What approach: Abdominal, laparoscopic, vaginal or combination Taking or leaving the tubes and ovaries? Tubes: What benefit do they provide? Risk? Ovaries: What benefit do ovaries provide? What about after menopause? Still have benefit for bones and cardiovascular health. 65yr old cut-off If it’s laparoscopic–listen to the LSC podcast for more details on the approach Let’s talk about important steps: The round ligament: What artery runs inside the round? Sampson’s. What structure conceals the blood flow to the ovary? The IP ligament (formerly the suspensory ligament of the ovary). The artery comes from the aorta, so if this is transected before it is fully sealed, it can hemorrhage while retracting back into the retroperitoneum. Badness! What are the four levels at which the ureter is injured during hysterectomy? 1- At the pelvic brim, 2- medial to the IP ligament, 3- as it passes under the uterine artery (water under the bridge) and 4- lateral to the vaginal cuff closure. Ligate and transect the uterine arteries–the uterus should blanch white. Colpotomy– disconnecting uterus from vagina Close vaginal cuff if total hyst