This video provides an educational guide on the gross examination and processing of a total hysterectomy specimen with bilateral salpingoectomy. The presentation begins by defining different types of hysterectomy procedures and reviewing the detailed anatomy of the uterus (fundus, cervix, myometrium, endometrium) and adnexa. It instructs on proper specimen orientation using peritoneal reflections (anterior being higher/rounder for the bladder, posterior being lower/more pointed for the rectum) and anatomical landmarks. The presentation covers common benign pathologies leading to hysterectomy, such as adenomyosis, endometriosis, and leiomyomas (fibroids), including key gross features to distinguish them, and highlights red flags for potential leiomyosarcoma. Finally, the video outlines the specific grossing methodology, including how to open the specimen in the coronal plane, standard measurement requirements, detailed description parameters (like noting the external cervical os shape), and required sectioning protocols, emphasizing the Modified SEE-FIM protocol for the fallopian tubes.
Summarizing the Total Hysterectomy Grossing Procedure
0:57 Specimen Identification and Definitions: The specimen is identified as a Total Hysterectomy with Bilateral Salpingoectomy (removal of uterus, cervix, and both fallopian tubes). A Radical Hysterectomy (1:28) is distinguished as involving the vaginal cuff, parametrium, and regional lymph nodes, usually for malignancies like cervical carcinoma.
2:05 Uterine Anatomy Review: The uterus is located between the urinary bladder (anterior) and the rectum (posterior). The cervix consists of the endocervix, ectocervix, and the Transformation Zone (3:00) where the two meet. Key internal structures include the fundus, endometrial cavity, endometrium, and myometrium.
5:54 Adnexa Orientation: The correct anatomical order of adnexa structures from anterior to posterior is Round Ligament, Fallopian Tube, and Ovary.
6:41 Specimen Orientation via Peritoneum: When adnexa are absent, orientation relies on peritoneal reflections: the anterior surface (bladder side) is typically rounder and higher up, while the posterior surface (rectum side) is lower and more pointed.
7:30 Common Benign Indications: Hysterectomies are often performed for benign conditions such as Leiomyomas (fibroids), Endometriosis, Adenomyosis, and chronic pelvic pain.
8:28 Key Pathologies (Adenomyosis): Defined as endometrial tissue within the myometrium. Gross features include an enlarged, rounded uterus, thickened myometrium, and a turbulated, lacy cut surface with pinpoint cystic spaces.
9:08 Key Pathologies (Endometriosis): Ectopic endometrial tissue outside the uterus. Ovarian involvement is seen as a "chocolate cyst" (filled with old, tar-like menstrual blood).
11:11 Leiomyoma vs. Leiomyosarcoma: Benign leiomyomas (fibroids) are typically well-circumscribed, white, whorled, and rubbery. Features concerning for the malignant leiomyosarcoma include a single large lesion, extensive necrosis, or an infiltrating appearance.
12:21 Opening the Specimen: The specimen must be opened along the coronal plane (usually from the external cervical os through the fundus) to expose the endometrial cavity for proper formalin fixation.
14:47 Cervical Os Shape: A slit-shaped external cervical os indicates a woman who has given birth vaginally (multiparous), whereas a round os (15:06, observed on the presented specimen) indicates a nulliparous woman.
18:16 Sectioning Protocol (Standard): Required sections include full-thickness sections of the anterior and posterior cervix and endomyometrium. Any polyps must be submitted in toto.
20:22 Sectioning Protocol (Fallopian Tube): The Modified SEE-FIM Protocol (Sectioning and Extensively Examining the Fimbriated End) is used. The fimbriated end (the highest risk area for early serous carcinoma) is amputated at 1 cm and submitted in toto after longitudinal bisection, alongside cross-sections of the remaining tube. (The full SEE-FIM is reserved for high-risk patients, e.g., BRCA mutation carriers.)