LAPAROSCOPIC TUBAL LIGATION OPERATIVE SAMPLE
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiparity, desires permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Multiparity, desires permanent sterilization.
PROCEDURE PERFORMED: Laparoscopic tubal ligation with Filshie clips.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 100 mL.
IV FLUIDS: 800 mL.
COMPLICATIONS: None.
DISPOSITION: The patient taken to the recovery room in stable condition.
PROCEDURE FINDINGS: Normal uterus, tubes and ovaries bilaterally with Filshie clips placed on midportion of fallopian tubes.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where her general anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion in the dorsal lithotomy position. The bladder was emptied prior to the procedure. The cervix was grasped with a single-tooth tenaculum. Hulka dilator was placed in the uterus for uterine manipulation.
A 5 mm infraumbilical incision was made with the scalpel. Veress needle was entered into the abdominal cavity. Saline was withdrawn and infused without difficulty, and low pressures were noted upon insufflation. A pneumoperitoneum was created. The 5 mm trocar was entered into the abdominal cavity. The patient was placed in Trendelenburg.
An 8 mm suprapubic incision was made 3 cm above the pubic bone, and the 8 mm trocar was entered into the abdominal cavity without difficulty. A blunt probe was used. The ovaries, tubes and uterus were visualized and felt to be normal. The tubes were followed out to the fimbria.
A Filshie clip was placed on the right midportion of the fallopian tube without difficulty, and a Filshie clip was placed on the left midportion of the fallopian tube without difficulty. Decision was made to end the procedure. The 8 mm trocar was removed under direct visualization. The pneumoperitoneum was released. The 5 mm trocar was removed.
The incisions were closed with 4-0 Monocryl. Mastisol and Steri-Strips were placed. The Hulka dilator was removed and Monsel was placed. The patient tolerated the procedure well. All sponge, lap and needle counts were correct x2.
