Hysterectomy — structured oral station (12 minutes)

Opening prompt — "Discuss the route of hysterectomy for this patient."

Model response — say it in this order: ^[1]

• "This patient is 44, para 2, with heavy menstrual bleeding refractory to first-line medical management (tranexamic acid, NSAIDs, hormonal IUD, combined oral contraceptive, oral progestogen). The uterus is 10-week size with fibroids, and she has one previous lower-segment Caesarean section. She has completed her family and does not wish for further pregnancies."
• "The Cochrane Pickett 2023 review (PMID 37642285) found that vaginal hysterectomy is preferred to abdominal when feasible — faster return to normal activities (MD −10.91 days), fewer wound infections, shorter hospital stay. The 10-week size reduces the chance of a successful vaginal approach in this patient, but it is worth examining under anaesthesia to confirm."
• "If the vaginal route is feasible, I would proceed with vaginal hysterectomy. If not, total laparoscopic hysterectomy is the contemporary default for most benign indications in trained hands — the laparoscopic advantages over abdominal include shorter recovery but with a higher urinary tract injury rate (OR 2.16, 95% CI 1.19–3.93)."
• "Abdominal hysterectomy via Pfannenstiel or midline is reserved for the bulky uterus beyond laparoscopic feasibility, suspected malignancy with staging, frozen pelvis, or when laparoscopic expertise is not available."
• "I would discuss ovarian conservation: in a 44-year-old without family history of ovarian or breast cancer, conservation is the default."

Examiner is listening for: named routes, named evidence, named indications, named contraindications, ovarian conservation discussion.

Probe 1 — "Describe the steps of total laparoscopic hysterectomy in order."

• "The first step is patient positioning in steep Trendelenburg with the primary port at the umbilicus (or Palmer's point in the hostile abdomen), two lateral ports at the level of the umbilicus in line with the anterior superior iliac spine, and an optional third midline suprapubic port."^[9]
• "I would then identify the ureter at the pelvic brim — visible through the medial leaf of the broad ligament, crossing over the bifurcation of the common iliac artery."
• "Coagulate and divide the round ligament; open the anterior leaf of the broad ligament; open the pararectal space (medial to the internal iliac artery and lateral to the ureter); open the paravesical space (medial to the obliterated umbilical artery)."
• "Develop the bladder flap off the lower uterine segment; in this patient with one previous Caesarean section, sharp dissection in the midline is required because the bladder is adherent."
• "Skeletonise the ureter down to the uterine artery; identify the lateral cervical branch of the uterine artery crossing over it; divide the uterine artery at its origin from the anterior trunk of the internal iliac."
• "Divide the utero-ovarian ligament (or the infundibulopelvic ligament if oophorectomy); open the posterior leaf of the broad ligament and the rectovaginal septum; divide the uterosacral ligaments at the level of the cervix."
• "Colpotomy along the Koh cup — circumferential incision of the vagina. Remove the specimen vaginally or by morcellation in a containment bag. Close the cuff with a continuous barbed suture or interrupted figure-of-eight absorbable suture."

Probe 2 — "At the lateral cervical step, brisk bleeding is encountered from the tissue crossing over the right ureter. What do you do?"

• "The most likely source is the lateral cervical branch of the uterine artery crossing over the ureter — the named source of bleeding at this step. The Kobayashi 2023 case series (PMID 37638335) documents this as the most common site of ureteric injury at TLH."^[9]
• "I would stop, apply pressure with a swab, do not blind-diathermy near the ureter, and identify the vessel exactly."
• "I would suture-ligate the vessel with a fine absorbable suture (4-0 or 5-0 PDS) or apply a clip; bipolar diathermy is acceptable if the ureter is identified and away from the field."
• "At the end of the case, intra-operative cystoscopy with indigo carmine and furosemide to demonstrate bilateral ureteric efflux; check postoperative creatinine on day 2."
• "If haemostasis cannot be secured or the anatomy is hostile, convert to laparotomy — the consultant-level response."

Probe 3 — "On day 5 the patient presents with sudden pelvic pain and visible small bowel in the vagina. What is happening and what do you do?"

• "This is vaginal cuff dehiscence with bowel evisceration — a surgical emergency. The risk factors include smoking, poor nutrition, early intercourse, steroid use, and poor closure technique. Cuff dehiscence is more common after laparoscopic than open hysterectomy."^[1]
• "Immediate resuscitation: IV access, fluids, analgesia, antiemetics, nil by mouth, broad-spectrum intravenous antibiotics (e.g. cefazolin plus metronidazole), group and screen, anaesthetic review."
• "Return to theatre for examination under anaesthesia, inspection of the small bowel for serosal tears or ischaemia, return of the bowel to the abdomen, and repair of the cuff with interrupted figure-of-eight absorbable sutures (e.g. 0 Vicryl). Consider laparoscopic or abdominal approach if vaginal access is inadequate. General surgical consult if bowel injury identified."
• "Postoperative plan: enhanced observation, nil by mouth until bowel function returns, IV antibiotics, VTE prophylaxis, smoking cessation counselling, advice to avoid intercourse and heavy lifting for 6–8 weeks."

Probe 4 — "What are the risk factors for cuff dehiscence and how would you prevent it?"

• "Risk factors: smoking (the single most important modifiable risk factor), poor nutrition, steroid use, immunosuppression, early intercourse, poor closure technique, and laparoscopic (compared with open) approach."^[1]
• "Prevention: optimise modifiable risk factors preoperatively (smoking cessation at least 4 weeks before surgery, nutrition, control of diabetes), use a continuous barbed suture (V-Loc or Stratafix) or interrupted figure-of-eight absorbable suture for cuff closure, ensure haemostasis at the cuff, and counsel the patient to avoid intercourse and heavy lifting for 6–8 weeks."

Probe 5 — "How would you respond to a creatinine of 280 µmol/L on day 2 in a patient who was well postoperatively?"

• "Asymptomatic postoperative ureteric injury presents with rising creatinine on day 2 — absence of symptoms does not equal absence of injury."^[9]
• "I would arrange an urgent CT urogram to identify the site and nature of the obstruction (ligation, kink, thermal stricture)."
• "In conjunction with urology, plan retrograde stent placement or percutaneous nephrostomy if the obstruction cannot be crossed retrogradely."
• "Document the critical incident, declare the event, and discuss with the patient."

Probe 6 — "The patient asks about ovarian conservation. What do you tell her?"

This is a scored domain, not a courtesy. Demonstrate it out loud:

• Move to her eye level, use her name, brief plainly: "You are 44, and you have a choice about your ovaries. The ovaries make hormones that protect your bones and your heart, and removing them would put you into a surgical menopause with the symptoms and the long-term risks. The risk of ovarian cancer in someone without a family history is low, but it is not zero. Removing the ovaries at the same time as the hysterectomy eliminates the risk of ovarian cancer and means you will not need another operation for ovarian problems in the future."^[1]
• "In your case, with no family history of breast or ovarian cancer, the default is to keep the ovaries unless you tell me otherwise. We can also remove the fallopian tubes, which reduces the risk of one type of ovarian cancer, even if we keep the ovaries."
• Acknowledge any concerns, invite questions, offer written information, and tell her how to contact the team.
• Document the conversation and the plan in the consent form.

Probe 7 — "What are your top three learning points from this case?"

• "Defend the route with named evidence. Cochrane Pickett 2023 (PMID 37642285) — vaginal preferred to abdominal when feasible; laparoscopic advantages over abdominal with higher urinary tract injury (OR 2.16)."^[1]
• "The lateral cervical branch of the uterine artery is the named source of bleeding at the lateral cervical step. Identify, clip, do not blind-diathermy. Confirm ureteric integrity at the end of the case."^[9]
• "Cuff dehiscence with bowel evisceration is a surgical emergency. Resuscitate, return to theatre, repair with interrupted figure-of-eight sutures. Counsel on the modifiable risk factors — smoking, nutrition, intercourse."^[1]