DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Menorrhagia.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Menorrhagia.
3. Endometriosis.
4. Right paratubal cyst.
OPERATION PERFORMED:
1. Laparoscopic laser fulguration of endometriosis.
2. Removal of right paratubal cyst.
3. Hysteroscopy.
4. NovaSure endometrial ablation.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
IV FLUIDS: 800 mL.
ESTIMATED BLOOD LOSS: Minimal.
OPERATIVE FINDINGS: Endometrial implants on the bilateral ovaries, bilateral pelvic sidewalls, and within the posterior cul-de-sac. The appendix, gallbladder, and liver were all grossly within normal limits.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room where general anesthesia was found to be adequate. She was then prepped and draped in the normal sterile fashion and placed in dorsal lithotomy position.
A bivalve speculum was first placed in the patient’s vagina, and the anterior lip of the cervix was grasped with an Allis clamp. The uterus was then gently sounded to 9 cm, and an 8 cm long Harris-Kronner uterine manipulator injector device was then entered atraumatically into the cervix in order to provide better uterine manipulation during the laparoscopic part of the case. The cervix was first gently sounded until the HUMI was easily advanced through the cervix. The Allis clamp and the bivalve speculum were then removed.
Attention was then turned to the patient’s abdomen where a 5 mm skin incision was then made vertically in the umbilical fold. The 5 mm Step Veress needle was then advanced without difficulty into the pelvis. The 5 mm trocar was advanced as well, and the pelvis was then insufflated with approximately 3 liters of CO2 gas. Intraperitoneal placement was confirmed under direct visualization using the laparoscope.
A second 5 mm skin incision was then made suprapubically and another 5 mm Step trocar was advanced without difficulty into the pelvis under direct visualization of the laparoscope. A blunt probe was placed through this port and then we identified and viewed the pelvic anatomy. We visualized the liver and gallbladder and located the appendix, which all appeared to be grossly within normal limits. We then viewed the pelvis, and the uterus appeared to be grossly within normal limits. The bilateral ovaries appeared to be normal. However, there were several endometrial implants on each ovary. There was enough evidence of endometrial implants along the bilateral pelvic sidewalls and also within the posterior cul-de-sac. The anterior cul-de-sac appeared to be free of any disease. We located the ureters on either side.
At that point, we placed another 5 mm Step trocar in the patient’s left lower quadrant under direct visualization using laparoscope as well. The periumbilical port was switched out for a 5 mm size. We then turned to the laser portion of the case. We first tested the laser and the CO2 and argon beam in order to ensure its integrity. The laser was advanced through the 10 mm periumbilical port. The laser was then used to fulgurate multiple areas of endometriosis within the pelvis.
Again, there were several areas on the bilateral ovaries and also on the bilateral pelvic sidewalls. Through the left lower quadrant site, we were able to advance a grasper in order to pull the peritoneum away from the sidewall at times when we desired to laser an area of endometriosis. This was done to ensure that we were far from the vessels and also the ureter. We also ablated several areas using the laser on the bilateral broad ligaments, and within the posterior cul-de-sac, there were a couple of areas as well. There was a small paratubal cyst noted on the right tube. This was attached at several places to the tube and also the right pelvic sidewall. The laser was used in order to remove the small paratubal cyst, and it was then removed from one of the smaller ports.
Periodically, the pelvis was irrigated. There was excellent hemostasis noted, and there was really no bleeding during the case. Once we felt that we had essentially fulgurated all the possible endometriosis that we found, the laser was removed. The remainder of the instruments was removed from the pelvis. The fascia and the 10 mm port were closed with 2-0 Vicryl, and the skin incisions were all closed with 4-0 Vicryl in a subcuticular fashion.
We then turned our attention to the pelvis and began the ablation part of the procedure. Since the uterus had previously been sounded to 9 cm and the cervix was approximately 4 cm, we set the length of the NovaSure device to 5 cm. We placed the NovaSure device atraumatically through the cervix after the cervix had been grasped again anteriorly with an Allis clamp. The ablation device was then expanded within the uterus and manipulated in several ways in order to achieve a maximum width of 4.4 cm. The NovaSure device was then set accordingly. We first activated the ablation device as a test to ensure the integrity of the cavity. Once this was established, the ablation began and the burn lasted approximately 90 seconds. The NovaSure device was then removed atraumatically through the cervix.
A 5 mm hysteroscope was advanced to visualize the endometrial cavity, which appeared to have excellent burn within all four quadrants. The hysteroscope was then removed. The Allis clamp was removed from the cervix as well, which also appeared to be hemostatic, and the speculum was removed as well. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in stable condition.
