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Anterior and Posterior Colporrhaphy Colpoperineoplasty Medical Report Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Symptomatic second-degree cystocele and rectocele.
2.  First-degree uterine prolapse.
3.  Desire for maintenance of uterus.

POSTOPERATIVE DIAGNOSES:
1.  Symptomatic second-degree cystocele and rectocele.
2.  First-degree uterine prolapse.
3.  Desire for maintenance of uterus.

OPERATIONS PERFORMED:
1.  Anterior colporrhaphy.
2.  Posterior colporrhaphy and colpoperineoplasty.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  200 mL.

DESCRIPTION OF OPERATION:  In the operating room, the patient was placed under general anesthetic in lithotomy position. Examination revealed a widened introitus with a second-degree cystourethrocele and prolapse of the cervix at the outer third. The uterus is mid position and mobile. There is a second-degree rectocele. Rectovaginal confirmatory. After appropriate prep, the patient was draped in the usual manner for major vaginal surgery.

A weighted speculum was placed posteriorly and the vagina was retracted anteriorly with a Sims retractor. At the 10 and 2 o'clock positions, at the cervicovaginal mucosal junction, vaginal mucosa was grasped with an Allis clamp and intervening tissue excised. The vagina was then opened in the midline to within a centimeter of distal urethral meatus. The bladder was then sharply dissected free from the overlying vaginal mucosa. Pubovesical-cervical fascia was identified and an initial suture at the urethrovesical angle was placed using 0 Vicryl in a transverse position through that fascial plane. The remainder of the cystocele was reduced with several interrupted 0 Vicryl. Redundant vaginal tissue was excised and the vagina closed in midline with simple and figure-of-eight 0 Vicryl.

The bladder was then retracted superiorly. The hymenal ring was grasped at the 4 and 8 o'clock positions. A triangular incision was made to within a centimeter of the anus. The intervening tissue was excised. The vagina was then opened in the midline to within a centimeter of the cervix. An anchoring suture was placed superiorly. The perineal body was freed and the rectum freed from the overlying vagina. Three perineal sutures were placed at this point using 0 Vicryl for eventual reapproximation. Perirectal fascia was then transversely sutured in the midline with several interrupted 0 Vicryl for support.

Redundant vaginal mucosa was excised and the vagina closed in the midline in simple fashion with 0 Vicryl, grasping the fascia. Perineal sutures were then tied and the remainder of the perineal body reapproximated with several interrupted 3-0 Vicryl. Rectal exam was negative. Bleeding point was noted anteriorly, which was suture transfixed with 3-0 Vicryl. The patient tolerated the procedure well. A Foley catheter drained approximately 30 mL of clear urine. Rectal examination was negative. No packing was placed. The patient was sent to recovery in good condition.

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