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Laparoscopic Supracervical Hysterectomy Operative Transcription Example

OPERATION IN DETAIL: The patient was taken to the operating room and placed in the supine position on the operating room table. General anesthesia was administered. She was then placed in the dorsal lithotomy position where examination under anesthesia was performed. The patient was prepped and draped in the usual sterile fashion for laparoscopic surgery. A Foley catheter was inserted into the bladder. A weighted speculum was inserted into the vagina. The cervix was exposed with a Sims retractor and a Hulka clamp was inserted into the cervix and passed into the cervix for later manipulation of the uterus. The weighted speculum was withdrawn. The Hulka clamp was covered with a sterile drape. Clean operating gloves were donned and a stab incision was made just superior to the umbilicus. The Veress needle was inserted into the peritoneal cavity. Proper location was assessed by the hanging drop method. Pneumoperitoneum using 3 liters of CO2 was instilled with an opening pressure of 8 mmHg. The Veress needle was withdrawn. The incision was extended a bit to allow placement of the 5 mm laparoscopic sleeve and trocar. The trocar was withdrawn and the laparoscope was inserted allowing visualization of the pelvic cavity. The patient was placed in the Trendelenburg position to allow the intestines to fall back out of the pelvis. The ovaries on both sides were found to be normal in appearance. Additional trocars were placed to allow the hysterectomy to be begun. In the right lower quadrant, a 10 mm incision was made after transillumination to assure avoidance of blood vessels. A 10 mm sleeve and trocar were introduced under direct visualization through the scope. On the left side, after transilluminating, another incision was made and a 12 mm sleeve and trocar were introduced, again under direct visualization through the scope. A suprapubic incision was made and a 5 mm sleeve and trocar were introduced here. A suction-irrigation apparatus was introduced through the suprapubic port. A tenaculum was introduced through the right lower quadrant port. The harmonic ACE scalpel was placed through the left lower quadrant port. The tenaculum was used to grasp the fundus of the uterus to retract it laterally. The harmonic ACE was used to divide the left round ligament and the left utero-ovarian vessels and then used to take a bite through the broad ligament inferior to the round ligament. Some back-bleeding was encountered on the uterus. Attempts to control this with the harmonic ACE were not successful. Therefore, the LigaSure device was obtained and was used to cauterize the bleeding vessels on the uterus. The anterior leaf of the broad ligament was undermined and incised down to the level of the cervix. The instruments were then switched with the tenaculum being placed through the left lower quadrant and the harmonic ACE through the right lower quadrant port. The tenaculum was again used to grasp the fundus of the uterus for traction. The right round ligament was divided with the ACE and the fallopian tube and the utero-ovarian vessels again divided. The anterior leaf of the broad ligament was undermined and incised down to the level of the cervix. The bladder was then bluntly dissected off the cervix and lower uterine segment. The bladder was somewhat advanced because of prior cesarean section making this procedure somewhat difficult. Kitner devices were used to aid in this dissection. The Foley bulb was manipulated from outside to help in identifying the bladder itself. When the bladder had been dissected down sufficiently, the harmonic ACE was used to divide the remainder of the broad ligament and the uterine vessels on the right side. Again, there was some back-bleeding on the uterus, which was controlled with the LigaSure device. The instruments were again switched and the harmonic ACE was used to divide the remainder of the broad ligament and the uterine vessels on the left side. The uterus was excised from the cervix using the harmonic ACE, using a drill technique, drilling into the tissue with the active blade and then closing the jaws of the clamp and dividing the tissue. In this fashion, working from both the left and right sides, the uterus was excised from the cervix completely. All the pedicles were inspected for hemostasis. The pressure in the abdomen was lowered to 6 mmHg so that hemostasis could be assured. The pelvis was irrigated with the suction irrigator and hemostasis was found to be excellent. At this point, the sleeve in the left lower quadrant was removed. The morcellator was introduced. A tenaculum was introduced through the channel of the morcellator and used to grasp the uterus. The morcellator was kept high up out of the pelvis away from any possible contact with the intestines and the uterus was gradually morcellated by pulling it up into the shaft of the morcellator, where the rotating blade excised cores of myometrial tissue. When the entire uterus had been morcellated, the pelvis was again irrigated and any residual bits of myometrial tissue were removed. The morcellator was withdrawn. A sheet of Interceed gauze was placed through the right lower quadrant port and maneuvered into position over the cervical stump. It was moistened with saline to hold it in place. The left lower quadrant incision was then closed using a fascia closure device to place a 0-Vicryl suture through the fascia. The right lower quadrant port was closed in a similar fashion using the fascia closure device. The pneumoperitoneum was then allowed to escape. The remaining sleeves were withdrawn and the skin incisions were closed with interrupted subcuticular 4-0 Vicryl sutures. The incisions were wiped clean. Dry sterile dressings were applied. The patient was returned to the supine position. She was awakened from anesthesia without difficulty and transferred to the recovery room in good condition. The patient tolerated the procedure well.

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