DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left ureterovaginal fistula.
POSTOPERATIVE DIAGNOSIS: Left ureterovaginal fistula.
OPERATION PERFORMED: Laparoscopic left ureteral reimplant with robotic assistance.
OPERATIVE FINDINGS: There was evidence of a left ureterovaginal fistula and a reimplant was performed over a 7-French stent without difficulty.
SURGEON: John Doe, MD
ANESTHETIC: General.
BLOOD LOSS: About 150.
COMPLICATIONS: None.
SPECIMENS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the lithotomy position. The entire abdomen and genitalia were prepped and draped in the usual sterile manner. Surgical time-out was performed. A Veress needle was inserted through the umbilicus. Pneumoperitoneum was established without difficulty.
After adequate insufflation, a 12 mm port was placed at the umbilicus. Laparoscope was inserted with no evidence of injuries or abnormalities. Two 8 mm robotic ports were placed on the left side, one on the right and 12 mm assistant port in the right lower quadrant, all under laparoscopic control. The patient was then positioned in a steep Trendelenburg position. Da Vinci surgical robot was brought into the field and docked in the usual fashion.
The posterior peritoneum on the left lateral side was incised. The ureter was identified below the level of the iliac vessels, fair amount of fibrosis around the ureter. Using cautery and sharp dissection, the ureter was mobilized. An umbilical tape was passed around it to provide traction. We did get some bleeding in the pelvic sidewall, which was controlled with cautery and then some hemostatic agent.
The ureter was then mobilized down to its insertion with the bladder and then it was completely freed up and then transected, taking the ureter off of the bladder as well as off of the vagina itself. The edges of the bladder were identified and then closed with a running V-Loc 3-0 Monocryl suture. We then placed a sponge stick in the vagina and identified the small hole in the vaginal mucosa, and this was closed separately with another 3-0 Monocryl suture with good result, taking care to keep the suture lines well separated from the bladder and the vagina.
We then trimmed the ureter and spatulated to nice healthy tissue, and we then continued to free up the ureter proximally until it would come down to the bladder without any tension. The bladder was then again filled with saline. The overlying peritoneum and the muscle on the anterolateral aspect were incised until the mucosa could be identified. The mucosa was then incised and then we used a double-armed 3-0 Monocryl V-Loc suture starting at the heel of the ureter, around the back wall and the mucosa-to-mucosa anastomosis, and then put the end of the stent into the bladder, which had been previously placed and then ran the front wall with the other arm of the 3-0 Monocryl suture with excellent result. We then closed the muscle and peritoneum over the top of the anastomosis in antireflux mechanism with excellent result. Filled the bladder, ensured we had no leak.
We then came back down underneath to the vagina. We mobilized some omentum, brought all the way down to the pelvis without any tension, then tacked it over the top of the vaginal incision with another 2-0 Monocryl suture with good result. A Jackson-Pratt drain was placed in the left pelvis, brought out through one of the port sites. The remaining ports were then removed after all the gas had been evacuated. The skin was closed with Monocryl followed by Dermabond. Dressings were applied. Anesthetic was reversed. The patient was transferred to the recovery room in stable condition.
