DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Fibroids.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Fibroids.
3. Probable adenoid masses.
4. Multiple pelvic wall, bowel, and omental adhesions.
5. Proximal tubal occlusion.
OPERATION PERFORMED:
1. Hysteroscopy.
2. Endometrial dilation and curettage.
3. Fallopian tube catheterization.
4. Laparoscopic laser ablation of adhesions.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
IV FLUIDS: 1300 mL lactated Ringer’s.
URINE OUTPUT: 50 mL.
FLUID DEFICIT: 2400 mL in and 2400 mL out.
SPECIMENS: Endometrial curettings.
OPERATIVE FINDINGS: Bilateral proximal fallopian tube occlusion with multiple adhesions of anterior abdominal wall to bowel, omentum, and uterus as well as to bilateral adnexa, anterior and posterior uterus, which was successfully lysed. However, there was no spillage of loose fluid from either fallopian tube, ether before or after lysis of adhesions. Liver, appendix, and gallbladder appeared grossly normal. Ovaries appeared intrinsically normal, despite dense adhesions.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room where she was placed under general anesthesia without difficulty. She was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.
A sterile speculum was inserted in the vagina. The cervix was visualized and grasped with a single-tooth tenaculum. The uterus was sounded to a depth of 9 cm, and the cervix was dilated to allow the passage of the RUMI uterine elevator. The RUMI was inserted and balloon inflated. Speculum was removed. Tenaculum was removed. All gloves were changed.
Attention was then turned to the abdomen. A small incision was made through the umbilicus and Veress needle placed to the umbilicus and proper intraperitoneal placement confirmed with opening pressures. A 10 mm step trocar was inserted. The laparoscope was then inserted through the trocar as well. Abdomen and surrounding bowel were examined and all found to be hemostatic with no traumas from port insertion. Upper and mid abdomen were surveyed as well as pelvis. The pelvis was noted to have dense adhesions from the anterior abdominal wall to the uterus as well as from the bowel and pelvic sidewall to the adnexa and posterior uterus.
Two additional ports were inserted suprapubically, approximately 3 cm up and 8 cm out from the midline of the symphysis. Two additional 5 mm trocars were inserted through these ports under direct visualization with the laparoscopic camera after transilluminating the abdomen ensuring clearance from any vessels. Blunt probe was used to elevate the uterus and moved bowel out of the way and adhesions were examined.
Laser was assembled and tested with gas flowing, and proper alignment of the laser arm and laser beam were ensured and tested outside the abdomen on a tongue depressor and later was then inserted, and multiple adhesions were taken down including the adhesions from the anterior pelvic wall to the anterior portion of the uterus followed by the right adnexa to omentum and sidewall, then followed by the posterior uterus and cul-de-sac and the left adnexa to the bowel omentum and side walls.
Prior to this, chromopertubation had been attempted and was unsuccessful. There was absolutely no spillage of blue dye from the fimbria and there was also none visible in proximal fallopian tube as well as no tubal distension upon insertion of liquid. After lysis of adhesions was performed, chromopertubation was once again attempted and was still unsuccessful with no spillage of dye from the fimbriated ends of the fallopian tube.
Given this, our attention was then again turned vaginally. The sterile speculum was reinserted and RUMI elevator was removed. Cervix was dilated to 29 Pratt dilator. The operative hysteroscope was inserted. Endometrium was noted to be extremely shaggy, and there was absolutely no visualization possible, so the scope was removed, and dilation and curettage was performed with copious amounts of shaggy endometrial tissue removed. The hysteroscope was then reinserted, and while the endometrium had been relieved much of its lining, it was still not possible to visualize either of the ostia despite multiple attempts.
Fallopian tube catheterization was attempted and was unsuccessful. The fallopian tube catheters were then angled in the direction of fallopian tubes and the chromopertubation attempted near either cornua, and both were unsuccessful. After the hysteroscope was removed, tenaculum was removed as well as the speculum. After that, cervix was examined and found to be hemostatic. Gloves were once again changed.
Our attention was once again turned to the abdomen. The abdomen was examined in all areas, and all areas of previous lysis of adhesions were found to be hemostatic. Interceed was placed over the area where the adhesions had been lysed. The gas was suctioned from the abdomen. The ports were removed. Umbilical incision was closed with 2-0 Vicryl. The two suprapubic incisions were closed with 4-0 Vicryl with excellent hemostasis obtained. The patient tolerated the procedure well. All counts were correct x2. The patient was transferred to PACU in stable condition.
