Place the patient in the lithotomy position. Empty the bladder by straight catheterization or by placing an indwelling Foley catheter. After general anesthesia has been administered, perform a pelvic examination to confirm the anatomy. A Trendelenburg position of about 15 degrees will facilitate pelvic exposure.

Total abdominal hysterectomy may be performed through a lower midline incision. However, the more cosmetically appealing Pfannenstiel incision is described here.

Make a transverse incision in the natural skin crease where the skin incision will be hidden by regrowth of pubic hair.
Make the incision about 10 to 15 cm long, depending on the habitus of the patient. Carry this incision through skin and subcutaneous tissue to the underlying rectus sheath. Incise the anterior rectus sheath in line with the skin incision. Develop flaps between the anterior rectus sheath and the underlying rectus muscle until the muscle is exposed well in the midline to about the level of the umbilicus. Retract the rectus muscles laterally to expose the midline fascia and underlying peritoneum. Incise the fascia and peritoneum vertically from the umbilicus to the pubis. Identify the bladder in the inferior aspect of the incision and gently retract it downward, out of harm’s way. Exposure through this incision is quite limited. Use it only when you do not anticipate a need for access to the upper abdomen.