DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Menorrhagia.
2. Uterine fibroids.
POSTOPERATIVE DIAGNOSES:
1. Menorrhagia.
2. Uterine fibroids.
OPERATION PERFORMED:
1. Laparoscopic supracervical hysterectomy.
2. Lysis of adhesion.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
FINDINGS AND PROCEDURE:
1. Enlarged multinodular fibroid uterus.
2. Filmy adhesion of the omentum to the left anterior abdominal wall.
ESTIMATED BLOOD LOSS: Approximately 100 mL.
IV FLUIDS: 2000 mL crystalloids.
SPECIMEN: Morcellated fragments of the uterus and cervix.
COMPLICATIONS: None apparent.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where a general endotracheal anesthesia was obtained without difficulty. The patient was placed in the dorsal supine position with legs in Allen stirrups. Examination under anesthesia revealed enlarged multinodular uterus. The patient was prepped and draped in the usual sterile fashion. Foley was placed under sterile condition. Anterior abdominal wall was elevated with a towel clamp. A Veress needle was placed directly through the umbilicus. SNAP, negative aspiration and a saline drop test ensured intra-abdominal placement. CO2 was used for insufflation. Once pneumoperitoneum was established, the Veress needle was removed and a 5 mm bladeless Xcel trocar was placed directly through the umbilicus. Intra-abdominal placement was verified with the laparoscope. No vascular or viscous injuries were noted. Examination of the upper quadrant revealed normal-appearing liver and stomach. Examination of the pelvis revealed a multinodular, enlarged fibroid uterus. The ovaries appeared to be normal. Under direct visualization, two 10 mm bladeless trocars were placed in the each lower quadrant. Prior to the trocar placement, spinal needle technique was used to minimize vascular injury. Using the 10 mm laparoscopic uterine manipulator, a Harmonic ACE, traction, countertraction, first the left uteroovarian ligament was clamped, coagulated and transected. Next, the left fallopian tube and round ligament were clamped, coagulated and transected. The anterior and posterior leaves of the broad ligaments were clamped, coagulated and transected. The uterine vessels were skeletonized. They were then clamped, coagulated and transected. Good hemostasis was noted.
Attention was then turned to the right side. The right uteroovarian ligament, round ligament and fallopian tubes were clamped, coagulated and transected with the Harmonic ACE. The anterior and posterior leaves of the broad ligament were clamped, coagulated and transected. The anterior leaf of the broad ligament was taken down to the midline and the bladder flap was created bluntly. The ascending uterine vessels were skeletonized. They were then clamped, coagulated and transected. Throughout the procedure, the ureters were identified. Following this, due to the bulky nature of the uterus, the right lower quadrant trocar was removed and a morcellator was introduced. In situ morcellation was performed to debulk the uterus. Once the uterus was sufficiently debulked, the morcellator was removed and a 10 mm bladeless Xcel trocar was reintroduced. Following this, a sponge stick was placed in the vagina. The bladder flap was further developed. Following this, the active blade of the Harmonic ACE was used to cut along the vaginal sponge to create an anterior and posterior colpotomy.
Following this, the uterine vessels were taken down and the cardinal ligament and uterosacral complex were taken down on both sides with the Harmonic ACE. The remainder of the uterus and cervix was detached from the vagina. The morcellator was once again reintroduced into the right lower quadrant and the remaining portion of the uterus and cervix was morcellated and removed. Following this, the pelvis was examined and all visible fragments were removed. The vaginal cuff angles were closed in a modified Richardson technique with 0 Vicryl plus.
The remainder of the vaginal cuff was closed with two additional interrupted sutures of 0 Vicryl. The pelvis was suction irrigated with normal saline. Low pressure check was performed and good hemostasis was noted at all surgical sites. A piece of Interceed was placed over the vaginal cuff. CO2 was released from the abdomen and pelvis. All trocars were removed under direct visualization. The fascia at the right lower trocar site was reapproximated with 1-0 Vicryl. The skin incision at the trocar sites were reapproximated with 4-0 Vicryl in interrupted fashion. The patient tolerated the procedure well. All sponge, lap, needle and instrument counts were correct x2. The patient was taken to the PACU in stable condition.
