DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Dysmenorrhea.
3. Menometrorrhagia.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Dysmenorrhea.
3. Menometrorrhagia.
4. Bilateral hydrosalpinges.
OPERATION PERFORMED: Laparoscopic subtotal hysterectomy with bilateral salpingectomies.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
IV FLUIDS: Crystalloids.
ESTIMATED BLOOD LOSS: 50 mL.
URINE OUTPUT: 500 mL with clear urine.
INDICATIONS FOR OPERATION: The patient strongly desired removal of the uterus due to symptoms delineated in her history and physical. There were no contraindications for the planned procedure. The risks, benefits, and alternative were discussed again with the patient and her family prior to commencing the surgery, and informed consent was obtained.
INTRAOPERATIVE FINDINGS: Uterus, 14 to 16 weeks’ size, quite boggy, and without adnexal masses or perineal, vaginal or perianal abnormalities. No cervical induration. The cervix was mobile. Intraoperative findings included an unremarkable-appearing liver edge, anterior abdominal wall, bilateral round ligament insertions, bilateral ovaries, bilateral uterosacral ligaments, bilateral ureters, retrocervical area, cul-de-sac, pelvic sidewalls, vesicouterine fold, and enlarged uterine fundus consistent with a 14 to 16 weeks’ size uterus. The right and left fallopian tubes were enlarged with evidence of bilateral hydrosalpinges with no evidence of malignancy. The ovaries were grossly normal. There was excellent hemostasis. The uterus was seen prior to, during, and after the procedure. There was normal peristalsis without evidence of hydroureter or other abnormalities. There was no evidence of trauma to the intestines, ureter or bladder.
DESCRIPTION OF OPERATION: After appropriate informed consent was obtained, the patient was taken to the operating suite, given general endotracheal anesthesia, and prepped and draped in the usual sterile fashion in the dorsal lithotomy position with a Foley catheter in place. A wet laparotomy pack and a single-tooth tenaculum were used to grasp the cervix and to retain pneumoperitoneum. A 5 mm infraumbilical incision was made and then later 5 mm left to right lower quadrant incisions were made. An optical trocar was placed under direct visualization into the peritoneal cavity angled toward the pelvis without trauma to underlying organs. Carbon dioxide was insufflated in the left and right lower quadrant. Trocars were placed under direct visualization.
The round ligaments, utero-ovarian ligaments, and broad ligament tissue immediately adjacent to the uterus were taken with the Harmonic scalpel with excellent hemostasis. The ureters were visualized during the entire procedure. After skeletonization was performed, the vesicouterine fold was developed anteriorly, and some adhesions were noted to the cervix. These were released with careful dissection. A clear plane was identified, and the bladder was brought down onto the cervix.
The patient’s cervix was fairly large. The uterine vessels were skeletonized, were identified, and were taken with the Harmonic scalpel using a triple-cautery technique. The tissue was then removed along the cardinal ligaments immediately adjacent to the cervix in order to perform a supracervical hysterectomy. A supracervical hysterectomy was performed by circumscribing the cervix using the Harmonic scalpel. Wall of the bowel and sidewalls were visualized.
The specimen was removed as was the right fallopian tube, but the left fallopian tube was taken so that it was a part of the specimen. The ovaries were grossly normal. There was excellent hemostasis. The ureters were visualized. Therefore, morcellation was undertaken by using the Gynecare morcellator immediately adjacent to the intra-abdominal wall and well away from the bowel. The blade was retracted when the specimen was being removed from the body.
All specimens, including the right fallopian tube, were taken uneventfully and sent for permanent pathologic evaluation. The pressure was dropped. Hemostasis was assured. Copious irrigation was undertaken and two separate 0-Vicryl sutures were used to close the anterior and posterior cervical tissue across the remaining endocervical tissue. The endocervical tissue just prior to this was cauterized with the bipolar cautery. A piece of SurgiWrap was placed in the pelvis and covered the cervix completely. Pressure was dropped. Hemostasis was assured and then the Carter-Thomason device was used along with a 0-Vicryl suture to close the right lower quadrant trocar site. There was an air-tight seal; therefore, the instruments were removed under direct visualization.
The carbon dioxide was released, and the incisions were sewn with running subcuticular 4-0 Vicryl sutures. Steri-Strips were applied. The catheter was removed draining clear urine, without any blood, and the patient was extubated and taken from the operating suite having tolerated the procedure without complications and with sponge and instrument counts correct.
