DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Ovarian cyst.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Ovarian cyst.
OPERATION PERFORMED: Diagnostic laparoscopy with left ovarian cyst aspiration and cystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia via oral endotracheal tube intubation.
FLUIDS: 900 mL of crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
URINE OUTPUT: 50 mL.
FINDINGS: Left ovary with ovarian cyst at the superior and inferior pole. The superior pole noted with a hemorrhagic cyst, otherwise normal findings.
COMPLICATIONS: None.
SURGICAL COUNT: Correct x3.
DRAINS: None.
SPECIMENS: Cyst and cul-de-sac fluid to Pathology.
DISPOSITION: To the recovery room in stable condition.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the dorsal supine position. She was then placed under general anesthesia and intubated. She was then placed in the dorsal lithotomy position and a slight degree of Trendelenburg. She was prepped and draped in the usual sterile fashion. The bladder was drained of 50 mL of clear urine. She was examined under anesthesia with notation of an anteverted uterus. With these findings noted, the speculum was placed into the vagina exposing the cervix. It was grasped on its posterior lip with a single-tooth tenaculum. The IUD was subsequently removed and sent to Pathology for culture, and Hulka tenaculum was then placed into the uterus for uterine manipulation. All other instruments were then removed.
Attention was then turned to the abdomen. An infraumbilical incision was then performed through which the Veress needle was advanced when the anterior abdominal wall was elevated. Once entry was confirmed with notation of an intra-abdominal pressure of 6, the abdomen was then insufflated with CO2 gas, approximately 1.5 L. The needle was removed and replaced with a 5 mm trocar, placed under direct visualization with Optiview system. Once entry was confirmed, the laparoscope was readvanced with initial notation of normal-appearing pelvis and fallopian tubes and ovaries. A second puncture site was then placed two fingerbreadths above the symphysis pubis in the midline through which a 5 mm trocar was advanced under direct visualization. With this, laparoscopic probe was used to aid in visualization of the pelvis. Notation was made at that time of the left ovary that was somewhat slightly enlarged with cysts at either pole. The superior system appeared to be somewhat bluish in tint. The right ovary, fallopian tubes, and uterus were within normal limits as were the serosal surfaces. The appendix was within normal limits. Liver’s edge and gallbladder appeared within normal limits.
With these findings noted, a second puncture site was then placed on the left mid abdomen lateral to the obliterated umbilical artery, through which another 5 mm trocar was advanced under direct visualization. Through this, the cyst was initially drained using the Nezhat pinpoint Bovie irrigator with an attempt to obtain the fluid through the suction trap. This met with very little success, primarily secondary to the size of the cyst inferiorly. The same was performed along the superior cyst, again with very minimal drainage. With this noted, a stellate incision was then placed in the superior pole of the uterus using the needle point Bovie with subsequent removal of a more dark serosanguineous-appearing material. This was suctioned and also sent to Pathology. The edges of the cyst wall were removed and finally the cyst wall was fulgurated with the electrocautery spatula. With these findings noted and hemostasis noted, the cul-de-sac fluid was subsequently suctioned, and this too was sent to Pathology for evaluation. This marked the end of the procedure.
Fluid, 250 mL, was left into the pelvis for adhesions prevention. The abdomen was then deflated. All the instruments were removed under direct visualization. The incisions were approximated using 2-0 Vicryl to reapproximate the fascia and 4-0 Prolene in a subcuticular fashion to approximate the skin. Steri-Strips and a Band-Aid were placed on the incisions. The Hulka tenaculum was subsequently removed and the cervix was reinspected with hemostasis noted. The patient was then returned to the dorsal supine position. Anesthesia was subsequently reversed. She was extubated and taken to the recovery room in stable condition.
