DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Menorrhagia.
2. Uterine fibroid.
3. Left ovarian cyst.
OPERATION PERFORMED:
1. Operative laparoscopy with left ovarian cystectomy.
2. Diagnostic hysteroscopy.
3. Fractional dilatation and curettage.
4. Endometrial ablation.
SURGEON: John Doe, MD
SEDATION: General.
ESTIMATED BLOOD LOSS: 10-15 mL.
OPERATIVE FINDINGS: A triple puncture video laparoscopy was performed and photographs were taken. Identified was an enlarged, fixed uterus with a large posterior wall fibroid, which was difficult to evaluate secondary to immobility. Anterior cul-de-sac was free of adhesions. Posterior cul-de-sac was free of adhesions. No significant endometriosis was identified. The right tube and ovary were otherwise unremarkable. The left ovary demonstrated a 2 cm distal left ovarian cyst, and there were also some very small clear excrescences on the left ovary. The patient desired to have retention of her left ovary, and therefore, a left ovarian cystectomy was performed with the Harmonic scalpel without difficulty. No bleeding was identified. Left ovarian cystectomy was submitted for pathological examination, as the patient did have a slightly elevated CA125 of approximately 100. Upper abdomen, liver edge, and bowel appeared to be normal. Diagnostic hysteroscopy was also performed and demonstrated otherwise unremarkable endocervical and endometrial cavities. Fractional curettings were obtained, and a NovaSure endometrial ablation was performed without difficulty in 1 minute 10-15 seconds. Both tubal ostia were clear. No evidence of intrauterine lesions identified and the curettings will be sent for pathology. Overall impression is the patient probably requires hysterectomy in the future.
DESCRIPTION OF OPERATION: The patient was placed on the operating table in the dorsal lithotomy position and prepped and draped in the usual sterile fashion. Foley catheter was placed. Exam under anesthesia was performed, which demonstrated enlarged, fixed uterus. Weighted speculum was placed, and the anterior lip of cervix was grasped with single-prong tenaculum. The Rubin’s cannula was carefully replaced in the endocervical canal for uterine manipulation. Subsequently, a stab incision was made in the inferior umbilical area. The Veress needle was placed. Opening pressure was 5-6 mmHg, and the abdomen was insufflated under normal pressure with approximately 3 L of carbon dioxide. Subsequently, the Veress needle was removed and the incision lengthened 10 mm, and a 10 mm trocar was placed without difficulty.
Under direct visualization, a 5 mm port was placed and a 12 mm port was placed to the lateral edge of the inferior epigastric vessel after transillumination, and no bleeding or vascular changes were identified. Pelvic contents were described above. Essentially, a large, fixed uterine fibroid posteriorly. Right tube and ovary were otherwise unremarkable. Left ovary demonstrated a 2 cm distal left ovarian cyst. The 5 mm Harmonic scalpel was placed and that half of the ovary was shaved off and no bleeding was identified. Specimen will be sent for pathological examination and was pulled up through the 12 mm port in an EndoCatch. Some serosanguineous fluid was obtained for cytological evaluation. No bleeding was identified. Ports were inspected. Subsequently, the 12 mm port was closed with an 0-Vicryl suture in a sterile closure without difficulty, and hemostasis was secured. The abdomen was allowed to be deflated. The trocar sites were inspected and felt to be hemostatic. The instruments were all removed.
After the ports were closed with 4-0 catgut in skin-to-skin interrupted fashion, 8 mL of 0.5% Marcaine was also placed in the incision length for postoperative pain relief. Subsequently, the attention was then turned vaginally. The uterus was examined. The cervix was dilated 8 mm. Cavity length was approximately 11 cm with an endocervical canal of approximately 5 to 5.5. The effective cavity length was set at 6 for the NovaSure ablation. Hysteroscope was placed. Endocervical and endometrial cavities were clearly visualized; again, no significant abnormalities were seen. Subsequently, a small sharp Kevorkian curette was introduced into the endocervical canal and curetting was obtained.
Subsequently, a small sharp curette was introduced in the endometrial cavity and a moderate amount of tissue was obtained for curetting. At the end of the procedure, the NovaSure apparatus was placed without difficulty with a cavity length of 6 cm and a cavity width of 4.5 cm, and after a normal safety check, the NovaSure ablation was performed in 1 minute and 10-15 seconds without difficulties. Subsequently, the instruments were removed. Sponge and needle counts were correct. No active bleeding was identified, and the patient went to the recovery room in stable and satisfactory condition.
