PREOPERATIVE DIAGNOSIS:
Complex pelvic/uterine mass.
POSTOPERATIVE DIAGNOSIS:
Uterine leiomyosarcoma with direct invasion into right pelvic sidewall.
OPERATION PERFORMED:
1. Modified radical hysterectomy.
2. Right ureterolysis.
3. Right pelvic lymphadenectomy and biopsies.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jean Doe, MD
ESTIMATED BLOOD LOSS: 1500 mL.
REPLACEMENT: 2 units of packed red blood cells and 2 units of fresh frozen plasma.
DRAINS: Foley to GU bag and pelvic Blake drain.
OPERATION IN DETAIL: The patient was taken to the operating room, placed in supine position, and given satisfactory general endotracheal anesthesia. The legs were placed in the Allen stirrups. The abdomen, perineum, and vagina were prepped with Betadine and draped in the usual sterile fashion and a Foley catheter was inserted sterilely.
Vertical incision was made from the symphysis pubis to above the umbilicus, subcutaneous tissue divided sharply to the fascia, the fascia was split in the midline, and the rectus muscles were separated. The peritoneum was entered. Washings were taken from the pelvis and the right upper quadrant. A very large uterine mass was sharply and bluntly dissected away from the small bowel mesentery. A couple of large packs were placed and the upper abdomen did display small bowel. Hand-held retractors were used for exposure.
At this point, ascites was aspirated. The right retroperitoneum was opened lateral to the infundibulopelvic ligament. Adhesions were taken down between distal small bowel mesentery and the pelvic sidewall. Bowel was then repacked. The ureter and major vessels were identified. The infundibulopelvic ligament was double ligated with locking Hem-o-lok clips and a Kelly clamp was placed on the back side. This pedicle was cut. The round ligament on the right was suture ligated and divided, held on a hemostat, and the anterior cul-de-sac peritoneum was then taken down with Bovie cautery.
In a similar fashion, the left retroperitoneum was opened with Bovie cautery. The ureter and major vessels were identified. The IP ligament was grasped with a Babcock clamp. The IP ligament was then double ligated with locking Hem-o-lok clips. The left round ligament was suture ligated and divided, and the anterior cul-de-sac peritoneum was then opened again with Bovie cautery, exposing the lower uterine segment. The uterine vessels on the left side were then clamped with a curved Zeppelin clamp.
At this point, the Bookwalter retractor was placed. The bowel was then further packed up with moistened laps. Attachments from the uterine mass to the presacral peritoneum were then taken down with Metzenbaum scissors. The ureter was lysed off the medial peritoneal leaf and retracted medially. The pelvic sidewall peritoneum was then cut with Metzenbaum scissors. The uterine mass was then elevated out of the cul-de-sac. The patient had brisk bleeding from vessels in the parametrium at the uterosacral ligament. This was managed with pickups, hemoclips, and Kelly clamp. The supravesical artery was dissected out on the right side. The takeoff of the uterine artery was hemoclipped for further hemostasis. The curved Zeppelin clamp was then brought across the uterine vessels at the lower uterine segment.
At this point, the uterine fundus was then cut away with a scalpel and a single-tooth tenaculum was placed on the cervix. A specimen was sent to the pathologist for further inspection which confirmed high-grade uterine leiomyosarcoma. Multiple bleeding points in the retroperitoneum were then controlled with pickups and hemoclips. The cardinal ligaments on each side were clamped with straight Zeppelin clamps. A thin malleable blade was then used to retract the bladder. The cardinal ligaments were cut and Heaney ligated with 2-0 Vicryl. Right-angle Zeppelin clamps were brought across the uterosacral ligaments at vaginal corners and the cervix cut away. The vaginal corners were suture ligated with 2-0 Vicryl. The vagina was irrigated and closed with figure-of-eight 2-0 Vicryl suture. Hemostasis was achieved on the peritoneum with multiple hemoclips and Bovie cautery. The pelvis was thoroughly irrigated.
Lymph nodes were then removed from the common iliac artery and vein, and the external iliac artery and vein on the right side with pickups, Metzenbaum scissors, and hemoclips. Avitene floss was then placed in the retroperitoneal spaces on each side. A 15 Blake drain was placed in the posterior cul-de-sac, brought through the left lower quadrant, and sutured using #2-0 silk suture. Upper abdominal packs were then removed. Biopsies were obtained from the undersurface of the small bowel mesentery where the mesentery had been adherent to the uterine fundus. The upper abdomen was thoroughly irrigated with warm sterile water, removing bloody ascites from the diaphragm on each side. Seprafilm was then placed along the right and left pelvic sidewall, the anterior and posterior cul-de-sac.
All laps and retractors were removed. Sponge and needle counts were correct. Seprafilm was placed across the anterior abdominal wall. The peritoneum and fascia were closed with running #2 Prolene, beginning at each end of the incision, proceeding toward the midline, and tying together and inverting the knots. Subcutaneous tissues were irrigated, bleeding points were cauterized, the skin closed with clips, and the wound was covered with sterile dry bandage. The patient tolerated the procedure without difficulty, was extubated, and taken to recovery in stable condition.
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