum. Both the right and left ovarian arteries originate off of the aorta. The right ovarian vein drains into the inferior vena cava while the left ovarian vein drains into the left renal vein. The ureter lies in close proximity to the infundibulopelvic ligament and must be identified prior to clamping and transection of the infundibulopelvic ligament to avoid injury.

To aid in identification of the ureter and to drop the ureter deeper into the pelvis, the posterior peritoneum is opened. This is done by lifting the peritoneum anteriorly with Debakey forceps and making a small superficial incision in the posterior peritoneum. This incision is extended superiorly parallel to the infundibulopelvic ligament. Care must be taken to remain superficial and to avoid the ovarian vessels. Once the peritoneum is opened and reflected, the ureter is more readily identified.

When locating ureters, it is helpful to look for their peristalsis, which can be elicited by gently "strumming" the ureter. The ureters may be most evident where they cross over the iliac vessels, at the level of their bifurcation from the common iliac to the external and internal iliac vessels. The left ureter may be more difficult to visualize secondary to being covered by the sigmoid colon. Once detected at the pelvic brim, they can be followed down the lateral pelvic side wall until they enter the cardinal ligament underneath the uterine artery.

After identification of the ureter, an avascular window in the posterior broad ligament is identified and opened using sharp, blunt, or electrocautery dissection. The infundibulopelvic ligament is clamped through this window using two curved hysterectomy clamps (Zeppelin, Heaney, or Masterson). The first clamp is positioned laterally while ensuring the ureter is at a safe distance. The second clamp is placed approximately 1 cm medial to the first clamp.

The infundibulopelvic ligament is then sharply transected between the two clamps with curved Mayo scissors and then suture ligated using 0 delayed absorbable suture. The proximal end of the infundibulopelvic ligament is often doubly ligated, first using a free tie and then suture ligated ensuring hemostasis of the uterine vessels. The specimen end may also be suture ligated to prevent back bleeding and avoid excess clamps, improving visualization. Alternatively, the infundibulopelvic ligament may be clamped, ligated, and transected with a vessel sealing device.

Once the infundibulopelvic ligament has been transected and secured, the portion of the broad ligament attached to the fallopian tube is taken down. This may be accomplished with either electrocautery of the broad ligament paralleling close to the fallopian tube, by clamping then transecting with suture ligation, or with the use of a vessel sealing device.

With the ovary and tube now detached from both the infundibulopelvic ligament and the broad ligament, the remaining attachment is now to the uterus. The ovarian ligament attaches the ovary to the uterus and the fallopian tube attaches to the uterine cornua. This entire pedicle (ovarian ligament and fallopian tube) is clamped, sharply transected, and suture ligated; alternatively, the pedicle may be clamped, ligated, and transected with a vessel sealing device.

Once the tube and ovary have been removed, they should be sent to pathology for tissue diagnosis. Often the pelvis is irrigated with warm saline to aid in the removal of any blood clots and debris.

The pedicles should be reinspected for hemostasis. After excellent hemostasis is assured, the self-retaining retractor is removed along with the laparotomy sponges used for packing the bowel. Care must be taken to ensure all sponges have been removed. The abdomen and pelvis should be inspected and a sponge count should be completed prior to closure of the incision.


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