DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Symptomatic uterine fibroids.
2. Menorrhagia.
POSTOPERATIVE DIAGNOSES:
1. Symptomatic uterine fibroids.
2. Menorrhagia.
3. Abdominal pelvic adhesions.
OPERATION PERFORMED:
1. Total laparoscopic hysterectomy.
2. Extensive enterolysis.
SURGEON: John Doe, MD
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with history of symptomatic uterine fibroids and menorrhagia. The patient desires definitive extirpative therapy. The patient understands and accepts all the risks and benefits of the procedure as described to her preoperatively, and therefore, the procedure was scheduled. Consent was signed preoperatively for the laparoscopic hysterectomy and enterolysis.
DESCRIPTION OF OPERATION: Following induction of general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion and placed in the dorsal lithotomy position for vaginal and abdominal surgery. Double clamps were used, and exam under anesthesia confirmed the presence of a globular enlarged uterus approximately 10 to 12 weeks’ gestational size. A weighted speculum was placed in the posterior vaginal fornix and a single-tooth tenaculum placed upon the anterior lip of the cervix. The uterus was carefully sounded to approximately 10 cm. A ClearView uterine manipulator was placed within the endometrial cavity and single-tooth tenaculum was repositioned at 12 o’clock. All the other vaginal instruments were then removed.
Under sterile technique, a subumbilical incision was made using a sharp knife and a Veress needle was carefully introduced within the abdominopelvic cavity. This allowed adequate insufflation of CO2 gas up to 3 L. This incision was extended and a 10 mm laparoscopic trocar was placed subumbilically. This allowed adequate visualization by the means of video laparoscope. The second and third puncture sites were placed in the right and left lower quadrants using 12 mm ports. A fourth puncture site was placed suprapubically in the midline using a 5 mm port. Direct visualization revealed significant adhesions between the omentum and the abdominal wall. A fifth puncture site was placed in the upper left quadrant in order to allow enterolysis of the adhesions noted the omentum and the abdominal wall. The uterus was enlarged, approximately 10 weeks size, consistent with large fibroids. The Ace Harmonic scalpel was used to cut across the round ligaments bilaterally. This allowed separation of the anterior and posterior leaves of the broad ligament. The vesicouterine fold was then dissected out the lower uterine segment.
The dissection of the infundibulopelvic ligaments was performed using the Ace Harmonic scalpel. This dissection was carried down to the uterosacral ligaments bilaterally. The cardinal ligaments were similarly dissected using the Ace Harmonic scalpel and the uterine arteries and veins were coagulated and cut. The vagina was entered at the 11 o’clock position just distal to the cervix and circumferential incision was made using the Ace Harmonic scalpel just cutting and coagulating the tissue, removing the cervix from its attachment to the vagina. The uterus and cervix were subsequently pushed through the vagina for easy removal. A vaginal pack was placed in the vagina to ensure insufflation of the abdomen. The vaginal cuff was closed using 2-0 PDS in a continuous noninterlocking fashion, thus everting vaginal mucosa. Lapra-Ty was used at the end of the procedure.
Copious amounts of warm normal saline solution were used to irrigate the abdominopelvic cavity at this time. Adequate hemostasis was noted. A piece of SurgiWrap was placed on the area of dissection. The patient was given perioperative antibiotics consisting of Cefotan 2 g. Closure was used at the 12 mm ports, placing a suture of 0-Vicryl through to the fascia and peritoneal layers in a figure-of-eight fashion. All 5 trocars were removed after as much gas as possible was removed. All 5 skin incisions were closed using 4-0 chromic suture on a cutting needle and subcuticular stitch. Vaginal instruments were removed and the patient was taken to recovery room in stable and satisfactory condition. Final pathology pending.
