DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Positive pregnancy test with possible ectopic pregnancy.
POSTOPERATIVE DIAGNOSIS:
Ectopic pregnancy, right fallopian tube.
OPERATION PERFORMED:
1. Dilation and curettage with laparoscopy.
2. Removal of ectopic pregnancy.
SURGEON: John Doe, MD
ANESTHESIA: General with intubation.
ANESTHESIOLOGIST: Jane Doe, MD
COMPLICATIONS: None.
SPECIMEN: Frozen section showing chorionic villi in contents of right fallopian tube.
DISPOSITION: Stable to recovery.
COUNTS: Sponge count correct at the end of the procedure.
PATHOLOGY: Permanent pathology and content of fallopian tube and endometrial curettings pending.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, anesthetized by general anesthetic. She was sterilely prepped and draped in usual sterile fashion. Pelvic exam revealed a slightly enlarged uterus in the midline. A single-tooth tenaculum was used to grasp the cervix. The uterus sounded to 9.5 cm. Cervix was dilated using Hanks dilators. Curettings were obtained and very scant amount of tissue was noted. We did place the tissue in saline and it did sink. We felt that it was not chorionic and most likely just decidualized endometrium.
A Foley catheter was placed in the bladder. Clear urine was noted. An acorn uterine manipulator was placed in the endometrial cavity. Gloves were changed and attention was directed to the abdomen. An infraumbilical incision was made and a 5 mm disposable trocar and sheaths were placed. Upon entering with the laparoscope, it was noted that there was a small amount of hemoperitoneum. The patient was placed in Trendelenburg position. A suprapubic trocar was placed, 12 mm size. A probe was placed. The uterus appeared normal. The left ovary has a small cyst. The left tube appeared normal. The right fallopian tube at the fimbriated end had a mass composing of clots and no chorionic tissue. This was removed. It was removed to the end of the tube. We did not know if there was tubal abortion or if this is where it implanted. We tried to inspect the tissue and could not determine if indeed it was chorionic or not. It was sent to pathology. Pathology performed a frozen section and did state that there were chorionic villi. In the interim, we did flush fluid through the tube, and there was good flow through the tube and we did not notice any other abnormalities. We explored the upper abdomen and it appeared normal. The bowel was peristalsing normally. There were no other gross abnormalities. We do not see any source for an ectopic pregnancy such as endometriosis or adhesions.
The 12 mm trocar was removed. The fascia was closed using a 0-Vicryl under direct visualization without any injury to intra-abdominal structures. Pneumoperitoneum was released. The incision was closed with 4-0 Vicryl. The instrumentation was removed. The patient tolerated the procedure well. All sponge counts were correct. The patient was transferred to the recovery room in stable condition.
