LAPAROSCOPIC SALPINGECTOMY PROCEDURE SAMPLE REPORT
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.
POSTOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.
OPERATION PERFORMED: Laparoscopic left salpingectomy and cervical exam under anesthesia.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 600 mL with 550 mL of hemoperitoneum.
SPECIMENS: Left tube.
COMPLICATIONS: None apparent.
CONDITION: Stable to recovery room.
OPERATIVE FINDINGS:
1. Actively bleeding left ectopic pregnancy with 550 mL of hemoperitoneum in the abdomen
2. Surgical absence of the right tube.
3. Normal-appearing ovaries bilaterally.
4. Uterus adhesed to the bladder in the anterior abdominal wall.
5. Omental adhesions to the anterior abdominal wall.
6. Normal-appearing appendix and gallbladder.
7. Multiple cervical divots indicative of prior cerclage placement but no visible cerclage due to cervical mucosa.
DESCRIPTION OF OPERATION: After informed consent, the patient was brought to the operating room and placed supine on the operating table for laparoscopic left salpingectomy and cervical exam under anesthesia. General endotracheal anesthesia was then administered by the anesthesiologist. The patient was then placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion for an abdominal and vaginal procedure. A Foley catheter was placed into the bladder.
A Graves speculum was placed into the vagina and the cervix was carefully examined and manipulated around. There could be seen several divots in the cervix, indicative of where the cervix had been pierced during cerclage placement. However, even though the patient reported a pulling or pinching sensation, especially during intercourse, no visible portion of the cerclage could be seen protruding through the cervical mucosa. A small portion of what was possibly eroded Mersilene tape was grasped with ring forceps and removed, but the entire cerclage by no means was able to be retrieved.
A HUMI uterine manipulator was then placed into the uterus and this passed through easily and attention was returned to the abdomen. The umbilicus was infiltrated with 0.25% Marcaine and a stab incision was made through it. A 5 mm trocar containing a 5 mm 0-degree scope was placed into the abdomen under direct visualization. Pneumoperitoneum was then created with CO2 gas. Two other ports were then placed under direct visualization, a 10 mm in the left lower quadrant and a 5 mm in the right lower quadrant.
Systematic examination of the pelvis revealed the above findings. The omentum was adhesed to the anterior abdominal wall in the midline. This was taken down with the Harmonic scalpel. The right ovary appeared normal in configuration; although, it was somewhat adherent to the right pelvic sidewall. The left ovary and tube were encased in clot. The 10 mm suction was used to evacuate all clots; this amounted to 550 mL. The left tube contained an unruptured ectopic; although, the ectopic was actively bleeding bright red blood from the tubal end.
The tube was stabilized using a grasper and a Harmonic scalpel was used to dissect the tube away from the mesosalpinx and the ovary and also used to come across the tubal insertion into the uterus. The operative site was examined and found to be hemostatic.
A 10 mm EndoCatch was then placed into the abdomen and the left tube was placed in the EndoCatch and it was removed with a 10 mm port. The pelvis was then copiously irrigated and suctioned. The patient was taken out of Trendelenburg, and all the blood from the upper abdomen was allowed to run down into the pelvis and this was suctioned away as well. The pressure was dropped to 6 and all operative sites were examined and found to be hemostatic. The procedure was then terminated.
A Carter-Thomason CloseSure device was used to close the 10 mm fascial port with 0 Vicryl. All instruments were then removed from the patient’s abdomen and the gas was suctioned out of her abdomen. Her skin incisions were closed with 4-0 Vicryl in a buried fashion and Dermabond was applied to the incisions.
All sponge and instrument counts were correct x2 at the end of the procedure. The Foley catheter and HUMI uterine manipulator were also removed, and the patient was returned to the supine position and awoken from anesthesia. The patient did tolerate the procedure well. She was transferred to the recovery room with vital signs stable.
