DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. History of left breast cancer, status post reconstruction.
2. Recurrent ductal carcinoma in situ in right breast.
3. Strong family history of breast cancer and ovarian cancer, developmentally impaired.
4. History of cardiac disease, pulmonary stenosis, and congestive heart failure.
POSTOPERATIVE DIAGNOSES:
1. History of left breast cancer, status post reconstruction.
2. Recurrent ductal carcinoma in situ in right breast.
3. Strong family history of breast cancer and ovarian cancer, developmentally impaired.
4. History of cardiac disease, pulmonary stenosis, and congestive heart failure.
OPERATION PERFORMED: Total abdominal hysterectomy and bilateral salpingo-oophorectomy with prior procedure of right mastectomy and reconstruction performed prior to the onset of this procedure.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
IV FLUIDS: 1350 mL.
URINE OUTPUT: 200 mL of clear urine, slightly blood tinged at the end of the case.
ESTIMATED BLOOD LOSS: 250 mL.
FINDINGS: Small uterus with multiple small 1 to 2 cm fibroids throughout the anterior and lateral surfaces down near the internal os. Ovaries and tubes normal. Normal-appearing appendix noted. Deep pelvis with narrow inlet.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was placed in the supine position after her right mastectomy and flap had been created by plastics. Once the patient was prepped and draped in a sterile fashion, a Pfannenstiel incision was made with a knife through her old scar for her prior reconstruction using a TRAM flap from her right rectus muscle. The incision was carried down to the level of the fascia. The fascia was nicked with the knife and extended to both sides with Mayo scissors. The fascia was then dissected off the rectus muscle on the left and the peritoneum subcutaneously on the right, carefully dissecting the superior pole of the fascia as well as the inferior pole of the fascia. The rectus muscle was then separated from the peritoneum on the right-hand side. Preperitoneal fat was then dissected and the peritoneum was grasped with a Kelly and opened bluntly. The peritoneum was then incised both inferiorly and superiorly as well as laterally to the left avoiding the bladder. The incision was stretched. A Balfour retractor was inserted into the incision and laps were placed because the bowel was protruding through the incision. The patient was not placed in Trendelenburg immediately secondary to plastics finishing their reconstruction at the same time. Bladder blade was inserted. Remaining bowel was packed into the upper abdomen using wet laps.
Two straight trocars were placed on either side of the uterus on the cornua incorporating the round ligaments. The round ligaments on either side were suture ligated with #1 Vicryl and transected with Mayo scissors. The broad ligament was then opened and carried down over the lower uterine segment to create a bladder flap. The broad ligament and peritoneum were then opened cephalad along the side of the ovarian vessels and dissected across. The ureter was deep in the pelvis and palpated well below the site needed to transect the infundibulopelvic ligament on both the right and the left. On the right-hand side, difficulty in maintaining and gathering all of the ovary into the initial curved Heaney was documented so the uterus was separated from the ovary on the right hand side. The ovary was taken on the left hand side. A hole was made in the broad ligament. The infundibulopelvic ligament was clamped with a curved Heaney, transected, and suture ligated with both free tie and suture ligation. The uterine arteries were then skeletonized and a curved Heaney was placed on the uterine artery on the left at the junction of the internal os, transected, and suture ligated. Similar procedure was performed on the right, transected, and suture ligated. Small amount of bleeding was noted from the right uterine artery. A straight Heaney was placed along the level of the cervix and a right angle was placed along the uterine artery stump with hemostasis acceptable. The right ovary was then better visualized. Clamp was placed further across the infundibulopelvic ligament incorporating all of the ovary into the specimen to be removed. This was transected with Mayo scissors and suture ligated x2. Good hemostasis was documented.
Again, the ureter was palpated below the level of the infundibulopelvic ligament where it was transected. The bladder was then pushed down off the lower uterine segment and the cervix with some adherence to the cervicovesical fascia with a small amount of bleeding noted on the posterior wall of the bladder at this point. The cervix was then removed by gradually sequentially ligating the cervical arteries on either side using straight Heaney cutting with a knife and suture ligating. The uterosacral ligaments were transected on either side and tied with #1 Vicryl and tagged with straight Kocher. The corners of the vagina were then grasped with curved Heaney, transected, and suture ligated as well. The center of the vagina was then closed using two figure-of-eight sutures of #1 Vicryl. A single suture was placed across the corner between the corner cuff and the left uterosacral ligament incorporating this as well because of a small area bleeding and a figure-of-eight suture was placed on the posterior wall of the bladder near the cervical fascia using 3-0 Vicryl secondary to bleeding vessel that was documented there. Good hemostasis was appreciated. The uterus was totally removed and passed off for pathology. Copious irrigation was performed. Small amount of bleeding was noted, cauterized. Gelfoam was placed behind the bladder and on the top of the vaginal cuff to help with hemostasis in that area due to small amount of oozing from the back of the bladder edge. No evidence of bladder injury was appreciated. No evidence of ureteral injury appreciated at this point. All lap counts and instrument counts were correct. All laps and instruments were removed from the abdomen. All sutures were tied.
Again, irrigation was performed with good hemostasis appreciated. The appendix was noted as all laps were removed and noted to be normal. Once all lap and instrument counts were correct, the fascia was closed using PDS loops #1 in a running fashion from the right to the left with a small section on the left corner repaired separately in order for adequate visualization. Good hemostasis was noted. The subcutaneous tissue was irrigated and the skin was closed using staples. A tight pressure bandage was applied. Vagina showed no active bleeding and slightly blood-tinged concentrated urine was documented. The patient received only 1350 mL of fluid during the procedure due to her risk of CHF and cardiac history. We will watch her urine output carefully. Recheck hemoglobin and follow the patient through ICU as per Surgery and Plastics as well.
