DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Stage IV endometriosis.
2. Pelvic adhesive disease.
POSTOPERATIVE DIAGNOSES:
1. Stage IV endometriosis.
2. Pelvic adhesive disease.
PROCEDURES PERFORMED: TAH BSO, total abdominal hysterectomy and bilateral salpingo-oophorectomy.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal tube intubation.
ESTIMATED BLOOD LOSS: Less than 100 mL.
COMPLICATIONS: Slight blood-tinged urine; however, no obvious bladder injury.
SPECIMENS:
1. Uterine cervix and fundus.
2. Bilateral adnexa.
DRAINS: Foley with slight blood-tinged urine.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and under adequate general anesthesia a Foley catheter was placed. The patient was prepped and draped in the supine position for an abdominal procedure. A low transverse skin incision was made with the knife approximately one fingerbreadth above the pubic symphysis and taken sharply through the subcutaneous tissue to the level of the fascia, which was nicked in the midline.
A fascial incision was extended laterally with the Mayo scissors. The underlying rectus muscles were bluntly and sharply dissected free. They were separated in the midline. The underlying parietal peritoneum was entered bluntly. The peritoneal incision was extended superiorly and inferiorly with the Metzenbaum scissors. A self-retaining O’Connor-O’Sullivan retractor was placed. A bladder blade was placed. The bowel and omentum were packed cephalad with moistened laparotomy sponges and held by an additional retractor. The fundus of the uterus was grasped with a Lahey clamp. There was a considerable amount of hemosiderin deposits in the anterior and posterior cul-de-sac consistent with endometriosis. Both ovaries were adherent to the posterior aspect of the uterus; however, they could be easily freed up.
The patient had received 3 months of Lupron prior to surgery, and there was evidence that the medication had improved the situation in her pelvis. The sigmoid colon was easily mobilized off the patient’s posterior aspect of the uterus. The right round ligament was doubly clamped with Kellys and transected. The retroperitoneal space was dissected; however, the tissues were very, very thick and it was difficult to see through them. Instead, the ureter was palpated and found to be deep in the pelvis and away from our dissection site. The round ligament was suture ligated with 0 Vicryl suture.
A defect was made in the broad ligament through which a Heaney clamp could be passed to encompass the infundibulopelvic ligament, which was then transected and suture ligated with 0 Vicryl suture followed by a 0 Vicryl free tie. The same procedure was performed on the contralateral side. The bladder flap was well developed and the bladder was pushed caudally. The uterine vasculature was skeletonized, clamped with Heaney clamps, transected with a knife and suture ligated with 0 Vicryl suture. Sequential bites were taken through the cardinal ligaments with straight Ballentine clamps, transecting the pedicles with a knife and suture ligating with 0 Vicryl suture.
At the level of the external cervical os, 2 Heaney clamps were placed in opposition and the cervix was then circumcised off the vagina. The vaginal cuff was closed using 0 Vicryl suture. The angle stitches were placed in a Heaney stitch fashion to provide support to the cuff by anchoring it to the uterosacral ligament. The remainder of the cuff was closed in interrupted figure-of-eight fashion.
At this point, we noticed that there was a very small amount of hematuria. The bladder was inspected and there was no obvious injury, and it was felt that most likely this was due to bruising secondary to dissection. The ureters were palpated and the left ureter was actually seen to be peristalsing. The right ureter, due to the thickness of the peritoneum, could only be felt; it could not be seen. The pelvis was irrigated with warm saline. There was no evidence of active bleeding from any of the dissection sites; however, there was a significant amount of raw area at the base of the pelvis.
A large piece of Gelfoam was placed to help cut down on the possibility of adhesions forming from the bowel to the pelvic floor. The self-retaining O’Connor-O’Sullivan retractor was removed. The laparotomy sponges were also removed. The parietal peritoneum was closed using 2-0 Vicryl suture in a running fashion. The fascia was closed using 0 Vicryl suture in a running fashion x2, running and meeting in the midline.
The subcutaneous tissue was reapproximated using 3-0 Vicryl suture in interrupted fashion. The skin was closed in a subcuticular fashion using 4-0 Monocryl. At the end of the procedure, sponge, instrument and needle counts were all correct. The patient tolerated the procedure well and was taken to the recovery room. The patient will be transferred to the floor when stable.
