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Diagnostic Hysteroscopy, Dilation and Fractional Curettage, NovaSure Endometrial Ablation, Laparoscopic Bilateral Tubal Ligation Operative Sample

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed on the operating table in dorsal supine position. After satisfactory general anesthesia was achieved, the patient was placed in dorsal lithotomy position using Allen stirrups. Examination under anesthesia was performed.  The patient was prepped and draped in the usual manner for a vaginal laparoscopic procedure. A weighted speculum was placed in the vaginal vault and the anterior lip of the cervix was grasped with single-toothed tenaculum. Endocervical canal was sounded to 3 cm and endocervical canal dilated to a #16 Hanks dilator. I used a 5 mm diagnostic hysteroscope with normal saline as distending medium to perform a diagnostic hysteroscopy. Photographs were taken and the scope was removed. Kevorkian curette was used to perform an endocervical curettage. The specimen was submitted as endocervical curettings. Cervical canal was dilated to a #20 Hanks dilator. I used a medium-sized sharp Sims curette to perform an endometrial curettage which produced endometrial tissue. I then probed the uterine cavity with uterine polyp forceps. No polyps were retrieved. The specimen was submitted as endometrial curettings. Attention was directed to performance of the NovaSure endometrial ablation. Cervical canal dilated to a #29 Pratt dilator. The NovaSure endometrial ablation device was removed from the package. It was test-fired and deployed to look at the fan-shaped blades, and they were intact. The meter went between 4.5 and 5. The device was withdrawn into the cylinder. I then placed it into the uterus. The dorsal fin was set at 6 cm which was uterine cavity sounding 9 cm minus 3 cm of endocervical canal, withdrawn approximately 1.5 to 2 cm and deployed. It was then seated. The sleeve was placed up against the endocervix and it was test-fired to do a cavity assessment, which was intact. It was then fired. At the end, the device was removed and another hysteroscopic examination was performed. I was satisfied with the ablation of the endometrial cavity. An acorn cannula was placed through the cervical canal and connected to the tenaculum for support. Red rubber catheter was used to drain the bladder and was left in place for the remainder of the case. The outer gloves of the surgeon were removed. Attention was directed to performance of laparoscopic procedure. The infraumbilical region was anesthetized with local anesthesia, 0.5% Marcaine and epinephrine. A small vertical skin incision was made through the skin and subcutaneous tissue. A 5 mm Optiview trocar was placed through the incision into the abdominal cavity. Diagnostic laparoscope with a video camera attached was placed through the trocar sleeve and carbon dioxide was used to inflate the abdominal and pelvic cavity. A small skin incision was made in the midpoint of the pubic hairline with a knife after anesthetizing with 0.5% Marcaine and epinephrine. Then, a 5 mm trocar was placed in the abdominal cavity under direct visualization through the scope. The pelvic contents were examined and the findings were described above. Photographs were taken. Attention was directed to performance of a bilateral tubal ligation. Kleppinger bipolar forceps was inserted through the second port. Left fallopian tube was identified, traced to its fimbriated end to assure its identification. Then, starting at the distal isthmus, proximal ampullary portion of the tube, it was coagulated in four contiguous areas. Each time the resistance meter went to zero and the tube had been retracted away from adjacent viscera. I was satisfied with the ligation and a photograph was taken. Then, on the left side, Kleppinger bipolar forceps was used to grasp the fallopian tube, traced to its fimbriated end to assure its identification, then it was coagulated in four contiguous areas starting at the distal isthmus, proximal ampullary segment. I was satisfied with the coagulation. A photograph was taken. Adjacent viscera were inspected. There was no damage. All the areas were inspected and it was decided to terminate the procedure. Second trocar was removed under direct visualization through the scope. The scope was removed and excess carbon dioxide was removed through the first port, before it was removed. The skin was reapproximated with running subcuticular stitches of 4-0 Vicryl suture, and extra 0.5% Marcaine and epinephrine were used for local anesthesia. Instruments were removed from the vagina. There was minimal bleeding from the cervix; silver nitrate was applied. The procedure was terminated. Estimated blood loss minimal. Final sponge, instrument, and needle counts were correct. The patient was awakened on the operating table and taken to the recovery room in satisfactory condition.

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