PREOPERATIVE DIAGNOSES:
1. Uterine prolapse.
2. Cystocele.
3. Rectocele.
POSTOPERATIVE DIAGNOSES:
1. Uterine prolapse.
2. Cystocele.
3. Rectocele.
OPERATIONS PERFORMED:
1. Vaginal hysterectomy.
2. Cystocele and rectocele repair.
SURGEON: Jane Doe, MD
ANESTHESIA: General.
TECHNIQUE: As soon as adequate general anesthesia was administered, the patient was put in dorsal lithotomy position and the perineal and lower abdominal area were prepped and draped. The labial folds were stitched out of the way and a heavyweight posterior vaginal speculum was inserted. Lahey clamps were placed in the anterior and posterior lips of the cervix and the cervix was drawn anteriorly. Diluted solution of Marcaine with epinephrine was injected into the upper part of the cervix along the mucocutaneous junction for hemostasis and also for hydrodissection. Circumferential incision was then made above the cervix and the anterior and posterior vaginal mucosa. The cul-de-sac was then entered, and the uterosacral ligaments on either side were clamped, divided and ligated.
The anterior vaginal mucosa was then dissected fully, anteriorly. The space between the vagina and bladder was entered. A small retractor was placed underneath the bladder, and the lower part of the cardinal ligaments on either side were clamped, divided and ligated. Then, the upper parts of the cardinal ligaments were clamped, divided and ligated. The uterine vessels on either side were clamped, divided and ligated. The proximal ends of the mesosalpinx and the mesovarian on either side were clamped, divided and doubly ligated. The uterus was then removed, and the peritoneum was closed by running pursestring suture of chromic #2-0 starting from the anterior parietal peritoneum, going to the sides, running it posteriorly, going to the sides again, and tying it anteriorly. This closed the pelvic peritoneum.
The cystocele was then repaired by pulling down on the anterior vaginal mucosa. A superficial vertical incision was made along the anterior vaginal mucosa. The bladder was then sharply separated from the vaginal mucosa until the endopelvic fascia was reached and the base of the bladder was reached. At this point, Dr. John Doe came to do sling bladder suspension.
After he tied all the sutures, I then imbricated the posterior cystocele bulge with interrupted sutures of #2-0 chromic material and excess vaginal mucosa was removed, and the anterior vaginal mucosa was approximated in the midline with interrupted sutures of #1 chromic suture material.
The rectocele was then repaired by making an incision across the introitus. Then, tunneling and cutting into the posterior vaginal mucosa was done until the apex of the rectocele bulge was reached. At this point, the rectum was separated from the posterior vaginal mucosa, and the rectal bulge imbricated in the midline with interrupted sutures of #2-0 chromic material. Levator ani muscles on either side were approximated in the midline with interrupted Vicryl #1. Excess posterior vaginal mucosa was excised, and the vaginal episiotomy was repaired by approximating the posterior vaginal mucosa with interrupted sutures of Vicryl #0 suture material. Packing was left in the vaginal canal, and an indwelling Foley catheter was left in place. Estimated blood loss was about 300 mL. The patient tolerated the procedure well. A suprapubic tube and an indwelling Foley catheter were left in place.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Cervical dysplasia, persistent, status post cold knife cone.
POSTOPERATIVE DIAGNOSIS: Cervical dysplasia, persistent, status post cold knife cone.
OPERATION PERFORMED: Total vaginal hysterectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
SPECIMEN: Uterus and cervix.
ESTIMATED BLOOD LOSS: 300 mL.
FINDINGS: Examination under anesthesia was within normal limits. Cervix was poorly visualized secondary to previous cold knife cone.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where general anesthesia was administered. She was prepped and draped and placed in dorsal lithotomy position for vaginal hysterectomy. The bladder was partially emptied. The cervix was grasped with tenaculum both anteriorly and posteriorly, and delineation of the cervix was made digitally given poor visualization. At this point in time, 5 mL of Pitressin 20:20 was injected, and the scalpel was used to make a circumferential incision. Afterwards, the anterior portion of the cervical fascia was pushed cephalad, and the anterior perineum was entered without difficulty. Posteriorly, Mayo scissors were used to enter the posterior perineum and a suture was used to tag this. At this point in time, Heaney clamps were used to grasp the uterosacral ligaments. These were cut, followed by suture ligature. Another set of clamps were used to grasp the uterine vessels and two more clamps were used until the uteroovarian ligaments were able to be grasped with double Heaney clamps, cut, followed by free tie and suture ligature. At this point in time, evaluation of the vesical pedicles confirmed hemostasis. There was bleeding noted along the right lateral wall, which was made hemostatic with a figure-of-eight. The perineum was then identified and tied in a pursestring closure. Identification of the uterosacral ligaments was made and extra reinforcing sutures were placed and were approximated together. At this point in time, no bleeding was noted along the vaginal cuff end. The vaginal cuff was approximated with interrupted sutures transversely. There was no bleeding noted at the end of the case. Foley catheter was inserted with clear urine, and the vagina was packed with Estrace vaginal cream. The patient tolerated the procedure well without complications. She was transferred to recovery in stable condition. All counts were correct. Repeat CBC tonight and in the a.m. will be performed.
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