DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left tubal ectopic pregnancy.
POSTOPERATIVE DIAGNOSIS: Normal pelvis. No signs of hemoperitoneum or ectopic pregnancy.
OPERATION PERFORMED: Diagnostic laparoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 100 mL.
INDICATIONS FOR OPERATION: This (XX)-year-old gravida 4, para 3 female, last menstrual period MM/DD/YYYY, presented with left lower quadrant pain and a positive pregnancy test. Ultrasound done showed fluid collection in the endometrial cavity, no gestational sac seen. A quantitative HCG was 27,800 mIU/mL. With this large HCG level and absence of gestational sac, an ectopic pregnancy was suspected.
DESCRIPTION OF OPERATION: Upon induction of excellent general endotracheal anesthesia, the patient was prepped and draped in the dorsal lithotomy position. Bimanual examination revealed the uterus to be anteverted and slightly enlarged with no adnexal masses palpable. A weighted vaginal speculum was placed into the vaginal canal and a single-tooth tenaculum was used to grasp the anterior cervix. A Cohen cannula was introduced for laparoscopic manipulation. The patient’s bladder was decompressed with straight gravity drainage.
Attention was then focused on the abdomen, where a vertical skin incision was made through the patient’s umbilicus. Using a drop-in technique, the peritoneal cavity was entered without difficulty. Hasson cannula was then placed in the umbilical area. Then, 5 mm trocars were placed suprapubically and in the left lower quadrant.
Operative findings were that of no hemoperitoneum. The uterus was slightly enlarged and hyperemic. Bilateral fallopian tubes appeared normal with no evidence of hydrosalpinx or adhesions. There was no blood noted from the fallopian tubal ends. There was evidence of a corpus luteum on the right ovary. The left ovary appeared normal and mobile. The cul-de-sac had some fluid, which was clear in nature. The rest of the peritoneal contents were inspected with normal liver edge seen without adhesions. The appendix was normal. No omental bleeding or masses were noted.
With no evidence of any ectopic pregnancy, the procedure was then terminated. The left trocar site was removed with some bleeding noted. This was controlled with tamponade with the scope and externally. Reinspection showed no further bleeding. The remainder of the trocars was then removed. Closure was then accomplished with 2-0 Vicryl in the umbilical fascia and 4-0 Vicryl on the skin. Then, 9 mL of 0.5% Marcaine was infiltrated for analgesia postoperative. Estimated blood loss was 100 mL. The patient was then taken to the recovery room in satisfactory condition.
