DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Persistent large right adnexal cystic mass and chronic pelvic pain.
POSTOPERATIVE DIAGNOSIS: Persistent large right adnexal cystic mass and chronic pelvic pain.
OPERATION PERFORMED: Exploratory laparotomy with excision of right adnexal cystic mass.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 25 mL.
CONDITION: Stable.
COMPLICATIONS: None.
URINE: Clear postop.
OPERATIVE FINDINGS: Uterus within normal limits. Left fallopian tube with evidence of partial salpingectomy. Left ovary within normal limits. In the right adnexal region, no fallopian tube and no ovary were identified. A large cystic mass, elongated, measuring approximately 8 x 4 x 3 cm, adhered to the right part of uterus and part of the right pelvic sidewall. This cystic mass was surrounded by fine adhesions and dense adhesions to the right part of the uterus.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where general anesthesia was administered. She was then cleansed and draped in usual sterile fashion and placed in the supine position. Foley catheter was placed.
A Pfannenstiel skin incision was done 2 cm above the symphysis pubis. The skin incision was then carried down to the underlying layer of fascia. The fascia was incised in the midline. The incision was extended bilaterally with curved Mayo scissors. Superior and inferior aspects of the fascia were separated from the muscle and muscle separated in the midline. Peritoneum was identified and entered sharply with Metzenbaum scissors while tenting with hemostats. The pelvic area was visualized with the above findings. Bowel was packed away with moist laparotomy sponges, and curved Deavers were used for retraction. Peritoneal washings were obtained in the pelvic area and sent to pathology for evaluation.
After this, with sharp dissection, the right adnexal cystic mass was separated from its fine adhesions, and using a curved Heaney clamp below the cystic mass, it was excised from its dense adhesions to the right part of the uterus. This cystic mass was then sent intact without rupture to pathology for evaluation. A Vicryl 0 suture was then used to obtain excellent hemostasis in the right part of the uterus. This area was doubly suture ligated.
Next, hemostasis was then assured multiple times. All laps and instruments were then removed from the abdominal cavity. The peritoneum was closed with 2-0 Vicryl in a continuous fashion. Fascia was approximated with Vicryl 0 in a continuous fashion and skin closed with sterile staples. The patient tolerated the procedure well without any complications and was transferred in a stable condition to the recovery room. All counts were complete x2.
