DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiparity, seeking permanent family planning.
POSTOPERATIVE DIAGNOSIS: Multiparity, seeking permanent family planning.
PROCEDURE PERFORMED: Bilateral partial salpingectomy.
SURGEON: John Doe, MD
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating suite and placed in the supine position. She had her abdomen appropriately prepped and draped and her bladder emptied. The skin in and about the umbilicus was injected with a mixture of Marcaine and Xylocaine with epinephrine and then a vertical incision was made through the umbilicus and then carried through the natural defect into the abdominal cavity. The fascia was then incised. The patient was placed in slight Trendelenburg. The right fallopian tube was visualized and grasped with a ring clamp and then Babcock clamps and followed to its fimbriated end. The midportion was then elevated and a window was made in the mesosalpinx. Two Kelly clamps were placed proximally and distally and the midsection removed. The tube was then tied proximally and distally using 2-0 plain gut. The tubal segments were then injected with the same local anesthetic. A similar procedure was done on the left. The peritoneum and fascia were closed in one layer using 0 Vicryl in a running nonlocked fashion. The skin edges were reapproximated using a subcuticular stitch of 4-0 undyed Vicryl. A sterile dressing was applied. The patient was taken to the recovery room in stable condition. The patient will be discharged later today.
Salpingectomy Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PROCEDURE PERFORMED: Laparoscopic left salpingectomy.
DESCRIPTION OF OPERATION: The patient was taken to the OR where general anesthesia was easily obtained. The patient was then prepped and draped in a sterile fashion and placed in dorsal lithotomy position. A weighted speculum was introduced into the patient’s vagina for cervical visualization. Once the cervix was visualized, a single-toothed tenaculum was applied to the upper lip of the cervix, and acorn manipulator was introduced into the patient’s cervix.
Attention was then drawn to the abdomen where a 10 mm horizontal incision was done below the umbilicus and carried down all the way to the fascia. Under direct visualization, a 10 mm trocar was introduced into the patient’s abdomen. Once intraperitoneal placement was confirmed, pneumoperitoneum was started. Opening pressure was 3 mmHg, so high flow was obtained and pneumoperitoneum was easily obtained.
Once pneumoperitoneum was easily obtained, a second port was put two fingerbreadths above the pubic symphysis, and under direct visualization, a 5 mm trocar was then introduced into the patient’s abdomen. The patient was placed in Trendelenburg position, revealed pelvic structures. Right ovarian cyst was noted, simple follicular-appearing cyst, 3 cm in diameter, on the left side, and ampullary ectopic was noted on the left side with some amount of hemoperitoneum and moderate amount of free fluid.
Attention was then drawn to the left fallopian tube, which initially was incised where the ectopic pregnancy was and products of conception were removed. Since no hemostasis was able to be obtained from the incision site from the salpingostomy and due to the amount of dense adhesions on that fallopian tube, decision was then made to proceed with left salpingectomy, so the IP ligament was identified and fallopian tube was then grasped by the fimbria and incised from the mesosalpinx. Good hemostasis was noted from the fallopian tube sites and the operative site. Specimen was then removed from the patient’s abdomen. Copious irrigation was done and all clots and debris were removed from the patient’s abdomen. Once good hemostasis was noted from the patient’s abdomen, pneumoperitoneum was deflated and all trocars were removed. Infraumbilical fascia was closed with 0 Vicryl and interrupted suture. The skin was closed with 4-0 Vicryl. The left infrapubic and suprapubic ports were closed with 0 Vicryl in running fashion, and third port, which was introduced two fingerbreadths above the pubis symphysis and 6 cm in the midaxillary line, under direct visualization, was also closed with 4-0 Monocryl. Sponge, lap and needle counts were correct x2. The patient was taken to the recovery room in stable condition.
