The patient is placed in the dorsal lithotomy position, and an adequate pelvic examination is performed with the patient under general anesthesia. This is extremely important because it allows the surgeon to become acquainted with the anatomy of the internal genitalia. This is frequently impossible when the patient is examined in the gynecologic clinic. The patient is then put in approximately a 15° Trendelenburg position. A Foley catheter is left in the bladder and connected to straight drainage. In general, midline incisions are preferred for malignant disease, since they allow accurate staging and exposure to the upper abdomen and aortic lymph nodes. If investigation of the upper abdomen and aortic lymph nodes is needed, the midline incision should be extended around and above the umbilicus for appropriate exposure.

For benign disease, the Pfannenstiel incision is an adequate alternative to the midline incision.

After the abdomen is entered, it should be thoroughly explored; including the liver, gallbladder, stomach, kidneys, and aortic lymph nodes.

Self-retaining retractors are placed in the abdominal incision, and the bowel is packed off with warm, moist gauze packs. A 0 synthetic absorbable suture is placed in the fundus of the uterus and used for uterine traction. The uterus is deviated to the patient's right. The left round ligament is placed on stretch and incised between clamps.

The distal stump of the round ligament is ligated with 0 synthetic absorbable suture. The proximal stump is held with a straight Ochsner clamp. At this point the leaves of the broad ligament are opened both anteriorly and posteriorly. This is performed by delicate dissection with the Metzenbaum scissors.

While retracting the uterus cephalad, the surgeon opens the anterior lead of the broad ligament to the vesicouterine fold. Steps 2-4 are carried out on the opposite side.

The vesicoperitoneal fold is elevated, and the fine filmy attachments of the bladder to the pubovesical cervical fascia are visible. The bladder can be dissected off the lower uterine segment of the uterus and cervix by either blunt or sharp dissection. If there has been extensive lower segment disease, previous cesarean sections, or pelvic irradiation, blunt dissection of the bladder off the cervix is dangerous, and a sharp dissection technique should be performed.

If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side with the infundibulopelvic ligament, tube, and ovary on tension. A finger should be inserted through the peritoneum of the posterior leaf of the broad ligament under the suspensory ligament of the ovary and Fallopian tube. The tube and suspensory ligament are doubly clamped, incised, and tied with 0 synthetic absorbable suture. The distal stump of this structure is best doubly tied, first with a single tie of 0 synthetic absorbable suture and then with a ligature of 0 synthetic absorbable suture. The same procedure is carried out on the opposite side.

The uterus is then retracted cephalad and deviated to one side of the pelvis with the lower broad ligament on stretch. The filmy tissue surrounding the uterine vessels is skeletonized by elevating the round ligament and dissecting the tissue away from the uterine vessels. Three curved Ochsner clamps are placed at the junction of the lower uterine segment on the uterine vessels. This is best performed by placing the tips of the curved Ochsner clamps onto the uterus and allowing them to slide off the body of the uterus, thus ensuring complete clamping of the uterine vessels. An incision is made between the upper Ochsner clamp and the two lower Ochsner clamps. This is suture-ligated with two 0 synthetic absorbable sutures, placing the first suture at the tip of the lower Ochsner clamp and tying the suture behind the base of the clamp. The middle Ochsner clamp is left in place and is similarly suture-ligated by a second ligature placed at the tip of the Ochsner clamp and tied behind the base of the clamp. No attempt is made to place a suture in the middle of the pedicle, since it contains blood vessels and a pedicle hematoma can be created.

The same procedure is carried out on the opposite side.

A delicate, transverse, curved incision is made in the pubovesical cervical fascia overlying the lower uterine segment. The separation of the pubovesical cervical fascia from the underlying cervical stroma is facilitated by placing traction on the uterus in the cephalad position.

The uterus is held in traction in the cephalad position, and the handle of the knife is used to dissect the pubovesical cervical fascia inferiorly. This step mobilizes the ureter laterally and caudally.

Two straight Ochsner clamps are applied to the cardinal ligament for a distance of approximately 2 cm. The cardinal ligament is incised between the two clamps, and the distal stump is ligated with 0 synthetic absorbable suture. The suture is tied at the base of the clamp; no attempt is made to place this suture within the body of the pedicle because vessels can be torn and hematomas created.

The same procedure is carried out on the opposite cardinal ligament.

The posterior leaf of the broad ligament is incised down to the uterosacral ligaments and across the posterior lower uterine segment between the rectum and cervix.

The uterosacral ligaments on both sides are clamped between straight Ochsner clamps, incised, and ligated with 0 synthetic absorbable suture.

The uterus is placed on traction cephalad, and the lower uterine segment and upper vagina are palpated between the thumb and first finger of the surgeon's hand to ensure that the ligaments have been completely incised. The vagina is entered by a stab wound with a scalpel and is cut across with either a scalpel or scissors. The uterus is removed. The edges of the vagina are picked up with straight Ochsner clamps in a north, south, east, and west direction.

a. The vaginal cuff is never closed in our clinic. This alone has accounted for a radical decrease in postoperative febrile morbidity and abscess formation. The edges of the vaginal mucosa are sutured with a running locking 0 synthetic absorbable suture starting at the midpoint of the vagina underneath the bladder and carried around to the stumps of the cardinal and uterosacral ligaments, which are sutured into the angle of the vagina.

b. The running locking suture is carried around the posterior wall of the vagina ensuring that the rectovaginal space is obliterated.

c. The cardinal and uterosacral ligaments of the opposite side have been included in the running locking 0 synthetic absorbable suture, and the reefing process has been completed to the midpoint of the anterior vaginal wall. At this point, meticulous care should be taken to ensure that the lateral angle of the vagina is adequately secured and that hemostasis is complete between the lateral angle of the vagina and the stumps of the cardinal and uterosacral ligaments. This can be a site of hemorrhage. 

At this point, the pelvis is thoroughly washed with sterile saline solution. Meticulous care is taken to ensure that hemostasis is present throughout the dissected area.

The pelvis is reperitonealized with running 2-0 synthetic absorbable suture from the anterior to the posterior leaf of the broad ligament. The stumps of the tubo-ovarian round, suspensory ligament of the ovary, and the cardinal and uterosacral ligaments are buried retroperitoneally.

Drains are rarely needed. If they are indicated, they are placed through the open vaginal cuff and carried along the lateral pelvic wall retroperitoneally.

If the tube and ovary are to be removed, they are removed at Step 6 in the operation. Instead of placing a finger underneath the tube and suspensory ligament of the ovary, a finger is placed under the infundilbulopelvic ligament on that side. Care is taken to ensure that the ureter is not included. In various forms of pelvic disease (endometriosis, pelvic inflammatory disease, etc.), the ureter can be deviated close to the infundibulopelvic ligament.

The infundibulopelvic ligament is doubly clamped and incised, and the distal stump of the ligament is doubly ligated with a tie of 0 synthetic absorbable suture plus a ligature of 0 synthetic absorbable suture.

For a bilateral salpingo-oophorectomy, the same procedure is carried out on the opposite infundibulopelvic ligament.

The tube and ovary have been mobilized medially with the uterine specimens. The remainder of the operation is carried out as described in Steps 7-13.

The peritoneum of the pelvis has been reestablished with the tube and ovary removed. The stump of the infundibulopelvic ligament is buried retroperitoneally.

Postoperatively, no vaginal packing is left in the vagina, and no Foley catheter drainage of the bladder is indicated.

The open vaginal cuff closes without difficulty. Rarely, a small bit of granulation tissue is noted in the upper vagina and is adequately treated by application of silver nitrate 4 weeks postoperatively in the clinic or office. The patient is allowed to resume sexual intercourse 4 weeks after examination in the clinic and is allowed to resume work 5 weeks postoperatively.