A Stepwise Strategy to Minimally Invasive Salpingo-Oophorectomy in the Post-Hysterectomy Patient

Post-hysterectomy salpingo-oophorectomy can be surgically complex. Up to 9% of women who chose ovarian preservation at the time of hysterectomy require future adnexal surgery. Some of the common indications for post-hysterectomy salpingo-oophorectomy are persistent adnexal masses or masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery. This video presents a 5-step strategy to facilitate a post-hysterectomy bilateral salpingo-oophorectomy to include pelvic and abdominal exploration, restoring normal anatomy, identification of the ureter, isolation, coagulation and transection of the infundibulopelvic ligament, and, lastly, hemostasis with re-evaluation of ureter. This stepwise procedure was highlighted in a patient with a prior total abdominal hysterectomy and a complex adnexal mass. We utilize these techniques on the side without anatomic abnormality and then safely apply this same 5-step strategy to remove a more challenging adnexal mass on the opposite side. We describe a 5-step surgical strategy to ensure safe, efficient, and reproducible salpingo-oophorectomy in the post-hysterectomy patient using a minimally invasive approach. Although this surgery can be challenging to perform in post-hysterectomy patients given anatomical variance and adhesive disease, by following these 5 simple principles we aim to standardize and simplify this potentially difficult procedure.