The document discusses techniques for performing a hysterectomy, including: 1) Identifying ligaments like the round ligament and infundibulopelvic ligament before division. 2) Dissecting the retroperitoneal space to identify the ureter and external iliac artery. 3) Dividing the peritoneum to access the utero-ovarian pedicle or uterine vessels for clamping/ligation.

1. Histerektomi
anatomi dan tehnik
murthy

8. • Identified the rotundum ligament and infundibulopelvicum ligament
• A 0 delayed absorbable suture is placed under the round ligament
approximately halfway between the uterus and the pelvic sidewall (Fig.
32A.1).

9. • With traction on these sutures, the round
ligament is held taunt and divided with
Metzenbaum scissors between the two
suture ligatures.
• opens the retroperitoneal space, which is
almost always a free space for blunt
dissection,
• If the ovaries are to be removed at the
time of hysterectomy, the peritoneal
incision then is extended superiorly,
lateral to the ovary and parallel with the
infundibulopelvic ligament. The peritoneal
incision also can be extended anteriorly
down to the bladder reflection, but the
peritoneum over the anterior cervix does
not need to be divided at this time
• With the index finger and the tip of the
suction or the back of a tissue forceps, the
surgeon gently divides the loose areolar
tissue of the retroperitoneum, identifying
the external iliac artery on the medial
surface of the psoas muscle
• The ureter always crosses the pelvic brim
at this location and should be identified
easily on the inside of the medial leaf of
the peritoneum at this point. The internal
iliac or hypogastric artery dives into the
pelvis at this location parallel to the
ureter, and it should be identified also.

11. • If the ovary and tube are to be left in situ at the time of hysterectomy, a window in
the peritoneum beneath the fallopian tube between the uterus and ovary is made
sharply or bluntly, and a heavy clamp—such as a Heaney, Kocher, or similar
clamp—is used to clamp the uteroovarian pedicle (Fig. 32A.3, see page 736)

12. • The next step is the dissection of the bladder from the anterior cervix. At
this point, the peritoneum is divided just inferior to its attachment to the
lower uterine segment. If the peritoneum is divided 5 to 10 mm below its
uterine attachment, it is usually mobile, and an avascular plane of loose
areolar tissue can be identified between the posterior bladder wall and
the anterior cervix.

14. • Once the bladder has been freed from the anterior cervix, the uterine artery and
vein are skeletonized (Fig. 32A.6). The uterus is pulled sharply to the patient's right
side, and the surgeon gently dissects the loose fatty tissue adjacent to the lateral
lower uterine segment on the left. The uterine artery is usually found immediately
adjacent to the uterus at the level of the internal cervical os.
• The tip of the clamp should not include too much cervical or uterine tissue
because this makes application of subsequent clamps more difficult. A second
clamp can be placed above the first for added safety, if desired, and a third or back
clamp used to prevent annoying back bleeding from the uterus after the vessels
have been cut.

15. • Hemostasis should be good at this point. If not,
any bleeding should be controlled. The bladder is
again checked to ensure it is well below the
cervix. If the rectum needs to be dissected from
the posterior cervix, this should be done now
• If the bladder and/or rectum is too densely
adherent and there is concern that further
attempts at dissection may damage them or
cause troublesome bleeding, a supracervical
hysterectomy should be considered

17. • Sharply angled large Zeppelin clamps are used to clamp
across the vagina below the cervix. These clamps include
the base of the cardinal ligaments laterally, the uterosacral
ligament posteriorly, and the vaginal wall anteriorly and
posteriorly.
• A clamp is applied from each side; in most cases, the tips of
these clamps meet in the middle just below the cervix (Fig.
32A.8). A knife or heavy, sharply angled Jorgenson scissors
is used to divide the vagina above these clamps and below
the cervix. The uterus is removed and placed in a pan on
the back table for later examination. A single figure-of-eight
suture is placed between the tips of the two clamps to
close the midportion of the vagina. The ends of this suture
are held initially and not tied.

18. • We generally close the vaginal cuff with a series of figure-of-eight
stitches of 0 delayed absorbable suture, taking care to incorporate
the uterosacral and cardinal ligaments into the cuff for support. We
have not run the vaginal wall with a locking stitch for hemostasis
and left the cuff open for drainage (closing the pelvic peritoneum
over the open cuff) since the advent of prophylactic antibiotics for
hysterectomy many years ago.

19. Supracervical hysterectomy

20. C L O S U R E
• After the pelvis has been copiously irrigated with warm saline, the
pedicles are inspected carefully to be sure that hemostasis is present.
• The location of the ureters, bladder, and major vessels should be known
when placing these sutures.
• Common sites of ureteral injury during abdominal hysterectomy include
the infundibulopelvic ligament where the ovarian vessels are ligated; the
area of the uterine artery ligation and the bladder base.
• The anterior peritoneum is closed with delayed absorbable suture,
although some surgeons today feel that it is unnecessary to close the
abdominal peritoneum.
• The fascial closure should be commensurate with the patient's risk of
infection and hernia. Generally, a running monofilament delayed
absorbably suture such as PDS (Ethicon) on a larger, curved, tapered
needle (CT-1, Ethicon) can be used.
• If there is a significant risk of dehiscence secondary to infection, obesity,
or other medical problems, interrupted sutures or a mass closure
technique may be used.

24. Postoperative management

25. abreviation
• IP ligament , bagian dari broad ligament, terdiri atas areteri ovarica
~ligamentum suspensorium ovarii
• Yang menghubungkan antara ovarium dengan didnding pelvis
• Kalo ligamentum ovarii, menghubungkan ovarium dengan uterus

26. The broad ligament may be divided into three subcomponents:[1]
• Mesometrium - the mesentery of the uterus; the largest portion of
the broad ligament
• Mesosalpinx - the mesentery of the Fallopian tube
• Mesovarium - the mesentery of the ovaries.
The contents of the broad ligament include :
Reproductive
Uterine tubes (or Fallopian tube)
ovary (some sources consider the ovary to be on the broad ligament, but not in it.)[3]
vessels
ovarian artery (in the suspensory ligament)[4]
uterine artery
ligaments
ovarian ligament
round ligament of uterus
suspensory ligament of the ovary (Some sources consider it a part of the broad ligament
while other sources just consider it a "termination" of the ligament.[5])

27. • The uterosacral ligaments (or recto-uterine ligament) belongs
to the major ligaments of uterus.
• The rectouterine folds contain a considerable amount of
fibrous tissue and non-striped muscular fibers which are
attached to the front of the sacrum and constitute the
uterosacral ligaments.

29. • The cardinal ligament (or Mackenrodt's ligament, lateral cervical ligament,
or transverse cervical ligament) is a major ligament of the uterus.
• Located at the base of the broad ligament of the uterus.
• It contains the uterine artery and uterine vein.
• There is a pair of cardinal ligaments in the female human body.
• It attaches the cervix to the lateral pelvic wall at the ischial spine, and is
continuous externally with the fibrous tissue that surrounds the pelvic
blood vessels. It thus provides support to the uterus.[3]
• It may be of clinical significance in hysterectomy,[4][5] due to its close
proximity to the ureters, which can get damaged during ligation of the
ligament.

31. miomektomi
Tujuan operasi:
• mengembalikan fungsi reproduksi
• Mengatasi keluhan
• Curiga ganas, doppler : gambaran arus darah
meningkat
• Penekanan ke organ sekitar
• Estetik
• Pertumbuhan progresif
• REMEMBER RULE OF FIVE

32. • Evakuasi mola
• Sterilisasi
• Seksio

33. Ujian hari rabu
• Ada panduannya
• Evaluasi sumatif dan formatif
• Ujian bawa kartu kendali
• Catatan harian/portfolio
• Buku log

34. • Pengisian kartu kendali
• Pengisian prtfolio
• Pengisisan logbook
• Diskusi sama penguji

35. Ujian hari kamis 14
• Ujian tulis T2B

36. • Induksi gyn tgl 26  masing2 membawa form
yng sudah dikasih

37. • After identification of the ureter, we pass
a large curved needle with a #0 chromic
catgut or polyglycolic acid suture through
the lateral aspect of the lower uterine
segment as close to the cervix as possible,
then back through the broad ligament just
lateral to the uterine vessels. The suture is
tied to compress these vessels. If this does
not control bleeding, the vessels of the
utero-ovarian arcade are similarly ligated
just distal to the cornua by passing a
suture ligature through the myometrium
just medial to the vessels, then back
through the broad ligament just lateral to
the vessels, and then tying to compress
the vessels (figure 1)

38. Artery iliaca interna ligation
• The technique for IAL is performed bilaterally as follows:
• Open the anterior leaf of the broad ligament (with a Metzenbaum scissors or
electrosurgery) and lyse the areolar tissue of the retroperitoneum.
• The external iliac artery is readily identified at the medial margin of the psoas
muscle, and is followed to the common iliac artery bifurcation. The internal iliac
artery is about 4 cm in length before it divides into anterior and posterior
branches.
• Ideally, the dissection should be carried caudally to the anterior and posterior
trunks of the internal iliac artery so that the anterior trunk can be selectively
ligated. In practice, this is so difficult that the entire internal iliac artery usually is
ligated at its origin.
• Dissect away the nodal tissue overlying the internal iliac artery by spreading the
tissue with a right angle or tonsil clamp or the tips of Metzenbaum scissors.
Continue the dissection anterior and lateral to the internal iliac artery. Proceed in
the same plane around the circumference of the artery to separate it from the
internal iliac vein, which is slightly medial and posterior to the artery. Pass a
number 1 silk or nonabsorbable synthetic suture (eg, polypropylene) around the
artery from lateral to medial and tie securely.