DESCRIPTION OF OPERATION: As soon as adequate general anesthesia was administered, with the patient in supine position, an indwelling Foley catheter was inserted. The abdomen was prepped and draped. A suprapubic Pfannenstiel incision was made. The incision was deepened into the subcutaneous fat and fascia and peritoneal cavity entered. Self-retaining retractors and wet laps were used to pack up the lower abdomen to give better visualization. Fluid was removed for cytology, and two large clamps were placed on each side of the uterus to be used as traction. The left round ligament was then taken in between two clamps, tissue cut in between clamps, and suture ligatures were placed at the distal clamp. The same procedure was done on the other side. A curvilinear incision was made on the vesicouterine peritoneal reflection, separating the bladder flap away from the lower uterine segment and pushed well below the cervix. Through the avascular space in the broad ligament, a Codman clamp was placed through this to incorporate the infundibulopelvic ligament. Two other clamps were placed in close proximity to this, tissue cut in between the first and middle clamps, and suture ligatures were placed at the distal clamp.
The left adnexa was then removed and sent for frozen section. The same procedure was done on the other side with the adnexa also sent for frozen section. They both came back as benign. The uterine vessels on each side were clamped, divided, and doubly ligated. The cardinal ligaments on either side were clamped, divided, and doubly ligated and the uterosacral ligaments clamped, divided, and doubly ligated. With the bladder pushed well below the cervix, the anterior vagina was entered. Complete amputation of the cervix from the vagina was done. Clamps were applied on the vaginal vault. Special angle sutures were placed at the angle clamps by incorporating the anterior to the posterior vault together with the stump of the uterosacral ligaments and the cardinal ligaments. Interrupted figure-of-eight suture was used to approximate the anterior to the posterior vault and closed the vault completely.
Peritonealization was done by approximating the anterior to the posterior parietal peritoneum with a continuous suture of #2-0 chromic material. Copious irrigation was done on the pelvic cavity. Proper hemostasis was observed. The appendix was localized, this was retrocecal, appeared to be very small and normal. This was left in place. No other pathology noted. As soon as sponge count and instrument counts were correct, the abdomen was closed in layers using a continuous suture of chromic #0 on the peritoneum, continuous suture of Vicryl #1 on the fascia, and continuous suture of plain catgut on the subcutaneous fat. The skin was approximated with subcuticular stitch of #4-0 Vicryl. Estimated blood loss was about 200 mL. The patient tolerated the procedure well. She was brought to the recovery room in satisfactory condition.