Obstetric and Gynecologic Surgery: Cesarean Section, Hysterectomy, and Laparoscopic GYN

Obstetric and Gynecologic Surgery: Cesarean Section, Hysterectomy, and Laparoscopic GYN

OB/GYN surgery places unique demands on the surgical technologist. Two patients are present during a cesarean section — the mother and the neonate — and the speed of delivery directly affects neonatal outcomes. For hysterectomy, precise instrumentation and anticipation of each surgical step protect the patient from blood loss and organ injury. Mastering these setups is essential preparation for the CST credential and for daily practice.

Anatomy Review

The uterus is a thick-walled muscular organ lying in the true pelvis, supported by the broad, round, cardinal, and uterosacral ligaments. The fallopian tubes arise from the uterine cornua; the ovaries lie adjacent, attached by the ovarian ligaments and suspended by the infundibulopelvic (IP) ligaments. Major vascular supply comes from the uterine arteries (branches of the internal iliac) and the ovarian arteries (arising directly from the aorta). The bladder lies anterior to the uterus; the ureters course beneath the uterine arteries — a critical relationship during hysterectomy. The bowel, especially the sigmoid colon, lies posterior. Knowing these relationships helps you anticipate injury risk and understand why retraction and careful instrument passing matter.

Cesarean Section: Setup and Sequence

A cesarean section (C-section) is delivery of the fetus through a uterine incision. The most common approach is the low-transverse (Pfannenstiel) skin incision followed by a low-segment transverse uterine incision (Kerr incision). Speed matters: from uterine incision to delivery should be brief to minimize fetal exposure to anesthetic agents and hypoxia.

Back table essentials include a cesarean-specific instrument set: lap sponges (counted carefully), retractors (Doyen uterine retractor, bladder blade), clamps (Pennington, ring forceps, cord clamps), scissors (bandage scissors for cord), suction (Poole suction tip), needle holders, and suture. A bulb syringe is placed on the field for immediate neonatal airway suctioning if needed. A sterile receiving blanket may be used to hand off the neonate.

Mayo stand sequence at delivery: When the surgeon calls for the uterine incision, pass the scalpel (No. 10 blade on a No. 3 handle) for the skin, then bandage scissors or the surgeon's fingers are used to extend the uterine incision bluntly. Immediately have a Doyen retractor ready to protect the bladder inferiorly. Once the neonate is delivered, clamp and cut the umbilical cord with cord clamps and bandage scissors. Pass the bulb syringe and receiving blanket. Oxytocin (a uterotonic agent) is administered by the anesthesia provider after delivery; be aware this is standard protocol and occurs without your direct action, but anticipate that uterine massage and bimanual compression instruments may be needed. Placenta is delivered manually; have lap sponges ready. Uterine closure typically uses a large absorbable suture on a heavy needle holder.

Safety points: Perform and verify all counts (sponges, sharps, instruments) before uterine closure and again before skin closure — two separate cavities are involved. Keep track of every lap sponge; a retained sponge in the uterus is a catastrophic error. Announce each count clearly. Never rush a count even under time pressure.

Total Abdominal Hysterectomy: Setup and Sequence

A total abdominal hysterectomy (TAH) removes the uterus and cervix through an abdominal incision. When the ovaries and tubes are also removed the procedure is called a TAH-BSO (bilateral salpingo-oophorectomy). The surgical sequence proceeds through: abdominal entry → identification and ligation of the round ligaments → development of the broad ligament → identification and ligation of the IP ligaments (if BSO) or preservation of the ovaries → securing the uterine vessels → dissection of the bladder flap → amputation at the cervicovaginal junction → closure of the vaginal cuff → abdominal closure.

Key instruments: Self-retaining retractor (O'Sullivan-O'Connor or Bookwalter), long tissue forceps (Russian or DeBakey long), long Metzenbaum scissors, Heaney or Masterson clamps for pedicles, free ties and suture ligatures, Jorgenson scissors for the vaginal cuff, and a long electrosurgical pencil. Have additional sponge sticks available for packing bowel superiorly.

Anticipation skills: Each clamp–cut–tie sequence on a pedicle happens in a predictable rhythm. Load a free tie, then a suture ligature on a needle holder, and hand them in sequence without being asked. When the surgeon approaches the uterine vessels, be especially alert — this is the highest hemorrhage risk step.

Laparoscopic GYN

Procedures such as laparoscopic hysterectomy, ovarian cystectomy, and tubal ligation use a camera and working ports rather than a large incision. The scrub must be proficient with trocar assemblies, 0° and 30° laparoscopes, laparoscopic clamps, harmonic or bipolar energy devices, and specimen bags (endoscopic catch bags). An open laparotomy tray must always be immediately available for conversion to open surgery. Keep all laparoscopic instruments organized and the camera lens clean with anti-fog solution.

General OB/GYN Safety Principles

• Counts are non-negotiable: Conduct initial, closing, and final counts on every case per facility policy and AORN standards.
• Scope of practice: The surgical technologist functions under the direction of the surgeon and does not make independent clinical decisions. Anticipate needs; do not act beyond your role.
• Sterile field integrity: OB/GYN procedures often involve rapid, high-pressure moments. Maintain sterility even when speed is demanded.
• Specimen handling: Label all specimens accurately and immediately. Uterus, tubes, ovaries, and placenta are each separate specimens.
• Sharps safety: Pass scalpels in a neutral zone. Never hand a sharp directly hand-to-hand.