Total Abdominal Hysterectomy Bilateral Saphingo-Oophorectomy (TAHBSO) is a surgical procedure in which the health care provider removes the

uterus including the cervix and the ovaries including the fallopian tubes. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. It is performed to treat cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids. TAHBSO may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after several attempts at non-surgical treatments. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. TAHBSO allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause. SURGICAL PROCEDURE OF TAHBSO Preparation and Positioning of the Patient The patient is supine; arms may be extended on arm boards. Apply electrosurgical dispersive pad. Skin Preparation A vaginal and an abdominal preparation are required. Put the patients legs in a frog-like position and prepare as for Dilatation and Curettage, Insert a Foley catheter and connect to continuous drainage. Return the patients leg to their original position, and replace the safety belt. For abdominal preparation using iodine solution, begin at the incision extending from nipple to midthighs, and down to the tables at the sides Procedure Draping Folded towel and a transverse or laparatomy sheet Procedure 0. A pfannenstiel or the bikini incision is employed. 1. The peritoneal cavity is entered and a self retaining retractor place. 2. The patient is placed in Trendelenburg position, and the intestines are protected with warm moist (saline) laparotomy pads. 3. The round ligaments of the uterus of the uterus are ligated, divided. 4. Sutured and tagged with a hemostat. 5. After identifying the ureters, the broad ligaments are Incised, and the bladder is reflected from the anterior aspect of the cervix. 6. The infundibulopelvic ligaments are ligated and divided. 7. The uterosacral ligaments are ligated and divided. 8. The ligaments are likewise divided. The vagina is incised circumferentially and the uterine specimen removed. 9. A free sponge may be placed in the vagina prior to closure. 10. After hemostasis is secured, the vaginal cuff is closed; a drain may be used. 11. The stumps of the uterosacral and round ligaments are sutured to the angles of the vaginal closure.

12. The pelvic peritoneum is approximated, and the wound is closed. 13. The free sponge is removed.

Pre Operative nursing care >Assess patient. The health history and the physical and pelvic examinationsare completed and the laboratory tests are performed. >Encourage patient to share details of her menstrual history, the date of her lastmenstrual period, the events leading up to admission and the current degree of vaginal blood loss or discharge. >Assess clients knowledge of her condition and the surgery.Perform skin operation: The lower half of the abdomen and the pubic and perineal area may be shaved and these areas may be cleaned with soap andwater.To prevent contamination and injury to the bladder or intestinal tract, the bladder and intestinal tract need to be empty before the patient is taken into the OR. >The patient who has previously been prescribed with oral contraceptive drug will have to stop taking the drug 6 weeks prior to operation.Preoperative medications may be administered before surgery to help the patient relax. >The patient must be allowed time to talk and ask questions. The nurse must know what information the physician has given the patient about the surgery. >Encourage patient to practice foot and leg exercises before operation to understand how to carry out the exercises while in bed after surgery. Let the patient will wear anti-embolism socks to prevent venous stasis during the operation. >Provide education: Loss of fertility if ovaries are to be removed in conjunction with the operation. Discuss surgical menopause. Discuss how sexual intercourse may change. Client whose ovaries are removed may complain of a decrease in libido. Tell the client that once healing has occurred, intercourse should be pain free. Let the patient relax on bed until she leaves the ward escorted by her nursewho completes a safe transfer to the operating theater staff

Anatomy and Physiology

Vagina Act as an organ of intercourse and to convey sperm to the cervixso that sperm can meet with the ovum in the fallopian tube. Complications: Vaginal Diseases Lumps Sores Discharge Uterus Its major function is to accept a fertilized ovum which becomesimplanted into the endometrium, and derives nourishment fromblood vessels which develop exclusively for this purpose. If egg does not implanted the menstruation occurs. Complication: Uterine Atony Hysterectomy Oviducts Fallopian tubes or oviducts provide the fertilization site where the egg meets the sperm. Complication: Pelvic Inflammatory Disease Salpingectomy Ovaries The main function is to produce, mature and discharge ova.Therefore, it is necessary for maturation and maintenance of secondary characteristics in females. Complication: Ovarian Cancer Patients with skin and soft tissue wounds commonly present to the emergency department (ED) for evaluation and treatment. Essential in the evaluation of these wounds is a careful assessment for retained foreign bodies (FB), as they are frequently missed on initial evaluation.[1, 2]Identification of a foreign body can be difficult, depending on the type and location of the wound and the timing and mechanism of injury. Soft tissue foreign bodies most commonly occur secondary to penetrating or abrasive trauma, and they can result in patient discomfort, deformity, delayed wound healing, localized and systemic infection, and further trauma during attempts at removal.[1, 3, 4] See images below for examples of foreign body presentations. Indications Indications for foreign body removal include the following:[28] Neurovascular compromise Evidence of infection Cosmetic deformity Functional impairment Chronic pain Patient request

The potential for complications due to the process of foreign body removal must be considered. Such complications may include the following:[27] Enlarging the wound or creating an additional wound Blunt or sharp dissection of nearby tissue Chemical or electrocautery required for hemostasis Additional infection risk for soft tissue that may require cosmetic repair with sutures following removal. Contraindications Contraindications to foreign body removal by a nonspecialist involve the following:[14, 21] Deep embedding Compromise of the integrity of nearby neurovascular or other structures during the retrieval process Poor or inadequate information on the position of the foreign body, leading to further exploration in the operating room Inadequate hemostasis or the potential for severe bleeding, especially if the patient has a clotting or bleeding disorder Cosmetic deformity related to the process of removal. Positioning

Patient positioning is important to achieve several goals. To dissipate force if substantial force is required Comfort during extended removal period to relieve the patient of the burden of supporting a limb or other body part (Additional personnel or hardware may be required.) Adequate visualization, inspection, and unhurried removal Various items may be helpful for proper positioning. Padding Pillows Adequate lighting, a seated position, and appropriate table and patient height can optimize the clinicians procedural outcome, as well.

Anatomy and Physiology

the clavicle or collarbone is a long bone of short length that serves as a strut between the scapula and thesternum. It is the only long bone in the body that lies horizontally. It makes up part of the shoulder and the pectoral girdle and is palpable in all people, and, in people who have less fat in this region, the location of the bone is clearly visible as it creates a bulge in the skin. The clavicle is a doubly curved short bone that connects the arm (upper limb) to the body (trunk), located directly above the first rib. It acts as a strut to keep the scapula in place so the arm can hang freely. Medially, it articulates with the manubrium of the sternum (breast-bone) at thesternoclavicular joint. At its lateral end it articulates with the acromion of the scapula (shoulder blade) at the acromioclavicular joint. It has a rounded medial end and a flattened lateral end. From the roughly pyramidal sternal end, each clavicle curves laterally and anteriorly for roughly half its length. It then forms a smooth posterior curve to articulate with a process of the scapula (acromion). The flat acromial end of the clavicle is broader than the sternal end. The acromial end has a rough inferior surface that bears a prominent line, the trapezoid line, and a small rounded projection, the conoid tubercle. These surface features are attachment sites for muscles and ligaments of the shoulder. It can be divided into three parts: medial end, lateral end and shaft. Medial end The medial end is quadrangular and articulates with the clavicular notch of the menubrium sterni to form the sternoclavicular joint. The articular surface extends to the inferior aspect for attachment with the first costal cartilage. It gives attachments to: fibrous capsule joint all around articular disc superoposteriorly interclavicular ligament superiorly Lateral end The lateral end is flat from above downward. It bears a facet for attachment to the acromion process of the scapula, forming the acromioclavicular joint. The area surrounding the joint gives an attachment to the joint capsule. Shaft The shaft is divided into the medial two-thirds and the lateral third. The medial two-thirds is thicker than the lateral third. Medial two-thirds of the shaft The medial two-thirds of the shaft has four surfaces and no borders.

The anterior surface is convex forward and gives origin to the pectoralis major. The posterior surface is smooth and gives origin to the sternohyoid muscle at its medial end. The superior surface is rough at its medial part and gives origin to the sternocleidomastoid muscle. The inferior surface has an oval impression at its medial end for the costoclavicular ligament. At the lateral side of inferior surface, there is a subclavian groove for insertion of the subclavius muscle. At the lateral side of the subclavian groove, the nutrient foramen lies. The medial part is quadrangular in shape where it makes a joint with the manubrium of the sternum at the sternoclavicular joint. The margins of the subclavian groove give attachment to the clavipectoral fascia. Lateral third of the shaft The lateral third of the shaft has two borders and two surfaces. The anterior border is concave forward and gives origin to the deltoid muscle. The posterior border is convex backward and gives attachment to the trapezius muscle. The superior surface is subcutaneous. The inferior surface has a ridge called the trapezoid line and a tubercle; the conoid tubercle for attachment with the trapezoid and the conoid part of the coracoclavicular ligament that serves to connect the clavicle with the coracoid process of the scapula. Axilla The axilla (or armpit, underarm, or oxter) is the area on the human body directly under the joint where the arm connects to the shoulder. It also provides the under-arm sweat gland.