DESCRIPTION OF OPERATION: The patient was taken to the operating room, where general anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion in the dorsal lithotomy position, in stirrups. A speculum was placed in the vagina and the anterior lip of the cervix was grasped with an Allis clamp. The acorn retractor was introduced into the uterus and attached to the single-toothed tenaculum. The speculum was removed. Gloves were changed. Attention was then turned to the patient's abdomen, where a Pfannenstiel incision was made on the skin using the scalpel and carried down to the underlying fascia using the Bovie. The fascia was incised and the incision extended laterally using the Mayo scissors and the Bovie. The fascia was grasped with two Kocher clamps and tented off the rectus muscles and dissected off with a combination of blunt and sharp dissection using the Bovie and Mayo scissors, both superiorly and inferiorly. Rectus muscles were separated bluntly. Peritoneal cavity was entered bluntly and the incision extended using Metzenbaum scissors. The uterus was palpated and noted to be large, approximately 18 weeks' size and irregular, with large fibroids. The Kirschner retractor was put into place, first at the sidewall retractors, then the bladder retractor, and then the upper abdominal retractor. The uterus was then able to be exteriorized from the abdomen initially, and, therefore, attention was turned to the large anterior uterine fibroid. Vasopressin was injected into the overlying serosa on the uterus to help it obtain hemostasis on the anterior fibroid along the line of the planned incision. The needle Bovie cautery was then used to incise the serosa and expose the fibroid. The fibroid was grasped with a towel clamp and shelled out using a combination of blunt dissection and Bovie cautery. The fibroid was removed. The base of the fibroid was then closed with a series of figure-of-eight sutures, then running suture, and then a third layer of running suture using 2-0 Vicryl in the fist layer, 2-0 chromic in the second layer, and 3-0 Vicryl in the third layer. Attention was then turned to the posterior aspect of the uterus, where the posterior fibroid was injected with vasopressin and then incised using the Bovie cautery, grasped with towel clamp, and shelled out using blunt dissection and Bovie cautery. The base of the incision was closed with several figure-of-eight sutures using 2-0 Vicryl, then a running 2-0 Vicryl suture, and then a running 3-0 Vicryl suture. Several small fibroids had been removed from the inside portion of this incision on the posterior portion of the uterus. The uterus was easily exteriorized after removal of the anterior and posterior fibroids. Several other smaller fibroids were removed from the surface of the uterus with the surface being closed with 3-0 Vicryl. Attention was then turned to the fundus where vasopressin was injected along the serosa of the fundus, over the fibroids, and then an incision was made using the Bovie cautery along the two fibroids on the fundus of the uterus. They were shelled out using blunt dissection and Bovie cautery as well. All small fibroids within the incision were removed. The incision was closed first with several figure-of-eight sutures using 2-0 Vicryl, then a running 2-0 Vicryl, and then a 3-0 Vicryl. The uterus was inspected for any other fibroids. None were noted. Fallopian tubes were then visualized and measured, given the patient's possible desire for tubal reanastomosis. The uterus was returned to the abdominal cavity, which was copiously irrigated, and the uterine incisions were inspected once again; no bleeding was noted. The Seprafilm was then placed across the posterior incision, the anterior incision, and the fundal incision in the uterus, and then placed over the bowel to prevent adhesions of the bowel to the uterus and the bowel to the anterior abdominal wall. The retractor was removed. All other instruments were removed from the abdomen. The rectus muscles were inspected. No bleeding was noted. The fascia was closed in a running fashion. The subcutaneous layer was copiously irrigated. All bleeders were cauterized. Subcutaneous layer was closed in a running fashion and the skin was closed with staples. All sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well.
