DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pelvic pain with history of endometriosis.
POSTOPERATIVE DIAGNOSIS: Pelvic pain with history of endometriosis with extensive omental adhesions to the uterus and mild endometriosis.
OPERATION PERFORMED:
1. Operative laparoscopy.
2. Lysis of adhesions.
3. Fulguration of endometriosis.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
IV FLUIDS: Approximately 1 liter.
URINE OUTPUT: Minimal.
OPERATIVE FINDINGS: The patient with several omental adhesions to the left fallopian tube remnant, left fundus of the uterus, and posterior fundus of the uterus in several places. Some dense and areas of powder-burn lesions noted in the left anterior broad ligament and anterior cul-de-sac. History of tubal ligation noted and small fundal posterior myoma noted, approximately 2 cm. Otherwise, normal ovaries bilaterally.
DESCRIPTION OF OPERATION: After informed consent and risks and benefits of the procedure were discussed with the patient, the patient was taken to the operating room where she was placed under general endotracheal anesthesia, and legs were placed in Allen stirrups. She was then prepped and draped in the usual sterile fashion. Sponge stick was placed in the vagina.
An infraumbilical incision was made with a scalpel, and 5 mm port was then advanced into the intra-abdominal cavity under direct visualization using a Visiport scope. The intra-abdominal cavity was then insufflated using CO2 to 50 mmHg, and the above findings were noted.
In the lower aspect of her prior midline abdominal surgery, a 5 mm incision was made and a 5 mm trocar was advanced under direct visualization. Then, using an Ace Harmonic scalpel, the adhesions were then removed from the left adnexa and posterior aspect of the uterus. Then, the areas of powder-burn lesions noted with probable endometriosis were then fulgurated.
After this was performed, adequate hemostasis was noted. No evidence of any residual endometriosis was noted. All adhesions had been lysed. The paratubal cyst was drained from the left adnexa and removed.
All instruments were removed under direct visualization, and the intra-abdominal cavity was desufflated. All ports and incisions were closed with 4-0 Vicryl in a subcuticular fashion. Steri-Strips were applied. Telfa and Tegaderm dressing applied. Sponge stick was removed from the vagina. All lap, needle, and instruments counts were correct x3. The patient was awakened and taken to the recovery room in stable condition.
