PREOPERATIVE DIAGNOSES:
1. Menorrhagia.
2. Anemia.
3. Fibroids.
4. Ovarian cysts.
POSTOPERATIVE DIAGNOSES:
1. Menorrhagia.
2. Anemia.
3. Fibroids.
4. Endometriosis with pelvic adhesions.
OPERATIONS PERFORMED:
1. Laparoscopy with lysis of adhesions.
2. Holmium laser ablation of endometriosis.
3. Diagnostic hysteroscopy.
5. NovaSure endometrial ablation.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 25 mL.
IV FLUIDS: 1600 mL.
URINE OUTPUT: 25 mL.
COUNTS: Correct.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old G2, P1, with a long history of menorrhagia resulting in anemia with a hemoglobin of approximately 7-8. The patient also has known uterine fibroids and bilateral ovarian cysts, multiple adnexal cysts, and possible diagnosis of endometriosis or pelvic adhesions. The patient desired surgical therapy. She declines hysterectomy. Decision was made to proceed with diagnostic laparoscopy with possible lysis of adhesions or ablation of endometriosis as well as diagnostic hysteroscopy with D and C and NovaSure endometrial ablation, if feasible. Indications, risks, benefits, and alternatives to the above procedure were discussed with the patient. The risks include but are not limited to bleeding, infection, damage to abdominal or pelvic organs, or possible blood transfusion. Consent was obtained.
OPERATIVE FINDINGS: Laparoscopy revealed myomatous uterus with filmy adhesions of the right ovary to the posterior aspect of the uterus as well as dense adhesions of large bowel to the left posterior aspect of the uterus at the junction of the utero-ovarian ligament. Endometrial lesions were noted in the anterior and posterior cul-de-sac.
DESCRIPTION OF OPERATION: After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was in the supine lithotomy position. A 1 cm transverse infraumbilical skin incision was made through the patient’s prior laparoscopy scar. The Veress needle was passed, but saline drop test was nonreassuring; therefore, the Endopath 10 to 12 mm trocar was passed with laparoscope under direct vision. We were able to pass through the fascia, but the preperitoneal fat versus adhesions was visible, we could not ascertain, and we passed into the peritoneal cavity. The trocar was therefore removed and Veress needle was again placed, this time with good result on the hanging drop test. Carbon dioxide gas was infused with initial filling pressures of 3 to 7 up to final filling pressure of 14 mmHg. A bladed trocar was then passed without difficulty. The laparoscope was placed at appropriate location within the peritoneal cavity and was verified by direct visualization.
Exploration of the pelvis revealed findings as described. Two additional 5 mm ports were placed in the right and left lower quadrant under direct vision. Of note, 0.25% Marcaine with epinephrine was used to anesthetize each skin incision site prior to placement of the trocars. A total of 7 mL was used. The adhesion of the right ovary to the posterior aspect of the uterus was filmy and was excised with scissors. Next, the holmium laser was prepared and used to ablate the peritoneal endometriosis lesions in the anterior and posterior cul-de-sac. Attention was then turned to the left lower quadrant adhesions. Some of these adhesions were able to be bluntly and sharply lysed; however, we were not able to free the bowel, which was densely adherent to the left posterior aspect of the uterus at the junction of utero-ovarian ligament. The laparoscopic portion of the procedure was therefore terminated at this time. The trocars were left in position for re-visualization following the endometrial ablation.
The operator’s gloves were then changed and attention was turned to the hysteroscopic portion of the procedure. The uterus was anteverted. It sounded to 11 cm. Single-toothed tenaculum had been placed on the anterior lip of the cervix and the acorn cannula, which had been placed previously, was now removed in order to sound the uterus. The cervix was then dilated using Hanks dilators. The endocervical canal was measured at 4.5 cm. The diagnostic hysteroscope was passed and the endometrial cavity was visualized. There was small amount of endometrial tissue. There was polypoid area near the right cornua. There was no impingement of the cavity by uterine fibroids.
The NovaSure instrument was then placed. Cavity assessment was satisfactory and power was applied for 60 seconds at a power of 178. The endometrial length had been calculated at 6.6 cm and the length at 5.5 cm. The NovaSure instrument was removed. The hysteroscope was passed again and direct visualization revealed adequate fulguration of the entire endometrial cavity up to the cornua bilaterally. Prior to placement of NovaSure instrument, endometrial curettings were obtained and sent to pathology. The instruments were then removed from the cervix and uterus. There was no active bleeding.
The peritoneal cavity was once again visualized through the laparoscope. There was no evidence of bleeding. The 5 mm trocars were removed. The scope was removed and gas was allowed to escape from the endometrial cavity. The infraumbilical incision was closed in two layers. The fascia was closed with 0 Vicryl and the skin with 4-0 Monocryl. The 5 mm incisions were closed at the level of the skin with 4-0 Monocryl. Steri-Strips and a sterile dressing were applied. The patient tolerated the procedure well.
DISPOSITION: The patient returned to the postanesthesia care unit extubated, awake, and in stable condition.
