This presentation provides a comprehensive guide for the gross examination and processing of a total hysterectomy specimen with bilateral salpingectomy, focusing primarily on benign conditions. The video reviews essential surgical terminology (defining total, radical hysterectomy, salpingectomy, and oophorectomy) and details the critical anatomical landmarks of the uterus and adnexa. Standard orientation techniques, utilizing peritoneal reflections and adnexal positioning, are explained. Key benign pathologies frequently encountered, such as adenomyosis, endometriosis, and leiomyomas, are discussed with their distinguishing gross features. Finally, the video outlines the proper grossing procedure, including standard measurements, opening techniques (coronal plane), and specific sectioning protocols, emphasizing the use of the Modified SEE-FIM (Sectioning and Extensively Examining the Fimbriated End) protocol for the fallopian tubes.
Gross Examination of a Total Hysterectomy Specimen
0:00 Specimen Identification: The specimen is a total hysterectomy with bilateral salpingectomy (removal of the uterus, cervix, and both fallopian tubes).
Total Hysterectomy: Removal of the uterus and cervix.
Salpingectomy: Removal of one or both fallopian tubes.
Oophorectomy: Removal of one or both ovaries.
Radical Hysterectomy: Removal of the uterus, cervix, vaginal cuff, parametrium, regional lymph nodes, tubes, and ovaries (typically for malignant conditions like cervical carcinoma).
2:05 Uterine Anatomy Review: Detailed review of the uterus, including the cervix (endocervix, ectocervix, transformation zone, internal/external os), lower uterine segment, fundus, endometrium, myometrium, and serosa.
5:54 Specimen Orientation: Orientation can be achieved using adnexal structures (anterior to posterior: Round Ligament $\rightarrow$ Fallopian Tube $\rightarrow$ Ovary) or peritoneal reflections (anterior surface is rounder/higher due to the bladder; posterior surface is lower/more pointed due to the rectum).
7:30 Common Benign Indications: Examples of benign conditions leading to hysterectomy include leiomyomas, endometriosis, adenomyosis, pelvic pain, and placenta creta/increta/percreta.
8:28 Adenomyosis Gross Features: Defined as endometrial tissue within the myometrium. Grossly, the uterus is enlarged and round, and the myometrium is thickened, turbulated, lacy, and may contain pinpoint cystic spaces.
10:07 Leiomyoma (Fibroid) Classification: Subserosal (under the serosa), Intramural (within the walls), and Submucosal (beneath the endometrium, often causing bleeding/fertility issues).
11:14 Malignancy Concern: Features concerning for leiomyosarcoma (malignant) include a single, large myometrial lesion, extensive necrosis, or an infiltrating appearance.
12:20 Specimen Opening Technique: Open the specimen along the coronal plane by inserting forceps into the external cervical os and cutting to expose the endometrial cavity for formalin fixation.
14:47 External Os Shape: A round external os indicates a nulliparous woman (has not given birth); a slit-shaped os indicates a parous woman (has given birth vaginally).
15:43 Grossing Template Details: Gross description must include measurements (uterus SI x AP x ML; cervix L x D; tubes L x D), endometrium color and thickness (typically 0.1β0.2 cm), and myometrial findings (thickness, number, size, and consistency of any lesions).
18:49 Sectioning Method: The uterus is sectioned transversely from superior to inferior; the cervix is sectioned longitudinally. Full-thickness sections (endometrium through myometrium to serosa) are submitted.
20:22 Fallopian Tube Protocol: Submit tubes using the Modified SEE-FIM protocol, which requires submitting the fimbriated end entirely (longitudinal section) and two cross-sections of the tube.
21:11 Full SEE-FIM Protocol: The full SEE-FIM (submitting the entire tube with specific longitudinal/perpendicular sections) is reserved for women at high risk of ovarian cancer (e.g., BRCA1/2 mutation) to detect early papillary serous carcinoma in the fimbriated end.
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