DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after adequate level of general anesthesia was achieved, the patient was placed in the Trendelenburg position, prepped and draped in the usual sterile fashion. Subsequently, a Pfannenstiel incision was made and the incision was taken down to the fascia. The fascia was opened up sharply. The fascia was extended to the length of the incision using the Mayo scissors. At this time, the rectus muscles were dissected from the fascia superiorly and inferiorly to the symphysis pubis. The midline rectus muscles were opened sharply and extended superiorly and inferiorly. The peritoneum was visualized, grasped, opened sharply, and extended superiorly and inferiorly towards the bladder. The abdominal contents were packed superiorly away from the operative site using the lap packs. At this time, the pelvic organs were noted. The inferior and superior blades were placed in place on the Balfour self-retaining retractor. Bowel was packed away from the operative site. The fundus of the uterus was then grasped with a triple-tooth tenaculum and retracted out of the pelvic cavity into the abdominal site. At this point, Kelly clamps were placed in both right and left adnexal regions. Subsequently, using the LigaSure cautery unit, the round ligaments were grasped, cauterized, and dissected. The bladder flap was then formed and the bladder flap was pushed away down anteriorly over the lower uterine segment, pushed away from the operative site on both the right and left sides. Subsequently, the posterior leaf of the broad ligament was opened sharply and the LigaSure instrument was then placed below the level of the ovary in both the right and left side, care being taken not to damage bowel or uterus and the infundibulopelvic ligament was then grasped, cauterized, and again dissected. Further dissection of the broad ligament was carried down posteriorly towards the uterine vessels. The bladder was pushed inferiorly down towards the vagina. Subsequently, the uterine vessels were then grasped again with the LigaSure machine, cauterized, and dissected. The cardinal ligaments were further grasped, dissected, and suture ligated, again with the LigaSure machine. At that point, the LigaSure machine instrument was stopped and straight Zeppelin clamps were used on the cardinal ligaments down towards the uterosacral ligaments. The cardinal ligaments were grasped, dissected with a scalpel and then ligated with transfixion sutures with #1 Vicryl suture down to the uterosacral ligaments. The uterosacral ligaments were grasped, dissected, and suture ligated again with #1 Vicryl suture and transfixion sutures. At that time, the bladder had been pushed over the vagina and at this time right-angle Zeppelin clamps were placed on the vagina at the level of the cervix, and using the Jorgenson scissors, the cervix was dissected away from the vagina. At this time, the vaginal cuff was then closed using interrupted sutures of #1 Vicryl suture from the midline to each lateral corner. After the good hemostasis had been achieved in the vaginal cuff, both the right and left adnexa was visualized and no more bleeding was noted. The cuff was intact with no bleeding noted. The bladder was visualized and no bleeding was noted. Seprafilm was then placed over the vaginal cuff. The Balfour self-retaining retractor was removed as well as the anterior and inferior blades. The lap packs were removed, and at this time, general closure of the abdomen was carried out. The peritoneum was closed with a 2-0 Vicryl suture and continuous running suture. The fascia was closed using a #1 Vicryl suture from each corner to the midline. Subcutaneous tissue was cauterized. No bleeding was noted. The subcutaneous tissue was then reapproximated using plain sutures and interrupted sutures, and the skin was closed using 4-0 Vicryl suture in a Keith needle. The patient tolerated the procedure well and was transferred to the recovery room in excellent condition. The patient returned to the floor for recovery.
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