Total Abdominal Hysterectomy (TAH-BSO)
Patient phenotype
Indications: fibroids, endometrial cancer, ovarian mass, pelvic pain. Age 40-70 typical. Often: anemic from chronic bleeding, possibly post-radiation, sometimes post-chemo for cancer.
Procedure
Pfannenstiel or midline incision, ligation of major vessels (uterine, ovarian arteries), removal of uterus + cervix ± ovaries + tubes. ~90-180 min. Lithotomy or supine.
Anesthetic plan
GETA. Multimodal regional: TAP block or epidural for postop analgesia. 18g PIV; consider second if cancer + extensive surgery. Type & screen + cross 2 units.
Setup
- ·Standard ASA + Foley + temp
- ·Two PIVs (16-18g)
- ·Type & cross 2 units
- ·TAP block kit OR epidural setup
- ·DVT prophylaxis (mechanical + chemical)
- ·Forced air warmer
Biggest concerns by phase
Pre-op anemia + iron stores
Many gyn patients chronically anemic from menorrhagia. Iron + EPO 4-6 weeks pre-op for elective if Hb < 12. Type & cross before surgery. Cell saver for cancer cases (debated).
Standard induction + RSI if reflux/obese
Standard GA induction. Consider RSI in obese / GERD. Routine intubation, NMB for relaxation.
Blood loss potential — vascular pedicles
Average 200-500 mL but can be > 2 L if cancer / endo / fibroids large. Type & cross active. Cell saver for benign disease (not for cancer). Surgeon ligates uterine arteries first to control flow.
Ureter injury risk — recognize sooner
Ureter runs near uterine artery; injury rate 1-2%. Postop watch: flank pain, decreased UOP, rising creatinine. Intraop sometimes IV indigo carmine to check ureter integrity.
Steep Trendelenburg if laparoscopic
Lap TAH = aggressive Trendelenburg + lithotomy. Effects: ↑ICP + ↑IOP + facial edema, ↑PIP, atelectasis, cerebral perfusion considerations. Strict shoulder support but avoid brachial plexus injury.
Postop: pain, PONV, VTE, urinary retention
Multimodal opioid-sparing pain (TAP block + APAP + NSAID). High PONV risk in this population. DVT prophylaxis early. Foley typically removed POD 1.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-year-old female TAH-BSO for endometrial cancer. Mid-case, surgeon notes 'lots of bleeding' from a uterine artery. BP drops 110/65 → 80/45. EBL is 1500 mL in 5 min. What's your plan?
What an examiner probes for
- ▹Activate massive transfusion if needed
- ▹Two large PIVs / convert one to central if difficult access
- ▹Crystalloid bolus + start blood
- ▹Anticipate coagulopathy + hypothermia
- ▹Communicate with surgeon, send TEG/labs
Sources
- Miller's Ch 71
- ACOG Guidelines: gynecologic surgery
Anatomy reference
Sourced reference images. 4 matches for "uterus pelvic gynecologic".
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