DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left adnexal mass.
2. Pelvic pain.
POSTOPERATIVE DIAGNOSES:
1. Left adnexal mass.
2. Pelvic pain.
3. Intestinal adhesions.
4. Left hydrosalpinx with left cystadenoma.
OPERATION PERFORMED:
1. Laparoscopic lysis of tuboovarian adhesions.
2. Laparoscopic enterolysis.
3. Laparoscopic left salpingo-oophorectomy.
SURGEON: John Doe, MD
ANESTHESIA: General via endotracheal tube.
ESTIMATED BLOOD LOSS: Less than 50 mL.
COMPLICATIONS: None.
SPECIMENS: Fallopian tube and ovary.
OPERATIVE FINDINGS: There were extensive adhesions over the bowel and omentum to the anterior abdominal wall, in the right lower quadrant, where the patient’s appendectomy site was. In addition, there was a large retroperitoneal mass arising from the left ovary into the left broad ligament measuring approximately 10.5 cm in greatest dimension. There was a left hydrosalpinx overlying this, and there were bilateral paratubal and paraovarian adhesions. The right ovary appeared normal. The right fallopian tube appeared normal; however, there were adhesions around the right ovary. The uterus appeared normal. There were no hernias. There was no endometriosis. The liver appeared normal. There were no perihepatic adhesions. The bowel appeared normal, except for the above-stated adhesions.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating table and underwent induction of general anesthesia via endotracheal tube. The patient was then placed in the dorsal lithotomy position in low adjustable Allen stirrups.
Examination under anesthesia revealed the above-stated findings. She was then prepped and draped in the usual sterile fashion. A Foley catheter was used to drain the bladder. A speculum was used to visualize the cervix. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus was sounded to 7 cm. A HUMI uterine manipulator was then inserted, and the balloon was inflated with 3 mL of air. The tenaculum was removed, and the tenaculum puncture sites were noted to be hemostatic. The speculum was removed leaving the uterine manipulator in place during the procedure.
The operator then changed gloves, and attention paid to the abdomen where the umbilicus was anesthetized with 0.25% Marcaine solution. A 5 mm stab wound was made through the umbilicus. This was carried down to the fascia, the anterior abdominal wall was elevated, and an Xcel visual trocar was inserted under direct laparoscopic visualization. Pneumoperitoneum was established, and the above-stated findings were noted.
An additional puncture site was made in the left lower quadrant by first finding an avascular area. This site was anesthetized with 0.25% Marcaine solution. A 1 cm incision was made in the left lower quadrant, and an Ethicon Xcel 10/12 mm blunt-tipped trocar was inserted under direct laparoscopic visualization. An Ace Harmonic scalpel was then used to very carefully perform an enterolysis freeing up the bowel and omentum from the anterior abdominal wall. On examination, all sites of viewed lysis noted, the bowel was completely free of any serosal injury. All sites of adhesion lysis were hemostatic.
Attention was then paid to the pelvis where a large mass was noted within the left broad ligament, appears to be arising form the left ovary with a large left hydrosalpinx and dense paratubal adhesions consistent with a tuboovarian complex, possible cystoadenoma with left hydrosalpinx. There were also filmy adhesions around the right ovary, and these were easily taken down. The right fallopian tube and ovary, however, were otherwise within normal limits.
An additional puncture site was made in the suprapubic area after first finding avascular area. The site was anesthetized with 0.25% Marcaine solution. A 5 mm stab wound was made at the suprapubic site and a 5 mm trocar inserted under direct laparoscopic visualization. The operative instruments were then inserted through this and used to dissect out the pelvic sidewall by first transecting the left round ligament. The anterior and posterior leaves of the broad ligament were opened with the Harmonic scalpel. Meticulous and careful dissection was used to dissect the mass off of the pelvic sidewall.
The left infundibulopelvic ligament was then identified, and this was coagulated with the Harmonic Ace in three separate locations and then transected. Then, a 0 Vicryl Endoloop suture was placed across the infundibulopelvic ligament as well with excellent hemostasis being achieved. The 0 Vicryl Endoloop suture was then cut with the mass further dissected off the left pelvic sidewall.
A small fenestration was then made in the medial aspect of the broad ligament just beneath the uteroovarian ligament and the fallopian tube at the cornua insertion and then a 0 Vicryl suture was passed through this fenestration and used to ligate the left fallopian tube and uteroovarian ligament at this site utilizing extracorporeal knot tying technique.
The fallopian tube and uteroovarian ligament were then transected with the Harmonic Ace scalpel, and the remainder of the mass was dissected free from the pelvic sidewall utilizing the Harmonic scalpel with careful and meticulous attention. The course of the left ureter was identified during this dissection process and noted to be free of any injury and noted to be peristalsing freely. There was an area of oozing from the uterus and a varicosity of the uteroovarian ligament, and this was rendered hemostatic with bipolar Kleppinger forceps.
Excellent hemostasis was achieved. The pelvic mass, once freed up, was placed within an Endobag, and this was brought up through the skin, perforated, drained, and then the mass was withdrawn out the left lower quadrant site. A large amount of serous, straw-colored hemorrhagic fluid was aspirated. This was saved per the patient’s request for a toxicology evaluation, and this was sent to pathology along with the mass. Note was made that the mass was drained within the Endobag.
The pelvis was then copiously irrigated and suctioned dry. Excellent hemostasis was noted throughout. The intraperitoneal pressures were decreased. There was no active bleeding noted in any of the sites. Left ureter could be seen peristalsing. Right ureter was also identified, and this was also seen peristalsing and appeared normal. The pelvis was suctioned dry. The 10/12 mm trocar in the left lower quadrant was then removed, and a Carter-Thomason fascial closure device was inserted. A 0 Vicryl suture was then passed through the fascia into the peritoneal cavity, and then under laparoscopic guidance, the suture was retrieved and withdrawn through the peritoneum and fascia.
The Carter-Thomason fascial closure device was removed, and the suture was closed thus closing the peritoneum and both layers of fascias together, and this was airtight to pneumoperitoneum. The fascia was palpated and noted to be free of any defects. The trocar site in the suprapubic area was then removed under direct laparoscopic visualization and noted to be hemostatic. The laparoscope was withdrawn, and the pneumoperitoneum was then evacuated. The laparoscope was reinserted, and the laparoscope and laparoscopic sleeve were removed together. The skin edges of the umbilical incision, suprapubic, and left lower quadrant sites were closed with 4-0 Vicryl subcuticular sutures, and Steri-Strips were applied.
Attention was then paid vaginally where the uterine manipulator balloon was deflated and removed. Excellent hemostasis was noted. The Foley catheter balloon was removed. The patient was placed once again supine upon the operating table and underwent reversal of anesthesia. She was extubated and taken to the postanesthesia care unit in a good condition. The patient tolerated the procedure well without complications.
