DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Chronic menometrorrhagia.
2. Uterine leiomyomata with submucous mass, probable submucous myoma.
3. Desires conservation of fertility.
4. Left Bartholin’s gland cyst.
POSTOPERATIVE DIAGNOSES:
1. Chronic menometrorrhagia.
2. Uterine leiomyomata with submucous mass, probable submucous myoma.
3. Desires conservation of fertility.
4. Left Bartholin’s gland cyst.
OPERATIONS PERFORMED:
1. Operative hysteroscopy with resection of submucous myomas and curettage.
2. Left Bartholin’s gland cystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General with LMA.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 40 mL.
DRAINS: Foley catheter to the bladder intraoperatively.
SPECIMENS TO PATHOLOGY: Submucous fibroids in shavings and left Bartholin’s gland cyst.
DESCRIPTION OF OPERATION: The patient was brought to the operating suite in stable condition. Intravenous prophylactic antibiotics had been administered. Informed consent had been obtained. The patient was aware of options. She strongly desired a conservative procedure with conservation of fertility. The risks had been outlined including embolus, stroke, pain, phlebitis, infection, hemorrhage, laceration of the cervix, certainly perforation of the uterine wall. The patient had received intravenous prophylactic antibiotics. She was placed under general anesthesia with LMA and then positioned in the lithotomy position. The perineum, vagina and lower abdomen were all prepped and draped in the standard fashion for surgery. The bladder was catheterized. Pelvic examination was performed. Attention was then turned to performing the operative hysteroscopy.
A weighted speculum was placed and the cervix was visualized. The anterior lip of the cervix was grasped with a tenaculum. The uterine cavity was sounded to 10 cm. The endocervical canal was then carefully and gently dilated to a #20 Pratt dilator. Initially, the 6.5 mm hysteroscope and sleeve were advanced into the uterine cavity and diagnostic hysteroscopy was performed, utilizing sterile saline as a distending medium with a suction apparatus attached. The submucous myomas were identified. Attention was then turned to proceeding with operative hysteroscopy. The VersaPoint bipolar electrocautery operative hysteroscopic system was utilized. The introducer was placed into the endocervical canal and then the operating hysteroscope was placed. We had attached a loop electrode to the operating hysteroscope to allow us to shave the fibroids out of the uterine cavity. Standard settings on the power generator were established and bipolar electrocautery was utilized. Normal saline was utilized as a distending medium.
The procedure was carried out until the larger submucous myoma had been totally resected and the other smaller one had been shaved down to the level of the surrounding uterine cavity. Curettage had been performed initially to sample the endometrial lining. We utilized the coagulation as needed, but there really was not any major bleeding from the resectoscope procedure, which had been utilizing bipolar electrocautery. Several times, the instruments were removed so that we could remove shavings, which had diminished visualization. At the end of the procedure, uterine cavity was flushed and inspected and all specimens had been noted to be removed. Hemostasis was noted in the operative areas as well. Representative photographs were obtained, pre and postprocedure. At this point, the instruments were removed. Inspection revealed minimal bleeding coming from the endocervical canal with a hemostatic tenaculum site. Bimanual pelvic examination was performed and was unremarkable. Calibration of inflow and outflow was obtained, and although we had lost some fluid into the drapes and onto the floor, we estimated at most the patient had 100 to 200 mL of saline passed through her tubes. Most likely, the amount was much less than this.
Attention was turned to performing a left Bartholin’s gland cystectomy. The operative area was infiltrated with Marcaine and epinephrine solution. With a #15 scalpel blade, incision was made over the cyst on the labia minora on the left. The cyst had been stabilized between the operator’s left thumb and forefinger. Dissection was then carried bluntly and sharply around the cyst. The cyst was totally excised. The base was clamped with hemostats prior to removal. These pedicles were suture ligated with 3-0 Vicryl sutures. Defect in the operative area was then closed with 3-0 Vicryl sutures in layers. Electrocautery was utilized to maintain hemostasis.
The area was copiously irrigated. The cyst contained a very viscid brownish fluid and there was scarring around it during its dissection. This always raises the possibility of endometriosis pending final pathology. The epithelium of the labia minora was closed with subcuticular sutures of 3-0 Vicryl. The area was, at this point, carefully inspected for several minutes and there was no significant bleeding or swelling within the vulva. At this point, the operative procedure was ended. The patient was awakened and returned to recovery in stable condition. The instrument, sponge and needle counts were reported as correct. Estimated blood loss was 40 mL. There were no complications.
