DATE OF PROCEDURE: MM/DD/YYYY
PRE-PROCEDURE DIAGNOSIS: A (XX)-year-old gravida 3, para 1-1-0-1 with history of previous cesarean section, declined vaginal birth after cesarean section, and undesired fertility.
POST-PROCEDURE DIAGNOSIS: A (XX)-year-old gravida 3, para 1-1-0-1 with history of previous cesarean section, declined vaginal birth after cesarean section, and undesired fertility.
PROCEDURE PERFORMED: Cesarean section and Parkland tubal ligation.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Approximately 350 mL.
FINDINGS: Female infant born weighing 8 pounds with Apgars of 9 and 9.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and given general endotracheal anesthesia, and anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion.
An elliptical incision was made over the previous keloid scar and removed. A Bovie was used to transect the subcutaneous tissue to the fascia, which was dissected laterally with curved Mayo scissors. The Kocher clamps were used to grasp the superior and inferior portions of the fascial incisions and subsequently dissected off with a Bovie and bluntly. The rectus abdominal muscles were divided in the midline.
The Alexis O cesarean retractor was placed in the incision. The vesicouterine peritoneum was identified, transected, creating the bladder flap. A scalpel was used to make a transverse incision in the low uterine segment and extended laterally with the bandage scissors. The head was delivered atraumatically. Mouth and nares were suctioned at the incision. The posterior shoulder was delivered followed by the anterior shoulder and entire body. The cord was clamped twice and cut in between. The infant was handed off to the awaiting pediatrician. The placental delivery was spontaneously intact 3-vessel cord. Twenty units of Pitocin in 1 liter of LR was given after placental delivery. The hysterotomy was repaired with 0 chromic in a running locked fashion. Hemostasis was assured.
Attention was turned to the right fallopian tube, which was carried to the fimbriated end. A window was created in mesosalpinx and 0 plain gut was used to create the Parkland tubal ligation. In similar fashion, the left fallopian tube was identified, carried to the fimbriated end. A window was created in the mesosalpinx. The 3-0 plain gut was used to create a Parkland tubal ligation. Hemostasis was assured.
The pelvis was copiously irrigated with warm normal saline. Interceed was placed on the hysterotomy repair. The rectus abdominal muscles were reapproximated in midline with 2-0 chromic in a U-stitch. The fascia was reapproximated with 0 Vicryl in a running fashion. The skin was closed with staples. The patient tolerated the procedure and was taken to the recovery room in stable condition.
